by Tim Noakes
This is a disingenuous response. The dietary guidelines have not changed since 1977, and they are still not evidence-based, as Nina Teicholz7 and Zoë Harcombe8 have clearly shown. The guidelines continue to be based on the dogma that dietary fat causes heart disease; a falsehood that remains the basis for the nutritional advice provided by the NSRDs. It is not I who continues to promote ‘outdated guidelines’.
In response to my suggestion that the public is now better informed than ever because of social media, the NSRDs responded: ‘Better informed, or misinformed? … The problem is that there is information out there that is also harmful and misleading, with quick fixes and false promises, leaving people conflicted, unsure and more confused than ever.’
They miss the point that the internet exposes false information and quackery even more effectively than it promotes correct information. The public is only confused to the extent that people are now finally realising that those in whom they put their trust were wrong. Once the truth is known, the public will no longer be confused. The confusion now lies with the dietitians, who must adapt to a new reality; a reality in which most of what they have been taught has been proved to be wrong.
To my suggestion that The Real Meal Revolution is successful because it provides a simple explanation and solution for the problem of weight control and obesity, the NSRDs offered the standard answer: ‘A simple explanation to a complex problem is a concern in any scientific field.’ Their problem is that millions of formerly obese or overweight people have now discovered that there is a simple solution to their weight issues: eat fewer carbs and no sugar, stop eating addictively, lose the feeling of hunger and watch the weight fall off. There is nothing complex about it.
This blog attracted 46 responses, including a number from people who have benefited from the LCHF diet and who wished to share their experiences. Andrew hinted at the problem: ‘From an outsider’s perspective, it looks as if Prof. Noakes – in saying that dietitians the world over, are essentially giving their patients the wrong advice – has indeed hit a nerve … For me, what is becoming increasingly evident, is that people seem to have lost faith in the dietitian industry, and are very clearly turning to their own guidelines based on what they read on the internet.’ While Charles Nankin noted: ‘What is perhaps more intriguing is to understand how and why our trusted institutions and industries are leading us into this mess on a global scale.’
Johan van Niekerk described how his father had adopted the LCHF ketogenic diet in preference to chemotherapy and had successfully survived what had been diagnosed as a terminal cancer. He added:
I have no faith in registered dieticians. The fact that The Real Meal Revolution is the no. 1 selling book in South Africa is testament to the fact that the rest of South Africans don’t trust dieticians. The prudent diet was advocated for many years and it makes us sick. I’ve seen results first hand, this shook our foundations and caused us to wake up. As a family we have never been healthier and never felt better and never performed better … Registered dieticians don’t make the grade. Professor Noakes and many other researchers such as prof Eric Westman do however and I trust their guidance, supported by proof, clinical studies and randomised trials. The fact that more and more medical doctors are following the diet is overwhelming.
Ellmer responded thus:
To hear that South Africans do not trust dietitians based on a book that is a recent best seller, really makes me wonder what the public understand about a role of a dietitian and what has happened to common sense and logic. To quote the person you love and trust with your life: ‘Group think?’
We are but the messengers. We implement guidelines to the best of our knowledge and available science, we work very hard to keep up to date with medical and nutritional sciences. We do the best we can at any given point in time.
We first attempt to do no harm. We don’t sell books to make our point, because that forms part of our daily job. That is what we get paid for. We do not publish millions of fan letters telling us how we have changed their lives, because its [sic] part of our daily job, what we get paid for. We do get acknowledged daily in our patient’s [sic] lives. We do receive fan mail and gratitude and thank you’s. You just don’t hear about it because I do not announce it on 5FM.
Whether a dietitian is right or wrong, to be judged by the amount of fans, or the fact that a book sells so well, surely is a very one-sided view?
If you as a family to do [sic] better and healthier according to a diet book by Tim Noakes, then wonderful for you. But to blame the worlds [sic] problems and shoot the messenger, and nullifying a role of a dietitian is unnecessary.
This is the classic straw-man argument that would increasingly be employed by my critics. Van Niekerk’s point is that the prudent low-fat diet has not worked for him and his family, and because this is the only diet that South African dietitians are allowed to prescribe, he has lost faith in the profession.
Instead of addressing his argument, Ellmer launches into an ad hominem attack, casting me as an egotist who writes books for financial gain (which is untrue – I donate all the royalties from all my books) and who craves media attention and praise. She does not understand that what I speak and write about in public is the result of 40 years of daily toil in the pursuit of science, or that, as we now have a diet that can reverse obesity and put T2DM into remission,9 the new reality is that from now on dietitians will be judged on the results they produce in their patients and not on how effectively they can badmouth those who promote ideas with which they disagree.
Van Niekerk was not convinced by her response, explaining in another comment that the only way he could control his weight when eating the prudent diet was to train for the Ironman triathlon:
If you are not active enough you just have a constant battle with picking up weight, controlling hunger and cravings [my emphasis] and trying to eat low glycemic to avoid spikes and falling asleep at your desk.
The only alternative was to really get very active. The road to and taking part in an Iron Man event solved it all. I could eat as much as I needed and still lose weight. I just had to train vigorously twice a day. In a modern world with demands of a professional career you can only be that active up to a point. After scaling down on such vigorous activity you start picking up weight again and then the starving and cravings control the rest of your day.
I’ve been to at least three dieticians for advice, none of the diets are the same. Although they make sense nutritionally I’m constantly hungry [my emphasis].
For me it’s about quality of life. After adopting the ‘Banting’ or ‘Modified Paleo with dairy’ or ‘Noakes’ or ‘Westman’ or what ever you want to call it diet, my quality of life has improved. In fact, I have not heard a single complaint from anyone who I talk to about this way of living. I don’t get hungry, I never have cravings, I can do a olympic triathlon without eating breakfast and not eating anything in a better time than in the past. My total cholesterol is down [from] 6.8mmol/l to 4.9mmol/l. I have not been ill since starting this lifestyle and my allergic rhinitis subsided.
Another dietitian, Magda Uys Pieters, also accused The Real Meal Revolution of demonising dietitians. In fact, the word ‘dietitian’ does not appear in the index, and I was unable to trace any reference, good or bad, to the profession anywhere in the book. Instead, the book focuses its criticism of the current obesity/diabetes epidemic squarely on the development and promotion of the 1977 US dietary guidelines, which were not drawn up by dietitians, but by a government agency.
Regardless, Pieters wrote:
As a dietician(RD) I feel very frustrated because our profession IS being attacked/damaged by the whole Tim Noakes debacle! If you read all the comments, you would swear we as dieticians are responsible for all the Obesity, Diabetes etc. as if ALL overweight people followed recommendation set out by a dietician! NO! Most people don’t care a tick about guidelines, they eat & drink merrily whatever taste good, and only seek advice AFTER their health deteri
orates, so the cancer, diabetes, insulin resistance, obesity start LONG before they visit a registered dietician.
This is the classic defence of blaming the victim for any unfavourable outcomes. The truth is that, while carefully adapting their dietary patterns to those prescribed by the 1977 US dietary guidelines, Americans have become fatter and sicker. A report by the Credit Suisse Research Institute titled ‘Fat: The New Health Paradigm’10 includes the following table (Table 8.1) listing the changes in dietary intake patterns in the US from 1971 to 2009:
Table 8.1 Potential nutritional drivers of the obesity epidemic that began after 1977
% change
1971–1975
2009–2010
1971–2009
Potential drivers
Calorie intake (NHANES)
1 955
2 195
12%
Macronutrients (NHANES)
Carbohydrates
Grams per day
% of daily energy intake
215
44
280
51
+30
Protein
Grams per day
% of daily energy intake
82
17
88
16
+7
Fat
Grams per day
% of daily energy intake
79
37
80.5
36
+2
Saturated fat
Grams per day
% of daily energy intake
29
14
27
11
-7
Food (FAOSTAT) (grams per day)
Eggs
Butter + lard
Corn
Wheat
Vegetable oils
Red meat
Chicken
Dairy
Sugar
48
23
17
180
44
235
59
669
133
38
14
34
218
83
179
141
703
166
-21
-39
+100
+21
+89
-24
+139
-5
+25
Table 8.1 clearly shows that, compared to what they ate in 1971, by 2010 Americans were on average eating 12 per cent more calories, 30 per cent more carbohydrates, comprising 100 per cent more corn, 21 per cent more wheat and 25 per cent more sugar. There had been a simultaneous 7 per cent reduction in saturated-fat intake as the result of an astonishing 89 per cent increase in vegetable-oil consumption, a 39 per cent reduction in butter and lard use, a 5 per cent reduction in dairy consumption, a 24 per cent reduction in red meat consumption and a 21 per cent reduction in eggs, all balanced with a 139 per cent increase in the consumption of (skinless, low-fat) chicken. With the exception of the rise in sugar intake, these changes align with what the 1977 dietary guidelines advocated. The unintended consequence of taking fat out of the diet was its replacement with sugar – this was not something that the people who drew up the guidelines ever considered.
I defended myself against the charges in the latest blog:
My goal is not to demonise dieticians (I focus almost exclusively on the distortion of science and the inability of my profession to see the reality especially as it relates to diet and heart disease) but to point out that current dietary advice is not working. There is no evidence that this is because the public is deviating greatly from these guidelines. They are eating low fat, high carbohydrate diets as they have been told to do. Interestingly the real deviation is in the carbohydrate intake. Those South African populations eating the most carbohydrate are amongst the illest – a paradox that no one seems too keen to address.
But the other evidence is that when people do the opposite to the guidelines and reduce their carbohydrate intakes, they suddenly start to do a whole lot better in all the health measurements that we have.
My privilege is to be insulin resistant and to have eaten both the prudent diet and the high fat diet and to have observed the quite opposite effects on myself and my health. I wish more dieticians could share my personal experiences because it would definitely influence how they see the ‘science’. And whether they are prepared to dig deeply into the very large body of evidence showing the benefits of low carbohydrate diets in those with insulin resistance. A good place to start might be with the premier researchers in the field – Jeff Volek and colleagues – The Art and Science of Low Carbohydrate Living and The Art and Science of Low Carbohydrate Performance.
Again, I focused on the question of hunger control, which the NSRDs seemed completely to ignore:
Finally the influence of fat and protein on satiety is never mentioned. The body is a complex organism with a brain that directs what we eat and how much. The brainless calories in/calories out model of obesity ignores the fact that nutrient poor, high carbohydrate diets do not satiate hunger and lead to the overconsumption of calories in very many. One needs to understand the control of hunger fully to appreciate this effect.
So in my opinion, promoting a high carbohydrate diet has to promote obesity simply because, for many, it does not satiate. And there is a strong biological explanation for this. Then you add in sugar addiction and the results are the explosive rise in obesity since 1980.
When other commenters supported my idea that the obesity/diabetes epidemic had to be the result of adopting the 1977 Dietary Guidelines for Americans, Ellmer conceded: ‘If Tim Noakes simply said, promotion of low fat, high carbohydrate diets lead [sic] to obesity epidemic we would certainly not have this debate. I think many dietitians including myself actually agree with this statement of his.’
This is pretty much all I say in my lectures, besides detailing why this happens biologically, why we need to understand IR if we want to reverse the obesity/diabetes epidemic, and why carbohydrate restriction is the key factor in managing IR, and therefore obesity and diabetes.
The third blog post, written by Ellmer on 4 March 2014, introduced the topic ‘Is the LCHF diet suitable and safe for infants?’11 By now I knew that Strydom had lodged a complaint with the HPCSA, and since I had not spoken about this topic during any of my talks, I could only assume that Ellmer had written this latest blog to support Strydom’s complaint. The blog did not contain anything of value, and did not muster any evidence that the LCHF diet is indeed unsafe for infants. But it clearly represented a shift in the focus of the blogs, which the NSRDs had promised before Strydom decided to report me to the HPCSA.
Ultimately, Ellmer failed to address the real issue: What are the (epigenetic) effects of mothers eating high-carbohydrate diets during pregnancy and weaning their infants onto these diets? The answer is that their infants will be increasingly insulin resistant and at greater risk of developing obesity and diabetes.12
The NSRDs seemed very keen to introduce Ellmer as their new anti-Noakes attack dog. Her special assignment would be to continue addressing the dangers of the LCHF diet for breastfeeding mothers and infants, presumably in anticipation of any potential HPCSA action against me. To this end, Ellmer concluded the series of blog posts on 5 March with a fourth, titled ‘LCHF diets continued: Are they safe for pregnant and/or breastfeeding mothers?’13
With this blog, Ellmer tried to build the case that the LCHF diet is detrimental for pregnant mothers. The sole lines of evidence she could muster were the following:
‘No human studies have been done in this area to date, but animal studies show a strong association between ketosis [produced by a reduced carbohydrate intake] and reduced milk production.’ Presumably Ellmer wishes us to conclude that the same will apply to human mothers who choose to reduce their carbohydrate intake when
breastfeeding.
‘One study carried out in 3601 pregnant mothers showed that high levels of urinary ketones led to a >2-fold occurrence of oligohydramnios (amniotic fluid insufficiency) and a significant increase in foetal heart rate decelerations.’ Ellmer fails to mention that the pregnant mothers in this study suffered from starvation and dehydration, and that any disorders detected in their infants were likely an effect of malnutrition and associated poor socio-economic circumstances, not ketosis.
‘It is widely acknowledged from nutrition studies that with LCHF diets, protein intake increases and high protein intakes are associated with bone mineral loss and calcium excretion. A pregnant and breastfeeding mother’s calcium requirements are higher than most adults, putting her at a risk for poor bone health.’ But the LCHF diet is not a high-protein diet, it is a high-fat diet – a distinction I would expect a registered dietitian to understand.
‘Excluding fruit and whole-grain from your diet may lead to inadequate intake of anti-oxidants and other nutrients and evidence has shown an association linking inadequate antioxidant status in utero and early childhood to an increase in the risk of allergic disease, amongst other concerns.’ This makes one wonder how hominin infants survived for two to three million years before the development of agriculture. According to Ellmer’s logic, they should have all died, taking the human race with them.
I commented on this blog some months later, on 4 July 2014, perhaps because by that time I had received confirmation that the HPCSA was considering an action against me.
After birth, the greatest threat to the long term health of the babies of mothers reading this website, is the development of insulin resistance, obesity and diabetes at increasingly younger ages. We know that each generation of children born to such mothers is getting fatter and is at higher risk of all these conditions. Since genes have not changed, this raises the possibility that epigenetic effects acting before and after the child’s birth may play a role. One factor that has changed in the last 50 years is the advice to mothers to increase their carbohydrate intakes during pregnancy and to wean the child onto cereal-based, high carbohydrate diets. But ingested carbohydrates have no essential role in human nutrition whereas fat and protein most certainly do. It is not possible to build healthy bones, brains and bodies on diets that are high in carbohydrate with obligatory reductions in fat and protein contents. Worse carbohydrates raise blood glucose and insulin concentrations needlessly – there is no biological advantage to having continuously elevated blood glucose and insulin concentrations. My point is that exposing the foetus to high glucose and insulin concentrations during pregnancy by having the mother ingest unnecessary carbohydrates makes no sense since it could produce epigenetic effects that may cause the child to be more likely to develop insulin resistance, obesity and diabetes mellitus. Unless you can be absolutely certain that this is not the case, and that your advice is not increasing the probability that children exposed to high glucose and insulin concentrations before and after birth are not being needlessly predisposed to the development of these conditions, you should perhaps be less certain (dogmatic) that your advice is the only correct option. Thank you.