Prof’s Words: Unpublished Foreword for Kath Megaw’s Book
Written by Professor Tim Noakes MBChB, MD, DSc, PhD (hc), FACSM, (hon) FFSEM (UK), (hon) FFSEM (Ire)
Emeritus Professor University of Cape Town
Author of Lore of Running, Challenging Beliefs, Waterlogged, Real Meal Revolution and Raising Superheroes
Once upon a time not so long ago, humans lived in fear of the pandemic infectious diseases that marched across the globe, decimating entire nations in their wakes.
The worst example perhaps was The Plague or Black Death that travelled the world between 1346 and 1353, killing as many as 75-200 million humans, with catastrophic consequences.
In their ignorance humans had no counter; for they knew not what caused these fearful afflictions. Just more than a century ago their cause was finally established. The bacterium Yersinia pestis transported around the world in fleas that infect some common ground rodents, including rats, causes the transmission of Plague. Today, secure in that knowledge, pest control, vaccination, and the treatment of infected individuals with appropriate antibiotics effectively keeps Plague in check. Provided nothing changes, neither we nor our children nor grandchildren need ever again fear The Black Death. Instead, we have other worries. Which could turn out to be much worse.
For the pandemic disease of the 21st century – the one that in the next 3 decades will cause as much death and destruction as ever did the Plague – is not an infectious disease. Rather it is a nutritional disease – diabetes mellitus. In particular that form of diabetes that occurs in those who, with age and incorrect nutrition, develop the condition of profound and progressive insulin resistance (IR). As a result, those affected with IR must produce increasing amounts of the hormone insulin, one function of which is to lower the blood glucose concentration. When the IR becomes so severe that even the highest rates of insulin production can no longer regulate the blood glucose concentration within the “normal” range, we have Type 2 diabetes mellitus (T2DM).
When I was a medical student four decades ago, we were taught that there were 2 forms of diabetes – Juvenile-onset and Adult-onset diabetes. Today we refer to these conditions as Type 1 (T1DM) and Type 2 Diabetes Mellitus (T2DM) respectively. An epidemic increase in the number of cases of T2DM in juveniles and young adults has forced the name change.
Juvenile-onset (T1DM) occurs as the name implies in children usually below about 10 years of age. The exact cause remains uncertain but the disease begins as an auto-immune reaction in which the affected individuals’ immune systems develop anti-bodies which destroy all their pancreatic insulin-secreting (beta) cells. Bereft of beta cells the affected persons are unable to secrete any insulin and so develops insulin-deficient (auto-immune) or insulin-dependant T1DM.
Whilst the source of this auto-immune attack is currently uncertain, one theory is that it occurs in response to changes in the barrier function of the intestine causing what is known as the “leaky gut” syndrome. The “leaky gut” then allows the entry of bacterial and other proteins directly from the gut into the blood stream. The immune system considers these proteins to be foreign invaders. So it mounts a vigorous response, the unintended consequence of which is the destruction of all the invaded’s insulin-secreting beta cells. According to this theory promoted especially by Harvard Medical School Professor Alessio Fasano, the leaky gut syndrome is caused in genetically susceptible individuals by the ingestion of the indigestible protein, gluten, present in wheat, rye and barley.
The point is that T1DM is due to an absolute lack of insulin so that its treatment requires the daily use of insulin in those with the condition. But we now appreciate that insulin treatment in those with T1DM (as in those with T2DM) is a double-edged sword. Because whilst it is life-saving in T1DM, like most medications, the (over)use of insulin produces one specific, long-term complication that is too little appreciated. That complication is the development of progressive IR. As a result, the patient with T1DM who (over)uses insulin, must, like the patient with T2DM who eats more than 25 grams of carbohydrate per day, develop progressively worsening IR requiring ever more insulin (in addition to other medications) until even maximal drug doses are no longer effective.
So the unfortunate truth is that insulin therapy and high carbohydrate diets in both T1 and T2DM, beget IR. And progressively worsening IR (with continuously elevated blood insulin concentrations (hyperinsulinaemia)) causes all the complications that ultimately prove fatal in both T1 and T2DM. Our ignorance of this inevitable consequence of insulin therapy and high carbohydrate diets – (or is it now our reluctance to acknowledge our ignorance?) – has caused us to become entrapped by a crippling, indeed devastating untruth. Which is that both forms of diabetes are progressive diseases that can only worsen with time and treatment, until we die of their inevitable complications. Our logic is this: On our current treatment, we are unable to prevent the development of complications in our diabetic patients. Since we are clever we cannot be prescribing the incorrect treatment. So it must be that the disease is the problem; that diabetes is a progressive disease that can only worsen with time (despite our best efforts and intentions).
But the exponential rise in the global prevalence of T2DM and its complications especially in the last 40 years tells us that this cannot be the truth. How does a disease that was rare 100 years ago become a pandemic in just a few generations? Certainly it cannot be because of some sudden genetic mutation in all humans in the very recent past. So it must have something to do with a recent change in our environment.
The clearest evidence is that T2DM is a modern disease that becomes epidemic in all populations within 20 years of their undergoing a major dietary change. A change from the foods those populations usually ate – often higher in fat and protein and lower in carbohydrates – to the modern industrial diet which is full of sugar, processed vegetable (seed) oils and refined carbohydrates, whilst low in critical nutrients. Indeed the rise in the global cases of T2DM neatly follows the growth in global sugar consumption since 1700 leading some to argue that it is sugar more than any other foodstuff that is driving the diabetes pandemic. Time will reveal whether or not sugar is solely to blame. Or whether sugar which is present in almost all processed foods, is simply a marker of this catastrophic change in human diet that was accelerated in 1977 by the promulgation and global promotion of the ill-conceived, hubristically-sounding and scientifically-unproven United States Department of Agriculture Dietary Goals (USDGA) for Americans.
Those guidelines warned that any fat in the diet will kill us so that to be healthy, we should “make starchy foods (especially cereals and grains) the basis of all meals”. So we took fat out of the diet and replaced it with carbohydrate, adding sugar in ever increasing amounts to give at least some semblance of taste to those now bland fatless foods. Too late we discovered that sugar is irresistible for most and addictive for some. The result was that in our addiction we began to eat too many calories, especially from carbohydrates, causing the epidemics of IR, hyperinsulinaemia, obesity and ultimately T2DM that have since engulfed the world.
Today more humans have T2DM than ever contracted the Black Death. And, if managed according to modern principles (including a high carbohydrate diet), most will die from the numerous complications of T2DM. The cost of this erroneous approach will be enough to bankrupt the medical services of most countries within 2 decades; the United Kingdom predicts this will happen by 2020; the United States by 2026. I suspect this will happen in South Africa well before 2026.
Faced with such a catastrophe, one would assume that the medical and governmental authorities around the world would already have declaring a war on diabetes. But you would be wrong. In my own province, the Western Cape of South Africa, diabetes is now the single greatest cause of mortality. Not TB, not HIV. Just plain old boring T2DM. And what has been done to reverse this catastrophe? Essentially nothing. Just more endless self-justifying talk about the difficulty of preventing such a complex disease.
And why is this? Simple. Unlike the Black Plague, the T2DM tsunami is of our own making. We caused it. We doctors, medical scientists and dietitians who promoted and continue to promote these failed 1977 dietary guidelines are the direct cause of the pandemic. And until we collectively accept our guilt and own up to our profound error, we will take our peoples further into the abyss. We cannot forever blame the patients for our continuing errors that have caused their unfortunate diseases. We have to be fearless. We have to take the burden of our guilt onto our own shoulders.
I finally realized my contribution to this catastrophe 5 years ago when I converted to the Low Carbohydrate High Fat (LCHF) eating plan, since known in South Africa as “Banting”. I publicly announced that for 33 years I had promoted the wrong high carbohydrate eating plan that was caused my own T2DM and which was busy wrecking our nation’s and the world’s health. The response of my colleagues was predictable. They wished to excommunicate me from the medical fold.
These then are the reasons why this book is so very, very important. It represents an intellectual breakthrough not just in South Africa but across the world. Its author Kath Megaw is trained in the conventions of nutrition and dietetics. She has been taught that T2DM is caused by a diet that is too high in fat. In her training she would have learned (as did I) that the complications of T2DM – the arterial disease that causes the peripheral gangrene, the heart attacks, the strokes, the kidney failure and the blindness – the hallmark complications of T2DM – are all due to diets that are too high in fat, too low in “healthy” carbohydrates. And so she would have been convinced, as was I, that all those with T2DM must avoid fat and eat plenty of carbohydrates to be healthy and long lived. But like me, she has now lived long enough to understand that this advice is quite simply wrong. And harmful. In fact it is the exact opposite of the truth.
So in the past 10 years, the realization came to the young Kath Megaw that there was something wrong with what she had learned. That encouraging her T2DM patients to eat more carbohydrates worsened their blood glucose control, increased their need to use progressively more medications, and expedite the onset of diabetic complications. The same advice increased the insulin requirements of her T1DM patients, worsened their blood glucose control (despite more insulin) and increased the frequency and severity of their hypoglycaemic attacks (caused by too much insulin). To a young practitioner with an open mind, the evidence was abundantly clear. Either she followed the dogma of her teachers and continued harming her patients, or she discovered another dietary solution. Like me she had to learn that allowing diabetics to eat more than a trace of carbohydrate progressively increases their IR, worsens their disease and hastens the onset of its most debilitating complications.
It takes great courage to turn your back on the dogmas you were taught by the “experts” and to strike out on your own path. For that path is and will always be, very, very lonely. Indeed we cannot predict what will be the effects of the publication of this book on Kath Megaw’s future career prospects. If she were Australian she would likely have lost her licence to continue practising as a registered dietitian and, due to subtle commercial pressures, her book might have gone unpublished. We can only hope that in time she will be recognized as the fearless pathfinder that she is.
For Kath Megaw knows that the greatest law to which she must answer is her own conscience. And in doing so she has thrown off the shackles of a disproven conventional teaching and has introduced us to the future – a future in which the plague of T2DM will be brought under control; a future in which all patients with diabetes can stride confidently into the future, knowing that by following the dietary rules she explains, they need no longer fear that their disease will progressively worsen.
In our hands we diabetics now finally hold the crucial key to our long-term good health and survival. We no longer need to fear our diabetes; just like we no longer need to fear The Plague.
Let us salute its author for giving us that freedom.