#NoakesHearing, day 1: Reflections on futility

hpcsaAs anyone who clicked through to this piece probably knows, yesterday saw the start of a Health Professionals Council of South Africa (HPCSA) hearing to assess whether Prof. Tim Noakes is guilty of unprofessional conduct. The charge against Prof. Noakes states:

That you are guilty of unprofessional conduct or conduct which, when regard is had to your profession, in that during the period between January 2014 and February 2014 you acted in a manner that is not in accordance with the norms and standards of your profession in that you provided unconventional advice on breastfeeding babies on social networks (tweet/s).

I attended all of yesterday’s session, and offer some thoughts on what transpired, below. I have not attempted to catalogue everything that happened – if you want a more detailed account, the News24 live-blog offers an accurate summary.

On futility – once more with the distinctions

It continues to exasperate that I can think of only one person a handful of people who understand that there are (at least) two distinct issues at play in the general discussion around Noakes, LCHF and Banting. The first is the set of questions related to diet, and which is healthier for you.

In this set of questions, I’m bundling in long-term vs. short-term, treatment for obesity and diabetes, what proportion of population X are insulin-resistant and so forth. I do not, in general, comment on those issues. They are not a field of expertise for me. As I’ve repeatedly said, Noakes might well end up being a frontrunner in what eventually becomes scientific consensus.

The second set of questions relates to logic and philosophy of science, and to our responsibilities as educators, or journalists, or health professionals to discourage sloppy thinking on matters of significance (well, on all matters, but the stakes are sometimes higher than others).

So, I’ve consistently (with a few lapses, I’m sure) focused on the quality of argument that emerges from the Banting camp, rather than on the superiority of any particular conclusion. If you don’t care about those issues (you of course should), then you shouldn’t be reading my comments on them.

You certainly shouldn’t be asking me to present evidence that low-carb is bad, because that’s not what I’m claiming. You also shouldn’t be telling me that “there’s so much more bad science for the consensus” or somesuch, because maybe there is, and maybe there isn’t, but that’s not what I’m talking about. The fact that someone else (proponents of the consensus view) also does things wrong doesn’t give anyone else a free pass to be sloppy in their reasoning.

On futility II – the hearing that never happened

We spend the entire day hearing arguments about the constitution of the panel that was set to hear the case, and proceedings were eventually terminated at around 15:30 when it was agreed that the panel was improperly constituted. Proceedings will resume on November 23, assuming nothing else interferes with the process.

Should this hearing be happening at all?

I have mixed feelings about this. As with so many of our policies (and even heuristics related to social interaction), there’s a vast difference between what made sense in a pre-digital era and what makes sense now. Noakes is often to be found on Twitter – he’s written an ode to it, in fact, and his fans love him for how much he engages there.

The point of highlighting the pre/post-digital era is of course it would be irresponsible for a physician to encounter you in the street and tell you what your baby should eat, unless your advice is something rather generic and consensus-based. Even if the consensus is wrong, as Noakes thinks it is, it does sit with an advantage here – his job is to create a new consensus, after which he’ll get the same advantages.

But perhaps Twitter is different, in that it’s a broad discussion or sounding board for ideas, in which we shouldn’t expect people to view what Noakes tweets as prescriptions in the medical sense. That’s presumably what he thinks. I think he’s wrong in practice, because people do view them as prescriptions, and he should know that and act accordingly.

However, it’s possible that holding him to account for all possible consequences of his tweets does overstate the importance and role of Twitter, and also paternalise his Twitter following. For example, a non-prejudicial look at the tweet that started all the trouble is consistent with slowly weaning a child onto LCHF, perhaps in a manner that doesn’t run the risk of causing the complications the complainants in this case claim it would.

So, this case is raising very important background issues related to the appropriateness (or not) of how people with positions of influence engage on social media.It’s not going to be a waste of time, but is rather going to force everyone to resolve what I think are important issues.

It’s a great shame that many of Noakes’ supporters are struggling to see anything beyond a vendetta or bad faith here, and also that Noakes himself misses the point that it’s not about freedom of speech, but rather about the responsibilities of healthcare professionals to avoid causing harm.

He’d retort that it’s the Association for Dietetics in South Africa’s (ADSA) advice that causes the harm, but even if true (and even if he’s even representing what their advice is accurately), that’s something you demonstrate in journals, not with other people’s babies.

Is Noakes speaking “outside his field of expertise”?

One of the things that caused a fuss during the hearing was a statement made by the HPCSA’s lawyer that Noakes was operating or speaking as if he were a dietician, and that this is not his field of expertise. To briefly return to my futility theme, this was immediately leapt on by the Noakes-supporters as an attempt to suppress Noakes’ freedom to research and write on nutrition, while it was in fact nothing of the sort.

The argument was simply that because he’s operating outside of the “normal” General Practitioner (GP) set of ideas but rather as a dietician, it makes sense to include a dietician on the panel. Nevertheless, the motivated reasoning in response to this was quite something to behold, as it was immediately taken up as further evidence of the conspiracy against Noakes, who was now “not allowed” to talk about diet.

The clue as to what GPs do is in the name – they consult on a general set of health-related concerns, one of which is diet. But the claim made by the HPCSA lawyer was that Noakes was presenting himself as more than a generalist, but rather as a specialist in this area, and he should thus be assessed by a specialist also.

What was the problem with the panel composition?

The technical problem that (rightly) led to the cessation of the hearing was that the panel was lacking one particular member as per the regulations, where that member needed to be in Noakes’ profession, i.e. a GP. There was one GP on the panel, who was also a pediatrician, as well as a dietician (who I’ll return to in a moment), but there needed to be another Medical and Dental Board-registered GP present for a properly constituted panel.

What was interesting about the debate on the panel composition?

Both sides seemed intent on creating as favourable a panel as they could, which should of course be no surprise. The complainants argued strongly for the presence of a dietician, and Noakes’ lawyers argued strongly against. Noakes, of course, thinks that the dieticians exemplify bad science in this area, and he’d probably argue that they aren’t competent to assess the evidence he’ll present.

However, the problem with ruling them out is two-fold: one, it presents a circular argument, in that it assumes they are incompetent (or rather, cedes the argument regarding their competence) as reason to rule them out as assessors of the evidence; and two, if they are as incompetent as he thinks, surely it would be a simply matter to demonstrate this in the course of the hearing?

There’s the risk of a strategic blunder from the Noakes team here – the more intent they appear on trying to rule a dietician out as a panelist, the more people might wonder what they are so concerned about. If they are as scientifically backward as Noakes would have us believe, why not publicly expose that via the hearings?

And then….

The strange case of Prof. Blaauw

The dietician panelist, Prof. Blaauw, was initially considered a perfectly acceptable member of the panel, until we discovered two things about her (and the second, only rather late in the day). Over lunch, she informed the (superb) Chair of proceedings, Joan Adams, that she had once co-supervised an ethics thesis on the “media implications of Tim Noakes”. This was claimed to not impair her objectivity, and the Noakes legal team seemed happy with her, despite this knowledge.

Later on, though, we discovered that she was also a member of ADSA, whose President in fact laid the complaint against Prof. Noakes. This caused significant dissent around her suitability, as you’d expect it to given the conflict of interest.

Debate then ensued as to whether she was in fact legally part of the panel at all, as given that it had already been ruled that the panel was improperly constituted, she could not officially or automatically be considered part of a future, properly constituted panel either. Noakes’ lawyers went as far as to say that they might consider taking this issue to the High Court, if Prof. Blaauw ended up remaining on that future panel.

Bad faith and Tex bars

In an amusing turn of events, we reconvened after lunch to find that some prankster had placed Tex bars (a chocolate) on the desks in front of each panelist. Some of the Noakes supporters on Twitter immediately assumed that this was ADSA’s doing, which seemed to fit the generally uncharitable attitude on the #NoakesHearing hashtag, which also included some fat-shaming of various members of the complainant’s party.

Yes, these are emotive issues, and I can understand why people feel that someone they respect and admire for standing up to orthodoxy is being unfairly singled-out, but you don’t make an effective case for his virtue by demonstrating a lack of virtue yourselves. Even if “the other side” sometimes do the same, that does not make your doing so more appropriate either.

One of the Noakes supporters seems to have cottoned on to the reality that people like me don’t have a vendetta, but is rather simply interested in the arguments and ethics of how we debate them. But there’s still far too much ad hominem, and accusations of trolling put in terms that are themselves distinctly trollish. This is the problem of the filter bubble, as I’ve argued before, and I’ll again simply suggest that there is a conversation to be had here, and some of us are having it in good faith – whatever you might believe.

In conclusion

The Noakes legal team seem better prepared, and certainly appeared more effective in their rhetoric and argumentation. Now that the hearings have been extended to run for 7 days, I suspect that the complainants are going to have a difficult time competing. And, at the end of the day, Noakes will “win” on any permutation.

If he is (in the extreme scenario) struck off the roll and disallowed from practicing medicine, that’s of little consequence to his main interest, which is research and (mostly public) dissemination of findings related to diet. And, he and his supporters will have further “evidence” of his persecution.

And if he wins, that will of course serve as his – and the Banting diet’s – most significant tipping point towards public acceptance yet…

Screen Shot 2015-06-05 at 09.50.27

P.S.: The screenshot above is from Noakes’ Real Meal Revolution website, and you might find the last bullet-point of interest.

Sugar given Carte Blanche to cause panic

When you (by which I mean, the average person) thinks about something as being “addictive”, I think we mean that the substance or activity in question is particularly likely to cause you to develop some combination of dependence, tolerance, cravings and withdrawal symptoms.

You’d also, if addicted, go to significant lengths to obtain the thing that you are addicted to. On a trivial end of this spectrum, people who smoke cigarettes might walk out into a cold and rainy evening to go and purchase cigarettes, instead of staying under the duvet like any sensible (i.e., non-addicted) person would.

When you think of addiction, in other words, I’d guess that you typically don’t mean that you know this fellow, George, who has become so obsessed with playing Minecraft that you describe Minecraft as addictive, as opposed to acknowledging that people can become “addicted” to Minecraft.

sugarThe distinction is important, and points to one of the significant problems in discourse around sugar “addiction”, as recently portrayed on the South African current affairs show, Carte Blanche. It’s important because the things we like are rewarding at the level of the brain, in that they result in dopamine release – but this does not necessarily mean that they are addictive in the stronger sense that we tend to reserve for things that you can’t help but find rewarding.

In other words, there’s almost zero chance of my becoming addicted to running, because I don’t like doing it, and tend not to do it. But there’s a significant chance – and a similar chance to your chance – of my becoming addicted to heroin, if either of us were to try it.

We’re using the word “addictive” in a very broad sense when we describe the Internet, exercise, and sugar as addictive. In fact, the sense in which it’s being used is broad enough as to mostly lose its meaning, by contrast to the strong sense in which certain substances are very likely to result in the sorts of reactions mentioned above, for many people.

Most of us exercise, use sugar or the Internet, and have sex quite unproblematically (in terms of addiction, Beavis). More of us use things like heroin or cocaine unproblematically than the standard sorts of addiction panics claim also, but that’s a story for another day. The point I’m making here is quite simply that any claim that sugar is “addictive” is using the word “addictive” in a misleading and hyperbolic way.

Long-term addiction is the exception, not the rule – we suffer from a confirmation bias here in the sense that we don’t get to hear about the people who live with addictions that are largely under control and remitting (in other words, most of them). We hear about the horror-stories, of people struggling with a demon, and (sometimes) heroically fighting it off.

And, as the cases and science detailed in Johann Hari’s Chasing the Scream persuasively suggest, the primary vehicle we have for escaping addiction is to give ourselves a sense of purpose and above all, agency – and agency is last thing that panics around things like sugar addiction have time for. Instead, the narrative is all about you being a victim of conspiracy.

You can watch the Carte Blanche insert yourself, in which you’ll be told that “sugar may be as addictive as nicotine and hard drugs”, that sugar can “hijack the brain” and so forth. But what you’ll mostly see is three self-described (and apparently self-diagnosed) sugar addicts telling you how addictive it is.

Their primary scientific resource, Prof. Nicole Avena, doesn’t even herself support the strong addiction claim, saying “a little bit of sugar won’t hurt you. It’s not a bad thing in general, it’s just the way we are consuming it is a bad thing”. The “we” is perhaps too broad there, in the sense that many of us who aren’t on LCHF-type diets have been restricting added sugars for our entire lives already, given that warnings about refined sugars have been a staple of dietary advice for quite some time now.

Nevertheless, I’d agree that people are eating too much sugar. And, people who are prone to compulsive behaviour might well find themselves becoming “addicted” to sugar – and you wouldn’t be surprised to find (as you do in one of the three cases presented in the show) that these people can become “addicted” or even addicted to a range of things over the course of their lives.

The problem, in short, might be with their lives and their circumstances – at least in large part – rather than in the substances or activities. We should not be surprised that our brains find food rewarding, and that we seek it out. We’d be surprised if it was any other way. But if we can (typically, as with most consumers of sugar) control the impulse to eat too much of it, then addicts need to shoulder a large portion of the responsibility themselves, and not hand it over to sugar.

But, say some (and as presented at 2m21s in the video, with an unfortunate reference to quack-central Natural News), studies prove that sugar is more addictive than cocaine. Unfortunately, studies prove what you want them to, depending on which studies you read, and which you ignore.

Plus, of course, how attentively you read them can be an issue – as I’ve noted before, Avena and others are far more circumspect and tentative than they are presented to be by the media and vested interests. Her own oft-cited paper is full of scare-quotes for the word “addiction”, and stresses that “whether or not it is a good idea to call this a “food addiction” in people is both a scientific and societal question that has yet to be answered.”

The hyperbole in blogs and online news sources, never mind repositories of the worst sorts of pseudoscience like Natural News, don’t help resolve these issues. Neither do personal anecdotes, regardless of our compassion for people who struggle with compulsive behaviour of various sorts. Movies like Fed Up are of little use also, in that they simply populate the scaremongering filter-bubble with cherry-picked and misrepresented data.

If you want to read about why the Lenoir et. al. study quoted in Natural News doesn’t resolve my doubts about sugar addiction, not to mention comparing rat data to human experience – especially given the fact that psychological rather than physiological factors seem most relevant to addiction – I’d recommend reading this Scicurious post closely.

That post points out that there’s perhaps a vast difference between the self-administration of drugs in humans compared with rats, who can’t reason about their choices like we can. It also notes that the study doesn’t measure a progressive ratio – in other words, it doesn’t tell us what the rat prefers when it really has to work to get its reward. When things get tough, will it prefer sugar, or will it quit trying?

We don’t yet have good human data for sugar addiction. What we do seem to have is limited evidence for “eating addiction“, but as I’ve stressed above, an addictive behaviour is not the same thing as an addictive substance. People who are addicted to eating might well find foods – including sugar – deeply rewarding, but it’s premature to blame the sugar itself.

To conclude: there’s no problem with saying we find sugar rewarding. Of course we do, as we would exercise and so forth. To say it’s addictive makes a far stronger claim, and that claim is the suggestion that it’s a sinister substance that’s out to get you, rather than something you’re free to enjoy in moderation, just as you can alcohol or any other drug, depending on the legislation where you live, and your own personal risk-tolerance.

One thing I’m quite concerned about, though, and have noted before, is that it seems quite likely to me that your risk-tolerance can only be compromised through being treated like a perpetual victim – and that believing your food is out to kill you seems a wholehearted embracing of that victimhood.

Saturated fat not exonerated in 2015 US dietary guidelines

I’m traveling back from giving a talk to a room full of dieticians about their social responsibilities, in which I emphasised that one of their important tasks is to try to beat back the surge of hyperbole and exaggeration coming out of the Banting and LCHF camps.

There are plenty of posts here on Synapses on the topic, many dealing with Professor Tim Noakes and how his confirmation bias has led him to re-tweeting false and potentially dangerous claims. You’d recall him “just asking questions” on vaccines and autism, or spreading the (false) idea that Sweden had become the first nation to “officially” adopt LCHF as their diet.

imagesAs I’ve said many a time, and repeated at the talk last night, some of the ways in which we can aid the spread of scientific literacy is through simply reminding people of the virtues of not overstating the evidence we have for our claims, and also through encouraging people to be consistent in their judgements – if something is wrong in one case, it’s usually wrong in similar cases also.

A recent example of salesmanship trumping science arrived in time to include in my remarks, and I also want to note it here for folks who have been following the topic. Yesterday morning, Prof. Noakes tweeted

The text of the tweet is a quote from the linked post, so not Noakes’ words, but I am fairly confident that he endorses the sentiment seeing as he’s frequently said similar things. Many times, they have in fact been described as “tipping points”, which makes one wonder how many tipping points are necessary before whatever it is actually gets around to tipping.

Anyway – if you go read the post that is linked to in the Tweet, you’ll find that it’s a smug “I told you so” by Dr Malcolm Kendrick, author of “The Cholesterol Con”. What he wants to gloat about is that he was right all along, and that in short, “cholesterol is healthy, saturated fat is healthy, salt is healthy and sugar is unhealthy”. Speaking of the 2015 Dietary Guidelines Advisory Committee’s (DAG) report, he says:

The entire report, I believe, stretches to about a bazillion pages. However, here are four of the highlights.

Cholesterol is to be dropped from the ‘nutrients of concern’ list. [I love that phrase ‘nutrient of concern’].

Saturated fat will be… ‘de-emphasized’ from nutrients of concern, given the lack of evidence connecting it with cardiovascular disease.’ [Whatever de-emphasizing may be. Pretending you never said it in the first place, I suppose].

There is concern over blanket sodium restriction given the… ‘growing body of research suggesting that the low sodium intake levels recommended by the DGAC (Dietary Guidelines Advisory Committee) are actually associated with increased mortality for healthy individuals.’

And… ‘The identification and recognition of the specific health risks posed by added sugars represents an important step forward for public health.’

The entire report does indeed stretch to a bazillion pages, or close enough at 571 pages. I presume that’s why Kendrick hasn’t read it, and therefore goes on to substantially misrepresent what it says.

To say that “cholesterol is healthy” is misleading because while dietary cholesterol has been de-emphasised, the DAG has not concluded that cholesterol in the blood is unproblematic – contrary to what Noakes’ journalist has reported.

To say that saturated fat will be “de-emphasised” is literally false, as that line comes from the Academy of Nutrition and Dietetics, who (this press release is even pasted in Kendrick’s post) say that they support “the DGAC in its decision to drop dietary cholesterol from the nutrients of concern list and recommends it deemphasize saturated fat from nutrients of concern” (my emphasis).

So, the Academy of Nutrition and Dietetics say to DGAC “good work, but you could do better” (on their model, of course). But the report does not say what Kendrick says it does, and the US Guidelines will continue to warn against overconsumption of saturated fat. If you read it, or even do a simply word-search for “saturated”, you’d know that, because you’d read that they recommend “less than 10 percent of total calories from saturated fat per day”.

I didn’t read up on the sodium commentary, and agree that added sugars are problematic (while not being addictive), so will say nothing about those last two bullet points, except to quote the report in saying “the DGAC also found that two nutrients—sodium and saturated fat—are overconsumed by the U.S. population relative to the Tolerable Upper Intake Level set by the IOM or other maximal standard and that the overconsumption poses health risks.” Go figure.

But before wrapping up by giving you a few quotes from the DGAC report’s conclusions, I’d like to note the double-standards at play in endorsing the Academy of Nutrition and Dietetics’ comment to the report, as Kendrick does and Noakes would likely do also, seeing as he’s explicitly told us that saturated fat is not a concern.

When the Association for Dietetics in South Africa (ADSA) decided to report Noakes to the Health Professions Council for “unprofessional conduct”, he and his supporters had a field day on Twitter looking at ADSA’s list of sponsors, and then dismissing ADSA’s case on the grounds that they had had financial dealings with Kelloggs and other (allegedly) evil corporations.

Why is the same standard not applied to the Academy of Nutrition and Dietetics, who have been the subject of a Senate enquiry thanks to their pharmaceutical connections, and who have a list of sponsors and funders a mile long, including Sarah Lee (makers of evil carb products!), Coca Cola (so very evil!) and evil Monsanto (the Great Satan!).

It can’t simply be because they say the right things, can it? Because that’s not how science works, as the Doctor and Professor surely know.

Lastly, seeing as the Noakes’ echo chamber on Twitter is in full swing with “see, he’s vindicated!” types of comments following the release of the DAG report, I’ll leave you with this quote from it. Make up your own minds as to whether it supports Banting, or whether it’s largely the same advice as ever.

The dietary patterns associated with beneficial outcomes for cardiovascular disease:

Dietary patterns characterized by higher consumption of vegetables, fruits, whole grains, low-fat dairy, and seafood, and lower consumption of red and processed meat, and lower intakes of refined grains, and sugar-sweetened foods and beverages relative to less healthy patterns; regular consumption of nuts and legumes; moderate consumption of alcohol; lower in saturated fat, cholesterol, and sodium and richer in fiber, potassium, and unsaturated fats.

The dietary patterns associated with beneficial outcomes for obesity:

Dietary patterns that are higher in vegetables, fruits, and whole grains; include seafood and legumes; are moderate in dairy products (particularly low and non-fat dairy) and alcohol; lower in meats (including red and processed meats), and low in sugar-sweetened foods and beverages, and refined grains; higher intakes of unsaturated fats and lower intakes of saturated fats, cholesterol, and sodium.

Dietary patterns in childhood or adolescence that are higher in energy-dense and low-fiber foods, such as sweets, refined grains, and processed meats, as well as sugar-sweetened beverages, whole milk, fried potatoes, certain fats and oils, and fast foods are associated with an increased risk.

(But the diet’s not for everyone, only for the insulin resistant!) The dietary patterns associated with beneficial outcomes for Type 2 diabetes:

Dietary patterns higher in vegetables, fruits, and whole grains and lower in red and processed meats, high-fat dairy products, refined grains, and sweets/sugar-sweetened beverages.

 

Flu vaccines might be ineffective, so try… water (otherwise known as Oscillococcinum)?

A friend forwarded a press release issued by “LeBron Health” to me, and the quackery it contains is too delightful to keep to myself. But because the press release also trades on fear-mongering of a rather pathetic sort, it’s also an reminder of how uninformed or unethical some medical “professionals” are, and of how quackery can harm in scaring people away from effective treatment.

The press release discusses the upcoming flu season in South Africa, and in particular, how to cope with the H3N2 strain of influenza. The H3N2 strain of influenza is indeed deadly, having reportedly killed dozens of children during the most recent US winter. That’s not good, of course – we’d like the number of deaths to either be 0, or much closer to 0 than that.

However, the number of deaths and hospitalisations this winter have not been significantly out of the normal range – the flu is not killing more people than it typically does. Furthermore, it’s also quite routine for the CDC to “issue a health warning to doctors”, as they are reported by the press release to have done. A “health warning” is not an advisory broadcast regarding an impending apocalypse, but (typically) simply information that the CDC thinks practitioners might find useful.

The health warning itself also reports something quite mundane on an aggregate level (though of course not mundane at all if you’re someone who has had flu-related illness or death in the family). It simply says that the current vaccine can’t compete effectively against H3N2, and that everyone should be prepared for a bad flu season.

This is also routine – vaccine developers select flu strains in January to May (for the US), based on which strains they predict will be most prevalent, and vaccination then begins in October. Things can change between those two phases – they are 5 months or more apart, after all – and one of the things that can change is the seriousness with which you could have (with perfect hindsight) regarded the threat of a particular influenza strain.

But you can’t know, 6 months in advance, and so you make the most informed predictions you can. Some years, the vaccine works very well, because you picked the right strains, and other years it works far less well.

And here’s the frustrating thing: in December last year (when the flu season hit the USA), the same scaremongering was prevalent. We read that the CDC had “admitted” that the vaccine doesn’t work, just as in this local press release’s headline, which claims that “flu vaccines may not work”.

Well, the CDC admitted nothing of the sort, and the flu vaccine “works” just fine, within the parameters of how it normally works, where the reasonable standard is never “perfectly”.

Even though this might be a particularly bad year for the vaccine’s efficacy, it’s still going to be better at helping you to avoid influenza than certain other “remedies” would be. It will help more than prayer, it will help more than avoiding cellphone towers, and it will certainly help more than homeopathy (with the caveat that hydration is good, so homeopathy in extreme quantities might help a little bit, because water).

Homeopaths disagree, as you might expect them to. One of those homeopaths is Dr Erika Coertzen, who suggests that we take a “reputable medicine such as Oscillococcinum, the most popular homeopathic product for flu symptoms in France”.

homeopath
This box contains as much medicine as a microscopic box of Oscillococcinum does.

That quote tells us that Dr Coertzen and my understanding of what the word “reputable” means is as orthogonal as our understanding of the word “medicine”. We can also note that a “medicine’s” popularity is only relevant to sales, profit, and analysis of marketing and gullibility – it tells us nothing about efficacy.

As with all homeopathic “remedies”, there is no good clinical data to support the claims made in favour of Oscillococcinum as treatment for influenza. It’s not going to help you to “rebalance and heal”, and even if it is true (no citation is given for this claim) that a “majority of patients who take Oscillococcinum at the onset of flu-like symptoms show improvement or resolution of symptoms after reduced time”, if this is in comparison to patients who take nothing, then the placebo effect is a perfectly good explanation for this observation.

But I suspect that the data is more… what’s the technical term?… made up than that, or that it at the least involves some fairly extravagant inferences being made from a poor data set. Dr Coertzen says that patients “symptoms show improvement or resolution of symptoms after reduced time” – if this is true, the data should support this claim. Unfortunately, they don’t.

As assessed by the Cochrane Collaboration, where trials do show favourable results for Oscillococcinum, “the overall standard of research reporting was poor, and thus many aspects of the trials’ methods and results were at unclear risk of bias. We therefore judged the evidence overall as low quality, preventing clear conclusions from being made about Oscillococcinum® in the prevention or treatment of flu and flu‐like illness.”

Amusingly, the Oscillo.com website – of course not a neutral scientific arbiter – claims that “unlike other flu medicines, Oscillococcinum does not cause drowsiness or interact with other medications”. Given that Oscillococcinum is a homeopathic “remedy”, therefore containing nothing that might cause drowsiness or negative interactions, this claim only gains traction if you’re able to persuade people that homeopathy is at all respectable or efficacious – surely nothing that any “reputable” healthcare practitioner would do?

In her defence, Dr Coertzen isn’t ever quoted as directly suggesting that you not take real medicine also, which might be the only thing that prevents the Health Professions Council (HPCSA) Medicines Control Council (MCC) from chastising her for this batshittery.

However, if she is the “medical expert” quoted in the headline, telling the public that vaccines might not work and that they should consider alternatives does seem to be a direct encouragement to forsake medicine in favour of homeopathy, and I do hope that a complaint is laid so that the MCC HPCSA can then rule against this idiocy.

Briefly, on Oscillococcinum itself, you’d be amused to read up on it, as the story of its origins and composition is quite the catalogue of pseudoscience in action. While there might be nothing that trumps Scientology for batshittery, Oscillococcinum gives it a damn good try…

 

PRESS RELEASE (source)

Flu vaccines may not work, consider alternatives — medical expert

Global health authorities have cautioned that current flu vaccines may not prevent a severe new strain of influenza, highlighting the need to seek alternative ways to protect against falling ill this winter.

The US Centers for Disease Control and Prevention (CDC) issued a health warning to doctors during the northern hemisphere winter about the severity of the 2015 flu season. It said the current flu vaccination protects against three or four strains but is not a match for the dangerous H3N2 strain which has mutated and has contributed to more deaths and hospitalisations of children and the elderly. (See: http://www.health24.com/Medical/Flu/Preventing-flu/Flu-vaccine-missing-its-mark-20150112)

Nearly 30 children died in one of the worst flu outbreaks in the US over their winter. In SA, a new modified vaccine is now available to match two of three new strains, including H3N2. However flu can still be contracted if other strains are not covered by the vaccine (See: http://www.health24.com/Lifestyle/Winter-Wellness/South-Africans-warned-of-severe-flu-strains-20150420).

SA doctor and homeopath, Dr Erika Coertzen, suggests boosting the immune system naturally by following a healthy, nutritious and balanced diet, getting enough sleep, regular exercise and taking preventative natural or homeopathic medicines to counter the onset of flu symptoms.

“A reputable medicine such as Oscillococcinum, the most popular homeopathic product for flu symptoms in France, has shown to help alleviate flu symptoms such as body aches, pains, chills and fever without drowsiness or the worry of negative interaction with other medication. Oscillococcinum works with the body to help rebalance and heal, and is suitable for all ages. Oscillococcinum’s efficacy in reducing the severity and duration of flu-like symptoms is well-known. A majority of patients who take Oscillococcinum at the onset of flu-like symptoms show improvement or resolution of symptoms after reduced time” she said.

For product info visit http://www.lebron.co.za/, www.oscillo.com or call 021-403-6390.

Assisted dying: not only God can decide – in fact, She can’t decide at all

It’s doubtful that you’d be able to find any medical school that still uses early translations of the Hippocratic oath, never mind the original Greek version. But if you read the unrevised English version, it would open with something like this:

I swear by Apollo the physician, and Asclepius, and Hygieia and Panacea and all the gods and goddesses as my witnesses, that, according to my ability and judgement, I will keep this Oath and this contract.

It will furthermore ask that physicians comport themselves in a “Godly manner”, and do so without “seeking reward”. The point, in short, is that it’s nothing like the modern understanding of the oath, where that understanding is typically summarised in the phrase “first do no harm”.

This, in turn, means that when you appeal to the Hippocratic Oath to justify (or to rule out) some course of action, you’re already appealing to an interpretation of that Oath – and you’ve already admitted that the Oath is therefore a guiding principle, rather than an absolute rule.

Which, in the context of a discussion about euthanasia, means that we are able to discuss further interpretations of that principle, including the question of whether more harm might be caused by keeping someone alive if they are in pain versus allowing them to die – or even hastening their death.

We are not obliged, in short, to think that a life ending is automatically and always a harm that trumps any other possible harm.

6f1216d4022843899161cdba9aeee7f0Not only because interpreting the oath as offering guiding principles rather than absolute rules allows for “avoiding harm” to (on balance) mean “cessation of life”, but also because physicians already don’t follow the oath to the letter anyway. I don’t know about you, but if I heard my surgeon swearing to Apollo, I’d try to find a new one before the anaesthetic kicked in.

Which brings me to Health Minister Aaron Motsoaledi, who seems to think Apollo is still relevant to modern medicine. Well, he talks about “God”, so it’s difficult to be sure that he’s talking about Apollo, but whichever God he means, he seems convinced of the fact that it’s God who gets to decide when you die. As quoted in the link above, he says:

“Doctors are human and make mistakes too. They can say a person has a few weeks left to live, based on medical observation, but only God can decide when a person dies,” Motsoaledi said.

He said as much as doctors played an important role in bringing life to this world, “they should not be given the right to end it because they did not create it in the first place”.

“When doctors begin their career, they take the Hippocratic Oath and pledge to do all they can to preserve life and not do anything that will intentionally harm or result in the death of a patient. Nowhere in the medical curriculum were doctors taught to kill,” he said.

This is all in response to the ruling on Robin Stransham-Ford, last week, in which Stransham-Ford was granted permission to seek assistance in dying, and the Judge furthermore ruled that the physician who so assisted him would not be prosecuted. Motsoaledi intends to make sure this does not set a precedent, for the reasons summarised in the quotes above.

Minister Motsoaledi has, on the whole, been a very competent, and even often an excellent, Health Minister. On this matter, however, he’s letting us down. Here’s why:

  • South Africa is a secular country. While the Health Minister can believe in whatever god(s) he likes, he has a responsibility to make laws that allow for secular justifications. When he speaks as Minister, he should not be suggesting that a certain policy should be motivated by anything to do with what a god might hypothetically want or not want.
  • He’s arguably wrong on the facts, and is relying on an uninformed gut feel rather than the evidence regarding the consequences of assisted dying being legal. He claims that we’ll soon see “families colluding with doctors to end the life of their loved ones because they wanted to cash in on insurance policies”, but as far as we can tell from the Netherlands and Belgium, you can eliminate much of this risk through devising legal safeguards for when assisted suicide is permitted and when not.
  • To that, he might say that safeguards are not enough – that risking even one death for this sort of profit motive is one death too many. And here is where our interpretations of “harm” are directly relevant – physicians are always or at least very often making decisions about treatment that might cause harm, but on balance are thought to stand the best chance of avoiding harm. Ending a life is one option in a range of interventions, for the purpose of serving that same goal.
  • And, ending a life can only be treated as uniquely forbidden as a form of “treatment” if we hold the view that life is somehow “sacred”, which we cannot do in a secular country.

As for the “playing God” sort of argument, Minister, it’s entirely spurious. We all play God when we walk across a street wearing our spectacles, because without them, the bus that God hypothetically sent to run us over would have succeeded in its mission. We play God when we take antibiotics, or when we fly to foreign countries in devices we’ve invented and constructed for that purpose.

With assisted dying, we get the chance to play God in a way that She doesn’t seem that interested in, and we should seize the chance to do so. In this case, we can – and should – play God through alleviating the pain of someone who is dying, and who wants their life to end.

It is to God’s discredit if she doesn’t want to permit or condone this course of action. And it is to our discredit also, if we instead choose to rely on self-serving interpretations of a centuries-old Oath, to evade the moral responsibility of eliminating suffering wherever we can.

Roundup – 2015 LCHF Summit #OMHealth #LCHF2015

In news that came as a surprise to some us who are here, myself included (thanks to the generosity of the organiser, Karen Thomson), critics of Noakes and the low carbohydrate, high fat diet are apparently “boycotting” the Old Mutual Health Convention, that wraps up today.

The convention took place over 4 days – the first 3 operating as a professional event, with healthcare practitioners earning continuing professional development (CPD) points for attending, and the last day defined as a public event.

Standards in science journalism – #LCHF, #Banting and @BiznewsCOM

If you only get your news from people and places that agree with your pre-existing view, then you are living in a filter-bubble. This is not a good thing, as it means that you’re (relatively) impervious to discovering any errors in your beliefs, while simultaneously getting constant affirmation that you’re “right”.

That’s true for individuals as consumers of news, but also presents an opportunity for producers of news to reflect on their responsibilities. If you purport to be an objective – or at least balanced, seeing as objectivity is impossible – purveyor of news, then you need to take care to publish fair representations of the current state of knowledge.

One South African site that constantly abrogates its responsibility to present a balanced view is Biznews.com, and the headlong rush towards partisan propaganda is led by Marika Sboros, who seems to have taken on the position of journalistic praise-singer for the low-carb, high-fat diet, and for Professor Tim Noakes in particular.

To be clear, I don’t have a problem with self-confessed fans – rather than people who present themselves as journalists – doing praise-singing. Whether they are right or wrong about the facts, individuals have no responsibility to be fair with regard to the totality of evidence, and/or how it’s interpreted, on their personal websites or Twitter feeds.

This doesn’t mean I’d encourage that sort of epistemic irresponsibility, in the least. As I say, they have no responsibility to us to be fair – I’d say that have that responsibility to themselves, but that’s not what’s at issue here. In this case, we’re talking about a news website that isn’t set up as a promotional vehicle for LCHF, and a “journalist” who presents herself as objective.

Sboros’ most recent piece of misrepresentation arises as a result of the USA’s Dietary Guidelines Advisory Committee announcing that they are set to reverse their cautionary stance on dietary cholesterol (so, the cautions against the cholesterol content of food, rather than the cholesterol content of your blood).

A second piece of new research is also described in the link above, namely a meta-analysis by Harcombe et. al. arguing that the dietary fat guidelines in 1977 and 1983 (cautioning against fat) were never justified by evidence from randomised controlled trials (RCTs).

The piece begins with nonsense, where Sboros’ italicised introductory text includes “In 2013, Sweden became the first country to ditch low-fat dietary guidelines, restoring cholesterol in eggs and bacon to its former glory”. That’s literally false, in that a Swedish advisory body, rather than “Sweden”, made certain recommendations. Second, that’s a gross misrepresentation of the recommendations they made, as even the advisory body themselves have noted.

Let’s take them one at a time, starting with the case of the USA. First, the headline Sboros chooses is “Science says Tim Noakes is right on cholesterol”. “Science” is rarely, if ever, dogmatic – pseudoscience is. Science – meaning what the totality of evidence suggests – points in one direction or another, and sometimes by very fine margins.

What I mean is, evidence in support of one particular point of view (Noakes’, for example) tips the scales in favour of their point of view, rather than “proving someone right”. And in this case, the misrepresentation is particularly bad, in that the only support for Noakes in these guidelines is for one leg of his argument, namely that cholesterol consumed has little impact on cholesterol in the blood.

As the Washington Post write-up makes clear,

The greater danger in this regard, these experts believe, lies not in products such as eggs, shrimp or lobster, which are high in cholesterol, but in too many servings of foods heavy with saturated fats, such as fatty meats, whole milk, and butter.

The new view on cholesterol in food does not reverse warnings about high levels of “bad” cholesterol in the blood, which have been linked to heart disease. Moreover, some experts warned that people with particular health problems, such as diabetes, should continue to avoid cholesterol-rich diets.

So, we see continued warnings about saturated fat, and continued warnings about blood cholesterol. Noakes says that saturated fat is fine, and that statins (to lower blood cholesterol) are bad, even toxic – he even uses the perjorative “statinators” for those who prescribe or recommend them. In other words, two key pegs of the Noakes argument are directly contradicted by this research.

Sboros, meanwhile, Tweeted a link to that same Washington Post piece, saying:

Well – if those doctors or dietitians actually read the linked piece, you’d imagine that they would carry on prescribing the statins, seeing as nothing in it recommends that they stop doing so.

Another interesting thing to note is that these guidelines seem to have been developed with the support of the Egg Nutrition Center and American Egg Board. Now, I don’t think that this automatically taints the research – as I’ve said before, “the fact that something is funded by a pharmaceutical company doesn’t guarantee bias. There’s a difference between being cognisant of potential biases, and writing something off in advance, just because of whence it came.”

I note it just to make the point that Sboros, Noakes and other LCHF supporters constantly use alleged taint via funding to dismiss research they don’t like – but then somehow seem to forget that principle when the research says things that they happen to agree with. For example:

Before moving on, read especially that second link for a contrasting view on what the revised guidelines mean, and on how they should be interpreted according to the holistic framework of knowledge related to diet. My concern here is about misrepresentation, rather than the science itself.

On the second issue (the Harcombe study), a key thing to note is that, as ever in the case of this “journalist”, only one view is being presented. The Harcombe study has already been subjected to a fair amount of criticism, some of which seems rather compelling. You might fall on either end of the contrasting views, or somewhere in the middle, but a piece of journalism, rather than praise-singing, would include relevant and plausible dissenting views at the same time.

To conclude, another recent Sboros post is worth highlighting, titled “Are you a vaccine zombie? Risks versus benefits of jabs debate goes on“. The piece expresses anti-vaccine fears, primarily the standard one amongst cranks, namely the risk of autism. The debate does not “go on”, except to the extent that those who hold fringe views pretend that it does – the scientific consensus on vaccines is clear, and long-settled.

This post embeds a video from (quoting Sboros) “one of my favourite sources of health information: Mike Adams, AKA the Health Ranger”. Mike Adams is the man behind “Natural News”, the site that argues that Microsoft are developing eugenics vaccines. And that HIV doesn’t cause Aids. It also publishes David Icke, the man who thinks the world is controlled by reptiles from outer space, who live in underground tunnels and take on human form.

This is a health journalist’s favourite source of health information?

To quote Ben Goldacre, speaking of Zoe Harcombe but with words that might apply equally well here, “you may disagree, but in a busy world, I’m not sure I see the point of a Zoe Harcombe”.

Noakes, #LCHF and the Professoriate of the Twitterati

LCHF SummitIn the conclusion of my previous post on Prof. Noakes’ Big Issue column, I mentioned that he had spoken of addressing the malignant influence of scientists via the power of crowdsourcing research findings on Twitter.

Today, I’ll conclude with my description of how much that Big Issue column gets wrong, and also provide a fresh example of shoddy thinking from the LCHF crowd, in the form of a debate topic that is being proposed for the upcoming “First International Low Carb High Fat Summit“.

(I don’t think it’s relevant here, but in case you think it is, I’ve been invited – and have accepted – to attend the LCHF summit as a guest of the organiser, Karen Thomson. So if you see me becoming all soft on LCHF in late February, you’ll know that I’ve either been bought off, lost my senses, or “seen the light”.)

Let’s first return to “The Digital Doctor” (the title of the Noakes column). One of the things he’s right about in the column is that increased availability of information via the Internet has undoubtedly given consumers and patients more power.

You’re able to shop around, whether through using Dr. Google to find out what your fellow sufferers have tried, or for crowdsourcing information about who seems to do good work in a certain area, for what price and so forth.

Patients can enter the consulting room armed with some understanding of what ails them, and I’m sure that can help (and also sometimes hinder, no doubt) the process of diagnosis and treatment. We’re no longer victims of as large an information asymmetry as we once were.

But this doesn’t mean that truth becomes something that is resolved via democratic process. The majority can be wrong, and this is especially the case when we’re dealing with a majority drawn from a select population, and where the audience does further filtering of what they think worth listening to and what worth ignoring.

In short, this is again the problem of the filter bubble, writ large.

To quote Noakes:

But the growth of social media and the internet has changed that reality irrevocably.

Today as a result of these very modern developments, patients now have access to the experiences of hundreds of millions of others producing what has been termed The Wisdom of the Crowds.

Exposing millions of people with common issues to a multitude of different interventions soon determines the relative efficacy of treatments more effectively, cheaply and swiftly than any other testing method yet invented. (Indeed, these crowd-based, uncontrolled experiments will add a new model of “scientific” research that will overcome the weakness of traditional laboratory-based research, which by its very nature is “unnatural”.)

We have access to the millions of anecdotes shared by the population that self-selects to be on Twitter, yes. But we have no way of verifying the (literal) truth of those anecdotes, and we also know that because they are uncontrolled experiments, there is no way of verifying their truth in the sense of having confidence that the right cause for the observed effect has been identified at all.

This is precisely why we have and value the scientific method: to rigorously test hypotheses, in a way that minimises errors that might result from selection bias and so forth. We’d should take care to compensate for – and not celebrate – the fact that all of our case reports come from a demographic (because they are on Twitter) that was perhaps on average wealthier, and with more leisure time, than the typical person.

Why? Because that characteristic might be associated with different dietary choices, or different levels of physical activity, both of which would be relevant to how we interpret the data. So the anecdotes can be useful, in pointing to what we should research, but they are not themselves the research we should treat as conclusive.

(Sidebar before moving to the next quote: I’m leaving the “unnatural” towards the end of that quote alone, but just to briefly note that it’s another example of the paranoid and conspiratorial talk Noakes seems partial to. Sure, lab-based research has flaws, but its lack of being “natural” – whatever that might mean – isn’t one of them.

One can say we can’t replicate some real experiences and effects in a lab, and there it becomes a potential problem, but describing this in terms of “natural” sets up an advantage for the Romantic Paleo argument, and poisons the well against anything positioned as non-natural, which might include GMOs, vaccines, etc.)

Then, we’d want to compensate for our own biases also. Later on in the column, Noakes says:

I soon learnt that Twitter is unquestionably the best way to acquire the most up-to-date information on my particular areas of scientific interest. By following a group of scientists who use Twitter to disseminate information they find interesting, I now have access to new knowledge within minutes of its first appearance in the scientific literature. The result is that acquiring new information is absolutely effortless, and dependent only on my choice of whom I follow on Twitter.

So, if I listen to the people who tell me things I like to hear, I get to hear a lot of things I like to hear. And, just to make certain that things I don’t want to hear don’t intrude on this, I’ll block people who post contrary research from my Twitter feed (he doesn’t say the latter above, but it is something he does, with me being one example of someone whose links to relevant research don’t get through).

The problem with the Big Issue article is that it takes a couple of sound points, and explodes them into such a grand narrative that they lose any sense they had.

Noakes tells us that “now it is only the advice that works that has long-term credibility”, and that is true, up to a point. You’ll get caught out on social media if you spread misinformation. But that doesn’t mean information gains credibility through being widely disseminated (on channels you’ve hand-picked) on social media. Those are separate issues.

It’s also true that professionals – in various spheres – were able to exploit the ignorance of the consumer to peddle quackery or defective goods, and that they are now less able to do so than in the past. But our easier access to information doesn’t mean that (proper) experts don’t often know better than we do. Those are also separate issues.

There’s a tendency in the LCHF narrative, at least how it’s playing out in South Africa, to continually hyperbolise the consequences of choice, and the lack of middle-ground options between one or another extreme.

To conclude, here’s a recent example of that elimination of the middle-ground (in logical terms, a false dichotomy), that comes from the Facebook page of the LCHF summit I spoke of at the top of this post. On that page, Karen Thomson says:

I am desperately trying to find medical professionals willing to debate: ‘Is the low carbohydrate diet the cause of, or the cure for the global epidemic of chronic ill-health?’ with our LCHF team.

Any thoughts? None of my invitations have been met with any success.

Here’s a thought: if a debate topic is framed so that only the pro-LCHF side have any chance of winning it, you’re unlikely to garner any interest from potential opposing speakers. The topic is itself a pithy example of the shoddy reasoning that I’ve written about so often here, in that:

  • The topic sets up a false dichotomy, because the truth might lie somewhere in the middle with LCHF being neither the cure nor the cause.
  • Second, the topic sets the non-LCHF people up for failure, in that it would be impossible to prove that LCHF is the cause of “the global epidemic of ill health”. This is true even on the simple grounds of chronology, where (leaving aside the contentious issue of what pre-social humans ate) modern humans haven’t been eating LCHF for long enough – or in large enough numbers – for LCHF to be identified as the cause of much at all except book sales, never mind a “global epidemic”. You might therefore think the topic indicates bad faith, but even if you don’t want to be uncharitable, the pro-LCHF folks have rigged the game here, by ensuring that they can amass at least some evidence for their position, while the opposition cannot.
  • Third, one can challenge the presumption of the topic that there is a “global epidemic” at all, in that despite diabetes, heart disease and the like, we somehow keep living for longer. So, simply accepting the premise of an epidemic accedes to one of the key claims made by the LCHF folk, namely that humans in the 21st Century are (in general) sick and dying, despite any appearances to the contrary.

 

Professor Noakes and the Echo Chamber Made of Lard

The 2014 “Collector’s Edition” of The Big Issue contains a number of interesting pieces, but there’s one specific piece that I’ve been looking forward to being able to share with you.

The day for doing so has finally arrived, so here is the first instalment of some thoughts on “The Digital Doctor”, contributed by Prof. Tim Noakes, and freshly uploaded to the Interwebs (thanks to @BigIssueSA on Twitter).

As a framing concept for this post, consider the “echo chamber“, which you can understand as roughly analogous to, or intersecting with, confirmation bias and the “filter bubble“.

Participants in online communities may find their own opinions constantly echoed back to them, which reinforces their individual belief systems. This can create significant barriers to critical discourse within an online medium.

Another emerging term for this echoing and homogenizing effect on the Internet within social communities is cultural tribalism.

What the extract highlights is the problem of “groupthink”: if you surround yourself with people who say the sorts of things that agree with the sorts of things you’d like to believe are true, you all end up reinforcing each others’ beliefs, and opposing views have a difficult time getting heard.

So, it seems fairly obvious – given we know that we’re prone to weighting confirmatory evidence more favourably than disconfirmatory evidence – that someone who cares about keeping their mental furniture nearly arranged would actively seek out ways in which they might be wrong.

Supporters of Prof. Tim Noakes believes that he does exactly that, and that this is why he could famously change his mind on something so fundamental as the value of an entire category of organic compounds (carbohydrates, in case you aren’t aware).

But – and yes, I have said this before – one change of mind, no matter how fundamental or (in)famous, does not indicate anything about a general disposition, and it’s perfectly possible that Noakes (again, regardless of whether his conclusions are correct or not) has adopted (and is encouraging) sloppy thinking in this regard.

Which brings me back to The Big Issue, where it wouldn’t be unfair to describe Noakes’ contribution as a love-letter to confirmation bias, or an attempt to attract companions to occupy an echo chamber made entirely out of lard.

The piece begins with a rejection of expertise, where it turns out (according to Noakes) that an “exclusive clan who have climbed the academic ladder of success” “carefully programmed” Noakes and his fellow students to believe that what the clan professed is the “absolute truth, for now and forever”.

Alien_probeTo help this conspiracy narrative along, these evil people with their degrees and academic credentials are given the sneery nickname of “The Anointed”, which helps to set up the us vs. them dichotomy, where the everyday folk are victims of an intellectual aristocracy, preserving their privilege at our expense.

At this point, some of us are perhaps thinking about how odd it seems that one of the people who has climbed the academic ladder about as high as one can in South Africa thinks he should be trusted, despite his own membership of this shadowy clan.

But by definition, Noakes cannot be part of The Anointed, for he has seen the light, and rejects their gospel. Perhaps he might be part of the New Reformed Anointed or somesuch, because he makes it quite explicit that the outdated dogma he was taught is false, and should be replaced by something else.

The something else, though, is never expressed with qualifications, or room for being wrong – it’s presented as absolute truth. And this is the problem – replacing one dogma with more (albeit different) dogma doesn’t help the argument for being critical of received wisdom. It simply asks you to replace received wisdom with an alternative version of the same.

There’s a problem in this simplistic account of dogma also, in that it’s only unthinking consensus that’s a problem (what we normally call dogma) – consensus isn’t a problem of necessity. So, if “The Anointed” happen to be wrong in this instance, we shouldn’t use that as an excuse for discarding the idea of expertise in general.

Experts do exist, and “common wisdom” is frequently very far from wise. Yes, “experts” can also be wrong – but as ever, we can assess arguments on their merits, rather than throw the epistemic baby of expertise out with the bathwater of a few bad arguments.

Then – crucially – we’re dealing with a complete misrepresentation of what “The Anointed” say. On the Noakes narrative, dieticians and these sneaky academic folk are pushing the line that fats are bad, and carbs at least not as bad as Noakes would have you believe (some might even say that some carbs can be good).

However, the truth doesn’t support these caricatures. It’s (now) common cause that we used to over-emphasise the dangers of fats in general. It’s (now) common cause that refined carbs are bad.

The point is that “The Anointed” have modified their position over the years, in light of the evidence. Noakes might say that they haven’t modified their position enough, or that they are ignoring some evidence or over-valuing other evidence.

But either way, they are not dogmatically pushing one line. Their arguments have evolved (whether rightly or wrong, time will tell), and it’s untrue and uncharitable to present them as inflexible purveyors of eternal “truths”.

There’s only one dogmatic voice in this conversation, and as far as I can tell, it’s not that of The Anointed.

P.S. Noakes’ solution to the problem of The Anointed is to rely on The Wisdom of the Crowds, and especially Twitter, which is “unquestionably the best way to acquire the most up-to-date information on my particular areas of scientific interest” (this is no joke. Well, I mean it’s an accurate quote.) But more on that another day.

Is Noakes the North Korea of epistemology?

On November 25, I gave a talk with the above title at an event hosted by SAAFoST* and ADSA**. Unfortunately, the proceedings weren’t recorded, so you won’t be able to hear the superb presentation that preceded mine, by Dr. Celeste Naude, who focused on an evidence-based approach for differentiating between varying macronutrient-focused diets.

Those of you who are interested in the topic of diets, and specifically the role Prof. Noakes has played in popularising the LCHF approach to diet, might already know of the recent study by Naude and others, which found that low carb diets showed a similar reduction in weight to other diets. Noakes’ response to that study was to say that the “researchers have no clue”. I leave it to you to determine who you find more persuasive.

You won’t be able to watch my talk as presented either, but in case it’s of interest, I decided to record a version of it in any case, accompanied by the slides I showed on the day. By contrast to Dr. Naude, who focused on science, I focused on rhetoric, hyperbole, and sound scientific reasoning – or, the lack of it.

You can find that recording immediately below, followed by the approximate text of the presentation. It hasn’t been edited into essay form, so is telegraphic in places. Lastly, I’ve embedded the presentation slides at the end, for no particular reason.

*SAAFost: the South African Association of Food Science and Technology

**ADSA: the Association for Dietetics in South Africa

Is Noakes the North Korea of epistemology?

Betteridge’s Law – any headline that ends with a question mark can be answered with “no”.

Of course, “no” is part of the answer here – if we are asking the question of whether Prof Noakes is a propagandist who leads a repressive state, and is implicated in various human rights abuses, the answer is clearly no.

I’m also make no claims with regard to their relative levels of sincerity. In the case of Prof. Noakes, I’m of the view that he is utterly sincere, and desires nothing but to enhance the health and wellbeing of those he engages with. He’s received far too much abuse related to claims regarding a profit motive, for example, and I think that sort of abuse unjustified, and deplorable.

But that’s not what my title is alluding to. Instead, I’m highlighting the fact that the North Korean press machine has a habit of making hyperbolic claims, and Kim Jong Un for appearing in various baroque, grandiose, and sometimes merely perplexing situations, all to buttress his mystique and support a particular narrative.

This narrative is of him being misunderstood, a maverick, and a person who has privileged access to knowledge and opportunity that he is able to share with the enlightened or anointed. He serves as an inspiration, and in doing so, the impression created is more important than the evidence – marketing is the point, rather than content.

This is the sense in which Noakes is the North Korea of epistemology. As I will show, he displays a pattern of what philosophers and psychologists call “motivated reasoning”, which can be defined as confirmation bias turned up to 11.

You all know what confirmation bias is, I’d imagine: our predisposition to take evidence that confirms what we believe seriously, while discounting contrary evidence. What motivated reasoning adds is a substructure or foundation to this, in which the agent develops background rationalisations to justify holding the beliefs that others argue are false, or at least not settled conclusively at this point.

The motivated reasoner might see conspiracy instead of disagreement, and tends to react defensively to contrary evidence, seeing conspiracy, or dismissing it out of hand for other reasons instead of responding to it on its merits.

I ignore what I consider not to be evidence” – Noakes.

The goal of my talk today is quite simple. I want to suggest to you that regardless of any debate on the virtues of the Banting diet – which I’m not interested in discussing, and haven’t expressed any public view on – there’s a language, method, and character that we should all value in scientists and scientific enquiry.

I believe that any of us who work in fields including science, education, or journalism have a responsibility to encourage a responsible epistemic approach, rather than to aim for persuasion above all else.

By this I mean an approach that is objective as regards the evidence, where we are willing to be wrong, and where we resist attacking the character or motives of opponents when arguments are the relevant issue.

Prof. Noakes has frequently set a bad example in these regards, and my concern as an educator – particularly one active in the field of critical reasoning – is that with 50 000 Twitter followers, and as an engaging and hard-working media personality who has garnered as many accolades as just about anyone you can think of in South African science, he has a powerful influence on how people perceive scientific activity.

One of the virtuous traits I mentioned a moment ago was a willingness to be wrong. Defenders of Noakes might immediately retort that of course he’s willing to be wrong – after all, he famously changed his mind on carbohydrates! And while this is a notable change of mind, it doesn’t (and shouldn’t) reassure anyone that it’s representative of a general disposition. As you’d know, it’s a single data point, and we don’t find a pattern in a single data point.

More to the point, perhaps, is that his own language regarding that change of mind comes with significant warning flags regarding his commitment to sound reasoning. Take this example:

At a public discussion with his erstwhile supervisor, Lionel Opie, in May 2014, Noakes told the audience “I’ve said one thing, and now I’m saying the exact opposite. And they can’t both be wrong. And that’s key.”

While a statement like that plays well to a crowd – and in this case, did result in some appreciative chuckles – it’s nonsense as far as logic is concerned.

He’s presenting his change of mind as evidence that he’s right now. And there are two immediate problems here – one is that the argument only gains traction if you agree with him that he was wrong before. If you think he was right then, then you’d think that he’s just strayed into error now.

The second way in which the logic is fundamentally flawed is that he’s suggesting that the audience embrace the logical fallacy of the false dilemma. What I mean is that the truth might actually be undiscovered, and exist somewhere in the middle – it’s not the case that one of the two extremes he’s suggested at various points have to be correct. We have other options, and he’s misrepresenting the choices available to us in leaving them out.

We should all – maybe A-rated scientists, teachers, and public figures in particular – have a concern for good scientific thinking and clear reasoning in expressing the conclusions we’d like to see adopted. Science does not work in absolute truths – it’s an inductive process, whereby we chisel away at falsehoods to arrive at a clearer understanding of what’s most likely to be true. The example above recommends absolutism, despite that being manifestly incompatible with the messy world of empirical data.

At various points in today’s talk, I’ll be showing you examples of statements like these, made by Prof Noakes on public media. There are many more such examples, but it would be tedious to belabor the point through repetition.

But I mention this to offset concerns you might have that I’m indulging in cherry-picking here – the pattern is unmistakeable in itself, and more to the point, many of the examples I’ll show you are examples of Noakes responding to critics accusing him of over-simplifying. In other words, even after applying the principle of charity and seeking clarification from him, his responses validate the concerns I’ll be highlighting.

A taxonomy of trouble

For ease of reference, I’ve loosely categorized the issues into 5 groups:

  • Indiscriminate use of sources
  • Ad hominem & double-standards
  • Exaggeration and immunity to error
  • Salesmanship over science
  • Errors in scientific reasoning

INDISCRIMINATE USE OF SOURCES

Chemicals that may cause diabetes – Noakes links to Natural News.

This is the site that argues that Microsoft are developing eugenics vaccines. And that HIV doesn’t cause Aids. And Icke? The world is controlled by reptiles from outer space, who live in underground tunnels and take on human form (Thatcher, Bush)

Next they say it has been discovered before. Lastly they say they always believed it. Louis Agassiz.” – Noakes links to evolution-denier.

This from a series of tweets explaining how his conclusions will be vindicated in the end. But if you’re going to suggest that there are better and worse ways of proceeding in science, perhaps better examples than Agassiz could be chosen. He is, after all, an evolution-denier, and a proponent of scientific racism – does one want to cite him as an authority on the scientific method?

“@natachab Weston Price http://amzn.to/15c8xRz believed superior nutrition of trad societies protected against TB. Need LCHF HIV/TB trial” – and to a “holistic dentist”.

Weston Price – “holistic dentist” whose treatments included homeopathy. The site carries numerous articles arguing that vaccines cause autism. Current board member Joseph Mercola has received at least three FDA warnings for making misleading and/or unsubstantiated claims regarding the products he sells.

AD HOMINEM & DOUBLE STANDARDS

Starting on a sound note…
. @katjanechild Only you know what motivates you, Katherine. My advice: Play the ball, not the man and you will go far.”

Obese dietician from British Dietetics Assoc tells us on BBC News that @DrAseemMalhotra article is wrong. Will believe her when she loses wt

I do not understand why you pay any attention to Dr Witt, who has absolutely no qualifications in this field and is a few years out of medical school.”

On Anthony Dalby, a more recent critic: “Noakes said the doctor who said that happened to weigh 120kg.”

.@Fatworks @Briganto @livinlowcarbman @youmustbenuts That happens when the truth is not on your side. Yet to meet an obnoxious LCHF advocate

Prescription? A mirror.

OVERSTATING THE CASE/IMMUNITY TO ERROR

If you don’t eat carbohydrates, you don’t have to worry about cancer” – @ProfTimNoakes . Moerse gevaarlike stelling!!!

Noakes responds: “@RugbyPrinses Where and when did I say that? Or did someone else say I said that?Do you honestly think I would make such absolute statement?

Franschhoek: “If you’re insulin resistant, you do not have to get any disease whatsoever. If you eat a high-fat diet all your life, you will not develop diabetes, you will not get cancer, you will not get dementia. That I can guarantee you” – that’s where, and when (audio).

“Sweden becomes first nation to reject high fat dogma!” Noakes was making this claim in 2013, when the SBU report wasn’t even available in English, RT’ing AuthorityNutrition & Diet Doctor.

The authors of the (independent) body eventually had to step in and tell people to stop saying this. Report just on obesity, not necessarily generalisable, and:

Two mis-interpretations have, in our opinion occurred in the wake of the publication of the SBU report. One is that low carb high fat is by far better. Yes, during the first 6 months you lose weight faster on low carbohydrate diets. But after one and two years that diet has no advantage than other diets for obesity.

After having this pointed out to her, Teicholz blocks me and others. I couldn’t point it out to Noakes, because contrary voices also get blocked from being heard on his timeline. Contrary to what I think the ideal approach – of seeking out ways in which you could improve your arguments – motivated reasoning can involve simply shutting out dissent.

Then, addiction, where I fear that the LCHF movement is doing great harm to public understanding of the difference between compulsive and destructive behavior, and lifestyle choices which can be better or worse but are not intrinsically problematic.

From Real Meal Revolution:

The final blow to the gut: because carbohydrates are nutrient-deficient and often packaged with salt and sugar, you feel the need to eat more of them, thereby putting yourself into a near-perpetual cycle of weight gain.
Unless, of course, you break the addiction…

There’s plenty of “addiction” talk on his Twitter feed, as well as a partnership with Harmony Clinic in Hout Bay, that offers in and outpatient treatment for sugar addiction. Well, Harmony Clinic now liquidated, so perhaps not anymore.

The problem is – there’s no compelling evidence for sugar addiction, yet, and the case is being overstated in the service of promoting Banting.

What should we then say about so-called “addictive” foodstuffs? The first thing to remember is the point Paracelsus made in the 15th century – “the dose makes the poison”.

While there might be no safe number of cigarettes to smoke, there will be a dosage of carbohydrates, or sugar, that’s unproblematic in all but the most rare of cases.

Let’s look more closely at sugar addiction, and addiction in general. Two papers are typically cited as evidence for sugar being addictive. But what they mostly reveal is that science journalists no longer read or understand the journals, and that the public – and some professionals – are far too trusting when it comes to the sensational headlines that convey elements of those studies to us.

First, the Avena study, published in Neuroscience & Biobehavioral Reviews in 2007:

“we suggest that sugar, as common as it is, nonetheless meets the criteria for a substance of abuse and may be “addictive” for some individuals when consumed in a “binge-like” manner.”

Pause there – who might be inclined to consume in a “binge-like” fashion? Perhaps someone with a pre-existing impulse control disorder, who happens to latch on to sugar – the reverse inference from the bingeing to the sugar might get the causal direction entirely back-to-front. We’ll get back to the neurochemistry later, but also, notice the scare-quotes – the author is hedging her bets, with the text only weakly supportive of any claim to sugar addiction.

One is perhaps reminded of a line from Lewis Carrol’s “Through the looking glass”, where Humpty Dumpty said: “When I use a word, it means just what I choose it to mean—neither more nor less.”

Then, there’s Johnson & Kenny’s paper in Nature Neuroscience (2010) on junk food and addiction, also conducted on rats.

“Notably, it is unclear whether deficits in rewards processing are constitutive and precede obesity, or whether excessive consumption of palatable food can drive reward dysfunction and thereby contribute to diet-induced obesity.”

As in the Avena study, we don’t know whether an impulse control disorder is simply being expressed – rather than discovered as an effect, resulting from the junk food – in this experiment.

Yes, if you grow to like something (or find it rewarding), you’ll seek it out. This does not mean the thing is innately addictive. In fact, Hebebrand’s recently published paper in Neuroscience & Biobehavioral Reviews concludes that if anything, “eating addiction” rather than “food addiction” best captures what’s going on when people compulsively over-eat. The food is an expression, not a cause of the impulse control disorder.

We can easily engage in a battle of link-sharing – but the point is that the truth is complex, and not settled by individual studies. In this case, there’s one clear issue with using these studies as definitive, and this is that both of these studies use brain imaging to support their conclusions.

As Sally Satel (who works as a psychiatrist in a methadone clinic) puts it, brain scanning is “a perfect storm of seduction”. The technology promises great revelations and great objectivity. More to the point of my presentation today, it offers the possibility of eliminating your responsibility for what’s wrong with you – we can say, “it wasn’t me, it was my brain!”

This image is interesting is that it neatly summarises why you can’t reach firm conclusions from fMRI data. This fish is in fact dead, yet the scanner showed signs of brain activity.

fMRI data are suggestive, and weakly so at that, in that they reflect neural correlates of various stimuli, and nothing of the perceived and subjective mental responses to those stimuli.

In slightly more detail: Increased blood flow and a boost in oxygen are treated as proxies for increased activation of neurons, and from there we induce to what those neurons are doing. We compare that data to a baseline, and subtract the one from the other, averaging out over the many data points of all participants in a study, with software filtering out background noise, and creating the seductive images.

But our experimental conditions are imperfect – think of the difficulties of creating appropriate baseline tests, for one – and large sample sizes cost a lot of money. Add to that the fact that our brains can process the same stimuli in different regions – no one specific area can reliably be said to perform the same task for all of us – and it should be clear that it’s far too soon to reach definitive conclusions from fMRI data.

The philosophical problem is one of reverse inference – we reason backward from neural activation to subjective experience. But if identified brain structures rarely perform single tasks, one-to-one mapping between activation in a region and a mental state is very speculative.

To avoid the false positive of the fish brain activity above, we need to use multiple comparison fMRI, which comes at far greater expense in terms of cost and time. But headlines don’t have space for subtleties, and furthermore, novel and exciting claims get the public’s attention. If your fMRI scans can be said to show that sugar is more addictive than cocaine, you’re guaranteed some prime media attention, and who can blame you for trying to capitalize on that? Well, perhaps nobody can blame you if you’re trying to sell newspapers. And perhaps we can blame you, or be rather concerned, if you’re presenting yourself as a responsible scientist.

We can’t tell – yet – whether fMRI scans indicate an impulse that is irresistible, or one that simply hasn’t been resisted. But it’s easier to make choices when you believe that there’s a choice to make, rather than a forced one, such that an “addiction” narrative might support. Diminished expectations of agency lead to diminished agency – if you’re not aware of your choices, it’s more difficult to make choices. So, it’s politically useful to say that carbs are addictive – but that isn’t equivalent to it being true.

But at least we have a following. The great failing in science is not to be wrong – it is to be irrelevant.” – Noakes

SALESMANSHIP OVER SCIENCE & SENSITIVITY

Robin Williams was a vegan.Vegetarians are twice as likely to suffer mental illness.Humans are designed to eat meat.” @ProfTimNoakes RT’ed, the day of Williams’ suicide.

Response when challenged:
“@theviscountess @HermanBeukes Was Mr Williams informed about association between meat-free diet and mental health? http://1.usa.gov/1t2janN”

Then when people point out how poor that paper is, he appeals to the association, even though when anyone cites associational data in favour of low fat, he rejects it.

Dr Bill Wilson wonders if the Carbohydrate Associated Reversible Brain (CARB) disorder played a role in Newtown tragedy http://bit.ly/URArgp”… Where a 20-year old fatally shot 20 kids, and gun control might be a more interesting conversation.

ERRORS IN SCIENTIFIC REASONING

What does the future hold for a pastry chef?
@PastryKeegan The public will decide. In era of social media, public will eventually discover what works for each, independent of “experts

Why are “experts” being trivialized here? Experts do exist, and the public are often misinformed. If experts disagree with you, then you defeat them in the battleground of expertise – peer reviewed journals. An army of laypeople doesn’t make the scientific case.

Why is journo Gary Taubes pushing for scientific studies into #LCHF diets (http://blogs.scientificamerican.com/cross-check/2014/10/07/gary-why-we-get-fat-taubes-speaks-out-on-diet-studies-including-his-own/ …) while @ProfTimNoakes focuses on populism?

“.@sarahemilywild Because change will only come when public understands truth expressed in @garytaubes book. New science will not change that”

“New science” will not change the truth? And again, a scientist calling for less science?

September 2014, Australia

So, I watched it. Here’s one rather interesting bit (the text below is copied from a previous post):

And you must never trust consensus guidelines, because they are anti-science. Science is not about consensus, it’s about disproof, disbelief and skepticism. It’s not about consensus. When you’ve got consensus, you’ve got trouble.

This conflates two very different stories into one, to serve the rhetorical purpose of granting credence to the underdog-story. The two stories are first, that yes, dogma is antithetical to science. The second is that if a preponderance of evidence points in a consistent direction, consensus guidelines could be well-justified, and it would only be irrational or inattentive people who would not believe in that consensus.

In the second story, you’d have been rational to believe in the consensus account even if it later turns out to be false. The point is that denying a well-justified consensus doesn’t make you a better scientist – it makes you a conspiracy theorist, or simply wrong about the facts.

In other words, consensus guidelines that emerge out of honest engagement with the evidence, and that are open to correction, are not anti-science at all. They are the product of good science, and their later overturning (if that happens) in favour of a new consensus is also the product of good science.

You don’t measure or identify good science from its conclusions – because we don’t know that those will survive future data – but by method, and by openness to correction in light of evidence. The first kind of story mentioned above, involving dogma, is of course an example of bad science. That doesn’t mean that consensus is by definition bad.

Science is indeed about “disproof, disbelief and skepticism” – but all of these serve to challenge any existing view and replace it with a better one. They are tools, or methods, for reaching a better consensus, not for rejecting consensus in general.

The simplest way of putting the point is this: Noakes would like it to be the case that medical practitioners and educational programmes see the light, and teach the same message he professes. In other words, he’d like his own views to be the basis of a new consensus, because he believes that the existing consensus is wrong.

When you’ve got dogma, you’ve got trouble. And when you’ve got consensus, you might have dogma. But you might also have a bunch of responsible people agreeing that yes, that’s what the data imply, and until we learn something to overturn our view, the evidence leads us – as rational, responsible scientists – to a certain consensus.

In short, while the quote above can play as a sexy soundbite for undercutting received wisdom, it’s another instance of Noakes playing scorched earth with understanding of the scientific method.

He might say that the public health concerns are too significant to care about niceties like the ones I’ve been talking about today. To that, there are two immediate responses. First, sloppy thinking should arguably never be encouraged. For someone who is regarded as an inspiration by many budding scientists, and who is one of South Africa’s most decorated scientists, one might even argue that he has a moral obligation to encourage sound scientific thinking.

The second response is that even if this were true – that we should misrepresent the strength and consensus behind a certain dietary position, in order to save lives – we should be able to debate how far we’re allowed to take the misrepresentation.

But this would require agreeing that misrepresentation occurs, and Noakes insists that it’s others who are being obtuse rather than himself. More disturbing, perhaps, is that those who do disagree are ignored or blocked, or characterized as shills, or victims of “groupthink”.

In conclusion, two tweets that show the best and worst of Prof Noakes:

.@Magarietha @umduzu @JSDKirby @davegreenway Many of my most vocal critics think science is easy and definitive. It is nuanced and complex

Yes, it certainly is, and I wish he’d take his own counsel on these matters.

Overlooked: If I am wrong, all that suffers is my reputation. If diet-heart is wrong, billions suffer. Scary responsibility.

This is the worst, obviously, in that the consequences of him being wrong could be far more acute. The logic here is entirely circular, in that his conception of being “wrong” simply ignores all the harms that competing views say could result from a high-fat diet.

He’s assuming he’s right, even while speculating about the consequences if he were wrong.

Even Noakes’ supporters should expect more of him, for two reasons:

  1. The scientific method deserves better.
  2. If he’s right, he’s impairing the credibility his viewpoint garners. The same dietary advice could be given without the “aid” of examples like these, and that might well get the revolution taken seriously in a far more widespread fashion.