[2017] Lore of Nutrition: Challenging Conventional Dietary Beliefs

by Tim Noakes

  ‘I find it baffling why so many have difficulty understanding this obvious truth,’ said Noakes. ‘Perhaps it is inconvenient?’

  Ironically, when Noakes himself first showed evidence of IR in the 1980s, he was helping drive the establishment of dietetics at UCT. It was only after his Damascene moment that he realised he had missed the signs that he was developing T2DM and that he had always been profoundly insulin resistant. He began to wonder what lay ahead. Would he lose his foot in six years and both legs in eight, as his father had? Would his cognitive functions deteriorate rapidly? His concern was not just personal. ‘Diabetes is the biggest challenge we face in the world in medicine,’ he told the hearing. ‘Insulin resistance, which I have, is the most prevalent medical condition in the world and we do not teach it in our medical schools. That is wrong and that is partly why I am here today.’

  In his evidence, Noakes addressed a myth that his critics frequently use to try to discredit him and LCHF. They claim that he only developed T2DM after going on an LCHF diet for three months in 2010, and that therefore the diet caused his condition. For proof, they cite the fact that Noakes still takes medication (metformin) to control his blood sugar. He easily dispatched the argument. It makes no sense, he said, to say that the diet he ate for 33 years did not cause his diabetes, but the one he ate for three months did. Anyone with even a basic knowledge of glucose metabolism knows that it takes years for T2DM to develop. Noakes explained that the reason why he still takes medication despite improving all his symptoms by eating LCHF foods is because he wants perfect blood sugar control. In this way, he hopes to further increase his chances of avoiding the grim fate that befell his father. He therefore chooses to add an appropriate dose of metformin.

  Unsurprisingly, the role of dietary carbohydrate was another key theme in Noakes’s evidence. He spoke ruefully of the consequences of buying into the prevailing dogma that ‘carbohydrates are good for you and the more carbohydrates you have, the better’. He had himself bought into the conventional ‘wisdom’ that diabetics should eat low-fat diets because they were especially prone to arterial disease. But with his father’s death, he had begun to question everything he had learnt in medical school. As a responsible and ethical scientist, Noakes said that he had always looked at what he thought was the totality of evidence; however, he had no idea at the time just how effectively experts in positions of power and influence, with vested interests in food and drug companies, were conspiring to suppress or hide evidence.

  Good science was another theme. During his testimony, Noakes readily acknowledged where he had made errors in his research and described how he typically responded. One example was a large methodological error in a study he had co-authored. Titled ‘High rates of exogenous carbohydrate oxidation from starch ingested during prolonged exercise’, it was published in the Journal of Applied Physiology in 1991.4 Noakes and his co-researchers had used a tracer to measure oxidation that did not track the starch. They therefore came to the wrong conclusions. They wrote a letter to the journal retracting their findings the moment they realised their error. ‘The point,’ Noakes told the hearing, ‘is that if you make an error, you acknowledge it.’ At least, that’s what ethical scientists do.

  Contrast that with the behaviour of the authors of the Naudé review, published in PLoS ONE in August 2014.5 When Noakes and Dr Zoë Harcombe did their own analysis of the Naudé review, they found it to be riddled with so many errors and bias as to undermine its conclusions. After they published their findings in the SAMJ in December 2016,6 the authors of the Naudé review immediately went on the defensive, attacking Noakes and Harcombe in a public statement in the Cape Times.7 When they eventually published an official response in the SAMJ in March 2017, they declined to address the errors that Noakes and Harcombe had identified.8

  The Naudé review was puzzling from the start. There was already a solid Brazilian meta-analysis and review from 2013 to show that very low carb/ketogenic diets were superior to low-fat diets for long-term weight loss.9 Why had the Naudé review authors felt the need to add another meta-analysis supposedly addressing the same question? And why had the HPCSA and its witnesses used it as evidence against Noakes when it was on adult nutrition, not infant feeding? It lent credence to Noakes’s theory that the purpose of the Naudé review was to target him and the growing support for LCHF in South Africa specifically. If true, the research remains suspect from a scientific perspective.

  Not one to shy away from his own faults, Noakes told the hearing how, in his earlier research, he had committed a cardinal intellectual error of bias similar to the one that the Naudé-review authors had committed. Just as they had seemingly ignored evidence that did not confirm their beliefs, so, too, had Noakes and his co-authors in a study published in the Journal of Applied Physiology in 2006.10 In a world-first, they compared a group of patients who had carbo-loaded before exercise with a placebo group. They expected the carbo-loaded group to show superior performance, and were surprised when the group showed no benefit when compared with the placebo. The scientifically correct thing to do would have been to acknowledge the null hypothesis and move on. Instead, when he came to write up the study, Noakes tried to explain why their data should have shown the effect they expected. Scientists call that ‘hiding or avoiding the null hypothesis’, he said, ‘but it’s just not on. You cannot get around a hypothesis by trying to explain why it did not work, and then saying it should have worked but didn’t.’

  Looking back on his behaviour, Noakes is embarrassed. ‘We were biased,’ he said in his evidence. ‘We were so convinced that carbohydrates would help those people. We could not get our minds around the idea that actually, maybe, there was something else involved.’ It was a measure of the abiding power of conventional ‘wisdom’ on the role of carbohydrate in the diet that prevailed for more than four decades. ‘I wasn’t ready [to admit that] in 2006. I only became ready in 2010. At this Damascene moment, I realised that I have been wrong on carbohydrates for 33 years.’

  Noakes also illustrated a key point about the scientific method: that scientists don’t have to be experts in a research area to come up with new ideas and evidence that impact on it. To that end, he traced how he had reached some of his most influential research conclusions, including how the brain regulates exercise performance. In 1996, he was the first to come up with the idea that the brain protects a person during exercise. Although he did not know too much about how the brain functions, Noakes came up with a model, now accepted in exercise sciences, that during exercise the brain determines performance. His research showed him, eventually, that ‘the brain is in control, and the same applies in obesity’. It is the brain that drives obesity, and carbohydrates that drive the addictive behaviours that prevent the brain from controlling appetite and weight.

  The key, Noakes said, is to look at the totality of evidence: ‘If you look at the totality … if you put it all together, you can come up with the truth.’ People miss the truth when they are ‘too expert in small areas’. One of his strengths as a scientist, he said, is that he ‘understands how the whole body functions, not just the heart, not just the lungs, not just the muscles’. That made him more able to ‘put it all together’.

  Ketosis and ketogenic diets formed another intriguing theme. The HPCSA’s lawyers had only themselves to blame for opening the door for Noakes to introduce compelling evidence on the safety and efficacy of ketogenic diets. They had allowed their witnesses to claim over and over again that Noakes had advised a ‘dangerous’ ketogenic diet for infants, despite the fact that his tweet made no mention of such diets. And despite the fact that the HPCSA had not charged him with advising a ketogenic diet, dangerous or otherwise. None of the witnesses was an expert on the subject, so why keep bringing it up? As it turned out, there was method in the madness.

  In her initial letter of complaint to the HPCSA, Strydom claimed that Noakes had advised ‘medical (medical nutrition therapy)’ in his tweet. The words made little sense, and so
Noakes thought she had left out the word ‘advice’. In his letter of response to the HPCSA, he thus wrote: ‘Ms Strydom claims that I am “giving incorrect medical advice…. that is not evidence based”.’ Bhoopchand would later allege that Noakes’s addition of the word ‘advice’ was a tacit acknowledgement that he had given advice, not information; knew that he had acted as a medical doctor, and therefore had a doctor–patient relationship with Leenstra. Noakes and his legal team had no problem undermining all these allegations.

  The problem for Strydom was that accusing Noakes of giving ‘medical nutrition therapy’ in his tweet required significant graft after the fact in order for it to stand up to even the most basic scrutiny. The only relevant treatment remotely resembling medical nutrition therapy at the time was the successful and relatively routine medical use of extreme ketogenic diets to treat epilepsy in cases where drugs had failed. Strydom and the other witnesses therefore had to introduce ketosis and ketogenic diets into evidence if they wanted to connect Noakes’s tweet to any sort of ‘therapy’.

  Noakes has never claimed to be an expert on ketosis and ketogenic diets; however, he has done extensive reading on and research into these diets. He can reasonably claim to be the most knowledgeable person in South Africa on the topic of LCHF in general and ketogenic diets in particular. In his evidence, he presented research to show that ketosis is a natural, benign state. He called it possibly ‘the healthiest state there is’. He showed that ketone bodies are an effective fuel source and may also be important for long-term health. He pointed especially to the work of Professor Stephen Cunnane on the importance of ketones for infants’ developing brains.11 Noakes said that infants are born naturally in a state of ketosis. He showed that there is something about breast milk that makes it a ‘ketogenic food’, despite its relatively high carbohydrate content – along with its high fat content, of course. Researchers are not yet clear why, he said. Furthermore, as much as 25 per cent of the newborn’s basic energy requirements in the first several days of life come from the use of ketones. Just as convincing is the finding that the foetus has a capacity to produce its own ketones independent of what its mother provides.

  ‘When you read that, you cannot conclude that ketones are dangerous, toxic or damaging to the infants,’ said Noakes. ‘The only way you could conclude that ketones were dangerous for infants would be because you did not know the literature. You did not take the effort to go and read the literature as I have, and as we have reported in [Raising Superheroes].’

  Bhoopchand was likely seeing more yawning chasms opening up in the HPCSA’s case. He repeatedly objected to Noakes’s evidence, arguing that, ‘while interesting’, much of it was irrelevant. He also claimed that Noakes was using the hearing as a ‘platform’ to gain media attention and support for LCHF. ‘We have indicated that, we repeat that,’ he said to Adams. He ‘pleaded’ with her and her ‘honourable committee’ to stop Noakes.

  Van der Nest was barely civil in response. ‘With all respect to our learned friend, that is outrageous,’ he said, before pointing out that Noakes had not asked to be prosecuted. He had not asked to spend two years under a professional cloud, living with significant stress and having to spend a fortune on his own defence. ‘Dietitians brought the case against Noakes because he disagreed with them,’ Van der Nest said. ‘Because he had the temerity to hold a different view to them, they thought he must be prosecuted.’

  Looking directly at Bhoopchand, a steely Van der Nest said: ‘Do not get upset when you prosecute someone and he puts up a fight. That is the consequence of prosecuting someone for a tweet that was ignored by the so-called patient, Ms Pippa Leenstra. That is why we are here. [Noakes] is the defendant. He is entitled to defend himself to the fullest, and he will.’

  After an adjournment, Adams ruled that while the charge against Noakes might seem simple on the surface, it was complex. It made no sense, she said, for the HPCSA to charge Noakes with giving ‘unconventional advice’ only to deny him the opportunity to give evidence showing that his advice was not unconventional. The committee unanimously agreed, she said, that there was no reason to limit Noakes’s constitutional right to defend himself fully.

  Noakes went on to address the claim that he had breached official paediatrics guidelines by telling Leenstra to stop breastfeeding. Again, his tweet said nothing about stopping breastfeeding, and the HPCSA had not charged him with giving such advice. Noakes is also well known for endorsing breastfeeding exclusively for the first six months of an infant’s life and for as long as possible thereafter. If anything, his tweeted comment about breast milk being ‘high fat’ and ‘very healthy’ was a ringing endorsement of breastfeeding. I would have thought even the HPCSA’s lawyers and experts could see that.

  Noakes spent a large portion of his evidence on another key theme of the case: South Africa’s official dietary guidelines, or rather ‘misguidelines’, as he calls them. As we know, they closely follow the influential Dietary Guidelines for Americans that the US government launched on an unsuspecting public in 1977, with no solid evidence.

  Noakes referenced the work of US investigative journalist Nina Teicholz, author of The Big Fat Surprise. (She would be another expert witness for Noakes, in October 2016.) The point Teicholz made about the guidelines, he said, is that they simply ‘do not make sense … They do not match up with the science that we have. They are causing so many [health] problems.’ So where is the disconnect, he asked, and why is it so enduring?

  Noakes also waded into the inappropriate influence of industry on nutrition advice. He added to compelling research from around the globe showing the insidious influence of food companies – especially the sugar and soft-drink industries – on top scientists and academics. Noakes referred to food-industry sponsorship of dietitians’ associations worldwide, including ADSA. He described the extensive web of interconnections between vested interests, academia and the HPCSA’s expert witnesses. For example, SASA and the SAMRC were funding the upcoming 2016 ADSA annual conference. Dr Muhammad Ali Dhansay works for the SAMRC.

  Noakes has never let himself off lightly on the subject of conflicted research. He has openly admitted to receiving funding from SASA, Leppin and Bromor Foods in the past for his research, but that was only until he and his fellow researchers proved that their products did not work and were ‘potentially not a good idea’. Unsurprisingly, at that stage he lost funding from the sugar industry as well as from Bromor Foods.

  In retrospect, Noakes’s evidence in his own defence benefited handsomely from what UK-based author Ian Leslie called the ‘prevailing wind’ of scientific evidence on sugar. ‘We read almost every week of new research into the deleterious effects of sugar on our bodies,’ Leslie wrote in The Guardian in 2016. ‘Sugar has become dietary enemy number one.’ 12

  Noakes showed how dietitians’ associations and their members globally help food and drug companies to ‘health-wash’ products. Health-washing is a particularly iniquitous activity in which companies use dietitians to give a veneer of respectability to their products by suggesting their health benefits. An offshoot is what is known as astroturfing, which is just as sinister in intent. In an allusion to fake grass (AstroTurf), astroturfing has a specifically political connotation. In a Content Technologies study guide, Doris A. Graber defines it in terms of political campaigns: ‘The goal of such a campaign is to disguise the efforts of a political or commercial entity as an independent public reaction to some political entity – a politician, political group, product, service or event.’13 In nutrition science, astroturfing denotes campaigns or organisations that claim to act in the consumer’s interest when their real aim is to benefit food, soft-drink or drug companies.

  Research shows that companies such as Unilever, Nestlé and Coca-Cola have embraced astroturfing to create the impression of genuine, grassroots movements to peddle their corporate agendas. Coca-Cola is a particularly egregious example. Research in 2016 showed that the company spent $118.6 million on health research and
partnerships in the US between 2011 and 2015. That included funding for a group criticised for downplaying the role of sugary drinks in obesity.14

  While it is tempting to finger companies such as Coca-Cola as the sole guilty party, the issue is more complex. As Leslie noted: ‘If, as seems increasingly likely, the nutritional advice on which we have relied for 40 years was profoundly flawed, this is not a mistake that can be laid at the door of corporate ogres. Nor can it be passed off as innocuous scientific error … It suggests instead that this is something the scientists did to themselves – and, consequently, to us.’15

  Noakes and his expert witnesses picked up on this theme: the active role that scientists themselves have played in dishing up bad dietary advice to the public. In their research, Harcombe, Teicholz and Noakes’s third expert witness, New Zealand–based dietitian and academic Dr Caryn Zinn, have highlighted the many interests keen to protect the current guidelines.

  Coincidentally (or not), Vorster wrote the ‘secret’ report that the HPCSA’s Fourth Preliminary Committee of Inquiry commissioned and used as evidence to charge Noakes. In his evidence, Noakes easily rebutted all the claims in Vorster’s report and said it was a pity that the committee members had not shown it to him before embarking on the prosecution. If they had, the hearing may never have taken place.

  It became clear from all the evidence that it was not so much what Noakes had said in his tweet as what he did not say that led to his prosecution. In her testimony, Strydom conceded that she ‘may have overreacted a little’ to the tweet. Vorster and Kruger acknowledged that LCHF aligns closely with paediatric dietary guidelines that promote meat and vegetables as good first foods. However, the South African Food-based Dietary Guidelines also heavily promote cereals and grains – starchy foods – as the basis of most meals for adults and babies older than one year. And while all dietitians profess to support a reduced intake of sugar and other processed carbohydrates, few are prepared to say that sugar has no role in a supposedly healthy, ‘balanced’ diet.