By Marika Sboros

University of Cape Town cardiologists say Prof Tim Noakes is a true “cholesterol denialist”. They accused him of being one in a letter to the media in 2012. They say the accusation holds true and he’s a danger to the public.

Cholesterol and hearts are a major focus of the Health Professions Council of SA (HPCSA) case against Noakes, a medical doctor and UCT emeritus professor on a charge of unprofessional conduct. So are minds and all other bodily organs, of course. Also under the spotlight:South Africa’s fat-phobic official dietary guidelines from which drug companies, food companies, doctors and dietitians have made fortunes, big and small.

But it is Noakes’ views on best diet for heart disease that really get cardiologists’ heart rates rising. Those views are one reason the HPCSA has gone after him. (For background on this strange saga click here to read the real beef dietitians have with him.)

In a post, I suggested that cardiologists might be at the heart of the hearing against Noakes that resumes in Cape Town on October 17.

There’s no evidence any of the cardiologists who wrote the 2012 letter is directly involved in the trial. However, their views will have helped the HPCSA and the Association for dietetics in SA (ADSA) build a case against Noakes. They will have fed ADSA and the HPCSA’s attitude towards  Noakes as the devil incarnate of nutrition science.

Challenging beliefsI contacted the authors of the 2012 letter to see if any has had a change of heart in the interim. That’s in the light of evidence on benefits of  low-carb, high-fat (LCHF) diets for  heart disease – and lots else besides. However, despite evidence to show that LCHF can treat obesity, diabetes, cancer and boost cognitive function in Alzheimer’s and other dementias, all stick to the letter’s contents.

The authors are: Patrick Commerford (at the time professor of cardiology and head of the cardiac clinic at UCT and Groote Schuur Hospital), Mpiko Ntsekhe (of the cardiac clinic at UCT and Groote Schuur), Dirk Blom (of the lipid clinic at UCT and Groote Schuur ), David Marais (of chemical pathology and clinical laboratory services at UCT’s Health Science Faculty), and UCT cardiologists Elwyn Lloyd and Adrian Horak.

I managed to speak to three via email: Commerford, Ntsekhe and Marais. All stick to the contents the 2012 letter.

Inter alia, they say in the letter that what Noakes proposes (for treatment of heart disease) is “contrary to the recommendations of all major cardiovascular societies worldwide”. While they agree with some of his sentiments, they say His diet is “unproven”. It may be “dangerous for patients with coronary heart disease or persons at risk of coronary heart disease”.

They say Noakes went “too far in suggesting that a switch to a high-fat, high-protein diet is advisable for all persons”.

Interestingly, Noakes’ dietary regimen is not high-protein. It’s high-fat. And he hasn’t ever said his diet is for “all persons”. He has recommended it only for those who are insulin resistant.

But it is Noakes’ views on statins that seem really to get cardiologists hot under their white collars. He has called statins “the single most ineffective drugs ever invented”. He has also said the diet-heart hypothesis is “unproven dogma”.



That hypothesis is another leitmotif throughout this trial. It says fat in the diet equals fat in your arteries. It’s the one responsible for demonisation of saturated fat. It says dietary fat causes “bad cholesterol”. Because cholesterol clogs arteries and is the sole cause of heart attack or stroke (the “lipid” hypothesis).

Dr Mpiko Ntsekhe

UCT cardiology professor Mpiko Ntsekhe

Ntsekhe is now professor of cardiology at UCT and Groote Schuur. He says advising people “not to be concerned about their blood cholesterol levels and not to use an agent (statins) whose mode of action is through altering cholesterol metabolism and with overwhelming evidence of life-saving efficacy constitutes a form of cholesterol denialism”.

He says there’s a “very big difference” between the cholesterol-heart (lipid)  hypothesis and diet-heart hypothesis. While most heart specialists believe “strongly in the former”, they recognise that the latter is “contested space”.

I’m not so sure about such a “big difference”.  The two hypotheses seem inextricably linked to me, and that it’s semantics to separate them. But that’s probably because I’m just a lay person. I would love to know what Scottish GP Dr Malcolm Kendrick, author of The Great Cholesterol Con, thinks. (Watch this space.)

Statins’ mode of action is through altering cholesterol metabolism and there is “overwhelming evidence of life-saving efficacy”, Ntsekhe says. Thus, Noakes’ views on statins really do make him a “danger to the public”.

Malcolm KendrickStatins are “central to the medical management and reduction of major adverse cardiac outcomes in patients with all forms of ischemic heart disease”, he says. The same applies to those at significant risk of developing ischemic heart disease.

Advising people not to use them is “potentially very dangerous”.

While Ntsekhe attacks Noakes on many points, he agrees that Noakes hasn’t got it all wrong. In the letter, he and colleagues say Noakes’ views on the contribution of refined carbohydrates to the obesity epidemic are “almost certainly correct”.

However, Ntsekhe says there is now “very strong evidence” that statins in patients with coronary artery disease improve mortality (they make you live longer). “Multiple placebo-controlled studies confirm this.”

He “still agrees strongly” that as an academic, Noakes should air his views in an academic forum and the medical literature. This would allow his peers to evaluate his views critically and challenge them.

Ntsekhe “still agrees strongly” that to present “controversial opinions as fact to a lay public in (Noakes’) un-refereed book (Challenging Beliefs) is dangerous and potentially very harmful to good patient care”.

Last, but not least, Ntsekhe still “strongly agrees” that scientists and clinicians have “an ethical obligation to ensure that the information they impart to their patients and the public at large is correct, in line with best available evidence, and will not cause harm”.

The subtext is that Noakes does not meet that ethical obligation. That ties in with the HPCSA’s attempts to prove Noakes guilty of unethical conduct that so far haven’t been successful.

Marais,  UCT professor of chemical pathology, says the letter aimed to “curb a global switch to a high-fat diet as there was scope to do harm”. Similarly, indicating that statins had no benefit  created “scope for harm”. The letter did not go into detail because it was simply to “convey caution to the public”.

It is “important and correct” to say that lifestyle has an enormous impact on health, Marais says. That has “never been contentious”. However, there are many aspects to lifestyle and cardiovascular risk, and  medical practitioners should “tailor  advice to the individual”.

Marais remains concerned about “generalising about diet and statins”.  People with severe inherited disorders could suffer harm if they followed advice to disregard dietary advice for specific disorders. The same applies if they stopped taking medication (statins) “proven to be of benefit”.

On the fact that Noakes’ diet is not high-protein, Marais says “these diet descriptions seldom define exact quantities”. This makes it difficult to know exactly what the proponents are advocating because “if the fat increases and the carbohydrate decreases, the protein could well increase”.

Commerford is now a UCT emeritus professor and editor in chief of the Cardiovascular Journal of Africa. He commented  briefly to endorse all Ntsekhe’s comments and the contents of the 2012 letter.

“If anything,” Commerford says, the evidence for statin efficacy “has continued to rise over the last few years”.