Tuesday, January 7, 2020

Guest Review of Real Food On Trial: How the diet dictators tried to destroy a top scientist by Dr Tim Noakes

Reviewer's note: ”Real Food on Trial” is a self-published re-release of the book “Lore of Nutrition.” RFoT has approximately 40 additional pages compared to LoN. I purchased LoN when it was first published in January 2018 and recommended it to friends often. I was very surprised one day when I went to Amazon to get the URL to email to a friend and saw that the e-book was no longer available. The paperback version was still listed for sale, however. A few months after that, again when getting the URL to send to a friend, I saw that the paperback version was no longer available either. After a little bit of digging I found RFoT. I do not know the reason LoN was dropped by its publisher, Penguin Random House of South Africa. It could be any of a number of mundane reasons, but after reading the book one cannot rule out threat of lawsuits by very deep-pocketed corporate interests. If anyone happens to know the back-story, please share. This review is actually based on LoR. I have not purchased the re-released edition. [CBS - This is the same guest reviewer who reviewed Bottle of Lies; @PdxSag.]

If I had to summarize Real Food on Trial in two sentences it would be:

“You can’t outrun a bad diet. Carbohydrates make a bad diet.”

The author tells his story of trying to literally out-run his bad diet, failing to out-run it, telling the world, and getting professionally crucified for it. As such, the book is at the nexus of many of the latest health topics and controversies:

  • Like many other low-carb converts, the co-authors each decided to try a low-carb diet almost by happenstance in response to chronic problems in their own health.
  • The co-authors are vilified and attacked professionally for the temerity to espouse a position at odds with the mainstream message. (Moreso, the financial interests that benefit from the mainstream – but don't call it a conspiracy.)
  • Bureaucratic mediocrities whose only authority is the flimsy credentials they bestow on themselves going on a witch-hunt against their clear intellectual superior using a bunch of administrative procedural technicalities.
  • Twitter as ground zero for a conflagration of lawsuits and controversy.
  • A stacked deck of grossly biased, if not outrightly fraudulent, research in support of mainstream health advice
I came to hear of Professor Tim Noakes and his trial by the South African licensing board for MD's via Twitter. At the time I started following the lawsuit a verdict had not been rendered, though the controversy and trial had been on-going for a couple years. After the trial and verdict, “Lore of Nutrition” was published, which I purchased wanting to get the whole story of the trial and what led up to it. What I got was not only the story on the trial and the events leading up to it, but also the story of an incredibly accomplished and highly respected scientist being subjected to an organized campaign to silence his message and trash his reputation.

The trial itself was over a seemingly innocuous tweet from Professor Noakes. In February 2014, a person on Twitter asks him:

“Is LCHF eating ok for breastfeeding mums? Worried about all the dairy + cauliflower = wind for babies??”

Noakes replies:

“Baby doesn't eat the dairy and cauliflower. Just the very healthy high fat breast milk. Key is to ween [sic] baby onto LCHF.”

Within 24 hours a dietician had lodged a complaint with South Africa's sanctioning body for practicing physicians for giving “incorrect,” “dangerous,” and “potentially life-threatening” advice.

First, however, it is probably necessary to introduce who Professor Tim Noakes is. He might not be known to many Americans, but in South Africa and in certain athletic circles such as professional rugby and ultra-endurance sports, he is one of the most preeminent experts. In South Africa he may be as big a celebrity as Dr. Oz here in the US. He has both an MD and PhD, though has spent the majority of his career in academia doing research and hasn't been in clinical practice in nearly 20 years. He is one of South Africa's highest rated scientists. He has written multiple bestselling books, the most successful of which was “Lore of Running” which publishers rated 9th ever, globally, in its category. He has also published 750 scientific articles, and has over 16,000 journal citations. He has been a tenured professor at the University of Cape Town for over 35 years. In 1995 he co-founded the Sports Science Institute of South Africa. He was awarded the South African Presidential Order, and a National Research Foundation Lifetime Achievement Award.

Professionally, his research is noteworthy for challenging orthodoxy and redefining what is regarded as generally-accepted knowledge in the realm of athletic performance. In 1991 he showed the industry-driven fallacy that individuals should hydrate as much as tolerable when exercising, especially in the heat, was without scientific basis. In fact, over-hydration was leading to an entirely preventable fatal medical condition among scores of athletes and military service personnel. In 1996 he disproved the “Hill Theory” of exercise performance, which had been the reigning dogma since it's introduction by Nobel laureate Archibald Hill in 1923, and replaced it with the “Central Governor Model.” In 2004, he wrote an editorial in the New England Journal of Medicine challenging Lance Armstrong as “the most doped athlete in the history of the sport.” This, at a time when Armstrong was still the darling of professional cycling, and American sports enthusiasts generally.

In short, Noakes was not shy to controversy. Rather, as any great scientist, he followed where the data and his research results lead him.

Neither was Noakes an iconoclast seeing conspiracy theories at every turn. Ironically, Noakes, himself, followed the conventional health advice with a carbohydrate rich diet and ever more exercise in a – largely futile – battle to keep his weight down and his fitness up. Finally, in 2010 he had what he called his “Damascene experience” where almost unable to complete a 5k for his morning exercise routine – for over 40 years he had been an avid ultra-distance runner – decided he should give the benefit of the doubt to a new book title he'd received an email advertising: “The New Atkins for a New You.” Despite his misgivings about what he felt was a “thoroughly debunked Atkins,” he was familiar with all of the three co-authors, and decided as a scientist – and nearly at the end of his rope health-wise – he should at least investigate their claims.

Marika Sboros' journey to a low-carb diet was not much different. She was a journalist on the health beat that had known Noakes prior to his conversion to prominent low-carb diet proponent. A struggling vegetarian herself, she wrote an article giving Noakes' side of the controversy he had touched-off in South Africa, largely out of a feeling that he was being unfairly attacked in the press at the time. (This was prior to the Twitter complaint and trial.) Immediately she began receiving attacks with the same ferocity as Noakes had been receiving. Among the charges was that she was a closeted “Banter” – the South African term for low-carb dieting. Having her own struggles with diet and weight, and now being charged as one anyway, she decided she should give the diet a try and see first-hand what it was all about.

Living in Portland, Oregon, I cannot tell you how many friends and acquaintances have the countenance and attitude of an endurance athlete, vegetarian, or vegetarian endurance athlete. Noakes and his co-author, Sboro, are virtually the everyman in this city. What I especially liked about this book is that I can recommend it knowing that the reader is going to personally identify with the authors in a way they wouldn't with a jacked-up P.D. Mangan and other high-agency meat and barbells practitioners.

With regard to the personal attacks, they were swift and suffered no quarter. Noakes started his personal low-carb diet experiment in December 2010. By winter 2011 he had decided he must come clean with the world and share his discovery. He wrote a regular column for Discovery magazine, which was also a large financial backer of his research at the Sports Science Institute. He titled his column against “Against the Grain,” and laid out the scientific case for a low-carb diet. He concluded his column thusly:

“There is a saying that to find the root cause, follow the money trail. If a low-carbohydrate intake is more healthy than we expect, then why is that fact hidden? The answer is that some very large industries, including the soft drink, sugar and confectionery industries (all of which produce high-carbohydrate products with minimal nutritional value) do not want us to know this.”

Soon after that was published, Noakes' column in Discovery magazine was cancelled. Despite that, throughout 2012 Noakes continued to advocate to the public the benefits of a low-carb diet for treatment of insulin resistance, obesity, and T2DM. In September 2012, on the day following his receiving a Lifetime Achievement Award from the National Research Foundation, a group of senior cardiologists at the University of Cape Town, where he had been on faculty since 1969 – 43 years – published an open letter criticizing him for putting people's lives at risk. A “high-fat, high-protein” diet for “all persons” is “contrary to the recommendations of all major cardiovascular societies worldwide, is of unproven benefit and may be dangerous for patients with coronary heart disease.” In a ‘tell’ as to who was really calling the shots, the letter further went on to advocate for statin drugs as both cheap and proven for extending life. Finally, in the oldest play in the ivory tower’s playbook, they suggested that Noakes should be expressing his opinions “in the academic forum and the medical literature where it could be critically evaluated and challenged. To present these controversial opinions as fact to a lay public is dangerous and potentially very harmful to good patient care.”

Therein lies the perverse joke of modern medical advice. Anything outside the orthodoxy is dismissed as anecdote. However, the gatekeepers of research funding will not fund anything that could challenge the orthodoxy. It's a Catch-22 that they used for 40 years to keep the public mis-informed and in an increasingly desperate state of ill-health. Of course, the Internet's ease of direct communication between and information sharing among the public has broken the gatekeepers' monopoly on information. They can cluck “the plural of anecdote is not data” all they like. However, the people making a huge improvement in their health by adopting a low-carb, low omega-6 diet and sharing the impact its made with their friends and family, don't care.

If anyone doubts that heterodox research would be squashed, I think the spin applied to the research that does get funded to keep it within the orthodoxy tells the tale. Peter Dobromylskyj's blog (Hyperlipid) was my first exposure to the unabashed spin in academic research.

This aspect comes up in the Noakes' book in an organized public debate prior to the tweet that instigated the lawsuit. Since one of the points of contention was that low-carbing was unproven and may be dangerous, Noakes set out to show research had proven it as both safe and effective. As regards the other side’s compromised research, one of the biggest smoking guns was the $700-million Women's Health Initiative. Buried in the text body was the finding of a 26% increased hazard ratio for women with previous heart attack that then followed the mainstream’s “heart-healthy” low-fat diet. Interestingly, this was the sole statistically significant finding of the entire $700-million study and it was not in the abstract or conclusion, and it was dropped from the table of significant results.

In a study from South Africa, three cities served as test subjects for comparison: one city received an intensive, hands-on, low fat heart-healthy information campaign – some might call it propaganda – for at-risk individuals; one city received a non-intensive low fat heart-healthy campaign; and one city acted as control and received no information campaign beyond what was available in the general media. Ironically – or perhaps not – after an 8 year follow-up the city receiving the most intensive campaign showed the worst results, while the other two were indistinguishable. One suggestive conclusion is that the intensive low fat heart-healthy advice is counter-productive. Instead, the research results were spun to suggest that low fat heart-healthy recommendation is so thoroughly “known” that further intensive information campaigns provide no additional benefit. Such obvious missing the forest for the trees is absolutely willful.

A landmark study was the Naudé Stellenbosch/UCT review which found no weight-loss benefit to low carb diets. It was published in July 2014 and was used as justification for bringing the complaint against Noakes to trial.

Ostensibly the Naudé Review’s goal was to perform a meta-analysis of low-carb diet research and determine whether the claimed benefits of low-carb diets stood up to rigorous scientific scrutiny. Naudé takes the common approach among slanted meta-studies and designs the inclusion criteria to cherry-pick studies that will be supportive of the conclusion the authors wish to provide. With regard to discrediting low carb diets, they include studies in which low carb is in name only -- up to 35% of total calories vs. 5-10% suggested by low carb advocates. They also throw out comparison studies in which the low carb and high carb diets are not iso-caloric. However, the biggest benefit of a low carb diet is the reduced hunger that goes along with reduced carbohydrate intake so that followers naturally eat less and make-up for the energy deficit via their own fat stores.

Noakes, in a brilliant display of Doyle-ian deductive logic noticed that the Naudé Review was 17 months late in being published. This was 17 months that Noakes was in the public eye advocating for low carb diets. Why would they delay publishing 17 months unless the review didn’t originally show what they wanted it to show? Noakes enlisted Dr. Zoe Harcombe a leading health statistician to investigate the Naudé Review. Noakes sent her the 14 studies that the Naudé meta-analysis was based upon. She found 15 material errors including 4 of the 14 studies that did not even fit Naudé’s own criteria for inclusion in the meta-analysis in the first place. Perhaps to no one’s surprise, when Harcombe repeated the meta-analysis using the 10 studies that actually fit the inclusion criteria and correcting for the other material errors “the data confirmed that the lower-[carbohydrate] diet produced significantly greater weight loss than did the balanced diet.”

As far as the trial, to cut to the chase, it was a set-up. If the breastfeeding tweet hadn’t brought about the complaint, some other tweet would have. They had been waiting on the Naudé Review to provide the scientific justification to initiate a complaint. Once Noakes became a vocal proponent of a low-carb diet, his profile in South Africa guaranteed that the reigning medical establishment would come after him.

The primary reason was to maintain the messaging that a low-fat diet and exercise leads to good health outcomes. Lies are delicate things and must be vigilantly guarded and protected. If nothing else, whoever owns the megaphone can be effective with Fear Uncertainty & Doubt. Secondarily, it was an obvious case of 'Pour Encourager Les Autres'. If a scientist of Noakes' eminence could have his reputation attacked and himself placed on a show-trial, younger less established scientists and doctors would certainly take heed.

The trial itself is interesting. It made a fitting climax to an outstanding book – and thanks to an honest judge and review board Noakes handily won – however, with regard to the science, it was anti-climatic. Noakes treated the trial as if the entire legacy of his career was on trial, which, perhaps, it was. However, the other side brought would could best be described as their C-team. It was not a fair fight. Noakes and his team were like men among boys. At first, that was a surprise to me. After reflection on the actual purpose of the trial, it made sense. The health establishment had sent a clear and unambiguous message just by putting Professor Noakes on trial. An actual weighing of the merits with their best scientists proffering their best research would not stand a chance against someone of Noakes' caliber. The other side stood nothing to benefit by a debate on the science. Sending the C-team allowed them the rationalization that Noakes hadn't bested their best.

I give the book 5/5 for being well-written, interesting, and providing a very good amount of science supporting a low-carb diet. I give it bonus points for blowing the lid off the bias and fraud upon the public that's been used to justify the mainstream diet and health advice of the last 40+ years. I give yet more bonus points for being delivered by scientist and doctor of impressive credentials who had been following the mainstream advice in his own life and nearly succumbed to it in the all too typical manner, just before rescuing himself and taking his message to the general public.

5 comments:

Anonymous said...

"Neither was Noakes an iconoclast seeing conspiracy theories at every turn. Ironically, Noakes, himself, followed the conventional health advice with a carbohydrate rich diet and ever more exercise in a – largely futile – battle to keep his weight down and his fitness up. Finally, in 2010 he had what he called his “Damascene experience” where almost unable to complete a 5k for his morning exercise routine – for over 40 years he had been an avid ultra-distance runner"

There's a couple of things going on here. Lots of long-interval, steady-state cardiovascular exercise slows down your metabolism and makes it a more efficient fat-burning, fat-storing machine. Fat is the primary fuel source during these athletic endeavors. It's probably true that the standard diet advice didn't work for him because he was an elite distance runner. It's the equivalent of having a small, 4-cylinder engine to move a light car at a steady average speed.

If you want to get lean, you need to put on muscle by lifting weights and eating a lot of carbohydrates. This is the equivalent of having a V-12 engine to move several tons. Just look at the physique differences between long distance runners and sprinters or tight-ends and wide receivers. Scott Abel has a bunch of material about this on his blog and YouTube channel.

So, high-carb probably didn't work for Noakes for good reason. It works quite well for other types of athletes. Carbohydrates are also the main fuel source of the brain.

All the Biblical evidence was that we were eating a lot of carbohydrates at the beginning. Meat was added later. The human body is very adaptable for a variety of food sources though. Grain farming, as James C. Scott put it, was historically a good way of taxing and enslaving people but that's about it. That doesn't mean grain was the only carbohydrate source on offer.

Allan Folz said...

standard diet advice didn't work for him because he was an elite distance runner.

Mainstream/standard diet advice was not presented with caveats.


If you want to get lean, you need to put on muscle by lifting weights and eating a lot of carbohydrates.

My lying eyes at the gym would have to disagree.


It works quite well for other types of athletes.

If by other type of athlete you mean, 20-somethings, sure.


All the Biblical evidence was that we were eating a lot of carbohydrates at the beginning.

Biblical evidence is an oxymoron. Anyway, if the question at hand is scientific in nature, I'm in the 10,000 year explosion camp.

Anonymous said...

"Mainstream/standard diet advice was not presented with caveats."

From the article:
"Neither was Noakes an iconoclast seeing conspiracy theories at every turn. Ironically, Noakes, himself, followed the conventional health advice with a carbohydrate rich diet and ever more exercise in a – largely futile – battle to keep his weight down and his fitness up. "


"However, the biggest benefit of a low carb diet is the reduced hunger that goes along with reduced carbohydrate intake so that followers naturally eat less and make-up for the energy deficit via their own fat stores."


Exactly. After turning his metabolism into the equivalent of a 3 cylinder Geo Metro, he needed barely any calories. The low carb diet increased his satiety and helped him cut his calories naturally while still feeling full. Weight gain or loss largely comes down to calories. Anyone arguing otherwise is usually fat.

"My lying eyes at the gym would have to disagree."

I don't know what you're seeing in the gym. If you're seeing the average American, he simply eats too much in all categories and is given the standard "DO STEADY STATE CARDIO" advice for weight loss. The latter will slow your metabolism to a halt. For added proof, just look at the physique differences between sprinters and long distance runners and decide for yourself which you like better. Also compare the diets of Olympic athletes in the two groups. Look at Husain Bolt's diet, for example.

Remember: everyone on the internet is an expert. My wife is a fit dietitian so even my "expertise" is second-hand and anecdotal.

"Biblical evidence is an oxymoron. Anyway, if the question at hand is scientific in nature, I'm in the 10,000 year explosion camp."

How wonderfully the concept of a 10,000 year explosion agrees with the Biblical data if you factor in the Carbon-14 dating errors due to improper latitude normalization and the exponential dating offsets that occur earlier than 1400 BC.



Allan Folz said...

I see a lot of remarkably strong, but flabby guys in the gym.

Anyway, it sounds like we agree more than we disagree. But why you are trying to make a distinction that there are situations where carbs can be a consequential part of one's diet without them necessarily making one fat? (rhetorical, don't answer that) In theory maybe (there's the whole pro-ageing aspect of insulin which carbs exacerbate), but even so, it's the exception that proves the rule:

*most people* should be doing the *exact opposite* of the mainstream diet & exercise advice.

Noakes tried telling the public that and was professionally attacked to the point of being subjected to a show trial!

That's the incredible take-away message.

If you want to complain that "hey, Noakes was doing high carb wrong," you've missed the plot, my friend.

Andy P said...

there is a reason he / she was posting as anonymous. to equate a high carb diet to a V12 engine is ludicrous. It is more like a heavily tuned 4 cylinder engine that will certainly have premature catastrophic engine failure.