By Marika Sboros
University of Cape Town emeritus professor Tim Noakes does many things that drive his critics nuts. Chief among them is his ongoing research and the evidence-based views he propagates on nutrition science and diet. For example, he says if you religiously eat three times a day you are addicted to food. Your appestat, the part of the brain that controls your appetite isn’t working properly.
Noakes continues to generate abnormally high levels of venom and bile from doctors and dietitians for a spectacular about-turn in favour of low-carb, high-fat (LCHF) in 2010. Noakes is facing a charge of ‘unprofessional conduct’ for tweeting his opinion to a breastfeeding mother that the best weaning foods for infants are LCHF – in other words, meat and veg. Ironically that’s advice the dietitian who reported him now routinely gives.
In the first of an updated two-part Q&A session with me, Noakes makes a tasty ‘real meal’ of his critics. He also refers to his new research to be published soon that will challenge conventional ‘wisdom’ yet again – and possibly prove his critics wrong once and for all?
Attacks aimed at Prof Tim Noakes are limited only by the imagination, and as personal as they are professional in nature. At best, he is called misguided, at worst a killer quack who flouts the Hippocratic oath: His theories on low-carbohydrate, high-fat (LCHF) eating, documented in the best-selling The Real Meal Revolution, have become known as the Tim Noakes Diet, and are regularly labelled “bad science”, “dangerous” and “criminal”. (For the fundamentals of his diet, and how to get started on it, read my Idiot’s Guide to Tim Noakes. )
Attacks on him intensified with publication of the so-called Stellenbosch review in PLoS (Public Library of Science) One in 2014: a meta-analysis of 19 international studies, led by Dr Celeste Naude of Stellenbosch University’s Centre for Evidence-based Medicine. The review quickly mustered an cardiologists, endocrinologists, epidemiologists, the Heart and Stroke Foundation of SA, the Association of Dietetics of SA (ADSA), and the Health Professions Council of SA (HPCSA) that claimed proof that Noakes’s “diet” will kill people.
Nutrition experts internationally were scathing about the study, pointing out the many flaws, including that it did not evaluate low-carb diets of the kind Noakes promotes. It also found that moderate dietary carbohydrate restriction was no better or worse than the high-carbohydrate, low-fat diet which the study authors, heart foundations and dietitians associations claim is “healthier”. The researchers spun a very different message to the media and the public than what their own data showed, says Noakes: that their supposedly more “healthy” diet was no better than the LCHF diet they were trying to discredit.
Next, top UCT academics wrote a letter to a Cape newspaper in August 2014 accusing Noakes of “outrageous, unproven claims about disease prevention”. The letter was signed by Prof Wim de Villiers, then dean of Faculty of Health Sciences (now Rector of the University of Stellenbosch), Prof Bongani Mayosi, then head of the Department of Medicine (now Dean of the Faculty of Health Sciences), emeritus professor, cardiologist Dr Lionel Opie, and Dr Marjanne Senekal, then Head of UCT’s Division of Human Nutrition and still with the university. The authors attacked Noakes for “maligning the integrity and credibility of peers who criticise his diet for being evidence-deficient and not conforming to the tenets of good and responsible science”.
Good read: NOAKES: LOW-FAT CAUSES HEART DISEASE!
I’ve been in personal contact with De Villiers and Senekal, and email contact with the rest to see if they have changed their minds in the interim; if they’ve read the vast body of solid research showing benefits of LCHF to treat obesity, heart disease, diabetes, cancer and even dementia – which doctors are now calling “type 3 diabetes” because of its links with diabetes. They have all declined to comment.
Noakes, formerly professor of exercise and sports science and director of UCT’s Research Unit for Exercise Science and Sports Medicine, wrote to the university pointing out that the letter was defamatory, and there is solid science behind his diet. Ditto for The Real Meal Revolution. The book’s runaway success serves only to infuriate critics. With word-of-mouth advertising only, in the first six months after publication in December 2013, it sold more 100 000 copies, making it South Africa’s bestseller ever. It has sold 250 000 copies so far, been translated into Dutch with a German version coming out soon. All Noakes’ royalties are donated to The Noakes Foundation which was established to research nutrition and challenge scientific dogma. In addition more than R1 million has been donated to The Smile Foundation that funds the surgical repair of South African children born with the cleft palate deformity.
Ironically, everything Noakes writes in The Real Meal Revolution is in Time magazine’s cover story on the science behind benefits of dietary fat in June 12 2014. That put him ahead of Time, and created something of an inconvenient truth for critics – how to prove him wrong when science proves him right. Things became even harder for Noakes’ critics last year when the research arm of a multinational investment bank entered the fray. The influential Credit Suisse document entitled Fat: The new health paradigm came to conclusions that mirrored precisely what Noakes has been saying for the past six years.
So what’s really behind attacks on Noakes, a medical doctor and an internationally renowned scientist, one of few in the world with an A1 by the National Research Foundation – for expertise in both nutrition and sports science? Noakes has learned the hard way about the perils of challenging medical and dietetic orthodoxy and the vested interests propping it up.
In Part 1 of a Q&A session, I put the most common criticisms to him:
What changed your mind about carbo-loading in 2010?
I discovered the work of (Eric) Westman, (Jeff) Volek and (Stephen) Phinney that had been suppressed, as described in The Big Fat Surprise, by Nina Teicholz. It’s no surprise I hadn’t seen it – I didn’t realise the degree of suppression there has been of the large body of evidence showing the beneficial effects of low-carbohydrate diets for a range of medical conditions but most especially for those with the most prevalent medical condition across the globe – insulin resistance. That’s condition that I have. Those scientists are now friends of mine.
Their book, The New Atkins For A New You, opened my eyes and quite literally saved my life. Had I not discovered that book and converted to the LCHF in 2010, my diabetes would probably by now have been uncontrollable even with high doses of insulin. And I now know that when you are on insulin, the future is not good for the diabetic.
Does the “Stellenbosch review” really prove your diet doesn’t work?
No. The researchers chose to include only those studies that would favour their bias. Thus they included studies that allowed much higher carbohydrate intakes than we promote in the Real Meal Revolution. In addition they chose studies in which the energy intake of both groups of subjects was equal and controlled. This completely negates the key advantage of the Banting (as LCHF is known in South Africa) diet which reduces hunger.
As a result, Banters can naturally eat fewer calories without being hungry. In contrast those eating calorie-restricted low fat diets – the comparators in the Naude study – are perpetually hungry when forced to eat as few calories as the Banters eat without experiencing hunger. The study is fatally flawed and that’s why it has not been taken seriously by the international community. In addition the authors ignored published research that contradicted their findings and which showed that subjects eating properly low-carbohydrate diets – that is 20-50g/day and not the 200g/day included in the Naude review – did better and lost more weight than those eating Naude’s “healthy balanced diet in moderation”.
Why do you advocate going so low in carbs?
There is a critical threshold for carbohydrate intake, below which you get massive benefits, above which you don’t. Orthodox dietitians don’t understand that. That’s why their advice on weight loss fails. This is a game of “inches”. If you don’t get the carbohydrate intake exactly correct for each individual, the outcome is failure. The same applies to sugar. Since sugar is so highly addictive, it has to be completely removed from the diet or the diet will fail. One cannot eat an addictive substance like sugar “in moderation”, any more than one can use cocaine in moderation. It’s either nothing or it’s all.
Is your “Noakes diet” ketogenic?
It can be ketogenic, but doesn’t have to be.
What’s a ketogenic diet?
One so low in carbohydrate and protein (protein will act as a partial carbohydrate), and high in fat, it causes blood ketone bodies to rise.
What’s a ketone?
Any of three natural chemicals produce from fat in the liver in response to a low-carb diet. Instead of burning glucose, the brain cleverly decides: let’s burn ketone bodies. Ketones are probably the most efficient body fuel.
When should a diet be ketogenic?
It depends. The sicker you are, the more ketogenic you need to be. That is, if you have uncontrolled diabetes or if you have epilepsy or perhaps if you want to use this diet to help in the management of cancer or dementia, then you will want to be in more marked ketosis. If you just want to lose weight or run better, your diet doesn’t have to be ketogenic.
You were diagnosed diabetic three months into starting your diet. Critics say that proves your diet doesn’t work, and caused your diabetes. Do they have a point?
That’s unbelievable logic: if you do one thing – eat a high-carbohydrate diet for 33 years – then change it for three months, what you did for the previous 396 months is irrelevant. In other words, the diabetes epidemic is from everyone suddenly eating high-fat diets across the globe. So, let’s get back to the facts: my father died of Type 2 diabetes which puts me at a 10-fold increased risk. Unfortunately, for 33 years, I followed Diabetes Association guidelines that said as long as I ran my marathons and ate a high-carb diet, I’d never get diabetes. They were wrong – very, very wrong.
Your critics say you take medication for diabetes, which proves your diet doesn’t work. Surely they have a point?
No. I just had to face facts. I was insulin resistant and had been eating a high-carb diet for three decades before I started a high-fat diet. The diagnosis of diabetes should have been made years before – I have evidence that already at the age of 28 when I was lean, running at least 120km/week and racing marathons – I was already profoundly insulin resistant. But I’m my own doctor – the worst thing. I was focusing on my “perfect” blood cholesterol concentration and my reasonable blood glucose levels. I didn’t understand then that one diagnoses diabetes by measuring insulin and HbA1c concentrations. Had I done those simple tests 20 years earlier and changed my diet to LCHF then, I would not now have type 2 diabetes. I would simply just be profoundly insulin resistant – a completely benign condition if one does not eat more than 25g of carbohydrate each day. After diagnosis, I thought I could get by without medication.
I spoke to specialists I trust internationally who confirmed the diagnosis of diabetes, and said I should take medication. If I was being treated conventionally but still eating my high-fat diet, I probably could get by without medication. But I want perfect control. I want my glucose to be as good as anyone without diabetes. I’m nearly there. By not eating more than 25 g carbohydrates per day, I do not have any spikes in my blood glucose concentrations even though my normal fasting values may be slightly higher than normal. I think it is the spikes and the associated over-secretion of insulin that causes the widespread arterial damage that kills in type 2 diabetes. So that’s the goal of my treatment.
Critics, including the UCT academics who wrote the letter to the Cape Times still insist your views on LCHF are unscientific and based only on anecdote. Are they right about the anecdote?
No. Science is my lifeblood. I understand the scientific method better than 99.9% of my critics, especially the ones who speak this garbage. It is a measure of their own ignorance and laziness – they are not prepared to read all the literature and especially the information that conflicts with their preconceptions. All of medicine begins with anecdote. Jenner started the vaccination theory based on anecdote. Scientists determine the truth on the basis of clinical trials, personal experience, and what patients tell us. None is more important than the other. At each level of evidence it is abundantly clear: if you are insulin resistant, there is only one safe diet for you to follow and that is one that is low in carbohydrates. The biological basis for this statement is irrefutable. Those who deny it simply do not understand the biology of insulin resistance and carbohydrate ingestion.
But is there any gold-standard (randomised controlled trials) evidence for your diet?
Yes. The first year after I made dietary changes, I didn’t know enough to make definitive statements. I’ve been reading the literature since – everything on both sides. I focused on the high-fat diet; turns out there is solid evidence in favour of it, and none, absolutely none, in favour of the low-fat diet. The evidence for high fat has been suppressed, but has been accumulating; it’s all there, in The Big Fat Surprise. More importantly with Canadian colleagues we have completed the first large scale trial of this diet in a free-living population in Canada. And the results were utterly revolutionary. They are due to be published in a medical journal soon. They show that this diet does things for the health of those with obesity and the metabolic syndrome that conventional medical care simply cannot achieve. Its publication will pose a huge challenge for conventional medicine. I am so keen to see how my critics are going to spin their way out of this one. For it shows that the “healthy” diet they promote is the cause of the ill-health they claim is being caused by “my” LCHF diet.
That’s a strong statement?
The question for Stellenbosch Rector (Wim) de Villiers and UCT medical Dean Bongani Mayosi is: how will they cope with the publication of this paper. Will they simply ignore it as if it does not exist – as they seem to have done for all the other evidence showing the value of the LCHF diet? And what will Prof (Marjanne) Senekal do with her hospital-wide order that no doctor at Groote Schuur Hospital may prescribe the low-carbohydrate diet for any patient?
What happens when their patients suddenly learn that the only proven long-term solution for their metabolic ill-health is a low-carbohydrate diet. Not bottles of drugs that do not address the causative mechanisms – insulin resistance compounded and exacerbated by high carbohydrate diets.
I am so glad I got out of this mess six years ago.
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