Noakes – really Public Health Enemy Number 1? Part 2

Tim NoakesIn Part 2 of a two-part series, sports scientist Prof Tim Noakes gives his final lecture to the first international low-carb, high-fat (LCHF) summit in Cape Town in February 2016. In it, Noakes throws much of what you think you know about nutrition into the ‘dustbin of bad science’.

He looks at the wealth of evidence showing the superiority of LCHF diets over conventional low-fat, high-carb diets for a wide range of health conditions. He lays waste to the myth that LCHF is not evidence-based. It’s a fascinating, iconoclastic read. – Marika Sboros 

By Timothy Noakes

There is now more than one substantial inconsistency that should long ago have relegated the low-fat diet to the dustbin of bad science.

My critics also like to say we only have anecdotal evidence for the benefits of low-carb, high-fat diet. That’s simply not true. There is significant anecdotal evidence, and all of

There is significant anecdotal evidence, and all of science begins with anecdote. But we also have a wealth of RCT evidence for the superiority of low-carb, high-fat diets over low-fat, high-carbohydrate diets.

Dr Jay Wortman

Dr Jay Wortman

A speaker at the first international low-cab, high-fat summit, Canadian associate professor Dr Jay Wortman, told how he became diabetic 12 years ago, cut carbs from his diet (as a doctor he knows carbs raise blood sugar), within days his symptoms had improved, and he has been without evidence of diabetes since.

Two of my clients attended the summit: Billy Tosh weighed 163kg in July 2012, was close to a heart attack, and had type 2 diabetes and hypertension. By March 2013, Billy had lost 84kg, his hypertension has gone, and he is free of symptoms of diabetes and hypertension. Brian Berkman weighed 153 kgs in July 2011, was diabetic, hypertensive and considering bariatric surgery. By January 2013, he had lost 82kg and is free of symptoms1 of diabetes, is no longer hypertensive, and avoided bariatric surgery.

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Is that all just anecdote? Probably not. I don’t claim they are cured, but they don’t require medication and are without evidence for diabetes.

There are many other case histories of spontaneous recovery from type 2 diabetes, a condition that my profession teaches is irreversible, will require increasing medication for life and has, in essence, a hopeless outlook with the only certainty – more drugs, more illness, more disability.

How many subjects do you require in a trial to prove an effect?

Dr Richard Feinman

Dr Richard Feinman

In his book, The World Turned Upside Down, author Richard Feinman said: “It depends on how many people recover spontaneously.”

If there has never been a reported reversal of Type 2 diabetes mellitus (T2DM) in patients following conventional medical advice (which there has not), then a single case is not an anecdote.

It is a black swan – in other words something that contradicts our previous beliefs, for example that all swans must be white to be classified as swans.

The presence of a black swan requires the immediate funding of a proper scientific study – a randomised controlled clinical trial – to test whether it is possible to reverse T2DM with a low carbohydrate diet.

A key question has been: you can’t prove causation without randomized controlled trials (RCTs). But as I’ve already shown, you can in fact surmise causation in cross-sectional study if you fulfill certain strict Bradford Hill criteria. And when applied to cross-sectional dietary studies, the Hill criteria support the health benefits of the low-carbohydrate diet.

But let’s first consider the evidence from RCTs.

Prof Jacques Rossouw

Prof Jacques Rossouw

One of my fiercest critics (Prof Jacques Roussouw) was involved in the most significant RCT: The Women’s Health Initiative Randomised Controlled Dietary Modification Trial, published in the JAMA in February 2006.

It was a large trial of 48,836 post-menopausal women, followed over 8.1 years looking at the effects of low-fat eating and costing about $700 million.

The study concluded: “Over a mean of 8.1 years, a dietary intervention that reduced total fat intake and increased intakes of vegetables, fruits, and grains did not significantly reduce the risk of CHD, stroke, or CVD in postmenopausal women and achieved only modest effects on CVD risk factors, suggesting that more focused diet and lifestyle interventions may be needed to improve risk factors and reduce CVD risk.”

Another two very expensive low-fat RCTs have come to the same conclusions.

The WHI study authors should have designed their study as the test of a null hypothesis: specifically, if you reduce your fat intake, you will reduce heart attacks and cancer rates. If the results don’t support the hypothesis, then the hypothesis is clearly wrong and must be abandoned (if one is practicing good rather than junk science).



Instead, when the authors discovered that the data did not support their original hypothesis, they simply added an ad hoc modification: In a news release, Dr Elizabeth Nabel, then head of the National Institute of Health,  the statutory body that had funded the study with taxpayers’ money, suggested that the findings “could have been due to chance”, and the participants could still have been eating too much fat.

Actually no, Dr Nabel. That’s not science. The study disproves your hypothesis. When the hypothesis is disproven, you have to come up with a new one and then attempt to disprove it.

EinsteinAlbert Einstein said: “No amount of experimentation can ever prove me right; a single experiment may at any time prove me wrong.”

The WHI study should have been considered definitive disproof of the authors’ hypothesis that eating less fat will prevent heart disease. Instead, the authors and the NIH marketed it as if it supported their hypothesis.That’s science driven by industry or governments that are determined to find an outcome that supports their position, regardless of the facts.

Why bother to do research if you “know” the outcome before the start? Of if you will interpret any outcome to support your ingrained prejudices?

The finding that low-fat diets did not reduce the risk of cardiovascular disease is entirely predictable as a high carbohydrate diet produces a specific atheroma-generating metabolic profile in those who are metabolically vulnerable because they have insulin resistance.

For example, there is one study that looked at the progression of coronary atherosclerosis (narrowing of the coronary arteries) in postmenopausal women by Harvard researcher David Mozaffarian and others, and published in the American Journal of Clinical Nutrition in 2004.


‘We have exposed the creaking, ugly edifice of conventional wisdom on nutrition’ – Tim Noakes


The study concluded: “In postmenopausal women with relatively low total fat intake, a greater saturated fat intake is associated with less progression of coronary atherosclerosis, whereas carbohydrate intake is associated with a greater progression.”

In other words, the study found that higher intakes of “healthy” carbohydrates and “healthy” polyunsaturated fats were associated with more rapid disease progression, whereas women who ate the most saturated fat showed NO disease progression.

Naturally, this study has been buried, never to be heard of again.

More recently, a study in the Journal of Nutrition in February 2015 confirmed that “dietary intake of saturated fat is not associated with risk of coronary events or mortality in patients with established coronary artery disease.”

Nina Teicholz

Nina Teicholz

But the strongest evidence against this fake hypothesis has been provided by Nina Teicholz in her riveting book, Big Fat Surprise: Why Butter, Meat and Cheese belong in a Healthy Diet. Teicholz reviews the absence of science behind the hypothesis that saturated fat causes disease.

Dr Richard Smith, a former editor of the BMJ, had this to say about this book which should be required reading for all:

“The title, the subtitle, and the cover of the book are all demeaning, but the forensic demolition of the hypothesis that saturated fat is the cause of cardiovascular disease is impressive.

“Indeed, the book is deeply disturbing in showing how overenthusiastic scientists, poor science, massive conflicts of interest, and politically driven policy makers can make deeply damaging mistakes.

“Over 40 years I’ve come to recognise what I might have known from the beginning that science is a human activity with the error, self deception, grandiosity, bias, self interest, cruelty, fraud, and theft that is inherent in all human activities (together with some saintliness), but this book shook me.”

At the Old Mutual Health Summit, British obesity researcher Dr Zoe Harcombe presented more novel evidence against the fake hypothesis. She asked the question: What evidence was available from RCTs in 1977 and 1983 to support the adoption of those novel low fat guidelines.

Dr Zoe Harcombe

Dr Zoe Harcombe

Harcombe’s study reported in the BMJ Open Heart journal one week before the Summit, concluded that “recommendations were made for 276 million people following secondary studies of 2467 (ill) males with reported identical all-cause mortality. RCT evidence did not support the introduction of dietary fat guidelines.”

So now we know there was no evidence available in 1977 to support the change in dietary advice that became the global standard. And we also know that no evidence has accumulated in the past 40 years to show retrospectively that those guidelines are correct and supported by the most rigorous science.

More global experts are weighing in their support almost on a daily basis.

Thus in an editorial in Diabetes Management in 2014, Dr Osama Hamdy, Medical Director of Joslin Obesity Centre’s Obesity Clinical Programme, wrote:

Obesity Epidemic“It is clear that we made a major mistake in recommending the increase of carbohydrates load to >40% of the total caloric intake (especially for persons with type 2 diabetes mellitus). This era should come to an end if we seriously want to reduce the obesity and diabetes epidemics. Such a move may also improve diabetes control and reduce the risk for cardiovascular disease.

“Unfortunately, many physicians and dieticians across the nation are still recommending high-carbohydrates intake for patients with diabetes, a recommendation that may harm their patients more than benefit them.”

Yet my critics continue to ignore all the evidence that favours the health benefits of high-fat diets and the absence of evidence supporting low-fat diets. Could be due to the Upton Sinclair Theorem which states: “It is difficult to get a man to understand something, when his salary depends upon his not understanding it.”

Perhaps the most important reason why the value of low-carbohydrate diets is not yet properly appreciated, especially by my profession, is because we do not appreciate the importance of  insulin resistance (IR). It is perhaps the single most important biological condition across the globe.

It is my argument that the global epidemics of obesity, diabetes, hypertension, gout, and atherogenic dyslipidaemia (high triglycerides, low HDL-C, increased number of small LDL-C particles, and increased triglyceride-rich remnant lipoproteins) and perhaps also cancer and dementia, are really the tip of the iceberg. These are markers of an underlying biological predisposition that becomes apparent in those exposed to high-carbohydrate diets and then presents as one of more of those conditions.


‘Ignoring insulin resistance undermines the modern practice of chronic medicine’ – Tim Noakes


It is my thesis that IR is the most prevalent biological condition in the world. It remains hidden as long as diets are not high in sugar and refined carbohydrates. But in the face of a high-carbohydrate diet eaten for decades, the IR leads to all the common chronic diseases that we face today.

The problem is that IR is not taught in many medical schools or schools of dietetics and nutrition and this perhaps is the key problem. If we don’t recognise the single most important factor predisposing to chronic ill health across the globe, then we are not likely ever to be able to cure or reverse those diseases. Especially if the cure is to remove the cause, which is a high- carbohydrate diet.

Ignoring IR undermines the modern practice of chronic medicine. If all the conditions linked to IR are caused ultimately by high-carbohydrate diets – that is, by a nutritional factor, as I believe they are – we don’t need medication and the pharmaceutical industry that is designed to market its drugs to treat those conditions.

These are not conditions caused by the lack of a specific pharmaceutical chemical. They are caused by too many carbohydrates in the diet. We fuel the fire with carbohydrates and try to put it out with pharmacologic drugs that do not address the real cause.

Our critics’ views are based on the belief that all humans can metabolise carbohydrates equally. The condition of IR disproves that idea. Instead, IR shows that for some, even the smallest amounts of carbohydrate eaten for decades are enough to seriously damage health in the long term.

In Black Holes and Baby Universes and Other Essays, Stephen Hawking says: “People are very reluctant to give up a theory in which they have invested a lot of time. They usually start by questioning the accuracy of the observations. If that fails, they try to modify the theory in an ad hoc manner. Eventually the theory becomes a creaking and ugly edifice.

“Then someone suggests a new theory in which all the awkward observations are explained in an elegant and natural manner.”

At the low-carb, high-fat summit in Cape Town, I believe that’s what we have done. We have exposed the creaking, ugly edifice of conventional wisdom on nutrition, and explained an alternative in an “elegant and natural manner”.