Low carbohydrate diets: A plea for balance, scientific rigour & death to dogma

05 Apr 2016 Posted by

The article below is a slightly longer, unedited version of what appeared in the South African newspaper, The Cape Argus, on April 4.  It is my view, publicly stated, on the manner in which the diet ‘war’ about carbohydrate has been conducted, particularly in South Africa.

For personal reasons, this was a very difficult article to write, one that was five years in the making.  I’ve been watching the extremism, dogma, defensiveness and bad science unfold from the front row, and felt compelled to comment in a lengthier article rather than the occasional comment on social media.

The intention in this entire debate, I hope from all concerned (though I do doubt the motives of many), is to drive healthier eating behaviours.  However I don’t believe that will happen unless the protagonists in this debate, particularly the ‘zealots’ who crusade and insult and force extremism on people, pull back on their positions somewhat.  

The first reality, proven scientifically, is that adherence to diet is the key determinant of success.  Which diet proves best depends on that adherence – a practical truth that is often lost in the theoretical battles that are so needlessly fought on this issue.  

The second reality is that if our intentions are genuine, and we want the best possible outcome for the highest possible number of people, then recognising what I’ve tried to explain below will help, because we’ll see that some people benefit more from X, and others from Y.  If we are rigid, and defensive, and if we own our own position too strongly, then we make it LESS LIKELY that this ever happens.

So I wrote the following to appeal for that, and I hope it helps the tenor of the debate, and is recognised as balanced and full of conviction, without being overly-personal.


“The human body is centuries in advance of the physiologist, and can perform an integration of heart, lungs and muscles, which is too complex for the scientist to analyse”.

Those words belonged to Sir Roger Bannister, famous to most as the man who first ran the mile in under four minutes.  But Bannister was more than a runner.  He was a physician and neuroscientist, who could speak with comprehensive authority on the complexity of the body.


The Noakes Hours

His wisdom was introduced to me in 2002, when as an Honours student in Exercise Science and Sports Medicine with the University of Cape Town, I experienced my very first “Noakes Hour”.  The hour was basically a personal conversation with Professor Tim Noakes, with no structure and no curriculum, just a scheduled weekly event on our calendar, where Tim shared his vision, opinion and thoughts on sports science.  He was particularly fond of that quote.

It was, for us naïve but ambitious students, the exercise science equivalent of an audience with the Pope.  It was only years later, when I attended an international conference with Professor Noakes that I truly appreciated the magnitude of the privilege we had.  Noakes spoke at this conference, and people were literally sitting on windowsills outside the venue to listen to this unique scientist’s vision.

More than the bricks, mortar and university courses that he set up in partnership with Morne du Plessis, Noakes led South Africa to the forefront of global sports science with his ability and willingness to challenge paradigms.  He took on topics ranging from heart disease in runners and rugby injuries to fatigue and dehydration myths, and dragged more than few reluctant doubters to a fuller understanding of the complexity that Bannister (and every scientist) spends their life pursuing.

We (my fellow students and I) got front-row seats during those halcyon days of sports science.  Some of us even got to share the stage with Noakes, a rare privilege.  It was no co-incidence that Noakes’ sabbatical and retirement (and that of Morne du Plessis) signaled the end of my UCT involvement – it was a good time to leave.  Noakes was the soul of the institution, and to adapt a Pep Guardiola quote on Johann Cryuff, Noakes built the chapel, everyone else can hope merely to restore it.


The Diet Wars

I hope the ‘chapel’ will remain intact as Noakes’ legacy within sports science and medicine one day.  That is far from certain, in the face of significant doubt and criticism from the scientific community about his views on nutrition.  As most South Africans know, he has led the debate on carbohydrates and fats, even pushing words like “banting” into our accepted vocabulary.

Generally, it is Noakes’ approach, more than the actual content of many of his arguments, that evokes controversy.  The actual merits of WHAT is being said by both sides can be debated in 1000 editions of this newspaper, so voluminous and complex are they.  Given that meta-analyses (the scientific tool designed to summarize the best available evidence on a given topic) cannot reach simple, definitive conclusions, it is not my place to proffer theories for or against low carb diets here.

One of the problems we’ve had in this debate (there are many) is that these meta-analyses are dismissed as the insidious outcome of big corporations and corruption as they drive their sugar agenda, so realistically, talking about data does not help anyway.  Also, advocates for both sides of this argument are quick to resort to “whataboutery”, which means issues raised by ‘opponents’ are never addressed, just buried by new ones.  This tactic was in full view at the ill-fated HPCSA-Noakes hearings recently, and I don’t wish to walk down this dark alley here.


Let’s elevate the debate

So let me instead say the following.  First, HOW we argue for and support our positions is more important than WHAT we argue.  Knowledge changes, but sound thinking, logic and common sense do not.  And so we have a responsibility to push back against hypocritical, narrow and incomplete debating methods, more than the actual content.  It’s about “how”, not “what”, and this goes for both sides in every discourse, including this one.

Let me also affirm that a good deal of what Noakes says is unquestionably true.  Did we unnecessarily and wrongly demonize fats?  Yes.

Is our intake of sugar, driven in part by fat-phobia, too high?  Yes.

Should we adopt a more balanced approach to nutrition, one that recognizes that processed food is almost always not the best option?  Without doubt.

However, at some point, advocates for sensible principles abandon balance and introduce conspiracy, extremism and dogma-without-evidence into the debate, and that in turn offends many, and ultimately detracts from the possible benefits that might have resulted from a grounded conversation.

Should we avoid all carbohydrates, replacing them indiscriminately with fats?  Probably not, based on consensus science, any more than we should avoid all fats, making the same error in the opposite direction.  There are many other concepts and theories that go beyond what can reasonably be supported with good evidence, where Noakes and others’ claims are questionable, but it is the method of the discussion that I wish to focus on.

First, Noakes has been criticized for changing his opinion on carbohydrates.  I disagree.  Scientists are compelled to change their minds – it is a sign of successful knowledge advancement when experts’ positions change in response to new information.  Anyone who rigidly, dogmatically adopts a position exposes their lack of expertise, because the entire process of acquiring knowledge, as I learned from Tim and every scientist I’ve ever had the privilege of learning from, involves constant questioning, and the answers to those questions nudge knowledge from where it is to where it should be.

The operative word is “nudge”.  We are long past the days of “The world is flat.  No wait, the world is round”.  Science and knowledge are not Miley Cyrus-adorned wrecking balls that swing from one extreme to the other destroying all previously held beliefs and scientific findings in their path.

It should also be self-evident that if good science and knowledge requires evolving opinions, then someone who moves from X to Y, and then becomes rigid about Y, is making a mistake.  If knowledge is fluid, then it remains fluid, and does not suddenly solidify after one change.


No simple solutions

This negates the kind of flawed, over-simplified thinking that has characterized the diet-wars.  A recent review article discussed theories for obesity, and identified that there are 104 separate models or theories to explain this growing health crisis.  Not one, but 104.  No single solution or explanation has worked, or will work.

When I, as an exercise physiologist, watch elite sport, I see Usain Bolt sprinting, Michael Phelps swimming, and Chris Froome cycling steep mountain passes, and I appreciate that there is no valid reason that these three men should have identical physiology.  I would never expect that their performances are interchangeable, that their training should be identical, or that they should eat the same foods for those performances and training regimes.

Similarly, if you are reading this article in a coffee shop, look at the family sitting a few tables away from you.  Is there any credible reason for you to expect that their physiology would be positively or negatively influenced by the same kinds of foods as yours?  You might relate to the fact that the same headache tablet that puts you to sleep has no benefit at all for your own family, let alone strangers.

So why do we so readily embrace the simplicity global concepts of food group “demonization” and “sugar addiction”, when people may not only have different needs, but entirely different biochemistry, endocrinology and physiology?

It is a self-defeating start-point to a complex problem to assume that what works for one person will work for another.  This is not the same as changing the wheel on your car, where a manual can take you through a step-by-step process, guaranteed to produce the result you’re after as long as you follow the instructions to the letter.

Sir Roger Bannister would be horrified with such reductionist, simplified thinking.  Professor Noakes should be too, as should every expert who has enjoyed both the pleasure and the burden of trying to comprehend the complexity of the human physiological machine.


Conflict is only destructive

Let’s also abandon conspiracy theories that serve only to offend and alienate people who could be allies, while obscuring the totality of the picture we are attempting to build.  Yes, people have conflicts of interest, sometimes financial, but to discard them and their opinions without engaging one’s mind is lazy and limiting, because even conflicted views hold some shred of truth.

There’s also the small matter that if money was being made on one side of this debate (by big-carb), then a total shift to the other side will create the same opportunities to make money by other companies.  And so rather than being anti-conspiracy crusaders, some might well look at themselves as pawns in a conspiracy game that they are only seeing half of!  Without common sense, conspiracy theories become foolish, counter-productive distractions. (On this note, I’d also like to point out that I don’t believe that Tim Noakes is motivated by financial gain.  I have never met someone so generous with money, so willing to give it away.  However, I will say that others in this debate undoubtedly are motivated by money, and they are exploiting the big corporate greed concept for their own gains.  When I see seminars being held where attendance costs thousands, I wonder about their motives.  Money aside, power and ego are big drivers of many of the most outspoken people in this fight)

And can we agree to stop insulting the intentions, integrity and competencies of people who do not share the same ideas around simple solutions to complex problems?  I expect to be on the receiving end of a few such personal attacks for this article, but fortunately (or perhaps naively), I don’t particularly care about popularity, another lesson I learned from Noakes.  However, if one wishes to get key influencers to help deliver a well-intentioned message of better nutrition (and I’ve no doubt that Tim’s intentions are great), it’s strategically unwise to offend their motives or capabilities out the outset.

I remember one particular instance of such strategic myopia.  Early on during the anti-carbohydrate campaign, Noakes spoke at a UCT event, addressing a group of colleagues, including a handful of dieticians who between them had at least 100 years’ worth of clinical and research experience in nutrition.  He held up a book written by Gary Taubes (a physicist, not a nutrition expert), and said that unless they had read this book, they should not be practicing dietetics, effectively wiping out 100 years of experience and good intention.

When dieticians were later accused of being in the pocket of sugar companies, the effect was compounded, and opportunities for dialogue gone.  Is it any wonder people were insulted and reacted badly to the message when it is prefaced in this way?  That they responded with antagonism that led to the perceived victimization of Noakes and LCHF diets?  The bridge was destroyed before it could be crossed.

By the same standard, let me say that the same applies to many dieticians, whose reaction to Noakes was accelerant on an open flame, when calmer, strategic heads might have turned this into a wonderful opportunity to collaborate with one of the few popular, “celebrity” scientists who could take a good message to far more people than it previously had.  Both sides failed to share a lifeboat, even though both could see problems with the ship they were on.

It is this sort of polarization that we have to avoid.  Progress will only come when the protagonists in the debate realize that a) it’s not always personal, and b) just because someone does not agree with you on Opinion A, they do not automatically hold Opinion Z, at the opposite extreme of yours.  There is an entire alphabet in between, and neither Noakes or the dieticians have effectively recognized this (I am generalizing of course, in the interest of illustrating a concept).


Three pleas for change

Let me conclude with pleas to all the parties involved in the great diet debate.

First, to dieticians:  If you are defensive, and take criticism personally, you cannot shift your thinking, when you may need to.  I have no doubt that 99 out of 100 of you have pure, noble intentions, and are committed to the health of South Africans.  In Tim Noakes, you have potentially the greatest ally you can hope for.  Seek to find agreement before you disagree, and turn the publicity machine into an opportunity to make yourselves more relevant and more effective.

To Professor Tim Noakes, thank you for challenging dogma and for teaching me to do the same.  We all benefited from being part of an era that will never be repeated.  I hate to see such positive contributions eroded because your passion and enthusiasm drive you to extreme viewpoints on complex phenomena.  I learned complexity from you, and it would be presumptuous of me to offer it back (it feels almost insulting), but it’s all I have.  That plus an appeal to be a little more nuanced, less dogmatic and to adopt a conciliatory tone.   Stop resorting to weak anecdotes that constitute poor science, because they undermine your position, and instead apply the rigor and scientific thinking that shook so many fallacies in fatigue and dehydration to your OWN arguments.  Your good messages will be stronger for it.

And finally, to every reader, don’t expect complex problems to be solved by simple answers.  Don’t expect your neighbor to respond the way you do.  Become your own critical thinker, and allow ‘experts’ to guide you, but not to dictate.  It would be wrong to say you are an experiment of one, because we (researchers) are not fumbling about blindly in a post-modern world where everyone obeys their own laws.  But you must respect science and Bannister’s complexity, and seek to find your own individual optimal plan.

I know that concepts like “balance” are not sexy.  We love simple solutions, at the extremes, capturing our imagination, especially when they agree with our desires.  But perhaps we, South Africa, can be the first nation to reject hyped up, fad/cultish diet thinking, and become the world leader in healthy eating, with balance.  It would stand forever as the tower of that chapel.


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