Exploring the “Lore of Nutrition”

For the last few days, my Kindle has been my closest companion.

“What are you reading”? my wife asked. “I’m reading Lore of Nutrition.”

Ooh, I was sure it was a thriller or one of your crime stories.”

In fact, she was right. Although Lore of Nutrition is a book about nutrition, it reads like a novel. The omertà, the courtroom drama, the hero and the villain (lots of them). Lore of Nutrition has it all.

And, if you’re a cardiologist, the book may read like a Stephen King horror story. However, this time, the horror is real. You’ll just have to hope for a happy ending.

Of course, Lore of Nutrition is not the first book to challenge accepted medical and scientific dogma. But, it rises above most of them due to its reliance on scientific evidence, its honesty, and bravery. Apart from being a book about nutrition, it is a fascinating story about a man fighting for his credibility and beliefs and his right speak out to the public.

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Lore of Nutrition

Lore Of Nutrition is co-authored by two South Africans; sports scientist Professor Tim Noakes and journalist Marika Sboros.

In the preface, Professor Noakes summarizes his background as a doctor and scientist. And what a distinguished career it is. Of course, one might wonder why he has to recapitulate it in such detail. However, when reading on, one learns why he is forced to underscore his credibility.

Tim Noakes has all the characteristics of an opinion maker. His charisma and ability to speak out and explain will make most of us want to listen.

Noakes describes his “Damascene moment”: “It happened after I came face to face with compellingly robust evidence that contradicted everything I believed was true about optimum nutrition to treat and prevent serious diseases, such as obesity, diabetes, and heart disease.”

Noakes challenges two deeply held dogmas: “the role of carbohydrate in nutrition and the diet-heart hypothesis that saturated fat causes heart disease”.

Unfortunately, Noakes learned that the results of his choice to admit his errors and try to correct them would be brutal for himself and his family, “beyond anything that he possibly could have imagined.”

Lore of Nutrition has three main parts.

The first part is about the low-carb revolution in South Africa and Noakes’s first experience with a low-carb, high fat (LCHF) diet. It covers, among other things, the 2015 Low-Carb Summit in Cape Town, the so-called UCT Professor’s letter, The Naudé Review (1), and “The Banting for Babies Tweet” which sparked the now famous Noakes Trial.

The second part covers the trial that was spread over three years, the hearing, the closing arguments and the verdict.

The third part summarizes essential scientific evidence supporting the LCHF dietary plan.

Noakes now claims the evidence for the LCHF dietary model is the “best evidence-based model of modern human nutrition. Conversely, the low-fat, high-carb (LFHC) “prudent”, “balanced” diet promoted by most health authorities, and religiously taught at all South African medical schools is at best not evidence-based, at worst completely wrong and extremely harmful because it has caused the obesity and type-2 diabetes epidemic.”

Why Does Tim Noakes Have so Many Powerful Enemies?

For an outsider, it is hard to understand why Tim Noakes has so many powerful enemies in his home country and why they believe it’s so important to demolish him. Why do the medical and dietic professional societies in South Africa (HPSCA and ASDA) go to such great lengths to shut him down? After all it’s just a scientific debate, isn’t it?

Of course, Noakes has expressed opinions that conflict with those taught at the universities. He believes that “the function of universities is to advance knowledge, not to insulate professorial opinions from external scrutiny and thus institutionalize what he calls the power of the anointed.” He writes: “I believe the very reason why universities exist is because we do not (yet) know everything. If we did, we would have no reason to invest so much in costly institutions.”

Noakes also claims the low-fat diet that has been highly promoted for decades is the most likely cause of the epidemic of obesity and type-2 diabetes. He writes: “It is difficult for those who have advocated this fallacy for the past 40 years to suddenly find the courage to acknowledge and apologize for their gross error.”

Or is it Noakes’s methods and how he reaches out to the public that is the problem? Is using social media inappropriate for medical professionals and scientists?

When covering the 2015 Low-Carb summit, Marika Sboros mentions that one of the attendees at the meeting was Jacques Rousseau, a lecturer at the UCT Faculty of Commerce, and an active critic of LCHF and Tim Noakes. Rousseau writes a personal blog called Synapses (2).

Being curious to find out more about a Noakes critic, I took a look at Rousseau’s blog. It is about politics, science, religion, and rationality.

Of course, I was not able to read everything Rousseau has written, but his blog appears to be of high quality, regardless of whether one agrees with him or not.

There are 32 articles on his blog in the series “Noakes”. I wonder if that should that be defined as an obsession?

Interestingly, I found a podcast interview with Rousseau where he says about Noakes: “My criticism has always been about the tone and the approach taken in making the arguments but not about the science and the arguments themselves (3).” So could it be that it is not about what Noakes believes is right or wrong but about how he goes about it?

In Lore of Nutrition, Noakes mentions that the regular headaches he had suffered from disappeared after adopting an LCHF eating plan. He writes: “This is understandable if an allergy to wheat gliadin is a common cause of recurrent headaches, as cardiologist Dr. William Davis proposed in his bestselling book Wheat Belly. Or if a majority of common headaches are caused by gluten sensitivity, as neurologist Dr. David Perlmutter suggested in another New York Times bestseller, Grain Brain.

Being a Noakes admirer, I thought: Please don’t say this. Speculating may be fine, but citing such controversial literature is not very scientific and best avoided in my opinion. I wonder if that’s what Rousseau’s all about.

In a blog post addressing Lore of Nutrition, Rousseau writes: “In short, there’s no vendetta, and if there is a conspiracy, I don’t know of it. Some people (like me) just think Prof. Noakes expresses contingent and as-yet-unproven claims too boldly, in a way that runs ahead of available evidence, whether or not they end up being proven true.”

In another instance, Rousseau writes: “There’s certainly a possibility that he (Noakes) and others are right. As I’ve tried to emphasize, it’s the tone and content of the argument for the conclusion – not the conclusion itself – that I’m addressing (4).”

Exploring the "Lore of Nutrition"
Tima Noakes, Gary Taubes, and Axel F. Sigurdsson (Reykjavik 2016)
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How Will the Cardiologists Respond?

Cardiologists get a fair share of beating in Lore of Nutrition. The critic is specifically aimed at those who do percutaneous coronary interventions (i.e., coronary angioplasty and stenting). I guess it’s fair to mention that I’ve been doing these procedures for more than 20 years myself.

Noakes writes: “Cardiology is responsible for initiating and performing more unnecessary, non-evidence based and costly medical interventions than perhaps any other medical discipline.”

In fact, he may be right. On the other hand, I would like to claim that cardiology is probably the most evidence-based of all medical disciplines.

Noakes goes on by saying that coronary artery bypass surgery “is unnecessary for the vast majority of patients with stable coronary artery disease.” He also says that “in patients with chronic stable coronary artery disease, in the absence of recent myocardial infarction (heart attack) percutaneous coronary intervention does not offer any benefit in terms of death, myocardial infarction, or the need for subsequent revascularization compared with conservative medical treatment.”

Of course, one might be surprised that I don’t disagree with these claims, but I wish Noakes would have mentioned that coronary angioplasty and stenting is an effective treatment strategy for acute coronary syndrome, particularly ST-elevation myocardial infarction (STEMI).

Acute coronary syndrome is a disorder caused by a ruptured atherosclerotic plaque which Noakes elegantly explains in Lore of Nutrition and is the most common reason for a sudden obstruction of blood flow to the heart. There is probably no medical intervention as effective as immediate angioplasty with stenting to open up a recently obstructed coronary artery.

Noakes’s take on statins is fast and furious: “It is of little value to take a drug that might marginally reduce one’s risk of suffering a heart attack or stroke if it increases the risk of dying from something else, without any extension in life expectancy.” Here he is citing the fact that no study has shown benefits of statin treatment in terms of mortality in patients without established cardiovascular disease (primary prevention).

Noakes writes: “Perhaps cardiologists should take heed of the old dictum that “those who live in glass houses should not throw stones”. If you make your money prescribing drugs or performing invasive procedures that have little or no proven benefit and which may cause harm, you need to be very wary of accusing others of doing harm. When it comes to the dietary advice that I promote you should be especially cautious, as there is no published scientific evidence that it causes harm.”

Luckily, not all cardiologists are stone throwers.

The Role of Insulin Resistance

According to recently published evidence, at least 50% of the adult population in the U.S. have insulin resistance, manifested as diabetes or prediabetes (5). Noakes believes this number may be at least 60%. He writes: “Insulin resistance is now certainly the most prevalent medical condition in the world, yet it is not taught or discussed in medical schools.

In the last part of Lore of Nutrition, Noakes writes: “By now it should be clear that all the evidence incriminates carbohydrates and insulin resistance as the key drivers of our current epidemics of ill health.”

Interestingly, he believes that insulin resistance is a relatively benign condition. However, a high carbohydrate diet turns it into a killer. Hence, if you’re insulin resistant, you cannot eat carbohydrates (6).

The Noakes Trial

On 3 February 2014, Twitter user Pippa Leenstra tweeted the following to Tim Noakes and Sally-Ann Creed, his co-author on The Real Meal Revolution: 

is LCHF ok for breastfeeding mums? Worried about all the dairy + cauliflower = wind for babies??

Two days later, Noakes tweeted his response to Pippa Leenstra and Sal Creed (7).

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

Time Noakes’s tweet is basically what initiated the HPCSA’s charge against him and the subsequent trial. He was accused of acting in a manner not in accordance with the norms and standards of his profession and for providing unconventional advice on breastfeeding babies on social networks.

Marika Sboros was the only journalist to cover all the hearing sessions of the Noakes trial. She elegantly summarizes the hearing, the closing arguments, and the verdict in Lore of Nutrition.

The Bottom-Line

Lore of Nutrition is a fascinating book. It contains a story that must be told and a message that has to be read.

However, don’t let the name fool you. It’s about so much more than nutrition. It’s about science, public health, cardiovascular disease, fatty liver disease, diabetes, the food industry, the diet-heart hypothesis, the pharmaceutical industry, obesity, social media, politics, corruption and academic bullying.

Noakes’s knowledge, passion, and courage allow him to write in a ruthless manner that is shockingly revealing. Of course, this may be too much and too bold for some of his peers.

Clearly, Noakes can’t be right about everything, but he certainly deserves to be listened to.

Marika Sboros’ contribution adds to the diversity of the book. Her coverage of the Noakes trial strengthens the storyline and makes the book unique.

It is quite clear that Lore of Nutrition will not help Tim Noakes make peace with his enemies. However, he might make some new friends.

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20 thoughts on “Exploring the “Lore of Nutrition””

  1. You’ve convinced me to read the book! I had followed the trial and was so appalled that Dr. Noakes was on trial for his opinions which he expressed on social media. You do that too! I have been on a ketogenic diet for 4 years and haven’t felt this good in a very long time as well I’ve lost 35 pounds and kept it off. Thanks for this post, Doc!

  2. Thanks very much as always for this excellent and very interesting article Dr Sigurdsson. Can I please just check whether the second sentence here was actually meant to read LFHC? Many thanks, Hilary

    Noakes now claims the evidence for the LCHF dietary model is the “best
    evidence-based model of modern human nutrition. Conversely, the LCHF
    diet promoted by most health authorities, and religiously taught at all
    South African medical schools is at best not evidence-based, at worst
    completely wrong and extremely harmful because it has caused the obesity
    and type-2 diabetes epidemic.”

    • Thanks Hilary.
      You’re absolutely right. There was a mixup with the letters, my bad. It’s been fixed now.
      Thanks for reading so thoroughly.

      • Thanks for helping us all to stay informed Dr Sigurdsson. It takes time, effort, deep analysis and courage to seek, wade through, consider and report on these matters and what we can do to best take care of ourselves and each other. So thank YOU.

  3. Thanks Doc. Noakes is always an interesting read, in particular his early work on sports drinks and their place in long term endurance events (he is very critical of them and the data supporting their use).
    In the dietray domain I feel he let’s himself down. Often he presents in the first person and uses ancedotes on occassion which are the lowest form of evidence available. Its important to dissect ‘fats’ as they can’t be lumped together just like ‘carbs’ are incredibly variable. No-one argues that fish oils and tran-fats are both fats, but clearly have different effects within our bodies. To suggest that fructose and complex carbs e.g.fibre within oats should be lumped together is simplistic.
    Both camps (LCHF/HFLC) have elemenst of truth and have more in common than they care to admit: Fruit, vegetables, lean meats, fish are probably ‘good.’ How do you define ‘good?” Trans fats-poisonous, dairy-debateable, added sugars-fructose in particular, bad. Complex carbs-ok, depending on your insulin sensitivy….
    PURE study-shambles. Presented prematurely with many unanswered questions and people seeing it as the ‘proof’ to support a particular camp. Frustrated. Retrospective food diaries, sig bias in recollection….aaagggh

  4. Just a quick ‘Thank you!’ Alex. I continue to read and very much enjoy your blog. Like Neil Jarvis posting below, I remain on the alert for analysis that provides greater break-down of broad food groups (carbohydrates, fats) with discussion of the varying effects of the (many!) sub-categories; will I find that sort of discussion in this book? In any event, thank you again, very much, for your efforts to keep the ‘bright white light of evidence’ (an expression I liked from my years in the law) on our constant search for health-related information and developments.

    • Noakes doesn’t seem to be particularly interested in the breakdown of carbohydrates. He just wants as little of them as possible. However, he’s mainly promoting that approach for people with insulin resistance (IR) and not necessarily the general population.
      So, his message is no carbs or very small amounts for those with IR. But maybe the types of carbs become important for the rest. At least most of us tend to think so.

  5. I’m half-ways through the book, Axel. It’s a slow read for me as I’m not skim reading. I think it’s great. I agree with one criticism, which is giving credence to people like Perlmutter and Mercola. It isn’t that much of what they say is correct, or probably correct, but it’s untested, and some of Mercola’s stuff is just quackery. Now, when you’re trying to promote a lifestyle change, which for me has been extremely successful (I’m the same height as Tim, was the same weight as he was and am now the same weight as he is!), the temptation is to seek all the publicity you can get, and Mercola has huge exposure, but I think it’s a bad idea. You should stay 100% scientific. Otherwise you’re open to attack.
    Mind you, many of those who attack Tim, should take a dispassionate look at the evidence they have for their diet (mostly none), before criticising him.
    I think the book is terrific so far. Some great science in there…

    • You’re right. Of course the quality of evidence may vary and there’s always a risk than one uses cherry picking to promote a concept. That’s something we have to live with and try to see through. I completely agree about your take on Perlmutter and Mercola.

  6. “Lore of Nutrition is a fascinating book. It contains a story that must be told and a message that has to be read.”

    Indeed. The story is that there’s plenty of pseudoscience around and the message is to exercise critical thinking. Just by looking at your review with selected quotes, one can easily see Noakes’ myth-making in action. Statin denialism and insulin fantasies. Nothing new, that is.

  7. I am currently reading “the Lore of Running” which is a 700-page textbook on Running science written by Noakes. I will probably never finish that book, but I’ve already learned a lot.

    By and large I don’t want to go down the rabbit hole of carb-wars… it’s mentally exhausting. But how does he reconcile the ample evidence that carbs improve performance during endurance events? You mention that he doesn’t like sports drinks, but he has a brilliant breakdown of glycogen and ingested glucose as nutritional sources… I’m curious to see how he reconciles these two positions of his, wonder whether he has gone too far in the other direction currently.

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