PHC Conference 2018

Dr Peter Brukner, former team doctor for the Australian cricket team, and Dr Karim Khan, editor of the British Journal of Sports Medicine, were stood next to me in the front row on Day 2 of the Public Health Collaboration (PHC) conference and both said that they had never seen anything like this, ever, at any conference they had attended. Professor Tim Noakes was the keynote speaker and he received a standing ovation just walking onto the stage. After an hour of captivating science and story – detailing how his own views had changed over decades of research and how his current views have ended up with him being on trial in South Africa – the audience rose as one and would not sit down. For several minutes, the Prof (as he is affectionately known), stood still – looking overwhelmed, humbled and rightly emotional as 250 people wouldn’t stop clapping. A number of us, who have been a part of Tim’s incredible journey, stepped up to hug him and still the cheering didn’t stop. Tim’s final slide had been a picture of Liverpool – his football team and the birthplace of his parents – and “You’ll never walk alone” was almost drowned out by the clapping, but we could hear just enough to join in the final chorus as one. There wasn’t a dry eye in the house. I’ve never seen so many grown men wipe their eyes and some people were openly sobbing.

To understand why this happened, you need to know Tim and his complete and utter integrity to science. You need to have witnessed him explaining how, for many, many years, the truth was staring him in the face, but he missed it because his conventional beliefs were too firmly held. You need to have gasped when Tim shared emails (acquired under the Freedom of Information act) between the dietician who reported him to the Health Professions Council of South Africa (the body that prosecuted him) and a board member of the HPCSA before the famous tweet was even posted (Ref 1). You need to have realised what this contrived and malicious trial has done to Tim and his wife – a couple for whom there is nothing more important than loyalty, decency and fairness – all of the values which have been so lacking from the other side in this sordid affair. You need to know just what a lovely, kind, warm man the Prof is and how he will never understand how people can be cruel to each other – let alone former colleagues to him. Peter and Karim were right – we will probably never see such a response to a presentation ever again. It was a privilege to be there.

Tim followed Dr Aseem Malhotra who had done a brilliant job with the Day 2 opening address. Aseem shared his own journey of realising that the little he had been taught about nutrition was wrong and how he stumbled across the truth and what he did next. He was very kind to credit me for playing a part in his journey – his father had advised him to read my obesity book and I remember Aseem calling me out of the blue in March 2012 and we have been friends ever since. Little did I know then that he would lead the charge to become the primary change agent in the UK challenging sugar and statins, defending fat and pointing out that “we can’t outrun a bad diet.” Aseem’s talk, like Tim’s, was an intriguing mix of factual and personal insights, as he shared some of his own repercussions of having questioned the status quo. Aseem also received a spontaneous standing ovation. Much of the audience reaction to such pioneers may well be because they too, as health care professionals, have had their share of push-back when they have rejected the industry-designed eatbadly plate and the culture of mass-medication. It’s shocking that support for real food/few drugs elicits such anger, but it does.

Dr Peter Brukner had also done a brilliant opening to Day 1 of the conference. My favourite one liner of the two days was “So UK – the bad news is that you’re the fattest in Europe – the good news is – you’re leaving Europe!” We had a lot of laughs over the weekend and heard a lot of evidence and saw a lot of results from doctors who shared what was happening with their patients when they ditched the advice “base your meals on starchy foods” to shun starchy foods and prioritise nutrient dense: meat; fish; eggs; dairy and green things. Some of the graphs were striking.

Judging from the audience reaction, many were real food/managed carb converts already, but the conference is growing in size each year, so more people are becoming more aware and this can only continue. There was a strong focus on diabetes with Dr David Unwin, Dr David Cavan and Dr Trudi Deakin all presenting on type 2 and Dr Ian Lake presenting on type 1, the condition that he has himself. There was also more on exercise this year with Dr Zoe Williams, from “Trust me I’m a doctor”, talking about the value of movement and a double act from Dr Simon Tobin & Tom Williams talking about Parkrun. That’s not even all the presentations listed – just a flavour of what you can look forward to when these presentations go on line (as they will).

My presentation

I’ll spend the rest of this note sharing the key points I tried to make in my presentation. It was quite a challenge to try to cover topics from thermodynamics to the F-plan diet in 40 minutes. The presentation was called “Kettles, Calories & Energy Balance: What went wrong?”

The story went like this:


We think that weight loss is about “eat less/do more” and this is wrong.

Q) Why do we say ”eat less do more?”
A) Because we think that there is a general principle that says “energy in = energy out” (i.e. calories in = calories out) and because we think that there is a specific formula that says “To lose 1lb of fat you need to create a deficit of 3,500 calories.”

Q) Why do we think that there is a general principle that says “energy in = energy out”?
A) Because we think that there is a Law of Thermodynamics that says so. But this is not correct…

There are four laws of thermodynamics, not one. Two are relevant to the human body, not one. These two are about conservation of energy and a concept called entropy. Kettles are the best way I know to explain thermodynamics. We turn the kettle on and the element heats and that warmth heats the water (thermodynamics means movement of heat). In a perfect system, only the water would heat, but the kettle itself get hot too and heat is lost out of the spout (and this gets more and more frantic – entropy – as the kettle boils). Law 1 says that energy will be conserved in a closed system. Law 2 takes many things into account – one of which is the fact that kettles are not closed systems (nor are humans) and so energy will be lost and energy will be used up in heating the water. There is no law that says “energy in = energy out.” Given that calories are the unit of energy for what we eat, there is no law that says “calories in = calories out.” You will see the claim that “calories in = calories out” online and in publications worldwide – it is abbreviated to CICO on the internet. It’s false.

The other vital thing to know about the laws of thermodynamics is that they say nothing about weight. They are about energy. They are about the movement of heat. They are not about weight. We invented the weight conversion and we got it wrong…


I have taken the calorie theory apart many times. An open post on the subject can be seen here (Ref 2). One pound does not even equal 3,500 calories. We will not lose 1lb if we create a deficit of 3,500 calories. We will not gain 1lb if we create a surplus of 3,500 calories. We have known this for at least 100 years (since the Benedict study). I headlined a few other studies throughout the history of weight loss literature to show that the formula has never held and never will (Ref 3). If anyone claims this to be true, simply ask them for one study that proves it.

Energy Balance

The CICO brigade (pronounced psycho!) start with “energy in = energy out” (which is incorrect) and then they leap to the claims that, if energy in is greater than energy out, we will gain weight and if energy in is less than energy out, we will lose weight. This is so wrong, on so many levels, it was difficult to know where to start.

1) Can you see how the CICOs have leapt from energy to weight? Despite the fact that the laws of thermodynamics say nothing about weight?

2) This claim assumes that the body is incapable of adjustment. The exact opposite is true – not only can the body adjust, it does. There are nine systems in the human body (Nervous, Skeletal, Endocrine, Reproductive, Digestive, Circulatory, Lymphatic, Urinary, Respiratory) any of which can and do adjust. Think of an anorexic woman – the reproductive system has long since been turned off; the circulatory system has slowed to a minimum, as has the respiratory system. The ‘heating’ is turned to its lowest setting – the skeletal woman is constantly cold and fine hair grows all over the body to try to keep warm. The body can and does adjust.

The CICO lot – who believe the general principle and the specific formula – think that, if we eat 500 fewer calories and expend 200 more in the gym, the body will give up 0.2lb (700/3,500) of fat as if it were a cash machine. This is so stupid; it is difficult to think of anything more stupid! The body can and does adjust.

Total Energy Expenditure

I then went through the component parts of Total Energy Expenditure (TEE). These are: the Basal Metabolic Rate (BMR); our Physical Activity Level (PAL); the Thermic Effect of Feeding (TEF) and something called Non-Exercise Activity Thermogenesis (NEAT) (the latter I didn’t dwell on, as it seems to be a creation from CICOs to try to keep the calorie theory alive).

– Basal Metabolic Rate (BMR), for most people, is approximately 45-70% of our total energy expenditure. We can think of BMR as the energy (calorie) intake we need even if we are lying ill in bed all day. It’s what the body needs to repair, build, fight infection, run the body processes etc. There are two really interesting things about the BMR:

i) We know by how much the calorie requirement drops when people go on a calorie deficit diet. A study from 1919 found that a 10% drop in weight was met with a 37% drop in energy requirement. If the participants ate more than two thirds of what they had been eating before the diet, they would gain weight. 100 years later, the DiRECT ‘reversing type 2 diabetes with a very low calorie diet’ recommended that participants would need to sustain one third fewer calories than they had been eating before the diet to avoid regain an sustain remission (Ref 4). This was what I called “the small print” of calorie controlled diets – everyone should be warned about this before they start any low calorie plan.

ii) Carbohydrates can only be used by the body for energy. A significant part of the BMR – growth, development and maintenance and running certain body processes – can only be fuelled with protein and fat. Calories are not equal. Carbs had better be used up for energy, or they will be stored as fat. Fat and protein have far more options in terms of being utilised by the body.

– Physical Activity Level (PAL) – given that BMR is such a large part of total energy expenditure, it can’t be surprising that physical activity requires far fewer calories than we might expect. This is the “you can’t outrun a bad diet” concept in practice. In this part of the presentation, I spoke about a concept I realised back in 2010 (I blogged about it here) (Ref 5) – we can’t use a “calories burned” calculator to claim that we have walked fast for 30 minutes and thus burned 164 calories (as an example). We need to deduct what we would have been doing anyway, otherwise we will double count our BMR! If the same person had been reading for 30 minutes, they would have burned 34 calories, so the fast walking has, in fact, only used up 130 calories extra. If the person would have been gardening instead of fast walking, they might have been better off not doing the fast walk.

– Thermic Effect of Feeding (TEF) – this alone negates the claim that a calorie is a calorie. The work of Tappy (1996) (Ref 6) set out the thermic effect of feeding – energy used up in making available energy (to use Law 2’s terminology). This was shown to be 0-3% for fat; 5-10% for carbohydrate and 20-30% for protein. Consume 100 calories of olive oil and almost all of them will be available to the body. Consume 100 calories of protein (egg whites come close) and approximately 75 will be available to the body. A calorie is not a calorie the minute it enters a human being.

I talked a bit about the type of energy going into the body. We can’t metabolise trans fats (so that’s energy in that doesn’t come out) – are we any better at handling vegetable oils? What about sucrose? Is that even a food? Alcohol is fascinating – it has approximately 7 calories per gram. If we consumed 500g of alcohol (about 50 small glasses of wine) would we a) gain 1lb of fat (7 x 500 = 3,500 calories) or b) die?! The body can’t store alcohol, so how can its calories make us fat? Where does the energy from alcohol go? Are we missing something in the total energy expenditure equation? Something hormonal? How else can we explain the weight loss from sudden type 1 diabetes, or the weight gain from PCOS or underactive thyroid?

I questioned if it is even possible to eat less and/or do more – notwithstanding that the body will just adjust if we can manage this. If we try to eat less, we get hungry. If we try to do more, we get hungry. If we eat less, we have less energy and so we do less. If we do more, we have less energy and so we do less. Not only does the body adjust to a calorie deficit, it will do everything it can to ensure that we don’t have a calorie deficit in the first place.

What does work?

The saying “eat less/do more” sounds so simple, it’s just a shame that it doesn’t work. There is an equally simple little phrase, which has the benefit of being right. Weight is not about eating less and/or doing more. Weight is about Storing fat and Un-Storing fat.

To lose weight, we need to stop Storing fat and start Un-Storing fat. To stop storing fat, we need to switch off insulin. To start Un-Storing fat, we need to enable glucagon. (Explanations for the roles of insulin and glucagon are in Ref 7). Note – we cannot switch glucagon on – we cannot force the breakdown of body fat (not easily anyway) – but we can create the right environment whereby glucagon is able to do its work.

The three most important ways to switch off insulin are i) Stop grazing: constant eating will keep insulin active and will keep us in an energy/fat storing mode. ii) Manage carb intake: every time we eat anything with a carb content (or a protein content to a lesser extent), we activate insulin. iii) Use the right fuel: I shared a photo with the ingredients in a Weight Watchers chocolate brownie and asked what on earth the body’s response to such a chemical cocktail would likely be (Ref 8).

ONLY once insulin has been switched off is it even possible for glucagon to break down body fat (which is what weight loss actually is). Once insulin has been switched off, the two most important ways to encourage/enable glucagon are i) Limit alcohol: the calories in alcohol don’t count, but alcohol impairs the operation of glucagon and can thus impair the breakdown of body fat. ii) Move: being active in some way signals a requirement for fuel and requires energy to be put back into the blood stream. The first energy to be used up will be any glucose stored. Once this is running low, the body will turn to fat. The lower the carb intake, the sooner the body will need to look for fat to breakdown to fuel activity.

If our mindset could be driven by thoughts of fat stored and fat un-stored, our corresponding behaviours would be far healthier and far more likely to drive weight loss. Conversely, eat less/do more leads to some really unhealthy behaviours and it doesn’t get the desired outcome.

It seems so obvious, but then Tim shared with us how obvious things should have been to him during many years of research. Tim was working in the area of optimal athletic performance and the elephant staring him in the face was that an elite athlete will have (approximately) a maximum of 1,500 calories of fuel stored as carbohydrate and a minimum of 50,000 calories of fuel stored as body fat. The obvious solution is to train an athlete to fuel on fat, but Tim couldn’t see this for years due to his limiting, conventional, beliefs.

Every speaker and attendee at the conference once held conventional beliefs. None of us were born or taught to believe what we now think. Once beliefs are seen to have no evidence base, they crumble astonishingly quickly. The tragedy is that the proponents of conventional beliefs rarely have the humility and honesty to admit that they were once wrong. That’s why Tim got a standing ovation and that’s why the audience stayed standing for a very long time.


Ref 1: January 2014 (Before the tweet). From Claire Julsing Strydom ASDA president (Association for Dietetics in South Africa) to Professor Wentzel-Viljoen (ADSA representative on the HPCSA board).
Subject:”Tim Noakes impact on the dietetics profession.”
Content included: “Here are other examples of what other people are writing about dieticians due to the negative attention we are getting from Tim Noakes…”
March 2014 (The month following the tweet) again from Julsing Strydom Wentzel-Viljoen.
Subject: “Tim Noakes and slating the RD profession.”
Content included: “Just would like to follow up on the Tim Noakes problem – the bashing of the profession continues and we need intervention from the HPCSA as a matter of urgency.”
Ref 2:
Ref 3: References from the presentation are here:
Ref 4:
Ref 5:
Ref 6: Tappy L. Thermic effect of food and sympathetic nervous system activity in humans. Reprod. Nutr. Dev. 1996.
Ref 7: Insulin is the hormone secreted by the pancreas which has a number of functions but primarily it removes excess glucose from the blood stream (by turning it into glycogen) and it facilitates the storage of energy (glycogen in the muscles and liver) and fat in fat cells. Think of glucagon as the ‘equal and opposite’ hormone to insulin. Glucagon’s jobs include putting glucose back into the blood stream – from glycogen or body fat. Glucagon and insulin are not ‘in play’ at the same time – the body is either in energy storage mode, or energy breakdown mode – this is critical for weight loss.
Ref 8: Water, sugar, glucose fructose syrup, skimmed milk powder, wheat flour, glucose powder, cocoa powder (2%), fructose syrup, milk chocolate (1.5%, sugar, cocoa butter, whole milk powder, cocoa mass, emulsifier – soya lecithin, natural flavouring), whey powder, inulin, chocolate (1%, cocoa mass, sugar, cocoa butter, emulsifier – soya lecithin, natural flavouring), vegetable oil, white chocolate (1%, sugar, cocoa butter, whole milk powder, whey powder, milk sugar, emulsifier – soya lecithin, natural flavouring), chocolate (1%, cocoa mass, sugar, cocoa butter, butter oil, emulsifier – soya lecithin, natural flavouring), dextrose, chocolate (1%, cocoa mass, sugar, cocoa butter, fat reduced cocoa powder, emulsifier – soya lecithin), stabilisers – pork gelatine, locust bean gum, guar gum, sodium alginate, carrageenan, xanthan gum, sorbitol syrup, egg powder, modified potato starch, barley starch, egg albumen, gelling agent pectin, natural flavourings.

10 thoughts on “PHC Conference 2018

  • Thank you so much for your insight and explanations. Is your presentation available online as a video? I would appreciate the opportunity to watch it in full and to promote it to others on various type 2 diabetes forums.

    • Hi Alan
      We understand that the presentations will be available some time – openly – just not sure when. If you follow me or @SamFeltham on twitter or any other people who presented, we’ll likely tweet when we see them out there.
      Best wishes – Zoe

  • Thanks Zoe,

    I found your article explained the processes really well as you have to relate to a wide audience some of who have a basic scientific understanding.

    I have jotted a few points down as I want to be able to recall the info. It’s great to have a clearer understanding of how these processes work in relation to weight loss/gain.

    Looking forward to seeing the conference online.

    Best wishes,


  • Hi Zoe,

    I think your kettle analogy for explaining the thermodynamics aspects may confuse some readers, so the following may help (I have to teach thermodynamics to undergraduate engineers).

    Thermodynamics is really describing how energy is converted from one form into another, traditionally: thermal energy (“thermo”) into mechanical motion (“dynamics”). The 1st Law of Thermodynamics is effectively stating that all energy, no matter what form it comes in, must be conserved, so the total energy going in to a thermodynamic system either comes out or stays inside.

    Thermodynamic systems may be classified as an open system (in which case, both mass and energy can enter, leave, or stay inside) or a closed system (in which case, there is no mass entering or leaving the system, only energy, which can also be stored inside the system). However, both both types of system ALWAYS obey the 1st Law – if a system appears to be contradicting this, then there’s either an energy input, output, or storage process or a mass input, output, or storage process that’s either been missed, or is assumed to be something it’s not. Any system (presumably, even a human body) that breaks the 1st Law of Thermodynamics is known as a perpetual motion machine, which can create energy from nothing, and various people over the last couple of centuries have deluded themselves that they‘ve invented one. It still happens, on occasion! Human beings are not perpetual motion machines – we need to eat.

    So, a human body is clearly an open system as there’s mass and energy going in and out, but it still obeys the 1st Law of Thermodynamics – it has to. Hence, to be more precise, the 1st Law must take into account all the mass coming in and the energy contained in it, all the mass coming out and the energy contained in that, any other energy transfers into and out of the body, and any net change of stored mass and energy within the body. This is the basis of the calories in equals calories out (CICO) argument; if the amount of energy going in (how much you eat) equals the amount of energy going out (how much you exercise), then the amount of energy in the body (i.e. your body mass) will stay the same. This sounds very plausible, but it is an oversimplification. It is assuming that there is no net change in energy within the body (either energy storage or depletion), and that the system is in what’s known in thermodynamic terminology as “steady state”. But it’s not that simple.

    This is because of the 2nd Law of Thermodynamics. This Law effectively states that it is impossible to convert energy from one form into another with 100% efficiency. However, the energy not converted is still somewhere (it has to be, according to the 1st Law), it’s just in a form that can’t be used, unless some other thermodynamic process converts it back into a more usable form of energy (and this process is also not 100% efficient). This “unusable” energy is known as entropy, and it’s been confusing many engineers and scientists since Rudolf Clausius figured it out in the 1850’s. Eating food and converting it into an energy form that’s more useful to the body is a process that must still obey the 1st and 2nd Laws of Thermodynamics.

    The CICO version of the 1st Law assumes that it’s relatively easy to determine the calorific energy going in (what you eat) and the calorific energy going out (how much exercise you do) but it seems to be ignoring the fact that it’s very difficult to determine precisely what’s going on inside the system, in terms of energy usage, energy storage, and the energy conversion efficiency of the different processes occurring within the system.

    So, as we so often see, even if a group of people have exactly the same calorific input (e.g. an isocalorific diet) and calorific output (e.g. the same exercise regime), it does not mean that all will maintain their current weight, as it will depend on how efficiently each individual converts their energy input into their energy output (2nd Law), and how much energy is required for their own individual homeostasis or converted and stored as body mass (1st Law). There are different amounts of energy in 1 g of muscle protein and 1 g of fat, and presumably the efficiency of the biochemical process of producing each of these is different too.

    Those individuals who convert their food input more efficiently into a more usable form of energy within the body will likely gain weight, as there will be more unused energy available for subsequent storage as body mass, FROM THE SAME CALORIFIC INPUT FROM THEIR FOOD, compared to those who convert this food input energy less efficiently. Similarly, those who convert the energy available in the body more efficiently into a calorific output via exercise will also likely gain weight, as there will then be more unused energy available for storage as body mass.

    Basically, the thermodynamics is correct, but people tend to get confused because I don’t think anyone’s really looked at the thermodynamics going on INSIDE the system.

    Best wishes,


    • Thanks @lowcarb_zealot that was a really good explanation. Given that information it strikes me that the countless studies and wads of money thrown at calories cannot ever hope to arrive at population level conclusions or consistent results due to the variability of the input energy (eg if two people ate a 100g steak each they are likely not getting exactly the same energy in) and the variability of the energy efficiency in the body.

  • Hi Zoe it’s good to hear that there was a lot of joy at the PHC conference.

    I do have a few comments/questions in relation to your article this week and also to add to Shaun’s comment.

    1. I am totally on board with the information you presented on CICO. We are not a closed system. In addition to energy losses via the TEF there are also energy losses due to ‘futile’ or substrate cycling that wastes a certain amount of ATP. This energy loss is primarily as heat. I too don’t get hour calories relate to weight. As I mentioned in a previous comment when you eat or drink, at that moment your weight increases by the weight of the food…not by the calories contained therein. Any weight lost from the body is primarily by CO2/water vapour exhalation, sweat, urine, faeces. If anything the law of conservation of matter applies. Unless what you ate comes out of the body via one of the above mechanisms, it adds to your weight.

    2. Under your ii) in the Total Energy Expenditure you claim that carbohydrates can only be used by the body for energy. This is not correct unless I am misunderstanding. Carbohydrates are used in the pentose phosphate pathway and also to produce glycoproteins. And carbs will only be stored as fat once glycogen stores are full.

    3. With respect to alcohol – there are 3 mechanisms for processing at the body’s disposal – the main one being conversion to acetate via acetaldehyde. The liver does indeed make metabolising ethanol a priority and it requires NAD+. The altered balance of NAD+/NADH inhibits gluconeogenesis and that is why chronic alcohol consumption leads to hypoglycaemia. Further, acetate can be broken down into Acetyl-CoA which can be used to synthesise fatty acids or feed into the Citric Acid cycle.

    4. I agree that ‘calories burned’ in exercise should be that over the BMR to avoid double counting. Weight loss during exercise is via water (sweat and breath) and CO2. Most people drink water following exercise so the water weight comes back. The CO2 weight doesn’t. So, the harder you work the harder you breathe and the more CO2 weight you lose via respiration. Agree it’s probably nothing to write home about but the effect is there,

    5. I would guess weight loss from T1 Diabetes is via glucose and/or ketones spilling into the urine and more frequent urination. In the case of underactive thyroid I think weight gain – not loss – is the result as certain BMR activities are throttled back.

    6. In your reference 7 – you state that glucagon’s job is to put glucose back into the blood stream from glycogen and body fat. Glucose is also produced from glucogenic amino acids. The only part of body fat (triglycerides) that can produce glucose is the glycerol backbone.



  • As an ambassador for the PHC I really wanted to be there this year but it wasn’t to be. A friend sent me the video of Tim’s standing ovation and there were tears in Yorkshire as well. Caught about ten minutes of your presentation as DBUK were streaming but it crashed on day one.

    • I didn’t know they were live steaming! I’d have told mum had I known! ;-)

  • Thanks Zoë
    Around the world we were applauding with you all!

    Great overview, thanks for sharing your work.

    Could you explain more about “calories in alcohol don’t count” ?
    What is the relationship between/ threshold for “ alcohol impairing the operation of glucagon”?


    • Hi Shaun
      Thank you!

      We can’t store alcohol, so I don’t see how the calories count in terms of weight. Alcohol doesn’t turn into fat. The body will likely preferentially use alcohol calories for energy so you could then have the indirect storing of other calories not needed because of the alcohol, but the biggest impact of alcohol (I think) is the impairment of the operation of glucagon.

      I don’t know what the threshold is – this implies ( that the liver will be prioritizing ‘sorting alcohol out’ as soon as you’ve had a drink.

      Food for thought eh?!
      Best wishes – Zoe

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