by Michelle de la Vega — Get free science updates here.
We thought it’d be fun to review a book (in this case How Not To Die) and highlight the kinds of things we noticed that perhaps most readers are not aware of.
Before we get started, just bear in mind that this is not a full, exhaustive, comprehensive analysis. Instead, we’d like to share some pointers so when you do read a diet or health book you keep them in mind.
How Not To Die – by Dr Michael Greger
The Book: How Not To Die: Discover The Foods Scientifically Proven To Prevent And Reverse Disease
The Authors: Dr Michael Greger, MD, Founder of NutritionFacts.org. Dr Greger is an American physician inspired by his late grandmother to follow, and actively promote, a plant based diet. Co-written by Gene Stone, author of many books on how to work, live, and thrive.
This book is epic! The index alone gives you an idea of the size and scope of this book. But don’t be daunted. Once you start, you’ll realise that it is so well-referenced that the last third of the book are references; even the preface referenced! That doesn’t mean there aren’t a few references missing, but it is just a few.
Dr Greger is very clear from the start that “it all started with his grandmother”. A woman who, after several heart bypasses, had been written off by the medical profession; but then a TV programme changed her life for ever. After switching to a plant based diet and exercise regime, his grandmother lived for a further 30 years. And so began Dr Greger’s career in medicine and his fascination with nutrition.
After setting the scene, Dr Greger uses the first half of this book telling the reader “how not to die” of some of the world’s most prevalent, non-communicable diseases, using scientific evidence to explore the relationship between diet and disease. He then uses the remainder of the book to provide advice and practical tips on improving your diet by increasing whole foods and avoiding commercially-processed foods and animal products.
The top 3 highlights
1. The division between the scientific evidence and the practical application. This book is written in two sections. Section one discusses the scientific evidence for foods causing disease. The second recommends foods you should eat to keep healthy and reduce your risk of disease.
2. It is widely accepted that lifestyle factors affect many types of diseases such as cancer, heart disease, and type II diabetes. But Dr Greger discusses 15 different diseases considering the evidence to support the relationship. He believes “most deaths in the United States are preventable, and they are related to what we eat”.
3. Dr Greger’s Daily Dozen are a worthy highlight too. Dr Greger says, ”If just half of the U.S. population were to increase fruit and vegetable consumption by a single serving per day, an estimated twenty thousand cancer cases might be avoided each year”. In How Not To Die, Dr Greger’s Daily Dozen provides a simple checklist to improve your diet and help ward off disease. 12 is his magic number for the practical tips he provides. He even includes portions of fruit, vegetables, spices, pulses, and exercise guidelines.
The heart-warming preface sets the scene perfectly for How Not To Die. Dr Greger was clearly moved by his grandmother’s experience and wants to tell the world that their poor diet is making them sick.
During the brief introduction, Dr Greger outlines the current burden of disease in the US before using the next 15 chapters to discuss the evidence for how poor diet is increasing individuals’ risk of disease. But, as Dr Greger identifies early on in the book, and is worth highlighting early in this review, Dr Greger is not promoting a vegetarian diet or a vegan diet.
“I advocate for an evidence-based diet, and the best available balance of science suggests that the more whole plant foods we eat, the better” – he says.
It is no coincidence that Dr Greger begins with telling the reader how not to die from heart disease as it is America’s biggest killer. Heart disease most certainly isn’t exclusive to the US, cardiovascular disease (CVD) is the leading cause of death worldwide.
In 2013, the Global Burden of Disease Study estimated that almost 30% of all deaths worldwide were attributed to heart disease.
He then takes the reader on a scientific journey through some other big hitters, cancer, diabetes and high blood pressure. But there are also some less obvious diseases discussed such as depression and Parkinson’s disease; it soon becomes clear why a third of the book is references.
The conspiracy theory
There is no doubting that poor diet is playing a role in global health. In fact, in 2015, research by Public Health England published in the Lancet found that, in the UK, diet is now a bigger risk factor for disease than smoking. It is clear that we seem to be getting something wrong with what we are eating. But are there any other factors at play here?
In How Not To Die, Dr Greger points the finger at the pharmaceutical industry, and therefore money! Health practitioners also come under fire when he says: “the US health care system runs on a fee-for-service model in which doctors get paid for the pills and procedures they carry out…. we do not get reimbursed for time spent counselling our patients on the benefits of healthy eating”.
If true, this statement is rather sad considering that, when declaring their commitment to the medical profession, practitioners pledge to “prevent disease whenever I can, for prevention is preferable to cure”. Although he does go on to highlight the lack of nutrition modules during medical training, so perhaps his earlier statement isn’t as cynical as it first sounds.
It is also a statement which doesn’t fit with a free health service model such as the NHS in the UK. However, the UK are not performing any better on the diet and disease front, with a recent comparison of 34 OECD (Organisation for Economic Cooperation and Development) countries by Public Health England which ranked the UK 8th highest for adult overweight and obesity, and 9th for children, so the free systems model does not seem to be getting it right either!
The post-antibiotic age
In How Not To Die, Dr Greger discusses antibiotic use, both in modern medicine and in agriculture.
“In the United States, meat producers feed millions of pounds of antibiotics each year to farm animals just to promote growth or prevent disease in the often cramped, stressful, and unhygienic conditions of industrial animal agriculture,” he states.
Overuse of antibiotics is not a new. In 2012, Director General of the World Health Organisation, Dr Margaret Chan, discussed a post-antibiotic age which could end modern medicine as we know it, because pathogens are developing resistance to multiple drugs, some to nearly all drugs.
Dr Greger isn’t advocating avoiding the use of antibiotics in the case of infection, but he highlights removing animal products from the diet as one way to reduce exposure. However, he doesn’t give consideration to organic animal products in his book.
Per the Soil Association, the UK’s largest organic certification body, organically reared animals are not routinely given antibiotics and are removed from the food chain if they have been prescribed antibiotics for medicinal reason, which, in theory, should remove the risk of pathogens developing resistance. Also, the use of antibiotics in animals in the European Union is regulated and very limited. You can see more here.
Does an apple a day keep the doctor away?
There is a lot of evidence for the benefits of increasing fruit, vegetables, and pulses in the diet. And virtually no evidence to the contrary.
However, the benefits of avoiding all animal products in the long term is less conclusive. A review paper published in 2012 reported benefits of following a plant based diet on cardiovascular health and diabetes, but this was not any stronger than diets which include some meat and fish (dairy was not discussed). Whilst the paper found no negative effects on health, it does highlight the nutrient deficiencies which can occur with restrictive or monotonous diets.
There is also a gap in the book on the disadvantages of the older population following plant based diets. It is important to maintain skeletal muscle as we age to avoid frailty, and increased dietary protein intake is linked with increased muscle mass and strength. A 2015 study highlighted animal protein as important in those who are 65 or older, as it provides more essential amino acids in comparison to plant protein sources which can stimulate muscle protein synthesis. Animal protein includes eggs, dairy, poultry, fish, or meat.
Another review paper in 2016 suggests that dairy products (excluding butter) may even be protective of heart disease. Dairy products are often avoided because of the high saturated fat content, but the evidence is mixed on this (see here).
There is also evidence that dairy products are associated with lower blood pressure, although at least a couple of these studies are supported by the dairy industry.
Further questions on the long-term avoidance of animal products came from Germany. In May 2016, the German Nutrition Society provided a position paper on vegan diets stating it is “difficult or impossible to attain an adequate supply of some nutrients” and it does not recommend pregnant and lactating women or infants, children, and adolescents to follow a vegan diet. Instead, it recommends a diet which is predominantly plant based but includes small amounts of meat as well as fish and eggs to ensure adequate micronutrient intake. It also recommends supplementation where foods fortified with iron and B vitamins are unavailable.
Deficient on deficiency
It shouldn’t be ignored that suddenly switching to diets which are devoid of animal products can be a risk for the development of a deficiency in the body of some nutrients. Dr Greger doesn’t fully acknowledge this in the book.
When cutting out whole food groups, consideration must be given to what these are being replaced with. Dr Greger does cover this comprehensively in his Daily Dozen, but we have to be realistic, only 30% of adults in the UK are eating 5 fruits and vegetables per day, so to expect the general public to remove animal products and not replace them with processed vegan products or refined carbohydrate might be stretch too far. To find out more about potential risk of deficiency, read our science report: Veganism 101: Which Nutrients Might Vegans Lack?
One vitamin which is consistently linked with diets devoid of animal products is B12. Dr Greger acknowledges this, however, you need to read right to the very end, past the conclusions and thank you pages before you find mention of it tucked away in the supplement pages. Here, Dr Greger lists the devastating consequences of deficiency and recommends supplementation. Something as important as B12 deficiency, particularly for pregnant women, should be raised earlier in the book, as some readers may miss out on this vital information.
Also listed in the supplement pages is the suggestion that individuals at risk of vitamin D deficiency should supplement. This is sound advice given the 2016 update on vitamin D from The Scientific Advisory Committee on Nutrition (SACN). However, Dr Greger recommends supplementing with D3. Vitamin D3 is primarily an animal derived product (made from sheep wool). Therefore, depending on the reasons for avoiding animal products, the algae-derived D2 should be recommended. Or at least the difference between the two types should be discussed to inform the reader. In case you’re wondering, vegan sources of vitamin D3 which are derived from lichen can be found if one looks hard enough.
Dr Greger also doesn’t address iodine consumption until the very end of the book. Iodine is a mineral which plays a key role in thyroid and hormone regulation and is particularly important for pregnant and breastfeeding women. Iodine sources are mainly from sea food, eggs, and dairy – with research finding that non-organic varieties of dairy have higher iodine levels. Therefore, removing these food groups from the diet without considering alternative vegan sources could lead to deficiency, particularly in countries which do not have iodised salt. As with vitamin B12 deficiency, this should have been considered earlier in the book.
Further inspiration to change your diet
Dr Greger runs a website, Nutritionfacts.org. This is a non-profit website providing science-based advice on diet and nutrition, with a focus on plant based eating. To learn more about following a plant based diet, visit Nutritionfacts.org.
If you’ve been inspired by Dr Greger and would like to try to incorporate “Dr Greger’s Daily Dozen” into your diet, you can download his mobile app of the same name to keep track and measure your daily progress.
To read or not to read
We should all be incorporating more plants into our diets. So yes, READ How Not To Die to find out how easy it can be!
To read or not to read? READ Entertainment value: 4/5 Impartiality: 3/5 Context and completeness: 4/5 New discoveries: 4/5 Readability: 5/5 Scientific references: 5/5 Our total score: 4/5
To read or not to read? READ
Entertainment value: 4/5
Context and completeness: 4/5
New discoveries: 4/5
Scientific references: 5/5
Our total score: 4/5
If you’ve been following our reviews, it’s unusual that we rate a book 4 out of 5! (Hint: How Not To Die is a good one).