by Tim Noakes
The HPCSA had not proven that Noakes ‘gave unconventional advice or advice which was not evidence-based’;
On the facts, ‘no actual or potential harm was proven, neither that any information provided on Twitter by the respondent, whether unsolicited or not, was dangerous or life-threatening’; and
The HPCSA had not proven that Noakes ‘as a medical practitioner acted unprofessionally and in a manner that is not in accordance with the standards and norms of the medical profession’.
At that moment, the silence in the conference room felt stifling. Adams stopped shuffling her papers and looked directly at Noakes. The professional legal mask she had maintained throughout slipped. With a smile that stretched from ear to ear, she slowly and deliberately delivered her verdict, emphasising the last two words: ‘Professor Noakes, on the charge of unprofessional conduct, the majority of this committee find you not guilty.’
The room erupted. People rose to their feet, cheering, applauding and hugging. Noakes remained seated. He dropped his head into his hands, but only for a moment. He later told me that he thought he would cry. Instead, he lifted his head, raised both arms and punched the air with clenched fists in victory, shouting, ‘Yes!’ His lawyers were equally jubilant, reaching over and embracing him and one another, their relief etched on their faces.
The ruling was as thorough a vindication as Noakes could have hoped for, under the circumstances.
Liddle’s dissenting opinion was anticlimactic. He prefaced it by saying that he could not presume ‘to profess a judgment’. Then he broke down and sobbed, saying that all he ‘sort of wanted to do’ was to give his reasons for voting against the rest of the committee. Liddle said that Noakes had given ‘advice’ that was ‘unconventional in the extreme’. He echoed Pienaar: the absence of any recorded harm from Noakes’s tweet was ‘a fortunate consequence and not an indication of innocence’. It did not exclude ‘unreported and presently unknown evidence of harm’. In essence, Liddle believed that the HPCSA had proved its case.
In his first interview after the verdict, Noakes said that the outcome of the hearing ‘could not have been better’. However, he looked forward to the day when the HPCSA investigated the veracity of the evidence-base on which universities train dietitians. He also said that he hoped to see the HPCSA investigate the effects of orthodox advice on the obesity and diabetes epidemics, which are crippling the health of populations in South Africa and elsewhere.
In her newsletter announcing the verdict, Dr Zoë Harcombe praised Adams, calling her the ‘magnificent Chair’. She said that Adams and her committee had ‘the emotional intelligence and decency to put themselves in [Noakes’s] shoes’. These were qualities that Strydom and the HPCSA ‘demonstrably lacked’.
It quickly became clear that the dietitians involved in prosecuting Noakes were not about to let go of their fight to silence him. Immediately after the ruling, ADSA president Maryke Gallagher said in a TV interview that her organisation would not change its advice to the public. Claiming that her association gave evidence-based dietary advice, Gallagher signalled that while Noakes had won a significant battle, ADSA’s war with him was still alive and well.
The HPCSA was also not ready to let go of its prosecution. It had 21 days to decide whether to appeal its committee’s decision. Eighteen days after the ruling, it did just that, shocking Noakes’s detractors as much as his lawyers and supporters. In announcing its decision, the HPCSA gave no reasons for lodging the appeal. All that was apparent was its continuing desire − or obsession, as some were calling it − to find him guilty.
PART III
THE SCIENCE
16
Once We Were Healthy
‘Human health depends above all on sound nutrition; sound nutrition means growing food and using it in accordance with nature’s laws; of all foods made “unnatural” by industrial processing the commonest are refined sugar, refined flour and certain processed vegetable oils. I know of no research that refutes this simple concept.’
– Dr Walter Yellowlees, A Doctor in the Wilderness1
My ‘trial’ was a unique event in the history of modern medicine. By placing my fate in the hands of a legal process, I challenged ADSA and the HPCSA to prove that the ‘unconventional’ nutritional ideas that I promote are not evidence-based.
In presenting their case, the prosecution produced just one ‘scientific’ paper, the disputed Naudé review. Importantly, that study had nothing to do with infant nutrition. Neither did the UCT professors’ letter and Hester Vorster’s secret report, both of which the Fourth Preliminary Committee of Inquiry had used, along with the Naudé review, to charge me.
That is why, over the prosecution’s protestations, my three expert witnesses and I focused our scientific defence on both adult and infant nutrition. Over 12 days of testimony, we argued that obesity and T2DM begin during pregnancy. If the mother eats a high-carbohydrate diet during pregnancy, and if she then weans her infant onto conventional, high-carbohydrate, rice- or maize-based ‘complementary foods’, the probability that her infant will develop all the scourges of insulin resistance as an adolescent or young adult is greatly increased.
Crucially, despite all the resources at its disposal, including an apparently unrestrained budget of between R7 million and R10 million, the prosecution failed to contest any of the facts that we presented. They were thus unable to prove that our ‘unconventional’ dietary advice is not evidence-based.
The sole conclusion I can draw is that the LCHF dietary model I propose is currently, in my opinion, the best evidence-based model of modern human nutrition. Conversely, the LFHC, ‘prudent’, ‘balanced’ diet promoted by ADSA, the CDE, the HSFSA and the HPCSA, and religiously taught at all South African medical schools, is at best not evidence-based, at worst completely wrong and extremely harmful, not least because it is has caused the obesity/T2DM epidemic. Hence, those who advocate the LFHC diet are promoting practices that are ‘unconventional’.
What this effectively means is that after 12h32 on Friday 21 April 2017, when Advocate Joan Adams completed her final judgment, all those South African dietitians and medical doctors who prescribe the LFHC diet are potentially liable for practising unconventional medicine/dietetics. What is more, because the HPCSA is responsible for the education of all South African doctors and dietitians, its top priority after 21 April 2017 should be to ensure that all present and future health practitioners are educated appropriately to provide only that dietary advice that is evidence-based, beginning with the scientific material that we presented during the trial and some of which is now in this book.
When Marika and I decided to write Lore of Nutrition, we soon realised that if we were to include ALL the scientific evidence supporting the prescription of the LCHF/Banting diet, the book would simply be too overwhelming for the vast majority of readers. Instead, we agreed that to supplement the science in the preceding chapters, I would write a couple of chapters at the end outlining the key themes underpinning the evidence that the three Angels and I presented at the trial. And to save the more complex details for a second book – a supplement to this one, as it were – for doctors, dietitians and others interested in the complete evidence that supports our promotion of the LCHF eating plan.
Modern humans evolved from herbivorous primates
Our story begins about six million years ago. Africa is the home of the great apes. Climate change beginning about eight million years prior has caused significant alterations in the immediate environment. Progressive global cooling with the formation of the large permanent ice sheet on Antarctica has reduced the amount of rain falling at the equator, causing a gradual but relentless replacement of the equatorial jungles and forests – the natural habitat of the great apes – with more open savannah. Some of the great apes living on the edge of the retreating forests decide to leave the safety of their natural habitat and venture forth into the unknown, where they must either change what they eat or face extinction.
; Others decide to remain in the jungle, eating the foods they have always eaten. Modern gorillas are their descendants. They have eaten the same diet for the past six million years, comprising, for the most part, plant stems and leaves with a small contribution from fruit.
But the challenge posed for all mammals eating a plant-based diet is that no mammals, and only some species of anaerobic bacteria, have the capacity to digest the cellulose that forms the cell lining of all plants. Mammals that survive exclusively on plant material have had to develop a symbiotic relationship with anaerobic bacteria. Billions of anaerobic bacteria are given safe residence in specifically adapted intestinal organs, where they busily ferment ingested cellulose into usable mammalian food. In gorillas, this special organ is a voluminous large bowel (colon), making gorillas ‘hindgut fermenters’, a feature they share with horses, pigs, zebras, elephants, warthogs, rhinoceroses, rabbits and other rodents. In other grass-eating ruminants, including cattle, sheep, antelope and gazelles, the special fermenting organ is a four-chambered stomach in the foregut. Hence ‘foregut fermenters’.
The basis for this symbiosis is that in exchange for an environment where they can safely reproduce, the bacteria convert the cellulose into a form of saturated fat called volatile fatty acids, on which the host mammal bases its existence.2 So this is the important point: grass-eating ruminants convert a 100 per cent nutrient-poor carbohydrate food – grass – into energy-dense saturated fatty acids that are essential for their survival.
In truth, the specifically adapted fore- and hindguts of these herbivores can rightly be labelled super-specialised organs for manufacturing saturated fats.
Equally remarkable, the proteins in the bodies of those same bacteria become the source of the proteins that these mammals need to build their own bodies. Thus the protein in the meat that humans eat is derived from the bodies of the symbiotic bacteria.
In this way, all plant-eating mammals use cellulose as the growth medium for the bacteria in their intestines. These bacteria then produce the fatty acids and proteins that are missing in the nutrient-poor grass, roots, fruits and shoots on which these mammals must survive.
The point is that simply by looking at the intestinal anatomy of any mammal, one can determine the foods for which that animal is designed – either carnivory or herbivory. An important but unanswered question is whether one can be a bit of both – an omnivore eating both plants and animal produce. The assumption is that since humans eat both it must be possible. But is it ideal?
Figure 16.1 on page 310 shows that the key difference between humans and the great apes is that humans have much shorter colons (large bowels).3 As a result, the percentage of the total gut length taken up by the colon is much greater in all great apes than it is in humans. This confirms that these apes are hindgut fermenters. And all the biological and social features of these mammals follow from that: their small brains; their need to spend most of their waking hours eating (nutrient-poor plants); their production of copious faeces, 20 to 40 times a day; their lower levels of physical vigour (gorillas especially); and their relatively simple social structures. All are the result of their nutrient-poor diets.
For example, a study of fossil bones found on the shores of Lake Turkana in northern Kenya showed that as far back as two million years ago, ‘hominins, predating Homo erectus, enjoyed access to carcasses of terrestrial and aquatic animals that they butchered in a well-watered habitat’.5 Included in this fossil record were the bones of elephants, rhinoceroses, crocodiles and many species of antelope. The authors drew attention to ‘the inclusion of various aquatic animals including turtles, crocodiles, and fish, which are rich sources of specific nutrients needed in human brain growth’. It is the eating of foods rich in these nutrients – protein, essential polyunsaturated fats (specifically docosahexaenoic acid), iron, zinc, copper, iodine, selenium, vitamin A, choline and folate6 – that some argue explains why human brain size began to increase progressively about two million years ago, before a second rapid acceleration about 200 000 years ago.7 This latter acceleration may have been triggered when our immediate ancestors at Pinnacle Point in the Southern Cape, South Africa, began to incorporate even more fish products into their diets.8
Figure 16.1
Relative volumes of the stomach, small intestine, caecum and colon in five species of primates compared to humans. Note that in all the primates, the small intestine comprises about 30 per cent of the total intestinal volume, whereas in humans it is ~60 per cent. In contrast, the colon comprises ~50 per cent of the total intestinal volume of the primates, but less than 20 per cent in humans. These features indicate that the primates are hindgut fermenters, whereas humans have evolved the intestinal features of carnivores. Redrawn from K. Mu, ‘What are chimpanzee digestive systems like compared to humans?’4
In contrast, humans share the typical features of a carnivore’s gut dimensions – think lions, wolves and wild dogs, animals that eat only meat. The key is that the digestion of nutrient-dense foods does not require the intervention of anaerobic bacteria in an extensive large bowel, but rather can be done very effectively within the confines of a relatively short small bowel. Table 16.1 includes all the other evidence showing that humans are designed for carnivory.
Figure 16.2
Left panel: Increase of brain size (cranial capacity) in humans over the past 3.5 million years. Note that human brain size begins to increase about 1.75 million years ago, with a rapid increase over the past 200 000 years. Right panel: Relationship between brain size and body weight in fossil hominids. Note that brain sizes are disproportionately large for body size in all hominids. Redrawn from http://www.indiana.edu/~brainevo/publications/dissertation/Dissertationch2.htm9
The conclusion from Figure 16.1 and Table 16.1 on page 312 is unambiguous. Humans are primarily carnivores designed to eat animal products. This irrefutable anatomical evidence fits well with the record of what our hominin ancestors ate.
There is also a growing body of evidence showing that our ancestors specifically chose to hunt animals that would provide the most fat. Surprisingly, these were the larger, healthier animals. In the Levant, this meant hunting elephants.10 Why was this, when logic suggests that ‘feeble’ humans would surely choose to hunt the weakest animals they could find? There is a constraint in the human ability to metabolise protein to energy.11 As a result, humans are unable to eat a diet in which more than about 40 per cent of their daily calorie intake is provided by protein; accordingly, the remaining 60 per cent of the energy must come from carbohydrate or fat. There is strong evidence that early humans specifically chose those animal species, and indeed individuals within those species, whose bodies contained the most fat.
Thus, ‘fat, not meat, was the essential food for survival to hunting and gathering cultures’;12 ‘it therefore must be fat rather than protein that drives the desire for meat in many foraging societies’;13 and ‘fat, not protein, seemed to play a very prominent role in the hunters’ decisions about what animals (male vs. female) to kill and which body parts to discard or take away’.14
Table 16.1 Function and structural comparison of man’s digestive tract with that of the dog and sheep
MAN
DOG
SHEEP
TEETH
Incisors
Molars
Canines
both jaws
ridged
small
both jaws
ridged
large
lower jaw only
flat
absent
JAW
Movements
Function
Mastication
Rumination
vertical
tearing, crushing
unimportant
never
vertical
tearing, crushing
unimportant
never
rotary
grinding
vital function
vital
function
STOMACH
Capacity
Emptying time
Interdigestive rest
Bacteria present
Protozoa present
Gastric acidity
Cellulose digestion
Digestive activity
Food absorbed from
2 quarts
3 hours
yes
no
no
strong
none
weak
no
2 quarts
3 hours
yes
no
no
strong
none
weak
no
8.5 gallons
never empties
no
yes – vital
yes – vital
weak
70% – vital
vital function
vital function
COLON AND CAECUM
Size of colon
Size of caecum
Function of caecum
Appendix
Rectum
Digestive activity
Cellulose digestion
Bacterial flora
Food absorbed from
Volume of faeces
Gross food in faeces
short, small
tiny
none
vestigial
small
none
none
putrefactive
none
small, firm
rare
short, small
tiny
none
absent
small
none
none
