The Creed of Ancel Keys

“From the very beginning, we had the statistical means to understand why things did not add up; we had a boatload of Cassandras, a chorus of warnings; but they were ignored, castigated, suppressed. We had our big fat villain, and we still do.”
~ Trevor Butterworth, The Wall Street Journal

“The paradox is that medicine is supposedly more enlightened, but it has never been more tyrannical, hierarchical, controlled, intolerant, and dogmatic. Working doctors who dissent are cowed because failure to comply with the medical orthodoxy threatens livelihood and registration. Much of modern medicine is an intellectual void.”
~ Dr Des Spence, Scottish GP

“The suppression of inconvenient evidence is an old trick in our profession. The subterfuge may be due to love of a beautiful hypothesis, but often enough it is due to a subconscious desire to simplify a confusing subject. It is not many years ago that the senior physician of a famous hospital was distinctly heard to remark, sotto voce, “medicine is getting so confusing nowadays, what with insulin and things.” It is a sentiment with which almost everybody who qualified more than a quarter of a century ago is likely to sympathize…. But ignoring difficulties is a poor way of solving them.”
~ Raymond Greene, in a letter to The Lancet, 1953

A popular documentary out right now is The Magic Pill. It’s about the Paleo diet with some emphasis on ketosis (low-carb consumption causing fat to be primary energy for cellular metabolism). There are several varieties of the Paleo diet, as there was much diversity in ancient dietary patterns, but there are some key commonalities.

Earlier humans ate little if any grains or beans, often even well into the agricultural period (hunting and gathering remained a mainstay of the American diet for many up into the early-to-mid 20th century, such as my mother’s family when she was growing up). In the distant past and continuing into about a century ago, it was typical to eat lots of raw, fermented, and cultured foods — including meats.

And of course, animal fats with plenty of saturated fats have always been a major food component until the past few generations. It turns out some of the healthiest populations on the planet, including the Mediterranean people, traditionally ate high levels of saturated fats. The Masai, for example, are about as carnivorous as a population can be with heavy emphasis on saturated fats and their health is amazing:

“The Masai are almost pure carnivores, eating mostly milk, blood, and meat. A Masai man drinks up to a gallon of whole milk daily, and on top of that he might also eat a lot of meat containing still more saturated fat and cholesterol. Mann expected the Masai to have high blood cholesterol but was surprised to find it was among the lowest ever measured, about 50 percent lower than that of the average American.”
(Real Food by Nina Planck, p. 61)

Interestingly, Americans too used to load up on animal-related foods and saturated fats, also with a ton of raw whole milk, cheese, and butter. It was only after decades of decline in this earlier diet that Americans began having high rates of all the major diseases that now plague us: obesity, heart disease, diabetes, etc.

This leads us to Ancel Keys, the many who promoted much of the present mainstream dietary myths. More than a half century ago, he did some research comparing diets in different regions of the world, but he did so by cherry-picking what fit his preconceptions and ignoring all else (great analysis can be found in numerous videos, articles, and books by Sally Fallon Morell and Mary Enig and at the Weston A. Price Foundation). In Nourishing Diets, Morell writes that (pp. 124-5),

“Critics have pointed out that Keys omitted from his study many areas of the world where consumption of animal foods is high and deaths from heart attack are low, including France — the so-called French paradox. But there is also a Japanese paradox. In 1989, Japanese scientists returned to the same two districts that Keys had studied. In an article titled “lessons fro Science from the Seven Countries Study,” they noted that per capita consumption of rice had declined, while consumption of fats, oils, meats, poultry, dairy products and fruit had all increased. […]

“During the postwar period of increased animal consumption, the Japanese average height increased three inches and the age-adjusted death rate from all causes declined from 17.6 to 7.4 per 1,000 per year. Although the rates of hypertension increased, stroke mortality declined markedly. Deaths from cancer also went down in spite of the consumption of animal foods.

“The researchers also noted — and here is the paradox — that the rate of myocardial infarction (heart attack) and sudden death did not change during this period, in spite of the fact that the Japanese weighed more, had higher blood pressure and higher cholesterol levels, and ate more fat, beef and dairy foods.”

About the Mediterranean diet, Morell considers the historical context to Keys’ study:

“The question that the believers haven’t asked themselves is this: was the lean, so-called Mediterranean diet they observed after World War II the true Mediterranean diet? Or were they observing the tail end of deprivation engendered by half a decade of conflict? Were the inhabitants of Crevalcore and Montegiorgio abandoning the traditional diet, or were they taking it up again? And did Keys miss the sight of Italians enjoying rich food in the early 1950s because Italians had never done such a shameful thing, or was the visiting professor too poor at the time to afford anything more than plain pizza in a sidewalk cafe?” (pp. 157-8)

Morell then goes on to look at numerous historical texts, including early cookbooks, from the region. All the evidence points to the traditional Mediterranean diet consisting largely of whole fat dairy products, meat products (lots of sausage), oils and animal fats, and eggs. As emphasized in the paleo diet,

“Italians love their vegetables for sure, and that’s because they know how to make them taste good. They know that salads taste better with a good dressing of aged vinegar and olive oil; and cooked vegetables blossom when anointed with butter, lard or cream” (p. 160).

Keys didn’t really understand the societies he was studying, much less the societies he chose to ignore. Yet he was charismatic and, though other contemporary research contradicted his data, he was able to promote his views such that they became adopted as mainstream ideology. This new belief system was enforced by the US government and by corporations, often in heavy-handed ways. Adelle Davis was a biochemist and nutritionist who was inspired by Weston A. Price’s research on traditional diets. In response, as described Joann Grohman, “The FDA raided health food stores and seized her books under a false labeling law because they were displayed next to vitamin bottles” (Real Food by Nina Planck, p. 30). “I find it dismaying that,” Planck says in another section (p. 201),

“the dangers of trans fats were known for sixty years. Weston Price cited 1943 research that butter was better than hydrogenated cottonseed oil. In the 1950s, researchers guessed that hydrogenated vegetable oil led to heart disease. Ancel Keys, the proponent of monounsaturated fat, showed in 1961 that hydrogenated corn oil raised trigydcerides more than butter. Year after year, the bad news piled up. [So, even Keys ultimately knew that saturated fat wasn’t the real culprit.]

“One dogged researcher, Mary Enig, helped get the word out. The author of Know Your Fats, Enig waged an often lonely battle. I’m afraid her efforts were not always welcomed with bouquets of roses. In 1978, Enig wrote a scientific paper challenging a government report blaming saturated fat for cancer, in which she pointed out that the data actually showed a link with trans fats. Not long after, “two guys from the Instituted of Shortening and Edible Oil — the trans fat lobby, basically — visited me, and oh boy, were they angry,” Enig told Gourmet magazine. “They said they’d been keeping a careful watch to prevent articles like mine from coming out and didn’t know how this horse had gotten out of the barn.”

“The stakes were high. “We spent lots of time, and lots of money and energy, refuting this work,” said Dr. Lars Wiederman, who once worked for the American Soybean Association. “Protecting trans fats from the taint of negative scientific findings was our charge.””

That sounds a lot like the corporatist defense of profits as happened with the decades of lies, spin, and obfuscation pushed by the tobacco and oil companies. Another more recent example is given in The Magic Pill documentary. In South Africa, the government put a doctor on trial for daring to give dietary advice that was in line with millennia-old traditions of human eating habits — fortunately, the doctor won his case but only after the government spent immense amount of taxpayer money trying to destroy him.

Dominant paradigms die hard and only after an immense fight, backed by the full power of the government and millions of corporate dollars. But that is only one part of what slows down change. Ideologies as worldviews hold on so long because they become entrenched in our minds and cultures. As often is noted, old scientists (along with old doctors, professors, bureaucrats, etc) don’t change their minds but eventually die and are replaced by a new generation with new ideas.

This was demonstrated with Michael Pollan’s latest documentary, In Defense of Food (transcript). In it, the professor of nutrition Marion Nestle adds a note of caution: “And it should be written on every single epidemiological study, ‘Red flag, association does not necessarily mean causation.’” Does that stop Pollan from basing conclusions on Keys problematic research? Nope. Instead, he promotes the belief that Keys’ conclusions are still valid: “But based on the strong association Keys saw in his data between heart disease and saturated fat, he advised people to eat less of it.” Not a single mention of any doubt or criticism.

It might be noted that Pollan was born in 1955. That was right in the middle of this now dominant ideology coming into ascendance. He reached adulthood as Keys’ ideology was being promoted by the USDA and as it became the new creed in mainstream thought. Now in his sixties, he is one of the older generation still clinging to what they were taught growing up. Yet, as a Boomer, his influence is still at its peak. Despite all the Western ailments, conventional medicine has allowed people to live longer and that means ideologies will remain entrenched for longer.

It’s going to be an uphill battle for younger generations to challenge the status quo. But the shift is already happening. From a personal perspective, this time lag of common knowledge creates a sense of disorientation, as it will take at least decades for official advice and public opinion to catch up with the research that has been accumulating over this past century.

This point was emphasized for me in reading a book published two decades ago in 1998, The Fats of Life by Caroline M. Pond — the author, a mainstream academic and researcher, notes that, “Heart attacks are thus seen as arising from a deficiency of polyunsaturated fatty acids rather than from an excess of saturates of cholesterol” (p. 293). This is far from being new knowledge. Pond doesn’t mention Weston A. Price, but she does discuss “the Oxford physician and biochemist, Hugh Sinclair (1910-1990), who studied the diet and habits of the Eskimos in northern Canada in 1944. Sinclair noted that Eskimos rarely suffered from the heart disease or strokes in spite of a very high-fat diet that included reindeer meat.” She goes onto say that, “The Masai people of Kenya eat large quantities of ruminant milk and meat, and Jamaicans eat saturated fats in coconut oil, but few of them die from heart attacks.”

In The Magic Pill, it is pointed out that Americans have been following the USDA Food Pyramid in eating less red meat and saturated fats while eating more grains, legumes, vegetables, and fruits. More Americans have been eating as they were told. What has resulted of this drastic dietary change? All the diseases this diet is supposed to prevent have gotten worse. This stark reality has yet to sink in because it would require thousands of officials and authority figures to not only admit they were wrong but that they caused immense harm to so many.

But why do others continue on with the sham? We’ve known much of this info for a long time now. Why are we still debating it as if the conventional view still has any relevance?

* * *

About silencing the critics:

Good Calories, Bad Calories
by Gary Taubes
pp. 191-194

This is where the story now takes some peculiar turns. One immediate effect of the revelation about HDL, paradoxically, was to direct attention away from triglycerides, and with them the conspicuous link, until then, to the carbohydrate hypothesis. Gordon and his colleagues had demonstrated that when both HDL and triglycerides were incorporated into the risk equations of heart disease, or when obesity and the prediabetic condition of glucose intolerance were included in the equations along with triglycerides, the apparent effect of triglycerides diminished considerably. This result wasn’t surprising, considering that low HDL, high triglycerides, obesity, and glucose intolerance all seemed to be related, but that wasn’t the point. The relevant question for physicians was whether high triglycerides by themselves caused heart disease. If so, then patients should be advised to lower their triglycerides, however that might be accomplished, just as they were being told already to lower cholesterol. These risk-factor equations (known as multivariate equations ) suggested that triglycerides were not particularly important when these other factors were taken into account, and this was how they would be perceived for another decade. Not until the late 1980s would the intimate association of low HDL, high triglycerides, obesity, and diabetes be considered significant—in the context of Gerald Reaven’s Syndrome X hypothesis—but by then the heart-disease researchers would be committed to the recommendations of a national low-fat, high-carbohydrate diet.

Heart-disease researchers would also avoid the most obvious implication of the two analyses—that raising HDL offers considerably more promise to prevent heart disease than lowering either LDL or total cholesterol—on the basis that this hadn’t been tested in clinical trials. Here the immediate obstacle, once again, was the institutional investment in Keys’s hypothesis. The National Institutes of Health had committed its heart-disease research budget to two ongoing studies, MRFIT and the Lipid Research Clinics Trial, which together would cost over $250 million. These studies were dedicated solely to the proposition that lowering total cholesterol would prevent heart disease. There was little money or interest in testing an alternative approach. Gordon later recalled that, when he presented the HDL evidence to the team of investigators overseeing MRFIT, “it was greeted with a silence that was very, how should I say it, expressive. One of them spoke up indicating he suspected this was a bunch of shit. They didn’t know how to deal with it.”

Indeed, the timing of the HDL revelations could not have been less convenient. The results were first revealed to the public in an American Heart Association seminar in New York on January 17, 1977. This was just three days after George McGovern had announced the publication of the Dietary Goals for the United States, advocating low-fat, high-carbohydrate diets for all Americans, based exclusively on Keys’s hypothesis that coronary heart disease was caused by the effect of saturated fat on total cholesterol. If the New York Times account of the proceedings is accurate, the AHA and the assembled investigators went out of their way to ensure that the new evidence would not cast doubt on Keys’s hypothesis or the new dietary goals. Rather than challenge the theory that excess cholesterol can cause heart disease, the Times reported, “the findings re-emphasize the importance of a fatty diet in precipitating life-threatening hardening of the arteries in most Americans,” which is precisely what they did not do. According to the Times, saturated fat was now indicted not just for increasing LDL cholesterol, which it does, but for elevating VLDL triglycerides and lowering HDL, which it does not, and certainly not compared with the carbohydrates that McGovern’s Dietary Goals were recommending all Americans eat instead.

In a more rational world, which means a research establishment not already committed to Keys’s hypothesis and not wholly reliant on funding from the institutions that had embraced the theory, the results would have immediately prompted small clinical trials of the hypothesis that raising HDL prevented heart disease, just like those small trials that had begun in the 1950s to test Keys’s hypothesis. If those confirmed the hypothesis, then longer, larger trials would be needed to establish whether the short-term benefits translated to a longer, healthier life. But the NIH administrators decided that HDL studies would have to wait. Once the Lipid Research Clinics Trial results were published in 1984, they were presented to the world as proof that lowering cholesterol by eating less fat and more carbohydrates was the dietary answer to heart disease. There was simply no room now in the dogma for a hypothesis that suggested that raising HDL (and lowering triglycerides) by eating more fat and less carbohydrates might be the correct approach. No clinical trials of the HDL hypothesis would begin in the U.S. until 1991, when the Veterans Administration funded a twenty-center drug trial. The results, published in 1999, supported the hypothesis that heart disease could be prevented by raising HDL. The drug used in the study, gemfibrozil, also lowered triglyceride levels and VLDL, suggesting that a diet that did the same by restricting carbohydrates might have a similarly beneficial effect. As of 2006, no such dietary trials had been funded. Through the 1980s and 1990s, as our belief in the low-fat heart-healthy diet solidified, the official reports on nutrition and health would inevitably discuss the apparent benefits of raising HDL—the “good cholesterol”—and would then observe correctly that no studies existed to demonstrate this would prevent heart disease and lengthen life. By 2000, well over $1 billion had been spent on trials of cholesterol-lowering, and a tiny fraction of that amount on testing the benefits of raising HDL. Thus, any discussions about the relative significance of raising HDL versus lowering total cholesterol would always be filtered through this enormous imbalance in the research efforts. Lowering LDL cholesterol would always have the appearance of being more important.

pp. 212-214

Reaven’s 1988 Banting Lecture is credited as the turning point in the effort to convince diabetologists of the critical importance of insulin resistance and hyperinsulinemia, but those investigators concerned with the genesis of heart disease paid little attention, considering anything having to do with insulin to be relevant only to diabetes. This was a natural consequence of the specialization of scientific research. Through the mid-1980s, Reaven’s research had focused on diabetes and insulin, and so his publications appeared almost exclusively in journals of diabetes, endocrinology, and metabolism. Not until 1996 did Reaven publish an article on Syndrome X in the American Heart Association journal Circulation, the primary journal for research in heart disease. Meanwhile, his work had no influence on public-health policy or the public’s dietary consciousness. Neither the 1988 Surgeon General’s Report on Nutrition and Health nor the National Academy of Sciences’s 1989 Diet and Health mentioned insulin resistance or hyperinsulinemia in any context other than Reaven’s cautions that high-carbohydrate diets might not be ideal for Type 2 diabetics. Both reports ardently recommended low-fat, high-carbohydrate diets for the prevention of heart disease.

Even the diabetes community found it easier to accept Reaven’s science than its dietary implications. Reaven’s observations and data “speak for themselves,” as Robert Silverman of the NIH suggested at a 1986 consensus conference on diabetes prevention and treatment. But they placed nutritionists in an awkward position. “High protein levels can be bad for the kidneys,” said Silverman. “High fat is bad for your heart. Now Reaven is saying not to eat high carbohydrates. We have to eat something.” “Sometimes we wish it would go away,” Silverman added, “because nobody knows how to deal with it.”

This is what psychologists call cognitive dissonance, or the tension that results from trying to hold two incompatible beliefs simultaneously. When the philosopher of science Thomas Kuhn discussed cognitive dissonance in scientific research—“the awareness of an anomaly in the fit between theory and nature”—he suggested that scientists will typically do what they have invariably done in the past in such cases: “They will devise numerous articulations and ad hoc modifications of their theory in order to eliminate any apparent conflict.” And that’s exactly what happened with metabolic syndrome and its dietary implications. The syndrome itself was accepted as real and important; the idea that it was caused or exacerbated by the excessive consumption of carbohydrates simply vanished.

Among the few clinical investigators working on heart disease who paid attention to Reaven’s research in the late 1980s was Ron Krauss. In 1993, Krauss and Reaven together reported that small, dense LDL was another of the metabolic abnormalities commonly found in Reaven’s Syndrome X. Small, dense LDL, they noted, was associated with insulin resistance, hyperinsulinemia, high blood sugar, hypertension, and low HDL as well. They also reported that the two best predictors of the presence of insulin resistance and the dominance of small, dense LDL are triglycerides and HDL cholesterol—the higher the triglycerides and the lower the HDL, the more likely it is that both insulin resistance and small, dense LDL are present. This offers yet another reason to believe the carbohydrate hypothesis of heart disease, since metabolic syndrome is now considered perhaps the dominant heart-disease risk factor—a “coequal partner to cigarette smoking as contributors to premature [coronary heart disease],” as the National Cholesterol Education Program describes it—and both triglycerides and HDL cholesterol are influenced by carbohydrate consumption far more than by any fat.

Nonetheless, when small, dense LDL and metabolic syndrome officially entered the orthodox wisdom as risk factors for heart disease in 2002, the cognitive dissonance was clearly present. First the National Cholesterol Education Program published its revised guidelines for cholesterol testing and treatment. This was followed in 2004 by two conference reports: one describing the conclusions of a joint NIH-AHA meeting on scientific issues related to metabolic syndrome, and the other, in which the American Diabetes Association joined in as well, describing joint treatment guidelines. Scott Grundy of the University of Texas was the primary author of all three documents. When I interviewed Grundy in May 2004, he acknowledged that metabolic syndrome was the cause of most heart disease in America, and that this syndrome is probably caused by the excessive consumption of refined carbohydrates. Yet his three reports—representing the official NIH, AHA, and ADA positions—all remained firmly wedded to the fat-cholesterol dogma. They acknowledge metabolic syndrome as an emerging risk factor for heart disease, but identify LDL cholesterol as “the primary driving force for coronary atherogenesis.” Thus, heart disease in America, as the National Cholesterol Education Program report put it, was still officially caused by “mass elevations of serum LDL cholesterol result[ing] from the habitual diet in the United States, particularly diets high in saturated fats and cholesterol.”

There was no mention that carbohydrates might be responsible for causing or exacerbating either metabolic syndrome or the combination of low HDL, high triglycerides, and small, dense LDL, which is described as occurring “commonly in persons with premature [coronary heart disease]. *53 In the now established version of the alternative hypothesis—that metabolic syndrome leads to heart disease—the carbohydrates that had always been considered the causative agent had been officially rendered harmless. They had been removed from the equation of nutrition and chronic disease, despite the decades of research and observations suggesting the critical causal role they played.

The Big Fat Surprise
by Nina Teicholz
pp. 57-58

It’s not that no one questioned Keys along the way, of course. There were plenty of skeptics, including esteemed, influential scientists. Remember that Swedish egg-eating doctor, Uffe Ravnskov? On my own travels through the world of nutrition as I researched this book, he was the first “skeptic” I met. Whereas once a large and prominent group of scientists had opposed Keys and his hypothesis, the great majority of them had disappeared by the late 1980s. Ravnskov picked up their torch later, with the publication of a book called Cholesterol Myths in 2000.

At a conference that we were both attending near Copenhagen in 2005, he stood out in the crowd simply because he was willing to confront this gathering of top nutrition experts by asking questions that were considered long since settled.

“The whole pathway, from cholesterol in the diet, to cholesterol in the blood, to heart disease—has this pathway really been proven?” he stood up and asked, rightly though rhetorically, after a presentation one day.
“Tsh! Tsh! Tsh!” A hundred-plus scientists wagged their heads in unison.
“Next question?” asked an irritated moderator.

The incident illustrated, for me, the most remarkable aspect of the nutrition research community, namely its surprising lack of oxygen for alternative viewpoints. When I started out my research, I expected to find a community of scientists in decorous debate. Instead, I found researchers like Ravnskov, who, by his own admission, was a cautionary tale for independently minded scientists seeking to challenge the conventional wisdom. His predecessors from the 1960s onward hadn’t been convinced by the orthodoxy on cholesterol; they’d just been silenced, worn out, or had come to the end of their careers. As Keys’s ideas spread and became adopted by powerful institutions, those who challenged him faced a difficult—some might say impossible—battle. Being on the losing side of such a high-stakes debate had caused their professional lives to suffer. Many of them had lost jobs, research funding, speaking engagements, and all the many other perks of prestige. Although these diet-heart opponents included a number of researchers who were at the top of their fields, including, notably, an editor of the Journal of the American Medical Association , they were not invited to conferences and were unable to get prestigious journals to publish their work. XIV Experiments that had dissenting results, they found, were not debated and discussed but instead dismissed or ignored altogether. Even being subject to slander and personal ridicule were surprisingly not unusual experiences for these opponents of the diet-heart hypothesis. In short, they found themselves unable to continue contributing to their fields, which of course is the very essence of every scientist’s hopes and ambitions.

To a surprising degree, in fact, the story of nutritional science is not, as we would expect, one of sober-minded researchers moving with measured, judicious steps. It falls, instead, under the “Great Man” theory of history, whereby strong personalities steer events using their own personal charisma, intelligence, wisdom, or wits. In the history of nutrition, Ancel Keys was, by far, the Greatest Man.

pp. 106-108

On the whole, said Manning Feinleib, an associate director at the NHLBI who attended the meetings as a rapporteur, the committee seemed to consider the downside of cancer to be less important than the upside of reducing heart disease. I spoke to him in 2009, and he was clearly dismayed that the issue of low cholesterol and cancer had still not been settled. “Oh boy, it’s been more than twenty-five years, and they have still not shed more light on what’s going on, and why not? That’s even more puzzling.”

In 1990, the NHLBI held yet another meeting on the problem of “significantly increased” death rates from cancer and other noncardiovascular causes for people with low cholesterol. The lower the cholesterol, the worse it looked for cancer deaths, and damningly, it looked especially bad for healthy men who were actively trying to reduce their cholesterol through diet or drugs. But there was no follow-up to these meetings, and the results did not change the enthusiasm for the “prudent diet.” The effects of low cholesterol are still not well understood.

When I mentioned all this to Stamler, he didn’t remember any part of this cancer-cholesterol debate. In this way, he is a microcosm of a larger phenomenon that allowed the diet-heart hypothesis to move forward: inconvenient results were consistently ignored; here again, “selection bias” was at work.

An Extreme Case of Selection Bias

There has been a lot of selective reporting and ignoring of the methodological problems over the years. But probably the most astonishing example of selection bias was the near-complete suppression of the Minnesota Coronary Survey, which was an outgrowth of the National Diet Heart Study. Also funded by NIH, the Minnesota Coronary Survey is the largest-ever clinical trial of the diet-heart hypothesis and therefore certainly belongs on the list along with Oslo, the Finnish Mental Hospital Study, and the LA Veterans Trial, but it is rarely included, undoubtedly because it didn’t turn out the way nutrition experts had hoped.

Starting in 1968, the biochemist Ivan Frantz fed nine thousand men and women in six Minnesota state mental hospitals and one nursing home either “traditional American foods,” with 18 percent saturated fat, or a diet containing soft margarine, a whole-egg substitute, low-fat beef, and dairy products “filled” with vegetable oil. This diet cut the amount of saturated fat in half. (Both diets had a total of 38 percent fat overall.) Researchers reported “nearly 100% participation,” and since the population was hospitalized, it was more controlled than most—although, like the Finnish hospital study, there was a good deal of turnover in the hospital (the average length of stay was only about a year).

After four-and-a-half years, however, the researchers were unable to find any differences between the treatment and control groups for cardiovascular events, cardiovascular deaths, or total mortality. Cancer was higher in the low-saturated-fat group, although the report does not say if that difference was statistically significant. The diet low in saturated fat had failed to show any advantage at all. Frantz, who worked in Keys’s university department, did not publish the study for sixteen years, until after he retired, and then he placed his results in the journal Arteriosclerosis, Thrombosis, and Vascular Biology , which is unlikely to be read by anyone outside the field of cardiology. When asked why he did not publish the results earlier, Frantz replied that he didn’t think he’d done anything wrong in the study. “We were just disappointed in the way it came out,” he said. In other words, the study was selectively ignored by its own director. It was another inconvenient data point that needed to be dismissed.

pp. 114-

In the United States, Pete Ahrens, who was still the prudent diet’s most prominent critic, continued to publish his central point of caution: the diet-heart hypothesis “is still a hypothesis . . . I sincerely believe we should not . . . make broadscale recommendations on diets and drugs to the general public now.” XVIII

By the late 1970s, however, the number of scientific studies had grown to such “unmanageable proportions,” as one Columbia University pathologist put it, that it was overwhelming. Depending on how one interpreted the data and how one weighed all the caveats, the dots could be connected to point in different directions. The ambiguities inherent to nutrition studies opened the door for their interpretation to be influenced by bias—which hardened into a kind of faith. There were simply “believers” and “nonbelievers,” according to cholesterol expert Daniel Steinberg. A number of interpretations of the data were possible and equally compelling from a scientific perspective, but there was only one for “believers,” while “disbelievers” became heretics outside the establishment.

Thus, the normal defenses of modern science had been flattened by a perfect storm of forces gathered in postwar America. In its impressionable infancy and compelled by an urgent drive to cure heart disease, nutrition science had bowed to charismatic leaders. A hypothesis had taken center stage; money poured in to test it, and the nutrition community embraced the idea. Soon there was very little room for debate. The United States had embarked upon a giant nutritional experiment to cut out meat, dairy, and dietary fat altogether, shifting calorie-consumption over to grains, fruits, and vegetables. Saturated animal fats would be replaced by polyunsaturated vegetable oils. It was a new, untested diet—just an idea, presented to Americans as the truth. Many years later, science started to show that this diet was not very healthy after all, but it was too late by then, since it had been national policy for decades already.

pp. 142-145

The Consensus Conference

If a large portion of middle-aged American adults are now cutting back on meat and taking statin pills, it is due almost entirely to the step that the NHLBI took next. Dispensing drugs and dietary advice to the entire US population is a huge responsibility, and the NHLBI decided it needed to create a scientific consensus, or at least the appearance of one, before moving forward. Also, the agency needed to define the exact cholesterol thresholds above which it could tell doctors to prescribe a low-fat diet or a statin. So once again, in 1984, NHLBI convened an expert group in Washington, DC, with a public meeting component attended by more than six hundred doctors and researchers. Their job—in an unrealistic two-and-a-half days—was to grapple with and debate the entire, massive stack of scientific literature on diet and disease, and then to come to a consensus about the recommended cholesterol targets for men and women of all ages.

The conference was described by various attendees as having preordained results from the start, and it’s hard not to conclude otherwise. The sheer number of people testifying in favor of cholesterol lowering was larger than the number of spaces allotted to challengers, and powerful diet-heart supporters controlled all the key posts: Basil Rifkind chaired the planning committee, Daniel Steinberg chaired the conference itself, and both men testified.

The conference “consensus” statement, which Steinberg read out on the last morning of the event, was not a measured assessment of the complicated role that diet might play in a little-understood disease. Instead, there was “no doubt,” he stated, that reducing cholesterol through a low-fat, low-saturated-fat diet would “afford significant protection against coronary heart disease” for every American over the age of two. Heart disease would now be the most important factor driving dietary choices for the entire nation. After the conference, in March 1984, Time magazine ran an illustration on its cover of a face on a dinner plate, comprised of two fried-egg eyes over a bacon-strip frown. “Hold the Eggs and Butter!” stated the headline, and the story began: “Cholesterol is proved deadly, and our diet may never be the same.”

As we’ve seen, LRC had nothing to say about diet, and even its conclusions on cholesterol were only weakly supported by the data, but Rifkind had already demonstrated that he believed this extrapolation was fair. He told Time that the results “strongly indicate that the more you lower cholesterol and fat in your diet, the more you reduce the risk of heart disease.”

Gina Kolata, then a reporter for Science magazine, wrote a skeptical piece about the quality of the evidence supporting the conference’s conclusions. The studies “do not show that lowering cholesterol makes a difference,” she wrote, and she quoted a broad range of critics who worried that the data were not nearly strong enough to recommend a low-fat diet for all men, women, and children. Steinberg attempted to dismiss the criticisms by calling her article a case of the media’s appetite for “dissent [which] is always more newsworthy than consensus,” but the Time cover story in support of Steinberg’s stated conclusions was clearly an example of the opposite, and on the whole, the media supported the new cholesterol guidelines.

The consensus conference spawned an entirely new administration at the NIH, called the National Cholesterol Education Program (NCEP), whose job it remains to advise doctors about how to define and treat their “at-risk” patients, as well as to educate Americans themselves about the apparent advantages of lowering their cholesterol. In the following years, the NCEP’s expert panels became infiltrated by researchers supported by pharmaceutical money, and cholesterol targets were ratcheted ever lower, thereby bringing greater and greater numbers of Americans into the category that qualified for statins. And the low-fat diet, even though it had never been properly tested in a clinical trial to ascertain whether it could prevent heart disease, became the standard, recommended diet of the land.

For longtime critics of the diet-heart hypothesis such as Pete Ahrens, the consensus conference was also significant because it marked the last time they could speak openly. After this conference, Ahrens and his colleagues were forced to fold their case. Although members of the nutrition elite had, over the previous two decades, been allowed to be part of the debate, in the years following the consensus conference, this was no longer true. To be a member of the elite now meant, ipso facto, supporting the low-fat diet. So effectively did the NHLBI-AHA alliance silence its antagonists, in fact, that among the tens of thousands of researchers in the worlds of medicine and nutrition over the next fifteen years, only a few dozen would publish research even gingerly challenging the diet-heart hypothesis. And even then, they worried about putting their careers on the line. They saw Ahrens, who had risen to the very top of his field and yet found himself having a hard time getting grants, because there was “a price to pay for going up against the establishment, and he was well aware of that,” as one of his former students told me.

No doubt this is why Ahrens, in looking back on the conference, which came to be his swan song, spoke with an uncharacteristic lack of reserve. “I think the public is being hosed by the NIH and the American Heart Association,” he declared. “They desire to do something good. They’re hoping to God that this is the right thing to do. But they are not acting on the basis of scientific evidence, but on the basis of a plausible but untested idea.” Plausible or even probable, however, that untested idea had now been launched.

pp. 319-328

These pioneering researchers of the Atkins diet continued to expand their work throughout the 2000s, conducting trials on a range of subjects: men and women, athletes, and those suffering from obesity, diabetes, and metabolic syndrome. XV XVI And while the gains have varied, they have consistently pointed in the right direction. One of the more extraordinary experiments involved 146 men suffering from high blood pressure who went on the Atkins diet for almost a year. The group saw their blood pressure drop significantly more than did a group of low-fat dieters—who were also taking a blood-pressure medication.

In most of these experiments, the diet with the best results contained more than 60 percent of calories as fat. XVII This proportion of fat was similar to what the Inuit and the Masai ate but was startlingly high compared to the official recommendations of 30 percent or less. Yet no other well-controlled trials of any other diet had ever shown such clear-cut advantages in the fight against obesity, diabetes, and heart disease, and for so many different kinds of populations.

Despite the consistency of these results, Westman and his colleagues have remained outsiders in the world of nutrition. Their work has perhaps predictably been met with silence, scorn, or both. Getting their research published in prestigious journals has been difficult, and invitations to major conferences are rare. Volek says that even when he’s been invited to present his findings at meetings, displaying research that confronts the very foundation of the conventional wisdom on diet, the reception is incurious: “people are just quiet.” And despite the substantial body of evidence now supporting the high-fat, low-carbohydrate regime as the healthiest option, his colleagues still routinely refer to the diet as “quackery” and a “fad.” Persevering in this field can be dispiriting, Volek told me. “You do deal with bias. . . . It’s very difficult to find grant money or journals that want to publish our studies.”

Westman has written poignantly about the predicament of working toward paradigm change when the existing bias is so strong: “When an unscientific fear of dietary fat pervades the culture so much that researchers who are on study sections that provide funding will not allow research into high-fat diets for fear of ‘harming people,’ ” as we’ve seen at the NIH and AHA, “this situation will not allow science to ‘self-correct.’ A sort of scientific taboo is created because of the low likelihood of funding, and the funding agencies are off the hook because they say that researchers are not submitting requests for grants.” […]

Gary Taubes and “The Big Fat Lie”

While these researchers have been ignored by most mainstream medical and nutrition communities, the one person who has successfully redirected the nutrition conversation over the past decade toward the idea that carbohydrates, not fat, are the drivers of obesity and other chronic diseases is the science journalist Gary Taubes. In 2001, he wrote a critical history of the diet-heart hypothesis for Science magazine, which was the first time a major scientific journal had published a thorough analysis of the low-fat dogma’s scientific weaknesses—at least since Pete Ahrens had ceded the battle against Ancel Keys in the mid-1980s. Taubes also reviewed all the science, from those prewar German and Austrian obesity researchers on through Pennington, and concluded that obesity was indeed a hormonal defect and not the result of gluttony and sloth. In his Science piece, Taubes described how the hormone causing obesity is most likely insulin, which spikes when one eats carbohydrates. One of his primary conclusions, in fact, was that dietary fat itself is the nutrient least likely to make you fat, because it’s the one macronutrient that doesn’t stimulate the production of insulin.

Other researchers and scientists had published critiques of the diet-heart hypothesis, but Taubes was the first to put together all the various ideas on the topic into one comprehensive narrative. And Taubes could reach a national audience. He followed up with a second foray in the New York Times Magazine , under the headline, “ What if It’s All Been a Big Fat Lie?” In 2007, he published a book on the subject, Good Calories, Bad Calories , a densely annotated and meticulously researched work that made a comprehensive and original case for an “alternative” hypothesis on obesity and chronic disease. It argued that the refined carbohydrates and sugars in our diet are what cause obesity, diabetes, and related diseases, and not the dietary fat or the “excess calories” that are thought to come from eating more than we should.

Taubes has been the most influential recent challenger to the diet-heart hypothesis. Even Michael Pollan, the popular food writer who says we should eat “mostly plants,” praised Taubes for exposing the pseudoscience in the low-fat dogma and dubbed him the Alexander Solzhenitsyn of the nutrition world.

Taubes’s work shattered dogma to such an extent that most nutrition experts have been unable to respond except by simply dismissing him, as the field has managed to do with challengers so many times before. When Taubes’s book came out, Gina Kolata, medical writer for the New York Times , called Taubes “a brave and bold science journalist” but ended her review with an airy, “I’m sorry, I’m not convinced.” XXIII The chill in the nutrition community toward Taubes was so palpable in the mid-2000s, when I started my own research for this book, that although many diet-and-heart experts had apparently read Taubes, I found that no one was willing to talk about him. Taubes’s work as a science journalist had won him many awards, including three science-in-society awards from the National Association of Science Writers, the most that the group allows for any single science reporter. Yet roughly two thirds of my interviews with nutrition experts began with something like: “If you are taking the Gary Taubes line, then I’d rather not talk to you.”

Taubes, in turn, was a provocative critic of nutrition science and its practitioners. After one talk at a research institute, a senior faculty member asked, “Mr. Taubes, is it fair to say that one subtext of your talk is that you think we’re all idiots?” “A surprisingly good question,” Taubes wrote later on his blog. He explained that generations of researchers weren’t unintelligent; they had simply been educated into a biased way of thinking. Yet if the pursuit of science is about getting the right answer, wrote Taubes, then “getting the wrong answer on such a huge and tragic scale borders on inexcusable.” In the last line of his 2002 New York Times Magazine article, he quotes a researcher asking the not-so-rhetorical question: “Can we get the low-fat proponents to apologize?”

Despite the no-love-lost nature of the relationship between Taubes and mainstream nutrition experts, much of what he wrote seemed so eminently believable that it was almost immediately adopted. Of course sugar and white flour were bad! Nutrition experts spoke as if this had always been known. A 2010 headline in the Los Angeles Times declared, “Fat Was Once the Devil. Now More Nutritionists Are Pointing Accusingly at Sugar and Refined Grains.” Researchers around the country who had read and digested Taubes’s work were suddenly studying sucrose, fructose, and glucose, comparing them to each other and looking at their insulin effects. Some investigators have made the case recently that the fructose found in fruits, honey, table sugar, and high-fructose corn syrup may be worse than glucose in provoking the inflammation markers linked to heart disease. XXIV The glucose found in sugar and starchy vegetables, meanwhile, seems to work more closely with insulin to cause obesity. The science on these different types of refined carbohydrates is still in its infancy, so we don’t really know if all carbohydrates play a role in obesity, diabetes, and heart disease, or if some types are worse than others.

The one statement that seems safe to make is that the refined carbohydrates and sugars that we were recommended to eat by the AHA as part of a healthy, fat-avoiding diet, are not merely indifferent, “empty calories,” as we’ve long been told, but are actively bad for health in a variety of ways. XXV Moreover, the clinical trials in recent years imply that any kind of carbohydrate, including those in whole grains, fruits, and starchy vegetables, are also unhealthy in large amounts. Remember that the Shai study in Israel found that the Mediterranean diet group, eating a high proportion of calories as these “complex” carbohydrates, turned out to be less healthy and fatter than the group on the Atkins-style diet, although they were healthier than the low-fat alternative. The Women’s Health Initiative, too, in which some 49,000 women were tested on a diet high in complex carbohydrates for nearly a decade, showed only marginal reductions in disease risk or weight. This big-picture message about how even too many unrefined carbohydrates might be bad for health is alienating for Americans, however, since we are now used to viewing these foods as healthy. And no doubt it would be difficult for nutrition experts to contradict their own half-century’s worth of high-carbohydrate advice.

Even so, whatever scientific progress has been made toward our greater understanding of carbohydrates generally in recent years has clearly been due to Taubes’s work. “This has been his most important contribution to the field,” said Ronald M. Krauss, an influential nutrition expert and the director of research at the Children’s Hospital Oakland Research Institute. For a journalist, it was an astonishing coup in the world of science. In 2013, Taubes became one of the rare journalists to write a peer-reviewed article for the highly respected scientific publication, the British Medical Journal . Yet given the stranglehold that Keys’s ideas have held on nutrition researchers for so many decades, it is perhaps inevitable that an alternative hypothesis had to come from an outsider.

Lore of Nutrition
by Tim Noakes & Marika Sboros
pp. 27-31
Preface by Marika Sboros

He explained that there was nothing new to what he was saying, that the evidence had been there for years, and that those in positions of power and influence over public nutrition advice had either ignored or suppressed this evidence. He directed me to scientific people, papers and places I didn’t even know existed.

I ended the conversation feeling unsettled. Noakes sounded eminently rational, reasonable and robustly scientific. I started reading all the references he gave me. I read the work of US physician-professors Stephen Phinney and Eric Westman, and Professor Jeff Volek. I read Eades; US science journalist Gary Taubes, author of Good Calories, Bad Calories and Why We Get Fat (and most recently The Case Against Suga r ); and one of British obesity researcher Dr Zoë Harcombe’s many books, The Obesity Epidemic . I also read The Big Fat Surprise by US investigative journalist Nina Teicholz. That book thoroughly rocked my scientific worldview, as it has done for countless others.

The Wall Street Journal said of Teicholz’s book: ‘From the very beginning, we had the statistical means to understand why things did not add up; we had a boatload of Cassandras, a chorus of warnings; but they were ignored, castigated, suppressed. We had our big fat villain, and we still do.’ Former editor of the British Medical Journal Dr Richard Smith wrote about The Big Fat Surprise in a feature for the journal in 2014, titled ‘Are some diets “mass murder”?’ LCHF critics have suggested that prescribing a diet restricted in carbohydrates to the public is ‘the equivalent of mass murder’. Smith gained a very different impression after ploughing through five books on diet and some of the key studies to write his feature. The same accusation of ‘mass murder’ can be directed at ‘many players in the great diet game’, Smith said. In short, he said, experts have based bold policies on fragile science and the long-term results ‘may be terrible’. 3

For her book, Teicholz researched the influential US dietary guidelines, which were introduced in 1977 and which most English-speaking countries, including South Africa, subsequently adopted. She discovered that there was no evidence to support the guidelines’ low-fat, high-carb recommendations when they were first introduced, and that any evidence to the contrary was ignored or suppressed for decades.

My research into LCHF left me uneasy. As a journalist, I’m a messenger. I began to wonder whether I had been giving the wrong messages to my readers for decades. Had I unwittingly promoted advice that harmed people suffering from obesity, diabetes and heart disease? Among those was my father, Demetrius Sboros, who suffered from heart disease for many years before his death in 2002. Had I given him advice and information that shortened his life?

I put those worries aside and wrote up my interview with Noakes. The backlash was instant. On Twitter, total strangers called me irresponsible, unscientific, unethical and biased. Astonishingly, some were medical doctors, mostly former students of Noakes. They said that I was Noakes’s ‘cheerleader’, and even accused me of having a ‘crush’ on him. Some said that Noakes must have been paying me handsomely to say nice things about him. (For the record, he has never paid me anything, nor would he think to offer to pay me or I to accept.) Others said I was a ‘closet Banter’, as if that was the worst possible insult.

At first I was irritated. After all, I had quoted Noakes accurately. I had reflected what critics said about him, to ensure that I gave both sides. And anyway, I readily confess to bias, but only in favour of good science. I’ve always said that if anyone can show me robust evidence that Noakes is wrong about LCHF, I will publish it. Knowing him as I do, so will he.

Most of all, though, I was shocked at the venom behind the attacks on Noakes. He had simply done what any good scientist does when faced with compelling evidence that contradicts a belief: he had changed his mind. I’ve never seen much sense in having a mind if you can’t change it.

The attacks against him grew more gratuitously vicious and libellous. Then, in July 2014, researchers at UCT and the University of Stellenbosch published a study in PLoS One that became known as the Naudé review. 4

In August 2014, four of Noakes’s UCT colleagues published a letter in the Cape Times . Dubbed the UCT professors’ letter, it accused him of ‘making outrageous unproven claims about disease prevention’ and of ‘not conforming to the tenets of good and responsible science’. […]

As I continued my research, it became apparent why so many doctors, dietitians, and food and drug industries want to silence Noakes. He threatens their businesses, reputations, careers, funding and sponsors. And cardiologists and endocrinologists are not the only ones at risk of class-action lawsuits if, or more likely when, LCHF diets become mainstream, especially to treat health problems such as obesity, diabetes and heart disease. All doctors and dietitians may be at risk if it is shown that they knew about LCHF but deliberately chose not to offer it as an option to their patients.

When the HPCSA eventually charged Noakes in late 2014 with allegedly giving unconventional advice to a breastfeeding mother on Twitter, I began to prepare to report on the hearing. The deeper I dug, the more unpleasant the experience became. In 2015, for example, I was having what I thought was a relatively civil phone call with Johannesburg cardiologist Dr Anthony Dalby. I asked for comment on research suggesting that the diet-heart hypothesis was unproven. ‘If you believe that, then I leave it to you,’ he said, and hung up on me. Other doctors, academics and dietitians followed suit, avoiding my emails, or slamming the phone down if I ever managed to get past their gatekeepers.

Teicholz told me of similar experiences while doing research for The Big Fat Surpris e . In response to a question on fat, an interviewee suddenly said, ‘I can’t talk about that,’ and hung up. Teicholz was shaken. ‘It felt as if I had been investigating organised crime,’ she said. The analogy was apt for her then. It became apt for me too.

The wall of silence I came up against while reporting on the HPCSA hearing should not have surprised me. I had a good working relationship with Claire Julsing Strydom, the dietitian who laid the initial complaint against Noakes – that is, until I started writing about her role in the whole affair. Strydom was president of the Association for Dietetics in South Africa when she lodged the complaint. Once I began asking uncomfortable questions, she stopped talking to me. ADSA executives and academics have followed suit, clearly acting on legal advice.

Like many, I enjoy a good conspiracy theory. However, at the first abortive attempt at a hearing session in June 2015, I wasn’t convinced of an organised campaign to discredit Noakes. By the trial’s end, I was.

Strydom and ADSA deny a vendetta against Noakes. Yet the signs were always there. Another ADSA executive member, Catherine ‘Katie’ Pereira, lodged a complaint with the HPCSA against Noakes in 2014 that was even more frivolous than Strydom’s. During an interview for a newspaper, Noakes had said that he didn’t know of any dietitian who told poor people not to drink Coca-Cola and eat potato crisps. (Most orthodox dietitians I know tell people that it’s fine to eat and drink these products as long as they do so ‘in moderation’.) The journalist made that comment a focus of the published interview. Pereira was offended on behalf of the entire dietetic profession. The HPCSA initially – and sensibly, to my mind – declined to prosecute. Strydom then intervened and pleaded with the HPCSA to charge Noakes. That case is still pending.

Nevertheless, to me, Strydom and ADSA have always looked more like patsies – proxies for Big Food and other vested interests opposed to Noakes. And this book turned into not so much a ‘whodunnit’ than a ‘why they dunnit?’.

pp. 32-34
Introduction by Marika Sboros

This is the story of a remarkable scientific journey. Just as remarkable is the genesis of that journey: a single, innocuous tweet.

In February 2014 , a Twitter user asked a distinguished and world-renowned scientist a simple question: ‘Is LCHF eating ok for breastfeeding mums? Worried about all the dairy + cauliflower = wind for babies??’

Always willing to engage with an inquiring mind, Professor Tim Noakes tweeted back: ‘Baby doesn’t eat the dairy and cauliflower. Just very healthy high fat breast milk. Key is to ween [ si c ] baby onto LCHF.’

With those few words, Noakes set off a chain of events that would eventually see him charged with unprofessional conduct, caught up in a case that would drag on for more than three years and cost many millions of rands. More difficult, if not impossible, to quantify is the devastating emotional toll that the whole ordeal has taken on him and his family, as critics attacked his character and scientific reputation at every turn.

At the time, it was open season on Tim Noakes. Doctors, dietitians and assorted academics from South Africa’s top universities had been hard at work for years trying to discredit him. They did not like his scientific views on low-carbohydrate, high-fat foods, which he had been promoting since 2011 . His opinions contrasted sharply with conventional, orthodox dietary ‘wisdom’, and the tweet provided the perfect pretext to amp up their attacks and hopefully silence him once and for all.

Within 24 hours of his tweet, a dietitian had reported him to the Health Professions Council of South Africa for giving what she considered ‘incorrect’, ‘dangerous’ and ‘potentially life-threatening’ advice. To Noakes’s surprise, the HPCSA took her complaint seriously.

Noakes is one of the few scientists in the world with an A 1 rating from the South African National Research Foundation (NRF) for both sports science and nutrition. In his home country, he has no equal in terms of expertise in and research into LCHF. Few can match his large academic footprint – quantified by an H-index of over 70 . The H- or Hirsch index is a measure of the impact of a scientist’s work. Noakes’s impact is significant. He has published more than 500 scientific papers, many of them in peer-reviewed journals, and over 40 of which deal exclusively with nutrition. He has been cited more than 17 000 times in the scientific literature.

Yet, remarkably, the HPCSA chose to back the opinion of a dietitian in private practice over an internationally renowned nutrition research scientist. They charged him with ‘unprofessional conduct’ for providing ‘unconventional advice on breastfeeding babies on social networks’ and hauled him through the humiliating process of a disciplinary hearing.

The public quickly dubbed it ‘the Nutrition Trial of the 21 st Century’. I’ve called it Kafkaesque. The HPCSA insisted that it was a hearing, not a trial, but the statutory body’s own conduct belied the claim.

At the time of Noakes’s tweet, I wanted to give up journalism. After more than 30 years of researching and writing about medicine and nutrition science, I was frustrated and bored. People were growing fatter and sicker, and the medical and dietetic specialists I wrote about weren’t making much difference to patients’ lives. Neither was my reporting.

Then I started investigating and writing about the HPCSA’s case against Noakes. The more questions I asked, the more walls of silence came up around me, and from the most unexpected sources. There’s an old saying that silence isn’t empty, it is full of answers. I found that the silence was loudest from those with the most to hide. I could not have foreseen the labyrinthine extent of vested inter ests ranged against Noakes, or the role played by shadowy proxy organisations for multinational sugar and soft-drink companies in suppressing and discrediting nutrition evidence.

It took a US investigative journalist to join many of the dots I had identified. Russ Greene’s research led to the International Life Sciences Institute (ILSI), a Coca-Cola front organisation. In an explosive exposé in January 2017 , Greene showed how the ILSI has worked to support the nutrition status quo in South Africa, as well as the health professionals and food and drug industries that benefit from it. It has opened a branch in South Africa and has funded nutrition congresses throughout the country. It has also paid for dietitians and academics opposed to Noakes and LCHF to address conferences abroad . *

Of course, it might be coincidence that so many doctors, dietitians and academics with links to the ILSI became involved, directly and indirectly, in the HPCSA’s prosecution of Noakes. Then again, maybe not.

The HPCSA’s conduct throughout the hearing and since its conclusion has been revelatory. To a large extent, it confirms the premise of this book: that those in positions of power and influence in medicine and academia were using the case to pursue a vendetta against Noakes. The trial highlighted the inherent perils facing those brave enough to go against orthodoxy. It is in Noakes’s DNA as a scientist to seek truth and challenge dogma. He has done it many times before and has been proved right every time. I have no doubt that this time will be no different. On this latest journey, he has demonstrated the unflinching courage, integrity and dignity that are his hallmarks as one of the most eminent scientists of his time.

pp. 112-113

In retrospect, I could not then appreciate the extent to which the Centenary Debate was the opening salvo of what I believe to have been a much wider campaign, the ultimate goal of which was to silence me through public humiliation. It is a well-known technique called refutation by denigration. My perception is that if the actions of my colleagues meant that my status as an A1-rated scientist, who had contributed greatly to the scientific and financial efforts of UCT’s Faculty of Health Sciences over 35 years, was destroyed, well, in their opinion, that was just too bad. According to their worldview, I was the architect of my own downfall.

Only later, when I read Alice Dreger’s Galileo’s Middle Finger: Heretics, Activists, and One Scholar’s Search for Justice , did I begin to appreciate what I was really up against. Dreger’s book explores the unrelenting battle between scholars who put the pursuit of hard truths ahead of personal comfort and the social activists determined to silence them. She uses the voice of the social activist to explain what drives activists in their battles with empirical science and scientists:

We have to use our privilege to advance the rights of the marginalized. We can’t let [scientists] say what is true about the world. We have to give voice and power to the oppressed and let them say what is true about the world. Science is as biased as all human endeavors, and so we have to empower the disempowered, and speak always with them. 64

The difference, of course, is that the activists I was facing, in my view, were not motivated to advance the voices of the oppressed and disempowered, but, either wittingly or by proxy, rather the opposite.

In the face of this, what is the responsibility of those scientists who see their role as the pursuit of ‘truth’? Dreger’s answer is this:

To scholars I want to say more: Our fellow human beings can’t afford to have us act like cattle in an industrial farming system. If we take seriously the importance of truth to justice and recognize the many factors now acting against the pursuit of knowledge – if we really get why our role in democracy is like no other – then we really ought to feel that we must do more to protect each other and the public from misinformation and disinformation … 65

We scholars had to put the search for evidence before everything else, even when the evidence pointed to facts we did not want to see. The world needed that of us, to maintain – by our example, by our very existence – a world that would keep learning and questioning, that would remain free in thought, inquiry, and word. 66

In the end, she concludes: ‘Justice cannot be determined merely by social position. Justice cannot be advanced by letting “truth” be determined by political goals.’ 67 Nor, I might add, can commercial interests be allowed to determine what is the ‘truth’.

Dreger’s final message is this: ‘Evidence really is an ethical issue, the most important ethical issue in a modern democracy. If you want justice, you must work for truth. And if you want to work for truth, you must do a little more than wish for justice.’ 68

As the media onslaught began, I did not understand that these academic activists seemingly did not care about the science. Neither did the tabloid journalists or Twitter trolls, including some medical colleagues, who at about the same time began to target me on social media. Were they also willing co-conspirators in the rush to silence my voice?

pp. 123-129

At the time, I was en route to the Western Cape nature reserve Bartholomeus Klip, near the village of Hermon. Early the next morning, I opened my email and read the attached letter with growing incredulity. It carried the names (but not signatures) of four UCT academics, as well as – importantly – the logos of UCT and the UCT Faculty of Health Sciences. It therefore, in effect, signalled my ultimate academic rejection by all members of the university, and especially the medical faculty that I had served with distinction for 35 years. Only the deaths of my parents, Bob Woolmer and a few other close friends surpassed the emotional devastation this email caused me. […]

What struck me most about the letter was its cruelty and inhumanity, and that the authors showed not the slightest hint of conscience in publicly shaming me. Medicine is meant to be a caring profession in which we are concerned with the emotional health and needs of not just our patients, but also our colleagues and students. De Villiers appears to understand this. When he was eventually appointed rector and vice chancellor of the University of Stellenbosch in December 2014, his university profile stated: ‘He believes the University should offer an experience that is pleasant, welcoming and hospitable – in an inclusive environment.’ 7 Those admirable sentiments were remarkable for their absence from the Cape Times professors’ letter.

Instead, the letter is a textbook example of academic bullying, a topic recently reviewed by Dr Fleur Howells, senior lecturer in psychiatry at UCT. Howells writes that there are three forms of academic bullying. The third, ‘social bullying, also known as relational aggression, is the deliberate or active exclusion or damage to the social standing of the victim through, for example, publicly undermining a junior academic’s viewpoint’. 8 The four key components of bullying are intent to harm, experience of harm, exploitation of power and aggression. The professors’ letter thus neatly fulfils all the diagnostic criteria for academic bullying.

Jacqui Hoepner is currently completing her PhD thesis at the Australian National University, studying the use of these bullying tactics to suppress or silence dissenting scientific opinions. 9 In a discussion with Daryl Ilbury, author of Tim Noakes: The Quiet Maveric k , Hoepner disclosed her original assumption that most cases of academic suppression or silencing arise from outside academic circles. To her surprise, she discovered the opposite – ‘the bulk of suppression or silencing came from within academia, from colleagues and competitors’, she told Ilbury. ‘This suggests that the assumed model of respect and disagreement between academics is inaccurate.’

Hoepner was astonished to uncover 43 different ‘silencing behaviours’ that fly in the face of the concept of academic freedom: ‘Every policy and university guideline I looked at suggested that academic freedom was absolutely central to what academics do and their place in society … [But] there’s a real disconnect between what academics think they are guaranteed under academic freedom and what the reality is for the life of an academic.’

She also discovered that the nature of these silencing attacks was ‘more of a personal gut response: that someone has crossed a boundary and we need to punish them. The exact motivation differed from case to case, but it seemed very much a visceral response.’

Typically, attacks are ad hominem, with accusations of conflicts of interest ‘to undermine credibility … without any attempt by the claimant of the accusations to provide any evidence’; and with allegations such as ‘You’re doing real harm’, ‘You’re causing confusion’ or you’re undermining the public’s faith in science; and ending with summons that the researcher be ‘fired or disciplined in some way’.

Perhaps with direct relevance to my experience, Hoepner said: ‘If a scientist discovers evidence that contradicts decades of public health messaging and says that data doesn’t support the messaging, and that person is attacked, and publicly … that’s insane!’

Returning to the professors’ letter, it is also blatantly defamatory because it implies that I, as a medical practitioner: promote a diet that may cause harm (‘heart disease, diabetes mellitus, kidney problems … certain cancers’); make ‘outrageous unproven claims’; malign the integrity and credibility of peers who disagree with me; and undertake research that is not ‘socially responsible’ in the judgement of UCT.

The letter also breaches the HPCSA’s own ethical guidelines. Professor Bongani Mayosi, another signatory to the letter, was involved at that time in a review of the HPCSA management and functioning, and therefore should have been well versed in the ethical guidelines of the organisation he was investigating.

pp. 145-146

I presented De Villiers and Mayosi with copies of Nina Teicholz’s book, The Big Fat Surprise , and an editorial published the previous week in the British Medical Journal ( BMJ ). The editorial was a review of Teicholz’s book written by a former BMJ editor, Dr Richard Smith. 26 In it, he wrote the following:

By far the best of the books I’ve read to write this article is Nina Teicholz’s The Big Fat Surprise , whose subtitle is ‘Why butter, meat, and cheese belong in a healthy diet.’ The title, the subtitle, and the cover of the book are all demeaning, but the forensic demotion 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 recognize 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.

After describing the bad science underlying all aspects of Ancel Keys’s diet-heart hypothesis, Smith concluded:

Reading these books and consulting some of the original studies has been a sobering experience. The successful attempt to reduce fat in the diet of Americans and others around the world has been a global, uncontrolled experiment, which like all experiments may well have led to bad outcomes. What’s more, it has initiated a further set of uncontrolled global experiments that are continuing. Teicholz has done a remarkable job in analyzing how weak science, strong personalities, vested interests, and political expediency have initiated this series of experiments. She quotes Nancy Harmon Jenkins, author of the Mediterranean Diet Cookbook and one of the founders of Oldways, as saying, ‘The food world is particularly prey to consumption, because so much money is made on food and so much depends on talk and especially the opinions of experts.’ It’s surely time for better science and for humility among experts.

In 2017, the other great British medical journal,

The Lancet , published a similar review, concluding: ‘This is a disquieting book about scientific incompetence, evangelical ambition, and ruthless silencing of dissent that shaped our lives for decades … Researchers, clinicians, and health policy advisers should read this provocative book that reminds us about the importance of good science and the need to challenge dogma.’ 27