“The 10 January edition of MedicalBrief carried a critique of the book written by myself and Marika Sboros, entitled Lore of Nutrition</em,” writes emeritus professor Tim Noakes. Dr Alastair McAlpine writes the Digital Clubbing “occasional column” for MedicalBrief.

Noakes writes:

My co-author has written her own criticisms. I choose to rebut the litany of specious comments and other errors.

To begin with we need to note that Dr McAlpine is a paediatrician with a special interest in the management of neonates. Whilst I would not for a moment question his expertise and dedication in that discipline, it is clear that he has no special training or expertise in nutrition or dietetics; he has yet to publish a single scientific article in a peer reviewed journal (as checked on PubMed) and, to my knowledge, has yet to complete a clinical trial dealing with any aspect of nutrition, especially in adults, which is the focus of Lore of Nutrition.

So, one might reasonably ask: What authentic professional qualifications and expertise does Dr McAlpine have for producing this column, which is potentially highly damaging to my professional reputation and to that of our book?

The one qualification that Dr McAlpine clearly does have is a long-standing, poorly disguised, bordering on the pathological, dislike for me personally but also for anyone else – those whom he dismissively calls my “acolytes” – who supports the low-carbohydrate lifestyle.

At least once a week for the past few years his Twitter feed (@AlastairMcA30) has carried derogatory comments about myself especially; more recently to his growing collection of targets, he has added insults to Marika Sboros. The comments about me are always unprofessional, frequently unethical and usually bordering on defamation. I have chosen not to invite the Health Professions Council of South Africa (HPCSA) to sample some of Dr McAlpine’s outpourings only because I suspect the resulting publicity is what he craves. That his comments are not actionable is not the reason for my reticence in this matter.

I will address Dr McAlpine’s column line-by-line.

Lines 4 to 9. Dr McAlpine acknowledges that the “world of nutrition” is a mess. This is an interesting admission. Why should this be if what we teach our medical students and dietitians is the final truth? A “truth” incidentally which Dr McAlpine spends an inordinate amount of his time defending on Twitter. His conclusion that Lore of Nutrition does not provide the answers to that mess is his untested personal opinion. We have no reason to believe that that is the definitive or universal conclusion. Only time will tell.

Fortunately, I am certain that the majority of South African medical practitioners who read MedicalBrief will be more than able to make up their own minds about whether or not Lore of Nutrition provides leadership and practical nutritional solutions of value to their patients.

Importantly, to conform with the model of postmodern intellectual deconstructionism that he practices, Dr McAlpine offers not a single solution to our current dietary “mess”. His job is to undermine any potential solution to the obesity/diabetes pandemic. His approach is best described as therapeutic nihilism.

Lines 11 to 15. As Dr McAlpine is not a published scientist who has ever been forced to defend his discovered facts in the global scientific community. So, whenever he deems it convenient, he is quite happy to present his personal opinions, rather than proven science, as proof of indisputable scientific facts. This is intellectual grandiosity.

For example, he performs an exemplary character assassination of me in these lines (11-15) but fails to extract any evidence whatsoever from what we have written to support his claims. Lore of Nutrition is most certainly not about conspiracy theories; the science is not cherry-picked; the conclusions are based solely on the extensive body of evidence that I present.

Recall that my HPCSA case, the topic of the book, lasted three years during which I prepared all the scientific material for the book and which occupied 12 days of testimony at the trial – again conveniently overlooked by Dr McAlpine who incidentally was nowhere to be seen when my HPCSA trial was in session. I certainly do not ever call those who disagree with me idiots, or shills or apologists except when we present the solid published evidence irrefutably proving any such allegations.

Placing this statement at the start of the article and without any supporting evidence is skillfully planned since it invites the reader to accept a particular truth in the absence of evidence; that acceptance will influence the reader’s bias for the remainder of the article.

Line 20. 30% of humans with the symptoms I described in myself are likely to be suffering from gluten sensitivity (reference 15 in Chapter 2). At the time I, like I suspect the majority of South African medical practitioners, was unaware that my symptoms might possibly have been due to the “healthy whole grains” that I had been advised to eat in order to be “healthy”. That’s the point I was making.

Line 33. There is no targeting of Professor Dirk Blom or anyone else who disagrees with me. I just point out when their statements are neither logical nor evidence-based. For example, Professor Blom is unable to explain why the majority of patients with acute heart attacks, for example those South Africans studied in the Heart of Soweto Study, do not have elevated blood cholesterol concentrations. So, given that evidence, I wondered why he believes that an elevated blood cholesterol concentration is the major cause of heart attack.

I further pondered whether the fact that his research is funded by manufacturers of statin drugs, might possibly influence his interpretation of the value of that category of drugs. There are entirely appropriate questions; they do not constitute “targeting”.

Line 34. Prior to the publication of her article entitled Is Tim Noakes the Malema of South African Medicine? Dr Stillwell was involved in a three-way Twitter conversation with Jacques Rousseau Jnr and another Johannesburg doctor. They were specifically discussing her upcoming article, especially its’ catchy title.

I find it interesting that the title for Dr McAlpine’s column has a rather similar catchy title suggesting it could have been created by someone with a journalistic training. (Editor’s note: All the headlines in MedicalBrief, “catchy” or not, are written by journalists.)

Line 42. At no point in the book do I specifically state that “simply” because someone accepts money from industry, then that person’s expert opinion cannot be trusted. What we provide repeatedly and at great length throughout the book, are the scientific facts that dispute various expert opinions. Rather than acknowledge that none of the experts was, in our estimation, able to provide reasonable explanations for their (incorrect) statements and beliefs, Dr McAlpine simply throws out this diversionary argument. If scientists cannot back up their beliefs with logical arguments, they need to be exposed. Not protected by a compliant colleague whose goal is to discredit (shoot) the messenger.

Line 44. The editorial was withdrawn for a week because I had failed to declare a conflict of interest; specifically, that I write books. At the time, I and most other authors were unaware that such must be declared.

Incidentally, this editorial has had a massive global impact becoming one of the top 0.1% of publicly-referenced articles in the entire medical literature in 2015. One unexpected consequence was to expose Coca-Cola’s deep involvement in funding scientists who promote the false dogma that obesity is a condition of physical inactivity, not of poor food choices.

Judging from Dr McAlpine’s other supportive comments relating to Coca-Cola (line 173), I suspect I understand why this article should attract his disfavour.

Lines 48-49. I have not fat-shamed anyone. I simply pointed out that the then chair of the British Dietetics Association, an unashamedly vegan/vegetarian front organisation, is obese. Obesity is a serious condition. I believe that if we are to tell people how to prevent obesity, then perhaps at the very least we need to understand how best to manage our own weight. Only after I reversed my own overweight state after December 2010, did I begin to feel that I understand the cause(s) of obesity sufficiently well to write what I do.

Lines 63-68. There is no direct evidence that LDL “unequivocally causes CVD”. Essentially all the evidence is from associational studies that, as Dr McAlpine should by now know, cannot prove causation. As I argue in Lore of Nutrition, 19 separate studies have shown that blood LDL cholesterol concentrations are unable to predict the extent of coronary atherosclerosis.

I also go to great lengths to show that the measurement of blood cholesterol concentrations in persons with Familial Hypercholesterolaemia (FH) cannot differentiate those who will die at a young age (before age 40) from those who will have a normal life expectancy. However, markers of insulin resistance predict those with FH who are at greatest risk of heart attack.

This evidence destroys the thrust of Dr McAlpine’s arguments. So not unsurprisingly, he chooses to ignore them.

Line 69. The association studies of Ancel Keys to which Dr McAlpine refers could not ever prove anything of value since they are associational studies. Dr McAlpine should by now know that associational studies cannot prove causation (except in exceptional cases when the Hazard Ratio is in excess of ~5).

But Keys’ real notoriety, detailed at length in Lore of Nutrition and again conveniently ignored by Dr McAlpine, is that when the results of The Minnesota Coronary Experiment (MSE), the first randomised controlled trial to test his diet-heart hypothesis, provided evidence that rather inconveniently disproved his hypothesis, Keys chose to hide that evidence. This is one of the grosser forms of scientific misconduct.

If, as he should have in 1974 when those data became available, Keys had displayed the courage to acknowledge that he was wrong, there would have been no need to write Lore of Nutrition. Because it would not have been possible to force the world to adopt the low-fat dietary guidelines that followed from his advocacy. And the modern global obesity/diabetes epidemic, which has been caused by the adoption of those guidelines, would never have happened.

It is surprising that in his search to expose truth, integrity and honesty, Dr McAlpine fails to mention these uncomfortable truths about his doyen, Ancel Keys.

Line 73. Further studies are “trotted out”. But I thought it was my duty as a scientist to “trot out” out all the evidence and not to be guilty of cherry-picking.

Most interestingly Dr McAlpine completely ignores the one pivotal study that destroys the low-fat theory – the eight-year randomised control trial (RCT), The Woman’s Health Initiative. That study showed that those post-menopausal women who reduced their dietary fat intake in the trial, worsened their diabetes and heart disease, gained more weight that those eating low-carbohydrate diets, and had no reduction in their incidence of breast cancer. We devote many pages of the book to the intellectual analysis of the importance of that study and how its’ definitive findings continue to be ignored in South Africa as elsewhere. If Dr McAlpine was really interested in exposing the truth, he would have reviewed the evidence we presented. Why did he not?

Line 82. It is interesting that I am always accused by my many South African critics, of seemingly being the only doctor or scientist in the entire world who is promoting the LCHF eating plan. In fact, the LCHF movement is a global phenomenon driven by tens of thousands of doctors and scientists.

So, Dr McAlpine implies that I am the sole driver (“His second big theory”) of the concept of insulin resistance as the key driver of the “chronic diseases of lifestyle”. This is completely false. This insulin resistance model of chronic disease was developed by Dr Gerald Reaven, emeritus professor of medicine at Stanford University.

But to acknowledge that this theory (which in my opinion could yet one day lead to the award of the Nobel Prize) originates in the hallowed halls of Stanford (not in my disturbed mind) would afford to it a degree of credibility with which Dr McAlpine must be uncomfortable.

Importantly, the major thrust of all my writing and lecturing, including all the diet books I have written, is to promote an understanding of insulin resistance as the key underlying factor driving these “chronic diseases of lifestyle”.

Line 87-98. Dr McAlpine misrepresents my argument. I am neither for or against the insulin-obesity hypothesis. But my focus is not on obesity; rather it is on insulin resistance as the ignored cause of the common “diseases of lifestyle” that daily overwhelm the medical resources in South Africa as they do in almost every other country in the world. Thus, these lines are once more a diversionary tactic; they are not relevant to my scientific arguments. The question I ask remains: Why is the most prevalent medical condition across the globe, insulin resistance, not taught in our medical schools to medical students and doctors? Once anyone has read Lore of Nutrition with an open mind, they will know the answer. Dr McAlpine skillfully avoids providing his own answer.

Line 99-103. To assist Dr McAlpine to improve his basic understanding of carbohydrate and fat metabolism by the liver, he might benefit by reading this article: Schwartz J-M et al. Hepatic de novo lipogenesis in normoinsulinemic and hyperinsulinemic subjects consuming high-fat, low-carbohydrate and low-fat, high carbohydrate isoenergetic diets. Am J Clin Nutr 2003;77:43-50. The conclusion of this study is that: “…both hyperinsulinemia and a low-fat diet increase de novo lipogenesis (in the liver) and that de novo lipogenesis contributes to hypertriglyceridemia”. The evidence that Non-Alcoholic Fatty Liver Disease (NAFLD) is the key driver of atherogenic dyslipidaemia and how the original diet-heart (lipid) hypothesis for heart disease needs to be replaced by the diet-liver-heart (carbohydrate) hypothesis is discussed in great detail in Lore of Nutrition.

Lines 102-126. To reduce 25 days of the HPCSA trial costing South African doctors (through their HPCSA fees) well over R10m and in which I and my 3 expert witnesses presented, under oath, 12 days of evidence involving in my case more than 1,000 slides summarising 6,000 pages of scientific studies and including a total of 4 and a half days of cross-examination, to these 24 lines of utter irrelevancy, is the best measure of Dr McAlpine’s mendacity. For if Dr McAlpine were properly to review the evidence I and my three international expert witnesses presented – evidence that the prosecution were unable to challenge – would negate everything he has written. So, he again simply ignores it by reducing all that evidence to irrelevancy. As if it never really happened. Perhaps it simply was too much effort to try to comprehend so much.

Lines 130-134. Clearly Dr McAlpine skipped Table 16.1 (page 312 of Lore of Nutrition) which list all the adaptations that humans show to carnivory. This evidence is irrefutable regardless of what the committed vegan Noah Yuval Harari writes.

Line 135-138. Any serious anthropologist reading this would simply advise Dr McAlpine to stick to his speciality. Even with the most primitive weapons, early humans became the most skilled hunters of large mammals the world has ever known. That is why within 1000 years of humans first appearing on the different continents, the largest (and fattest) mammals were hunted to extinction.

Line 139-149. Unfortunately, these hoary old colonial “experts” knew a little more about life, nutrition and health than does the 34-year-old Dr McAlpine. For they all dedicated their lives to the study of nutrition in different populations around the world. All established that populations were remarkably healthy when eating their traditional foods. However, their health began to fail dramatically following the introduction of the “displacing foods of modern commerce” (the colonialists’ foods) particularly sugar, flour and refined vegetable oils.

Perhaps some of the best evidence for this comes from the experience of Scottish GP Dr Walter Yellowlees who observed a large deterioration in the health of the Scottish farming community whom he served for 50 years after the end of the Second World War. This shows how recent has been this rapid decline in human health.

Once again, Dr McAlpine devotes just 11 lines to dismiss the 29 pages of hard science in this chapter, concluding that this is “perhaps the most disappointing” section of the book. Importantly, to understand this information I had to purchase and read all the books to which I refer. It is clear that Dr McAlpine was not prepared to do the same so that his opinion is uninformed. It is difficult to pass informed comment on that which one has not read.

Predictably, Dr McAlpine has to find the information in this chapter “disappointing”. For it proves that our modern diet is the cause of our modern “diseases of lifestyle”. If Dr McAlpine were to admit that, his diatribe becomes toothless.

Indeed, I find his reference to colonialism most interesting. The irony is that these “hoary old colonial experts” understood that the peoples they were studying had been perfectly healthy before the arrival of colonialism. Thus, these hoary old men were outspoken critics of the dietary changes brought by colonialism on formerly very healthy people. These colonialists did not defend colonialism as Dr McAlpine’s newest diversionary trick – colonialist-shaming – would want us to believe.

Line 150. It was clear in my HPCSA trial that the expert witnesses for the prosecution had absolutely no understanding of ketone metabolism and the importance of ketone bodies for brain health and brain development in neonates. Dr McAlpine clearly shares this ignorance which is dispelled by the material we review in Lore of Nutrition. Again, if Dr McAlpine disagrees with what we wrote, then he is most welcome to provide the scientific evidence to support his beliefs. But personal opinion is no substitute for scientific facts. At least for scientists.

Line 156. Perhaps Dr McAlpine needs to read the work of Harvard Professor Dr Alessio Fasano before he labels the “leaky gut syndrome” as pseudoscience. A good reference among others in Lore of Nutrition is: Fasano A. Leaky gut and autoimmune disease. Clin Rev Allergy Immunol 2012;42(1):71-78 doi: 10.1007/s12016-011-8291-x. One is surprised that Dr McAlpine, a paediatrician, is not aware of the work of Dr Fasano who discovered the zonulin pathway and is another potential Nobel Prize winner.

Line 156. Nowhere in the book do I state that child health in South Africa is deteriorating. I say that nutritional stunting is a major problem amongst South African children and that stunting could be improved if South African infants were fed more dietary protein and fat. We present all the evidence to support that statement in Lore of Nutrition as we did in the HPCSA trial.

Line 157. Nowhere in the book do we advise against exercise for weight loss. We simply repeat the evidence that diet is the more important intervention to produce sustainable weight loss, than is exercise.

Line 158. Lore of Nutrition is one of the few books of which I am aware in which the author, that is I, reproduces all the criticisms to which he has been exposed over the past seven years. I exclude nothing. Uniquely I respond to each of those criticisms by first reproducing my critics’ opinions before presenting my detailed counter-arguments.

Of course, the challenge for Dr McAlpine is that the evidence I present is so overwhelmingly in favour of my position that, like the prosecution’s experts in the HPCSA trial, he has no answers other than to use his usual diversionary arguments by charging that I am dogmatic and that I reach unsubstantiated conclusions by cherry-picking the evidence. But Lore of Nutrition refutes that allegation. We provide all the evidence. And when the strength of the evidence is overwhelming, it is time to rid ourselves of that which is incorrect. That is what we aim to do in Lore of Nutrition.

Line 171. As an A1-rated scientist with more than 500 publications and over 17,000 citations, I have learned to take exquisite care of my references. I take exception to the statement that the references in Lore of Nutrition are “shoddy”. What exactly does that mean? I worked for three years on the science presented in this book; I read many thousands of articles and perhaps 200 to 300 books. For someone without any expertise in nutrition to say without any documentation, that my references are “shoddy” is simply gratuitous.

Line 173. Russ Greene’s “frankly bizarre conspiracy article” which exposed the influence of the Coca-Cola front organisation, the International Life Sciences Institute (ILSI), in dietetics research and teaching in South Africa with possible influence in the HPCSA trial against me, is factually correct. If he believes otherwise, Dr McAlpine needs to provide real evidence.

Line 177-179. The HPCSA trial gave me four years to consider all the evidence about nutrition. I submit that there is no one in South Africa who knows more about the LCHF diet than I know. I am only dogmatic in the sense that I understand the totality of the evidence. And the evidence as I understand it, is what we wrote in Lore of Nutrition.

Lore of Nutrition tells the story of the past seven years of my life after I changed my mind about the role of carbohydrates in a “healthy” diet. Most of the focus is on my HPCSA trial on charges of professional misconduct. To avoid that trial, I could have chosen to terminate my professional registration with the HPCSA. But this would have left my scientific legacy in tatters as was clearly the goal of those professional colleagues who initiated the actions against me. Instead my wife and I decided that we were not going to submit to those dark forces. So, our only recourse was to fight the charges, whatever the financial and emotional costs to us and to our family.

As a result, we became involved in a four-year trial which has already, by our estimation, cost the doctors of South Africa (through their HPCSA dues) between R7m-R10m. We have now established that the trial came about as the result of what be believe to be a collusion between the HPCSA and the Association for Dietetics in South Africa (ADSA), the goal of which, we believe, was to silence me, once and for all. That is, to take away my constitutional right to freedom of speech.

During the trial, perhaps the first of its kind in modern science, I and my three expert witnesses presented, under oath, 12 days of testimony. This included a total of four-and-a-half days of cross-examination. On 21 April, 2017, I was declared innocent on all charges. The result was that all 10 decisions by the judging committee were ruled in my favour.

But the key point which Dr McAlpine chooses to ignore, is that none of the evidence that either I or any of my three expert witnesses presented was challenged by the prosecution or its experts. It is unfortunate that Dr McAlpine could not bring himself to acknowledge this remarkable event.

This is not a small matter. For as we argue in Lore of Nutrition, the future of our nation’s health will be determined by which of these ideas we adopt and promote.

Ends

Digital Clubbing columnist Alastair McAlpine responds:

I acknowledge the responses of Prof. Noakes and Ms. Sboros, and thank them for confirming my analysis of Lore of Nutrition in their respective contributions to the debate.

American Journal of Clinical Nutrition research

Clinical Reviews in Allergy & Immunology research

McAlpine’s column: Less lore and more science, please