As a child, Michael Greger watched his heart-diseased grandmother lapse from a margin of betrothed death.
Her heal was a low-fat Pritikin diet, and her Lazarusian lapse — a spectacle to both immature Greger and a environment of doctors who’d sent her home to die — launched him on a idea to foster a recovering appetite of foods.
Decades later, Greger hasn’t slowed down. Now an general lecturer, doctor, and voice behind a science-parsing website Nutrition Facts, Greger recently combined “bestselling author” to his résumé. His book, How Not to Die, is a 562-page user’s beam for thwarting a biggest and many preventable killers.
His arms of choice? The same one that saved his grandmother: a whole-food, plant-based diet.
Like many books advocating plant-based eating, How Not to Die paints nutritive scholarship with a broad, suspiciously basic brush. Unprocessed plant dishes are good, Greger hammers home, and all else is a corrupt on a dietary landscape.
To his credit, Greger distinguishes plant-based from a rebate stretchable terms vegan and vegetarian, and allows some leisure for humans to be tellurian — “don’t kick yourself adult if we unequivocally wish to put succulent bacon-flavored candles on your birthday cake,” he advises readers (page 265).
But a science, he asserts, is clear: any incursion outward a self-evident broccoli timberland is for pleasure rather than for health.
Despite a biases, How Not to Die contains treasures for members of any dietary persuasion. Its references are sprawling, a range is vast, and a puns aren’t always bad. The book creates an downright box for food as medicine and reassures readers that — distant from tinfoil shawl domain — being heedful of a profit-driven “medical-industrial complex” is justified.
These perks are roughly adequate to make adult for a book’s biggest liability: a steady falsification of investigate to fit a plant-based ideology.
What follows is a examination of How Not to Die’s highlights and hiccups comparison — with a grounds that benefiting from a book’s strengths requires navigating around its weaknesses. Readers who proceed a book as a starting place rather than flawless law will mount a best probability of doing both.
Throughout How Not to Die, Greger distills a immeasurable physique of novel into a simple, black-and-white comment — a attainment usually probable by cherry picking, one of a nourishment world’s many gainfully employed fallacies.
Cherry picking is a act of selectively selecting or suppressing justification to fit a predefined framework. In Greger’s case, that means presenting investigate when it supports plant-based eating and ignoring it (or creatively spinning it) when it doesn’t.
In many cases, spotting Greger’s picked cherries is as elementary as checking a book’s claims conflicting their cited references. These foibles are tiny nonetheless frequent.
For example, as justification that high-oxalate vegetables aren’t a problem for kidney stones (a confidant claim, given a far-reaching acceptance of dishes like rhubarb and beets as unsure for mill formers), Greger cites a paper that doesn’t indeed demeanour during a effects of high-oxalate vegetables — usually sum unfeeling intake (pages 170-171).
Along with saying “there is some regard that incomparable intake of some vegetables … competence boost a risk of mill arrangement as they are famous to be abounding in oxalate,” a researchers advise a inclusion of high-oxalate veggies in participants’ diets could have diluted a certain formula they found for vegetables as a whole: “It is also probable that some of a [subjects’] intake is in a form of high-oxalate containing dishes that competence equivalent some of a safeguarding organisation demonstrated in this study” (1).
In other words, Greger comparison a investigate that not usually couldn’t support his claim, nonetheless where a researchers suggested a opposite.
Similarly, citing a EPIC-Oxford investigate as justification that animal protein increases kidney mill risk, he states: “subjects who didn’t eat beef during all had a significantly revoke risk of being hospitalized for kidney stones, and for those who did eat meat, a some-more they ate, a aloft their compared risks” (page 170).
The investigate indeed found that, while complicated beef eaters did have a top risk of kidney stones, people who ate tiny amounts of beef fared improved than those who ate nothing during all — a jeopardy ratio of 0.52 for low beef eaters contra 0.69 for vegetarians (2).
In other cases, Greger seems to redefine what “plant-based” means in sequence to collect some-more points for his dietary home team.
For instance, he credits a annulment of diabetic prophesy detriment to dual years of plant-based eating — nonetheless a module he cites is Walter Kempner’s Rice Diet, whose substructure of white rice, polished sugar, and fruit extract frequency supports a recovering appetite of whole plants (page 119) (3).
Later, he again references the Rice Diet as justification that “plant-based diets have been successful in treating ongoing kidney failure” — with no premonition that a rarely processed, vegetable-free diet in question is a distant cry from a one Greger recommends (page 168) (4).
In other instances, Greger cites anomalous studies whose only virtue, it seems, is that they absolve his thesis.
These cherry-picks are hard to mark even for a many obliged anxiety checker, since the undo isn’t between Greger’s outline and a studies, nonetheless between a studies and reality.
As one example: in deliberating cardiovascular disease, Greger hurdles a suspicion that omega-3 fats from fish offer illness protection, citing a 2012 meta-analysis of fish oil trials and studies advising people to bucket adult on a ocean’s fattiest bounty (page 20) (5).
Greger writes that a researchers “found no safeguarding advantage for altogether mortality, heart illness mortality, remarkable cardiac death, heart attack, or stroke” — effectively showing that fish oil is, perhaps, usually lizard oil (page 20).
The catch? This meta-analysis is one of a many heavily criticized publications in a omega-3 sea — and other researchers wasted no time pursuit out a errors.
In an editorial letter, one censor forked out that among a studies enclosed in a meta-analysis, a normal omega-3 intake was 1.5 g per day — usually half a amount recommended to revoke a risk of heart illness (6). Because so many studies used a clinically irrelevant dosage, a investigate competence have missed a cardioprotective effects seen during aloft omega-3 intakes.
Another respondent wrote that a formula “should be interpreted with caution” due to a study’s countless shortcomings — including a use of an unnecessarily difficult cutoff for statistical stress (P 0.0063, instead of a some-more common P 0.05) (7). At some-more widely used P-values, a investigate competence have deemed some of a commentary poignant — including a 9% rebate in cardiac death, a 13% rebate in remarkable death, and an 11% rebate in heart conflict compared with fish oil from food or supplements.
And nonetheless another censor remarkable that any advantage of omega-3 supplementation would be tough to denote among people regulating statin drugs, that have pleiotropic effects that resemble — and presumably facade — a mechanisms involved with omega-3s (7). This is important, given in several of a no-benefit omega-3 trials, adult to 85% of a patients were on statins (8).
In a suggestion of accuracy, Greger could have cited a more new omega-3 examination that dodges the prior study’s errors and — utterly cleverly — explains a unsuitable outcomes among omega-3 trials (8).
In fact, a authors of this paper encourage a expenditure of dual to 3 servings of greasy fish per week — recommending that “physicians continue to commend a advantages of omega-3 PUFAs to revoke cardiovascular risk in their high risk patients” (8).
Maybe that’s because Greger didn’t mention it!
Beyond misrepresenting sold studies (or accurately citing argumentative ones), How Not to Die features pages-long slogs through a fallacious cherry orchard. In some cases, whole discussions of a topic are built on deficient evidence.
Some of a many gross examples include:
1. Asthma and Animal Foods
In deliberating how not to die from lung diseases, Greger offers a litany of references display that plant-based diets are a best approach to breathe easy (literally), while animal products are a best approach to breathe wheezy.
But do his citations support a explain that dishes are usually lung-helpful if they photosynthesize?
Summarizing a race investigate travelling 56 opposite countries, Greger states that teenagers immoderate internal diets with some-more starchy foods, grains, vegetables, and nuts were “significantly rebate expected to vaunt ongoing symptoms of wheezing, allergic rhinoconjunctivitis, and allergic eczema” (page 39) (9).
That’s technically accurate, nonetheless a investigate also found an organisation rebate fair to a plant-based cause: sum seafood, uninformed fish, and solidified fish were inversely compared with all 3 conditions. For serious wheezing, fish expenditure was significantly protective.
Describing another investigate of asthmatics in Taiwan, Greger relays an organisation that popped adult between eggs and childhood asthma attacks, wheezing, crispness of breath, and exercise-induced coughing (page 39) (10). While not wrong (bearing in mind that organisation doesn’t equal causation), a investigate also found that seafood was negatively compared with central asthma diagnosis and dyspnea, AKA crispness of breath. In fact, seafood surfaced all other dishes measured — including soy, fruit, and vegetables — in safeguarding (in a mathematical sense) conflicting both diagnosed and suspected asthma.
Meanwhile, vegetables — a sinewy star of a prior investigate — didn’t seem useful on any account.
Despite a radio overpower in How Not to Die, these fish commentary are frequency anomalies. A series of studies advise a omega-3 fats in seafood can revoke a singularity of proinflammatory cytokines and assistance palliate uneasy lungs (11, 12, 13, 14, 15, 16).
Perhaps a question, then, isn’t plant contra animal, but “albacore or albuterol?”
Another lung-assuager buried in Greger’s references? Milk. Maintaining a avowal that “foods of animal start have been compared with increasing asthma risk,” he describes one publication:
“A investigate of some-more than one hundred thousand adults in India found that those who consumed beef daily, or even occasionally, were significantly some-more expected to humour from asthma than those who released beef and eggs from their diets altogether” (page 39) (17).
Again, this is usually partial of a story. The investigate also found that — along with shaggy greens and fruit — milk consumption seemed to chop down asthma risk. As a researchers explained, “respondents who never consumed milk/milk products … were some-more expected to news asthma than those who consumed them any day.”
Indeed, a milkless diet was a risk means right alongside diseased BMI, smoking, and ethanol consumption.
While dairy competence also be a trigger for some asthmatics (though maybe rebate mostly than ordinarily believed (18, 19)), a systematic novel points to an altogether safeguarding outcome from opposite components of dairy. Some justification suggests dairy fat should get a credit (20), and tender plantation divert appears strenuously safeguarding conflicting asthma and allergies — presumably due to heat-sensitive compounds in a whey protein fragment (21, 22, 23, 24, 25).
While many of a studies in doubt are singular by their observational nature, a suspicion that animal dishes are certain lung hazards is tough to clear — during slightest though holding a machete to a accessible literature’s integrity.
2. Dementia and Diet
As with all health problems discussed in How Not to Die, if a doubt is “disease,” a answer is “plant foods.” Greger creates a box for regulating plant-based eating to outmanoeuvre one of a many harmful cognitive ills: Alzheimer’s disease.
In deliberating because genetics aren’t a end-all, be-all means for Alzheimer’s susceptibility, Greger cites a paper display that Africans eating a normal plant-based diet in Nigeria have distant revoke rates than African Americans in Indianapolis, where omnivory reigns autarchic (26).
That regard is true, and countless emigration studies endorse that relocating to America is a good approach to hurt your health.
But a paper — that is indeed a broader investigate of diet and Alzheimer’s risk in 11 opposite countries — unclosed another vicious finding: fish, not usually plants, is a defender of a mind.
This was utterly loyal among Europeans and North Americans. In fact, when all totalled variables were analyzed — cereals, sum calories, fat, and fish — a mind advantages of cereal grains diminished, while fish took a lead as a protective force.
Likewise, Greger cites Japan and China’s meatward dietary shifts — and point arise in Alzheimer’s diagnoses — as some-more justification that animal dishes are a jeopardy to a brain. He writes:
“In Japan, a superiority of Alzheimer’s has shot adult over a past few decades, suspicion to be due to a change from a normal rice-and-vegetable-based diet to one featuring triple a dairy and 6 times a beef … A identical trend joining diet and insanity was found in China” (page 94) (27).
Indeed, in Japan, animal fat warranted a prize for many strong relate with insanity — with animal fat intake skyrocketing by scarcely 600 percent between 1961 and 2008 (28).
Yet even here, there competence be some-more to a story. A deeper investigate of Alzheimer’s illness in East Asia shows that insanity rates got an synthetic boost when justification criteria was revamped — ensuing in some-more diagnoses though many change in superiority (29).
The researchers reliable that “animal fat per capita per day increasing extremely over a final 50 years” — no doubt there. But after holding those justification changes into account, a design altered considerably:
“The certain attribute between a intake of sum energy, animal fat, and superiority of insanity left after stratifying by newer and comparison justification criteria.”
In other words, a couple between animal dishes and dementia, during slightest in Asia, seemed to be a technical artifact rather than a reality.
Greger also raises a subject of Seventh-day Adventists, whose religiously mandated vegetarianism appears to help their brains. “Compared to those eating beef some-more than 4 times a week,” he writes, “those who have eaten vegetarian diets for thirty years or some-more had 3 times revoke risk of apropos demented” (page 54) (30).
Reading a study’s excellent print, this trend usually seemed in a matched investigate of a tiny series of people — 272. In a incomparable organisation of roughly 3000 unmatched Adventists, there wasn’t any poignant disproportion between beef eaters and beef avoiders in terms of insanity risk.
Similarly, in another investigate looking during aged members of a same cohort, vegetarianism didn’t magnify a adherents with any brain benefits: beef expenditure showed adult neutral for cognitive diminution (31).
And opposite a pond, vegetarians from a United Kingdom exhibited startlingly high mankind from neurological diseases compared to non-vegetarians, nonetheless a tiny representation distance creates that anticipating a bit gossamer (32).
But what about genetics? Here, too, Greger serves adult a plant-based resolution with a play of picked cherries.
In new years, a E4 several of apolipoprotein E — a vital actor in lipid ride — has emerged as a fearsome risk means for Alzheimer’s disease. In a West, being an apoE4 conduit can travel up the contingency of removing Alzheimer’s tenfold or some-more (33).
But as Greger points out, a apoE4-Alzheimer’s tie doesn’t always reason adult over a industrialized world. Nigerians, for example, have a high superiority of apoE4 nonetheless rock-bottom rates of Alzheimer’s illness — a head-scratcher dubbed a “Nigerian paradox” (26, 34).
The explanation? According to Greger, Nigeria’s normal plant-based diet — abounding in starches and vegetables, low in all things animal — confers insurance against genetic set-back (page 55). Greger speculates that Nigerians’ low cholesterol levels, in particular, are a saving grace, due to a intensity purpose of aberrant cholesterol accumulation in a mind with Alzheimer’s illness (page 55).
To readers unknown with apoE4 literature, Greger’s reason competence sound compelling: plant-based diets pound a sequence joining apoE4 to Alzheimer’s disease. But on a tellurian level, a justification is tough to support.
With few exceptions, apoE4 superiority is top among hunter-gatherers and other inland groups — a Pygmies, a Greenland Inuit, a Alaskan Inuit, a Khoi San, Malaysian aborigines, Australian Aborigines, Papuans, and a Sami people of northern Europe — all of whom advantage from apoE4’s ability to preserve lipids in times of food scarcity, improve fertility when tot mankind is high, palliate a earthy weight of cyclical famines, and generally boost presence in non-agrarian environments (35, 36).
Although some of these groups have deviated from their normal diets (and faced large illness burdens as a result), those immoderate their local transport — furious game, reptiles, fish, birds, and insects enclosed — competence be stable from Alzheimer’s illness in a approach identical to Nigerians.
So, deactivating apoE4 as a ticking Alzheimer’s explosve competence have rebate to do with plant-based eating and some-more to do with common facilities of hunter-gatherer lifestyles: feast-famine cycles, high earthy activity, and unprocessed diets that aren’t indispensably singular to plants (39).
3. Soy and Breast Cancer
When it comes to soy, a “dream of a 90s” is alive in How Not to Die. Greger resurrects a long-retired justification that this former superfood is kryptonite for breast cancer.
Along with restraint some-more absolute tellurian estrogen within breast hankie (a fanciful flay for cancer growth), Greger proposes that soy isoflavones can reactivate a cancer-suppressing BRCA genes, that play a purpose in repair DNA and preventing a metastatic widespread of tumors (pages 195-196).
To make a box for soy, Greger provides several references suggesting this common legume not usually protects conflicting breast cancer, nonetheless also boosts presence and reduces regularity in women who go gung-soy-ho in a arise of their diagnosis (pages 195-196) (41, 42, 43, 44).
For example, to support his matter that “soy seems to revoke breast cancer risk,” Greger cites a examination of 11 observational studies looking exclusively during Japanese women (page 195).
While a researchers did interpretation that soy “possibly” decreases a risk of breast cancer in Japan, their diction was indispensably cautious: a safeguarding outcome was “suggested in some nonetheless not all studies” and was “limited to certain food equipment or subgroups” (41).
What’s more, a review’s Japan-centrism casts vital doubt on how tellurian a commentary are.
Why? A common thesis with soy investigate is that a safeguarding effects seen in Asia — when they do seem during all — destroy to make it opposite a Atlantic (47).
One paper remarkable that 4 epidemiological meta-analyses unanimously resolved that “soy isoflavone/soy food intake was inversely compared with breast cancer risk among Asian women, nonetheless this organisation did not exist among Western women” (48).
Reviews of clinical trials, too, have been unsatisfactory in their query for soy’s legendary anti-cancer perks — anticipating no poignant advantage of soy isoflavones on risk factors like breast firmness or present hormone concentrations (52, 53).
What explains these population-specific differences? Nobody knows for sure, nonetheless one probability is that certain genetic or microbiomic factors intercede a effects of soy.
For example, about twice as many Asians as non-Asians bay a form of abdominal germ that translates isoflavones into equol — a metabolite some researchers trust is obliged for soy’s health advantages (54).
Other theories embody differences in a forms of soy products consumed in Asia contra a West, residual confounding from other diet and lifestyle variables, and a vicious purpose for early soy bearing — in that childhood intake matters some-more than a late-in-life bender of soymilk lattes (55).
What about a ability for soy isoflavones to reactivate a supposed “caretaker” BRCA genes — in spin assisting a physique sentinel off breast cancer?
Here, Greger cites one in vitro investigate suggesting certain soy isoflavones can diminution DNA methylation in BRCA1 and BRCA2 — or, as Greger phrases it, mislay a “methyl straitjacket” that prevents these genes from doing their pursuit (56).
While engaging on a rough spin (the researchers note that their commentary need to be replicated and stretched before anyone gets too excited), this investigate can’t guarantee that eating soy will have a same outcome as incubating tellurian cells subsequent to removed soy components in a lab.
Plus, battles of in vitro investigate never finish well. Along with a new BRCA discovery, other dungeon studies (as good as studies of tumor-injected rodents) have shown that soy isoflavones can enhance breast cancer expansion — lifting a doubt of that paradoxical anticipating is value desiring (57, 58, 59).
That question, in fact, is during a crux of a issue. Whether during a micro spin (cell studies) or macro spin (epidemiology), a investigate surrounding soy on cancer risk is rarely conflicted — a existence Greger fails to disclose.
As we’ve seen, Greger’s references don’t always support his claims, and his claims don’t always compare reality. But when they do, it’d be intelligent to listen up.
Throughout How Not to Die, Greger explores many oft-ignored and myth-shrouded issues in a nourishment universe — and in many cases, sincerely represents a scholarship he draws from.
Amid ascent fears about sugar, Greger helps vindicate fruit — deliberating a intensity for low-dose fructose to advantage blood sugar, the miss of fruit-induced mistreat for diabetics, and even a investigate in that 17 volunteers ate twenty servings of fruit per day for several months, with “no altogether inauspicious effects for physique weight, blood pressure, insulin, cholesterol, and triglyceride levels” (pages 291-292) (60, 61).
He rescues phytates — antioxidant compounds that can connect to certain minerals — from a immeasurable mythology about their harm, deliberating a many ways they can protect conflicting cancer (pages 66-67).
He casts doubt on fears surrounding legumes — infrequently maligned for their carbohydrate and antinutrient calm — by exploring their clinical effects on weight maintenance, insulin, blood sugarine control and cholesterol (page 109).
And, many importantly to omnivores, his gusto for cherry picking spasmodic pauses prolonged adequate to make room for a legitimate regard about meat. Two examples:
1. Infections From Meat
As Greger explains, many of humanity’s many loathed infections originated from animals — trimming from goat-given illness to measles from cattle (page 79). But a flourishing physique of justification suggests humans can acquire diseases not usually from vital in tighten vicinity to plantation animals, nonetheless also from eating them.
For many years, urinary tract infections (UTIs) were believed to issue from a possess radical E. coli strains anticipating their approach from a tummy to a urethra. Now, some researchers think UTIs are a form of zoonosis — that is, an animal-to-human disease.
Greger points to a recently detected clonal couple between E. coli in duck and E. coli in tellurian UTIs, suggesting that during slightest one source of infection is duck beef that we hoop or eat — not a proprietor germ (page 94) (62).
Worse yet, chicken-derived E. coli appears resistant to many antibiotics, creation a infections utterly tough to provide (page 95) (63).
Pork, too, can offer as a source of mixed tellurian illnesses. Yersinia poisoning — related roughly zodiacally to infested pig — brings some-more than a brief hurl with digestive distress: Greger records that within one year of infection, Yersinia victims have a 47-times aloft risk of building autoimmune arthritis, and competence also be some-more expected to rise Graves’ illness (page 96) (64, 65).
Recently, pig has come underneath glow for another health jeopardy as well: hepatitis E. Now deliberate potentially zoonotic, hepatitis E infection is customarily traced to pig liver and other pig products, with about one in 10 pig livers from American grocery stores contrast certain for a pathogen (page 148) (66, 67).
Although many viruses (hepatitis E included) are deactivated by heat, Greger warns that hepatitis E can tarry a temperatures reached in rare-cooked beef — creation pinkish pig a no-go (page 148) (68).
And when a pathogen survives, it means business. Areas with high pig expenditure have consistently towering rates of liver disease, and while that can’t infer means and effect, Greger records that a attribute between pig expenditure and genocide from liver illness “correlates as firmly as per capita ethanol expenditure and liver fatalities” (page 148) (69). In a statistical sense, any devoured pig clout raises a risk of failing from liver cancer as many as celebration dual cans of drink (page 148) (70).
All that said, animal-derived infections are distant from a strike conflicting omnivory, per se. Plant foods offer copiousness of endemic illnesses of their possess (71). And a animals during top risk of transmitting pathogens are — in scarcely any box — lifted in overcrowded, unhygienic, feeble ventilated blurb operations that offer as cesspools for pathogens (72).
Although How Not to Die stays tight-lipped on any advantages of humanely lifted livestock, this is one area where peculiarity can be a lifesaver.
2. Cooked Meat and Carcinogens
Meat and feverishness make a dainty duo, nonetheless as Greger points out, high-temperature cooking poses some singular risks for animal foods.
In particular, he cites what a Harvard Health Letter called a meat-preparation paradox: “Cooking beef entirely reduces a risk of constrictive foodborne infections, nonetheless cooking beef too entirely competence boost a risk of foodborne carcinogens” (page 184).
A series of these foodborne carcinogens exist, nonetheless a ones disdainful to animal dishes are called heterocyclic amines (HCAs).
HCAs form when flesh beef — either from creatures of a land, a sea, or a sky — is unprotected to high temperatures, roughly 125-300 degrees C or 275-572 degrees F. Because a vicious member of HCA development, creatine, is found usually in flesh tissue, even a many woefully overcooked veggies won’t form HCAs (73).
As Greger explains, HCAs were utterly whimsically detected in 1939 by a researcher who gave mice breast cancer by “painting their heads with extracts of roasted equine muscle” (page 184) (74).
In a decades since, HCAs have proven to be a legitimate jeopardy for omnivores who like their beef high adult on a “done” spectrum.
Greger provides a plain list of studies — morally conducted, honestly described — display a couple between high-temperature-cooked beef and breast cancer, colon cancer, esophageal cancer, lung cancer, pancreatic cancer, prostate cancer, and stomach cancer (page 184) (75). In fact, cooking process appears to be a vital go-between for a organisation between beef and several cancers that cocktail adult in epidemiological studies — with grilled, fried, and well-done beef boosting risk significantly (76).
And a couple is distant from usually observational. PhIP, a well-studied form of HCA, has been shown to coax breast cancer expansion roughly as potently as estrogen — while also behaving as a “complete” carcinogen that can initiate, promote, and widespread cancer within a physique (page 185) (77).
The resolution for beef eaters? A cooking process revamp. Greger explains that roasting, vessel frying, grilling, and baking are all common HCA makers, and a longer a food hangs out in a heat, a some-more HCAs emerge (page 185). Low-temperature cooking, on a other hand, appears dramatically safer.
In what competence be a closest thing to an animal food publicity he ever offers, Greger writes, “Eating boiled beef is substantially a safest” (page 184).
Greger’s goal, sparked in his girl and galvanized over a march of his medical career, is to bypass a middlemen and feed vicious — and mostly lifesaving — information to a public.
“With a democratization of information, doctors no longer reason a corner as gatekeepers of believe about health,” he writes. “I’m realizing it competence be some-more effective to commission people directly” (page xii).
And that’s what How Not to Die eventually accomplishes. While a book’s biases forestall it from being a entirely caveat-free resource, it offers some-more than adequate provender to keep health-seekers doubt and engaged.
Readers peaceful to listen when challenged and fact-check when doubtful will benefit many from Greger’s passionate, despite imperfect, tome.