Tim Noakes: ‘Why I won’t practise medicine of failure’

University of Cape Town deputy vice chancellor and law professor Danie Visser calls emeritus professor Tim Noakes a “force in the world”. The Health Professions Council of South Africa (HPCSA) is more likely to call Noakes a tsunami. When the HPCSA resumed its hearing this week against Noakes on a charge of  unprofessional conduct for giving unconventional advice to a breastfeeding mother on Twitter, he deluged its legal team with research to show he had been neither unprofessional nor was the advice he gave not evidence-based. If the HPCSA hoped the new addition to its legal team, advocate Ajay Bhoopchand who is also a medical doctor, would stem Noakes’ defensive tide, it was wrong. Bhoopchand tried hard to stop Noakes presenting evidence on the influence of food and soft drink industries on dietary guidelines and nutrition advice, saying it was ‘irrelevant’, he was ‘lecturing’ and giving ‘too much minutiae and detail’. Noakes’ own medical doctor advocate Ravin ‘Rocky’ Ramdass explained the relevance in minute detail to Bhoopchand. Chair of the HPCSA panel hearing the charge against Noakes, Pretoria advocate Joan Adams, overruled Bhoopchand, saying it was not in the interests of fairness or justice for the HPCSA to charge Noakes with giving advice that was not evidence-based, then stop him presenting evidence to show his advice was evidence-based.

Bhoopchand was powerless to stop Noakes in full sail as he waded into these vested interests worldwide, showing how they are embedded in academia, have bought off top scientists and academics,  sponsor dietitians’ associations – including the Association for Dietetics in SA (ADSA), whose former president, Claire Julsing Strydom, laid the complaint that led to the charge against him – to spin their products, and influence dietary guidelines, nutrition advice and our ideas about obesity and weight loss. He showed how  food and soft-drinks industries have made low-fat, high-carb foods the dominant ‘conventional’ dietary paradigm without any science to back it up, contributing to global epidemics of obesity, heart disease, diabetes to name but a few. Noakes took special aim at the sugar industry, but had many other targets, including his own profession, saying doctors were telling patients diabetes was incurable when they had the means to reverse it: ’We are practising medicine of failure. I don’t want to practice that kind of medicine.’ He also explained – in minute detail – why heart disease in future will be treated not by cardiologists, but by hepatologists (liver specialists). In this fourth part of a series, science and business writer Rob Worthington-Smith looks at Noakes’ views on how and why obesity and heart disease began in the cradle of civilisation. – Marika Sboros

By Rob Worthington-Smith

Tim Noakes
Prof Tim Noakes (left) and advocate Dr Ravin ‘Rocky’ Ramdass. Picture: copyright Jonno Proudfoot

Part Three was dedicated to understanding the importance of mankind’s early evolution from largely herbivorous ape to largely carnivorous hunter. We saw that it took 100,000 generations for our ancestors to develop the brain we have today, and to lose three quarters of our large colon-dominated digestive tract. Lithe and trim, we became, in Professor Noakes’ words, uniquely advantaged as mid-day persistence hunters, subsisting predominantly on nutrient-rich animal foods.

Then, in the blink of the evolutionary eye, we discovered how to farm grains, forcing our ancestors to settle in one place, but thus allowing the development of new technologies, complex societies, more complex governance structures, art and language, and material wealth.

It is easy to understand that such rapid progress has brought with it detrimental consequences to our lifestyle and our health. But should we be putting our trust in a story sponsored by Big Food and Big Pharm? Yes, rich (fatty) eating and a paucity of exercise fits well with the development of modern cuisine and an environment aimed at sedentary and convenient living. It is an easily accepted story, well advertised by the agricultural revolution’s modern successors.

Rob Worthing-Smith
Rob Worthing-Smith

However, there are serious flaws in the logic of this story. If our digestive tract had evolved for a carnivorous diet over 99.6% of its evolutionary journey, could it not actually be the high prevalence of carbohydrate in the modern diet (whether in the form of starch or sugar) that is making us ill?

Noakes will be presenting this hypothesis via a number of avenues, including the science behind the body’s metabolic pathways (to be described in Part Five). Here we will go through the evidence that has emerged from population studies, described below:

Firstly, researchers have found that the most obese and unhealthy populations have been those living in impoverished conditions, often expending considerable energy through manual work.

One such population cited in the research was identified in South Africa, back in the 1920s. Others, identified around the same time, were found living on reservations in North America. Further, these populations were all eating relatively low fat diets, with most energy being consumed in the form of grain-based staples. 

Secondly, the biggest health disaster facing populations around the world is the growing incidence of Type 2 Diabetes (the Afrikaans term is suikersiekte, or sugar sickness). Some 12% of all South African adults are already diabetic, and it is expected that double this number will be diabetic by the year 2040. This increase begins 20 years after the introduction of the 1977 US Dietary Guidelines that promoted the adoption of diets high in carbohydrates and based on cereals and grains.

Read also: Tim Noakes: why I’ve been waiting for this trial for years

This is compatible with the finding that populations that undergo the transition to this modern industrial diet begin to develop diabetes 20 years after the dietary change. There is growing evidence that persons with Type 2 Diabetes dramatically improve their health when they restrict their dietary carbohydrate intakes.

Third, for Noakes’ hypothesis to be true, even early civilisations that converted to carbs should show evidence of metabolic disease. Indeed, this is exactly what the evidence has shown. A standard indicator of the existence of hunter populations versus farmer populations used by archaeologists when excavating burial sites is the state of dental decay in skeletal remains. In practically every recorded case, hunter populations show healthy teeth and bones, while settler populations eating grains show evidence of tooth caries and decay, malnutrition and stunted growth.

Possibly the most fascinating evidence comes from studies of Egyptian mummies. The ancient Egyptians built their civilisation on the cultivation of wheat and were even nicknamed ‘Artophagoi’, or eaters of bread. Stable isotope analysis of the well-preserved remains of these mummies confirms that relatively little protein in their diet was of animal origin. Further, this was at a time when no sugar was available, nor any transfats as found in manufactured “vegetable oils” and margarine. We can be assured they were not eating junk food. In fact, their diet was almost exactly the same as that recommended in our South African dietary guidelines (in turn based on the 1977 US dietary guidelines).

And yet, heart disease was rife in this ancient population! Recent studies of hundreds of mummies dating from around 1500 BC and ranging across the lower-, middle-, and upper classes, has found overwhelming evidence of atherosclerosis and heart disease, often in individuals as young as their late twenties and early thirties. These studies confirm the findings of earlier studies conducted using basic dissection of preserved mummy tissue early in the 20th century. These people were not healthy; inded surviving statuary confirms that many carried considerable adipose fat around their midriffs.

Read also: Noakes, low-carb, high-fat on trial: will the evidence ruin a good story?

The association between a high, but apparently healthy, carbohydrate diet and metabolic disease is strong, but does it make the case for causation?

Noakes’ final exhibits come from studies of different human populations, the Plains Indians and the Masai warrior tribes. Both have been described as tall and athletic, and exhibiting none of the symptoms of metabolic disease. The Plains Indians co-evolved with the North American Bison and, until the time of the American Civil War, were predominantly hunters. Once the bison were shot out by advancing frontiersmen, these people were forced to eat a Western diet of cereals, grains and processed foods. They are now amongst the most obese populations in America.

The rural Masai have remained healthy, eating meat and drinking blood and cows milk, a typical LCHF diet. Their urban cousins have been less fortunate, as comparative studies have shown.

In Southern Africa, local nations, in particular the Zulu-speakers, derived most of their diet from their vast herds of Nguni cattle. After the Anglo-Zulu war, these herds were destroyed and further calamity came towards the end of the 19th century, when cattle disease (the Rinderpest) wiped out more than 5.2 million head of cattle south of the Zambezi.

Considering the growing mining industry in South Africa and the requirement to provide energy-rich food for the labour force, the colonial government encouraged the establishment of the so-called maize triangle, providing a cheap, staple food, but transforming the nation’s diet within a few decades from animal fat-based energy to carbohydrate derived energy.

While this evidence may not prove causation, the correlation between populations free of metabolic disease and a protein/fat-rich diet is high, as is the correlation between populations eating a high carb diet and metabolic disease.

Can Noakes move beyond association to causation? Can he make the case that the main cause of obesity, diabetes, heart disease and other symptoms of metabolic disease is not the high-fat diet of our early ancestors, but the apparently healthy carbohydrate diet that became the predominant source of energy after the agricultural revolution?

As a corollary, the introduction of sugar into our diets towards the end of the 19th century, and of the development of corn syrup in the 1960s as a key ingredient in the manufacture of processed food products only accelerated what was already a slippery path towards widespread metabolic disease, so prevalent in our society today.

In the next article, we’ll look for causation in the science behind insulin resistance, its role in obesity and the metabolic syndrome.

  • Rob Worthington-Smith is a science and business writer. While his day job is to analyse companies’ non-financial capitals for the responsible investor, he also pursues a wide range of interests including evolutionary biology and behavioural economics. Rob enjoys the challenge of bringing perspective to contentious issues, such as the moral landscape, how to address inequality in a developing economy, progressive approaches to education, parenting (as a widowed, single parent of four), and the science and pseudo-science behind health and nutrition. Worthington-Smith holds a BSc Honours degree in Agricultural Economics from Stellenbosch University. Disclosure: Whilst as yet undecided on every aspect of the issue, Rob is currently working with Prof TIm Noakes to bring perspective and balance to the current debate on dietary guidelines.
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