When I wrote the book ‘Devil in the Milk’ back in 2007, I introduced Bob Elliott in the first paragraph. Bob was the Auckland paediatrician who first identified A1 beta-casein from milk as a big risk factor for Type 1 diabetes.
Type 1 diabetes is the form of the disease that often strikes in childhood and then requires daily insulin injections throughout life.
In the years since then I have often thought that history will in time regard Bob as one of the great heroes of modern medicine. He sowed the seeds on which others have continued to build, with a particular focus on A1 beta casein but with those findings also having relevance to other food-derived opioids.
When Bob Elliott finally became ‘Sir Bob’, or more formally ‘Sir Robert’, in the Queen’s Birthday Honours of 2020, he had less than three months to live before succumbing to cancer at the age of 86. I wrote to him on hearing of his knighthood, and asked him how he was going with his memoirs.
Bob replied that they had stalled somewhat. From that I should have guessed his health was failing, but alas I missed the signal. I knew that he had been working on those memoirs at least intermittently for the previous two years. I hope that someone in his family has access to the reminiscences that he did pen, and that they might form the basis of a biography that some medical historian might choose to take up.
Bob’s life is a story that does indeed need to be told. However, there will be some who prefer it stays untold. That is because Bob trod on many toes as he fought without fear or favour in the interests of children and childhood afflictions. Bob’s style was to take up issues with directness, and at times he took on people and groups who did not like either what he was doing or the way he was doing it.
Bob came to Auckland University from Adelaide in 1970, having been appointed as the Foundation Professor of Paediatrics. Early-on, he co-founded the Child Heath Foundation, now known as ‘Cure Kids’. Bob roamed widely in his journey to find answers to child illness, but cystic fibrosis has been a key field where his contributions are already well acknowledged.
Early in his career, Bob, developed a heel-prick test for cystic fibrosis that could be given to babies. This early identification of the condition has made a big impact on extending the life expectancy of cystic fibrosis sufferers.
My own association with Bob Elliott did not occur until 2004. That was when I became aware of his work on Type 1 diabetes and milk that had come out of left field.
Bob had been puzzled as to why Type 1 diabetes was extremely rare in Samoan children living in Samoa but was relatively common in Samoan children living in New Zealand. The ethnicity of the children was the same so clearly it had to be something in the environment.
Perhaps it was something in the physical climate, such as sunlight affecting vitamin D levels? That is a theory that still gets talked about widely by people interested in Type 1 diabetes. However, it was also easy to pick holes in that theory such that at best it could only be a contributing factor.
Eventually, Bob’s investigations led to diet. The obvious difference there between childhood diets in Samoa and New Zealand is that a lot more milk is drunk in New Zealand than Samoa. Was there something about cows’ milk that was triggering the disease. However, the answer was never going to be that easy.
The reason that Bob knew the answer could never be that simple was that Type 1 diabetes was also very uncommon in parts of East Africa where the human diet was focused on cow milk. That gnawed away at Bob until eventually in 1993 he called the Dairy Research Institute and asked them whether there was any difference in the protein chemistry of African milk. The answer came back that there was indeed a small difference in the beta-casein protein. All beta-casein in African cattle was of the A2 type, whereas many European cattle produce beta-casein of the A1 type. It seemed a long shot, but to Bob with his explorer mind it was worth looking at.
It didn’t take long for Bob to identify that the geographic distribution of Type 1 diabetes, which was already known to correlate with milk consumption, correlated much more tightly once A1 beta-casein rather than milk itself was used as the explanatory variable. Bob then went on to test his theory by taking diabetes-susceptible mice, splitting them into two groups, and feeding A1 beta casein to half the animals and A2 beta-casein to the others. Remarkably, 47 percent of the mice fed A1 beta-casein developed Type 1 diabetes but none of those fed A2 beta-casein became diabetic. It all made sense, particularly once it became apparent that a mu-opioid fragment called beta-caseomorphin7 was released from A1 beta casein, but under normal circumstances did not release from A2 beta-casein.
Bob was convinced he had the answer but not everyone else was. The dairy industry in particular was more than a little hostile to the notion that a milk component could be the problem.
Given my own involvement with the dairy industry as Lincoln’s Professor of Farm Management and Agribusiness, I saw some of the fighting at first hand. Indeed, the debate got real nasty and Bob was more than a little wounded by the barbs. I remember Bob saying to me once that the dairy industry and one company in particular had destroyed his career.
It is a long story, far too long to be told here, but I spent many pages in my book ‘Devil in the Milk’ outlining the to-ing and fro-ing that occurred through to 2006, and then updated this in a later edition though to 2010. Now, more than another ten years later, there is more to be said but much of that will have to wait.
Going back to the year 2000, and having seen Bob Elliott’s findings, Corran McLachlan quickly identified parallel findings for ischaemic heart disease. Together with Dunedin entrepreneur Howard Paterson, he set up the A2 Corporation, which with its current identity as ‘The a2 milk Company’ is Australasia’s largest agri-food company by capital value.
Although Bob was largely on the sidelines of the A2 issue for the last decade, the A2 issue continued to be a big help to his ongoing work through Cure Kids. The key diabetes patent was owned 50 percent by Cure Kids (with Cure Kids renamed from the Child Health Foundation) and 50 percent by the NZ Dairy Board (which in 2001 was folded into Fonterra). The A2 Corporation paid $8 million for the 50 percent share owned by Cure Kids, and many children have subsequently benefitted from those funds.
I said that Bob was in recent years largely on the sidelines of the A2 issue, but that was not totally the situation. In 2017, Bob Elliott, plus Professor Boyd Swinburn from Auckland Medical School and myself, with me by then retired from Lincoln University but still working on A2 issues, were three New Zealand-domiciled Kiwis who together with four Australian medical scientists jointly authored an article in the journal Nutrition and Diabetes. There we set out a more sophisticated explanation of how genetic and environmental factors work together to first load the gun and then pull the trigger leading to Type 1 diabetes exposure. That paper is getting considerable traction, with 42 citations already from other papers in the scientific literature, but is not yet fully mainstream thinking.
With hindsight, I think we still missed a key component of the mechanism in that paper. I don’t think any of us were aware that the islet cells of the pancreas, which produce insulin and are destroyed in Type 1 diabetes, contain mu-opioid receptors. This had been known since at least 2014 but it is impossible to read everything and none of us had apparently picked this up. It was in a different literature unrelated to diabetes and we had not seen it.
The presence of mu-opioid receptors in the pancreas helps explains why the beta-casomorphin7 released from A1 beta-casein is inevitably attracted to the islet cells on the pancreas where it attaches to them. When the human immune system then attacks the beta-casomorphin7, there is a risk that it will also accidentally kills the insulin-producing cells themselves to which the beta-casomorphin7 is attached. That is how autoimmune diseases often work. We have known for a long time that there is a protein in the pancreas with a somewhat similar structure to beta-casomorphin7, and that this is capable of confusing the human immune system, but we did not identify the reason why beta-casomorphin7 is attracted to the pancreas in the first place.
It was only in late July of 2020 that I put those evidential streams together and made a note to myself to write to Bob about it. Some weeks later I had still to write to Bob when my wife called out to come quickly to the TV. Alas, it was a news report telling of Bob’s life and now death.
My memories of Bob are of a kindly man, loved by many children, who spent his working life trying to make the world a better place. I think Bob’s full contribution is yet to be recognised.
Most of the world’s leading dairy companies are now working quietly on their own A2 milk projects, with the alternative A1 having now been linked to many health conditions. Companies like Nestlé, Danone and Mead Johnson, plus the biggest Chinese Companies, all have their own A2 projects and nutritional products. In time, history will look back and say that it all started with Sir Bob Elliott.