by Tim Noakes
Marais should acknowledge that the LCHF eating plan might have a special role in the management of heart disease, even if it can only reverse the ‘other factors’ that he admits contribute to its development. Recall that even in FH, environmental factors including diet are critically important in determining health outcomes.130
Stassen does present my IR theory of heart disease, but counters it by saying, ‘Marais says there is more than enough scientific evidence to show that [sic] impact of blood cholesterol on coronary heart disease.’ As I describe in detail in Chapter 17, there is no such evidence, and there is still no definitive evidence that an elevated blood cholesterol concentration is the direct cause of arterial disease.
The article ends with Van der Merwe saying:
The whole concept of insulin resistance being the root of all evil comes from a poor understanding of metabolic and biochemical pathways … An elevated insulin level purely means that your pancreas is stimulated by the capacity of your body to over secrete insulin. It doesn’t mean to say that you have IR. IR only becomes a reality when you’ve developed glucose intolerance … and the glucose is spilling over into the blood stream.
Van der Merwe falls into that group of endocrinologists who believe that T2DM is an inevitable consequence of being human in the 21st century. So the IR that causes the disease can simply be ignored. When the obese patient with IR finally develops T2DM and ‘glucose is spilling over into the blood stream’, he or she can always be treated with insulin. Or bariatric surgery. So what’s the problem?
The problem is that T2DM patients treated with insulin do rather poorly in the long term, as we have seen. Our key responsibility should therefore be to ensure that people with IR do not develop T2DM. But it seems that some endocrinologists, like cardiologists, are not particularly partial to preventive medicine. I wonder why that is?
Is it because our profession has become programmed to produce customers for the pharmaceutical industry, instead of cures for sick patients?
*The HSFSA declined permission for the authors to publish the article in full in this book. It can be found on the HSFSA website at http://www.heartfoundation.co.za/topical-articles/highs-and-lows-low-carb-high-fat-lchf-diet.
8
The Banting for Babies Tweet
‘A man’s errors are his portals of discovery.’
– James Joyce, Irish novelist
On the suggestion of Lewis Pugh, whom I assisted in his ice-cold-water swims in the Arctic and Antarctic, I joined Twitter on 9 April 2012. Lewis suggested that this would be a great medium to expose my ideas about the low-carbohydrate diet to a global audience. Although acting on his advice would ultimately lead to the HPCSA’s hearing against me, it was one of the best pieces of guidance I have ever received, because Twitter is perhaps the best educational tool I have yet encountered.
I began by ‘following’ those physicians and scientists who are at the forefront of the science and practise of LCHF diets. Immediately, my understanding of this topic began to increase dramatically. There is no other medium that, if properly used, can provide 24-hour coverage of exactly what is happening around the world in one’s specific areas of academic interest.
But to enjoy all the advantages of Twitter, I first had to develop immunity to its evil offshoot: the personal attacks of the Twitter trolls, the porch dogs of the internet community, as well as those of the activists and the astroturfers.1 Just as I was learning how to handle their annoying attentions, something much more threatening started to emerge.
Once The Real Meal Revolution had been released in November 2013, I began to receive invitations to talk about the book and the Banting revolution that it had sparked. Over the next 14 months, I would give more than 100 talks to as many as 30 000 South Africans across the length and breadth of the country. Without fail, the reception was the same. I would speak for about an hour, answer questions for another 45 minutes, and then autograph books and interact with the book buyers for perhaps another hour or two, depending on the size of the audience.
I doubt that any South African doctor or scientist in history has ever spent so much time interacting with the South African public on a single medical/scientific topic. This unique, in-your-face experience has taught me exactly what it is that the South African public wants to know about nutrition. An experience, I might add, not shared by colleagues hiding in the academic ivory tower, expressing their displeasure from on high.
One such talk, on 28 January 2014, formed part of the Extraordinary South Africans Series. It was no different from any of the other lectures that I would give over the next 12 months, except that it lasted a little longer, about 75 minutes, and included introductory material about my challenging of established dogmas. I ended the introduction with a summary of what I then considered to be the ‘Four Absolutes for Healthy Nutrition’:
Healthy nutrition requires the best possible nutrition for the gut and the brain.
What you eat determines what you eat.
Absolutely no sugar or artificial sweeteners.
Keep carbohydrates between 0 and 200 grams per day, depending on your level of insulin resistance.
I then discussed how we had been taught to fear fat (lipophobia); how there is no evidence that a high-fat diet causes heart disease; how obesity and T2DM rates rose dramatically after the introduction of the 1977 US dietary guidelines; and how the insulin model of obesity could easily explain why exposing populations with high rates of IR to high-carbohydrate diets produced the diabetes/obesity epidemic. I indicated that all the evidence supporting this interpretation was available in The Real Meal Revolution.
I began to wrap up with a review of my recently published paper in the SAMJ, describing the stories of the five ‘miracle’ responses to LCHF contained therein,2 before ending, as I tend to do, with quotes from eminent persons. Thus, I quoted American historian Daniel Boorstin, whose statements would prove frighteningly predictive of what was about to happen to me:
The greatest obstacle to discovery is not ignorance – it is the illusion of knowledge … I have observed that the world has suffered far less from ignorance than from pretensions to knowledge. It is not skeptics or explorers but fanatics and ideologues who menace decency and progress. No agnostic ever burned anyone at the stake …
My concluding slides stated the following:
Current dietary guidelines based on lipophobia are not evidence-based and are harmful.
Adoption of the 1977 Dietary Guidelines for Americans caused the global epidemic of obesity and diabetes after 1980.
This can be explained by exposing those with IR to inappropriately high carbohydrate intakes.
Carbohydrate-rich diets are the cause of a wide range of modern chronic diseases of lifestyle.
So that:
The hidden role of carbohydrates in our ill health needs to be acknowledged.
Diabetes and obesity are carbohydrate-dependent diseases.
All cancers are carbohydrate-dependent diseases.
Dementia is a carbohydrate-dependent disease (type-III diabetes mellitus).
Certain bowel disorders are carbohydrate-dependent diseases.
My final slide quoted the words of biologist Louis Agassiz: ‘Every scientific truth goes through three states: first, people say it conflicts with the Bible; next, they say it has been discovered before; lastly, they say they always believed it.’
These were the themes that I would take with me as I travelled across South Africa speaking about the biology of the LCHF diet and why this eating plan should be the first choice for all those with IR and who have difficulty controlling either their hunger or their weight when eating the typically prescribed LFHC ‘prudent’ diet. In none of my talks did I ever detail what anyone should eat – in other words, not once did I prescribe a detailed diet for anyone, either in private or in public. That is not my job. I am a scientist interested in informing the public about science, something I have been doing for more than 45 years.
Impo
rtantly, in that talk, as in all my others (which ante-dated publication of our book on child nutrition, Raising Superheroes), I made no mention of breastfeeding or infant nutrition. And so I was perhaps a little surprised during the question time when I was asked to explain why, if breast milk contains carbohydrate, it does not prove that humans have an essential need for carbohydrates. Since the talk had focused solely on nutrition in adults, I considered the question unusual, but thought no more about it.
Over the next few days I became aware via Twitter and social media that a group of Johannesburg dietitians, who practise jointly as Nutritional Solutions Registered Dietitians (NSRDs), had been present at the talk. In a subsequent blog post on their website, published on 31 January 2014 and titled ‘Prof Tim Noakes: Clarifying the Controversy’, they proudly stated that each had recorded my talk.3 This is the first time in 42 years of public speaking that anyone has admitted publicly to taping what I said without having the decency to first inform me. Why had they done this, I wondered, since essentially all the material is in The Real Meal Revolution or on YouTube?
It is important at this point to note that one of the NSRDs was Claire Julsing Strydom, the dietitian who would lodge the complaint about me with the HPCSA on 6 February 2014, less than a week after this first post appeared.
On their blog, the NSRDs wrote that they had decided to attend the lecture to discover what dietary ‘advice is being dished out’. In which case they must have been disappointed, because, as I have said, I do not ‘dish out’ dietary advice in my talks. Among others, they made the following points:
[Noakes] constructs his argument cleverly by starting with disregarding the majority of nutrition studies – ‘pharmaceutical industries support doctors and research’, and ‘90% of nutrition research is associated evidence, association does not prove causation’ … most of the audience left feeling slightly overwhelmed and confused by the actual advice [to restrict carbohydrates by eating more fat, to eat only when hungry and only once a day] that was given – besides of course that bacon, liver and eggs should be staple foods from 6 months onwards … We were also very interested in the way the Dietetics profession was described; somewhat dowdy, backward thinkers, close minded and heavily relying on the food pyramid from back in 1977.
They concluded by saying that they would be ‘developing a series of blogs that will be posted over the next few days which will hopefully provide some evidence-based, objective guidance and a better understanding of healthy eating’.
A number of the comments at the end of the post were extremely supportive of what I had said. In response to one comment from a user defending me and alleging that I had been misquoted, the NSRDs observed: ‘it is concerning how easily information that Prof Noakes is disseminating, can be misinterpreted. It is this issue that causes us, and a number of other health professionals, grave concern.’ So it is not what I am saying that is wrong – it is how it ‘can be misinterpreted’. But, I would argue, it can only be misinterpreted because it conflicts so absolutely with what the NSRDs advocate.
On 1 February, I responded with the following comment:
My talk was not primarily about what people should eat. It is about the absence of science behind the current dietary guidelines. I then state what I think nutrition should be about especially for those with insulin resistance. I wish you would represent what I said more honestly. Suggest you listen to all 13 hours of what I have said on the internet as has clearly Jan Nel (above). Why not focus on the absence of evidence for the 1977 Dietary Guidelines that was the main point I made in the lecture? The rest follows from that but is not my main message.
My point is that the internet has changed everything. The general public is now better informed on nutritional issues than ever before in our collective history. They are searching for what works. If they are given by me or anyone else information that does not work, they will no longer feel compelled to listen to that advice. They will simply go onto the internet to find what others have found to work for them. And they will follow that advice.
The success of Real Meal Revolution is because the book provides a simple explanation of what people who are struggling with their weight or health, because they are insulin-resistant, should be eating. They try this ‘unhealthy’ diet and suddenly find renewed vigour and health as did I. Then they wonder why they had been mislead to believe that what they had been eating and which caused their ill health continues to be promoted as healthy for all by a majority of dieticians globally. That is the question that you need to answer. Because if you fail to answer it, your profession will pass into history as an interesting anomaly. And it will happen very quickly. In this modern world with modern communication, bad ideas can become obsolete very quickly (think Nokia and Blackberry). My profession, especially the medical care of chronic illness, faces exactly the same problem.
I always say that your profession is the most important of all the caring professions. You need to embrace and act on these ideas and not see them as threatening.
I look forward to reading your blogs on insulin resistance and the use of HbA1c in monitoring health and preventing the diabetes epidemic.
We really should be friends.
It was at this point that Stellenbosch dietetics graduate Marlene Ellmer entered the debate. She would become an active participant in the HPCSA hearing, including offering to be an expert witness against me. But as the trial drew nearer, she had second thoughts and withdrew. She did, however, provide a summary of the evidence she wished to present (see Chapter 10).
In her first comment on the NSRD blog post, published on 2 February, Ellmer began:
I think the important issue here is that nutrition information is sent out to the general public in an assertive and effective way, which could be potentially dangerous and harmful to a nation’s general health over the long-term. I can draw the comparison to a dermatologist who stands up and dishes out information about a heart condition and in the process discredits all the cardiologists.
Ellmer seemed unaware that I am an A1-rated scientist in nutrition who has published more than 150 publications dealing specifically with nutrition topics, and that for just those articles I have an H-index of 45, higher than that of any of the nutrition experts who would testify against me and whose publications deal solely with nutrition. As far as I can tell, besides her master’s thesis,4 Ellmer herself has co-authored a single publication in a peer-reviewed journal.5 Neither deals with nutrition for health.
She continued by saying that ‘Tim Noakes makes the argument that we all got sick from a low fat, high carbohydrate diet over the past 20 years’, then adds the non-sequitur, ‘so why should we take the risk of making the same mistake all over again’. Except, of course, for the fact that the diet I am proposing is the diet that humans ate for more than two million years before the introduction of the 1977 US dietary guidelines, and which was associated with low rates of obesity and diabetes in all populations around the globe (see Chapter 16). What new evidence do we need to prove that the diet we ate in the 1960s, which was much lower in carbohydrate, was unhealthy?
In another response, on 5 February, Ellmer stated that: ‘There is not [sic] such thing as a low carb diet without high protein.’ This erroneous statement suggested that perhaps her understanding of the LCHF diet was based on emotion, not fact. She continued: ‘What worries me is if messages are sent to the public that are not well researched or important research are [sic] ignored to state a case and also when these diets are advocated for children who rely on their ignorant parents to feed them well. I will always stand up against that.’
She concluded by proposing that: ‘A good person to follow for excellent but “less sexy” advice for how to be totally disease proof is Dr. David Katz … My money would be on him if then not “trusting a dietitian with nutrition”.’
I will deal with Katz and how money helps influence which nutritional ‘science’ he supports later.
It is interesting that Ellmer’s c
oncern about messages being ‘sent to the public’ does not extend to the current dietary guidelines, which are not evidence-based and which have clearly caused great harm. And neither Ellmer nor any of the NSRDs address the comments of people who found benefit in the LCHF diet. For example, on 3 February Etienne Marais wrote:
Most of the top LCHF advocates openly say it’s not for everyone, but it’s certainly for me. Curious about why we have never heard about this from dietitians, I entered into an e-mail discussion with a few dietitians in South Africa. All I have got is negative scare tactics about health risks, which frankly I don’t believe because LCHF is as old as the hills and if this was really known then people like Dr Eric Westman … would have been sued a long time ago!! … Gone are hunger pangs and the need to snack all the time.
The NSRDs produced a further three blogs, which continued the debate that ended with my final response six months later, on 4 July 2014. This is important, because it shows that I was actively involved in discussions with these dietitians at the same time that at least one of them was working with the HPCSA to ensure that I would be charged for expressing my opinions on social media (see Closure).
In the second blog, published on 6 February, the NSRDs responded to seven points I had made in my comment on their initial blog.6 None of the responses was particularly enlightening or presented any hard science to disprove what I had said or written. Most were defensive.
In response to my question of why they had not highlighted my contention that the 1977 US dietary guidelines are not evidence-based, they wrote: ‘Why focus on something that was used 37 years ago? Dietary guidelines have changes [sic], nutrition is an evolving science. Getting stuck on evidence for outdated guidelines will get us nowhere – for us to move forward in this debate we suggest that the focus is on current research.’