by Tim Noakes
The authors reveal their petticoats of bias when they claim that the benefits of LCHF diets ‘are unproven, and in particular whether it is safe in pregnancy and childhood’. The Real Meal Revolution makes no mention of using this diet in pregnancy and childhood. At the time, I had never even spoken about pregnancy nutrition, and there was nothing in the Cape Times report saying that I had mentioned pregnancy and childhood nutrition to the parliamentarians.
The reason for the inclusion of this sentence in the letter would only become apparent during the HPCSA hearing in 2016. The UCT professors’ letter turned out to be a crucial part of the evidence trail that the HPCSA needed to create in order to charge me with unprofessional conduct. It is why I conclude that De Villiers felt it essential to copy the letter to the minister of health and the South African Committee of Medical Deans. The letter would be the final piece of evidence the HPCSA preliminary inquiry committee required as proof that all of South African academic medicine was united in its disapproval of Professor Timothy Noakes’s unprofessional conduct in questioning current medical orthodoxy.
In this context, having Opie’s signature on the letter was vitally important for the herd. Like me, he is an A1-rated scientist, and perhaps the most decorated UCT medical scientist of all time. It is widely known that he was my MD supervisor, that I wrote a glowing foreword for his nutrition book, Living Longer, Living Better, and that I have the highest regard for him, as I unreservedly expressed in my biography, Challenging Beliefs.** To have Opie’s signature on the letter would be a massive coup for De Villiers and his team. It would be the final repudiation of me, my ultimate outing as a devilish, ‘dietary quack’.
Next, the authors’ acknowledgement that the LCHF diet ‘may lead to initial weight loss and associated health benefits – as indeed would a balanced weight loss diet’, indicates their limited understanding of how different diets produce weight loss.
Standard teaching at the UCT Faculty of Health Sciences is that fat is the most energy-dense macronutrient. So people just need to remove fat from the diet if they want to lose weight. That is according to the uber-simplistic CICO model of obesity discussed in detail in The Real Meal Revolution. Importantly, this is the model that the food industry advances, because it allows nutrition scientists to promote the false idea that the sole impact different foods have on our human physiology can be predicted from their varying calorie contents. We can therefore eat junk food, including, importantly, sugary soda drinks, as long as we burn off any excess with plenty of vigorous exercise.
In their letter, the four UCT experts now seem to be acknowledging that their model must be wrong, since they agree that it is possible to lose weight on a high-fat diet. What forced them to acknowledge their error? Quite simply, the effects of The Real Meal Revolution. They would have been exposed daily to stories of South Africans who had lost substantial amounts of weight. They may even have read my article in the SAMJ detailing patient-reported experiences with the LCHF diet, including the stories of Billy Tosh, Brian Berkman and Dr Gerhard Schoonbee (see Figure 5.2).
The ‘associated health benefits’ of the LCHF diet that the UCT professors admit to are, in their view, simply because weight loss itself is ‘healthy’. But how do they know that the improvements in health of those on the LCHF diet are due simply to weight loss? What if they are due, instead, to the removal of the toxic effects of excess dietary carbohydrates in those who are insulin resistant, and the accompanying reversal of persistent hyperinsulinaemia and NAFLD, improvements that are not produced to the same extent by their calorie-restricted, hunger-generating, low-fat diet?
Then they add the great non sequitur: if weight loss always produces beneficial health outcomes, how are those health benefits suddenly reversed in patients who have managed to keep the weight off by continuing to eat the hunger-busting LCHF diet?
The faculty experts have chosen not to explain this anomaly. Instead, they have stayed loyal to the omertà, slipping into the standard dogma that ‘this diet may rather result in nutritional deficiencies, increased risk of heart disease, diabetes mellitus, kidney problems, constipation, certain cancers and excessive iron stores in some individuals in the long term. Research leaves no doubt that healthy balanced eating is very important in reducing disease risk.’
I am always intrigued by my profession’s casual use of the words ‘may’ and ‘could’. One day during the course of the HPCSA hearing, I asked my legal expert and friend Advocate Dr Rocky Ramdass, a practising medical doctor who trained to become an advocate: ‘Rocky, what is the difference between medicine and law?’
‘Simple,’ he responded. ‘Medicine is what might or could be. The law is what is.’
Certainly, until the possibility is disproven, any diet ‘might’ cause anything. But our scientific responsibility is to back up our contentions with hard science. And there is no data or any definitive evidence (from appropriate RCTs) that the LCHF diet increases the risk of heart disease, T2DM, kidney problems, constipation, cancer and/or excessive iron storage. Instead, heart disease, obesity, dementia and probably cancer have all been shown to be symptoms of the same underlying abnormality – insulin resistance. And it is a high-carbohydrate diet that turns the benign condition of IR into the killer condition that is destroying global health. The irrefutable evidence for this is presented in Chapter 17.
It is the next paragraph in the letter (‘It is therefore a serious concern that Professor Timothy Noakes …’) that constitutes defamation.
The professors start by saying that I am respected for research in sports science, ignoring my A1 rating in both exercise science and sports nutrition. (It goes without saying that it is not possible to be an expert in sports nutrition if you do not understand nutrition in general.)
Their first complaint is that I was ‘aggressively’ promoting the diet as a ‘revolution’, whereas all I did was provide a 25 000-word chapter to a recipe book and to suggest that the title should include the word ‘revolution’. What happened afterwards – my subsequent lectures on the biology of IR and obesity, and how to treat both, delivered to about 30 000 South Africans during the book’s promotion – was not of my doing. I did not force any of those 30 000 to come and listen, and I certainly did not force them to believe what I said or to follow an LCHF diet. If they did so, it was because they had weighed the evidence and chosen to change. After that, it was the South African public who drove the ‘revolution’, not Tim Noakes. I was perhaps the spark that lit the flame, but those who have benefited are the ones carrying forward the ensuing conflagration.
South African Rita Venter has a Banting support group on Facebook, ‘Banting 7 Day Meal Plans’, which she launched in September 2014. As of September 2017, she had more than 800 000 followers, growing by around 2 000 a day. Many people have written to say they have lost as much as 50 kilograms, ‘reversed’ their diabetes and hypertension, and have more energy. Any one of these achievements in hundreds of thousands of South Africans would be enough to spark an aggressive revolution. My continuing contribution has become unnecessary.
We are now dealing with a ‘viral’ phenomenon in which South Africans are taking control of their own health and using social media particularly to drive the diet revolution. They are increasingly ignoring the advice of professionals constrained by the omertà. The four UCT professors need to understand what is happening here; in choosing to blame me, they will not turn back the revolutionary tide.
Their second complaint is that I was ‘making outrageous unproven claims about disease prevention’. I presume they are referring to the case reports I included in my SAMJ article and subsequently in The Real Meal Revolution. But these were not my claims; these were the claims of the individuals involved. Of course, they are ‘outrageous’ to colleagues who believe and lecture daily to doctors, medical students and dietitians that all these conditions – including obesity, T2DM, metabolic syndrome and hypertension – are the fault of slothful and gluttonous patients, and are irreversible
and degenerative.
My view that conventional medical training does not address the real causes – IR and a high-carbohydrate diet – must be deeply disturbing to these anointed professors. For, if it is true, what I and many others are saying strikes at the very core of the current practice of clinical medicine. It is much easier to simply demonise Tim Noakes as a quack making outrageous claims than to consider the possible truth in what many South Africans and others around the globe are now saying.
In a final irony, the professors accuse me of trying to prevent intellectual debate. In reality, it is they who have tried to stifle the debate that I ignited with the publication of Challenging Beliefs and The Real Meal Revolution. They are the ones who ensure that UCT medical and dietetics students are not taught the LCHF diet. It is UCT’s Division of Human Nutrition that decrees that no doctor at Groote Schuur Hospital may prescribe any diet other than one low in fat and high in carbohydrate. It is the students in that division who are warned never to mention the words LCHF or Banting within earshot of their professors and lecturers.
In the next paragraph, the professors say that the letter ‘is not the forum to debate details of diets’, and then list all the aspects of the LCHF diet that require investigation. Yet three years after their letter’s publication, I am not aware that any of these professors have produced any evidence against LCHF. I, however, have contributed to an intervention trial showing the remarkable effects of a high-fat diet in reversing metabolic syndrome.17
I am not sure what the authors mean when they say that the Banting diet is ‘“one dimensional” in focus’. I also do not know exactly what constitutes ‘healthy carbohydrate containing foods’. And their accusation that I ignore physical activity is ironic, given that I wrote one of the most famous running books of all time and introduced the science of sport to an extremely reluctant Faculty of Health Sciences in the 1970s. Of course I promote physical activity, but, as an expert in nutrition, I understand that nutrition is more important than physical activity when it comes to weight loss. I understand that you cannot out-exercise (or out-medicate or out-monitor) the effects of a bad diet.18
In a final personal insult, the authors distance themselves from me, one of the very few A1 scientists in their faculty. They omit that, through my efforts over 40 years, I personally have contributed in no small measure to the development of the faculty’s ‘reputation for research excellence’.
I spent much of that weekend at Bartholomeus Klip responding to the UCT professors’ letter. I emailed a four-page private response, addressed to Wim de Villiers, to Linda Rhoda and the Cape Times on the evening of Sunday 24 August.
The letter includes information that is private, and so I will not reproduce it here in full. It will, however, be housed in the UCT archives, along with other relevant material, for posterity. Instead, this is a summary of the key points I made:
The UCT professors’ letter is defamatory.
The letter is littered with errors of fact and interpretation that are an embarrassment to the authors.
The insinuation is that I have no credibility in studying or talking about low-carbohydrate diets, but the facts speak differently.
I gave an account of my credentials, saying that I had published my first paper on low-carbohydrate eating in 1980 in the Journal of Physiology.19 My most recent publication at the time was an editorial in the British Journal of Sports Medicine, which I had written with two of the world’s established leaders in the field, American professors Jeff Volek and Stephen Phinney.20
I outlined my involvement in The Real Meal Revolution, describing the 32 pages of text and four pages of references that I personally wrote on the science supporting the low-carbohydrate eating plan. These pages were, I said, an extension and refinement of what I initially wrote in Challenging Beliefs. All the evidence I presented to support the book’s claims was fully referenced and most of the articles were peer-reviewed. That evidence refutes the claim in the UCT professors’ letter that there is no evidence for the beneficial effects of low-carbohydrate diets in the management of IR, the one condition for which I promote such an eating plan. I suggested that ‘it behoves you and your colleagues to go through all those references and to explain why the conclusions I have reached in that book are invalid’. I continued: ‘I was trained by Professor Lionel Opie between 1976 and 1981 to ensure that I knew ALL the evidence before I came to any hypotheses/conclusions. It appears that this dictum may no longer apply in the new teaching philosophy in your Faculty.’
I drew attention to a study that I and my colleagues in Canada had just completed, which showed that a large percentage of obese rural Canadians had reduced their prevalence of metabolic syndrome from 60 to 20 per cent within three to eight months of adopting a rigorous low-carbohydrate diet without any exercise. Those who had reversed their metabolic syndrome would no longer need to use pharmaceutical products. (This paper has since been published.21) The problem for these four UCT academics, I said in my letter, is that they and all who practise conventional medicine teach that metabolic syndrome is irreversible. They also fail to ask why the prevalence of metabolic syndrome has increased exponentially since the introduction of the 1977 US dietary guidelines, which promote the ingestion of ‘healthy carbohydrates’. Those clinicians who do understand that high-carbohydrate diets produce metabolic syndrome in people with IR will easily appreciate the importance of this study, I said.
I also described how I had invested the R500 000 prize I received for my 2012 NRF Lifetime Achievement Award in a study of 14 subjects habitually adapted to either a high-fat or a high-carbohydrate diet. This study was the first in the world to measure liver glucose production at rest and during exercise in athletes adapted to the LCHF diet. (The subsequently published paper proved that we have the ability to measure liver glucose production accurately, and that we can now use this technique to study the response of patients with T2DM to the LCHF diet.22)
I also drew attention to the fact that I had raised funds for a study of obesity and IR in marathon runners, directed and subsequently completed by MSc student David Leith. We had also raised a grant of R1.6 million from an overseas donor to study the biology of the reversal of T2DM. When completed, this study, I said, will no doubt bring further credit to the UCT Faculty of Health Sciences. (We have since raised a further R4 million from the same donor.)
I concluded my letter with the following:
Fortunately, neither of my parents is still alive so that neither will be subjected to the humiliation of reading you and your colleagues’ letter in tomorrow morning’s Cape Times.
Unfortunately, my wife, myself and my family do not have that option.
Predictably, and in line with my initial assessment, at the time of writing in September 2017 I have received a response solely from Professor Lionel Opie. No word yet from De Villiers, Mayosi or Senekal. Not that I am expecting one.
Over the course of the weekend, Francesca Villette of the Cape Times corresponded with me at length. When the UCT letter was subsequently featured on the front page of the newspaper on Monday 25 August, she included significant input from me – something I would discover was usual for her, but unusual for many other South African journalists with whom I interacted. She quoted me as saying: ‘If that message [that a high-carbohydrate diet is detrimental to the health of people with IR] is without scientific support, then the faculty has every right to cross the civil divide as it has now chosen – an action which, I suspect, is unprecedented in the history of the faculty and perhaps also in the history of UCT.’ I added:
Carbohydrate restriction in this group can be profoundly beneficial as it can reverse obesity and in some cases type 2 diabetes mellitus – the two conditions that will ultimately bankrupt South African medical services unless we take appropriate preventive actions.
If there is evidence for my position, then the faculty is guilty of failing fully to inform its past and present science, medical and dietetics graduates in a manner that s
hould be appropriate for a faculty that considers itself a world leader.23
As Marilyn and I drove back to Cape Town from Bartholomeus Klip, we wondered how Lionel Opie could have allowed his name to be attached to this unscientific personal attack. For as long as I had known him, he’d had one overriding dictum: ‘No data, no paper.’ In other words, opinions are worthless unless supported by data. But where was the data in the Cape Times letter? Could his name have been added without his consent? Marilyn and I both knew that I would have to confront my lifelong mentor to hear his side of the story.
The response in the media to this personal onslaught reflected the individual biases of the respondents. The anti-Banters were delighted that the hierarchy had finally put me in my place; those who supported me suggested that De Villiers and his herd needed to provide scientific evidence for their position. Others wrote about how the Banting diet had improved their health in ways that the ‘balanced’ diet had never done and, in their opinion, never could.