[2017] Lore of Nutrition: Challenging Conventional Dietary Beliefs

by Tim Noakes

  In one report on the hearing, I described the Angels as all slender, gorgeous, glamorous women, highly intelligent and packing heavy scientific weaponry. The Twitter trolls didn’t like that, and attacked me for being sexist, irresponsible, untrustworthy, unscientific, etc. I was simply stating the obvious. These women are the best advertisements for what they preach and practise – and the benefits of ignoring the conventional LFHC dietary guidelines.

  All the Angels have impeccable scientific pedigrees. Harcombe is a Cambridge University graduate in mathematics and economics. She has spent years researching nutrition. Her doctoral thesis, on the evidence for the introduction of dietary fat recommendations in the US and the UK in 1977 and 1983 respectively, earned her a letter of commendation as well as a PhD. Her thesis is a fascinating nutrition science ‘whodunnit’, in which she looks at why the official dietary guidelines in the US, the UK and elsewhere are woefully inadequate, unscientific and yet still persist.

  Harcombe co-authored a much-cited meta-analysis in the BMJ’s Open Heart in 2015, which showed that evidence from RCTs did not support the introduction of the dietary guidelines in the US and the UK in the late 70s and early 80s. ‘Dietary recommendations were introduced for 220 million US and 56 million UK citizens by 1983, in the absence of supporting evidence from RCTs,’ the authors concluded.1 Harcombe followed that meta-analysis with another in the British Journal of Sports Medicine in 2016, showing that evidence from prospective cohort studies does not support current dietary fat guidelines.2 She has also authored many books, among them The Obesity Epidemic.

  Teicholz took pre-med courses at both Yale and Stanford, graduating from the latter with a major in American studies. She also has an MPhil from Oxford University in the UK, and was the first journalist elected to Phi Tau Sigma, the elite American honour society for food science and technology. She is best known as the author of the international bestseller The Big Fat Surprise: Why Butter, Meat and Cheese Belong in a Healthy Diet, which is widely acknowledged by doctors and scientists as a seminal contribution to the understanding of nutrition and disease, and the politics of nutritional science. In her book, Teicholz documents the, personalities, politics and history of nutrition science, and shows how the belief that dietary fat, especially saturated fat, causes heart disease was enshrined in the public consciousness in English-speaking countries by health authorities. The Big Fat Surprise is the first mainstream publication to argue that saturated fats – found in dairy, meat and eggs – do not cause disease and can actually be considered healthy.

  So influential has Teicholz become that in 2015 the Canadian senate invited her to give an hour of testimony on the findings of her book to its committee charged with overseeing the country’s dietary guidelines. Some months later, the committee announced that the dietary guidelines would need a complete overhaul – a process that is now well underway. The USDA followed suit in 2016, inviting Teicholz to give testimony on how to improve nutrition policy. She also helped convince the United States Congress that it needed a formal peer review of America’s dietary guidelines. The National Academy of Medicine began this review in 2016.

  Zinn calls herself a ‘proudly South African Kiwi’. She is a senior lecturer at the Auckland University of Technology Faculty of Health and Environmental Sciences and a registered dietitian and director of a private practice. She graduated from UCT with an honour’s degree in nutrition and dietetics. She also has a master’s degree in sports nutrition and a doctorate in weight loss from AUT. While she is an expert in sports nutrition and LCHF for optimum athletic performance, Zinn specialises in ‘diabesity’, a term coined by doctors for the twin global epidemics of diabetes and obesity.

  With more than 21 years’ experience as a nutritionist and registered dietitian, Zinn’s views on diet have evolved alongside the research and science of nutrition. Many experts have ‘got it all wrong with existing high-carb, low-fat guidelines’, she says. Zinn is a ‘whole-food’ advocate. She believes that everyone can benefit from eating foods that are lower in carbohydrate and higher in healthy fat than the current guidelines recommend. She has done ground-breaking work on hyperinsulinaemia,3 an under-recognised, poorly diagnosed but highly prevalent condition, which a low-carb diet can alleviate. She has also co-authored books on nutrition with New Zealand nutrition scientist Professor Grant Schofield, including What The Fat? Fat’s IN, Sugar’s OUT.

  All of Tim’s Angels had relevant expertise in all the issues pertaining to the case against Noakes. Despite this – or perhaps because of it – the HPCSA’s legal team did its best to clip their wings and prevent them from appearing before the Professional Conduct Committee.

  When I heard that the defence was applying to add Harcombe and Teicholz to their list of experts (Zinn had been on the list from the start), I emailed the HPCSA to ask if there would be an objection and on what grounds. As usual, they stayed resolutely mum. The instructing attorney, Katlego Mmuoe, politely declined to answer my questions. I wasn’t all that surprised to learn later that Mmuoe had refused a written request from Noakes’s legal team prior to the October session to allow the Angels to appear. Thus, when the hearing resumed on Monday 17 October, the HPCSA wasted most of that first day trying to block the defence’s application.

  Bhoopchand put up a spirited fight that added to the impression of ferocity with which the HPCSA was prosecuting Noakes. Up until now, the defence had called only one witness: Noakes himself. The HPCSA had called six. While Noakes did have ‘two hats on’, as Bhoopchand noted, giving both factual and expert testimony, he was still just one witness. One might reasonably have thought that, on the grounds of fairness alone, the HPCSA would have agreed to Tim’s Angels beforehand. After all, six against four were still favourable odds, and there would have been some benefit in being seen to be reasonable for once. But perhaps the HPCSA realised just how big a threat the three women posed to its case.

  In his vociferous objection to the inclusion of Harcombe and Teicholz, Bhoopchand used a shotgun approach to cover as much ground as he could. That included attempting to block any new evidence Noakes wanted to introduce (at this point, Noakes was still giving evidence). Bhoopchand’s first major objection was procedural. He claimed that Noakes was introducing new and old evidence and witnesses too late in the proceedings. He said – ironically, given the HPCSA’s well-documented delaying tactics and their own inclusion of last-minute witnesses – that this would ‘cause delays’ that would prejudice both Noakes and the HPCSA.

  Bhoopchand likened Noakes’s evidence to a ‘deluge’ and contended that the burden of evidence was so heavy that he would not be able to conduct a proper cross-examination. I didn’t think it was so smart of Bhoopchand to suggest that he wasn’t up to the job of cross-examining Noakes.

  His major objection to Harcombe’s and Teicholz’s evidence had to do with relevance. The inclusion of Teicholz, in particular, rankled him. ‘What my colleagues didn’t tell me is that she’s a journalist,’ he said with emphasis, before adding with even heavier emphasis, ‘an investigative journalist.’ She writes books about science ‘in layman’s terms’, he observed. He completely ignored Teicholz’s academic qualifications, as well as the acknowledged scientific content of her book, The Big Fat Surprise.

  ‘Breathe deeply,’ Van der Nest muttered audibly to himself as he rose to challenge Bhoopchand’s objections. Portraying Teicholz as ‘only a journalist’ was an insult to a witness who had spent time at Yale, Stanford and Oxford, Van der Nest said. What was ‘particularly egregious’, however, was Bhoopchand’s objection on the basis of relevance. He had clearly not read The Big Fat Surprise or Harcombe’s doctoral thesis. ‘I’ll bet folding money on it,’ Van der Nest said, adding, ‘You can only say something is irrelevant if you have read it.’ Bhoopchand remained silent at that suggestion.

  Van der Nest also pointed out that the HPCSA’s duty was ‘not to secure a conviction’, but rather to assist its Professional Conduct Committee in determining the truth. Hearing al
l relevant evidence was crucial to that process. Ramdass would later describe as ‘unfathomable’ Bhoopchand’s argument that the evidence of Teicholz and Harcombe was irrelevant.

  In the end, the Professional Conduct Committee agreed with the defence. The chair, Advocate Joan Adams, gave a short and concise ruling, using the HPCSA’s own actions and statements in calling surprise witnesses to rebut their arguments. She pointed out that just as the HPCSA had argued for new evidence and new witnesses on the grounds of PAJA, so Noakes had the same right. ‘[He] is quite entitled to call witnesses, including expert witnesses, to submit background documentation and to lead evidence on certain documentation, in order to assist him to conduct a proper defence in this matter,’ she said. ‘This is his constitutional right and also his right in terms of [PAJA].’ The committee then ruled unanimously that Noakes be allowed to call his Angels.

  On the afternoon of Friday 21 October, with Noakes’s evidence and relentless cross-examination now over, Zoë Harcombe embarked on the ritual slaughter of many nutrition sacred cows. She based the first part of her testimony on her PhD thesis, which focused on the lack of an evidence-base for the US and UK dietary guidelines. She pre-empted cross-examination by emphasising the direct relevance for South Africa, which closely follows the US guidelines.

  Although the charge against Noakes made no mention of the guidelines, the HPCSA had made it clear that, in promoting LCHF, Noakes had gone against the country’s guidelines and was therefore guilty of giving ‘unconventional advice’. Harcombe said that she had researched South Africa’s guidelines for all ages to see how closely they related to the US dietary guidelines. South Africa’s paediatric guidelines, she said, are ‘very good in relation to the rest of the adult guidelines’. She showed how Noakes’s tweet aligned closely with South Africa’s paediatric guidelines. The HPCSA’s own expert witnesses had conceded as much under cross-examination, Harcombe said. Thus, his advice could not be considered unconventional, unprofessional or dangerous, as witnesses had suggested.

  Keeping with the paediatric guidelines, Harcombe said they contained one problematic element in that they recommended starchy foods as key complementary foods for infants. ‘Without that, it would be excellent advice for infants aged 12 to 36 months,’ she said. In Harcombe’s opinion, the introduction of starchy foods was unnecessary. Every time people eat starchy foods, she explained, they miss the opportunity to eat more nutrient-dense foods. And that exacerbates the risk of childhood obesity.

  Harcombe spent much of her evidence on the currently unproven diet-heart hypothesis that saturated fat causes heart disease. In particular, she looked at South Africa’s dietary fat guideline to determine if it still advises a total fat limit of no more than 30 per cent. It does. That advice still ‘prevails across the world despite the fact that there has never been any evidence for that guideline’. She told the hearing that there is still extensive ignorance about cholesterol. Humans make cholesterol for good reason, she said. It is therefore ‘probably not a good idea to be replacing it with a cholesterol that is intended for plants’, as South Africa’s guidelines recommend. Harcombe explained that there is a mechanism by which some plants can lower cholesterol, but commented: ‘Please do not necessarily assume that to be a good thing.’

  ‘Ignorance’ is probably the best word to describe public opinion on dietary fat, Harcombe said. She gave the hearing a mini lecture on the composition of fats, explaining that there are three ‘real’ fats: saturated, monounsaturated and polyunsaturated. All foods that contain fat – olives, avocados, meat, fish, eggs, dairy, etc. – contain all three types, no exceptions. Only dairy products have more saturated than unsaturated fat – ‘not that any real fat is better or worse than any other’, she said. Ironically, red meat has far less saturated fat than oily fish and even olive oil, yet the experts still tell people to avoid eating red meat. They also regularly give messages that seem to suggest that it’s possible to avoid saturated fat, for example, and increase consumption of polyunsaturated fat, Harcombe said. This is especially the case with recommendations to replace animal fats with vegetable oils or fats.

  ‘It becomes a very complex exercise to try and swap some of them out,’ Harcombe said. The only really hazardous fat that is truly unfit for human consumption is trans fat, she said. Trans fatty acids, or trans fats as they are more commonly known, are artificial industrial fats. They are created in a process that adds hydrogen to liquid vegetable oils to make them more solid (see Chapter 7).

  Under cross-examination, Bhoopchand suggested that Harcombe had erred by not pointing out the fact that trans fats occur naturally in dairy and meat from grass-fed ruminants. Harcombe said that she took it for granted that experts would know that. She also drew attention to the important distinction between traces of naturally occurring trans fats in ruminants versus industrially produced trans fatty acids on a much larger scale, as she had previously clarified.

  Harcombe gave another mini lecture on macro- and micronutrients and the constituents of nutrient-dense, ‘real’ foods. Real foods became a recurring theme in the Angels’ evidence. There is only one food that is 100 per cent carbohydrate, Harcombe said, and that’s sucrose (a type of sugar). Sucrose is arguably not even a food, as it has no nutritional value whatsoever. At the other extreme are foods that are 100 per cent fat, such as oils and lards. Every other food we come across, said Harcombe, has protein, whether it is of animal or plant origin.

  ‘Nature makes foods either fat- or carbohydrate-based. Rarely does it put the two together,’ she said. It is therefore unhelpful to set targets for macronutrients because, inevitably, when you set a limit of 30 per cent fat, you also set the recommendation of 55 per cent carbs. Instead, Harcombe said it would be more helpful if experts gave the same advice that Noakes gives: ‘Just tell people to eat real food.’

  Harcombe’s armoury for undermining the evidence-base for ‘conventional’ dietary advice in South Africa was extensive. She used data from her meta-analysis published in Open Heart in 2015 to show that there was no evidence from RCTs at the time the US government introduced its guidelines to 264 million Americans.4 There was still no evidence when the UK and most other English-speaking countries, including South Africa, slavishly followed suit. The UK essentially did a ‘U-turn in dietary guidelines’, Harcombe said. In 1969, the advice was to avoid fattening farinaceous (starchy) foods. In 1983, people were told to base their meals on these foods.

  ‘So we move from the position of understanding starchy and sugary foods to be fattening to essentially “base your meal on starchy foods”,’ Harcombe said. She pointed out that this advice is a key theme running through the South African Food-based Dietary Guidelines for all ages. North-West University professor Hester Vorster, for example, admitted in her evidence that she wrote the guideline to ‘make starchy foods the basis of all meals’, but was unable to provide robust evidence for the recommendation.

  The British and South African guidelines followed the American advice to restrict total fat intake to no more than 30 per cent of calorie intake, and saturated fat to no more than 10 per cent. The recommendation to increase carbohydrate content was an inevitable consequence of setting that dietary fat limitation, Harcombe argued. And the ‘inevitable’ negative consequences for health have been rising rates of obesity, diabetes and heart disease.

  Harcombe looked at epidemiological evidence available when the dietary fat guidelines were introduced four decades ago. At the time, she said, research showed merely an association to indicate benefit. Some experts interpreted it according to the calories-in, calories-out model of obesity: that obesity is the result of gluttony and sloth, and that people just eat too much and move too little. Harcombe explained in detail why CICO is an inadequate model, not least because it contradicts one of the laws of thermodynamics. Tongue-in-cheek, she quoted US science writer Gary Taubes: ‘We woke up somewhere around this point and decided to become greedy and lazy. We had managed to stay slim for three and a half millio
n years, but suddenly 30 per cent of us became obese and almost 70 per cent of us overweight or obese.’

  The reality, Harcombe said, is that since the guidelines were introduced, obesity has more than doubled and diabetes has increased sevenfold in the US. In the UK, obesity has increased almost tenfold, and diabetes four- to fivefold. Referring to South Africa’s sky-rocketing obesity rates in the wake of the official dietary guidelines, Harcombe wrote at the end of her thesis that this ‘at least deserves examination’.

  ‘We are failing our populations if we do not look at the association between obesity and diabetes and the introduction of those dietary guidelines,’ Harcombe told the hearing. If anyone is giving unconventional, unscientific advice, she said, it is not Noakes. It is more likely those who slavishly recommend the country’s food-based dietary guidelines to people with obesity, diabetes, heart disease and other serious health issues.

  Harcombe also raised the issue of compromising links between food industries and ADSA and its former president, registered dietitian Claire Julsing Strydom. Under cross-examination, Bhoopchand asked Harcombe for proof of her contention that ADSA was conflicted. Harcombe had evidence at her fingertips; she showed a slide of the association’s long list of sponsors, which have included Nestlé, Unilever, the sugar industry and Coca-Cola. ADSA executives deny any influence from sponsors. Harcombe, Teicholz and many others have pointed out that – just like drug companies – food companies don’t sponsor organisations that don’t promote their products.

  Harcombe went on to review and thoroughly undermine the Seven Countries Study, Dr Ancel Keys’s seminal study underpinning the US dietary guidelines. Keys’s own data did not support his conclusions about the link between dietary fat and coronary heart disease, Harcombe said. ‘The dietary information in the Seven Countries Study is scant,’ she noted. Keys also erred by not considering factors such as cigarette-smoking, sedentary behaviour, obesity and relative weight in people with CHD. Furthermore, the Seven Countries Study wasn’t even a dietary study, although Keys presented it as such. And as an inter-country study it provided ‘the lowest form of evidence’. Still, Keys concluded that saturated fat was linked to increased risk for heart disease.