by Tim Noakes
In time, Ellmer re-published these blogs on the website of her Somerset West dietetics practice, Vergelegen Dietitians. One of the blogs included the advert: ‘Book a consultation with us and find out what type of weight loss diet will work best for you.’ With these blogs, Ellmer self-identified as the South African dietitian most willing to speak about infant nutrition and who, equally importantly, was zealously antagonistic to me and my advocacy of the LCHF diet. And so, when Strydom and the head of the HPCSA’s legal team, Advocate Meshack Mapholisa, were looking for expert witnesses to testify against me, Ellmer was one of the first they approached.
In the midst of all this blogging, on 3 February 2014, Twitter user Pippa Leenstra tweeted the following to me and Sally-Ann Creed, my co-author on The Real Meal Revolution:
@ProfTimNoakes @SalCreed is LCHF eating ok for breastfeeding mums? Worried about all the dairy + cauliflower = wind for babies??
That the tweet was addressed to both Sally-Ann and me, and specifically referenced LCHF, indicated that Leenstra was aware of The Real Meal Revolution and was writing to us as its authors. Most importantly, she asked about breastfeeding mums and expressed concern for babies – not a specific mum or baby, or even her baby, but mums and babies in general. In doing so, she clearly defined the context of her question. She was not asking for medical advice in order to treat herself and her child. Rather, she was asking for general information that might be applied to all breastfeeding mothers. This is a crucial distinction that should have dictated how the HPCSA dealt with the complaint against me.
The HPCSA’s rules regarding what information a dietitian – and by extension a medical doctor such as myself – may give are very clear. Schedule 2(b)(ii) of the Health Professions Act 56 of 1974: ‘Regulations Defining the Scope of the Profession of Dietetics’ differentiates between dietetics information given as part of a medical consultation and that which serves to promote ‘community nutrition’, defined as ‘the professional communication of scientifically-based nutrition knowledge, according to need, to individuals and groups within the community in order to motivate them to maintain or change nutritional behaviour in order to improve quality of life and to prevent nutrition-related diseases’.14
Because Leenstra was asking a ‘we’ question, I was completely within my rights to give general information without examining the ‘patient’. And, crucially, by answering the question, I was not entering a doctor–patient relationship with Leenstra.
Two days later, on 5 February, I tweeted my response:
@PippaLeenstra @SalCreed Baby doesn’t eat the dairy and cauliflower. Just very healthy high fat breast milk. Key is to ween [sic] baby onto LCHF.
In this tweet, what I did not say is as important as what I did. I did not answer Leenstra’s question directly, because I personally had no knowledge of a link between dairy and cauliflower in the mother’s diet and wind in the breastfed infant. Thus, in keeping with the nature of Twitter, which is an open public forum for the sharing of information, I left the answering of that particular question to anyone else who might have the relevant knowledge that I lacked; Sally-Ann Creed, for example. I also did not instruct mothers to stop breastfeeding. Rather, my tweet endorsed breastfeeding. As fully expressed in Raising Superheroes, I believe that mothers should breastfeed for as long as possible, aiming for two to three years if feasible.15
I added the part about weaning babies onto LCHF because I strongly believe that infants should not be weaned onto the usual high-carbohydrate, high-cereal diet, which, in my opinion, predisposes them to the development of IR, obesity and T2DM. Alan Greene, professor of paediatrics at Stanford University, shares my view: ‘In fact, I think [white rice cereal] is the tap root of the child obesity epidemic … The problem is that it is basically like feeding kids a spoonful of sugar … I’m saying you might as well be putting soda in the bottle as feeding the white rice cereal.’16 In retrospect, had I written that the key is to wean baby onto real foods (instead of LCHF), the HPCSA trial may never have happened. But I had run out of characters, and it was clear that Leenstra was referring to The Real Meal Revolution, which meant she had to understand that, in my book, LCHF and real foods are synonymous.
Leenstra responded with the following:
@ProfTimNoakes @SalCreed ok, but what I eat comes through into my milk, is that not problematic for baby and their winds at newborn stage?
I chose not to respond to this question for two reasons. First, Leenstra had now asked a direct ‘I’ question, so that any answer I gave might be construed as medical advice. And second, she was asking for information on a topic about which I have no special expertise. Since the focus of my Twitter account is the dissemination of scientific information, not medical information about topics on which I am not an expert, I did not reply, hoping rather that someone more knowledgeable than I on the subject would offer Leenstra the appropriate advice.
Which is exactly what happened. Within a few minutes of posting my tweet, Leenstra received a response from Ellmer, who described herself as a ‘paeds dietitian’:
@PippaLeenstra Pippa, as a paeds dietitian I strongly advise against LCHF for breastfeeding mothers. #notokay
To which Leenstra responded:
@Mellmer80 thx, why do u say that?
Ellmer chose not to answer her question on Twitter. Rather she suggested they take the discussion offline:
@PippaLeenstra Why dont you email me on [email protected] and I will explain. Ps food flavours are definately [sic] passed through BM
This tweet is important for one critical reason. Central to the HPCSA’s case against me was their belief that my original tweet constituted medical advice given to a patient from whom I had failed to take an adequate medical history and whom I had not properly examined. The key contention was that my tweet established a doctor–patient relationship with Leenstra, and once a doctor–patient relationship exists, my registration with the HPCSA as a medical practitioner obliges me to fulfil certain ‘duties of care’. The HPCSA would contend that I had failed to perform these responsibilities.
If this were the case – in other words, had I established such a doctor–patient relationship – then Ellmer’s latest tweet constituted supersession. By providing her contact details to Leenstra, Ellmer was seeking to make Leenstra her patient; in effect, she was stealing my patient. And stealing another medical professional’s patient is a breach of the HPCSA’s rules. If I were to be charged for breaching the rules, then the HPCSA would have had to act against Ellmer, too.
On 6 February, Claire Julsing Strydom entered the discussion with the following tweets:
@ProfTimNoakes @PippaLeenstra @SalCreed I AM HORRIFIED!! HOW CAN YOU GIVE ADVICE LIKE THIS????
@ProfTimNoakes @PippaLeenstra @SalCreed YOU HAVE GONE TOO FAR, BE SURE THAT I WILL BE REPORTING THIS TO THE HEALTH PROFESSIONAL COUNCIL SA
@ProfTimNoakes @PippaLeenstra Pippa I am a breastfeeding mom of a 4 month old & a RD [registered dietitian] with a MSc in dietetics this info is shocking.
@ProfTimNoakes @PippaLeenstra Pippa please contact me on 011 023 8051 or [email protected] for evidence based advice
Strydom, it seemed, was also now actively trying to steal my ‘patient’.
That they did indeed ‘chat’ was confirmed by Strydom’s next tweet:
@ProfTimNoakes @PippaLeenstra Was great chatting to you Pippa – good luck with your little one.
And by Leenstra’s response:
@DietitianClaire @ProfTimNoakes thx for the call and advice Claire.
Had Leenstra been my patient, here was proof that supersession had taken place.
The next person to get involved was Anne Till. Till was one of the senior dietitians advising Discovery Health when I was the Discovery Health Professor of Exercise and Sports Science at UCT. She and I had participated in a documentary TV series in which my main contribution was to nod sagely while Till gave the standard nutritional advice embraced by Discovery and based on the USDA’s food py
ramid, loaded with ‘healthy’ grains.
Since then, Till had immigrated to the US, intent, she told me, on ‘making Americans healthy’. Her participation on 7 February allowed Strydom to repeat her statement about my ‘dangerous advice’:
@AnneTillRD @MicheChelle @ProfTimNoakes thanks Anne. I can’t just ignore such dangerous advice especially when it comes to infant nutrition
Strydom next told Till that she had reported me to the HPCSA:
@AnneTillRD it is out of control! I have reported the infant nutrition recommendations made by TN to the HPCSA we will see the response
My interest all along has been the promotion of a questioning science, so in my response to Strydom and Till the following day I asked whether the consequences of weaning infants onto high-carbohydrate, cereal-based foods could be the early onset of obesity and T2DM. At the time, I did not yet understand that the reason why the South African dietary guidelines promote weaning onto cereals is not because they are healthy, but because they are regarded as affordable to the ‘masses’. I tweeted:
@DietitianClaire @AnneTillRD What if the childhood obesity epidemic is caused by the high carb diets to which we now expose our children?
In response to Strydom’s statement that she had reported me to the HPCSA, I indicated that I was keen to read her evidence that a high-carbohydrate diet is essential for infant health:
@DietitianClaire @AnneTillRD Can’t wait. Look forward to your published evidence that high carb diet essential for health of infants/kids
To another Twitter user, Strydom suggested on 8 February that feeding infants real foods would increase infant mortality rates:
@albie_cilliers Shocking -reported it to HPCSA. How can he give advice like that in SA where infant mortality rates are already high
She does not ask if it is possible that the high-carbohydrate, cereal-based diets onto which the majority of South African infants are weaned could be the cause of South Africa’s high infant mortality rates. As they say, insanity is repeating the same mistakes and expecting different results. And never considering an alternative explanation.
That same day, Strydom tweeted:
@drgail3 @MicheChelle Please forward me the literature that indicates that it is safe to wean an infant onto a LCHF diet!
A challenge that all proponents of the LCHF diet experience almost daily is having to deal with the sceptics’ question: Yes, but where is the data? Surprisingly, these same sceptics never ask the question of those who defend the 1977 US dietary guidelines.
In time, I discovered that this feigned scepticism is simply a front, because when we presented 12 days of testimony at the HPCSA hearing showing why the LCHF diet is safe, and indeed essential, for infants, those who had been the most vociferous in assuring South Africans that the LCHF diet is dangerous were notably absent.
Five days after her original tweet to me and Sally-Ann Creed, Leenstra re-entered the discussion:
@2catsandababy @ProfTimNoakes @SalCreed thx but I’ll go with the dieticians recommendation
As a result, I considered my job done, and I disengaged. Leenstra had received the information she had sought. She had made her choice. That is why Twitter exists: to share knowledge that allows the interested participants to make their own informed decisions.
In a subsequent interview with Netwerk24 on 28 November 2015, Leentra stated that she could not care less about the HPCSA hearing that her Tweet had precipitated and which she described as a ‘circus’.17 She explained that, in 2014, her husband had come home with The Real Meal Revolution and she had started to prepare his evening meals according to the Banting guidelines. At the time she was breastfeeding their then six-month-old son, and she wondered if the LCHF diet might affect him adversely. This is what motivated her tweet.
When she read my Twitter response, Leenstra said she laughed, because she had no intention of weaning her son onto a Banting diet. When Strydom phoned her the next day and ‘pleaded’ with her not to follow my advice, she felt it was a moot point because she had never planned to follow the diet anyway.
The dietitians, however, would not let it go. They continued to post tweets that provided insights into not only their own feelings on the topic, but also their understanding of human biology, as well as how they viewed themselves and their professional responsibilities.
On 15 February, Ellmer hinted that she had fears about the dangers of ketone bodies for the suckling infant:
@drgail3 @PippaLeenstra @SalCreed And we havent even started on effect of ketones transferred in BM to BF baby?
Reading the summary of her testimony for the HPCSA hearing, my conclusion is that, at the time Ellmer wrote this tweet, she had little understanding of the critical role that ketone bodies play in the development of the neonatal brain. Which is a little disturbing for someone who considers herself a ‘paeds dietitian’.
The truth is that ketones are absolutely essential for early brain development in newborn and suckling infants (see Chapter 17). If registered dietitians in South Africa do not understand this because it is not included in their curriculum, then this poses a significant academic challenge.
On the same day, Ellmer indicated that dietitians have a responsibility to educate their colleagues (presumably she was referring to ignorant doctors like me):
@drgail3 @PippaLeenstra I hear you. The onus are on us to also ensure our colleauges [sic] are properly educated and up-to-date with science
Yet Ellmer was absent when Nina Teicholz, Zoë Harcombe, Caryn Zinn and I presented our testimony supporting our position during the HPCSA hearing. How can you be an educator if you are not prepared to consider all the published evidence? Does Ellmer believe that a ‘proper education’ is one that only considers current dietary dogma? Her absence from the hearing is even more startling when one considers this tweet, from 15 March, in which she underscored the importance of lifetime learning:
Powerful Chinese Proverb. http://t.co/hkVlnoooup We are never beyond learning and almost never so wise
Two days earlier, she had complained that LCHF proponents had failed to send her information on the Banting diet:
@snooplambylamb Ross I have asked for 3 LCHF proponents to send me lists of scientific studies to support their view and no reply so far
Yet when the opportunity to listen to world authorities on LCHF arrived on her doorstep, at no cost to her, she failed to turn up. This is a classic case of confirmation bias: we accept the ideas that we like uncritically, and then demand mathematical certainty for all the concepts we dislike.
Finally, she dismissed the ‘science’ in The Real Meal Revolution without ever explaining why:
@ProfTimNoakes If anything like the ‘science’ provided in RMR I will be dissappointed and dissillusioned [sic]. For sake of arg I will read it
On 3 April, Strydom tweeted that she and her colleagues were collecting the names of the many people whose health was suffering as a result of adopting the LCHF diet:
@ianlane88 @nooralrefae_RD @ProfTimNoakes we are collecting these case studies to hand over to the HPCSA.
I asked her what her control group would be, but she did not respond. No list was forthcoming at the HPCSA hearing.
On the same day, Strydom indicated that everything she says is ‘evidence based’:
@cclauson i have studied nutrition for many years and have been in private practice for over a decade. Everything I say is evidence based
The only problem is that most of the current nutritional ‘evidence’ is fictitious, based on meaningless observational, associational studies, the weaknesses of which I discussed in Chapter 7. While Strydom’s training may indeed be ‘evidence based’, there is little hard evidence to support what she has been taught. The focus of the HPCSA trial would gradually swing from the consideration of my unprofessional conduct to a review of the absence of any evidence for the current dietary guidelines and, by extension, for much of what dietitians currently prescribe.
Strydom also retweeted material from o
thers who believe that dietary fat is harmful to human health. Two such tweets drew attention to the ideas of American physician David Katz, who would soon become a new best friend of ADSA, flying to Cape Town to be the keynote speaker at their 2016 Nutrition Congress. Katz, who appears to be a vegetarian and leader of the plant-based food movement, has had a chequered medical career. In 2015, he was found to have written laudatory reviews for one of his own books under a pseudonym.18 He is also one of the most highly paid consultants to the food industry, leading US investigative journalist Russ Greene to dub him ‘Junk Food’s Slyest Defender’.* It seems highly improbable that Katz would come to South Africa to speak on ADSA’s behalf without expecting a sizeable fee from the congress funders, the South African Sugar Association.
