[2017] Lore of Nutrition: Challenging Conventional Dietary Beliefs

by Tim Noakes

  A Somerset West doctor, Jacques Breitenbach, was typical of those who believe that, as the leader of supposedly the most scientifically rigorous health-science faculty in Africa, De Villiers should stick to the science. In a letter to the Cape Times on 26 August 2014, under the heading ‘Produce evidence’, Breitenbach wrote:

  Dr Wim de Villiers and others claim Noakes is making ‘outrageous, unproven claims about disease prevention’. I have read Dr Tim Noakes’ books and he provides some compelling arguments to back up his diet.

  De Villiers and the naysayers went on to state that ‘there is good reason to believe it could result in nutritional deficiencies and increase the risk of heart disease, diabetes, kidney problems, constipation and some cancers’.

  On what evidence do you make those outrageous statements? You and your fellow doctors at the Faculty of Health Sciences will have to do a lot better than that.

  Another general practitioner who trained at UCT, Dr Rosalind Adlard, also suggested that De Villiers and his colleagues ‘read the evidence’. In her letter to the Cape Times on 29 August, Adlard wrote:

  As a graduate of UCT medical school myself, I owe Professor Noakes an inordinate debt of gratitude for opening my eyes to an alternative explanation for obesity which I was not taught at medical school.

  However, one thing I consistently find is that most people who criticize the Banting diet don’t know much about it and have not read any of the books Professor Noakes recommends.

  I would thus like to challenge all doctors – and indeed anyone interested in the debate – to read Gary Taubes’s book, Why We Get Fat (and what to do about it). It’s easy to read, inexpensive and readily available, in both print and electronic format.

  At worst, you’ll understand some of the theory and evidence behind the Banting diet, even if you disagree with it. At best you may, like me, also reap benefits for yourself and/or your patients.

  Less than two weeks later, the publication of another scientific study in the Annals of Internal Medicine dealt a blow to the official UCT position by showing the superiority of the LCHF diet over the so-called heart-healthy, prudent, balanced diet when it came to weight loss and coronary risk factors.24 ‘This is now the 24th such study showing these outcomes,’ I was quoted as saying in the press. ‘The other 23 have been ignored but it seems this one might not be so easy to ignore.’25 At the time, Linda Rhoda responded to the media saying that the professors were ‘working on a response’. By September 2017, they had still not responded.

  One retired Cape Town medical practitioner, Dr Jack Slabbert, did respond. Under the heading ‘Work with Noakes’, his letter to the Cape Times on 6 September read:

  A month ago, a letter from professors in the faculty of medicine at the University of Cape Town appeared in your paper. They were highly critical of the views held by Professor Tim Noakes regarding a low-fat/high-carbohydrate diet versus a high-fat/low-carbohydrate diet, the latter being advocated by Noakes.

  The story ‘New study supports Noakes’s low-carb, high-fat diet’ (Cape Times, September 4) states that a study supporting Noakes’ views has been published in the Annals of Internal Medicine, a publication held in very high regard by the medical profession.

  Noakes has told your reporter that this is the 24th study stating support for his views, but ‘the other 23 have been ignored’. Now I find this statement most disturbing because, if true, the reputation of UCT’s medical faculty will suffer a significant blow.

  Sixty years ago, I graduated with an MBChB degree from UCT and now, long retired from medical practice, it hurts me to see an internal strife in the medical faculty becoming front page news, probably all over the world.

  What clinical research had the professors undertaken to statistically prove Noakes to be wrong, and also to make ‘outrageous, unproven claims about disease prevention’?

  Noakes has been well-known and well-regarded in medical sports circles for many years. I do not know him personally but he has earned my respect in being honest and forthright in dealing with difficult medical problems in sport. As far as I am concerned, he has served UCT well, and I just cannot see him acting as a doctor who has no regard for the welfare of his patients.

  This dispute has some significant practical consequences for UCT. Are the medical students now being told that Noakes is a charlatan? The Annals of Internal Medicine would appear to negate such a belief.

  There is a way out of this impasse. It should be possible to do research together, although it will require a willingness to let ‘bygones be bygones’.

  The dietary treatment for coronary and stroke recovering patients, followed-up for a long-term period, needs to be done. There is an epidemic of obesity, particularly severe in South Africa. UCT must lead the way. A dietary solution is urgently required.

  Be the leader in this research in Africa! Appoint Noakes as a consultant to the Department of Medicine. All parties working together is what UCT needs. The rewards will be great.

  Dr Slabbert raised an interesting point. How active is the UCT Faculty of Health Sciences in researching dietary solutions for the diabetes/obesity epidemic that has swamped the Western Cape in the past 40 years? Indeed, what is the quality and relevance of the research being undertaken at UCT’s Division of Human Nutrition, the then head of which (Marjanne Senekal) was a co-signatory of the Cape Times letter?

  One particularly challenging response came from a senior colleague, UCT emeritus professor Max Klein, who sent an email to De Villiers on 4 September, cc’ing me. Sadly, Klein passed away suddenly in early 2015, without ever receiving a response, or even an acknowledgement, from De Villiers.

  The key point that I learnt from Klein’s email was that De Villiers had sent the letter to the Cape Times on behalf of the board of the Faculty of Health Sciences without even consulting the board for its approval. Yet readers would have assumed that the letter carried the full support of the faculty as well as that of UCT. At the time it was unclear to me whether or not the university had been consulted. If it had not, UCT’s senior management should have called De Villiers in to explain to Vice Chancellor Max Price why he had written such a defamatory letter with the apparent backing of UCT and its Faculty of Health Sciences without consulting either.

  Price should then have informed De Villiers that UCT defends and treasures academic freedom, and that academic debate should always be respectful and free of public vilification and humiliation of anyone with whom those in power do not agree.

  That the university’s senior management failed to respond in this way indicates, sadly, that they were complicit in the entire affair.

  But were De Villiers and UCT complicit in a much larger action against me? And what of Lionel Opie’s involvement in the drafting of the letter?

  Over the course of the next two years, Marilyn and I pondered how Opie had become involved. At a meeting I requested with De Villiers and Mayosi at UCT in December 2014, De Villiers was adamant that not only had Opie signed the letter, but he had also been the person most responsible for its writing. Opie, he assured me, had also suggested that the letter be sent to the minister of health. I was incredulous because, at the time, Opie had assured both Marilyn and I that this was not the case. As that meeting broke up, I presented De Villiers and Mayosi with copies of Nina Teicholz’s book, The Big Fat Surprise, and an editorial published the previous week in the British Medical Journal (BMJ). The editorial was a review of Teicholz’s book written by a former BMJ editor, Dr Richard Smith.26 In it, he wrote the following:

  By far the best of the books I’ve read to write this article is Nina Teicholz’s The Big Fat Surprise, whose subtitle is ‘Why butter, meat, and cheese belong in a healthy diet.’ The title, the subtitle, and the cover of the book are all demeaning, but the forensic demotion of the hypothesis that saturated fat is the cause of cardiovascular disease is impressive. Indeed, the book is deeply disturbing in showing how overenthusiastic scientists, poor science, massive conflicts of interest, and politically
driven policy makers can make deeply damaging mistakes. Over 40 years I’ve come to recognize what I might have known from the beginning that science is a human activity with the error, self deception, grandiosity, bias, self interest, cruelty, fraud and theft that is inherent in all human activities (together with some saintliness), but this book shook me.

  After describing the bad science underlying all aspects of Ancel Keys’s diet-heart hypothesis, Smith concluded:

  Reading these books and consulting some of the original studies has been a sobering experience. The successful attempt to reduce fat in the diet of Americans and others around the world has been a global, uncontrolled experiment, which like all experiments may well have led to bad outcomes. What’s more, it has initiated a further set of uncontrolled global experiments that are continuing. Teicholz has done a remarkable job in analyzing how weak science, strong personalities, vested interests, and political expediency have initiated this series of experiments. She quotes Nancy Harmon Jenkins, author of the Mediterranean Diet Cookbook and one of the founders of Oldways, as saying, ‘The food world is particularly prey to consumption, because so much money is made on food and so much depends on talk and especially the opinions of experts.’ It’s surely time for better science and for humility among experts.

  In 2017, the other great British medical journal, The Lancet, published a similar review, concluding: ‘This is a disquieting book about scientific incompetence, evangelical ambition, and ruthless silencing of dissent that shaped our lives for decades … Researchers, clinicians, and health policy advisers should read this provocative book that reminds us about the importance of good science and the need to challenge dogma.’27

  My hope was that Teicholz’s book would be well read, especially by Mayosi, a long-time defender of Keys and the diet-heart hypothesis, who has since been appointed, in September 2016, as UCT’s dean of health sciences, succeeding De Villiers.

  More than two years after that meeting, in early 2017, my legal team gained access to an email chain describing at least some of the events leading up to the writing of the UCT professors’ letter. The emails revealed, rather surprisingly, that the person driving the letter was the Faculty of Health Sciences’ marketing and communications manager, Linda Rhoda. In her original email, Rhoda referred to my ‘crusade’ that seemed ‘to have reached Parliament’.

  It is interesting that the head of marketing and communications has the power to decide how the faculty should respond to what she calls my ‘crusade’. I would have thought her job was to project the faculty in a positive light, not to try to bring the career of a devoted faculty member into disrepute by protesting about his actions to the minister of health. It smacks of kindergarten politics.

  Unfortunately, within 10 minutes Opie had responded, indicating his support for the initiative. By the same time the next day, a draft letter of 208 words, apparently crafted by Rhoda, was circulating. By Thursday afternoon, Opie and Senekal had added their comments, bringing the word count to 647.

  Rhoda responded by asking that De Villiers and Mayosi complete the article in time to get it into ‘Monday’s Papers’. She also indicated that the article would need to be sent timeously to ‘Max Price’s office and the UCT Director of Communications and Marketing’.

  This email seems to confirm that, at the very highest level – the office of the vice chancellor, Dr Max Price – UCT was complicit in this action against me.

  The university chose not to provide any further emails to my legal team, so it is not clear exactly how much of the letter-writing was undertaken by De Villiers and Mayosi. It seems that Rhoda and Opie concocted the core, with inputs from Senekal.

  I suspect the reason why Opie did not recall any of these events was that he was extremely unwell at the time. Already on the afternoon of Tuesday 19 August, the same day that the Cape Times carried the story about my speech, Opie was ill enough to consult a medical practitioner. His condition worsened over the following days, culminating in his admission to hospital on Friday 22 August. He underwent emergency surgery the next day and was only released from hospital on 8 September. Thus, on the Friday that the letter that would humiliate me and damage my reputation was being finalised under Rhoda’s stewardship, Opie was battling a potentially fatal condition.

  Do I think that Professor Opie was in any condition on that Friday to properly add his intellectual support to the final draft of the letter that would appear in the Cape Times three days later? My answer is no. Having worked with Opie for five years in the late 1970s, and having observed him ever since, I learnt much about the way he conducts himself. He is meticulous and would only ever submit work when he considered it to be perfect. I learnt that his process of finalising a manuscript could last days, if not weeks, as he carefully read and reread and re-corrected the work until finally he would say: ‘Yes, Tim, this paper is now ready for submission. We can do no more.’

  The UCT professors’ letter was not perfect – far from it. Its use of language lacked the elegance and attention to scientific detail and integrity that has always characterised Opie’s thoughts and ideas. Worse, it had no basis in science. Over more than 40 years, Opie had taught me that science must be the sole basis for anything I might choose to profess.

  So I can only conclude that if he did read the final draft of the letter and if he did support its publication, then Opie was acting completely out of character. Indeed, when we subsequently discussed the matter, Opie gave me a copy of another letter he had sent to De Villiers in November 2014. It included the following:

  The fact is I strongly disassociate myself from certain statements and particularly with the aggressive tone of 4th paragraph starting: ‘It is therefore a serious concern that Professor Noakes …’

  Any disagreement with the views of Professor Noakes could have been expressed in a way appropriate to academic discourse and healthy debate which should be devoid of hostility and aggression. Incidentally, no reference was made in the letter to Professor Noakes’ fine achievement in initiating and building up the Sports Science Centre as the Director over many years, to the credit of UCT. He funded the construction entirely from 5 major donors listed in the entrance. No one can dispute the fact that due to his very considerable personal efforts SA and UCT in particular have appeared as world-class players in the area of exercise physiology.

  Accordingly, I would like to have the opportunity of sending a letter of disagreement and correction as based on the details of my objections as given above.

  I would appreciate your personal views on this matter.

  I suspect that Opie is still awaiting a reply to his request.

  He is correct to recoil from the aggressive tone of the email because he understands that it represents nothing more than academic bullying and the silencing of a dissenting opinion. In our most recent correspondence, in early 2017, I put it to my long-term sage that associating himself with the Cape Times letter and its three authors had perhaps been an ‘error of judgement’ on his part.

  To which he instantly agreed.

  *Under ‘Consultative Service’ on his CV, De Villiers declares that he worked with the following 18 pharmaceutical companies: Abbott, Abbvie, AstraZeneca, Axcan-Scandipharm, Berlex, Centocor, Elan, Genentech, Johnson & Johnson, Novartis, Santarus, Prometheus, Proctor & Gamble, Protein Design Labs, Shire, UCB, UCG and Wyeth. Of these, nine – Abbott, Abbvie, AstraZeneca, Berlex, Johnson & Johnson, Novartis, Procter & Gamble, UCB and Wyeth – have been dues-paying members of the ILSI. In addition, four of these companies – Abbott ($1.5 billion), AstraZeneca ($520 million), Johnson & Johnson ($1.1 billion) and Novartis ($423 million) – feature among the top 10 pharmacuetical companies that paid the largest fines for research misconduct and fraud between 2007 and 2012 (Gøtzsche, Deadly Medicines and Organised Crime). De Villiers also declares that from July 1999 to June 2000 he was the recipient of the Atorvastatin Research Award. Marketed under the trade name Lipitor, atorvastatin (a cholesterol-lowering statin drug) became the w
orld’s bestselling drug with more than $125 billion in sales over approximately 14 years, from 1996 to 2012.

  **In the acknowledgements to Challenging Beliefs, I wrote the following: ‘Four of my tutors – Lionel Opie, the late Ralph Paffenbarger, George Brooks and the late George Sheehan – are (or were) utterly extraordinary individuals: the best of the very best. It is said that a guru gives himself and then his system, whereas a teacher gives us his subject and then ourselves. From these gurus I learnt the methods of scientific inquiry, of scientific and popular writing, and of public speaking; through their personalities and their teachings, these icons gave me myself.’ (pp. viii–ix)

  ***In fact, sales of The Real Mal Revolution would generate in excess of R1 million for Operation Smile, allowing surgical correction for more than 200 children with cleft-lip deformities. This was never acknowledged by any of the four professors, the Faculty of Health Sciences or UCT. One wonders why not.

  6

  The Naudé Review

  ‘It is difficult to get a man to understand something, when his salary depends on his not understanding it.’

  – Upton Sinclair, American writer

  I suspect that in writing their defamatory letter to the Cape Times, the four UCT professors had been emboldened by the publication, a month earlier, of a meta-analysis that would become known as the Naudé/Stellenbosch/UCT review comparing the effects of LFHC and (allegedly) LCHF diets on weight loss and other health markers.1 I would later learn that the Naudé review was also decisive in directing the decision of the HPCSA preliminary inquiry committee to charge me with ‘disgraceful conduct’ in September 2014.