[2017] Lore of Nutrition: Challenging Conventional Dietary Beliefs

by Tim Noakes

  7Prior to the publication of The Real Meal Revolution in November 2013, the term Banting was essentially unknown in South Africa. Today the word appears in the South African Afrikaans dictionary. The ‘Banting 7 Day Meal Plans’ Facebook page, begun in Cape Town in 2014, now has more than 800 000 members and grows by a minimum of 2 000 new members each day. It has more Facebook members than any South African political party. A similar Banting/low-carb Facebook page in Nigeria has more than 1 million members.

  8The Salt Watch, which drives the low-salt movement in South Africa, lists the following as its funders and partners: HSFSA, North-West University, Nutrition Society of South Africa (NSSA), ADSA, Consumer Goods Council of South Africa, SAMRC, University of Pretoria, Unilever, PepsiCo, Tiger Brands, and ‘retailers and other industry partners’. Among the latter, perhaps too shy to acknowledge their support, are Kellogg’s and the South African Sugar Association (SASA). Focusing on salt as the cause of hypertension is especially attractive if it removes any potential inquiry into the effects of sugar as the far more likely cause of hypertension, especially in those with IR.

  9In 2004, the College of Physicians granted Levitt fellowship of the college by ‘peer review’, which is highly unusual, and in what appears to have been an exclusive arrangement for the college. Acceptance into the college is usually achieved only after an onerous training and examination process.

  10Cholesterol is insoluble in water. Thus it does not exist in the bloodstream as cholesterol, but travels within water-soluble fat–protein particles called lipoproteins. Certain of these lipoproteins are associated with CHD, in particular large numbers of small, dense LDL particles, especially when they become oxidised. Using the terms ‘good’ and ‘bad’ cholesterol is dated and unhelpful, and fails to explain what is currently known about the true relationship between cholesterol, lipoproteins and CHD.

  5

  The UCT Professors’ Letter

  ‘The paradox is that medicine is supposedly more enlightened, but it has never been more tyrannical, hierarchical, controlled, intolerant, and dogmatic. Working doctors who dissent are cowed because failure to comply with the medical orthodoxy threatens livelihood and registration. Much of modern medicine is an intellectual void.’

  – Dr Des Spence, Scottish GP1

  I have written many books and most have taken years, even decades, to complete. The Real Meal Revolution, however, which I co-wrote with nutritional therapist Sally-Ann Creed, adventure runner and chef David Grier, and chef and aspiring endurance athlete Jonno Proudfoot, took just five weeks in July/August 2013. It is the book that has caused me both the greatest pleasure and the worst pain. For while the book would sell in excess of 250 000 copies in South Africa, and set off the Banting Revolution in this country, it would be the direct cause of the worst moment in my entire academic career: the publication of the letter signed by four University of Cape Town professors, three of whom were long-standing colleagues of mine at the time.

  In retrospect I now realise how inconvenient the publication of The Real Meal Revolution in November 2013 was for those who, behind the scenes, were busily sharpening their knives in anticipation of my early elimination. They were waiting for the Naudé meta-analysis, which would play a pivotal role in the HPCSA’s decision to charge me. The study, which should have been published in February 2013, was now already nine months overdue.

  During that time, I, their intended quarry, had published an article in the SAMJ that would become one of the journal’s most-read articles of all time. I wrote it after receiving letters from people who had changed their diets to LCHF. Some of the letters contained stories that were nothing short of miraculous, so I decided to collate and analyse the best 100 or so for a scientific publication in the SAMJ.

  I was careful to make the point that this was an ‘occasional survey’, not definitive evidence, and that it had significant limitations. Thus, I began the discussion acknowledging that:

  The study has several potential limitations. First, all data are self-reported and were not verified but it is unlikely that all participants would fabricate this information. Second, there is no record of exactly what each person ate. Third, all reports describe only short-term outcomes. To collect this information as part of an RCT involving 254 subjects would have been very costly.2

  It was probably the next sentence that really caused the trouble. ‘Despite these substantive limitations, this information challenges current conventional wisdom (widely taught at medical schools),’ I wrote. I was perhaps still too naive to appreciate that, in the educational climate of today, one does not challenge what is taught at medical schools.

  Further, to indicate that I at least understood that this was not conventional research, I concluded the abstract with the sentence: ‘A randomised controlled clinical trial is urgently required to disprove the hypothesis that the LCHF eating plan can reverse cases of T2DM, metabolic syndrome and hypertension without pharmacotherapy.’

  The high point of the paper for me was the chance to describe five ‘miracle’ cases that at the time challenged what I had been taught about medical care for patients with T2DM.

  Billy Tosh lost 83 kilograms in 28 weeks (see Figure 5.1) and reversed his hypertension and T2DM. The solution was simple, he said: absolutely no sugar, no processed foods and less than 25 grams of carbohydrates per day. He concluded that the LCHF diet had ‘saved’ his life and that ‘label reading has opened my eyes to the almost criminal levels of carbs in everyday processed foods and the propensity of these foods to cause weight gain’.

  Brian Berkman also reversed his T2DM and lost 73 kilograms over 18 months by adopting the LCHF eating plan, limiting his carbohydrates to less than 25 grams per day and avoiding all sugar. He concluded: ‘I totally subscribe to the view that sugar and carbohydrates are drugs to the body. I was an addict.’

  Dr Gerhard Schoonbee, a 57-year-old rural general practitioner, had warned his wife that he did not expect to reach his 65th birthday because of the effects of his T2DM. He also had hypertension, a high blood cholesterol concentration, sleep apnoea and constant fatigue. In May 2012, he read about the LCHF diet, adopted it, lost 25 kilograms in eight months and cured himself of all his afflictions so that he no longer needed any medications. He now prescribes the LCHF diet for his patients of all social classes.

  Figure 5.1

  Weekly weights of Billy Tosh following adoption of the LCHF diet. Note that in 28 weeks, Tosh lost 83 kilograms and put his hypertension and T2DM into remission

  Figure 5.2

  Two of the three Capetonians who lost a total of 181 kilograms by adopting the LCHF diet. None now requires medications to treat their T2DM and only one continues to use medication to control hypertension. Markers of blood glucose control are now normal in all three without medication use. This picture was taken in September 2017, more than four years after each had begun the diet. These individuals taught me that, at least in some, the LCHF diet can ‘reverse’ T2DM, the disease that killed my father

  A 23-year-old mother began to eat addictively after the birth of her first child. Her weight ballooned to 120 kilograms and she developed T2DM. She adopted the LCHF diet, lost 45 kilograms and reversed all diabetic symptoms. She concluded: ‘for the life of me I don’t know why I struggled so much [to control my weight] since it really isn’t that difficult. It was more of a lifestyle change for me than a diet.’

  Thirty-seven-year-old Simon Gear, a lifelong runner, was finding it increasingly difficult to control his weight. To activate weight loss, he decided to run nine marathons in nine weeks, culminating in the 2012 Two Oceans 56-kilometre ultra-marathon. Instead, his marathon running caused him to gain three kilograms. He finished the ultra-marathon two minutes short of the official cut-off time, in 6 hours 57 minutes and 57 seconds, in 7 668th place. He sought my advice, and after much persuasion agreed to experiment with the LCHF diet for an initial 100 days. He lost 2 kilograms in the first week and a total of 15 kilograms over the next seven months.
Most of his weight loss occurred when he was running the least. On 16 March 2013, he completed the Two Oceans 56-kilometre ultra-marathon in 3 hours 59 minutes and 42 seconds, in 208th position, nearly three hours and 7 460 positions better than his performance 12 months earlier.

  Simon concluded: ‘The weight loss enabled my training, not the other way around. I feel like I have won my life back.’ He had discovered, in the clearest possible way, that it is not possible to outrun a bad diet.

  When my father battled with T2DM, dying a diminished man as a result of the complications of disseminated obstructive diabetic arterial disease, my medical training allowed me to hide behind a false reality. I believed that some outcomes in medicine are just inevitable: that people with T2DM are predestined to become progressively sicker until they die an awful death. That is just the way it is.

  But here were four people with T2DM telling me that it does not have to be this way. By just changing their diets, they had managed to reverse all their symptoms. It seemed a reasonable assumption that as long as they continued to follow the LCHF eating plan and their new lifestyle, they would not necessarily die from the arterial complications that had claimed my father. As someone with T2DM, I found this information profoundly liberating and hopeful. That we might finally have an intervention that could truly help patients with T2DM was a revelation. I assumed that my colleagues and peers would embrace the article as an exciting opportunity to try something new to address a problem for which we did not have a solution.

  After all, there was nothing to lose, as current treatment methods are pretty ineffective. Imagine, I thought, how much good we could do if we offered this simple, cheap intervention to the millions of South Africans suffering from these harmful chronic diseases. Finally, we could offer hope to our patients with T2DM.

  I was underestimating the power of the omertà.

  The response was immediate and, in retrospect, predictable. Within a day or two of the article’s publication, then editor of the Mail & Guardian Nic Dawes tweeted to the effect that it was a disgrace for the SAMJ to publish this type of article in the guise of ‘science’.

  Others joined in. The theme of their collective message was ‘Noakes has lost it’. Perhaps he was once a good scientist, they said, but if he thinks this is ‘science’, then he is clearly senile. We need to warn the world of his mental decline. No longer can anything he says be trusted.

  My conclusion now is that these attacks were not random events.

  Yet in writing The Real Meal Revolution, we had also begun to attract our strongest ally – the general public – although we did not know it at the time. I also did not then appreciate that it would be the public support generated by The Real Meal Revolution that would ultimately save my scientific credibility.

  However, it was the introduction of The Real Meal Revolution to a group of South African parliamentarians and their support staffs that produced the most ferocious response from my academic colleagues at UCT.

  On two previous occasions, I had spoken to different groups at Parliament about the role of IR and high-carbohydrate diets in many of our nation’s health problems. I spoke about how restricting the intake of sugar and refined carbohydrates, and increasing the intake of ‘healthy’ fats, could reverse our nation’s progressive slide into ill health.

  On the basis of those two talks, I was invited to speak to a larger group of perhaps 150 people in one of the luxurious chambers at Parliament on another of their regular Wellness Days. Importantly, I did not seek out the invitation. In no way was I taking my crusade to Parliament, as my colleagues would later claim. I was asked to speak and, out of courtesy, I accepted the invitation. As is usually the case for such public talks to wellness groups, my foundation was not paid for my time.

  Shorty after I began my talk to Parliament’s Wellness Unit on 18 August 2014, the data projector failed. I was reduced to speaking without the prepared script provided by the slides, but managed to give a selection of the most important ideas from the 120 lectures on nutrition that I had given around the country since December 2013. During the talk I did not mention The Real Meal Revolution, but I did say that the solution to the South African obesity/diabetes epidemic was the promotion of the LCHF diet. I could tell that the organisers and the audience were receptive to my lecture. They also treated me with respect and consideration.

  The next morning, I awoke to find my picture on the front page of the Cape Times, presenting a copy of The Real Meal Revolution to the Deputy Speaker, Lechesa Tsenoli. He had requested this picture and had possibly innocently encouraged the newspaper to publish it. The lead story was about my presentation to the Wellness Unit.3

  The article quoted me accurately enough, saying that South Africa was sitting on a disease ‘time bomb’, and that we ran the risk of becoming the ‘fattest’ country in the world (note, we are currently the world’s third fattest). ‘Noakes said one way to address the problem would be through his high-fat, high-protein diet (including meat, full-cream milk, cheese and butter) and by consuming less sugar and processed food, and fewer carbohydrates,’ the journalist wrote. That statement was not altogether correct: I had, and always have, made it clear that the evidence is for a moderate-protein, not high-protein, diet.

  The article further quoted me as saying that ‘if we don’t reverse [the] obesity and diabetes epidemic, our nation disappears … because we will go financially bankrupt because we don’t have the money to provide medical services in the near future’.

  I also said:

  We (South Africa) are sitting on a time bomb if we don’t do anything about it. It is not rocket science what I’m going to tell you. The obesity and diabetes epidemic has one cause and we can sort it out. We are told that it’s our fault, we’re lazy, we eat too much, we don’t exercise. That is nonsense. It does not say exactly what is the cause of the obesity and diabetes epidemic and we either accept it, address it and cure the nation. Or … we will become the fattest nation in the world.

  The article included my suggestion that we should feed children in poorer communities protein, such as offal from animals, and that we should all ‘eat animals from nose to tail’. It concluded with a comment I have made frequently over the years:

  I was born in 1949 and when I went to school everyone looked like me, everyone. We had one kid who was a bit fat and we thought he had cancer because it was so uncommon. When I go and speak to the young girls of South Africa across every grouping and every social class, I’m astonished and frightened at the obesity that I see.

  Tsenoli was quoted as saying that my message was ‘very powerful’ and that it must be ‘translated and communicated in all languages’. He continued: ‘It’s interesting stuff. What I like about it is that the guy is being scientific. There are some who would like to portray him as someone who is talking bullsh*t, yet what he’s saying makes sense and he’s nuanced. He’s not articulating anything in absolute terms.’ He said that my talk had exposed the risks of the ‘commodification’ of things like sugar and what that did to our general health.

  Only in time did I realise that this newspaper report posed a massive threat to those I believe were busily plotting the HPCSA actions against me. They were, at that very moment, about to convene a preliminary inquiry committee of senior medical and legal colleagues to decide whether or not I should be charged. If some members of Parliament and, worse, the minister of health supported me, that would seriously jeopardise their actions and case against me.

  Willem ‘Slim Wim’ de Villiers had recently been appointed dean of the UCT Faculty of Health Sciences, but was already eyeing the vacated post of rector of the University of Stellenbosch. I did not know it then, but De Villiers was flexing his muscles as head of the medical ‘herd’.

  Dr Jay Wortman, one of the speakers at the Cape Town low-carb summit in February 2015, has explained the dynamics and dangers of the herd mentality and the key role of the alpha male in directing the actions of the herd. Wortman is an associate professor o
f medicine at the University of British Columbia. He is a First Nation, Métis Canadian, born in the small northern Alberta village of Fort Vermilion, an early settlement in the network of fur-trading posts developed by the Hudson’s Bay Company in Canada’s formative years. Wortman relates the story of the American Plains Indians and their relationship to their vital food source, the American bison. Each bison herd has only one male leader. Without their leader, herds have no idea what to do when threatened. The Plains Indians learnt an important lesson: to control a Bison herd successfully, the first step is to remove its alpha-male leader.

  Medicine, Wortman says, is a bit like that. Our herd mentality forces us to follow the single powerful Anointed, typically the professor of medicine or, even better, the dean of the medical faculty. That Anointed alpha male knows that if he wishes to depose a hostile opinion that threatens his position, all he need do is oust the leader of the competing herd. He knows that his own loyal medical herd will never threaten his status.

  So it was that at the height of the LCHF debate in South Africa, a new alpha male was introduced into the herd of those controlling medical education in the Western Cape. The threat had been identified for De Villiers: the LCHF/Banting position already gaining traction throughout South Africa as a result of the publication of The Real Meal Revolution. And he had his mandate: neutralise the leaders of any and all competing opinions to conventional medical care.