1-Page Summary

Plant Diets Reduce Disease

Our genes only account for 10-20% of the risk for most leading causes of death, like high blood pressure, heart attacks, cancer. As evidence of this, when people move from low- to high-risk countries, their disease rates change to those of the new environment. For example, a Japanese person who moves to America raises her risk of heart disease, even though she is genetically Japanese.

But aren’t we dying less, and living longer? Not necessarily. Even though lifespan in America has increased slightly over the past decades, the quality of life at the end of life is worse.

The author Michael Greger argues diet is behind all of this. Specifically, that a diet heavy in meat, dairy, eggs, and processed foods is much less healthy than a diet based on whole foods and plants.

Here’s some evidence of how plant-based diets increase health:

• People who used to be vegetarians but who went back to eating meat increased their risk of disease significantly—they increase heart disease odds by 146%, stroke by 152%, diabetes by 166%, weight gain by 231%. Their life expectancy drops by 3.6 years.
• Women who eat more whole plant foods reduce odds of breast cancer by 90%.

In total, lifestyle accounts for 78% of risk of chronic disease. Not smoking, having normal body weight, exercising half an hour a day, and maintaining a healthy diet can reduce the risk of chronic disease by a huge margin.

A plant-based, whole-food diet has been shown to decrease your likelihood of getting a large panel of diseases, from heart disease to Alzheimer’s. Here’s a selection of the many research results cited in the book:

• Drinking 3-4 shots of kale juice a day over 3 months lowers bad LDL cholesterol and boosts HDL cholesterol as much as running 300 miles does.
• Increasing fiber by 7 grams/day reduces risk of stroke by 7%. For the maximum reduction in stroke risk, eat 25 grams/day of soluble fiber and 47 grams/day of insoluble fiber.
• The more plant-based foods you eat, the lower your hypertension rates. Flexitarians show 23% reduced risk of hypertension; vegans show 75% reduced risk.
• Japanese men showed a 25x increase in prostate cancer risk after World War II. This is also associated with a 7x, 9x, and 20x increase in egg, meat, and dairy consumption respectively.
• Premenopausal women who ate 6g of fiber a day had 62% lower odds of breast cancer, compared to those eating <4g a day.

Diet can reverse disease, not just halt it. It's not too late if you already have heart disease or diabetes. Studies have shown that switching to a plant-based diet can reverse atherosclerotic plaques, reverse the influence of smoking on lung cancer, and decrease the inflammation that leads to many cancers.

Preventing disease is better than treating it. Drugs have side effects, and some disease is irreversible

Nuances to Plant Diets and What We Eat

Why does plant-based diet improve health? Humans evolved over millions of years eating primarily vegetables, so many of our biological responses to food were wired to prehistoric diets.

Today’s modern environment is unnatural, in the sense that we haven’t evolved to handle the new types of food available to us, as well as the quantity available.

• Processed foods now contain much more fat, sodium, and caloric density than we evolved eating. Our normal biological processes haven't adapted to surviving on modern diets.
• Modern foods are so nutrient dense that they amplify the dopamine reward circuit. After eating ice cream, ordinary mangos are nowhere near as enjoyable. By eating whole foods, you can reset this sensitivity.

Regulation of food is often strongly influenced by industry. Just like how the tobacco industry fought to show smoking didn't cause cancer, there is a strong agriculture lobby promoting meat and processed foods.

Why Plants Help and Meat Hurts

Meat itself seems negatively correlated with health and mortality, even controlling for vegetable intake. In other words, if group 1 eats vegetables, and group 2 eats the same amount of vegetables but adds meat, group 2 shows higher mortality and risk of disease.

In these research studies, are vegetarians healthier simply because they tend to be skinnier? No—in population studies, plant-based diets show lower mortality even controlling for BMI, wealth, and other confounding factors.

In research studies, eating health supplements doesn’t have as positive an effect as whole foods. This might be because whole foods contain many other benefits, such as fiber and other micronutrients. Supplement extracts also introduce risk of contaminants and toxicity.

Even More Reasons to Eat Vegetables and Fruit

Think of your diet everyday as a bank account of 2000 calories you can spend everyday. Eating one 800 calorie hamburger displaces eating 7 sweet potatoes or 26 cups of broccoli. Which one would benefit your body more?

Some might shy away from a plant-based diet because it seems expensive. This is partly true—on a calories-per-dollar basis, junk food and fat are the cheapest. But on a nutrients-per-dollar basis, vegetables offer 6x more nutrition compared to processed food.

• Meat costs 3x more than vegetables but deliver 16x less nutrition. Thus, meat is 48x more expensive on a nutrient basis than vegetables.

Diet by Traffic Light

Eating a plant-based diet doesn’t have to be complicated. Michael Greger suggests thinking of food as a traffic light system:

Green Foods: Unprocessed plant foods

• Unprocessed means nothing bad is added, and nothing good is taken away.
• Sometimes, processing actually makes food healthier. Tomato juice may be healthier than whole fruit because the nutrient lycopene is more available. Similarly, cocoa powder is processed to remove saturated fat.
• You can eat unlimited amounts of green foods.

Yellow Foods: Processed plant foods, Unprocessed animal foods

• Processed means something bad is added, or something good is taken away.
• For example, almond milk is worse than eating pure almonds.
• Ideally you’d replace yellow foods with their corresponding green foods, which are more nutritious.

Red Foods: Ultra-processed plant foods, Processed animal foods

• Eat red foods sparingly. In driving, you might run a red light once in a while, but you don’t make a habit of it. The same is true of red foods.
• It’s OK to eat these in small amounts, if they help you eat more green foods (such as bacon bits or hot sauce with vegetables).

Dr. Greger’s Daily Dozen

As a simple checklist for what to eat everyday, Dr. Greger recommends these 12 components. Each box represents one serving.

• Beans: 3 Servings [ ] [ ] [ ]
• Berries: 1 Serving [ ]
• Other Fruits: 3 Servings [ ] [ ] [ ]
• Cruciferous Vegetables: 1 Serving [ ]
• Greens: 2 Servings [ ] [ ]
• Other Vegetables: 2 Servings [ ] [ ]
• Flaxseeds: 1 Serving [ ]
• Nuts: 1 Serving [ ]
• Spices: 1 Serving [ ]
• Whole Grains: 3 Servings [ ] [ ] [ ]
• Beverages: 5 Servings [ ] [ ] [ ] [ ] [ ]
• Exercise: 1 Serving [ ]

These 12 recommendations form “Dr. Greger’s Daily Dozen.”

Shortform Introduction

Caveats

How Not to Die contains many good ideas, and it's one of the most rigorously cited mass-market books on nutrition out there.

That said, because it's written for a wide audience and doesn't want to bog readers down in scientifically precise language, Michael Greger sometimes cuts corners on his claims. Here are issues to note:

The magnitude of effects is important. Does eating organic blueberries have a 5% effect or a 50% improvement of health, compared to conventionally grown blueberries? Does meat-eating cost 1 year of life, or 5 years? Often Greger simply says the difference "is significant"—but this is a statistical term, which laymen may misconstrue as "the difference is huge." He often does this more when the difference is small (below 5%). When the difference is big, he'll use the actual number ("a 20% difference!"). This is misleading and over-represents the effects of some diet choices.

Whenever Greger says something has "up to a [X%] difference", this is misleading. When doing statistical analysis, science uses confidence intervals—"the effect can be as low as 1%, as high as 10%, and an average of 5%." Greger would sometimes represent this to mean "up to 10% improvement." This is misleading as it over-represents the likely effect.

Many of the underlying cited studies are questionable in scientific rigor. This includes issues such as small sample sizes, unclear controls, unclear selection of the patient group, funding by the agricultural group that would benefit from positive results, and only one study done for the conclusion. Remember that all scientists have an agenda and naturally bias toward publishing positive results. But based on a single study, he might say confident blanket statements like “citrus protects DNA from damage.” By far the most convincing studies are large population studies, or large randomized controlled trials, which are highlighted in the next section.

Occasionally his interpretations of research is questionable. For instance, to promote organic foods, he says “organic fruits and vegetables do appear to have more nontraditional nutrients like polyphenol antioxidants.” However, his cited study found “no consistent differences in plasma or urine carotenoids, polyphenols, vitamins E and C content, LDL cholesterol, antioxidant activity, ability to protect against DNA damage, immune system markers between participants consuming organic and conventional diets.” Now, they do say slightly different things—he’s talking about nutrient density in foods, and the study is talking about blood levels. But it’s disingenuous to use this citation to back up his point. By far he says what most of his references say, but this error occurred more often than expected, thus possibly requiring a slight downweighting of his recommendations down a notch.

The Most Convincing Studies

How Not to Die features hundreds of nutritional studies to back up its claims. While many of them suffer from the issues discussed above, a handful of them stand out as particularly robust and well-known among scientists. If you’re interested in digging deeper into the book, you might find these studies especially meaningful.

• The Nurses’ Health Study showed that consumption of processed and unprocessed red meat was associated with an increased risk of death from cancer and heart disease, and shorter life spans. Each increase of 1 serving of meat per day increases mortality in a stepwise fashion. Processed red meat is worse than unprocessed red meat.
• Similar conclusion from NIH-AARP study, showing a higher mortality risk between the highest and lowest quintile of red meat eaters, for both men and women. Both of these control for BMI, smoking, alcohol, physical activity, energy intake, and vegetable consumption. So meat itself looks damaging, even after controlling for vegetables.
• The Ornish Lifestyle Heart Trial showing that lifestyle changes could reverse heart disease, reducing stenosis by 8% over 5 years, compared to 28% worsening for control.
• The PREDIMED randomized controlled trial showed that the Mediterranean diet with olive oil or nuts reduced the risk of stroke by 30-50% and reduced mortality risk by 39%.
• A Taiwanese population study showed that even eating just a little meat (a serving every few days) increased the rates of diabetes by 2x in men and 4x in women, compared to vegetarians.
• Fruit and vegetable consumption reduces stroke by 30% and coronary heart disease by 20% when controlled for typical factors (like BMI, smoking, and alcohol).

Organization of the Book

The book is divided into two major parts:

• Part 1: A discussion of the 15 most common causes of death, in decreasing order, starting from heart disease and ending with deaths caused by medical care. For each disease, Greger explains how the disease arises and its risk factors, as well as ways to decrease your chance of dying from this disease.
• Part 2: A discussion of what to eat to reduce your risk of all causes of death. Based on a whole-foods, plant-based diet, Greger discusses the benefits of foods like vegetables, berries, and nuts. He also recommends certain foods within a group as healthier than others.

Preface

The US healthcare system runs on a fee-for-service model: doctors get paid for pills and procedures they perform, not for patient health outcomes. Thus, actually preventing disease and improving patients’ lifestyle is undervalued in medical care.

To wit, most medical schools don’t have any courses on nutrition. Doctors receive very little training on how diet can reduce the risk of serious disease and death. No wonder the medical establishment has paid so little attention to the value of nutrition.

Introduction

Our genes only account for 10-20% of the risk for most leading causes of death, like high blood pressure, heart attacks, cancer. As evidence of this, when people move from low- to high-risk countries, their disease rates change to those of the new environment. For example, a Japanese person who moves to America raises her risk of heart disease, even though she is genetically Japanese.

But aren’t we dying less, and living longer? Not necessarily. Even though lifespan in America has increased slightly over the past decades, the quality of life at the end of life is worse.

The author Michael Greger argues diet is behind all of this. Specifically, that a diet heavy in meat, dairy, eggs, and processed foods is much less healthy than a diet based on whole foods and plants.

Here’s some evidence of how plant-based diets increase health:

• People who used to be vegetarians but who went back to eating meat increased their risk of disease significantly—they increase heart disease odds by 146%, stroke by 152%, diabetes by 166%, weight gain by 231%. Their life expectancy drops by 3.6 years.
• Women who eat more whole plant foods reduce odds of breast cancer by 90%.
• Whole plant foods have been associated with longer telomeres (parts of your DNA that are associated with aging), while refined foods and meat are associated with shorter telomeres. Is this because vegetarians eat less? No—caloric restriction and exercise alone didn’t improve telomere length, so seems like telomeres were affected by the quality of food eaten.

In total, lifestyle accounts for 78% of risk of chronic disease. Not smoking, having normal body weight, exercising half an hour a day, and maintaining a healthy diet can reduce the risk of chronic disease by a huge margin.

But wait—can’t we just take medication to reduce our risk of disease? Not really. Drugs can’t protect you fully from disease, and they have side effects. Here’s an analogy—you have a running faucet that is causing a sink to overflow. Taking drugs is like mopping up the floor around the overflowing sink constantly, instead of turning off the faucet.

Preventing the disease is often far better than treating it over years and decades. And diet is the way this book recommends you prevent disease.

Part 1: How Not to Die from Disease | Heart Disease, Lung Disease

Heart Disease

Annual deaths from heart disease: 375,000

About Heart Disease

Coronary heart disease didn’t use to exist in some populations. It appears to be predominantly an environmental problem—when people move from low-risk areas to high-risk areas, their disease rates increase to match their new homes.

Atherosclerotic plaque—the hardening of blood vessels and a contributor to heart attacks—can start to be seen in childhood.

Elevated cholesterol and LDL is the only risk factor for atherosclerotic plaque. To reduce LDL, you need to reduce intake of trans fat, saturated fat, and dietary cholesterol

• A single unhealthy meal can stiffen your arteries within hours.

Ideally, your optimal LDL is 50-70 mg/dL, and your total cholesterol under 150 mg/dL. The usual recommendation from doctors is below 100 mg/dL and 200 mg/dL, respectively, but keep in mind this is the average recommendation in a country where heart disease is the #1 killer. It’s better to aim for better than average, if you want to beat the average statistics on heart disease deaths.

Heart disease itself is reversible—plaques can actually shrink in size! Your body actually wants to heal itself. But if you cut yourself and keep slicing open the cut 3 times a day, it’s not going to heal

How Not to Die from Heart Disease

Meat eating is associated with heart disease and atherosclerotic plaques. A possible mechanism is that bacterial endotoxins in meat might trigger inflammation, even when the meat is cooked.

Foods shown to reduce heart disease:

• Brazil nuts lower LDL cholesterol within hours, and the effects persist a month later.
• Drinking 3-4 shots of kale juice a day over 3 months lowers LDL and boosts HDL as much as running 300 miles does.
• A diet of 6-8 sweet potatoes a day lowered blood pressure by 5 points.

Things that don’t reduce heart disease:

• Fish oil shows no proven benefit for overall mortality, heart attack, or stroke.
• Statin medications are good for patients who won’t comply with diet, but they have side effects of liver and muscle damage, as well as diabetes.

Why doesn’t the idea that diet can reverse heart disease get more public attention? It likely has to do with lobbying interests by powerful industry groups.

• In 1977, the US Senate committee released dietary guidelines advising that the population cut down on animal-based foods. But the meat, milk, and egg industries successfully lobbied to remove this recommendation from the report.
• Professional medical organizations are often funded by food companies, which aim to influence doctor recommendations.

Lung Disease

Annual deaths from lung disease: 296,000

Within lung disease are three sub-diseases:

• Lung cancer: 160,000 deaths per year
• Chronic obstructive pulmonary disease (also known as emphysema): 140,000 deaths per year
• Asthma: 3,000 deaths per year

Lung Cancer

Smoking is the most serious risk factor for lung cancer.

• Male smokers are 23x more likely to get lung cancer than non-smokers. Female smokers are 13x more likely.
• If you think the author’s suspicion of lobbying efforts sounds a little nutty, remember that tobacco company Philip Morris executed a Whitecoat Project to influence doctors to publish research studies discrediting the link between secondhand smoke and lung disease.
• The risk is not permanent—within a year of quitting smoking, a smoker’s risk of heart disease drops to half of current smokers.

A quarter of lung cancer comes in never-smokers. Fumes from frying foods could contribute to the development of cancer, since they release volatile chemicals that increase DNA mutations and thus increase cancer risk.

• Smokers who stir-fry meats every day have 3x the lung cancer odds as smokers who stir-fry foods other than meat daily. Chemically, frying meat creates heterocyclic amines.
• Mothers who were exposed to fumes from grilled meats tended to have babies with smaller head size and lower IQ. The chemicals involved are believed to be polycyclic aromatic hydrocarbons.
• Bacon causes more DNA mutations than beef patties, by releasing nitrosamines.

How Not to Die from Lung Cancer

• Smokers eating a single stalk of broccoli a day show 41% fewer DNA mutations in their bloodstream.
• From cruciferous vegetables (like broccoli and cauliflower), an extract of the compound isothiocyanate showed stunting of cancer growth.
• Curcumin in the spice turmeric causes a drop in DNA mutation rate in smokers, and it reactivates apoptosis in cancer cells.

Chronic Obstructive Pulmonary Disease

COPD is caused by inflammation in lung that leads to long-term breathing problems. The main cause is tobacco smoking, with air pollution and genetics having smaller influences.

Eating cured meat seems to increase the risk of COPD, possibly because of nitrites used in curing meats..

How Not to Die from COPD

• One extra serving of fruit a day showed a 24% lower risk of dying from COPD. This is possibly due to the antioxidant and anti-inflammatory properties of compounds in fruit.

Asthma

How Not to Die from Asthma

• Antioxidants from fruits and vegetables are thought to neutralize free radicals in the respiratory tract that contribute to asthma. Oxidation by-products lowered with plant-based diet
  • Kids living in areas where whole-plant diets are more common are significantly less likely to show asthma, wheezing, and allergic eczema.
  • Removing eggs and dairy from diet improves asthma within 8 weeks. Adding fruits and vegetables to the diet reduced asthma exacerbation rate by half.
• Supplements of fruit and vegetable extracts don’t work—equivalent servings of fruit and vegetables in pill form didn’t improve asthma.
• Some asthma patients who were thought to be medically unmanageable even dropped asthma medications altogether after switching to a plant-based diet.

Part 1-2: Brain Diseases, Digestive Cancers

Brain Diseases

Annual deaths from brain disease: 215,000

This includes:

• Stroke: 130,000 deaths per year
• Alzheimer’s: 85,000 deaths per year

Stroke

Strokes are caused by a clogged artery in the brain, leading to a lack of oxygenation of the brain and death of part of the brain. Like heart disease, hardening of the blood vessels through atherosclerotic plaques is a contributor to the risk of strokes.

How Not to Die from Strokes

Reduce your risk of strokes by 1) reducing cholesterol and blood pressure and 2) improving blood flow and antioxidants.

Fiber

• Increasing fiber by 7 grams/day reduces risk of stroke by 7%. For the maximum reduction in stroke risk, eat 25 grams/day of soluble fiber and 47 grams/day of insoluble fiber.
• It’s not known exactly why fiber reduces risk of stroke. It might help control cholesterol and blood sugar, which in turn reduces atherosclerotic plaque.
• It may also lower blood pressure, reducing risk of brain bleeds.

Potassium

• 1,640 mg increase of potassium is associated with a 21% reduction in stroke
  • Best source of potassium: greens, beans, sweet potatoes. Not bananas.

Citrus

• Citrus reduces stroke risk, possibly through the compound hesperidin, which increases blood flow throughout the body.
• In one study, there were three experimental groups given different treatments: 1) orange juice, 2) hesperidin solution, and 3) control. Hesperidin lowered blood pressure and increased endothelial reactivity (a measure of blood vessel health). Orange juice performed best, better than the chemical extract of hesperidin.
• In another study, women with poor extremity circulation were placed in a cold room. Those who drank orange juice cooled half as fast, suggesting it improves circulation.

Sleep

• Those at lowest risk of stroke sleep 7-8 hours a night. Much more or much less sleep than this increases risk of stroke.

Antioxidants

• Your body needs energy to function, and oxygen normally plays a critical role. Because oxygen is very reactive, it also tends to steal electrons from other chemicals, becomes a radical oxygen species, and oxidizes substances like DNA, causing mutations (which can lead to cancer). Antioxidants slow this down by placating oxygen and reacting with it instead of your DNA.
• Physiologically, antioxidants prevent circulation of oxidized fats that can damage blood vessels. Antioxidants decrease artery stiffness, prevent blood clots from forming, lower blood pressure, lower inflammation
• In population studies, people who eat the most antioxidant-rich foods had the lowest health risks.
• Plant foods contain 64x more antioxidants than animal foods
  • (Shortform note: Why do plant foods contain so much more antioxidants than animal foods? One theory suggests that antioxidants are needed to protect against sun damage. Plants spend much of their time in the sun, immobile, getting energy for photosynthesis. In contrast, animals get their energy from eating food, and they can escape from sun damage.)
• Foods that brown slowly (like mango) have more antioxidants than foods that brown quickly.
• Herbs and spices: adding cinnamon, oregano can add a lot to antioxidant power.
• As is a theme, supplements of antioxidants don’t seem to help much at all. Natural foods perform much better in experimental studies.

Alzheimer’s Disease

The immediate proximal cause of Alzheimer’s Disease is amyloid plaques in the brain; the plaques damage neurons and neuronal networks. A total cure for people with Alzheimer’s is likely impossible, given that the neuron networks have been damaged. But prevention may be possible.

The root cause of Alzheimer’s could be vascular in nature.

• Atherosclerosis is associated with Alzheimer’s and lost brain function
• Cholesterol may help seed amyloid plaques. Autopsies show that brains of Alzheimer’s patients have significantly more cholesterol buildup than brains without Alzheimer’s.

While genetics has been implicated in Alzheimer’s disease, it’s not the full story. The environment affects risk of Alzheimer’s too.

• Migration studies show that Japanese men in the US have dramatically higher Alzheimer’s rates than native Japanese people. Similarly, African-Americans show higher risk than Africans in Nigeria.
• The closest link to explain this discrepancy is animal fat consumption. Non-meat eaters cut their risk of dementia by half.
• A mutated ApoE4 gene is implicated for increasing Alzheimer’s risk dramatically—a person homozygous for this mutated gene increases risk by 9x; a heterozygous person has 3x the risk. What does the protein ApoE4 do? It’s a major cholesterol carrier in the brain.
  • For people with homozygous mutations, controlling blood pressure and cholesterol cuts risk of Alzheimer’s from 9x to 2x.

How Not to Die from Alzheimer’s

As is a common theme now, eat whole plant foods and avoid meat.

A diet with less saturated fat relative to unsaturated fat is protective against Alzheimer’s. In a population study, people with the highest level of saturated fat intake had a 60% greater chance of cognitive deterioration.

Antioxidants from diet may cross the blood-brain barrier and protect against oxidative damage in the brain, inhibiting formation of the plaques that cause Alzheimer’s.

• Women who ate one serving of blueberries and two servings of strawberries a week had slower rates of cognitive decline, by as much as 2.5 years.
• People who drank fruit and vegetable juices regularly had 76% lower risk of Alzheimer’s.
• This effect may be mainly caused by polyphenols—concord grapes and cranberries are especially rich in these compounds.

Saffron

• Saffron was better than placebo in improving cognitive function among patients with mild dementia.
• In a double-blind study, it was as effective as the drug donepezil (Aricept), a drug used to enhance cognition for Alzheimer’s patients.

Eat less meat to reduce the level of advanced glycation end products (AGEs).

• AGEs are formed by dry-heating fat-rich and protein-rich foods. Chicken, bacon, and hot dogs are the worst offenders. Baking, broiling, and grilling such meats is far worse than boiling or steaming.
• AGes accelerate aging by cross-linking proteins, which causes tissue stiffness, oxidative stress, and inflammation.
• People with higher AGEs in their diet show faster loss of cognitive function.

Exercise

• Aerobic exercise reversed age-related shrinkage in brain and improved memory performance. There was no effect in the group that just stretched and did non-aerobic strength-training.

Digestive Cancers

Annual deaths from digestive cancers: 114,000

This includes:

• Colorectal cancer: 50,000
• Pancreatic cancer: 46,000
• Esophageal cancer: 18,000

The digestive system has a surface area of thousands of square feet, much more than the 20 square feet of skin and hundreds of square feet of lungs. Consider your digestive tract the interface with the world.

Colorectal Cancer

Colorectal cancer is among the most treatable cancers—if diagnosed before it spreads the colon, the 5-year survival rate is 90%.

• Starting at age 50 to 75, get stool testing every year, or stool testing every 3 years plus sigmoidoscopy every 5 years, or a colonoscopy every 10 years.

How Not to Die from Colorectal Cancer

Have larger stool size during bowel movements.

• Larger stools and faster intestinal transit time are associated with lower rates of colon cancer.
• A good stool weight is half a pound. People with quarter pound stools have 3x the rate of colon cancer.
• The larger the stool, the faster the transit time. A good time is 24-36 hours. This can be tested by eating beets, then noticing when your stool turns pink.
• Constipation can be solved with dietary fiber.

Phytates

• Found in seeds, grains, beans, and nuts.
• Phytates have a host of good health properties: they’re antioxidant, anti-inflammatory, anti-angiogenic, and immune-enhancing (by activating natural killer cells).
  • In lab studies, phytates also inhibit the growth of human cancer while leaving human cells alone.
• Phytates remove excess iron, which can generate hydroxyl radicals.
  • Meat eaters absorb high amounts of heme iron, which is often not counterbalanced by eating more seeds and nuts.
• Phytates were once feared to inhibit mineral absorption, but later studies showed that people eating high levels of phytates tend to have greater bone mineral density and fewer hip fractures.
• High vegetable, low-meat diets have 8x risk of colorectal cancer compared to low-vegetable, high-meat diets.
• Increasing bean consumption by ¼ cup a day cuts polyp recurrence by 65%.

Berries

• Berries contain antioxidants, which suppress cancer cell growth in vitro.
• Eating black raspberries cut the polyp count of patients with familial adenomatous polyposis in half.

Turmeric

• Contains curcumin, which has antioxidant and anti-mutagenic properties. Curcumin doesn’t get absorbed well into the bloodstream, but it stays intact in the digestive tract to interact with polyps.
• In a study, curcumin reduced the occurrence and size of polyps throughout the spectrum of colorectal cancer, from aberrant foci to benign polyps to cancerous polyps, by up to 40%.
• Cancer rates in India are much lower than those in the United States—for example, the US shows 10 times more colorectal cancer, 12x more kidney cancer. Turmeric may explain part of it, but another contributor may be less meat-eating: only 7% of Indians eat meat on a daily basis, with most of their diet consisting of leafy vegetables and legumes.

Red meat problems

• Eating processed and unprocessed red meat is associated with increased mortality from cancer and heart disease, and lower lifespans—even after controlling for age, weight, alcohol, exercise, smoking, family history, and intake of plant foods. This suggests there is something bad about eating meat itself.
• It could be heme-iron—iron is a pro-oxidant (the opposite of an antioxidant) that generates free radicals. The heme-iron in meat is also absorbed more effectively by the digestive tract compared to non-heme iron from plants, and heme-iron also has less autoregulation of absorption to prevent you from absorbing too much. In short, if you have too much iron in your body, you stop absorbing non-heme iron from plant foods, but you keep absorbing heme iron from meat.
• Good plant sources of iron include whole grains, legumes, nuts, seeds, dried fruits, and green leafy vegetables.
• Vitamin C helps with iron absorption.

Pancreatic Cancer

Pancreatic cancer is one of the deadliest cancers because of late detection. Only 6% of patients survive 5 years after being diagnosed with pancreatic cancer, compared to 90% for colorectal cancer.

How Not to Die from Pancreatic Cancer

Risk factors for pancreatic cancer include smoking, obesity, and alcohol.

Avoid animal fat.

• Fat from animal sources is associated with pancreatic cancer risk. No correlation was found with plant fats.

Avoid chicken.

• Workers who slaughter chickens have 9 times the odds of pancreatic and liver cancer. In comparison, smoking only doubles the odds of pancreatic cancer.
• For every 50g of chicken consumed daily, you increase your risk of pancreatic cancer by 72%.
• The cause is not currently clear. One suspect is chicken cancer viruses that cause warts.

Eat more turmeric.

• For pancreatic cancer patients, 2 out of 21 responded to treatment with turmeric. One patient had a 73% reduction in tumor size until a curcumin-resistant tumor appeared. Another showed improvement over 18 months.
• While these numbers sound low, a similar % of patients responded to chemotherapy.

Esophageal Cancer

Esophageal cancer has a 5-year survival rate of <20%.

How Not to Die from Esophageal Cancer

Risk factors for esophageal cancer are smoking, alcohol, and acid reflux (heartburn).

Reduce acid reflux through diet.

• Over the past 30 years, esophageal cancer has increased 6-fold. This is possibly due to better detection of the disease, but also possibly due to an increase in acid reflux.
• 28% of people in the US suffer weekly heartburn, compared to 5% in Asia.
• Meat and high-fat meals are associated with acid reflux, followed by cancer in the esophagus. This could be because the hormone cholecystokinin is triggered by meat and eggs, and this may relax the esophageal sphincter, causing stomach acid to spill into the stomach.
  • Meat-eaters have 2x the odds of reflux-induced esophageal inflammation, compared to vegetarians.

Fiber

• High fiber intake reduces the incidence of esophageal cancer by ⅓.
• Low-fiber diets cause straining while passing stool. This increases abdominal pressure and can push the stomach out of the abdomen, which leads to acid reflux. High abdominal pressure also causes hemorrhoids and diverticulosis.

Strawberries

• Eating 1-2 ounces of freeze-dried strawberries everyday for 6 months caused reversal of disease in 80% of patients with precancerous esophageal lesions.

Stomach Cancer

How Not to Die from Stomach Cancer

• Risk factors for stomach cancer are high sodium in diet and meat eating. These are on par with smoking or alcohol.
• Korea has the highest rate of stomach cancer in the world, possibly because of their fondness for kimchi.

Part 1-3: Infections, Diabetes

Infectious Disease

Many infectious diseases resulted from human domestication of animals. We got tuberculosis from goats, measles and smallpox from cattle, typhoid fever from chickens, and the cold virus from horses.

Your immune system consists of a few types of cells:

• White blood cells
  • Neutrophils destroy pathogens like bacteria and parasites directly.
  • Natural killer cells kill your body’s cells that are infected.
• B cells
  • Produce antibodies that bind to a specific antigen (like a bacterial protein).
  • These antibodies then deactivate pathogens, or signal to natural killer cells that a cell is infected.

For some reason, people suffering from allergies have lower risk for some cancers. One theory is that an overactive immune system also protects against threats like cancer cells.

Reducing Infections and Boosting Immune System

Fruits and vegetables

• An evolutionary theory for the relationship between eating plants and the immune system: to reduce energy expenditure, the immune system activates itself periodically at times of greatest risk—including eating food with potential pathogens. As cavepeople, we evolved over millions of years mainly eating plants, not meat—therefore, plants serve as better triggers to activate our immunity.
• A host of experiments show the benefits:
  • In an experiment, people over 65 who ate 5+ servings of fruits and vegetables had a 82% greater protective antibody response to vaccine, compared to people who ate <3 servings.
  • Raw kale extract stimulates 5x greater antibody production in vitro
  • Broccoli activates intraepithelial lymphocytes.
  • Phytonutrients from plants reduce the toxicity of dioxins (common in pollution) in vitro, but the effects only last for a few hours.
  • Blueberries (1.5 cups per day for 6 weeks) doubled natural killer counts in athletes after intense exercise, when normally exercise cuts those cell counts in half.

Other diet

• Cardamom activated the activity of natural killer cells against lymphoma cancer by 10x in vitro.
• Probiotics: Babies delivered via C-section have increased risk for allergies. The theory is that natural birth babies are exposed to the mother’s vaginal bacteria, which then reside in the baby’s gut.
  • There isn’t enough evidence yet to suggest that supplementation of probiotics is necessary.
• Mushrooms: Eating button mushrooms daily over a week increased IgA antibody levels in saliva by 50%.

Exercise

• Exercise may activate IgA antibody production in saliva, eyes, and nostrils.
• Aerobic exercise for 30 minutes a day, 3 times a week for 12 weeks increased IgA levels in saliva by 50%, compared to control.
• Elderly sedentary women have a 50% chance of getting a cold in the fall. 0.5 hours per day of walking reduces the risk to 20%. Conditioned runners have just an 8% risk.
• Overtraining, like with marathons, increases risk of infection. This can be addressed through eating chlorella and nutritional yeast—both reduce the risk of infection and maintain IgA/white blood cell levels.

To prevent transmitting diseases to other people when you’re sick:

• Cough into the crook of your arm (inner elbow), not your hand.
• Sanitize your hands after every bathroom visit and handshake, before preparing food, and before touching your eyes or mouth.
• Alcohol-based rubs are preferred for sanitation.

Food Poisoning

Animal foods are the most common source of food poisoning. The common pathogens like E. coli are intestinal bacteria and common in animal feces. Plants don’t have intestines, and so they don’t naturally harbor pathogens.

• Outbreaks of food poisoning in vegetables are often caused by contamination by manure or animals and delivered to plants, eg through irrigation water

Food poisoning often resolves within days, but children and the elderly are especially at risk for worse infections and complications.

The most common food poisoning pathogens:

• Eggs and Salmonella: these can survive the egg cooking methods of scrambling and sunny-side-up.
• Poultry and Salmonella: even when chicken is cooked well, cross contamination spreads bacteria to the kitchen counter, faucet, refrigerator handles, and elsewhere.
• Meat and E. coli: beef has gotten safer over time to eat, partly because of the regulation on the sale of contaminated beef.
• Pork and Yersinia
• All meat and C. difficile: this bacterium resides in your gut and can flare up when you take antibiotics and disrupt your gut microbiome

There’s a lot of concern about bacteria that are resistant to antibiotics. 80% of antibiotics produced go to the meat industry, where animals living in poor conditions tend to get disease that needs antibiotic dosing. This creates an environment enriching for drug-resistant bacteria. By reducing our collective meat intake, we can reduce the development of more serious infections.

Diabetes

20 million Americans have been diagnosed with diabetes.

Annual deaths from diabetes: 76,000 direct deaths, plus 50,000 cases of kidney failure, 75,000 lower limb amputations, and 650,000 cases of vision loss.

The Disease

Diabetes mellitus is a condition in which blood sugar levels are chronically elevated.

High blood sugar damages nerves, leading to neuropathy and pain. It also damages blood vessels, which 1) leads to blindness and 2) cuts off circulation in the extremities, leading to amputation of limbs.

There are two major types of diabetes. Both types concern insulin, the hormone that causes cells to absorb glucose from blood. Insulin is secreted by beta cells in the pancreas.

• Type 1 diabetes is genetic and caused by autoimmune destruction of beta cells. Less insulin production means higher blood sugar. Type 1 diabetes can be treated with insulin injections.
• Type 2 diabetes is caused by insulin resistance. Insulin secretion can be normal or elevated, but insulin doesn’t work as effectively as normal, leaving sugar in blood. This is treated with drugs and sometimes with insulin.

Prediabetes in children is increasing because of obesity. Developing diabetes in childhood cuts life expectancy by 20 years and increases the risk of disease across the board.

Insulin Resistance and Fat

Fat is heavily associated with insulin resistance. 90% of type 2 diabetics are overweight.

• The biological mechanism: fat disrupts the insulin signaling pathway.
• Obese patients have about 2-5x the level of free floating fat in the bloodstream compared to people of normal weight. Obese people are basically spilling fat into the bloodstream constantly.

A person’s diet affects fat levels and insulin resistance, even controlling for the person’s weight.

• A 1927 study put people in two groups: Group 1 had a fat-rich diet, while Group 2 had a carb-rich diet. In high-fat Group 1, insulin resistance increased within days, far more than high-carb Group 2.
• People eating low-carb, high-fat diets can reach the same free floating fat levels as obese people.

Vegetarian Diet on Diabetes

Vegetarians have a 61% lower prevalence of diabetes compared to non-vegetarians.

• It’s not just because they’re skinner—even after controlling for weight, vegans have a <50% risk of diabetes compared to omnivores. Between people of the same weight, vegans have less fat trapped in deep calf muscles compared to omnivores
• Plant-based diets reduce insulin resistance, improve blood sugar control, and reduce LDL cholesterol.

Vegetarian diets have multiple effects that lower the risk of diabetes.

• Eating fewer calories: people tend to eat the same volume of food per meal, regardless of calorie count. Vegetables are calorically far less dense but feel more filling.
• Insulin sensitivity: even without causing weight loss, plant-based diets improved insulin sensitivity and A1C levels in diabetics, within weeks.
• Better eating habits: the plant-based diet group felt less likely to binge and felt less hungry.
• Intrinsic benefits of plant foods: eating five cups of legumes each week had better effects on cholesterol and insulin regulation than cutting 500 calories a day.
• Saturated fats in meat vs unsaturated fats in vegetables.
  • Saturated fats like palmitate cause a variety of bad effects: toxic byproducts like free radicals, inflammation, and mitochondrial dysfunction.
  • Unsaturated fats are less harmful, easier to detoxify, and may suppress inflammation.
  • Saturated fats and LDL cholesterol are toxic to beta cells; monounsaturated fats are not.
• Lower potentially toxic chemicals: PCBs in salmon and canned sardines can disrupt metabolism. People with the highest level of pollutants have 38x the odds of diabetes.
• Higher resting metabolism: vegetarians have higher gene expression of carnitine palmitoyltransferase, which helps metabolize fats.
• Better mood: plant-based group reported better quality of life and higher mood scores than conventional diet.
• Reduces neuropathy pain and can restore vision loss.

While the risk of disease scales with the amount of meat you eat, even a little meat eating is destructive.

• In Taiwan, people’s diet includes little meat to begin with—women ate a single serving each week, and men had a serving every few days. Vegetarian men had half the odds of diabetes as occasional meat eater. Vegetarian women had 25% the odds.
• Meat consumption was associated with weight gain, even after adjusting for calories. In other words, even when eating the same number of calories, meat eaters tend to gain more weight.
  • Specifically, an increase in meat intake of 250g per day (like one steak) leads to a 2-kg higher weight gain after 5 years (Source).
• Poultry is potentially the most fattening meat—people eating 1oz of chicken a day had a significantly greater gain in BMI than non-chicken eaters. This could be caused by industries fattening chickens over time—100 years ago, a serving of chicken may have 16 fat calories; now, it has over 200 fat calories.

Other Interventions on Diabetes

Drugs are commonly prescribed to treat diabetes, but they can increase mortality.

• A seminal NEJM study showed that intensive blood sugar management by drugs led to increased mortality compared to standard therapy. The intensive group had a lower HA1C target and were subject to more drugs and higher doses.
• Insulin administered as a drug can accelerate aging and promote inflammation in arteries.

Gastric bypass surgery reduces diabetes in up to 83% of patients. This is great, but the same effect can be achieved with extreme diets, without the surgery: within a week of eating 600 calories daily, blood sugar levels normalize.

• Hypothesis: during extreme diets, fat is pulled out of fat storage in muscles and liver, allowing normal function of those organs.

Part 1-4: High Blood Pressure, Liver Disease

High Blood Pressure

Annual deaths from high blood pressure: 65,000

The Disease

High blood pressure, or hypertension, is cited as the #1 risk factor for death in the world, leading to 9 million deaths worldwide annually (source: the Global Burden of Disease Study in the Lancet). 78 million Americans have hypertension.

Blood pressure consists of two numbers: systolic is the pressure when blood pumps through the artery, and diastolic is the pressure between beats.

• 110/70 is an ideal blood pressure, even though 120/80 is cited as normal
• 140/90 is hypertensive

Hypertension promotes atherosclerosis (which leads to heart attacks and strokes). It also puts strain on the heart leading to heart failure; it damages blood vessels and leads to kidney disease.

Blood pressure tends to increase with age—65% of Americans age 60 or above have hypertension. But Kenyans of that age eating a low-sodium diet based around whole plant foods had normal blood pressure.

Sodium

Evolutionarily, we ate plant-based diets consisting of 500mg of sodium a day.

Now, average daily consumption is 3,500mg, and the AHA recommends 1,500mg. (Remember that it might not be wise to follow the standard guidelines in a country where heart disease is the #1 killer.)

The relationship is simple: sodium raises blood pressure.

• Double-blind randomized trials show that salt increases blood pressure.
• A single meal increases blood pressure over the next 3 hours, and decreases endothelial function within 30 minutes.

Inversely, cutting sodium from diet lowers blood pressure:

• Dietary changes alone reversed malignant hypertension (240/150) down to 105/80.

The mechanism of action could be free radicals.

• In Doppler flowmetry, sodium reduces blood flow, but vitamin C (an antioxidant that scavenges free radicals) blocks the sodium effect.
• Sodium suppresses an antioxidant enzyme called superoxide dismutase.

How to Reduce Sodium Intake

Understand the major dietary sources of sodium:

• ¾ of salt in the average diet comes from processed foods.
• For kids, the major source of sodium is pizza; for people aged 20-50, it’s chicken; for ages 50+, it’s bread.

Why is there so much salt in food?

• Partly it’s for preservation of food.
• Adding sodium to meat increases water retention, increasing the weight of meat that’s sold.
• Saltier food tastes better than unsalty food, so competition with other products increases sodium across the board.

How to cut back on sodium:

• Adjust your taste buds back to normalcy.
  • Your taste buds adapt to whatever food you give it. Cut sodium, fat, and sugar from your diet for a few weeks—food will taste bland at first, but eventually your taste buds will revert to normal. Food will taste more flavorful, and you will actively dislike aggressively salty and fatty foods.
• Don’t add salt at the table.
• Don’t add salt when cooking.
• Stop eating out so much.
• Avoid processed foods.
• Buy foods with fewer milligrams of sodium than there are grams in the serving size or calories (e.g. <100 milligrams sodium for 100g of serving or 100 calories).

Diet for Hypertension

Whole grains

• Three portions of whole grains a day reduce the risk of heart attack and stroke as effectively as high blood pressure medications (without side effects).
• These have to be whole grains—refined grains like white rice increase the risk of diabetes.

Vegetarian diets

• Rural Kenya and China people (with a low-sodium plant-based diet) show ideal blood pressures throughout all age, unlike Westerners who increase blood pressure with age.
• The more plant-based foods you eat, the lower your hypertension rates. Flexitarians show 23% reduced risk of hypertension; vegans show 75% reduced risk.
• Even controlling for weight, vegetarians show better blood pressure.

Flaxseed

• A few tablespoons a day may be more effective than exercise.
• Double-blind, placebo-controlled, randomized trial showed blood pressure drop from 158/82 to 143/75, compared to no change in control. This drop was multiples that achieved by medication!

Hibiscus

• 3 cups of hibiscus tea a day dropped blood pressure by 6 points over control.
• Hibiscus ranks #1 in antioxidant content of beverages, above green tea.
• Precautions: it’s acidic, so rinse your mouth after drinking. And because of its high manganese content, don’t drink more than a quart a day

Nitrates

• Nitric oxide dilates blood vessels and lowers blood pressure. Nitric oxide is created by NO synthase from nitrates. Free radicals consume NO and disrupt NO synthase. Antioxidants prevent free radicals from causing damage this way.
• A high-antioxidant diet improves endothelial function (the ability of vessels to relax and dilate).
• Best foods for nitrates, in descending order: arugula, rhubarb, cilantro, butter leaf lettuce, mesclun greens, basil, beet greens, oak leaf lettuce, swiss chard, beets.
• Beet juice can lower blood pressure by 10 points within hours, and by similar amounts over weeks with daily consumption. It also seems to allow higher aerobic performance from less oxygen, allowing more time to exhaustion and longer breath-holding.

Wine with alcohol removed

Hypertension Drugs

Drugs are not as effective as diet in reducing blood pressure.

• Calcium-channel blockers drop blood pressure 8/3 points, and ACE inhibitors by 5/2 points, compared to 15/7 for flaxseed.

Drugs also come with lots of side effects

• Diuretics cause electrolyte disturbances
• Calcium-channel blockers (Norvasc, Cardizem) increase breast cancer risk
• Beta blockers (Lopressor, Corgard) cause lethargy and impotence
• ACE inhibitors (Vasotec, Altace) cause swelling

As is the theme of the book, it’s best to fix your medical issues with lifestyle changes and diet first, before needing to rely on drugs.

Liver Diseases

Annual deaths from liver disease: 65,000

This includes cirrhosis and liver cancer.

Liver Function

• All blood coming from intestines passes through the liver first.
• The liver metabolizes nutrients and deactivates toxins.
• You can survive without a kidney, stomach, and gallbladder, but you can’t survive without a liver.

Liver Diseases

We’ll cover three major diseases of the liver:

Diet-induced fatty liver disease

• This is the most common cause of chronic liver disease, affecting 70 million people in the US. Nearly all severely obese people have liver disease.
• Mechanism of action:
  • Fat deposits in liver cause inflammation, which cause liver scarring, which leads to liver failure.
  • Cholesterol overload causes cholesterol to crystallize. White blood cells try to eat cholesterol crystals and die, causing inflammatory compounds to leak out and cause liver disease.
• Diet causes big changes quickly:
  • One week of a fast food-heavy diet can cause pathological liver function tests.
  • One can of soda per day raises fatty liver disease by 45%.
• Studies show animal fat and cholesterol cause liver disease. Eating the equivalent of >14 chicken nuggets per day of meat causes 3x the rate of fatty liver disease compared to <7 nuggets per day.

Alcoholic liver disease

• Excessive alcohol consumption causes fatty liver, which leads to inflammation in the liver and irreparable scarring. What is excessive? It’s defined as >2 drinks per day for males, or >1 drink per day for females.
• Heavy drinking can lead to fatty liver in 3 weeks. Luckily, in most people, stopping drinking allows the liver to resolve within 4-6 weeks.

Hepatitis

There are five types of hepatitis:

• Hep A—foodborne through feces, preventable with vaccine.
• Hep B—bloodborne, transmitted sexually and maternally through birth. Also preventable with vaccine.
• Hep C—bloodborne, transmitted through needle sharing. No prevention. Hep C is the leading cause of liver transplants.
• Hep D—only infects people with hep B, so prevent hep B and you won’t get hep D.
• Hep E—pigs may be the primary reservoir. 11% of pig livers show Hep E virus. Pork consumption in countries correlates with liver disease. Hep E is highly risky for pregnancy, so, while pregnant, cook pork well or avoid entirely.

Preventing Liver Disease

The most important behaviors to avoid liver disease: don’t be obese, eat less fat and cholesterol, don’t drink alcohol heavily, and don’t share needles.

Foods shown to be good for livers:

• Oatmeal
  • A double-blinded, randomized, placebo-controlled trial in overweight people showed oatmeal reduced liver inflammation and led to weight loss.
  • Refined grains like white rice are associated with an increased risk of liver disease.
• Cranberries
  • Beat out other common fruits in suppressing liver cancer cells in vitro.
  • Extracts failed to match the anticancer effects of whole cranberries.
  • It’s best to eat them fresh or frozen, not juiced or dried.
• Coffee
  • In the group at highest risk for liver disease, people who drank >2 cups of coffee per day showed less than half the risk of chronic liver problems.
  • Among smokers, >4 cups of coffee per day showed 92% lower risk of death from chronic liver disease.
  • Mechanism of action: coffee may reduce DNA damage, increase the clearance of infected cells, and slow the scarring process.

Is Alcohol Protective?

Whether alcohol is healthy or not has been the source of continuous flip-flopping in the media.

The simple facts:

• Alcohol decreases mortality, but only for those in poorer health.
• Drinking decreases heart disease, but increases cancer risk. Since heart disease is more common, this may be why alcohol is net protective.
• People who are reasonably healthy show no protective effect from alcohol. “Reasonably healthy” means people who exercise 30 minutes a day, don’t smoke, and eat at least one daily serving of fruits/veg

Part 1-5: Blood Cancers, Kidney Disease

Blood Cancers

Annual deaths from blood cancers: 56,000

This includes a range of diseases:

• Leukemia: 52,000 diagnosed each year, 24,000 die
  • In leukemia, bone marrow produces abnormal white blood cells, crowding out the ability to produce red blood cells and white blood cells. Leads to anemia, infection, death.
• Lymphoma: 70,000 diagnosed, 19,000 die
  • Lymphoma is the proliferation of lymphocytes, which are white blood cells.
  • These cells collect in lymph nodes and disrupt immunity.
• Myeloma: 24,000 diagnosed, 11,000 die
  • Myeloma is the proliferation of plasma cells, which are antibody-secreting white blood cells.
  • These cells displace bone marrow and make abnormal levels of antibodies that clog kidneys.
  • Multiple myeloma happens when cancer is discovered in multiple bones.
  • This is particularly resistant to treatment; most people diagnosed do not survive beyond 5 years.

Animal Viruses Causing Cancer

Of all foods in the large population EPIC study, poultry showed the greatest risk for blood cancers. For every 50g of poultry you consume daily, your risk of blood cancer increases between 56 and 280 percent. By comparison, a chicken breast weighs 350 g.

Why could this happen? A hypothesis: poultry viruses cause cancer. The viruses include avian herpesvirus, avian leukosis virus, and lymphoproliferative disease

• People who grow up on poultry farms show almost 3x the odds of blood cancer.
• Farmers, slaughterhouse workers, and butchers all show higher rates of blood cancers.
• Some other animal products like milk show no such cancer risk, so it’s not from exposure to toxins like dioxins.
• Eating well-done meat lowers the risk of lymphoma compared to rare meat, even though it increases exposure to cooked meat carcinogens.
• There’s still no smoking gun yet on viruses directly causing cancer through infection and genetic mutation. This is an area of active research.

How Not to Die from Blood Cancers

Besides reducing your consumption of poultry, eating specific things helps protect against blood cancers:

Greens

• A plant-based diet reduces all cancer forms, lowering risk of blood cancer by half.
• Patients with lymphoma that eat >3 vegetable servings a day show a 42% improved survival rate. Green, leafy vegetables and citrus showed the most protective effects.
  • It’s not clear whether the diet reduced cancer effects, or it improved tolerance to chemotherapy.
• In healthy patients, >5 servings of green, leafy vegetables per week showed half the odds of lymphoma.
• Sulforaphane in cruciferous vegetables kills cancer in vitro while ignoring healthy cells.
• Vitamin C and carotenoid in diet lowers lymphoma risk, but supplementing vitamin C doesn’t do anything.
  • High-dose supplements actually increase the risk of death. Why? A large dose may disrupt the natural balance of antioxidants that reduce disease

Acai Berries

• An extract of acai triggers apoptosis in cancer cell line in vitro, and it increases the activity of macrophages.
• To get better antioxidant bang for your buck, look to purple cabbage, cinnamon, and cloves.

Curcumin (from turmeric)

• In randomized, double-blind, placebo-controlled study, curcumin reduced antibody levels in myeloma patients.
• In vitro, curcumin stopped myeloma cell growth.

As a side note, pet ownership seems to lower lymphoma risk. The mechanism might be by boosting immunity.

Kidney Disease

Annual deaths from kidney disease: 60,000

Kidney Disease

• Kidneys filter 150 quarts of blood daily to make 1-2 quarts of urine.
• Kidney malfunction leads to accumulation of toxins, causing weakness, shortness of breath, and confusion.
• Kidney failure requires dialysis, but the life expectancy of a patient requiring dialysis is less than 3 years.
• Only 41% of Americans have normal kidney function, compared to 52% 10 years ago. Something in the environment is likely causing this trend.
• Most people with kidney failure die from other causes like cardiovascular disease. Patients under 45 with kidney failure are 100 times more likely to die from heart disease.

Animal Meat and Kidney Disease

Animal protein, animal fat, and cholesterol all implicated in declining kidney function.

• Animal protein causes hyperfiltration, or an increase in workload of kidney.
  • Kidney filtration rate shoots up within hours of eating animal protein.
  • Humans evolved a hyperfiltration capacity to handle sudden boosts in protein intake, say from a fortuitous killing of a large animal. Eating a lot of animal protein once in a while is OK. But now we’re overloading daily.
• Mechanism of action: animal products cause inflammation in the kidney.
  • In an experiment, giving an anti-inflammatory drug along with eating animal protein shows no hyperfiltration response.
• Another mechanism of action: meat protein increases acid load to the kidneys. Animal protein tends to have higher levels of sulfur-containing amino acids like methionine
  • The worst offenders are fish (including tuna), pork, poultry, cheese, beef
  • Acid load requires ammonia production to balance pH. Chronic exposure to ammonia is toxic and degrades kidney function over time
  • Eating sodium bicarbonate can lower the acid load, but this comes with excess sodium which itself causes kidney damage.

There is no correlation between plant protein or plant fat with kidney damage.

• Compared to eating animal protein, eating an equivalent amount of plant protein causes no noticeable stress on kidneys.
• A six-month, double-blind, randomized, placebo-controlled trial showed that plant protein helps preserve function in diseased kidneys, compared to dairy protein.
• Unlike animal foods which are acidic, plant foods are basic.
  • Plant protein does not contain as much acidic amino acid
  • Plant-based diet can return acidic urine to neutral within a week
  • Best performing plants here are vegetables, fruits, and beans.

Kidney Stones

1 in 11 Americans are affected by kidney stones today.

They’re formed from crystallized calcium oxalates and uric acid.

Eating less meat reduces the risk of kidney stones a lot.

• Eating extra animal protein (1 can of tuna fish daily) increased the risk of kidney stones by 250%.
• Eating less meat and salt reduced kidney stone risk by 50%, compared to a low-calcium diet which only decreased by 25%.
• Removing all meat reduces risk of uric acid crystallization by over 90% in 5 days.
• Higher vegetable intake does not increase risk of stone formation, despite increase in oxalate dosing

Phosphorus

Excess phosphorus increases risk of kidney failure and heart failure. It seems to damage blood vessels and hasten aging and bone loss.

Americans consume twice as much phosphorus as needed.

The source of phosphorus matters—animal phosphorus is much more damaging than plant phosphorus.

• Animal phosphorus comes in phosphate form, which is readily absorbed.
• Plant phosphorus comes in phytate form, which is not readily absorbed.
• This is similar to the difference in absorption of animal heme iron vs plant non-heme iron (from the chapter on colorectal cancers).

Phosphorus additives are the worst. These are found in cola drinks, and they’re added to meat to enhance color and add water weight.

• Avoid foods that contain pyrophosphate and sodium triphosphate.

Nitrosamines

Nitrosamines are carcinogens that result from nitrites used for curing meat.

The chemical reaction involved has nitrates turning into nitrites, which then turn into carcinogenic nitrosamines and nitrosamides.

• Thus, nitrates and nitrites are precursors to nitrosamines.
• For nitrite free food, look at the fine print—the label often says “nitrite-free, except those naturally occurring in celery juice.” This is equally as bad—fermented celery juice contains nitrites.

Tobacco use is a big risk factor for kidney cancer because of nitrosamines. Nitrosamines stick to blood vessel walls and continue harming—so-called thirdhand smoke.

One hot dog has as many nitrosamines and nitrosamides as 4 cigarettes. To reduce your risk, reduce your processed meat consumption to under 20g a day.

Once again, animal sources of amines are more harmful than plant sources.

• Animal products contain amines and amides, thus creating nitrosamine in the stomach.
• Plant foods contain not only contain less amines and amides, but they also contain vitamin C and other antioxidants that block the formation of nitrosamine. Thus, unlike meat, plant foods do not show an increased risk for kidney cancer.

Part 1-6: Breast Cancer, Suicide

Annual deaths from breast cancer: 41,000

• 230,000 are diagnosed each year.

Risk Factors for Breast Cancer

Alcohol

• The metabolic product of alcohol, acetaldehyde, is the carcinogen.
• Even moderate drinking—one drink a day—shows a small increase in risk of breast cancer.
• Red wine is exempt from this effect, possibly because of compounds in grape skins that suppress estrogen synthase.

Decreased melatonin

• Melatonin regulates sleep and circadian rhythm and is secreted in the dark. Melatonin suppresses cancer growth.
• Blind women (who secrete melatonin constantly) shows half the odds of breast cancer.
• Women who work on night shifts show an increased relative risk (1.14) for breast cancer.
• Higher vegetable intake increases melatonin levels; meat lowers melatonin.

Heterocyclic amines (HCAs)

• HCAs are produced when cooking meat at high temperatures.
• Meat eaters who eat well-done meat eaters show 5x the odds of breast cancer compared to people who eat rare meat. Well-done meat eaters also show a higher risk of colon, esophagus, lung, pancreas, prostate, and stomach cancer.
• Mechanism of action: a particular HCA (PhIP) has estrogen-like effects and induces breast-cancer cell growth.

Cholesterol

• LDL may be used by breast cancer to synthesize estrogen or tumor membranes for cell growth.
• Women with total cholesterol >240 show a 17% increased risk of breast cancer vs. those with cholesterol <160.

How Not to Die from Breast Cancer

Exercise

• Five hours a week of vigorous aerobic exercise lowers estrogen and progesterone by 20%.
• Walking an hour a day shows reduced relative risk (0.91) when controlled for BMI.

Fiber

• Premenopausal women who ate 6g of fiber a day had 62% lower odds of breast cancer vs those eating <4g a day.
• Every 20g fiber/day showed a 15% lower risk of breast cancer.
• Getting up to a minimum of 25g/day may be required to show an effect. The average vegetarian may only get 20g/day.

Apples

• Daily apple eaters show 24% lower odds of breast cancer (and also of ovarian, laryngeal, and colorectal cancers).
• Apples contain antioxidants in skin that seem to suppress breast cancer cell growth in vitro.
• Compounds in skin reactivate maspin (mammary serine protease inhibitor) which reduces cancer growth.

Cruciferous Vegetables

• 250g each of broccoli and brussels sprouts per day reduced heterocyclic amine (HCA) levels in urine by around 22%.
• Mechanism of action: may improve liver function to detoxify HCAs.
• Sulforaphane suppresses the ability to form tumors. To match the levels of sulforaphane used in in vitro studies, you would need to eat ¼ cup of broccoli sprouts a day

Flaxseeds

• Contain lignans and phytoestrogens that dampen the effects of human-made estrogen.
• 1 tbsp of flaxseeds can extend a woman’s menstrual cycle by a day.
• A study of cancer patients showed that eating a 25g flaxseed muffin caused a 31% increase in apoptosis and a 71% reduction in C-erB2 (a marker of cancer aggressiveness).

Soy

• Women with breast cancer who ate the most soy had reduced mortality and recurrence of cancer.
• Eating soy during childhood cuts the risk of breast cancer in adulthood by half. Eating soy as an adult reduces risk by 25%.
• Soy contains phytoestrogens, which stimulate the estrogen receptor less strongly and compete against estrogen for binding.
• Soy may reactivate the anti-cancer BRCA genes through demethylation.

Miscellaneous Foods

• Green tea consumption is associated with a 30% reduction in breast cancer risk.
• Mushrooms: >1/2 a mushroom per day shows 64% lower odds of breast cancer.

Suicidal Depression

Annual deaths from suicide: 41,000

7% of the population suffers from at least one depressive episode each year.

Depression

The definitive cause of depression is unknown.

The monoamine theory suggests that depression arises from the relative depletion of neurotransmitters like serotonin and dopamine.

• The enzyme monoamine oxidase breaks down monoamines; people with depression show higher levels of this enzyme.
• Tryptophan is an amino acid and precursor to serotonin. Depletion of tryptophan worsens mood.

How to Reduce Risk of Depression

Disclaimer: there are big confounds with associative studies between mood and diet.

• Vegetarians are often reported to be happier than omnivores. However, it’s not clear the vegetarian diet is causative—it could be that happier people tend to seek out vegetarian diets.
• The gold standard, as always, is a randomized placebo-controlled trial

Reduce arachidonic acid from meat.

• This is a proinflammatory compound; produced naturally in our bodies, but enriched in animal products.
• Omnivores consume 9x more arachidonic acid than vegetarians.
• In multiple studies, omnivores that go onto a plant-based diet report significantly increased energy, better sleep, and general health.
• Highest sources of arachidonic acid: chicken and eggs have the highest level; beef, pork, and fish.

Avoid aspartame.

• An experiment showed a high-aspartame diet shows more depression and irritability and lower cognitive function

Plants are natural monoamine oxidase inhibitors.

• Phytonutrients from plant foods like apples, berries, onions, spices naturally inhibit MAO, which increase levels of neurotransmitters in the brain.

Tryptophan

• If tryptophan is important to produce serotonin, why not eat more of it?
  • Tryptophan supplements led to deaths in the 1980s and subsequent bans.
  • High-protein meals fail to increase tryptophan, possibly because other amino acids compete for absorption in the gut or across blood-brain barrier.
• Carb ingestion improves mood and lowers depression.
  • This might work by shunting non-tryptophan amino acids from the bloodstream into muscles, which then allows tryptophan more access into brain.
• Seeds like sesame, sunflower, and pumpkin have high tryptophan-protein ratios.

Saffron

• Worked as well as Prozac for depression.
• Smelling diluted saffron improves anxiety for 20 minutes.

Coffee

• Suicide risk drops with increases in coffee dose.
  • People who drink 6 cups of coffee daily were 80% less likely to commit suicide.
• Adding sugar to coffee negates its positive effects on mood.

Antioxidants and folate

• Free radicals and oxidative stress cause tissue damage.
• Higher levels of carotenoids reduce damage.
  • Lycopene from tomatoes has the highest antioxidant activity.
  • Daily eaters of tomatoes have half the odds of depression.
• Antioxidant supplements do not seem protective, while whole foods do.

Exercise

• An interventional study showed exercise was equivalent to Zoloft for relieving depression in people over 50 years old.

Part 1-7: Prostate Cancer, Parkinson’s

Prostate Cancer

Annual deaths from prostate cancer: 28,000

Prostate Function and Disease

The prostate surrounds the urethra and secretes the fluid part of semen.

Half of men over 80 have prostate cancer, but most die with the disease.

Dietary Risks for Prostate Cancer

Milk and hormones

• High intake of dairy products increases total prostate cancer risk with a relative risk of 1.07.
• Overall, each daily glass of milk showed higher rates of premature death, heart disease, and cancer in women.
  • 3 or more glasses of milk a day show a mortality hazard ratio of 1.93!
• Women who drink milk have 5x the rate of twin births.
• Japanese men showed a 25x increase in prostate cancer risk after World War II. This is also associated with a 7x, 9x, and 20x increase in egg, meat, and dairy consumption respectively.
• Cow’s milk stimulates human prostate cancer cells in vitro by 30%.
• The culprit could be D-galactose, which induces premature aging in lab animals and causes acute symptoms in patients with galactosemia, possibly from oxidative stress.

Eggs and choline

• Men eating 2.5+ eggs/week show 81% increased risk of dying from prostate cancer.
• The culprit could be choline, which is converted into the toxin trimethylamine.
• Overall, men eating poultry showed 4x the risk of prostate cancer progression (like metastasis) which could be due to cooked-meat carcinogens like HCAs.

Meat and IGF-1

• IGF-1 (insulin-like growth factor 1) stimulates cell production. This is useful for growth as a child, but less helpful in adulthood.
  • Laron syndrome is caused by a natural inability to produce IGF-1. These patients almost never get cancer.
• IGF-1 is triggered by animal protein consumption.
  • After 11 days of avoiding animal protein, IGF-1 levels drop by 20%, and IGF-1 binding protein levels increase by 50%.
• An increase in animal protein consumption of 3% is associated with a 15% increased risk of bladder cancer.
• Vegetarians who include eggs and dairy in diets don’t achieve significant reduction in IGF-1.

How Not to Die from Prostate Cancer

Vegetarian diet

• In vitro, blood from a standard diet slowed down prostate cancer cell growth by 9%. Blood from men placed on a plant-based diet for a year reduced cancer cell growth by 70%.
• Cruciferous vegetables are especially helpful, cutting cancer progression by over 50%.
• Increasing plant protein intake of 2% is associated with a 23% decreased risk of cancer.
• Vegetarian diets can reverse prostate cancer. PSA levels in people on a plant-based diet decrease, while levels increase in a control group.

Exercise vs Diet

• Exercise is helpful, but not as helpful as a plant-based diet.
  • This was shown by comparing 3 groups: 1) the control, which was sedentary, 2) exercise-only (15 years exercising for an hour each day, 5 times a week), and 3) plant diet + moderate exercise (14 years of plant-based diet, and moderate exercise like a daily walk)
  • In vitro, blood from the control group killed 1-2% of cancer cells. Blood from the exercise group killed 20x more cells. Blood from plant-diet group killed 40x more cells.

Flaxseed

• Lignans are phytoestrogens shown to slow prostate cancer cell growth in vitro. Lignans are especially concentrated in flaxseeds.
• Prostate cancer patients eating 3 tablespoons per day of flaxseed after a month show lower cancer proliferation rate.
• Flaxseed is also comparable to drugs like Flomax in causing relief for benign prostatic hyperplasia.

Parkinson’s Disease

25,000 people die from Parkinson’s every year

Mechanism of Parkinson’s Disease

Dopaminergic neurons in the part of the brain called the substantia nigra control movement.

In Parkinson’s, these cells die off. 70% of the cells could be dead before symptoms appear.

Head trauma increases risk of Parkinson’s (think Muhammad Ali). So wear helmets, and don’t box or play football.

Toxins Linked to Parkinson’s

Toxins have been linked to elevated levels of Parkinson’s. Parkinson’s brains show elevated levels of pesticides and PCBs. The higher level of pollutants, the more damage seen in the substantia nigra.

Chemicals flow into oceans and into animal feed, and then get concentrated in meat.

Toxins last in the environment for a long time.

• The halflife of mercury is 2 months. The halflife of dioxins, PCBs, and DDT is much longer, as long as 10 years.
• Breast milk shows higher concentrations of pollutants in the first pregnancy vs. subsequent ones. This suggests toxins accumulate in the mother’s body over decades, then are extruded through milk.

Top sources of common toxins:

• Arsenic: poultry, tuna
• Lead: dairy
• Mercury: seafood
• DDT: fish
• PCB: fish and fish oil
• Hexachlorobenzene: dairy and meat
• Dioxins: butter, eggs, processed meat

Children are more at risk of arsenic, the pesticide dieldrin, dioxins, and DDE (DDT by-product).

Aren’t most of these toxins banned from industrial usage? How do they get into meat even after they’ve been banned?

• Toxins get concentrated down the food chain. Toxins appear in rain and water at low levels and enter plants. Then animals that eat a large quantity of those plants, like cows and pigs, severely concentrate the toxins in their meat.
• Animal feed sometimes consists of animal trimmings itself, and animals further concentrated by eating other animals. So toxins accumulate in generations of cannibalistic animals, then we eat the animals that have highly concentrated toxins.

Finally, these toxins show a link to Parkinson’s Disease.

• Toxins cause direct damage to protein folding: pesticides are able to trigger accumulation of alpha-synuclein proteins in vitro.
• Eating more than half an egg a day is associated with 2-3 times higher odds for cancers of the mouth, colon, bladder, prostate, and breast. THis might be because of dioxins.
• The risk of Parkinson’s may increase 17% for every daily cup of milk drunk.
  • This may not necessarily be due to toxins, since the effect seemed more closely tied to lactose than to milk fat, and to milk than to butter. Galactose could be the culprit.
  • Milk may also lower uric acid, an antioxidant in the brain.

Constipation is associated with Parkinson’s.

• This could be because Parkinson’s causes a lack of thirst and decreases fluid intake.
• Alternatively, it could be causative—the longer feces stay in the bowel, the longer time feces can be absorbed from the diet.

How Not to Die from Parkinson’s Disease

Nicotine

• Smoking has repeatedly been associated with lower Parkinson’s risk.
• Obviously smoking comes with all sorts of other problems, so it’s best to get nicotine from outside the diet. The highest non-tobacco sources of nicotine are in bell peppers, then tomatoes, and small amounts in potatoes. Pepper eating is associated with lower risk of Parkinson’s.

Plant-based diet

• People who eat dairy-free, plant-based diets show lower levels of PCB toxins associated with Parkinson’s.
• Mercury in the hair of plant-based diet eaters were up to 10x lower than in hair of people who ate fish.
• A plant-based diet removes 98% of dioxin intake.

Berries and flavonoids

• Flavonoids inhibited alpha synuclein deposits from accumulating in vitro
• A population study showed berry eating does lower risk of Parkinson’s.

Coffee and caffeine

• Coffee consumption is associated with 1/3 lower risk of Parkinson’s.
• Caffeine seems to be the main effector—tea is protective, but decaf is not.
• Giving the equivalent of 2 cups of coffee per day in caffeine improved movement symptoms in Parkinson’s patients in 3 weeks.

Part 1-8: Deaths from Medical Treatment

Annual deaths from iatrogenic causes: 225,000

Iatrogenic causes relate to illness caused by medical treatment. This includes:

• 106,000 deaths from side effects from medications
• 99,000 deaths from hospital-acquired infections
• 20,000 deaths from hospital errors
• 12,000 deaths from unnecessary surgery complications
• 7,000 deaths from wrong medication
• 199,000 deaths from drug side effects

How Not to Die from Medical Treatment

Reduce medical error.

• Residents used to have 36-hour shifts until they were shortened. Residents who undergo all-nighters increase serious medical errors by 36% and diagnostic errors by 5x.

Reduce radiation through diet and reducing exposure.

• Medical treatment and diagnose entail many sources of radiation:
  • A single CT scan for a baby girl could cause cancer at a rate of 1 out of 150.
  • A chest CT has the same cancer risk as 700 cigarettes.
  • An angiogram could cause cancer in 1 out of 270 women.
  • A cross-country flight could expose you to as much radiation as a chest x-ray.
• Reduce radiation damage through antioxidants in foods like spinach and kale. Vitamin C and E supplements don’t seem to help.
• Survivors of the Hiroshima and Nagasaki bombings show that plant-rich diets cut cancer risk by 36%.
• Ginger, garlic, turmeric, goji berries, mint leaves, and lemon may also be protective against radiation.

Use diet instead of drugs.

• Patients routinely overestimate the power of drugs to treat disease.
  • Patients believe statins are 20x more effective than they actually are. In reality, the benefit of preventing heart attack is <5% over a period of 5 years.
  • In comparison, a plant-based diet may reduce the risk of heart attack by 60% over 4 years
• Patients who overtrust drugs may be less likely to adopt lifestyle changes.

Reconsider taking aspirin.

• Salicylic acid (the active ingredient in aspirin) acts as a blood thinner by inhibiting pro-coagulant enzymes. It also suppresses proinflammatory prostaglandins. People at risk of heart attacks take it regularly.
• Aspirin is not generally recommended for people who haven’t had the first heart attack, because of the side effects it causes.
• Fruits and vegetables contain salicylic acid—blood levels of salicylic acid in people on plant-based diets are comparable to that in people who take low-dose aspirin.
  • Cumin, chili powder, paprika, and turmeric have the highest concentration of salicylic acid. As suggestive evidence, India has very low rates of colon cancer, which is the most sensitive cancer to aspirin.
  • Organic produce seems to have more salicylic acid, possibly because salicylic acid is used as a defense mechanism against bugs. Produce that rely on pesticides don’t have a need for this defense mechanism.
• Fruit and vegetables may cause fewer side effects than taking aspirin. Furthermore, if you take it naturally in diet, salicylic acid comes packaged with other gut-protective nutrients.

Understand colonoscopies.

• Starting at age 50, you should get a colonoscopy per decade, have your stool tested for blood each year, or have a sigmoidoscopy every 5 years.
  • It’s unclear which of these three options is best until the experimental results come out.
  • But doctors generally over-prescribe colonoscopies because they bill the most.
• Serious complications, like perforations and bleeding, happen in 1 out of 350 colonoscopies.
• Eating peppermint oil capsules reduces the strength of colon contractions, which can reduce complications.

Exercise: Reflect On Your Health Concerns

You’ve just read about the top 15 causes of death. Think about what you took away.

• Which of the causes of death covered so far are you personally most worried about? Why?

• What can you personally do to reduce your risk of this cause of death?

• To what extent are you willing to go to reduce this risk?

Part 2: What to Eat | Main Ideas

As you’ve seen throughout Part 1, the themes of How Not to Die include:

• Eating a plant-based diet decreases your risk of a host of diseases.
• Eating supplements that extract the active ingredient from fruits and vegetables leads to less benefit than eating the whole plants themselves.
• Meat and animal products increase your risk of disease, even after controlling for calories eaten and weight.

Even More Reasons to Eat Vegetables and Fruit

If the massive health benefits aren’t enough to convince you to eat more plant-based foods, here are a few more.

Think of your diet everyday as a bank account of 2000 calories you can spend everyday. Eating one 800 calorie hamburger displaces eating 7 sweet potatoes or 26 cups of broccoli. Which one would benefit your body more?

Some might shy away from a plant-based diet because it seems expensive. This is partly true—on a calories-per-dollar basis, junk food and fat are the cheapest. But on a nutrients-per-dollar basis, vegetables offer 6x more nutrition compared to processed food.

• Meat costs 3x more than vegetables but deliver 16x less nutrition. Thus, meat is 48x more expensive on a nutrient basis than vegetables.
• Increasing fruit and veg spending by 50 cents/day can decrease mortality by 10%.

And if you’re the type to dislike the influence of big corporations, remember that dietary guidelines are often influenced by the industries themselves.

• When regulators discourage the public from buying certain products, they talk about biochemical components rather than what foods to avoid. For example, guidelines tend to say “eat less saturated and trans fats” instead of “eat less meat and junk food.” This is likely to appease agricultural groups.
• Remember how the meat, milk, and egg industries successfully lobbied to remove a federal recommendation to eat less animal-based foods.

Today’s Foods Work Against Us

Modern foods are optimized to develop unhealthy eating habits.

Our primate brains have evolved to have natural drives for food, water, and sex. Modern industries exploit and amplify this in ways we don’t consciously perceive. Processing foods takes them into an unnaturally addictive state. As we eat more of these hyper-rewarding foods, we raise the barrier for enjoying other foods, and we decrease dopamine sensitivity.

As an analogy, natural coca leaves have not been shown to be addictive over millennia of consumption, but it does become addictive when processed into cocaine

Similarly, ice cream gives such an intense dopamine response (to both sugar and fat) that it deadens your response to natural foods like fruits. Then, because fruits are not rewarding and ice cream is what you’ve come to expect, you start seeking an even greater dopamine high than what ice cream provides.

The good news is, eating normal whole foods for a period of time can return dopamine sensitivity to normal levels.

Diet by Traffic Light

Eating a plant-based diet doesn’t have to be complicated. Michael Greger suggests thinking of food as a traffic light system:

Green Foods: Unprocessed plant foods

• Unprocessed means nothing bad is added, and nothing good is taken away.
• Sometimes, processing actually makes food healthier. Tomato juice may be healthier than whole fruit because the nutrient lycopene is more available. Similarly, cocoa powder is processed to remove saturated fat.
• You can eat unlimited amounts of green foods.

Yellow Foods: Processed plant foods, Unprocessed animal foods

• Processed means something bad is added, or something good is taken away.
• For example, almond milk is worse than eating pure almonds.
• Ideally you’d replace yellow foods with their corresponding green foods, which are more nutritious.

Red Foods: Ultra-processed plant foods, Processed animal foods

• Eat red foods sparingly. In driving, you might run a red light once in a while, but you don’t make a habit of it. The same is true of red foods.
• It’s OK to eat these in small amounts, if they help you eat more green foods (such as bacon bits or hot sauce with vegetables).

How to Succeed in Plant-based Diets

If you generally eat an animal-based diet with little in plants, then transitioning to a plant-based diet might be a transition. Here are a few steps to help you transition successfully.

Don’t worry about going 100% into a plant-based diet immediately.

• Don’t feel like you have to give up things you love, like never eating pizza again
• Instead, make wise choices day to day. Have pizza once a month instead of once every 3 days. Aim for 80% and succeed, rather than aiming too high for 100% and failing.

Remove decision fatigue from your diet.

• Willpower depletes throughout the day with decisions. When your willpower is low, your inhibition is low, and you make worse decisions.
• Adopt strict rules like “never cook with oil” or “eat only whole grains” so you won’t even think about the choice.
• Remove junk food from your house so you don’t adopt a habit of snacking. When the temptation isn’t around, you’ll find you don’t even think about junk food as much as you did.

Replace your typical meals with healthier alternatives

• Most families rotate through the same 8-9 meals. Rotate in whole-foods, plant-based options gradually.
• Step 1: Add health to plant-based meals.
  • Turn spaghetti and pasta sauce into whole-grain pasta with vegetables.
• Step 2: Adapt 3 meals to plant-based meals.
  • Turn beef chili into bean chili.
• Step 3: Discover new healthy options for plant-based meals that can be part of your normal schedule.

Consider it an experiment first, not a lifetime change.

• Lower the bar for yourself. Commit to a plant-based diet for just 3 weeks. This is mentally easier to handle than a lifelong change.
• Your health may improve so much during those 3 weeks that you won’t want to go back to your previous diet.

Dr. Greger’s Daily Dozen

As a simple checklist for what to eat everyday, Dr. Greger recommends these 12 components. Each box represents one serving.

• Beans: 3 Servings [ ] [ ] [ ]
• Berries: 1 Serving [ ]
• Other Fruits: 3 Servings [ ] [ ] [ ]
• Cruciferous Vegetables: 1 Serving [ ]
• Greens: 2 Servings [ ] [ ]
• Other Vegetables: 2 Servings [ ] [ ]
• Flaxseeds: 1 Serving [ ]
• Nuts: 1 Serving [ ]
• Spices: 1 Serving [ ]
• Whole Grains: 3 Servings [ ] [ ] [ ]
• Beverages: 5 Servings [ ] [ ] [ ] [ ] [ ]
• Exercise: 1 Serving [ ]

These 12 recommendations form “Dr. Greger’s Daily Dozen.”

In the following chapters, we’ll cover each of these dozen options in more detail. Each category will contain specific recommendations on what to eat and how much a serving is.

Part 2-2: Beans, Berries, and Other Fruits

Beans

Daily Recommendations

3 servings per day

Serving sizes

• ¼ cup of hummus or bean dip
• ½ cup cooked beans, tofu, tempeh
• 1 cup of fresh peas, sprouted lentils

What to eat: Black beans, black-eyed peas, butter beans, cannellini/garbanzo beans, chickpeas, edamame, kidney beans, lentils (beluga, French, red), miso, navy beans, peas, pinto beans, small red beans, tempeh

Nutrients and Benefits

Nutrients: protein, iron, zinc, fiber, folate, potassium

• Canned beans are as nutritious as boiled beans, except for the salt they contain.

Studies show:

• Beans drop LDL and total cholesterol.
• Every 20g increase in daily legume intake reduces premature death by 8%.

Specific Choices

Soy

• Half of nutrients are lost when soybeans are converted into tofu or soy milk.
  • For tofu, choose ones made with calcium.
• Tempeh or miso are whole soy foods that are preferable to tofu and soy milk.
  • Don’t boil miso since it has probiotics.
  • Despite its salt, miso may have protective effects that cancel out the increased risk of stomach cancer and hypertension.

Lentils

• There is a healthy “lentil effect”—when eaten, lentils blunt the sugar spike of foods eaten hours later. Compounds in lentils seem to relax the stomach and slow the rate of sugar absorption.
• When lentils are sprouted, the level of antioxidants doubles.

Black beans

• Have more phenolic phytonutrients than other legumes.

Berries

Daily Recommendations

1 serving per day

Serving sizes

• ½ cup fresh or frozen
• ¼ cup dried

What to eat: Acai berries, barberries, blackberries, blueberries, cherries, concord grapes, cranberries, goji berries, kumquats, mulberries, raspberries, strawberries

Nutrients and Benefits

Nutrients: 10x more antioxidants than other fruits and vegetables by density

• Compared to fresh berries, frozen berries are roughly the same in nutrition or about 20% less nutritious in antioxidant activity, but tend to last longer and are cheaper.
• However, berry jams lose the majority of nutrients.

Studies show:

• Protection against cancer
• Immune system boost
  • 1.5 cups/day of blueberries for 6 weeks doubled natural killer counts in athletes after intense exercise, when normally it drops by half
• Protection for the brain
  • Women who ate one serving of blueberries and two servings of strawberries a week had slower rates of cognitive decline, by as much as 2.5 years.
• Fructose in fruit is less harmful than added fructose
  • Fiber, antioxidants, and phytonutrients in berries may cancel out the harmful effects of fructose, such as by lowering the rate of absorption.
  • A small trial found that feeding a diet that included 20 servings of fruit per day had no effect on weight, blood pressure, or triglycerides, but lowered LDL by 38 points.
• Flavonoid intake is associated with lower risk of fatal cardiovascular disease.
• Moderate your intake of berries and anti-inflammatory drugs during 3^rd trimester of pregnancy, since berries contain anti-inflammatory polyphenols

Specific Choices

Blackberries

• Contain the highest antioxidant density at 650 units, vs. blueberries at 380, raspberries at 350, strawberries at 310, mangoes at 110, and apples at 60.

Cherries

• Can reduce inflammation. Useful for gout.

Goji Berries

• Highest concentration of melatonin. 3^rd highest antioxidant capacity of common dried fruit.
• Zeaxanthin content helps protect against macular degeneration.

Black Currants

• Improves computer eye strain—may be due to anthocyanins.

Other Fruits

Daily Recommendations

3 servings per day

Serving sizes

• 1 medium-sized fruit
• 1 cup cut-up fruit
• ¼ cup dried fruit

What to eat: Apples, dried apricots, avocados, bananas, cantaloupe, clementines, dates, dried figs, grapefruit, honeydew, kiwi, lemons, limes, lychees, mangoes, nectarines, oranges, papaya, passion fruit, peaches, pears, pineapple, plums, pomegranates, prunes, tangerines, watermelon

Nutrients and Benefits

Studies show:

• A diet low in fruits is found to be the second leading dietary factor for global disease burden in DALYs
• Fruit is associated with lower cardiovascular disease and type 2 diabetes.

Are fruits and nuts fattening?

• In an experiment, one group was told to eat two fruit-and-nut bars daily. Despite the extra 340 calories from the bars, they didn’t gain weight after two months.
• Fruits and nuts are satiating. They offset calories elsewhere, while delivering better nutrients than common processed foods.

Specific Choices

Watermelon

• Seeds have respectable antioxidant levels.
• Citrulline is useful for erectile dysfunction.

Apples

• In a study, eating a dozen dried apple rings a day dropped LDL 16% in 3 months.

Grapefruit

• Be careful with grapefruit when you’re on medication—grapefruit can suppress liver enzymes that metabolize drugs.

Avoid olives

• This is an anti-recommendation: avoid eating high-sodium olives.
• Olive oil has most of the olive’s nutrition removed, so try cooking without oil.

Part 2-3: Green, Leafy, and Other Vegetables

Cruciferous Vegetables

Daily Recommendations

1 serving per day

Serving sizes

• ½ cup chopped
• ¼ cup Brussels or broccoli sprouts
• 1 tablespoon horseradish

What to eat: Arugula, bok choy, broccoli, Brussels sprouts, cabbage, cauliflower, collard greens, horseradish, kale, mustard greens, radishes, turnip greens, watercress

Nutrients and Benefits

Nutrients: sulforaphane is thought to be the main beneficial component.

• Protects against DNA mutations and ability to form tumors
• Protects brain, eyesight, immunity
• May help with autism

Sulforaphane requires the enzyme myrosinase to be produced.

• Raw cruciferous vegetables suppress cancer cell growth in vitro, but not cooked vegetables.
• Michael Greger suggests a “hack and hold” technique—chop, then wait forty minutes while sulforaphane is produced.
• Frozen cruciferous vegetables lose much of the antiproliferative anti-cancer effect, because tyrosinase is destroyed before packaging. Powdered mustard seeds have tyrosinase and increase sulforaphane production.

Supplementing sulforaphane seems ineffective.

• Bioavailability is 8x better when eating broccoli sprouts vs. supplements that contain the same amount of precursor chemical.

Too much sulforaphane could cause DNA damage.

• How much is too much? Over 4 cups of broccoli sprouts.

Specific Choices

Red cabbage

• More antioxidants per dollar than other foods

Broccoli sprouts

• When grown yourself, these are a very cheap source of sulforaphane.

Greens

Daily Recommendations

2 servings per day

Serving sizes

• 1 cup raw
• ½ cup cooked

What to eat: Arugula, beet greens, collard greens, kale, mesclun mix, mustard greens, sorrel, spinach, swiss chard, turnip greens

Nutrients and Benefits

Nutrients:

• Chlorophyll blocks carcinogen activity, possibly by regenerating coenzyme Q10
• Warning: Greens contain vitamin K. If taking warfarin or blood-thinners, can nullify the drug

Studies show:

• Greens decrease cancer risk
• An increase of 1 serving a day is associated with 4% lower risk for coronary heart disease.
  • Vitamin C-rich foods contributed most to the effect.
• People who were in the highest quintile in fruit and vegetable intake showed a much lower relative risk (0.69) for ischemic stroke, compared to those in the lowest quintile.

Eat greens with fat to better absorb nutrients.

• Fat-soluble compounds like beta-carotene, lutein, vitamin K, zeaxanthin are better absorbed when paired with fat.

Method of preparation—fresh is better.

• Fresh kale showed much better antiproliferative effects than frozen and heated-in-bag kale (in some assays, cooked kale showed no antiproliferation while fresh did).
• Boiling broccoli removes 50% of glucosinolates. Steaming broccoli doesn’t change the nutrient levels significantly.

Specific Choices

Kale

• Green kale is best, as it showed greater antiproliferative anti-cancer effects in vitro.

Vinegar

• (Shortform note: this isn’t a green, but it was included in the chapter.)
• In type 2 diabetics, 2 tbsp of apple cider vinegar at bedtime reduced fasting sugar by 6%, compared to 0.7% in control.
• Acetic acid may lead to improved nitric oxide production.

Avoid alfalfa sprouts

• Salmonella outbreaks seem most common in alfalfa sprouts.

Other Vegetables

Daily Recommendations

2 servings per day

Serving sizes

• 1 cup raw leafy vegetables
• ½ cup raw or cooked non-leafy vegetables
• ½ cup vegetable juice
• ¼ cup dried mushrooms

What to eat: Artichokes, asparagus, beets, bell peppers, carrots, corn, garlic, mushrooms (button, oyster, Portobello, shiitake), okra, onions, peas, purple potatoes, pumpkin, seaweed, squash, sweet potatoes, tomatoes, zucchini

Nutrients and Benefits

Studies show:

• Improved attractiveness.
  • Carotenoids from yellow/red vegetables deposit in skin and make rating of your face more attractive.
  • Intake of green/yellow vegetables is associated with decreased facial wrinkling in Japanese women (controlling for age, smoking, BMI, and sun exposure).

Diversify your vegetables.

• Different vegetables have different phytonutrients and different benefits to the body.
  • Cabbage, cauliflower, broccoli, and Brussels sprouts lower the risk of colon cancer on the middle and right side of the body.
  • Carrots, pumpkins, and apples lower risk on the left side.
  • In vitro, radishes do nothing to stop pancreatic cell growth, but do stop stomach cancer.
• Population studies might underestimate the effect of plant foods because people tend to concentrate on eating a small selection of typical fruits—apples, bananas, and grapes.
• In studies, variety of intake was a better predictor of decreased inflammation than absolute quantity.

Promote vegetable eating with better names.

• Restaurants can call vegetable dishes exotic names, like “traditional Cajun red beans and rice” rather than “red beans with rice.”
• For kids, calling broccoli “Tiny Tasty Tree Tops” doubles vegetable eating.

Cooking methods: raw is best.

• Raw vegetables generally have the most nutrients available.
• But cooking can compensate if it makes you eat more vegetables.
• How much cooking destroys nutrients varies with the vegetable.
  • Steaming destroys 10% of vitamin C in broccoli.
  • Boiling and pressure-cooking reduces antioxidant capacity by 20-50% depending on the vegetable.
  • Microwaving reduces nutrients on average by 5%, but some vegetables show a 50% decrease, and some actually increase activity (carrot, celery, and green beans).
  • Artichokes, beets, and onions aren’t affected by cooking method.
  • Cooking can sometimes help: cooking carrots increases vitamin A, and cooking tomatoes increases lycopene.
• If you’re afraid of germs, wash vegetables with a 5% acetic acid (vinegar) solution or 10% saltwater to clean the vegetables.

Is organic food better?

• Organic fruits and vegetables do not produce higher serum levels of vitamins or nutrients compared to conventional fruits and vegetables.
• Pesticide contamination risk was 30% lower in organic foods, but still under allowed limits.
• In any case, people tend to far overestimate the risks of pesticides, equating pesticide risk to motor vehicle driving. In truth, they have far less of a consequence than most people think, and it’s far better to eat vegetables than to avoid them for fear of pesticide exposure.
• (Shortform note: the Environmental Working Group publishes the dirty dozen and clean 15 lists for pesticide exposure. The worst foods, most likely to be exposed to pesticides, are strawberries, spinach, kale, apples, and grapes. The best foods, least likely to be exposed, are avocados, corn, pineapples, peas, and onions.)

Specific Choices

Tomato

• The yellow fluid surrounding seeds has anti-platelet compounds.
• Choose whole, crushed, or diced tomato products instead of tomato sauce or puree.

Mushrooms

• Ergothioneine is an antioxidant that works in the mitochondria.
• Our cells have a specific ergothioneine transporter; humans don’t synthesize it.
• Oyster mushrooms have 1000 units of ergothioneine, 9x more than black beans.
• It’s best to cook mushrooms because of the agaritine toxin.
• Morel mushrooms have higher levels of toxins; Dr. Greger recommends not eating morels.

Sweet potatoes

• Phenolics and antioxidants are at highest levels when raw. Boiling decreases nutrients by ~10%, roasting by 20-30%

Spinach

• Spinach shows the top in vitro antiproliferative action against breast, brain, kidney, lung, pancreatic, prostate, and stomach cancer.

Other antiproliferative vegetables

• Brussels sprouts, cabbage, kale
• Garlic, green onions, leek

Part 2-4: Nuts, Seeds, and Spices

Flaxseeds

Daily Recommendations

1 serving per day

Serving size

• 1 tablespoon ground

What to eat: Golden or brown flaxseeds

Nutrients and Benefits

Nutrients

• Contains lignans and omega-3 fatty acids
• It’s best to blend flaxseeds for better digestion. Ground flaxseed should last at least 4 months at room temperature.

Studies show:

• A double-blind, placebo-controlled, randomized trial showed blood pressure drop from 158/82 to 143/75 after eating a few tablespoons of flaxseed a day, compared to no change in control.
• Prostate cancer patients eating 3 tablespoons per day of flaxseed after a month show lower cancer proliferation rate.

Nuts and Seeds

Daily Recommendations

1 serving per day

Serving sizes

• ¼ cup nuts or seeds
• 2 tablespoons nut or seed butter

What to eat: Almonds, Brazil nuts, cashews, chia seeds, hazelnuts, hemp seeds, macadamia nuts, pecans, pistachios, pumpkin seeds, sesame seeds, sunflower seeds, walnuts

Nutrients and Benefits

Studies show:

• ¼ cup of nuts daily may lead to lifespan extension of 2 years+
• Nuts have high caloric density, but studies show that adding nuts to diet cause lower weight gain than control. Where do the high calories from nuts go?
  • 70% of nut calories displace other foods.
  • 10% of calories are not absorbed by the gut.
  • 20% may come from nuts boosting metabolism.

Specific Choices

Walnuts

• Have the highest antioxidant and omega-3 levels and suppress cancer proliferation in vitro.
• The PREDIMED study showed the Mediterranean diet with nuts reduced stroke risk by 50%, and lowered all-cause mortality risk by 39%, while olive oil did not reduce all-cause mortality.

Peanuts

• Women at high risk for heart disease who eat nuts or peanut butter daily halve their risk of heart attack compared to non-eaters.

Pistachios

• Erectile dysfunction is an early sign of vascular disease and can predict heart disease.
  • 40 over 40 rule: 40% of men over age 40 have erectile dysfunction.
• 3 to 4 handfuls of pistachios a day for 3 weeks show improvement of erectile function by 50%
• The Nurses’ Health Study show pistachios can also improve female lifespan.

Herbs and Spices

Daily Recommendations

1 serving per day

Serving sizes

• ¼ teaspoon turmeric
• • any other you enjoy

What to eat: Allspice, barberries, basil, bay leaves, cardamom, chili powder, cilantro, cinnamon, cloves, coriander, cumin, curry powder, dill, fenugreek, garlic, ginger, horseradish, lemongrass, marjoram, mustard powder, nutmeg, oregano, smoked paprika, parsley, pepper, peppermint, rosemary, saffron, sage, thyme, turmeric, vanilla

Nutrients and Benefits

Nutrients: Spices have high antioxidant density.

This can be too much of a good thing

• Poppy seeds contain opium, and you can overdose—the safe dose is below 1 teaspoon for 10lbs of body weight.
• Nutmeg can create amphetamine-like compounds—the safe dose below 2-3 tsp per day.
• Cassia cinnamon contains coumarin, which may be toxic to liver—the safe dose is below a teaspoon per day.

Specific Choices

Turmeric

• Curcumin appears to be the dominant active ingredient.
• Turmeric has been shown to reduce lung disease, brain disease, cancers, rheumatoid arthritis, osteoarthritis, and ulcerative colitis.
• 1/8 teaspoon of turmeric daily reduces free radical damage and DNA breakage by 50%, in extracted blood cells.
• A compound in black pepper (piperine) inhibits drug metabolism in the liver and increases the bioavailability of turmeric.
• Cooked turmeric seems to offer better DNA protection. Raw turmeric offers better anti-inflammatory effects.
• What about curcumin supplements?
  • Turmeric appeared to have twice the effect of curcumin in inhibiting cancer cell growth in vitro.
  • Curcumin-free turmeric has similar effects as turmeric, so other compounds in turmeric may contribute to its health benefits.
  • Eating curcumin supplements also raises more of a risk of overdosing on curcumin.
• Don’t take turmeric if you have gallstones (it pumps the gallbladder and causes pain) or if you’re prone to kidney stones (turmeric contains oxalates; restrict to <1 teaspoon daily of turmeric if you have kidney stones).

Fenugreek

• Found to improve 1 rep max lifts for leg press and bench press, by about 100%. (For the leg press, placebo improved 48kg, while the fenugreek group improved 84kg.)
• It has an odd site effect—it causes armpits to smell like maple syrup.

Cilantro

• Reduces inflammation levels in arthritis patients and reduces uric-acid levels

Cayenne pepper

• Might be useful for cluster headaches and irritable bowel syndrome, because it depletes a pain neurotransmitter (substance P).

Ginger

• A randomized controlled trial showed 1/8 tsp of ginger worked as well as the drug sumatriptan for migraines.
• 1/8 tsp a day, 3 times a day reduced menstrual cramp pain from an 8 to a 3 over 2 months (using the 10-point pain scale).
• Ginger counters vomiting and motion sickness.
• During pregnancy, the maximum amount of ginger recommended is 20g.

Peppermint

• This is the most antioxidant-dense common herb.

Oregano and marjoram

• Containing antioxidants, these herbs reduce chromosome damage from radioactive iodine by 70% in vitro.

Cloves

• This is the most antioxidant-dense common spice.

Amla (powdered dried Indian gooseberry fruit spice)

• This is the most antioxidant-dense uncommon spice, at 261.5 units compared to 9.24 for blueberries.

Spice mixes

• Spice mix, when applied to a high-fat chicken meal, doubled antioxidant presence in bloodstream and reduced triglycerides in blood by 30%.

Liquid smoke

• Smoke compounds are carcinogenic, but they’re fat-soluble. Therefore, the cancer-causing compounds don’t reside in spices or liquid smoke.

Part 2-5: Whole Grains and Beverages

Whole Grains

Daily Recommendations

3 servings per day

Serving sizes

• ½ cup hot cereal or cooked grains, pasta
• 1 cup cold cereal
• 1 tortilla or slice of bread
• ½ bagel or English muffin
• 3 cups popcorn

What to eat: Barley, brown rice, buckwheat, millet, oats, popcorn, quinoa, rye, teff, whole-wheat pasta, wild rice

Nutrients and Benefits

Studies show:

• From the Nurses’ Health Study, the highest quintile of whole grain intake showed a reduced total mortality and reduced cardiovascular mortality.
• Whole grains reduce the risk of heart disease, type 2 diabetes, obesity, and stroke.
• Whole grains reduce inflammation across a panel of markers (e.g. CRP, interleukins, TNF-alpha).

Eat whole grains according to the Five-to-One rule:

• The ratio of grams of carbohydrates to dietary fiber should be 5 or less.
• When grains are processed into flour, they are digested more rapidly, and glycemic index increases.

Specific Choices

Gluten

• Outside of celiac disease, is gluten sensitivity real? Two randomized controlled trials show most people who claim to feel better on a gluten-free diet feel worse on a no-gluten placebo. Exposure to gluten can induce feelings of depression. So it appears gluten sensitivity isn’t just in people’s imagination.
• But some people showed wheat sensitivity, which is correlated to sensitivity to other foods like eggs and milk. If you remove eggs and milk from the diet and challenge with gluten, there’s no effect. So going on a healthier diet may be the reason gluten-free diets work.
• About 2% of the population may have celiac disease or wheat allergies. For the other 98%, there is no evidence that a gluten-free diet has benefits, and it may actually negatively affect gut flora.

Pigmented grains

• Pigmented rice (red, purple) may have antioxidant benefits over brown rice.

Oats

• Contain avenanthramides, which are anti-inflammatory compounds.
• They suppress inflammation for skin rashes.

Beverages

Daily Recommendations

5 servings per day

Serving sizes

• One glass

What to drink : Black tea, chai tea, chamomile tea, coffee, earl grey tea, green tea, hibiscus tea, hot chocolate, jasmine tea, lemon balm tea, matcha tea, oolong tea, peppermint tea, rooibos tea, water, white tea

Nutrients and Benefits

The common “8 glasses a day” recommendation seems to originate from a 1921 paper measuring urine and sweat output.

The new recommendation is 10-15 cups of water a day for men, and 8-11 for women, including liquid from foods. Net of food, this translates to 6-11 cups for men and 4-7 for women.

Studies show:

• Low liquid intake is associated with heart disease, kidney disease, urinary tract infections, and other diseases. But it’s unclear whether low fluid drinking is to blame—it’s associated with other unhealthy behaviors like lack of exercise and poor diet.
• Each extra daily cup of fluid reduced risk of bladder cancer by 7%.
• The Adventist Health Study showed that people drinking >5 glasses of water a day showed half the risk of heart disease, compared to <2 glasses.
• Dehydration causes lower cognitive function and depressed mood.
• 2/3 of children might be in a state of mild dehydration!

Specific Choices

Coffee

• Overall, each additional cup of coffee drunk per day showed a 3% lower risk of premature death.
• The NIH-AARP study showed >6 cups of coffee per day caused a 10-15% lower mortality rate for people over the age of 55. Below the age of 55, coffee increased the risk of death.
• Coffee shows benefits for liver disease, mood, and Parkinson’s Disease.
• It improves energy, alertness, and cognitive performance.
• Drawbacks to coffee:
  • Coffee induces acid reflux. Decaf has less of this effect.
  • Coffee may increase cholesterol when it’s not prepared using a paper filter. This might be caused by the fat-soluble compound cafestol.

Tea

• Tea reduces risk of cancer, diabetes, and tooth loss. It also lowers cholesterol, blood pressure, body fat, and allergic symptoms.
• Mentally, it promotes alpha brainwaves (which is associated with a mindset that is alert, focused, and calm).
• White tea has more antioxidants than green tea if you add lemon, as some phytonutrients are activated at a lower pH.
• Cold-steeping tea (2 hours in the fridge) reduces caffeine content and may improve antioxidant activity (by around 20%).
• Topical green tea can clear genital warts.
• Drawbacks to tea:
  • Green-tea extract pills have caused liver toxicity.
  • Overdose of tea causes fluorosis problems.
  • The safe limit of tea is 20 bags of black tea, 30 of green tea, or 80 of white tea per day.

Sweeteners

• Greger approves blackstrap molasses and date sugar as green-light foods used for sweetening.
• The low -calorie sweetener erythritol is absorbed by the gut, so it doesn’t cause the laxative effect of sorbitol and xylitol. It also hasn’t been implicated in disorders like hypertension or headaches like other low-calorie sweeteners
• Artificial sweeteners may cause excess calorie consumption in a few ways:
  • Consciously knowing that you’re consuming fewer calories makes you compensate by eating more.
  • Subconsciously, the sweet sensation could trigger body to want to eat more. In the past, the sensation of sweetness meant you were around food like blueberry bushes.
  • It maintains your cravings for sweet things, instead of letting your taste buds adjust to more naturally-tasting foods.

Hibiscus

• Hibiscus tea has the highest antioxidant content among beverages, at 6.99 units compared to 2.11 for jasmine tea and 1.21 for black tea.
• 3 cups of hibiscus tea a day dropped blood pressure by 6 points over control.
• Hibiscus tea is acidic, so rinse your mouth after drinking.

Part 2-6: Exercise and Supplements

Exercise

Daily Recommendations

1 serving per day

Serving sizes

• 90 minutes of moderate-intensity activity
• 40 minutes of vigorous activity

What to do

• Moderate-intensity activity includes cycling, hiking, housework, ice skating, shoveling snow, walking briskly (4 mph), yard work, yoga.
• Vigorous activity includes basketball, jogging, rock climbing, running, vigorous swimming, tennis, and weightlifting.

Nutrients and Benefits

Is exercise more important than eating for body weight? No—eating is still the principal cause of obesity.

• Compared to past times, people may actually be increasing physical activity over time, but foods are more calorically dense now and cause a net increase in calories eaten.
• Compared to exercising away 100 calories, simply not eating those 100 calories is usually much easier.
• Diet is the #1 risk factor for decreasing lifespan, responsible for 26% of deaths and 14% disability-adjusted life years, compared to tobacco smoking at 22% and 12% respectively.
• Losing 1% of the nation’s body-mass index could reduce 2 million cases of diabetes, 1.5 million cases of heart disease, and 127,000 cases of cancer.

Specific Choices

Sit less.

• Every extra hour spent watching TV per day is associated with 11% increased risk of death.
• Men who sit for >6 hours per day have a 20% higher death rate compared to men sitting <3 hours. Women show a larger increase in mortality at 40%. This is true even among people who exercise daily for an hour.
• A possible mechanism is endothelial dysfunction—when active, blood flow increases, and blood vessels signal to arteries to relax. This effect doesn’t happen when a person is inactive.
• Walking 300 minutes per week reduces mortality by 14%. Walking 150 minutes per week reduces mortality by 7%, and walking 60 minutes/week reduces mortality by 3%.

Other options for activity:

• Switch to a standing desk—this causes an extra 30,000 calories burned per year.
• Have walking meetings or stand-up meetings instead of sit-down meetings.
• Take short breaks from work, taking just 1 minute to walk or climb stairs.
• Turmeric can improve endothelial function, along with 1 hour per day of exercise.

Reduce muscle soreness and oxidative stress from exercise.

• Reduce lactic acid with bioflavonoids from citrus.
• Reduce inflammation with anthocyanin flavonoids in berries.
• Whole-food antioxidants reduce DNA damage from exercise, whereas vitamin C supplements promote even more oxidative stress.

Supplements

While Dr. Greger recommends that all your nutrients come from whole foods, he does suggest that a few nutrients be supplemented when on a plant-based diet.

Vitamin B12

• B12 is made only by microbes, and is present in meat but not plants.
• B12 deficiency can lead to paralysis, psychosis, and blindness.
• Dosing
  • If you’re under 65: 2,500 micrograms of cyanocobalamin once a week, or 250 micrograms a day
  • If you’re over 65: up to 1,000 micrograms daily

Vitamin D

• If you live above 40 degrees latitude, during the months of November through February, you might get so little direct sunlight that you don’t produce any vitamin D.
• Dosing
  • One 2,000 IU vitamin D3 daily

Iodine

• Dosing
  • 150 micrograms daily
• Green-light: Seaweed has iodine; eat two sheets of nori.
• Yellow-light: Seafood and dairy milk
• Red-light: Iodized salt—the sodium is too high.

Omega-3s

• Dosing
  • 250mg omega-3s
• Algae oil or yeast products are best.
• Avoid fish oil. They contain PCBs, mercury, and pollutants. Mercury from seafood can worsen cognitive performance.