Today’s note happens to fall on World Diabetes Day. I thought I’d share with you the introduction that I wrote for a book called Diabetes Unpacked. This was a collaboration with a number of authors – most will be well known to you – to raise funds for The Noakes Foundation and to assemble consistent alternative views on diabetes.
To accompany this week’s note we have an option to try to give you the book as close to free as possible. If you would like a kindle book, Diabetes Unpacked will be available for 1 £/$/€, or equivalent local currency, for World Diabetes Day. Here are the links to your local kindle store:
The rest of this note is the introduction to Diabetes Unpacked…
My teenage brother, Adrian, had been in Canada at a scouting convention for three weeks. When we waved him off he had been in great shape – a natural sportsman excelling at all games, but cricket, hockey and swimming especially. A week into his trip, our relatives in Toronto contacted us to say that Adrian had left the event ‘suffering exhaustion’ and was staying with them, but they were quite worried about his weight loss. When we collected Adrian from the airport, he was a shadow of the young man we had seen not even a month earlier.
A mad cricket fan, Adrian installed himself in front of the TV when he got home – watching every ball of five-day matches, as he loved to do. It was the summer holidays, so we had much freedom to spend our days. I would do anything for my big brother so when he gave me some coins and asked me to pop to the local shop to get some fizzy pop, I happily set off on my bike. No sooner had I delivered a two-litre bottle, Adrian would be asking me to take the previous bottle back for the deposit and to get another one. His thirst was insatiable.
I returned from one such fizzy drink excursion to a note from mum saying that she’d decided to take Adrian to hospital. Later that afternoon, dad came home early from work, collected me and we headed off to the hospital together. Adrian was already in a hospital bed with mum on one side and a consultant on the other. The endocrinologist gave the whole family a serious talk about what life would be like, now that we were living with a Type 1 diabetic.
The symptoms were so obvious – dramatic weight loss and insatiable thirst – that Adrian should have been diagnosed in Canada. But this was long before the current era of diabetes awareness. We were shocked and the messages delivered with gravity by the consultant stuck with me from that day. We were taught how to recognise low blood glucose (too much insulin) and high blood glucose (too much sugar). If experiencing hypoglycemia (low blood glucose), Adrian would likely become withdrawn, dopey, maybe a bit incoherent. His hands might shake and he might feel clammy to the touch. If experiencing hyperglycemia (high blood glucose), Adrian might appear drunk, gregarious, ‘high’ – he was given a bracelet announcing that he was a Type 1 Diabetic, so that he wouldn’t be mistaken for a drunk if a hyper-episode occurred.
Family members were trained to administer an insulin injection and we kept sugar cubes to hand, so that we could counter ‘a hypo’ as necessary. I used to help Adrian to inject in the arm, as he could more easily inject himself in the leg and this avoided particular skin areas becoming over-used.
This was my introduction to diabetes – Type 1 Diabetes Mellitus (T1DM) specifically – the rarer kind. The one that we still don’t fully understand. Is it hereditary? Is it an auto-immune condition? Why do some people get it and not others? Why did it only used to occur in young people and yet we now have middle aged people being diagnosed with T1DM? The type, which represents fewer than 10% of all cases of diabetes is a complex condition indeed.
In contrast, Type 2 Diabetes Mellitus (T2DM) is emerging as the condition that is easier to understand and certainly the one that is easier to address. It is by far the more common type (more than 90% of diabetes cases) and one that is now being described as an epidemic. Why? Why has T2DM gone from being “what granny with a sweet tooth gets” to a condition seen in children?
The beliefs we share
Diabetes Unpacked is a collection of chapters by thought leaders, academics and doctors with personal and/or patient experience of diabetes – mostly T2DM, by virtue of the proportion of diabetes that this type comprises. The traditional view of diabetes is that is it a “chronic and progressive” condition and that nothing can be done about it. Serious complications include loss of eyesight, amputations and death. The writers in this book approach diabetes from many different angles, but they all share one common belief: Diabetes does not need to be “chronic and progressive.” Both types can be substantially alleviated and T2DM can be ‘reversed’.
A quick word on words here, as the idea that T2DM can be ‘reversed’ or ‘cured’ is contentious. May I suggest that this comes down to terminology and may I propose a clarification to ease the contention? I don’t think that T2DM can be reversed per se, in that a person diagnosed with T2DM will have T2DM from that point on. However, it is clear that lifestyle changes can be made by someone with T2DM, enabling them to get to the point that they effectively don’t have T2DM. The T2DM person can make changes such that they would not be diagnosed with T2DM today. To that extent, the T2DM has been reversed or cured. If the person resumed their previous lifestyle, the changes would abate and the T2DM would manifest itself again. Some people refer to T2DM being ‘in remission’ and I prefer this term, as it more accurately describes where the person is. However, I completely understand the importance of terminology in this world. I have met many people at conferences who introduce themselves by saying “I’m a cured Type 2 diabetic” or “I have reversed my diabetes.” The idea that this ‘chronic and progressive’ disease can be ‘reversed’ is hugely motivational to people diagnosed with T2DM. If this means that the words ‘reversed’ and ‘cured’ are used in preference to ‘in remission’ – don’t knock it. Anything that motivates individuals to dramatically improve their health is to be encouraged, not discouraged.
So, what are these changes? How can T2DM be reversed? The writers in this book share the common belief that diabetes does not need to be chronic and progressive. We also share the common belief as to how. We know that the macronutrient that diabetics (both types) are least able to handle is carbohydrate. We therefore cannot understand that dietary advice for diabetics is to eat the majority of one’s diet in the form of carbohydrate – the very substance that cannot be handled. (This is the same advice for non-diabetics, which is why we continue to make more people diabetic daily).
My husband, Andy, and I wanted to produce and publish a book, gathering together some of the finest minds worldwide, to give intelligent and interested readers some unconventional thinking on this serious condition. We want to stimulate thinking, share logic and personal/patient experiences and challenge the status quo that diabetics should “base their meals on starchy foods” and thus suffer the consequences of sugar ravages in their body as time goes by.
We have all donated our work for free and we are hoping that contributions from this book will raise valuable funds for The Noakes Foundation, founded by Professor Tim Noakes. This is particularly fitting for a number of reasons. First, the goal of The Noakes Foundation is “To support the dietary revolution that will reverse the global epidemics of obesity and Type 2 diabetes mellitus.” This not-for profit organisation is thus perfectly suited to address the condition that this book is largely about. Second, Professor Noakes has been the inspiration to so many of us in this field. It is an honour for us to be working with the person who has been so evidence-led and determined to find the truth that he has ripped up one of his own early books! (The Lore of Running). Finally, Professor Noakes has been one of an elite few who have been put on trial, or worse – convicted with no trial – simply for daring to suggest that Type 2 diabetics should eat less carbohydrate.
The practitioners on trial
Jennifer Elliott had been a dietician for 35 years and for 10 of those had recommended carbohydrate restriction to clients with T2DM. She was taught the standard advice – a low-fat diet, with plenty of whole grains, fruit and vegetables. Her daughter developed a weight problem between the ages of 12 and 14 and had classic abdominal obesity. A general practitioner tested the young girl for insulin resistance and confirmed the diagnosis. Jennifer began her own research into insulin resistance and found a wealth of evidence that had not been taught in dietetics training. It became clear to Jennifer that carbohydrate was not the friend of diabetics and/or those with insulin resistance. Jennifer changed her daughter’s diet and started to change the diet of clients similarly afflicted. The results were immediate: weight loss; improved blood glucose levels; and a reduced need for medications.
You would think that the dietetic association would have been thrilled and would have sought to emulate the advice that had proved so effective. The opposite happened. Jennifer was reported by a Dietitians Association of Australia (DAA) registered dietician and charged with using a "non-evidence-based" approach.
The Dietitians Association of Australia (DAA) conducted the investigations into the allegation. You can check the conflicts of the official body for dieticians in Australia for yourself. Around the time that Jennifer was under investigation, the “corporate partners” of the DAA included Campbell Arnott’s "one of the largest food manufacturers in Australia"; Nestle; and the Australian Breakfast Cereal Manufacturers Forum.
The outcome of the investigation was that Jennifer was de-registered by the DAA in May 2015. Her employer, a local Health District, dismissed her.
Jennifer paid a heavy personal and financial price for suggesting that people who can’t handle carbohydrate should eat less of it.
Australian dieticians have shown themselves to be particularly vicious in their determination to eliminate any practitioners stepping outside their own belief system. Surgeon Dr. Gary Fettke was the next high profile health practitioner to be targeted by those wedded to the low-fat high-carb dietary advice. Gary is a surgeon. He amputates limbs. He mainly amputates the limbs of diabetics whose bodies have been damaged by the ravages of sugar. As a doctor, who took an oath to “first do no harm”, he felt compelled to advise patients that – if they didn’t consume the sugar that was destroying their limbs, he wouldn’t need to cut their limbs off. That’s the kind of direct guy that Gary is!
Again – you would think that this limb and life saving advice would be welcome. Again, you’d be wrong. Again, it was a dietician who (anonymously) reported Gary – this time the Australian Health Practitioners Regulatory Authority (AHPRA) acted as judge and jury. After two years, in August 2016, they ruled that Gary must not give nutritional advice to patients. Specifically, they said: “In particular that he does not provide specific advice or recommendations on the subject of nutrition and how it relates to the management of diabetes or the treatment and/or prevention of cancer.”
Have dieticians managed to silence these two pioneers? Has the DAA monopoly on low-fat diet advice been preserved? Thankfully not. As of early 2017, Gary has defied the authorities and gone back to speaking out publicly on nutrition and in particular the benefits of Low Carbohydrate Healthy Fat living. It’s just too important for him. As he said: “Once you see the results for people, you cannot unsee them.” Thanks to the networking wonder that is the internet, Jennifer’s personal web site (babyboomersandbellies.com) prevails and she has partnered with Franziska Spritzler, a low carb dietician, to offer a program for diabetes.
Professor Tim Noakes
A different continent, but a similar story. Professor Tim Noakes had gained such a following in South Africa that the term “Banting” (Ref 1) had become commonplace. When I spoke at a conference in Cape Town in February 2015, there were two Banting restaurants and it was quite normal to see menu items tagged with “Banting” or “LCHF” (low carb high fat) to indicate their suitability for this way of eating.
On 3 February 2014, someone called Pippa Leenstra tweeted: “@ProfTimNoakes @SalCreed is LCHF eating OK for breastfeeding mums? Worried about all the dairy + cauliflower = wind for babies??” (@SalCreed is Sally-Ann Creed, a co-author of The Real Meal Revolution with Tim).
On 5 Feb 2014, Tim tweeted: “@pippaleenstra @SalCreed Baby doesn’t eat the dairy and cauliflower. Just very healthy high fat breast milk. Key is to ween baby onto LCHF.”
This became the most expensive tweet in the history of twitter! A South African dietician, Claire Julsing Strydom, reported Tim to the Health Professions Council of South Africa (HPCSA). Tim was charged with giving unconventional advice. Several million rand and three years later, the verdict was delivered on 21 April 2017. Tim was found not guilty of professional misconduct. In fact, the committee delivered verdicts on 10 aspects of the hearing and they found Tim not guilty for all 10 counts. However, ‘the most expensive tweet’ continues to accrue costs, as, at the time of this book going to print, the HPCSA had announced that it was going to appeal the decision.
Along with two other authors in this book (Dr Caryn Zinn and Nina Teicholz), I had the privilege of being invited by Tim to appear as an expert witness at the hearing, It was an extra-ordinary experience on so many levels: Extra-ordinary to present evidence and be cross-examined in an open court session in a foreign country; Extra-ordinary that something so monumental ostensibly started with a tweet (Ref 2). Extra-ordinary that anyone could think that twitter is a doctors’ surgery and that a doctor-patient relationship is even established with open exchanges; Extra-ordinary that one of the finest, A1 rated, scientists that South Africa will ever see has been subjected to a witch-hunt for daring to point out that the dietary guidelines are not fit for purpose – for diabetics especially – if not, to avoid diabetes.
This case also involved one or more dieticians. The professional association for dieticians in South Africa is conflicted, as elsewhere. Russ Greene did an outstanding forensic on the conflicts of interest in the Professor Noakes hearing (Ref 3). The common factors with Jennifer, Gary and Tim are dieticians protecting their non-evidence based, conventional thinking with big food conflicts all over the crime scene. If John Grisham turned his attention to these cases, the book would need to appear in the non-fiction section.
Decent upstanding citizens should be utterly appalled that big food and dieticians are able to silence health practitioners who are simply trying to advise those who can’t handle carbohydrate to cut back on it.
It has been an honour for Andy and me to initiate, assemble and produce this book. I have had the privilege of editing it, which has enabled me to give you a taste of the delights you’re in for…
Setting the scene
The scale of the problem is set out by Mike Gibbs, a Cambridge University graduate. Mike co-founded “OurPath” with Chris Edson, an Oxford University graduate. OurPath is an online education and behavioural change programme, which uses technology to address the growing burden of Type 2 diabetes. With a combination of dietary changes, exercise, support groups and other lifestyle interventions (better sleep and stress management, for example), Mike and Chris are trying to prevent people getting into the diabetes pipeline as well as helping those already living with T2DM to better manage the disease.
The rest of the section “Setting the scene” contains three chapters from three of the greatest thinkers in the world on diabetes. The genius of Dr Malcolm Kendrick, Dr Jason Fung and, perhaps less well known to some of you, Dr Robert Cywes, kicks off the book in brilliant and witty style. The way that these men think is simply delightful. It is concise, logical, memorable and so darned sensible that you read their contributions thinking – why, why, why do the powers-that-be not see this?
Malcolm sets out to explain what diabetes is, in as simple a way as possible, while cautioning that, as H.L. Mencken famously said, "For every complex problem there is a solution that is simple, easy to understand – and wrong." Malcolm keeps it as simple and right as is possible. What is the slow progression of diabetes? Is it impaired glucose tolerance or impaired fasting tolerance? Do we have the right focus on sugar? insulin? Is what we observe insulin resistance, or are the liver and muscles simply full of glycogen causing a re-direction of glucose? How can lipodystrophy or PIMA Indians help with our thinking?
Jason asks similar questions – what is T2DM? What causes it? What’s the difference between type 1 and type 2 in terms of insulin? Jason takes us through his insulin resistance model of diabetes. What causes insulin resistance? What is hyperinsulinemia? Why do we develop insulin resistance? Does it serve any useful purpose? With wonderful imagery and analogies – from suitcases to sugar bowls to Japanese subway pushers – Jason takes us on a tour-de-force to see what life is really like in ‘DiabetesVille’:-)
I had the privilege of seeing Dr. Robert Cywes present at the Feb 2015 conference in Cape Town, South Africa. A self-confessed carbohydrate addict (in remission!), Robert understands carbohydrate addiction better than anyone I have ever come across. He just gets it. He talks, as he writes, in sound bites. You feel like you want to write down what he’s just said, because it’s so insightful. While you’re writing, the next thing he says is equally insightful and you want to write this down too. Then you realise that you want to write down everything he says because it’s all equally quotable and brilliant. Here are some of my favourite quotations from his chapter: “Asking a diabetic to count their carbohydrates is no different than asking an alcoholic to count their drinks.” “The cause of T2DM is not a lack of insulin, it is a chronic excess of carbohydrate consumption that results in genetically predetermined failure of the insulin-glucagon blood glucose management system.”
Robert is a bariatric surgeon, but he tries to use very low carbohydrate diets as a preferable ‘last resort’ to bariatric surgery, which is usually called the last resort when very low carb diets have not been tried. If surgery is deemed necessary, Robert uses his knowledge of carbohydrate addiction to help him to help the patient after surgery. He knows that their stomach may have been taken away, but their addiction hasn’t been surgically removed. As he says: “No operation on the stomach cures the head.”
Our first case study in the book is Indya – one of Robert’s patients and she credits him with saving her life. Just wait until you see her before and after pictures.
The different types
Section two opens with a Type 1 diabetic general practitioner from the UK, Dr. Ian Lake, sharing how he transformed his own health after 20 years of following the conventional advice. He has stopped his progressive deterioration and he explains how – as well as giving invaluable information for any T1DMs keen to exercise and wondering how this can be done while managing their condition. Carbs, fats, background insulin and meal response insulin – all are wonderfully detailed in a chatty, first-person chapter, which gives a heartfelt insight into life as a T1DM.
Lars-Erik Litsfeldt is a T2DM from Scandinavia – part of the world known for leading the way with the low carbohydrate approach to obesity and diabetes. Lars shares his personal diagnosis as a T2DM and the traditional advice that he was given, alongside his discovery of a woman taking on the conventional world in Sweden – Dr. Annika Dahlqvist. In November 2006, two dieticians reported Annika to the Swedish National Board of Health (sounds familiar?!) and I’ll let Lars tell you what happened. I very much enjoyed the warmth and humour of Lars’ chapter – some probably a result of a Swedish person incredibly writing for us in a foreign language. It’s quite adorable in places.
Then we’re back to the UK, honoured to have a contribution from the famous “Fixing Dad” team. Jen Whitington, has written an eloquent and moving chapter about her father-in-law, Geoff Whitington. Geoff’s story has featured on BBC2 – one of the major UK television channels – and in the national press. Geoff and his son Anthony speak often at conferences and they have produced a book and a film of the family’s inspirational and tear-jerking story.
Nigel is our next case study. Nigel was diagnosed with diabetes – the medical profession couldn’t even decide which type he was. He discovered the low carb ‘fix’ for himself and, in six months, Nigel went from literally being at death’s door, to being “fitter than he had been since a teenager.” The response of his carb prescribing practitioners? Halving his HbA1c in such a short time was “too quick” and he should be more careful! He continued to ignore their advice.
Dr. Caryn Zinn tells a page turner of a story about how her colleague, Professor Grant Schofield, made some ‘outrageous’ statements saying that low carb diets and saturated fat had been wrongly demonised. Caryn stormed off in search of the evidence ‘to show him’ and you’ll have to read Chapter eight to see what happened next. If I tell you that Caryn, like Gary, Jennifer and Tim above, became one of the practitioners at risk of being stopped from helping patients by zealous dieticians, you may be even more curious. My admiration for those within the system, who challenge the system, knows no bounds.
Dr. Neville Wellington is on the board of The Noakes Foundation. He is also a doctor in Cape Town who was becoming increasingly upset at his inability to help the increasing number of T2DM people walking into his surgery. Neville was contacted by Professor Noakes in 2012. Tim shared with Neville his journey into evidence-based nutrition and how it led to low-carbohydrate diets, especially for diabetics. Neville followed along the same path and found the same. Neville now has quite a tool kit to help his patients and his chapter is an invaluable guide to glucose monitoring – why do it, when to do it, how to do it. “Ultimately, it becomes obvious that diabetes is controlled (or even reversed) one meal at a time.” This is a wonderfully practical and helpful chapter for any diabetic and anyone who knows a diabetic – that’s most of us. One of Neville’s sentences should be pinned on fridges across the globe: “In general, it becomes very obvious that ‘lows’ (hypoglycemia) are caused by too much medication, and ‘highs’ (hyperglycemia) are caused by too much carbohydrate.”
The final of our three practitioners is a GP (General Practitioner) in the UK. If you’ve seen Dr. David Unwin present at conferences, you’ll know he has a bedside manner to die for (no pun intended!) He is warm, calm and encouraging. David also currently has the excitement of a 5-year-old on Christmas Eve because, like Caryn and Neville, he has – after 30 years as a GP – found something that works for his diabetic patients. He is getting the most extra-ordinary results – and these have not gone unnoticed. David was awarded the UK National NHS (National Health Service) Innovator of the year award (2016) out of ten regional finalists.
Lindy’s case study closes this section. Life took Lindy to Holland and, when she finally left the country, she had gained 40kg and Type 2 diabetes. Faced with the usual advice of high carbohydrate intake and metformin, Lindy recalled having read one of my books and upped her reading – soon coming across Dr. Jason Fung, Dr Andreas Eenfeldt and more. Lindy adopted a very low carbohydrate diet, embraced fat and you may be able to guess how that worked out.
The big issues
The final section is the big issues. You can read any of the book’s chapters in any order you like and some of you may wish to start with these – or jump around from your favourite authors to new writers that you are keen to discover. In Chapter 11, I ask and answer the question: “Why do we eat so much carbohydrate?” There’s a short answer (because we demonised fat), but the really interesting story is how, when and why we came to demonise fat. Thankfully that was the subject of my Ph.D, the finale of which I share in this chapter.
Dr Jeff Gerber and engineer Ivor Cummins pick up the baton of the diet-heart hypothesis and investigate why do diabetics die from heart disease? What a great question. There’s a great answer too, as Jeff and Ivor walk us through atherosclerosis as a metabolic disease, the Framingham study and where cholesterol and insulin fit in with all of this. I loved this chapter. It should be compulsory to have doctors and engineers work together because the problem solving logic is just a joy to be swept away with. This is a first rate Irish-American collaboration.
The pièce de résistance comes from “The Prof”, as he is affectionately known in the real food world – the professor among all professors: Professor Tim Noakes. Tim’s chapter explains why a low carbohydrate high fat (LCHF) diet is the only ethical option for people with diabetes. (Tim focuses on T2DM, but T1DM’s need to lower their carb intake to similar levels) and why virtually all athletes should also be adopting this way of eating. As you would expect from one of the world’s few A1 rated scientists, this is an academic chapter, beautifully explained and well referenced. You will wonder at the end of it, as I did when I had the honour of being involved at his hearing, how is this man on trial for his advice? Why has he not been made head of public health in South Africa?!
We are thrilled to have the author of the best-selling, award-winning, “Big Fat Surprise” closing the book. That honour could have gone to Tim, but, as a huge fan of Nina’s work himself, Tim will appreciate that this is the logical final chapter. When all the evidence has been presented – from thought leaders, surgeons, doctors, enlightened dieticians, academics, engineers and public health nutritionists – and all the evidence overwhelmingly concludes that carbohydrate is the worst macronutrient for diabetics, one is left baffled as to why governments have not already implemented change. Nina explains why – the interested parties, the money at stake, the conflicts embedded – there is no incentive to change from the perspective of big pharma or big food or the government bodies they lobby.
As Lars says in his chapter: “A moderately ill patient, with a long life, would be the perfect customer!”
Jason emailed me in the early stages of developing the book and, in his usual brilliant and concise way, he nailed it. What this book needs to show, he said is: 1) T2DM is reversible and 2) T2DM is a dietary disease, which demands a dietary solution. Drugs don’t work.
I think we’ve done it – by gum, I really think we’ve done it.
Ref 1) Banting W. Corpulence: a letter addressed to the public. Melbourne: W.B. Stephens, 1864.
Ref 2) During the hearing, it became clear that a particular paper had played a significant part in the prosecution of Professor Noakes. Several prosecution witnesses admitted to “waiting for” this particular paper so that they had the “evidence” to charge “the Prof.” The paper was:
Naude CE, Schoonees A, Senekal M, Young T, Garner P, Volmink J. Low Carbohydrate versus Isoenergetic Balanced Diets for Reducing Weight and Cardiovascular Risk: A Systematic Review and Meta-Analysis. PLoS One 2014.
Ref 3) https://therussells.crossfit.com/2017/01/05/big-food-vs-tim-noakes-the-final-crusade/