Comments on How Not to Die by Michael Greger, MD, Flatiron Books, 2015

Joseph E. Scherger, MD, MPH

I am thankful to an Eisenhower Medical Center Internal Medicine resident urging me to read this book.  The resident follows a whole food plant based diet as advocated by Dr. Greger, who is also the founder of the website,  Dr. Greger follows in the tradition of Nathan Pritikin and Dean Ornish, MD, all champions of eating only foods from plants and very low in fat.

When I was a medical student at UCLA in the early 1970s, I was curious about the work of Nathan Pritikin and often wondered what went on in the Pritikin Center in Venice, CA.  I knew he was achieving amazing results through eating only whole plant foods very low in fat.  I became a runner in the late 1970s and remember when the editor of Runner’s World magazine declared that marathon runners could eat anything they want.  When the famous runner Jim Fixx dropped dead of a heart attack in his 50s this was blamed on his family history (genetics).  Nathan Pritikin proved that wrong in his book, Diet for Runners (1985), where he chronicled many runners who died of heart disease in their prime by eating unhealthy fatty foods.

Dr. Dean Ornish in the 1980s gave academic proof to the work of Nathan Pritikin by showing that a very low fat whole food plant based diet reversed coronary heart disease, the first time that this was demonstrated.  I used his Reversing Heart Disease book (1990) with many patients.

In the late 1990s, Dr. Walter Willet at Harvard, and principle investigator of the Nurses’ Health Study, began to show that healthy oils such as olive oil gave added benefit by improving the serum lipids, a major factor in heart disease.  Dr. Ornish recommended against all oils stating that they were 100% fat. However the evidence became clear that healthy oils in modest amounts gave added benefit and the dietary guidelines changed to put them on the top of the new food pyramid. 

After 2000 it became clear that a Mediterranean diet was exceptionally heart healthy and those who followed it lived the longest and the healthiest.  The fats in this diet were expanded to include tree nuts, avocado and wild caught fish such as salmon.  The Blue Zones are the healthiest and most long lived people on earth and most follow this type of diet that includes healthy fats even from animal products in small amount (Dan Buettner, The Blue Zones, 2008).  However, the great majority of the diet is whole food and plant based, and free of the processed foods and sugars that we Americans consume in our Western diet.

I found some weakness and bias in How Not to Die.  The UC Berkeley science philosopher Thomas Kuhn, in The Structure of Scientific Revolutions (1962), observed that scientists tend to ignore data that does not fit in to their scientific paradigm.  This is the case with Dr. Greger.  His book would be more accurately called How Not to Diet from Foods from Animals.  All his How Not to Die… chapters speak only about animal based foods.  For example his How Not to Die from Infections covers all the toxins that can be found in animal foods, not addressing that many plant foods have been contaminated with E. coli and other dangerous bacteria, and that some plant foods like unwashed or uncooked beans have lectins that cause serious disease.

The weakest part of How Not to Die addresses overweight, obesity and type 2 diabetes.  Americans have been eating meats for many decades yet these health problems are more recent.  Dr. Greger tries to blame animal meats and fats for obesity and diabetes, barely mentioning the role of the high glycemic carbohydrates such as sugars and grains that make up so much of processed fast foods.

For a clear academic look at the predominant cause of overweight, obesity and type 2 diabetes, I recommend books by Harvard internist David Ludwig, MD Always Hungry (2016) and UC San Francisco pediatric endocrinologist Robert Lustig, MD Fat Chance (2012).  High glycemic carbohydrates, all derived from plants through processing, are the biggest health threat in the Western diet.

Since carbohydrates should be limited to what is in whole foods only, and Dr. Greger agrees that protein intake should be modest and only what the body needs (about 15 % of calories), it becomes clear that healthy fats from healthy foods are part of a healthy diet.  Aversion to fat caused us to create unhealthy foods such as margarine and vegetable oils high in the inflammatory omega 6 fats polyunsaturated fatty acids (PUFAs) that should be avoided.

Dr. Greger does not have a section on How Not to Die from Autoimmune Disease.  It is becoming clear that much autoimmune disease comes from small intestinal bacterial overgrown (SIBO or “leaky gut”) causing proteins to enter our blood stream that we develop antibodies to and then cross react out tissues.  The worst offenders here are the grains such as wheat, oats, barley, rye and corn, products that make up much of our diet directly or in animal and fish feed.  Eating such grains result in an unhealthy intestinal microbiome (dysbiosis) and is the basis for GI disease and autoimmunity. 

I have no doubt that Dr. Greger is healthy and those who eat his diet to the letter will be too.  He recommends only whole foods and to avoid processed foods and sugars.  Since as Paracelsus said, the poison is in the dose, Dr. Greger’s recommendation of three small servings of grains a day (one slice of bread or one half bagel is a serving) may be tolerated by most patients.  However these foods are still inflammatory and care health risks.  Dr. Gerger’s aversion to fat causes him to recommend only ¼ cup of tree nuts and only 1 tablespoon of ground flaxseed, two of the healthiest foods.  The evidence is clearly showing that both saturated fats and monounsaturated fats from real wild foods are healthy and may be consumed liberally.

I benefitted from Dr. Greger’s book and will recommend it to cancer patients since the evidence for reversing cancer is the strongest for eating a whole food plant based diet.  I eat and recommend an 80-90% plant based diet to prevent cancer and stay healthy, and am not concerned about the fats in healthy plants such as nuts, seeds and avocados. Thanks to Dr. Greger I am now consuming a ¼ teaspoon of organic curry powder with my breakfast for the turmeric and black pepper.

Nutrition science is evolving and that is very exciting.  I gain much from every book I read, being careful to read only authors who are science based and do not have a commercial bias.  We are what we eat and it is very rewarding to learn more and keep open to new possibilities.  Dean Ornish is recommending wild caught salmon in his most recent book, The Spectrum (2007).  I hope Dr. Greger will expand his science to look honestly at healthy fats and healthy foods from all sources.