by Tim Noakes
Such research has shifted the ground, and ‘conventional’ nutrition increasingly finds itself needing to provide evidence to defend its innocence in contributing to the worldwide obesity and diabetes pandemics instead of Noakes needing to provide the evidence that defends the ‘unconventional’.
Medical and other healthcare professionals who oppose Noakes’s views would benefit from reviewing the depth of evidence that was so thoroughly provided during the inquiry and is now presented in this book, before dismissing it as inappropriate. Or they need to provide a convincing rebuttal.
After the Noakes inquiry there were rumours that the HPCSA wished to engage on a retrial. My memory of challenged HPCSA cases runs to two: the Steve Biko and Wouter Basson cases, in both of which the council bowed to outside pressures. Should the HPCSA decide to challenge the outcomes of their failed case, this would raise more questions. Would it signify that the HPCSA considered their team to have been incompetent? Should the members, who pay all of the HPCSA costs, not question further, possibly fruitless, expenditure?
Since few cases have been more exhaustively examined, what is there still to be explored? Who would make this decision and on what grounds? If they fail again, should those whose decision it was to proceed not be personally responsible for the costs on both sides? Would this also not seem like a religious persecution of those of another persuasion? Finally, such inquiries are not the appropriate mechanism to resolve such major and complex academic debates.*
J.P. DE V. VAN NIEKERK
EMERITUS PROFESSOR (FORMER DEAN) UCT FACULTY OF HEALTH SCIENCES
EMERITUS EDITOR SAMJ
*The foreword was published in the Cape Doctor in September 2017.
Preface
‘Few will have the greatness to bend history itself, but each of us can work to change a small portion of events, and in the total of all those acts will be written the history of this generation.’
‘Each time a man stands up for an ideal … he sends forth a tiny ripple of hope, and crossing each other from a million different centers of energy and daring, those ripples build a current which can sweep down the mightiest walls of oppression and resistance.’
‘… only those who dare to fail greatly, can ever achieve greatly’.
– Robert F. Kennedy, Ripple of Hope Speech, delivered in Jameson Hall, University of Cape Town, Cape Town, South Africa, 6 June 1966
‘… as the skilled and professional people of South Africa and the world, you will be largely removed from contact with the hungry and the deprived, those without ease in the present or hope in the future. It will require a constant effort of will to keep contact, to remind ourselves everyday that we who diet have a never ceasing obligation to those who starve.’
– Robert F. Kennedy, speaking at the University of Stellenbosch, Stellenbosch, South Africa, 7 June 1966
Once upon a time, long, long ago, in another world, I was considered quite a good scientist. Since 2004, the South African National Research Foundation (NRF) has rated me an A1 scientist for both exercise science and nutrition. That is the NRF’s highest possible rating, signifying that the foundation judges me to be a world leader in my fields.
I have published more than 500 scientific papers, many in leading international peer-reviewed journals, and have been cited more than 17 000 times in the scientific literature. My scientific H-index stands at over 70 for all my research outputs and at over 40 for those publications dealing exclusively with nutrition. (The H- or Hirsch index is a measure of the impact of the work of a particular scientist.)
I have also won several important scientific awards, including a South African Presidential Order, the Order of Mapungubwe (Silver), and an NRF Lifetime Achievement Award, making me one of few at my alma mater, the University of Cape Town (UCT), to have won this award. For 25 years – an unusually long time – I directed a research unit funded by the South African Medical Research Council (SAMRC). During all that time, the SAMRC regularly rated that unit among the top two or three in its group. I am also a bestselling author of books, including Lore of Running, which became known as the ‘runners’ bible’. Publishers rated it globally as the ninth best ever in its category.
Together with Springbok rugby legend Morné du Plessis, in 1995 I co-founded the Sports Science Institute of South Africa. This would become a beacon of South African excellence for the application of science in the practice of sport.
Perhaps more significantly, during that former life, I challenged accepted medical and scientific dogma six times. Each time, I was proved to be correct, and my view eventually became accepted mainstream teaching.
The most significant of these contributions was to disprove the prevailing dogma that during all forms of exercise, a catastrophic failure of human whole-body physiology, beginning in our exercising muscles, imposes significant limits on human performance. This theory, which British Nobel laureate Professor Archibald Vivian Hill advanced as a novel idea in 1923, had dominated the exercise sciences and had survived uncontested by successive generations of exercise scientists. That was before I became the first to challenge it decisively in 1996.
Remarkably, Hill published very little experimental proof to support his hypothesis. His work deftly confirmed the principle that a new theory requires much less evidence for its original acceptance than its ultimate refutation would demand. In my new and what some have considered pseudo-scientific life after 2010, I would learn that there is no better example of this ‘truth’ than Ancel Keys’s diet-heart hypothesis.
Yet through a series of logical deductions and relatively simple experiments, I led a research team that disproved Hill’s hypothesis with relative ease. Instead, we proposed that the human brain determines our athletic performance by anticipating what lies ahead, from the moment any exercise bout begins. According to those predictions, our brain then sets the limits of how hard it will allow us to push ourselves. It does this to ensure that we reach the finish of all exercise sessions with some physical reserve – and still alive!
Our model, grandly titled the Central Governor Model of Exercise Regulation, represents perhaps one of the more important advances in the exercise sciences of the past century.
I then led our team to disprove the Dehydration Myth. That was the industry-driven fallacy that unless we humans drink ‘as much as tolerable’, we risk our health every time we exercise, especially when in the heat. Our publication in 1991 established beyond doubt that this advice can be deadly.1 It may even cause the novel, potentially fatal but utterly preventable medical condition known as exercise-associated hyponatraemic encephalopathy (EAHE) in some susceptible humans. As I detailed in my book Waterlogged: The Serious Problem of Overhydration in Endurance Sports, EAHE has caused the avoidable deaths of scores of athletes and military personnel since 1981.2 That was when we were the first to recognise and describe the condition.
Importantly, sports medicine authorities ignored our definitive 1991 evidence that simply ensuring that athletes do not over-drink during exercise will prevent EAHE. Indeed, an industry seemingly intent on selling as much product to athletes as possible still disregards those definitive findings, ostensibly oblivious of the consequences.
We have made other, rather less spectacular scientific advances. These include disproving an improbable theory first advanced in the early 1970s that running 42-kilometre marathons confers lifelong immunity from coronary heart disease; our finding that catastrophic neck injuries in the sport of rugby are not random chance events but rather occur under predictable circumstances; and that the dehydration that naturally occurs during exercise does not cause the occasional cases of exercise-associated heatstroke in running and other similar sports (as a result, encouraging athletes to drink more during exercise – another false feature of the Dehydration Myth – will not prevent cases of heatstroke).
During that former life, I also convinced Jake White, coach of the 2007 Rugby World Cup–winning Springbok rugby team, to rest key players at crucial periods
in the final year before the 2007 competition. This advice was profoundly unconventional and provoked indignant attacks on me in the press and on social media. How could I, who clearly knew so little about the sport, possibly suggest that professional rugby players needed to rest? After all, they are paid – too much, according to some – to play rugby; it is their job.
The error these critics made was a failure to understand the delicate balance between winning major competitions, such as the Rugby World Cup, which happens every four years, and playing just enough competitive rugby in the preceding four years.
My unconventional approach came from the best source: it was based on what I had learnt from studying athletes in other sports. In the end, according to Coach White, I contributed significantly to the Springboks’ ultimate victory. He later kindly wrote: ‘I had full faith in what Tim said, because I knew he genuinely wanted South Africa to win. I always had the feeling in every meeting we had that he genuinely wanted to find ways in which we could have the edge over the opposition. And he never gave me reason to doubt him. He never said to us, “Don’t do it like that, do it like this.” He always gave you options and the pros and cons of both options.’3
Another previously overwhelmingly unpopular position I adopted, albeit cautiously in public for fear of retaliatory action, was that cyclist Lance Armstrong was the most doped athlete in the history of sport. An editorial I wrote in the New England Journal of Medicine began with the question: ‘Is it possible for the “natural” athlete who competes without chemical assistance to achieve record-breaking performances in sports requiring strength, power, speed, or endurance?’4
My answer in the article was a resounding ‘No!’ My closing argument featured the story of Werner Reiterer: ‘In disclosing his own drug-enhanced performances, former Australian world discus champion Werner Reiterer, who chose to retire rather than risk winning a tainted medal in the 2000 Olympic Games in Sydney, has written, “There was something pathetically wrong with the fact that a packed home arena – an entire country – would urge me on without any concept of the truth behind my ultimate athletic achievement, or of the sham of which they were unwittingly a part.”’
I concluded: ‘Our burden is that no longer do we share this ignorance. We can no longer pretend that we do not know.’
Seven years later, Lance Armstrong was exposed as, well, yes, the mastermind responsible for ‘the most sophisticated, professionalized and successful doping program that sport has ever seen’. That was according to the US Anti-Doping Agency report5 that finally exposed him.
In my mind, the most incriminating evidence against Armstrong was not what he said; it was what he failed to say. Not once did he complain that other cyclists were doping. If he was truly competing without the aid of drugs, surely he should have emphasised repeatedly that he was winning despite competing at a significant disadvantage? But he never did, confirming his guilt – to me, at any rate.
In time, I realised that any such failure to state the obvious is also a definitive test of the true allegiance of individuals or organisations outwardly committed to making us healthier. Those who refuse to state that the monopoly of companies responsible for the toxic modern food environment are the primary drivers of ill health, confirm that they have no interest in our health. Whether witting or unwitting, these individuals and organisations will usually prove to be nothing other than hired hands for those interests that benefit the most from rising rates of global ill health. I return to this theme in Chapter 17.
But there is another lesson from the Armstrong saga. David Walsh, who had concluded in 1999 that Armstrong was a fraud – ‘Lance Armstrong perpetuated what may well be the most outrageous, cold-blooded and elaborate lie in the history of sport’ – spent the next 13 years pursuing the truth.6 Of his experience he wrote: ‘How can you reveal the truth if those to whom you are speaking don’t want to hear? The UCI [Union Cycliste Internationale] didn’t want to know their sport was diseased; the Tour de France preferred to turn a blind eye to the circus the race had become, and too many of the fans couldn’t bear to be told the saints were sinners.’7
Walsh wrote of the small group of whistleblowers who finally ensured that the truth was exposed: ‘What set Emma O’Reilly, Betsy Andreu, Stephen Swart and Greg LeMond apart was their willingness to tell the truth at a time when there was nothing in it for them except vilification and other forms of bullying.’8 Whistleblowers, my experience would teach me, should expect no favours.
Between 2004 and 2007, I used my medical and scientific skills to assist UCT graduate Lewis Pugh to become the first person in history to swim one kilometre in water of minus 1.8 °C at the geographical North Pole.9 One outcome was that the United Nations Environment Programme named Pugh ‘Patron of the Oceans’. In 2016, after five years of negotiations, he successfully convinced the Russian government to remove their veto and support his campaign to have the Ross Sea in Antarctica declared a Marine Protected Area. That has made the Ross Sea the largest protected area on land or sea. In his negotiations with the Russians, Pugh became known as the ‘Speedo diplomat’. In the Antarctic summer of 2016/17, he turned his attention to swims off the Antarctic Peninsula, hoping to add the seas off East Antarctica, the Weddell Sea and the Bellingshausen Sea to the list of Marine Protected Areas by 2020.
As a result of some of these contributions, at least two – Waterlogged and the Central Governor Model of Exercise Regulation – considered seminal, UCT bestowed on me its highest degree, Doctor of Science, at age 53.
According to a developing fable, all that ended on 13 December 2010, when, as a new generation of critics claimed, I apparently turned my back on my former life of dedicated, hard-core science. After that day, I began my ‘descent into quackery’.
Because of this narrative, beginning in 2011, I converted overnight into just another self-aggrandising celebrity impostor, a snake-oil salesman promising miracle cures to a gullible public. Critics seemed to believe that the nutrition path I was now advocating was based on nothing more than anecdote and my misleading suggestions of a placebo effect without any biological basis.
According to this account, to boost my profile, I had begun to work tirelessly to cherry-pick data and suppress any information that disproved my dogma about the benefits of low-carbohydrate, high-fat (LCHF) diets. I did so, according to their theory, in part by attacking my opponents publicly. My goal, apparently, was to berate, humiliate and silence anyone brave enough to challenge my opinions.
And so, in a few short months, I morphed from a distinguished scientist with a globally acknowledged reputation into a faith-based nutrition activist, ruthlessly advocating an unproven, clearly dangerous ‘fad’ diet.
The reality, as I explain in this book, is rather different. My scientific conversion came about after what I call my ‘Damascene moment’. It happened after I came face to face with compellingly robust evidence that contradicted everything I believed was true about optimum nutrition to treat and prevent serious diseases, such as obesity, diabetes and heart disease.
I started to question whether much of what my professors at medical school had taught me as incontrovertible nutrition truths were, in fact, no more than myths – lies, even. Much like with the other six myths that I had disproved when I was still a perfectly ordinary, hard-core scientist, I challenged two deeply held dogmas: the role of carbohydrate in nutrition and the diet-heart hypothesis that saturated fat causes heart disease.
I was left facing an ethical dilemma of monumental proportions: I had spent the better part of 34 years disseminating nutritional advice both locally and internationally to patients and athletes, not least through the pages of Lore of Running, that I now knew to be wrong. Not just wrong, but in all likelihood harmful to many, especially those with insulin resistance (IR) and pre-diabetes.
I had two options: I could either continue preaching these wrong and potentially harmful lies and maintain the scientific nutrition status quo, the so-called conventional ‘wisdom’,
or I could admit my errors, try to correct them and deal with the consequences. For me, there was no choice. I had been raised by parents who viewed honesty, truthfulness and taking responsibility for your actions as ethical absolutes. I knew that to honour their lives, I had no option other than to acknowledge my errors and to live with the consequences.
In my mind, I was just doing what any good scientist does when faced with incontrovertible evidence that contradicts a view, no matter how deeply held: I changed my mind.
I expected that my colleagues in the medical profession – I am also a medical doctor, although I have not practised clinical medicine for more than 17 years – and in academia, including my own university, would be intrigued. They would want to know why I had changed my mind. They would be open to dialogue on matters of science and evidence-based medicine. They would want to learn.
I could not have been more wrong.
The results of my personal choice would prove to be brutal for myself, my wife and the rest of our family, beyond anything I could possibly have imagined.
In the beginning, the earliest criticisms seemed to be nothing more than gentlemanly disagreements between consenting academics. But these were covers for more devious actions, the implications of which would become apparent only much later. Prominent doctors, in particular cardiologists, began criticising me by name in public. That was probably to be expected, since I was going against one of the most enduring dogmas of cardiology, the diet-heart hypothesis and its close cousin, the lipid hypothesis.
Endocrinologists followed suit, as did academics from my own university.
On reflection, my biggest error was to start asking inconvenient questions of my profession – questions that doctors and academics appeared to want to keep hidden from public scrutiny, preferably forever.
