by Tim Noakes
The future health of the South African nation depends almost entirely on health professionals finally getting to grips with the condition of IR. Once they do that and realise that the treatment is simple – the LCHF diet – the nation’s health will be on the road to recovery, and the sacrifices my family and I have made in defending my position will have been more than justified.
Modern medicines don’t work
If the arguments I have presented are correct, then the modern pharmacological model of disease management has to fail, because it ignores the cause of so much chronic disease – specifically, high-carbohydrate diets in those who are insulin resistant. Which raises the question: What is the evidence that treating the modern chronic diseases linked to IR with pharmacological drugs really makes any difference in the long term? I will detail the evidence only as it relates to those conditions linked to IR.
Obesity
Drugs for treating obesity are pretty ineffective – average weight loss in these trials is between three and six kilograms,76 and the drugs come with many harmful side effects.77 Whereas at least seven drugs have been passed for the treatment of obesity in the US, the European Union allows only one, orlistat.78 The listed complications of using orlistat include decreased absorption of fat-soluble vitamins, steatorrhea (the presence of excess fat in faeces), oily spotting, flatulence with discharge, faecal urgency, oily evacuation, increased defecation and faecal incontinence.
When you see people losing 10–130 kilograms on the LCHF diet without any side effects, it is difficult to understand why medical practitioners continue to prescribe these drugs. There is an easier way.
Type-2 diabetes mellitus
In Chapter 7, I presented the evidence that more than 90 per cent of patients with T2DM can stop taking insulin if they follow the LCHF diet. Which raises the question: What is the effect of using insulin if you have T2DM? The answer: Not good.
Two recent studies show that progressive use of injected insulin is associated with increases in all-cause mortality, major cardiovascular events and, in one study, cancer rates.79 Other large-scale observational studies from Canada and the UK show exactly the same outcomes. This fits with Reaven’s model that insulin is the driver of much ill health.80
It is better to stop eating the carbohydrates that are driving the hyperinsulinaemia.
High blood pressure (hypertension)
According to a meta-analysis by M.R. Law, J.K. Morris and N.J. Wald, treatment of high blood pressure with medication reduces the relative (not absolute) risk for a subsequent heart attack by about 25 per cent, and for a stroke by about 33 per cent.81 This effect requires that systolic blood pressure fall by 10 mmHg or diastolic blood pressure by 5 mmHg. In our Canadian intervention, studying the effects of the LCHF diet on metabolic syndrome, we achieved larger average reductions in systolic blood pressures (14 mmHg) with diet alone. Many of our subjects had also stopped taking their blood pressure–lowering medications during the trial.82
My point is that the LCHF diet might lower blood pressure more effectively than pharmacological treatments. In addition, the LCHF intervention includes many other benefits that can never be achieved by drugs, because the latter fail to address the primary cause: IR, hyperinsulinaemia and high-carbohydrate diets.
Furthermore, the authors of the aforementioned meta-analysis use relative not absolute risk reduction, and so, by default or design, dramatically inflate the apparent value of the drugs. For example, in this meta-analysis of 464 164 people, 22 115 (4.76 per cent) suffered heart attacks and 17 890 (3.85 per cent) strokes during the average of four years that the trials lasted. If the drugs reduced heart attack risk by 25 per cent and stroke risk by 33 per cent, the percentage of subjects suffering a heart attack would be 4.05 per cent and a stroke 2.54 per cent. Which means that the absolute risk reduction for a heart attack is 0.71 per cent (4.76 minus 4.05), and for stroke, 1.31 per cent (3.85 minus 2.54).
Which further means that to calculate the number needed to treat (NNT),** we divide the absolute risk reduction percentage into 100, giving NNTs for heart attack and stroke reduction of 141 and 76 respectively. Thus, to produce one beneficial outcome in one single patient, we must treat between 76 and 141 hypertensive patients with (expensive) medications for at least four years.
Interestingly, the NNTs for the 10 highest-grossing drugs in the US range between 3 and 24,83 suggesting that the overwhelming majority of people in the US are not benefiting from the drugs they are prescribed.
Perhaps a dietary change might be more beneficial. And less expensive.
Coronary heart disease
The best possible absolute heart-attack risk reduction in people with established heart disease treated with cholesterol-lowering drugs (statins) is between 1 and 3 per cent, with little evidence that all-cause mortality is reduced or life is prolonged by much more than a few days (Chapter 3). This means that between 33 and 100 patients with heart disease must be treated for one person to benefit. Definitive evidence that people without heart disease benefit at all from the use of these drugs must still be provided.84
Alzheimer’s disease
There are no pharmacological drugs that make any difference to this disease. Some argue that promoting ketogenesis with a ketogenic LCHF diet may improve memory in patients with this condition. But because Alzheimer’s is a form of diabetes (type-3 diabetes),85 perhaps the best solution would be to prevent the condition in the first place by following the type of LCHF diet that has been shown to ‘reverse’ T2DM in a large number of people with advanced IR.86
Cancer
As discussed earlier in this chapter, cancer was essentially unheard of in populations eating their traditional diets. Even the mid-Victorian English did not suffer greatly from cancer (Figure 16.7 on page 324). That is why cancer is considered to be a disease of ‘civilization’. Today, cancer is the second-leading cause of death among Americans, with one in four deaths in the US due to cancer. In 2013, 1 536 119 Americans received a new diagnosis of cancer and 584 872 died of the disease. The direct medical costs of cancer in the US are estimated at $74.8 billion.87 Clearly, modern medicine does not yet have any answers for the prevention and treatment of cancer.
But perhaps the Inuit, the Plains Indians, the Masai, the Pathans and other ‘manly, stalwart and resolute races of the north [of India]’, the Australian Aborigines, the Nguni tribes of Southern Africa, the Swiss inhabitants of the Lötschental Valley, the New Zealand Maori and even the mid-Victorians, did.
Our fault is that perhaps we are just too proud to listen.
*Cholesterol is not water soluble, so it does not exist in the bloodstream as pure cholesterol. Rather, cholesterol exists in the blood in the form of water-soluble lipoproteins. Lipoproteins are specific particles containing fat in their centre surrounded by a single layer of phospholipid molecules (fats attached to a phosphorus-containing group), which make them water soluble. Specific lipoproteins were linked to heart disease by Dr John Gofman in the 1950s. But to simplify public understanding of the lipid hypothesis, the AHA and others decided that ‘bad’ cholesterol, not lipoproteins, determines risk of heart disease. This erroneous simplification became a pillar of the false diet-heart hypothesis and the subsequent damage it has caused to global health.
**The NNT provides a measure of the relative efficacy of different medical interventions. For example, if a specific intervention produces a 50 per cent absolute (not relative) risk reduction in a particular condition, the NNT for that intervention is 100/50, which equals 2. This means that the intervention will produce a benefit in every second patient. Most people I know will intentionally submit to an intervention that benefits every third or perhaps fourth patient. Compare this to the use of statins, which benefit one in between 50 and 140 treated patients. I conclude that if most patients were properly informed of the NNTs for statin drugs, they would probably not use them. The number needed to harm (NNH) is calculated in the same way, but for harmful outcomes.
Closure
‘Soon it became apparent, in interview after interview, that the story went far beyond the cold, empirical data, it tapped into base psychology, human limitations, economic incentives, and the deep-rooted, powerful forces of groupthink, forces that carry the inertia of the Titanic. Scientific progress doesn’t glide from one exalted epiphany to the next, like the story of Isaac Newton getting hit on the head by an apple. It is a torch carried by human beings, it lurches, stumbles, wanders into dead ends, and then finds its way back out. It doesn’t march in a straight line – it trips its way toward the truth. But the beautiful thing about science is no matter how bumpy the ride, eventually, because of the process itself, the truth is slowly, inevitably, mapped out.’
– Travis Christofferson, Tripping Over the Truth1
Advocate Joan Adams’s comprehensive ruling achieved what Professor Tim Noakes and his lawyers had dedicated more than three years of their lives to accomplishing: complete vindication before a global audience. No longer did he have to endure the shame of being presumed guilty of nebulous charges by his peers. No longer could they consider him a mad, bad scientist and Public Health Enemy Number One.
Adams’s ruling also confirmed that in a reasonable world, the HPCSA hearing would never have happened. In that world, universities are free of covert influences and are the supreme defenders of intellectual thought and scientific rigour. They do not throw their distinguished scientists to industry-led wolves for daring to challenge orthodoxy. But this is not a reasonable world, as we have demonstrated. Our book therefore reflects badly on all three of South Africa’s top universities: Cape Town, Stellenbosch and Wits. UCT is arguably the most culpable, with Stellenbosch a close second and Wits not far behind. But that’s only relatively speaking. North-West University does not acquit itself well, either.
We have also identified many imponderables weighing down the trial; so many, it’s a wonder the HPCSA managed to get it off the ground.
One of those imponderables is whether the hearing would have happened at all were it not for the inordinately large, incestuous web of UCT academics that eventually spread to the other universities. And what can reasonably be perceived as coordinated smear campaigns against Noakes that began in the wake of his Damascene moment at the end of 2010.
Chief among those academics were cardiologists, lipidologists and dietitians from his scientific home, UCT’s internationally renowned Faculty of Health Sciences. The faculty’s nutrition department, headed by Professor Nelia Steyn, ably assisted by associate professor Marjanne Senekal, was a special hotbed of anti-Noakes and anti-LCHF sentiment.
In condoning and apparently colluding with what was effectively a scientific witch-hunt, UCT created the conditions for the smear campaigns to take root and spread nationally. UCT effectively declared open season on Noakes by condoning academic bullying from within its own ranks. It sent out a sinister signal to all its academics: it would exact a heavy price from even the most eminent scientists for the ‘crime’ of going against dogma. In colluding, all the other universities involved in this extraordinary saga sent the same signal.
The first sign of UCT’s willingness to silence Noakes and suppress the science for LCHF was the cardiologists’ letter to the press in September 2012. At the helm was Patrick Commerford, then cardiology professor and head of the cardiac clinic at UCT and Groote Schuur Hospital. Actually, an even earlier sign of UCT’s innate antipathy towards boat-rocking scientists emanated from a far less scientific space: the personal blog of a lecturer in UCT’s Faculty of Commerce, Jacques Rousseau.
Rousseau’s first blog attacking Noakes appeared in 2012. At last count, he had devoted 30 posts to denigrating and demonising Noakes and LCHF, using religious and cultish terminology. He has compared Noakes to a ‘faith healer’ and called him a bad and dangerous scientist who ‘sounds like a quack’. UCT’s silence on such ad hominem attacks by one of its own lecturers was a prelude to what was to come.
Rousseau’s obsession with Noakes can perhaps best be explained by who his father is: UCT graduate and epidemiology professor Jacques Rossouw, former head of the NIH Women’s Health Initiative in the US. Rossouw is one of Noakes’s most virulent and venomous critics. As we have shown in this book, the Rossouw family has made it their mission to malign Noakes at every turn.
A follow-up to the cardiologists’ letter was also telling: the UCT Centenary Debate in December 2012, in which members of the Faculty of Health Sciences facilitated a debate between Noakes and Rossouw on the science behind diet and disease. What appeared to be a set-up from the start was not so much a debate as a kangaroo court. Rossouw was in Cape Town as a guest of his close friend Professor Krisela Steyn, a UCT Faculty of Health Sciences researcher and an implacable Noakes foe. In an interview with the SAMJ after the debate, Rossouw, Steyn and another UCT colleague, Professor Dinky Levitt, joined forces in coordinated attacks. Rossouw accused Noakes of going down a ‘very dangerous path’ and ‘flouting the Hippocratic Oath’. Steyn called his theories on nutrition a ‘public danger’. Levitt echoed by referring to Noakes as ‘dangerous’.
That was followed by perhaps the most egregious attack on Noakes by his colleagues: the defamatory, inflammatory UCT professors’ letter, published in the Cape Times in August 2014. Signatories included then faculty dean Professor Wim de Villiers, then department head Professor Bongani Mayosi, and Senekal.
Preceding that letter by just a few weeks was the publication of the Naudé review in PLoS One. As we’ve shown in this book, the HPCSA used the Naudé review to build its whole case against Noakes. The review became the oxygen for the ferocious prosecutorial fire that the HPCSA unleashed against him. Who requested the review is significant: the industry-fed Heart and Stroke Foundation of South Africa. The HSFSA is a mouthpiece of the food and drug industries that benefit from the conventional LFHC dietary guidelines. The HSFSA has yet to explain the rationale for requesting the review when there was already a robust Brazilian review on the same topic, which came to precisely the opposite conclusion. The Naudé review remains mired in accusations of scientific fraud, yet all the universities involved have blithely averted their eyes to claims of misconduct.
This raises the question of whether the hearing would have happened had the HSFSA not requested the review. It also raises another imponderable: Senekal’s influence and the three ‘hats’ she wore in the war against Noakes (she was co-signatory of the UCT professors’ letter, co-author of the Naudé review and consultant for the HPCSA during the hearing).
A prominent academic could have cut off the air supply to the HPCSA’s case from the very start. One of the biggest imponderables is why Wits University professor Amaboo Dhai chose not to do so, as chair of the HPCSA’s Fourth Preliminary Committee of Inquiry. The trial against Noakes might never have happened were it not for Dhai and her fellow committee members’ ‘highly irregular’ conduct, as his lawyers diplomatically phrased it.
If Dhai were unbiased, she should have first sought the informed opinion of a paediatrician steeped in the science and practice of complementary feeding. If there was no such person of sufficient gravitas in South Africa, she should have looked further afield. Out of respect for Noakes as an internationally renowned scientist, one of few in the world with an A1 rating, she should have sought an opinion from an international expert.
One is Professor Nancy Krebs of the University of Colorado in Denver. Krebs is perhaps the world authority on this topic and has undertaken a series of RCTs of complementary feeding. Recall that RCTs are considered the ‘gold standard’ of scientific evidence. As Noakes presented in his evidence, Krebs has shown that the introduction of meat as an early complementary food for infant weaning has significant benefits. These include a reduction in childhood stunting,2 increased linear growth without increased adiposity,3 improved zinc4 and iron status,5 and what appears to be a superior gut microbiome.6 Krebs also writes that infants should be weaned onto diets that contain 30–40 per cent fat. South Africa’s dietary guidelines
would consider this a high-fat diet. She continues:
While median intakes of fat among US toddlers are within these guidelines, approximately one-quarter of toddlers consume diets below the recommended range of fat, while only 3% exceeded the recommended range. The traditional emphasis placed on cereal, fruits, and vegetables as first foods, all of which are low in fat, contributes to an overall sharp reduction in the percentage of energy from fats in older infants and may be associated with inadequate energy intake, especially in those who are breastfed.7
Instead of an expert of Krebs’s stature, the HPCSA inexplicably turned first to a local registered dietitian, Marlene Ellmer. Unlike Krebs, Ellmer has yet to publish her first RCT of complementary feeding. In a summary of her evidence against Noakes, which Ellmer wisely ended up not giving, she claimed that there was no published evidence of the effects of a ‘high-protein or a high-fat complementary diet’ on infant growth and development. She also claimed that ‘poor dietary intake’ contributes to deteriorating child health in South Africa. Perhaps if Ellmer had acquainted herself with Krebs’s work, including the study of the beneficial effects of increased meat consumption on infant stunting in Guatemala, Pakistan, Zambia and the Congo,8 she might have shown the HPCSA where the real threat to infant health lies.
And if Dhai had done some basic homework, she might have consulted a recently published study showing that the early introduction of eggs as a complementary food significantly improved growth in infants in Ecuador. The authors concluded that: ‘Generally accessible to vulnerable groups, eggs have the potential to contribute to global targets to reduce stunting.’9 Despite the power of the grain industry, perhaps weaning onto eggs rather than maize could begin to address the problems of stunting among South African infants. Several of the prosecution’s expert witnesses referred to the issue of childhood malnutrition in South Africa.