In the December 2019 issue of The Greyton Mail a letter was published where Prof Noakes was referenced. Below you will find Prof Noakes’ written response to this letter. You can view and read the original letter from The Greyton Mail here. 

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To the Editor,

Greyton’s well-renowned vegan activist Mr Rohan Millson unexpectedly informed me that he had recently published a letter in the December 2019 issue of The Greyton Mail (pages 1-2). He suggested that, since I was mentioned in his letter, I might care to respond.

For the record, this is not the first (nor the last) such article Mr Millson has, or will, write that demeans me and my professional opinions. I generally resist any urge to respond. I’ve learned over the years to avoid responding to articles that include vulgar taunts like “Low-Carb Bullshit Artists like diabetic Tim Noakes”. Or: “As with much else Noakes says and writes, this is almost certainly false”. Or: “That’s a lot of sick and dead people on Noakes’s conscience… if he has one”. So I will keep my response as brief, as restrained and as courteous as possible.

In this response I’ll restrict myself to addressing Mr Millson’s statements that: “The biochemistry of diabetes at the cellular level explains why – at the population level – those of us who eat the most carbohydrates, from whole plant sources (and the fewest animals, and the least junk) experience far less insulin resistance and diabetes than those who eat the fewest plants and the most animals”.

Unlike Mr Millson I invest substantial amounts of my personal money and expend significant time and effort raising funding via The Noakes Foundation in order to research the effects of low carbohydrate, largely animal-based diets, on human health. Because I am not, as Mr Millson subtly implies, a psychopath – I do have a conscience and have been known, on occasion, to show remorse – I also put my money where my mouth is. I want to be certain that what I promote to the general public is the best possible information.

One of our funded studies has recently been published (1). It reports our analysis of the experiences and diets of 28 local South Africans, formerly with type 2 diabetes mellitus (T2DM), who had personally chosen to follow the low-carbohydrate high fat (LCHF)/Banting diet despite resistance from doctors and dietitians, whose opinions about the LCHF/Banting diet are probably not much different from those of Mr Millson. Many adopted the diet after reading our book, The Real Meal Revolution (2) and began to follow the eating plans described in that book.

We first confirmed with their health care providers that the diagnosis of T2DM was water-tight before subjecting 28 subjects to detailed interrogation and investigation over a 15-month period.  We also ensured that the subject had adhered rigorously to the LCHF/Banting guidelines (as described in The Real Meal Revolution). For the purposes of this letter, it’s important to point out that the Real Meal Revolution diet is based around animal produce. It is about as far from the vegan diet as it is possible to eat.

The complete conclusions from the study were the following. To ensure full transparency I have taken these quotations directly from the text of the published article that was rigorously peer-reviewed before publication:

“This observational study documented 28 T2D patients who reported following a self-administered LCHF diet that was rich in full-fat dairy, fatty meats, coconut oil, non-starchy vegetables, nuts, eggs, olives, olive oil, and avocados. While following their LCHF diets, HbA1c, body weight, and T2D medication requirements were dramatically reduced, with the majority of participants having achieved complete or partial T2D remission. Participants perceived reduced hunger and cravings as one of the most important aspects of their diets. Of concern, many participants felt unsupported by their doctors which may have resulted in suboptimal medical supervision. This study described the characteristics and nuances of an LCHF ‘lifestyle’ that was sustainable and effective for certain T2D patients in a real-world setting” (Reference 1, page 2580).

Importantly, here are findings that may be of special interest to readers of The Greyton Mail. 

1.   Weight loss.

“All 28 participants reported weight loss from Start-LCHF to First-Assessment and median weight loss as a percentage of weight at Start-LCHF was 17 (7–25) %. At Follow-Up, there were 10 participants who had sustained weight losses of more than 25 kg for 3.5 ± 1.3 years, including 4 participants who had lost over 50 kg” (page 2574).

2.   Reversal of Type 2 diabetes mellitus.

“Of the 24 participants tested at Follow-Up: 7 were in complete T2D remission (HbA1c < 5.7% and no T2D medications at First Assessment and Follow-Up); 3 were in potential complete remission (they met the definition of complete remission at Follow-Up but partial remission at First-Assessment); and 7 were in partial remission (HbA1c < 6.5% and taking no T2D medications other than metformin at First-Assessment and Follow- Up). Seven participants were not in remission as they were taking glucose lowering medications in addition to metformin and/or had HbA1c greater than 6.5% at Follow-Up” (page 2574).

My summary:

So choosing to follow this diet that Mr Millson asserts promotes T2DM, these subjects lost enormous amounts of body fat – some up to 50kg; they lost their hunger and their food cravings and the majority “reversed” the dreaded condition, T2DM, that is considered by my profession to be a progressive, irreversible condition with a uniformly fatal outcome.

They achieved all of this without support from medical or other professionals. And more usually despite warning from lay experts like Mr Millson that this diet choice is either ineffective or is frankly dangerous, perhaps fatal.

Of the 24 subjects who were followed for 15 months, 7 (29%) were in complete T2DM remission so that they no longer need any medications, especially insulin, to maintain normal blood glucose concentrations. Another 10 (42%) were in partial remission in that they still require to use some medication (other than insulin) to maintain normal blood glucose levels. So 71% of T2DM subjects were able to normalize their blood glucose levels just by following this supposedly harmful diet. It is a reasonable assumption that most if not all of these subjects in complete or partial remission will be spared the usual catastrophic complications (kidney failure; blindness; heart attack; stroke; lower limb amputations) that afflict persons with T2DM who choose to follow conventional medical treatments.

To my knowledge, there are few if any reports in the medical literature of remission of T2DM with conventional medical care that includes a high-carbohydrate low-fat “heart-healthy, balanced, prudent diet in moderation”. Or in anyone eating the vegan or “plant-based” diet, as I will reveal shortly.

Importantly, and unfortunately, Mr Millson’s understanding of the biology of T2DM is simplistic and quite wrong. He believes that eating a high fat diet fills our muscles with fat, worsening insulin resistance so that “people like Noakes who eat huge amounts of animal fats tend to have the diabetes persist (wrong again – my T2DM is in documented remission exactly because I eat more fat and virtually no carbohydrate – my addition)… because they’re filling their (muscle) cells with fat at each meal, thus preventing the insulin from working well”.  

In fact, as taught in Biochemistry 101, ingested dietary fat goes directly to the body fat stores, not to the muscles, or internal organs like the liver or the pancreas. From the body fat stores, fat is released as when required particularly for the provision of energy.

In contrast excess ingested carbohydrate, as might happen on the high-carbohydrate vegan diet that Mr Millson promotes, initiates a large insulin response. This insulin then directs the liver to produce triglyceride (fat) from the excess ingested carbohydrate. The newly produced fat (a process known as de novo lipogenesis) then accumulates in the liver and pancreas, causing the condition of non-alcoholic fatty liver disease (NAFLD) and fatty pancreas. Crucially, it is the accumulated fat in the liver and pancreas, NOT in the muscles, that is most clearly linked to the onset of T2DM (3). Also the extent to which de novo lipogenesis occurs is a function of the individual’s level of insulin resistance.

Thus the prediction has to be that, in susceptible individuals with more advanced insulin resistance, a high carbohydrate vegan-type diet would be much more likely to produce NAFLD and fat accumulation in the pancreas leading to T2DM than would the LCHF/Banting diet which severely restricts dietary carbohydrate.

Other studies that confirm the value of the LCHF/Banting diet for the management of T2DM.

An important requirement for science is that findings like ours need to be confirmed before they are more generally accepted. Fortunately, a number of studies have recently been published which show that the only intervention that can effectively put T2DM into remission is one that severely restricts dietary carbohydrate by promoting the LCHF/Banting type diets usually, but not always, based on the consumption of animal produce.

For example the Virta Health company in San Francisco, California is currently conducting a 5-year clinical trial of the LCHF/Banting diet in the management of T2DM in 262 adults. So far they have reported the results of the first two years of the trial (4,5). The results have been nothing short of astonishing.  

At the end of the first year, insulin therapy, the (very expensive) backbone of conventional T2DM medical treatment, was reduced or eliminated in 94% of subjects; overall the use of diabetes medications dropped by 48%. Remarkably despite this large reduction in medication use, 60% of participants “reversed” their T2DM – an unprecedented finding.

The results continue to be spectacular at the end of the second year (5). T2DM “reversal” rate was 54% with a further 18% in remission.

Another small, recently published study (6) found that 11 obese females aged 18-45 years with T2DM were able to “reverse” their T2DM within 90 days of beginning an LCHF/Banting diet that restricted carbohydrate intake to less than 30 g/day. The authors concluded: “These findings indicate that a short-term intervention emphasizing protein and fat at the expense of dietary carbohydrate functionally reversed the diabetes diagnosis, as defined by HbA1c. Furthermore, the intervention lowered body weight and blood pressure, while eliciting favorable changes in blood lipids” (6, p.1).

Another recent study (7) compared the effects of a 12 month very low-carbohydrate ketogenic (LCK) diet versus a moderate-carbohydrate, calorie-restricted, low-fat (MCCR) diet in 34 adults with T2DM or with pre-diabetes. The LCK diet provided 20-50g/day of carbohydrate whereas 45-50% of the daily calories in the MCCR diet were derived from carbohydrate. The LCK was also low in fat and subjects were encouraged to “eat 500 fewer kilocalories (kcal) per day than their calculated maintenance needs to reduce weight”.  At the end of the trial persons in both groups were ingested very similar amounts of total energy daily but persons in the LCH group were eating more fat (105 vs 75 g/day) and less carbohydrate (74 vs 150 g/day). These differences might reflect the sort of differences to be expected between either an LCHF/Banting or a vegan diet.

The conclusions from the study were the following: “In a 12-month trial, adults with elevated HbA1c and body weight assigned to an LCK diet had greater reductions in HbA1c, lost more weight, and reduced more medications than those instructed to follow an MCCR diet” (7, p.1).

Thus adults with T2DM or prediabetes fared better – losing more weight and improving their blood glucose control – when they ate more fat and less carbohydrate. This again is the opposite of Mr Millson’s prediction (based on his erroneous understanding of basic human biochemistry).

It appears that these benefits are not restricted solely to the management of T2DM. Another recent study (8) found in children with type 1 diabetes (T1DM): “Exceptional glycemic (blood glucose – my addition) control of T1DM with low rates of adverse events was reported by a community of children and adults who consume a very low carbohydrate diet (VLCD). The generalizability of these findings requires further studies, including high-quality randomized controlled trials”.

So there are more than enough studies to show that the LCHF/Banting diet is the ONLY diet that has been shown consistently to put T2DM into remission in those who are prepared to restrict their carbohydrate intakes to ~25-50 grams of carbohydrate/day.

Is there published, peer-reviewed scientific evidence that a strict vegan diet can also put T2DM into remission?

So what of the vegan diet? Is there any scientific evidence that persons with T2DM can place their T2DM into remission if they follow a vegan diet?

Recall Mr Millson’s definitive assertion that: “It’s routine for people who adopt a whole-plants-only diet to reverse even the most long-standing type II diabetes in less than a month. (Consult a competent, nutrition-savvy doctor, because you will have to decrease your meds!)”. 

But are Mr Millson’s hubristic claims supported by appropriate evidence from carefully conducted clinical trials?

Fortunately there is one such study in the scientific literature. The study (9) reported in 2008 “compared the effects of a low-fat vegan diet and conventional diabetes diet recommendations on glycemia, weight, and plasma lipids” in two group of 50 individuals with T2DM.

At the end of the trial there was no difference in blood glucose control in either groups. Importantly diabetes control in both groups was no better at the end of the trial than at the start. “Reversal” or “remission” of T2DM did not occur in either group.

Thus neither the standard best-practice management of T2DM nor the vegan diet improved the state of T2DM in these subjects.

So why does a high-carbohydrate vegan diet have no role in the management of T2DM?

T2DM is, quite simply, a state of carbohydrate intolerance – an acquired inability to safely metabolise ingested carbohydrate.

A vegan diet, as Mr Millson acknowledges, is a high carbohydrate diet.

It seems entirely illogical to believe that a condition of carbohydrate intolerance is best treated by a diet that provides a high carbohydrate intake as does a vegan diet.

We do not treat patients with lactose or gluten intolerance or peanut allergies by exposing them to high intakes of lactose, gluten or peanuts respectively. Instead we remove the foods that contain those damaging chemicals from the diet.

So why should it be different in T2DM, a condition of carbohydrate intolerance?

Such advice simply does not make any logical sense.

Final words.

Mr Millson concludes his article with the statement that: “All that’s necessary for the triumph of evil is that good people should do nothing.”

That is the sole reason why I have chosen to write this response.

Yours Faithfully,

Timothy Noakes

Professor Timothy Noakes OMS, MBChB, MD, DSc, PhD (hc), FACSM, (hc) FFSEM (UK), (hc) FFSEM (Ire). Emeritus Professor.

 

References:

1.   Webster CC, Murphy TE, Larmuth KM, et al. Diet, diabetes status, and personal experiences of individuals with type 2 diabetes who self-selected and followed a low carbohydrate high fat diet. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 2019:12 2567–2582.
2.   Noakes TD, Proudfoot J, Creed S-A, Greer, D. The Real Meal Revolution. Quivertree Publications; Cape Town. 2013.
3.   Taylor R. Banting Memorial Lecture 2012. Reversing the twin cycles of Type 2 diabetes. Diabet Med 2012;30:267-275.
4.   McKenzie AL, Hallberg SJ, Creighton BC, et al. A novel intervention including individualized nutritional recommendations reduces hemoglobin A1c level, medication use, and weight in type 2 diabetes. JMIR Diabetes 2017;2(1):e5
5.   Athinarayanan SJ, Adams RN, Hallberg SJ, et al. Long-term effects of a novel continuous remote care intervention including nutritional ketosis for the management of type 2 diabetes: a 2-year non-randomized clinical trial. Front Endocrinol 10:348. doi:10.3389/fendo.2019.00348
6.   Walton CM, Perry K, Hart RH, Berry SL, Bikman BT. Improvement in glycemic and lipid profiles in type 2 diabetes with a 90-day ketogenic diet. J Diabetes Res 2019:8681959.
7.   Saslow LR, Daubenmier JJ, Moskowitz JT, et al. Twelve-month outcomes of a randomized trial of a moderate-carbohydrate versus very low-carbohydrate diet in overweight adults with type 2 diabetes mellitus or prediabetes. Nutrition and Diabetes 2017;7:304 DOI 10.1038/s41387-017-0006-9  
8.   Lennerz BS, Barton A, Bernstein RK, et al. Management of Type 1 Diabetes With a Very Low–Carbohydrate Diet. Pediatrics 2018;141:e20173349
9.   Barnard ND, Cohen J, Jenkins DA, et al. A low-fat vegan diet and a conventional diabetes diet in the treatment of type 2 diabetes: a randomized, controlled, 74-wk clinical trial. Am J Clin Nutr 2009;89(suppl):1588S–96S.