Noakes trial: ‘Angel’ Harcombe aims at its heart

Prof Tim Noakes with Dr Zoe Harcombe
Prof Tim Noakes with Dr Zoe Harcombe

By Marika Sboros

If South African scientist Prof Tim Noakes were enough to raise cardiologists’ blood pressure, British obesity researcher Dr Zoë Harcombe’s could raise it instantly into the stratosphere.

Noakes once memorably called statins “the single most ineffective drug ever invented”.  In her evidence at the Health Professions Council of SA (HPCSA) hearing in Cape Town, Harcombe called statins “one of the biggest crimes against humanity that the pharmaceutical industry has unleashed”.

She also said that health professionals had a duty to tell the public that advice the Association for Dietetics in SA (ADSA) dishes up is biased in favour of industry.

The HPCSA has charged Noakes with unprofessional conduct. That’s for one tweet to a breastfeeding mother in February  2014. He tweeted that good first foods for infant weaning are low-carb, high-fat (LCHF). In other words, meat, fish, chicken, eggs, dairy foods and vegetables.

The ‘angels’ fly in

Harcombe is one of three expert witnesses for Noakes that the public has dubbed “Tim’s Angels”. The other “Angels” are US investigative journalist Nina Teicholz, author of The Big Fat Surprise, and South African-born New Zealander Dr Caryn Zinn, a registered dietitian and academic.

Harcombe continued her evidence in chief on day six of the hearing on Monday, October 24. She aimed her prodigious scientific weaponry at South Africa’s guidelines. Also in her sights was the diet-heart hypothesis: that saturated fat causes heart disease.

She showed how obesity rates in the US and the UK began climbing in both countries after they introduced the guidelines in 1977 and 1983 respectively.

Her PhD thesis was on An examination of the randomised controlled trial and epidemiological evidence for the introduction of dietary fat recommendations in 1977 and 1983. It formed the basis of her evidence.

Although Harcombe’s research is US- and UK-based, she showed direct relevance for South Africa. South Africa closely follows the US guidelines and shows the same disease patterns.

Harcombe began with the origins of the diet-heart hypothesis. And no, the originator wasn’t US scientist Ancel Keys and his infamous Seven Countries Study. That’s despite what many doctors and dietitians still think.

‘Tripartite relationship’ on hearts

Dr Ancel Keys on the cover of Time magazine, 1961
Dr Ancel Keys on the cover of Time magazine, 1961

Keys established the “tripartite relationship” between coronary heart disease, saturated fat and serum (blood) cholesterol levels, Harcombe told the rapt hearing.

However, the notion that cholesterol, either dietary or blood (serum) cholesterol, could be an issue in human physiology started earlier, she said.

Russian pathologists doing autopsies at the beginning of the 20th Century noticed fatty deposits in the arteries of corpses. They observed cholesterol in those arteries – also phospholipids and protein. In essence, it was cholesterol, Harcombe said.

They wanted to investigate whether dietary cholesterol may have increased blood cholesterol. Thus, they considered whether this could have caused those people’s deaths. They fed rabbits foods of animal origin to see if they developed deposits in their arteries.

They did. However, rats fed animal foods did not. Rabbits fed cholesterol in plant food showed no arterial damage.

“The key point,” Harcombe said, “is that rabbits are herbivores so they can’t digest animal fats”.  Omnivorous rats had no problem with dietary cholesterol. Even rabbits fed the dietary cholesterol directly did not suffer any harm.

“That was a  misinterpretation from the very outset,” she said.

Birth of Seven Countries Study

The pathologists did not make that distinction.  Actually one did, but his colleagues didn’t follow him.

Harcombe went on to review – and thoroughly undermine – the science behind Keys’ Seven Countries Study. She explained how Keys launched the study in 1956-8. That was after exploratory research on the relationship between diet and the prevalence of coronary heart disease (CHD) in some countries, including the US and Japan.

Keys was convinced that fat intake (animal or vegetable – it made no difference to him) affected serum cholesterol. He was convinced that there was a link between dietary fat and CHD. Specifically, Keys was convinced that fat calories in the diet provided the most consistent relationship to CHD mortality.

Harcombe showed a graph that Keys plotted  in 1953. The graph established that Japan and the US would form the endpoints of a line plotting fat and CHD, with Italy on it as well. These were three of the countries Keys chose for examination in the Seven Countries Study.

And Keys just happened to have friends in Greece, Italy, Finland, Japan, Netherlands and Yugoslavia. Thus, his Seven Countries Study was born.

Keys’ own data did not support his conclusions about the link between dietary fat and CHD, Harcombe said.  He dismissed factors such as cigarette smoking; sedentary behaviour; obesity; and relative weight in CHD.

Diet, drugs and hearts

His Seven Countries Study wasn’t even a dietary study as she showed. As an inter-country study, it provided “the lowest form of evidence”, Harcombe said. Still, Keys concluded that saturated fat was linked to increased risk of heart disease.

Harcombe showed that World Health Organisation (WHO) data for 192 countries showed a different picture. The higher the deaths per 100 000, the lower the cholesterol. She has written a brilliant blog on the topic. Click here to read: Cholesterol & heart disease – there is a relationship, but it’s not what you think

“This strengthens when you look at cardiovascular disease deaths and cholesterol in females,” she said. In other words, the higher the cholesterol level, the lower the death rate from CVD and all-cause mortality (ACM).

The problem with Keys, Harcombe said, was his bias from the outset. That bias created the conditions under which statins could become the most prescribed drug in modern medical history. They have also made billions for drug makers – despite compelling evidence on risks.

Click here to read: Statins ‘insanity: Sir Prof Collins of Statinshire at the helm

Dietary guidelines

Harcombe then honed in on South Africa’s official dietary food-based guidelines. She looked at evidence from randomised controlled trials (RCTs)  available at the time the US introduced its guidelines to 264 million Americans. RCTs are known as the “gold standard” of modern scientific research. She also looked at what evidence is currently available.

In a meta-analysis in the BMJ Open Heart in 2015, Harcombe showed that there was no RCT evidence then to support the guidelines. Still, the US guidelines recommended 30% total fat and 10% saturated fat.

The UK followed suit. The country essentially did a “u-turn in dietary guidelines”, Harcombe said. In 1969, the advice was to avoid fattening farinaceous and vegetable foods. In 1984, it became: base your foods on these foods. At the same time, the guidelines advised people to restrict their total fat intake to no more than 30% of calorie intake, saturated fat to no more than 10%.

She showed why advice to increase the carbohydrate content was “an inevitable consequence of setting that dietary fat guideline”. She also showed the “inevitable” negative consequences on health – rising obesity, diabetes and heart disease rates.

In praise of fats

Harcombe also looked at currently available epidemiological evidence.  Her study in British Journal of Sports Medicine in 2016 shows that even this evidence was lacking when the US and UK first introduced their guidelines.

At heart, Harcombe says that the diet-heart hypothesis and unscientific dietary guidelines are the result of misunderstandings about the nature of fat. She gave the hearing a mini lecture on dietary fats. There are three  real fats:

  • Saturated;
  • Monounsaturated; and
  • Polyunsatured.

All foods that contain fat contain those three fats, with no exceptions, she said. Only dairy products have more saturated than unsaturated fat – “not that any real fat is better or worse than any other”. Harcombe also told the hearing that red meat has far less saturated fat than oily fish or olive oil have.

“Yet we tell people to avoid eating red meat.”

Trans fats dangers

HPCSA advocate Ajay Bhoopchand
HPCSA advocate Ajay Bhoopchand

The only really hazardous fat, Harcombe said, is trans fat.

About the only concession HPCSA advocate Ajay Bhoppchand managed to achieve from Harcombe is that she didn’t mention that trans fats also occur naturally. There are trans fats in dairy fat and meats from grass-eating “ruminant” animals.

However, that concession was minor. Harcombe would have assumed that this was common knowledge.

She told the hearing the really dangerous trans fat are the artificial industrial ones (trans fatty acids). Those are created in a process that adds hydrogen to liquid vegetable oils to make them more solid.

Harcombe gave another mini lecture on macro and micronutrients and “real food”. There is only one food that is 100% carbohydrate, she said, and that’s sucrose. It is arguably “not a food” as it has no nutritional value whatsoever. At the other extreme are foods that are 100% fat, such as oils and lards.

“Every other food we come across has protein, whether it is animal or plant origin,” she said. “Nature makes them either fat- or carbohydrate-based. Rarely does it put the two together.”

Aiming at the right targets

It’s unhelpful to set targets for macronutrients, she said. And inevitably,  when you set a limit of 30% fat, you also set the recommendation of 55% carbs.

“Just eat real food. That is what (Noakes) is advising.”

Harcombe proposed a way forward for nutrition advice in future.

She referred to the HPCSA’s own guidelines (27a). It states that a practitioner shall at all times “provide adequate information about the patient’s diagnosis, treatment, options and alternatives… pertinent information to enable the patient to exercise a choice in terms of treatment and informed decision-making pertaining to his or her health and that of others.” (her emphasis)

South African dietary guidelines that the Association for DIetetics in SA (ADSA) supports
South African dietary guidelines that the Association for DIetetics in SA (ADSA) supports

That brings practitioners back simply to “advising real food”. However, dietitians’ associations such as ADSA, that are a source of much dietary advice to the public, don’t always do that, she said.

Health professionals in South Africa would be “unprofessional and unethical” if they did not share the fact that ADSA’s advice has conflicts, she said.

When Bhoopchand asked Harcombe for proof, she had it at her fingertips: ADSA’s long list sponsors, including Nestle, Unilever and even Coca Cola at times.

Dietitians’ COIs

The hearing heard that ADSA’s close links with industry made it very conflicted indeed. ADSA president Maryke Gallagher, for example, is on record as saying that ADSA’s  sponsors don’t influence its advice. However, as Harcombe, Dr Marion Nestle in the US and others have pointed out, food and drug industries do not sponsor organisations unless they say nice things about their products.

Click here to read:  Why does Big Food love dietitians quite so much?

Harcombe had other advice for health professionals:

  • They would be unprofessional and unethical not to share the fact that when 30% fat is wrong, 55% carb is concomitantly wrong;
  • They would be unprofessional and unethical not to share the fact that the most nutritious foods are of animal origin and naturally LCHF;
  • And they act professionally and ethically when they give patients all relevant information, options and the chance to make their own, informed choices, Harcombe said.

The hearing continues.



  1. If you judge a man by the quality of his friends and allies, and by the abject quality of his oppenents, Tim Noakes is outstanding. Well done, Zoe Harcombe – a rare beacon of intelligence and principles in this field.

    How an association of dietitians can be sponsored by producers of junk food and, sometimes, Coca Cola beggars belief. And this third-rate organisation prattles on about ethics? ‘Conflicted’ is polite word for the ADSA. There must be some dietitians in South Africa who have the intelligence and sense to be deeply embarrassed.

      • I have it on very good authority that Adv Bhoopchand’s bill for the February hearing alone was around R1 million. That’s not much in pounds sterling, though better in pounds these days than pre-Brexit … still, it’s nicely paid work if you can get. Whatever his bill was last time, it’ll be the same this time round. The costs have been astronomical. I address that in post coming up today.

  2. In essence (yoiks), what all the proponents of the Real Food, LCHF, lifestyle change paradigm need to do is create a very simple message with three elements. Firstly, avoid all processed foods and foods containing sugar. Secondly, establish the current state of your 5 markers for metabolic syndrome and take steps to bring all of these within acceptable limits with the help of your GP (in need). Thirdly, eat only foods off the so called green list or its equivalent. Spell it out carefully because what you eat will drive step two. That is a one page message that all informed members of the health care community can buy into and thereafter spread to the metabolically challenged people of the world.

    There is a pressing need to create a message which has current relevance without overwhelming people with unnecessary information about the mistakes of the past. I am suffering from profound Ancelenemia and I am sure there are many others like me who would be quite happy never to hear his name again. Even Keyes admitted that he was wrong.

    In essence (yoiks) the main element for success in the future is getting ALL health care professionals (including dietitians and cardiologists) to buy into that single simple message which will work for the vast majority of people. Sure there will be exceptions who will not be served by the simple message, but if you try and cater for everyone then consensus will become impossible and we will all get fatter and sicker and ,in essence, die.

    • It’s going to take some work to overturn memes like Arterycloggingsaturatedfats and Hearthealthywholegrains and replace them with Hearthealthysaturatedfats and Artyerycloggingwholegrains.

      This trial truly is science v. dogma. I have a horrid feeling dogma may still “win” but at least the science has been put out there.

    • What I think works well with Kleinschmidt’s statement and something that often gets left out of these heated but relevant discussions is sticking to recommended portion sizes. In the UK, most people have no idea of what a portion of food actually is and are horrified when the nutritional portion size is pointed out. Even when portion size recommendations are printed on packaging it is often overlooked or dismissed.

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