The BabyGate Files: Tim Noakes Just WRONG on Protein

UPDATE 6/5:  Hearing has been postponed, and expanded to 7 days beginning November 23.  Some info on why here.

Recent news piece

In the tweet, Noakes advised a mother to have her baby follow a diet high in fats and low in carbohydrates.
This week he said:
“She was asking for advice on what to feed her child and I advised her to wean the child on to low carbohydrate, high protein, nutrient-dense food. By that I was implying that she shouldn’t wean the child on to cereals.

BUMP: 6/4

Noakes' hearing is tomorrow and Friday, June 4th and 5th.  Since this was originally published on a holiday weekend here in the States, I'm bumping this post.   His personal cheerleader has written another article on the topic too:  Tim Noakes: will the Nutrition Inquisition finally silence him?
As a sports scientist for decades, Noakes’ specialty has always been a specialist in dietetics and nutrition. He has also been studying infant nutrition for the past four years, and will be bringing out a book soon, titled Raising Superheroes. Medical specialists, including a paediatrician, have already denounced it even before it is published. If that isn’t a sign of professional jealousy and territoriality, I don’t know what is.
Realize, he now says he knew nothing all those decades (the meme below is altered slightly - grin).  And now we're told he has been studying infant nutrition for twice as long.   This only makes matters worse!

Original Publish 5/24/2015
Background & Previous BabyGate Files:
  1. Mammalian Infant Food Macronutrients ~ Especially Human
  2. Common Themes: The Chef Evans & Prof. Noakes Controversies, and Robb Wolf vs. North Carolina (use your browser to search on Tim Noakes for background on this specific situation)
  3. The Obesity Paradox (contains some information on stunting in infancy)
  4. The BabyGate Files: Tim Noakes Blames Gerber for Baby Cereals

As of the writing of this post, Prof. Tim Noakes is still actively championing a revolution to get the world to adopt a "healthy" #LCHF diet.  He also does not appear to have dialed back much on what has gotten him in a bit of hot water:  suggesting to a woman on Twitter to wean her baby onto a low carb, high fat diet.  Noakes has opposition in his country, but he has a zealous following as well.  A following that includes a low carb activist "journalist" named Marika Sboros.  Sboros gave Noakes both favorable coverage and a podium with this article:  Is Tim Noakes REALLY SA’s new ‘Dr Death’? Here’s a big fat surprise!

The gang's all well represented in Sboros' propaganda:  Harcombe, Taubes, Teicholz with nods to other (I suppose "real") researchers who support the low carb cause.   It really is maddening at this point how these clowns portray all nutrition advice as lacking a scientific basis, when, in fact, infant nutrition has been one of the most thoroughly researched aspects of the field.  Although it doesn't pertain directly, a ton of information has been gleaneed from the plethora of "metabolic ward" studies done in the NICUs across the globe, and that is just the tip of the iceberg.  

So from the article, it appears Noakes believes the inquiry into his professional behavior is:
“possibly the best thing that’s ever happened to medicine in the past 10 or 20 years”.
How so?
The HPCSA will have to investigate not just him, but “what the South African public are being taught about nutrition”, and the scientific basis – or lack thereof, Noakes says. It will have to rule on the science around porridge as a first food for infants if suggesting meat and veg constitutes “unconventional advice” and “unprofessional conduct”.
The strawman martyrdom streak of these folks is strong.  The LCHF diet is unlike any diet ever consumed by a human culture on this planet ... ever.  
Noakes has been researching infant nutrition for the past two years, and told Grootes porridge is “not an ideal food”, not just because it is fattening. Infants need food in their first two years of life that provide critical “brain–specific nutrients”, Noakes says. “Animal-based foods are proven to provide these nutrients in excess. Cereal-based foods, such as porridge, are not.”

It is unfathomable that anyone, let alone a scientist, could seriously research infant nutrition for even two hours and be able to say that.  Perhaps for the cherry picker we might need to allow two days, but two years?   It was quite a while ago that I was looking into something else about infants, I believe it was birthweight and adipose tissue, when I came across the seemingly counterintuitive relationship between protein intake in infancy and adiposity later in life.  I had to do a double take, because higher protein intake in adults tends to have a favorable relationship with body composition, especially in the context of weight loss and management.  How could protein be different in infancy?  It's a period of growth and that requires protein -- perhaps more for current body size -- right?  Furthermore, unlike some of the often conflicting outcomes with nutritional interventions and assessments in adults, the data from scientific inquiry into infants and protein intake appears to point pretty consistently in the same direction.    Someone who has looked into this at all would never make the statement Noakes made in this minipodcast, that:  
... you will never regret giving your child more protein and fat in their growing years, you will regret it if you give your child a 65% carbohydrate diet.
So rather than acknowledging that he has no particular expertise in the area, Noakes plans to claim further authority into such matters and thinks he's going to put some misguided dietitians on trial for the advice they have been giving.

Back to the Sboros article, there's this update at the end of the articl:
ADSA president Claire Julsing Strydom replied through Twitter, directing me to the association’s Guidelines on Infant Nutrition, posted on April 27, the day before this blog. These guidelines appear to say ADSA and its members support Noakes’ advice, and no longer routinely advise cereal as a first food for infant weaning, though cereal is still there as an option. I have asked for clarification and confirmation from ADSA.
Noakes responded on Twitter:

I do not see any indication that the guidelines at the link above (SA based on WHO) jive with anything similar to LCHF.
The WHO and the Institute of Medicine (IOM) (IOM, Dietary Reference values 2006) recommend that an infant’s energy (which is provided by breast milk and complementary foods) should come from about 30 – 45% of total fat, 6 – 7% of protein with the remainder from carbohydrates. This is very much in line with the composition of breast milk at that age.
The 45% fat is the very low end of a diet the LCHFers would consider "high fat", and the carbohydrate content ranging from 48% to 64% (which is the calculated range from the above numbers) is not low carb by any stretch of the imagination.  So NO.  This is not LCHF.  I do not know what SA's typical dietary intake is for adults, but in the US, that is right in line with and higher than that consumed according to NHANES throughout the history of the survey (and on a percentage basis, little has changed since the onset of the uptick in obesity).  
It is also recommended that infant diets do not contain more than 15% of energy from protein, until more is known on the effect of protein on obesity later on in life (Michaelsen & Greer 2014).  Major expert paediatric committees such as the The European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN), American Academy of Paediatrics (AAP) and Canadian Paediatric Society (CPG) support these guidelines, until more research becomes available on the matter.
Here is a link to that Michaelson & Greer citation (full text):  Protein needs early in life and long-term health.   Now unless Noakes is actually recommending true Banting for babies -- e.g. wine and pure spirits -- something has to give with the three macronutrients and if one is weaning a baby onto meat and veggies (non-starchy at that) the protein is likely to be too high.   I hesitate to even write that, because some LC zealot is likely to interpret this to mean that a baby should be weaned onto an even more high fat diet and limit protein as well!  But I'd point out that if the baby is weaned onto customary baby foods -- foods they have been weaned onto around the globe for centuries and even thousands of years -- there is little to worry about in terms of the baby getting too much protein.   

When I get done here, I'd really like to hear your thoughts on something.  When I read the literature, it seems that the advice re: protein is not cautionary enough!  The only thing I can think might be behind that is that the focus for infant nutrition has always been -- and largely continues to be -- about getting adequate nutrition and avoiding malnutrition and deficienies.  The WHO is far more worried (as they probably should be) with infants around the world getting enough rather than excesses, and there's probably never been much worry that populations targeted with these recommendations would turn them into promotion of excess or even have the means to do so.

But first, the rest of the Guidelines on suitable complementary foods.  These are attributed to Du Plessis, et al., 2013 (click on full screen for easier reading of the original source), but are more appropriately a reiteration of the WHO, etc. guidelines listed in the paper.  The concluding guidelines by DuPlessis differ in some ways.  First they are (due to political thinking that ignoring reality will make all women breastfeed for two years so we'll only discuss that option rather than confusing people /minor sarcasm) for breastfeeding and include the following bulletpoints not in the WHO "template".  Also, they are preceded by "the following messages are proposed and should be field tested for South Africa".  
  • From six months of age, start giving your baby small amounts of complementary foods, while continuing to breastfeed for up to two years and beyond.
  • Gradually increase the amount of food, number of feeds and food variety as your child gets older.
  • Start spoon feeding thick foods, and gradually increase to the consistency of family food.
  • Avoid giving tea, coffee, sugary drinks, and snacks that are high in sugar, fat or salt. 
The ADSA's bulletpointed list is provided below:
  • Provide a variety of foods to ensure that nutrient needs are met. This includes vegetables, fruit, whole grains, meat and meat alternatives (meat, poultry, fish, eggs, legumes, nuts, seeds and nut butters) and dairy products (from the age of 12 month and in addition to, but not replacing breast milk).
The second bullet point is the one the LCHFers are latching onto as being in keeping with their views.  I've included both the ADSA and original DuPlessis points:
  • ADSA: Foods from animals (meat, poultry, fish or egg) should be eaten daily, or as often as possible to meet protein and iron needs. In infants and young children, vegetarian diets cannot meet nutrient needs, unless nutrient supplements or fortified products are used.
  • DuPlessis: From six months of age, give your baby meat, chicken, fish, liver and eggs every day, or as often as possible.
I grayed out the part there on the ADSA site to emphasize that this, especially the part about vegetarian diets, is NOT a statement by DuPlessis. It is from the WHO. While it may be more difficult to meet needs, the DuPlessis recommendations are in the context of alongside continued breastfeeding.  More importantly, however, taken out of context, one might read the "as often as possible" to mean "more often, the more the better".  If you read the entire paper, it is clear that we are dealing with the current undernourished status of babies in the "Third World" regions of South Africa (and the world), not Noakes' "First World" Capetown niches.  So it's intended as encouragement to strive for some meat every day, but settle for as often as you can swing it.  This is hardly a recommendation to wean your baby onto steak and kale.
  • Dark green leafy vegetables and orange coloured vegetables and fruit rich in Vitamin A (e.g. sweet potato, carrot, pumpkin, broccoli and spinach, mango, peaches, apricot, paw-paw) should be eaten daily.
No argument here with itemizing good sources and such without editorializing. Interestingly to the other BabyGate from Australia, meat and liver aren't included for Vitamin A here.   Lastly there's these, which are not part of the DuPlessis list:
  • Provide diets with an adequate fat content (from plant foods e.g. vegetable oils, avocado, nut butters and foods from animals, listed above, and also including breast milk)
  • Use fortified complementary foods or vitamin-mineral supplements for infants, as needed or prescribed.
A goodly part of the DuPlessis paper is what inspired my recent Obesity Paradox post.  The ADSA and other organizations dealing with so-called Third World nations or populations, are dealing with the complex issue of combatting malnutrition and obesity concurrently. The solutions to these problems require much more than Noakes' sound bite proclamations about fattening carbs and how meat is more nutritious than maize.   I'm going to save those issues for another BabyGate Files.  For now, let's get back to protein.  Here are a sampling of studies and reviews:

We propose that the protective effect of breast feeding is related in part by the induction of a lower weight gain in infancy, which is related to differences in substrate intake. 
Protein intake per kg bodyweight is some 55-80 % higher in formula fed than in breast fed infants. We hypothesize that high early protein intakes in excess of metabolic requirements enhance weight gain in infancy and increase later obesity risk (the “early protein hypothesis”). 
Also ...
A high protein intake in excess of metabolic requirements may enhance the secretion of insulin and insulin like growth factor 1 (IGF1). Indeed, infants fed formula had far greater postprandial levels of insulin on day six of life than infants fed cows’ milk based formula. High insulin and IGF1 values can enhance both growth during the first 2 years of life as well as adipogenic activity and adipocyte differentiation (fig. 2).  High protein intakes may also decrease human growth hormone (hGH) secretion and lipolysis.   {emphasis mine}
Indeed, high protein intakes in early childhood, but not the intakes of energy, fat or carbohydrate, were significantly related to an early occurrence of adiposity rebound and to high childhood body mass index (BMI), corrected for parental BMI.   {emphasis mine}

Well this is an interesting twist!  Insulin is fattening (hallelujah!)  but it's the insulin from protein?  Perhaps that IGF-1 then ...  Again, IGF-1 is associated with improved metabolic markers in adults (see for example this LoBAG post).  So what is good for the adult -- particularly the overweight/obese and/or glucose intolerant/diabetic one -- may again NOT be good for the first few years of life.    This draws the rationale of those who would use the composition of breastmilk to fashion their adult diets even further into question.

Early protein intake and later obesity risk: which protein sources at which time points throughout infancy and childhood are important for body mass index and body fat percentage at 7 y of age?
... The ages of 12 mo and 5-6 y were identified as critical ages at which higher total and animal, but not vegetable, protein intakes were positively related to later body fatness....

... A higher animal, especially dairy, protein intake at 12 mo may be associated with an unfavorable body composition at 7 y. The age of 5-6 y might represent another critical period of protein intake for later obesity risk.
Note: these studies are looking at "body fatness", not BMI.  We are not talking about mini Derek Jeters here who are building muscle because of  higher protein intake, we're talking body fat.   Dairy is especially insulinogenic, but also IGF-1 promoting.  I haven't really looked into veggie vs. animal proteins and IGF-1 secretion, but this may well be a factor for why veggie protein is apparently not a culprit.  Human "dairy" is lower in protein than cow's milk.  
Lower protein in infant formula is associated with lower weight up to age 2 y: a randomized clinical trial

In a multicenter European study, 1138 healthy, formula-fed infants were randomly assigned to receive cow milk–based infant and follow-on formula with lower (1.77 and 2.2 g protein/100 kcal, respectively) or higher (2.9 and 4.4 g protein/100 kcal, respectively) protein contents for the first year. For comparison, 619 exclusively breastfed children were also followed.
A higher protein content of infant formula is associated with higher weight in the first 2 y of life but has no effect on length. Lower protein intake in infancy might diminish the later risk of overweight and obesity.

We analyzed the association of different protein intakes during 6–24 mo with body mass index (BMI; in kg/m2) and percentage body fat (%BF) at 7 y of age.

.... Although protein intake at 6 mo of age was not associated with the outcomes, a consistently high protein intake at the ages of 12 and 18–24 mo was independently related to a higher mean BMI SDS and %BF at the age of 7 y ...
Conclusions: High protein intakes during the period of complementary feeding and the transition to the family diet are associated with an unfavorable body composition at the age of 7 y.

But Tim Noakes says ... 

Should you trust him when he says you will never regret giving your kid too much protein?  Keep in mind that even LCHF levels of protein are considerably higher than breastmilk and the usual full array of complementary foods.  

I could have listed a dozen more papers all pointing in the same direction.  The issue with the maize porridge in South Africa is that on its own it is likely to be protein insufficient.  Combined with some milk, with modest amounts of animal protein, and/or replaced by more complete and/or higher protein veggie sources (e.g. potatoes, peas, beans, amaranth ...) there should be little worry over protein deficiency.

Have you seen much real thought being put into this by Noakes' defenders?  I haven't.  No, all I've seen in the #WeSupportTimNoakes hashtag flurry are myriad before-after shots of adult weight loss.  As if a diet that helps an overweight adult lose weight is somehow appropriate for a growing infant?   So I actively encourage the hijacking of that hashtag with #WeSupportTimNoakes-NOT on any and all informative tweets against his short sighted self promotion.