Geoff

Professor Tim Noakes, really a pleasure to have you on the H.V.M.N. Program.

Tim N.

It's a privilege to be on it with you. Thank you so much.

Geoff

Our honor. So our listeners are probably very familiar with your recent saga, or relatively recent saga, with some South African regulatory folks related to nutrition by your stance and your thoughts around low-carb ketogenic diet for metabolic health and health and wellness. But, on the other hand, you also have really had a storied career as an exercise physiologist. A lot of the common "folk wisdom" around carb-loading or hydration or this notion of fatigue and a central governor theory came from you. Given this storied career and the interesting notion from going from a carb-loading advocate to now talking about low carb, how would you describe yourself at this point in your career?

Tim N.

Well, I'm now every much retired. But I'm not retired, because I'm still very active in promoting low carbs. But if we go back over my career, I trained as a medical doctor. During my training, I realized a couple of things, firstly that I was much more interested in science and discovering new ideas than in simply regurgitating what was already known. I'd rather write the book than have to read it and learn it. I also had saw that the costs of medicine were rising dramatically already in the '70s, and most of it was the treatment of chronic disease. I thought, "Well, that's not a help," because I saw how ineffective the treatments were. And I said, "It would be much better to spend a little bit of the money on prevention." And I said, "Well, there are many good doctors looking after chronic disease. I think there need to be some doctors who try to promote prevention."

So I chose to go that route. I helped develop sports science and sports medicine in South Africa. During that time, as you indicated, I got interested in foods and exercise and how the brain regulates performance, and for a long time thought that carbohydrates were the king; they really were essential for exercise performance. Then, in about 2010, I suddenly realized I got it all wrong and decided that I better stop harming people because the books that I'd written said that high-carbohydrate diets are ideal. I realized I was wrong. If you had insulin resistance and you followed that advice, you were very likely to develop Type 2 diabetes. So I said, "It's time to change." I acknowledged my error, and I said, "I apologize, but we really have to understand that these high-carbohydrate diets are not for everyone." The consequence to that was that I irritated my profession so much that they decided I had to be tried for unprofessional conduct for doing a few things on Twitter which they didn't like. That was actually a front. It had nothing to do with that because everything I said on Twitter was completely correct medically, as we eventually proved.

So I went through 28 days of trial, and what my legal team advised me to do is, "Let's put the high-carbohydrate diet on trial and see which wins." At the end of the day, the low-carb diet won. So we were very happy about that. I managed to save my career because I'd been targeted publicly to be humiliated in South Africa and the world. I decided I wasn't going to let that happen because my whole career would've collapsed, and I felt I had to keep going and make sure that legacy was intact.

Geoff

100%. That just reminds me of Galileo, of these historical scientists. We can let history judge the comparison there, but obviously, within your field... I just want to underline and unpack some of the things we're talking about. Just as a reminder, in the '70s and '80s, sports science wasn't a field. So when you're saying that you helped develop sports science, I don't think it's a far stretch to say that you're one of the first seminal people to really make this a profession, giving the timing and perhaps the... So that's interesting. And then second, which I think is very interesting, is that it's very rare for anyone, but I think especially in academia, to say, "Whoops. I was wrong for 20 years of my career, and I'm going to correct that." I guess we should probably go into the sports field first and then probably unpack just in terms of chronological order here the typical notion of carb loading, hydration, central governor theory. Perhaps we can go through one at a time. Maybe we can talk about carb loading first. That's a meme that's very popular in endurance sports. What is still valid there? Because, obviously, there is some role, potentially, for carbohydrates, especially for performance. What was overstated, and what should we be more nuanced about?

Tim N.

Yeah, absolutely right. Carbohydrate loading came in in the 1960s, and just to remind you that before 1968, there was no real interest in sports science. But that was the year that the Olympic Games were held at altitude in Mexico City, and athletes went to Mexico City not knowing how to compete at altitude. A few countries sent their athletes there to train before the Olympic Games, and people said, "We absolutely don't know what's going to happen to these athletes." That was really the stimulus for the beginning of sports medicine. It was also because the East Germans competed for the first time, and they were successful. They had applied science. Of course, they'd applied drugs as well, but they'd applied science.

Geoff

They're pharmacologically enhanced.

Tim N.

The US realized that here's a real competitor, and we need to get involved in sports medicine. I know that the doctor who went with the US team to the Olympic Games in 1968, he was literally found a couple of nights before the Olympic team went to the games and said, "Would you like to come to the Olympic Games?" I mean, that's how unprofessional, how amateur it all was. I was so fortunate because I started my career in medicine in 1969, a year later. Therefore, the first 20 years of my life, I could actually know most about what was happening in sports medicine because it was still so small you could be knowledgeable about everything. Today, of course, it's such a vast field. Anyway, 1970, I start doing physiology and realize that this is my real passion.

The first studies of carbohydrate loading are starting to come forth, and the people from Sweden are doing muscle biopsies. They're measuring muscle glycogen. And they're coming to the conclusion that this is everything. Carbohydrates in the muscle determines your performance. Of course, we should've been warned. Listen, it's not one thing. You can't reduce all of performance to one thing. But we were so enticed by it that we fell into the trap. When I started becoming a serious exercise physiologist in the 1980s, you had to be able to do two things to be a physiologist. You had to measure an athlete's maximum red oxygen consumption. If you couldn't do that, you were hopeless because that was the one factor that determined performance.

Geoff

Right. VO2 max is a common part in this. People love citing their VO2 max scores.

Tim N.

Absolutely. Our problem was we started looking at VO2 max and we said, "Well, actually, there's such a wide range." You could have the same athlete performance, but their VO2 maxes could be quite different. The other thing was that we were told, and this... If you wanted to publish a paper in those days, you had to say this. You had to say that there was a plateau in oxygen consumption before the athlete terminated exercise. In other words, you were made to see the oxygen consumption goes up, up, up, up like this. Then the athlete tires, and no more oxygen consumption. There's this plateau phenomenon.

That was a gold standard. If you didn't say that, you couldn't publish your papers. And we didn't find that on every athlete. We were using fairly simple systems, and we couldn't find it. So we would say, "We can only find this plateau phenomenon in 10% of the population or of the athletes." So you either had to lie or... We told the truth. Fortunately, then that made me realize that if you don't get a plateau, then it's not the muscle running out of oxygen. And, in time, we realized it's the brain regulating performance, and the system is regulated. It's homeostatically regulated. You can't ever let the system fail because then you're dead. So exercise physiology was based on a false premise that the system failed, and then you got tired. We, over the last 10 years or so, have shown that fatigue is purely an emotion. It's just your brain is using this fake emotion to make sure you don't kill yourself. So that's been a major advance, as you know. But to get back to the muscle... Sorry. So, what I was saying, to be in exercise physiology, first you have to measure VO2 max. Then you have to do a muscle biopsy and measure glycogen in the muscle.

Then you're all systems go. Then you're word class. Now you can do everything. I was the first guy to do muscle biopsies in South Africa. We did muscle biopsies on everyone. We loaded them with carbohydrates. We couldn't find much evidence that carbohydrates were really helpful, but that didn't matter because we knew it was true. We were also the first in the world to develop those goos or squeezes that you run with and you squeeze into your mouth. We know all about those. So we developed them. They're called a Lepin FRN. Fordyce was the great ultra-marathon runner in South Africa. Bernard Rose was the marathon champion, and I was the exercise physiologist. So it was FRN, and if you go and Google Lepin FRN, you'll see that we were the first to develop it. So I'm acutely embarrassed now that we took athletes down the wrong road for so many years that carbs are going to make you go faster. But the end result was, when I wrote my book, Lore of Running, which was very widely read, it said carbohydrates are crucial for performance. The first three or four chapters are all about how nutrition is the key driver of performance, and particularly carbohydrates. I realize now that, actually, the brain is the key driver. So, as I rewrite the book, I'm focusing more on how these chemicals in the periphery, in response to what you're eating and drinking, influence the brain to allow you to go faster. The key is that it has to act through the brain in some way to allow you to go faster.

Geoff

I think we touched upon a couple interesting aspects of the central governor theory. We talked about VO2 max and we talked a little bit about carbohydrate and glycogen. I think I want to say, in the modern era, it seems almost intuitive that the brain is a central governor or critical to performance. I think we all have the intuitive experience that we feel really, really good today; we do better. We feel very depressed; we do worse. Some would say that some of the most interesting findings or results seem intuitive or obvious after the fact. I think it was interesting to hear the history that, in the past, VO2 max and muscle glycogen or carbohydrate availability were the two primal causes. But we're moving towards this notion that, actually, the brain is the central proximal cause, and there's many inputs going into the brain.

So, unpacking specifically on carbohydrates, would you say that... Obviously, if you eat a low-carb diet, you can go through the process of gluconeogenesis, produce carbohydrate from protein, or some of your exogenous nutrition coming in. Given your recent evolution on this topic, is there a role for carbohydrate for heavy weight lifting, anaerobic exercises, or are we very much in the camp now of you don't even need to worry about it; if you eat a well-formulated ketogenic diet or low-carb diet, you can still have maximal performance in anaerobic-style performance?

Tim N.

Yeah. I don't think we have the evidence here to say absolutely one way or the other. I know that there are athletes who can do it, but the reality is that they are probably using carbohydrate whilst they are doing those intense exercise. So it's not as if you don't have any muscle glycogen because you're on a high-fat diet. You do have muscle glycogen. So it would be impossible for us to say that this person is not using carbohydrates when they're doing those explosive events, and almost certainly are. So it's very difficult, but where I think the change has come is, as you become fat adaptive, and what guys like Jeff [Foley 00:13:40] kept showing and our own studies have shown and Louise Burke from the Australian Institute of Sport has shown, is that world-class athletes have an incredible capacity to burn fat and that we've completely underestimated the ability of the muscle to burn fat. I think Louise Burke's study is the one which I really find most interesting because she's not very pro-high-fat-diet.

But, if you look at her data, she shows that within three weeks, she took world-class walkers, race walkers, and she showed that within three weeks of this high-fat diet, during racing intensity at 25k racing intensity, these people were burning 1.5, 1.7 grams of fat per minute and about half a gram of carbohydrate per minute. They will almost completely close down all their carbohydrate metabolism. And they were racing at competitive speeds. My view would be that this is not because they've tooled up the muscles dramatically. It's because all that capacity is there. What they've done is, going on the high-fat diet, they've reduced their insulin and they've allowed, now, the fat to become the major fuel. We have a paper that we've submitted, and I don't want to go too far to say what it's all about, but what we did show was that in high-intensity exercise at any percent of VO2 max, it doesn't matter whether the person's eating a high-fat diet or high-carbohydrate diet. Their performance is the same.

Geoff

Interesting.

Tim N.

So that would be performance of 5Ks, or let's say 3 to 5Ks. So I think we're focusing in now. And if you're running 3 to 5Ks, you've got enough glycogen in the muscle, and you can burn lots of fat. You don't need a high-carbohydrate diet. That's really interesting because I think, once you get beyond that 5, 16, 15, 20Ks, for the average athlete, they can uptool and just burn fats. And they certainly don't need high-carbohydrate diets. That leaves us with people exercising from 100 meters up to, say, 3 to 5Ks. That's where the question remains. Will they benefit by high-carbohydrate diets? That we can't yet answer.

Geoff

Absolutely. I appreciate the nuance there because I think, in the world of Twitter and polarizations, it's easy to be, "Carbs are king," or, "Carbs are useless," and I think, as you're unpacking here for us, a lot of nuance. I would say that one paradigm that I've been thinking a lot about and curious to hear your thoughts is that there is some orthogonality between maximal longevity or metabolic health versus performance. Is there an argument that if you're looking to win an Olympic gold medal at your event, maybe within the sub-5K range as you're describing, is it worth it to spend two years, four years, eight years jamming as much carbohydrate as possible and potentially harming your long-term health? But you maybe get that advantage of having very up-regulated carbohydrate function. Maybe you can do some training around being metabolically flexible; fast a little bit in between.

But the main point is have a lot of carbohydrate during that period for that short-term potential benefit at the cost of potentially decreasing your health span long term. Is there a potential argument to be made there, to basically differentiate or just tease out longevity, health span, versus "I want to just burn the candle real quick, eat a bunch of carbs, maybe give myself diabetes or pre-diabetes in 10 years. But, hey, I have a shot to win the gold medal"?

Tim N.

I think you make the point very clearly. You see, I'm a great example. I was never an elite Olympic athlete, but on checking my own data from when I was 28, I was profoundly insulin resistant. I had a fasting insulin of 30 units, and we like to be below six units. Once you're above six, we know that you've got long-term problems. If you're running with a fasting insulin of six or seven, you will get problems in the long term. And, of course, higher, it'll just come quicker. So I was a walking time bomb, and no one had told me, although I saw the data. We didn't know what insulin resistance was in those days. So I developed my Type 2 diabetes at the age of 60, and I probably had it about 55. But I didn't check for it enough, and my fasting glucose looked okay. It wasn't great, but it wasn't diagnostic of diabetes. But I think if I'd done better testing, I would've known that I actually had had diabetes for 10 or 15 years, or 10 years before I made the diagnosis.

So I'm a really good example of what happens if you take a person who's insulin resistant on a genetic basis and eats a high-carbohydrate diet. You will run into trouble in the long term. So I don't see any advantage of eating one gram more carbohydrate than you need. That's the key. I would like to encourage people to experiment and not to say as I do in the book Lore of Running, that you must just overload on carbohydrates as much as you possibly can. I mean, we were telling people to eat a kilogram of carbohydrate every day. I don't know how they survived on that. Their insulin spiking must have been horrendous.

Geoff

For Americans, that's 2.2 pounds of carbohydrate, which is a lot of food. That's just a lot of food.

Tim N.

Exactly. And I would rather say skid by on the minimum amount of carbohydrates that you need because that's going to be for your long-term life expectancy. That's going to be the ideal. Now, I think athletes are realizing that, that there's no real advantage of over-ingesting carbohydrate. You see, when we were working through this paper about how intense exercise could you do on a high-fat diet, I discovered this study saying that you actually burn quite a lot of fat in high-intensity exercise, even maximal exercise. It's difficult for us to measure it, but it's there. People are burning fat. And the one study by [Larsen 00:20:11], my friend Paul Larsen in New Zealand, showed that the difference between the best sprinters that he studied wasn't because the fastest guys were burning more carbs. They were burning more fat. He used an unusual technique to show it because it's so difficult to measure it. But that was his conclusion. So, again, I just mentioned that sprinters may actually burn quite a lot of fat, and it doesn't fit with the paradigm.

Geoff

How would you explain that? Because, as you said, the paradigm is, okay, if you are sprinting, you're probably reaching VO2 max very, very quickly, and you'll go into fermentation or anaerobic metabolism.

Tim N.

The problem is that a 1920 study is quoted. This is the basis of the fact that you can't exercise on a high-fat diet. There was an intervention where they had athletes or humans exercising on high-carbohydrate or high-fat diets. The guys on the high-fat diet did very badly, and so they said you can't oxidize fat rapidly for high performance. And that's 1920. It's one of those foundation myths on which we build everything. So everyone quotes that study, and then they say that Olympic athletes have to burn carbohydrates to win gold medals. But, when you look for the evidence, it's actually... It's not there. That's point one. Point two is that, as you know, the physiology, as you start to exercise more vigorously and you become more acidotic, you release carbon dioxide from your body's stores. This comes out, and so that falsely raises your respiratory quotient. We use the respiratory quotient to predict how much fat and carbohydrates you're burning. The higher the respiratory quotient, the more carbohydrates you're burning. During exercise, we are biased. We are underestimating how much fat you're burning. That's why we can't really measure it. It took Paul Larsen to show that, actually, we do burn some fat during high-intensity exercise, and it may be much more than we think.

Geoff

Essentially, the argument is that there is... Obviously, you're still breathing. You'll still be able to use fat oxidation, and fat will be a substantial portion of overall fuel expenditure. I think that's a nuance that I think is left out of the Twitter sphere where most... Everyone's always burning a mix of substrate. It's never just sugar, just fat. It's always a mixture.

Tim N.

Let me just add another point which I had some argument with another guy, and then he actually stopped on Twitter. He just went off. I said, "If you're a Tour de France cyclist..." And he's saying, "Oh, but, you see, you've got to have lots of glycogen so you can sprint up the mountains." Well, okay. That's fine. But you could get that glycogen by burning fat. So, if you can exercise at 85% of your VO2 max burning mainly fat, the time you have to go to 90% as you're finishing up these huge hills that they go up, then you've got the glycogen. It's stored in the muscle. It's still there because you stored it the night before, and you haven't used it in the first four hours of this last stage. You're just burning fat. So now you can use more carbohydrates at the final slope.

But that doesn't come into their equation because they're so convinced that you can't burn fat at high-intensity exercise. The question I ask is, so where do you make the cut-off? What is high-intensity exercise? We've studied an athlete, too, at 92% of VO2 max while still burning way more than 50% of his energy was coming from fat. That's how much, if you really adapt... But you have to adapt. You have to do high-intensity training on a high-fat diet. Then you can increase your fat oxidation rates remarkably, even at high intensities. So the future, for me, is that athletes will use less and less carbohydrates in training and do more training on the higher-fat diets to make their muscles burn at 90%. They'll be burning predominantly fat. That's the capacity is there. If it's not there in everyone, the athletes who can do it will be the ones who will be the winners in the long term. In other words, if it's a genetic thing, they'll be selected and they'll start to win as a result.

Geoff

Absolutely. I think that's a good segue into some of the more popular topics in discussion with the folks that we work with in physiology in sport, which is this notion of metabolic flexibility, which you're describing. How much can you switch back and forth between different substrate, and how high can you be burning fat at higher and higher intensity?

Tim N.

The idea has risen that a high-fat diet makes you metabolically inflexible.

Geoff

Really?

Tim N.

It's a high-carbohydrate diet that makes you metabolically inflexible. It's not my idea. My PhD student, Chris Webster, pointed that out to me. We took this athlete who could burn at 90%. He could burn so much fat. And then we did a VO2 max test on him, and he did a great VO2 max in which he burned lots of carbohydrate. So here he was with a capacity to burn 1.7 grams of fat per minute, but he could also burn a huge amount of carbohydrate when he was at VO2 max.

Geoff

Interesting. What I was getting to was that... One, let's talk about adaptation period because I think that's something that a lot of people don't... Or, at least as an open discussion of debate, do you need six weeks to adapt? Do you need two years to adapt? And then part two, which I think was interesting, was that what you're suggesting, what your PhD student described, is that it's kind of a one-way door where, if you're very optimized for fat metabolism, you don't lose your ability to metabolize carbohydrate. But if you're fully optimized towards carbohydrate metabolism, you potentially build up insulin resistance, and that reduces your ability to metabolize fat.

I think that's an interesting point to discuss. But the first part of the question, which is, I think, potentially an open area of discussion and work, is what does adaptation mean? I think some people say they feel really crappy on switching to a keto diet for two weeks. Is that too short? What, in your experience, is the right level to fully adapt, and are there strategies to accelerate that adaptation? Should one consider intermittent fasting, high-intensity interval training on top of reducing carbohydrate intake to potentially accelerate up-regulating fat oxidation?

Tim N.

My general view would be that you don't want to add too many stresses at the same time so that if you are adapting to the diet, just adapt to the diet. Don't now increase your intense training, because it's going to happen. If it happens in six weeks or three months doesn't really matter. In a study we did where we repeatedly tested people over six weeks on short-duration, high-intensity exercise, within two weeks their performance had normalized. So, in this group, just two weeks was good enough. But, on the other hand, I've helped world-class athletes, and some of them say it took them 10 months to really get fully adapted in training. And they notice now the advantages in competition. So I think it can be a long time, and maybe it takes 10 months. But you keep going until you see what the outcomes are.

Geoff

That's a good point because I think if you were to argue or steel-man the opposite argument, it is that "I've been doing this for three months. My performance is still not there. I've been doing this for six months." I guess you could say the argument, could you be in a impossible, looping situation where you just need to adapt longer? Adapt longer. This is argument to regression. How would you counter that argument that "Okay, there's no bar"? There's no true Scotsman. You just haven't done it hard enough. How would you address that concern?

Tim N.

I'd give you six months, and if you haven't adapted after six months, I'd say that's it. You're not going to adapt. And go back to your standard carbohydrate diet.

Geoff

That might be a genetic component that-

Tim N.

There are going to be outliers who don't adapt. That will always happen. I remember one guy phoning me and saying... He was a really good athlete, and he said, "At 20 grams of carbs a day, I can't even get out of bed." I said, "Okay. Maybe we should put you back to 100." On 100 grams of carbs a day, he was perfect. He could do everything that he could do. So we say that carbs are not essential, but it's clear to me that some people do need a little bit of carbohydrate, external carbohydrates, to perform. Why that should be, who knows? But they probably have some sort of slight metabolic difference, and they need carbohydrates to fuel the Krebs cycle and so on.

Geoff

100% agree with that. Now, moving to central governor theory, what are some of the key insights that brought you that notion? Again, going back, it seems intuitive, almost obvious, today that the brain is so important for performance. But, again, rewind 20, 30 years ago. This was a new field of inquiry. Everyone was looking at VO2 max and muscle glycogen as the two drivers of performance. It sounds like you started seeing some data that there was very little correlation between those two markers for performance. What centered you around the brain, and what does that inform us about training? The one thing that's funny to me is that knowing that it's the brain doesn't mean that you can just trick your brain. The best way to almost trick your brain is to exercise a lot and eat well. So it's almost like you might know the mechanism. How do you use that mechanism to inform your training and form your lifestyle to optimize performance?

Tim N.

The key bit of evidence for me was when we started measuring electrical activity in the muscles. For the other model to be true, it predicts that you get tired when you're activating all the muscles in your lower level. That's the point. As you get tired, the muscle fibers start working properly. You have to recruit more muscle and more muscle and more muscle until you've recruited everything, and then you're fatigued and you have to slow down because all the fibers have been activated and they're all getting tired. Now, when we tried to test that hypothesis, we found it was completely wrong, that that's not what happened, that you only recruit up to about 40% of your muscle mass. Then it would decrease as you got tired. In some circumstances, it might increase, but it would never get to 100%. So the model was wrong, and that's where we realized, well then, obviously the brain's in charge.

I think people forget this: that to run faster, you have to recruit more muscle. You can't run faster without recruiting more muscle. That kind of a message still hasn't got through to people. It's "You must eat more something, and then that'll make you run faster." No. You recruit more muscle, and then you run faster. So that was what we began to realize, that that was the case. In time, we realized, where does the brain come in? It's producing this fatigue. And our most recent papers show that the key is that you have an emotional response to how you feel when you're running. So you get all this feedback, and it either makes you feel good or bad or whatever. Then you get an emotional response. In our clinical trials where we race athletes against each other in the laboratory, the moment that one athlete goes ahead, the other guy starts to feel bad. His emotional state gets worse.

That's the first thing that happens. And in the second thing that happens, he starts questioning, why is he doing it? Is it really worth continuing? That's called the stopping wish or the quitting wish. Those are the three components, which we now understand in the central governor model, is that, firstly, there is feedback from the periphery, from your internal, and from your assessment of the environment. Then there's this emotion. How do I feel about what I'm doing? Is it making me happy, or am I not happy? And I'm feeling distressed. Finally, you start asking the question, "What's it worth? Do I really want to continue hurting myself for another hour to win the gold medal? Maybe I can slow down and win the silver medal, and that's acceptable." So that's what's going on in your head. And then you asked about training. Well, I think that training is to convince yourself that you can cope. But much more important than that is, what's the goal? Why are you doing it? That's the key. The coach has to get that across to you that this is really important and that you are the only athlete in the whole world who can do it.

Geoff

Yeah. One of the elegant things that you've written or you've said in the past about this notion is that, well, we've all been to the point that you think you're going to die in performance. But then you just... You go a little bit further, or you take a 30-second break and you can keep going. Obviously, you're not even close to dying. So there is something going on that's preventing you from hurting yourself, which I think is a very intuitive way to explain this physiological model that you're describing. Given that the brain is so central to performance, obviously, traditional exercise is very focused on physical exercise to gain performance. If the brain is so important, could we hypothesize that things like meditation or mental training or working on your mental fortitude to absorb pain and really define what your goals are... Is there a role to just look at the brain as a substantial portion of training where I think that is starting to come into vogue, I would say, in recent years? People start working on the mindfulness of the athlete. Does the model that you have suggest or propose specific protocols to work on the brain? Have you looked at that? Is that something of interest? Are there any potential strategies or hypotheses you have there to optimize training of the mind?

Tim N.

I haven't really thought about that. I've been involved more in the physiology, and I haven't really spent my time, "How do we train people to perform better?" Yeah, because to me, this is a black box still. I have to leave that to other people. I think my contribution was to say you've got to look at the brain. You've got to work on how people can train their brains. I think that there's so much to do with it's either genetic or the way you were brought up as a child that is so critical to performance. I'm reading a book at the moment, and it looks at some of the greatest teams of all time, teams that perform beyond belief. So this is not individual sports. It's the team. An interesting thing that they discover is that when you get a team together, each of them underperform slightly. By themselves, they're able to perform slightly better. But as soon as you get in the team, they all sort of become dependent and let everyone else do the work. That's really interesting. It turns out that the best teams, that all comes down to the leader. It all comes down to the captain, that he's able to lift the team to a different level because of his own leadership skills. So there it is. He just manages to get these guys, or she manages to get the girls or the boys, to perform at a higher level and not to let their performance go down because they're a team.

Geoff

That's interesting. Yeah.

Tim N.

It's fascinating that the natural inclination is to underperform. That's the natural inclination. But there are certain individuals. That's part of point two, is if you look at some of the great athletes of all time, they came from abusive families. They had a family member who abused them. I'm talking about physical, not sexual but physical abuse. It was coping with the physical abuse of the father particularly that allowed them... When they got discomfort in exercise, it wasn't an issue because they'd lived with this abuse for so long. That may be the one, but the other one, of course, is just a father that disappears from the family. These are like psychiatric illnesses that help people do better. So it's very complex, and it's not always the way you think it might be.

Geoff

Yeah. No, it's an interesting proposition where... to have an outlier, extraordinary performance, you have to have some sort of extraordinary starting point or initial condition. Potentially, that's the line between madness and genius. If you are that far outlier, you literally are the best human out of seven billion humans at something. There is some strange initial condition likely, and that might be really, really bad, negative six standard deviation or positive six standard deviation. I think, going back to your story about leaders really buffering up the whole team's performance, I think that really resonates with me in our conversations with groups in the military, groups in sports teams, this notion of leadership. If you have a bad team leader.... People in Navy SEAL training are buds. Talk about that. You swap a team leader. The boat-racing team that would always win with that team leader. You swap the captains with the worst-performing boat. That next boat race, that worst-performing team is now winning those races. Do you have some sense of what are characteristics of that leader? What can we learn from this? What can we model ourselves after? Do you have some sense of pattern there?

Tim N.

I worked with a team that won the Rugby World Cup in 2007. You could walk into the room and know this team was unbeatable. It was this sense of purpose and discipline and character and do the right thing when you have to. It was pervasive. It was astonishing. I think there were four or five great leaders on the team, and they lifted everyone. I must mention that Joe Montana is one of the people in the book, and I know that you have an interest with Joe Montana in San Francisco. One of the reasons I have to get back to San Francisco to meet you again in your offices is to meet Joe Montana.

Geoff

Yes. I remember we talked about that. We will make that happen.

Tim N.

I have a series of football or rugby jerseys, and I have to get him to sign-

Geoff

Okay. Let's coordinate that. We can absolutely make that happen.

Tim N.

I would love to do that. That would be super because I have this one lecture on performance, and I have the catch. I go through the catch in great detail, which is really interesting for South Africans who follow rugby, which is of course not American football. I have to explain exactly what the circumstances were and what it meant and why it was such an amazing moment and how perfection comes down to inches. That just epitomizes that moment.

Geoff

Absolutely. Well, I think it just speaks to the sport broadly. I think one part of me is that, who cares about other humans playing some artificial game? But I think it's really a personification of ethic discipline, some of the cultural values that we choose to honor. So I think that's a good analogy. It's a good personification of some of these soft qualities, which is also... I mean, going back to the point around the pneumatic feel of, okay, you sound like the energy in the room, I guess, matched the leaders who had this confidence, this swagger, this inevitability. And that permeated across the entire organization.

Tim N.

In that episode, Winning the World Cup, there was a moment where South Africa could've got knocked out in one of the earlier games. The score was suddenly 20-20. It had been 20-null, and it was suddenly 20-20. The captain realized that the team had lost it, and he called them together. He said, "We didn't come here to lose to this team." He spoke to them because he picked up immediately, and the team just went away and quickly scored the points needed to win the game. They were totally dominant at the finish. Again, the just understanding his colleagues and understanding what was wrong and making the correct diagnosis and initiating the right intervention.

Geoff

Yeah. If there is one takeaway that I can draw from this anecdote, it's that there's some intuition here. Spot the flagging confidence, and when there's that fear, have courage and lift everyone up. Let's push this a little bit more, which I think we all should think about when we have that flagging of courage. Can we have the discipline or willpower to, "Yes, that is happening, but no. We're going to power through this"?

Tim N.

Be brave. And, in fact, that's what the coach told them. Before the final, he said, "Be brave. Just be brave."

Geoff

That is inspiring. I think we discussed quite a bit about how you essentially almost created, or were at least a seminal player in creating, sports science. Going to a second big area that you've contributed towards and are now very vocal about and, I would say, a thought leader in the space of is this notion of low-carb diet for metabolic health, metabolic syndrome. As we all clearly know, and I know our audience is very aware of this, that diabetes rates skyrocketing. Obesity rates skyrocketing. These are unsustainable chronic diseases that essentially, if we do not leave checked, will make society unlivable. If all of us are obese with diabetes with neurological conditions like Alzheimer's, etc., etc., etc., it's just not going to be sustainable. How did you transition or expand your interest from the physiology world into broader health conditions? Was there some trigger point there? Was it just a realization over your career as a doctor, physiologist, realizing... and perhaps your personal journey seeing that a lot of the things that we're working on in exercise physiology can apply to everyone's just daily living, daily health.

Tim N.

I think there are two factors. Firstly, my father died of Type 2 diabetes. I watched him die over 10 years, being treated conventionally. He got all the complications of diabetes, and there I was as a trained medical doctor, not helping him. I couldn't help him. That was very frustrating because I'd been taught that Type 2 diabetes is a reversible condition. It took him 10 years to die from diagnosis to death, and it was just too terrible. I won't even go into his condition when he died. It was appalling. So I watched this process, and ultimately, then, I developed Type 2 diabetes myself and realized I had 10 years to sort the problem out because that was what had taken my father 10 years to die. I realized there were 10 years to sort this thing out, and fortunately, I had a low-carb diet and sorted my problem out relatively quickly and put my Type 2 diabetes in remission.

I've probably had the condition for 12, 13 years now. And, cross fingers, I don't have any complications as yet. I'm hoping I'm going to avoid them. So when I learned that insulin resistance is the most prevalent condition in the world but we don't even teach it in medical school, then I asked the question, why not? What I realized is that 85% of chronic disease is linked to insulin resistance, and the treatment is nutrition. What we do and what we're taught as doctors is we put each of the components of insulin resistance into a separate silo: heart disease, dementia, obesity, hypertension, cancer. We treat them in these different silos, whereas if I was head of a hospital or a medical school, I'd say, "No, no, no. They're all in the same silo. They're all the same disease."

Geoff

Right. The same primal cause.

Tim N.

Exactly. And it's not pharmaceutical interventions. They don't work. They don't help. We've got to sort out the cause. When I was in medical school, we were taught to look for the cause. That doesn't happen anymore. It's now, what's the diagnosis? And here's the road to treatment. And if it doesn't say, "This is how you treat it," you don't treat it that way because then you're in trouble. That's what's motivated me because, as you indicated, we face a tsunami, a disaster heading our way. The obesity/diabetes epidemic is going to destroy medicine, and people don't see it. And we just delay, delay, delay. We have to do something. The answers are relatively simple. It's not rocket science what we have to do.

Geoff

I think everyone, I would say, has good intentions, assuming good faith. I think we would both agree that doctors or researchers that are more of the standard-of-care methodology are not trying to harm people. Academics aren't trying to mislead people when they're publishing about carbohydrates in the exercise physiology world. I think that's something that I think more and more people are starting to realize, is that what are the institutional blocks here where there are actually quite aggressive in blocking novel thought? I mean, this happened in your academic career when you're publishing papers. You were mentioning that if you didn't have this kind of characteristic in publishing for VO2 maximal performance, they would reject the paper or ask you to reanalyze your data.

We're looking at insulin resistance as a root cause, and obviously, I would say in recent years that has more wider acceptance. But standard of care is very, very far from that. Perhaps, just starting at the very, very philosophical or high level there, why is this happening? I think the goals are the same, right? I would think that the doctor on the other side who is arguing for standard of care is saying, "I want to help people, too. This is a tsunami. We should do something about it."

Geoff

What do they have wrong, or what do we have wrong? Someone is wrong. I think good faith... Everyone wants to work on this problem. What's going on here?

Tim N.

I don't want to promote conspiracy theories, but I've looked at it for a long time, and what happened to me was clearly coordinated because I was asking questions that people didn't want to answer. I just happen to think that the pharmaceutical industry and the food industry is so powerful that they control what's being taught at the medical schools. They control what the public are reading. They control the television networks. They control everything. That's the reality. So there's only one message that people are going to get, and that's the one that promotes the industrial diet and the use of pharmaceutical agents. To get past that, it's impossible. You can't do it. The only way we can do it is to train each individual human to question and to experiment with different diets and find out what works for them. Then we slowly work through the doctors because if we can convert doctors, eventually they will realize that this is the way to go.

I think social media has been very important in this because now, today, people will see what works and what doesn't work. I tell my medical students that in 10 years' time, if you're prescribing things that don't work, you won't have any patients because they will have gone onto the internet, and they'll see that doing X, Y, and Z is what works. And there are millions of people reporting that it worked for them. They will try it, and if it works, they won't go back to medicine. So I think with the social media is the only force we have to reverse what's been happening.

Geoff

Would you say you're optimistic? I think the social media, just given what we've seen in our community and the growth and interest in the internet world around ketogenic diets, low-carb diets... Would you say you're optimistic? You have built quite a following on Twitter. We've seen an uptake in interest and discussion. Should we be optimistic? I think conversations like these, where we're nuanced, we're thoughtful, we're unpacking some of the mechanisms of action here, is going to help accelerate this change. I think we see it already where our listenership has been growing quite quickly over the last couple of years. Do you sense a tidal shift?

Tim N.

Absolutely. Just go back five years. No one knew about the banting diet. No one knew about the low-carbohydrate diet. For a period it was the topic of discussion among South Africans. I can't go anywhere without being embraced and thanked every day for saving people's lives. They start crying, and, well, I didn't do anything. I just wrote a book on something. They did it for themselves. And those people... The examples are remarkable. There's a Facebook page, The Banting Seven-Day Meal Plan Facebook Page in Cape Town. 1.5 million people. Three years ago, had no followers. It's got 1.5 million. And it's from every possibly groups of South Africans. Any race, any ethnicity, any age, any gender, they're all there. This start was thought to be for the elite, and it's gone right across the country.

Geoff

Yeah. It's very encouraging.

Tim N.

We're currently working with a domestic servant. So she's quite low on the social scale. She's written her own book on the low-carb diet, a banting book. Isn't that astonishing?

Geoff

It's a movement. Yeah.

Tim N.

She cured her diabetes on the diet. She now helps people like herself.

Geoff

I want to play devil's advocate here for a little bit. So banting, the banting diet, this was a very old diet. Banting, I believe, was the '20s. I don't remember the exact decade, but this is-

Tim N.

1860.

Geoff

'60. Okay. Yeah. Okay. 1860?

Tim N.

Yeah.

Geoff

Okay. Yeah. So this has been around for 150+ years. We had the resurgence of the Atkins diets, I would say... What, '80s? 1980s, 1990s? That was popular for a while. So there's been a couple, I would say, false starts. What's different today versus the initial banting introduction in 1860s, the introduction of Atkins in 1980s? Was it a difference in the specific nuances of how to apply this low-carbohydrate diet, or is there just a much better understanding of how to measure the physiological health markers? What's different today versus the previous false starts?

Tim N.

I think one false start was that the Atkins diet was taking off in the early 2000s, and then he died, sadly. Then that killed it for... People said, "Oh, he died because of X, Y, Z," which wasn't true. His diet didn't kill him. I think what's changed now is that the internet and social media has helped, but I think the science is coming through. And you can tell the science is coming through because the backlash is huge. Industry's backlash and getting published rubbish data, which is absolutely appalling because there's been this onslaught of nonsensical science, which has been published by beta journals in Britain and the United States.

It just shows how scared they are because they're allowing this rubbish to be published. So I think that's what's happening, and let's not forget the company that lives very close to you, Virta Health, which has now shown that we can reverse Type 2 diabetes. That is a massive, massive event. If it hadn't been for Virta Health, we would still be 10 years away from showing that you can reverse Type 2 diabetes. They accelerated the acceptance of it. And the impact of Virta Health... You have to understand the American Diabetes Association has finally, this year, accepted the low-carbohydrate diet can be used in the treatment of diabetes because they couldn't ignore the Virta Health data. So that is a major change because for the last 50 years, they've been promoting high-carbohydrate diets as healthy for diabetics. And how they've got to say, "Actually, a low-carbohydrate diet is acceptable treatment."

Geoff

Right. For folks that might not have seen that paper, this was a two-year study, a one-year study?

Tim N.

Two years. Yeah.

Geoff

Yeah. It's a two-year study of a low-carbohydrate diet, and I think Virta Health has a app to help people go through and coach them through some of these applications. But it's essentially a ketogenic diet. And people essentially got off insulin. People's fasted glucose, fasted insulin would drop. Those are impressive results. Perhaps dive into some of the steel-manning of the other side of the argument. Some might describe that this is... You didn't cure the root cause of carbohydrate intolerance. You just have managed the condition. Did you actually manage Type 2 diabetes, or did you actually cure Type 2 diabetes? For some of the more nuanced discussions, I think it's unquestionable that you are managing this, right? People don't need insulin as much. They can reduce insulin load. But when people reintroduce carbohydrate back into their life, my understanding is that you don't reverse carbohydrate intolerance, necessarily. What are your thoughts there?

Tim N.

Oh, absolutely. It's semantics, but you see, the carbohydrates is the problem. It's like if you're using poison. For us with diabetes, carbohydrates are poison. We can never start eating the poison again. It's going to activate the illness again. So that's the reality. You can't reverse insulin resistance because insulin resistance probably is beneficial in people eating high-fat diets. But it's not beneficial if you're eating a high-carbohydrate diet. Why would insulin resistance be so prevalent as a genetic component of so many populations in the world? Like the Australian aborigines, profoundly insulin resistant. Also the people living in the Pacific Islands, very, very insulin resistant. Why would that be? It has to have some biological reason, some survival value. So I wouldn't want to get rid of my insulin resistance. I just don't want to activate it with a high-carbohydrate diet.

Geoff

Interesting. So maybe this is a protective mechanism. It's sort of the analogy that this is the ambulance on the scene and not necessarily a causal factor, which is interesting. Obviously, I think you're right. Over the last three, five years, this banting diet, this low-carb diet notion has really taken off. And I would say within the last year, carnivore, this notion of only eating meat, has taken off. We've spoken to a number of folks who are advocating that. I've seen you post and discuss that a little bit. Curious to hear your thoughts on carnivore. I've actually experimented with carnivore myself, doing a couple four-week blocks of carnivore. Curious to hear your thoughts on this new, somewhat fringe, perhaps fringe, perhaps interesting diet.

Tim N.

Well, when I first started writing about the high-fat diet, I got letters from people who said they've reversed their Type 2 diabetes. And I said, "It's impossible. I don't believe you." Now, we now accept that, that this diet can reverse Type 2 diabetes. The messages we're getting now is people reversing their autoimmune disease on the carnivore, plant-free diet, plant-based diet that there's no plants in it. I have to say I think that's the next generation of effects, that if I was a scientist today and I was treating people with autoimmune disease, I would like to see what happens if you put them on a diet that was completely free of plants foods and only carnivorous. We're going to have some spectacular results. I don't suggest that it's for everyone, but there will be some spectacular results. Then you can start understanding what's causing autoimmune disease, and there there's a Nobel Prize waiting out there. If I was at the University of California, San Francisco, that's what I'd be doing. If I was a gastroenterologist or leading with other autoimmune diseases, I'd be studying that.

Geoff

I know we have PhD students out there listening, so a Nobel Prize tip here.

Tim N.

Quickest way to the Nobel Prize.

Geoff

What would you say was the hypothesize mechanism of action here? People talked about plants being... Some of the polyphenols are actually triggering immune reaction. What would you hypothesize is in plant material that is not in animal material that is triggering this? What would you specify? What would you hypothesize?

Tim N.

I think that it's the leaky gut syndrome, that there's something in plants, like lectins or other agents that cause the leaky gut to develop. They cause the interest sites to move apart and then allows the bacterial protein to get in. And you cross-react with a protein that comes in which looks like one of your tissues. So you produce an antibody as a response, a cell-based response to that. So you get autoimmune disease. It is so simple, and it's so obviously probably wrong, but it's such an obvious hypothesis to test that that's what I would be doing. I would be looking for leaky gut, reversing the leaky gut and autoimmune disease healing itself.

Geoff

Interesting. Yeah. I think the case studies or the N=1 anecdotes suggest there is some signal here. I think that, to me, is the foundation of science. You see some observation, like here's quite a number of folks who are claiming some autoimmune disease attenuation or some sort of fix with a carnivore diet. There's clearly some signal there. I think that it's premature for folks or professional doctors or researchers to say that is completely wrong. I think the curious mind would say, "Why is that happening? There seems to be some signal here. Can we investigate?" If people do the research and it is wrong, then we will know. But now I think if we just completely ignore it, I think that's unscientific. A fascinating conversation. I'm sure we could go on for a few hours here, but I always want to wrap up with one final question here. And that is, if you had infinite resources, infinite subjects, you could do whatever you want with them, what would be the one trial, the one study that you would want to run? And how would you set that up? You can put people in the metabolic wards. You can put people in the... Whatever you want. What is the Tim Noakes experiment?

Tim N.

One of them would be carnivore diet and its role in autoimmune disease. I think, to me, that would be one of the most spectacular interventions. I think the reversal of dementias with interventions like ketone bodies, that would be really interesting. But I think that the damage has been done to some extent, and I'm not sure how we could go forward there. The other one is cancer. I would love to study cancer on this low-carb diet plus a whole bunch of other supplements. I get feedback from people who use supplementary treatment for cancer, and five years ago, I said they were quacks. It's nonsense. It can't work. But I would like to consider that. In other words, it's not just the ketogenic diet. It's the addition of ketones, and it's the addition of other supplements. I think that that would be really, really interesting. So I would focus on autoimmune disease, and I would focus on cancer because if we can show that we can reverse those two or put those two conditions into remission, that would completely revolutionize medicine.

Geoff

Via a low-carb-diet intervention.

Tim N.

Yeah, off the top of my head. I think that we solved the diabetes issue. Although we continue to research it, I think we've got it. And, finally, because obviously I know your interest, I think the use of ketones in medical conditions needs to be addressed. And, just to finish up, when I was last with you and I was given some of your product, my ketone bodies shot up and my glucose shot down. It was astonishing. I couldn't believe it. So there's a treatment for high glucose. The effect was greater than the drugs I take for controlling my blood glucose.

Geoff

Yeah. Work to be done there. That's a very interesting signal. Absolutely. We're looking into it.

Tim N.

The role of ketones in health is a huge area. But there we go.

Geoff

Professor Tim Noakes, thank you so much for your time. Really a pleasure to have this conversation, and hope to speak to you soon.

Tim N.

Thank you for all the wonderful questions and the chat. I really, really appreciate it. Good luck to you and great success for your company.