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Cavities and Coronaries: Our Choice

Coronary heart disease, our #1 cause of death, was found to be almost non-existent in a population eating a diet centered around whole plant foods.

November 27, 2013 |
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Sources Cited

W. A. Thomas, J. N. P. Davies, R. M. O'Neal, A. A. Dimakulangan. Incidence of myocardial infarction correlated with venous and pulmonary thrombosis and embolism. A geographic study based on autopsies in Uganda. East Africa and St. Louis, U.S.A. Am J Cardiol. 1960 5(1):41 - 47.

A. G. Shaper, K. W. Jones. Serum-cholesterol, diet, and coronary heart-disease in Africans and Asians in Uganda: 1959. Int J Epidemiol. 2012 41(5):1221 - 1225.

P. J. Stoy. Dental Disease and Civilisation. Ulster Med J. 1951 20(2):144–158.

H. zur Hausen. Red meat consumption and cancer: Reasons to suspect involvement of bovine infectious factors in colorectal cancer. Int. J. Cancer 2012 130(11):2475 - 2483.

I. Levin. III. The Study of the Etiology of Cancer Based on Clinical Statistics. Ann Surg. 1910 51(6):768–781.

T. Tarver. The Chronic Disease Food Remedy. Food Technol. 2012 66(10):22-31.

D. P. Burkitt. Western diseases and their emergence related to diet. S. Afr. Med. J. 1982 61(26):1013 - 1015

D. Burkitt. Are our commonest diseases preventable? Pharos Alpha Omega Alpha Honor Med Soc. 1991 54(1):19 - 21

N. Temple, D. Burkitt. Towards a new system of health: the challenge of Western disease. J Community Health. 1993 18(1):37-47.

D. Burkitt. Are our commonest diseases preventable? Pharos Alpha Omega Alpha Honor Med Soc. 1991 54(1):19 - 21.

J. F. Brock, H. Gordon. Ischaemic Heart Disease in African Populations. Postgrad Med J 1959 35(402):223-232.

J. Higginson, W. J. Pepler. Fat Intake, Serum Cholesterol Concentration, and Atherosclerosis in the South African Bantu. Part II. Atherosclerosis and Coronary Artery Disease J Clin Invest. 1954 33(10):1358–1365.

D. Burkitt. An approach to the reduction of the most common Western cancers. The failure of therapy to reduce disease. Arch Surg. 1991 126(3):345 - 347.

W. Martin. Nathan Pritikin and atheroma. Med Hypotheses. 1991 36(3):181 - 182.

N. R. Poulter, N. Chaturvedi. Commentary: Shaper and Jones, 'serum-cholesterol, diet and coronary heart-disease in Africans and Asians in Uganda': 50-Year-old findings only need interpretational fine tuning to come up to speed!. Int J Epidemiol. 2012 41(5):1228 - 1230.

A. G. Shaper. Commentary: Personal reflection on 'serum-cholesterol, diet and coronary heart-disease in Africans and Asians in Uganda'. Int J Epidemiol. 2012 41(5):1225 - 1228.

M.M. Benjamin, W.C. Roberts. Facts and principles learned at the 39th Annual Williamsburg Conference on Heart Disease. Proc (Bayl Univ Med Cent). 2013 26(2): 124–136.

D.P. Burkitt. The Etiological Significance of Related Diseases. Can Fam Physician. 1976; 22: 63, 65, 67, 69, 71.

Acknowledgements

Images thanks to Sappymoosetree via Flickr.

Transcript

Many of today's lifestyle medicine doctors, myself included, were greatly influenced by Nathan Pritikin, the nutrition pioneer who started reversing heart disease with a plant-based diet and exercise, opening up arteries without drugs and without surgery, effectively curing our number 1 killer disease. But where did he come up with it? We tend to think of rural China as a place with a fraction of our disease rates, forgetting about Africa.

Pritikin was 43 when he was told by his cardiologist that he was at great risk of death from heart attack, so he began to live on a diet patterned after the black population in Uganda. This was a population living off plants that was essentially free from death from heart attacks. After curing his own heart disease with a plant-based diet he went on to save the lives of thousands of others. What was the data that so convinced him?

Last year, the International Journal of Epidemiology reprinted this landmark article from the 50's that started out with a shocking statement: "In the African population of Uganda, coronary heart disease is almost non-existent." Our number one cause of death, almost nonexistent? What were they eating? Plantains and sweet potatoes, other vegetables, corn, millet, pumpkins, tomatoes and, "green leafy vegetables are taken by all." Their protein was almost entirely from plant sources, and they had the cholesterol levels to prove it, similar to modern-day plant-eaters. Apart from the effects of diet and of the blood cholesterol levels the researchers couldn't figure out any other reasons for their freedom from heart disease.

50-year-old findings just as relevant today. They showed dietary intake to be a key, modifiable, established and well-recognized risk factor for heart attacks…without needing to invoke novel, as yet undiscovered, risk factors. This contrasts with the rather desperate search in recent decades for even newer cardiovascular risk factors. We have all the risk factor we need, cholesterol, we've had it for 50 years, and we can do something about it.

According to the Editor-in-Chief of the American Journal of Cardiology this year, the only risk factor required for these atherosclerotic plaques, our #1 killer, is cholesterol. Elevated LDL or "bad" cholesterol in our blood. To drop our LDL cholesterol, we need to drop our intake of three things: trans fat, found in junk food and animal foods; saturated fat, found mostly in animal foods; and dietary cholesterol, found exclusively in animal foods.

The epidemiology journal actually went back and located Dr. Shaper, now 97 years old, and asked him to personally reflect on this groundbreaking study he performed a half-century before. It would be cheering to think that his article actually helped, and attitudes to diet have been changing in recent years, however to his personal surprise and disappointment we still lack a deep commitment to the diet–heart hypothesis, and it is likely that atherosclerosis and its complications will follow us throughout the next half century.

What he discovered is that heart disease may be a choice. Like cavities…

If you look at the teeth of people who lived over 10,000 years before the invention of the toothbrush, they pretty much had no cavities. Didn't brush a day in their lives, never flossed, no Listerine, no water pik… yet no cavities. That's because candy bars hadn't been invented yet. Why do people continue to get cavities when we know they're preventable though diet? Simple. Because the pleasure people derive from dessert may outweigh, the cost and discomfort of the dentist… And that's fine!

Look, as long as people understand the consequences of their actions, as a physician what more can I do? If you're an adult and decide the benefits outweigh the risks for you and your family, then go for it—I certainly enjoy the occasional indulgence (I've got a good dental plan). But what if instead of the plaque on your teeth we're talking about the plaque building up in your arteries? Another disease that can be prevented by changing your diet.

Then what are the consequences for you and your family? Now we're not just talking about scraping tarter. Now we're talking life and death. The most likely reason most of our loved ones will die is heart disease. It's still up to each of us to make our own decisions as to what to eat and how to live, but we should make our choices consciously, educating ourselves about the predictable consequences of our actions.

To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video. This is just an approximation of the audio contributed by Ariel Levitsky.

To help out on the site please email volunteer@nutritionfacts.org.

Dr. Michael Greger

Doctor's Note

Who is Nathan Pritkin you ask? I briefly intro him in Engineering a Cure and talk about the impact he personally had on my family in Our Number One Killer Can Be Stopped and The Answer to the Pritikin Puzzle.

Dr. William Clifford Roberts is the distinguished cardiac pathologist who doubles as the Editor-in-Chief of the American Journal of Cardiology that I quoted. More from him in Eliminating the #1 Cause of Death and Heart Attacks and Cholesterol: Purely a Question of Diet.

More on lowering LDL in Trans Fat, Saturated Fat, and Cholesterol: Tolerable Upper Intake of Zero.

What about the rates of other diseases among those eating traditional plant-based diets? That’s the topic of the next video, One in a Thousand: Ending the Heart Disease Epidemic.

This is among the most powerful material I’ve ever come across. I hope you’ll share it with your circles and consider donating to the 501c3 nonprofit that keeps this website alive so I can keep digging!

If you haven't yet, you can subscribe to my videos for free by clicking here.

  • Guest

    This video gives me confidence to keep going plant-based. And it does not seem like they had a lot of dietary fat in their food choices. Lately I have been struggling with whether or not to eat my sweet foods and high-glycemic foods with fat, as I get advice that you should always mix insulin increasing foods with fat, but I also get advice that the fat can actually be what is causing the diabetes. So does the fat help or hurt? Maybe it helps in the short-term but hurts (makes diabetes worse) in the long term. Is it actually not wise to eat my rice cakes without fat? This is all confusing to me. So many contradictory opinions and theories on this specific dietary regimen.

    • Chrissy

      The general rule is that fat hurts. Whole grains generally have a low glycemic index, meaning that they don’t cause big spikes and crashes in blood sugar levels. And when it comes to the addictive qualities of certain foods, the combination of sugar and fat is HIGHLY addicting – the calories are so concentrated that your body responds as it would to an opiate, like heroin or cocaine. So having sweets with added fat is not a great idea.
      Good luck with your plant-based journey. I went vegan for ethical reasons but subsequently got a certificate in plant-based nutrition. Now I’m beyond convinced it’s the only way to go health-wise!

      • Markus

        I’m sorry to give you contra but the GI of whole wheat is much higher that than that of e.g. icecream or even a snickers:

        http://www.genalivings.com/wp-content/uploads/2013/10/Glycemic-index.jpg

        Puffed wheat:110
        Glucose; 100
        Rice flour:95
        Brown Rice: 81
        Sweet corn:80
        White rice:70
        Rice cakes:85
        Coke: (with HCFS):70
        Whole Grain Bread:68
        Whole Grain Spaghetti: 61

        http://www.oneresult.com/sites/default/files/u3/GI%20Index.png

        Wholemeal flour
        68-85 (depending on origin)
        http://i2.wp.com/foreveryoungforeverfit.files.wordpress.com/2013/04/wheat-bread.jpg

        • Israel Navas Duran

          Breads and bakery products, including those made with wholemeal wheat flour aren’t good representatives of whole grains since these have been grinded, thus making the starch much more accessible to amylase enzymes and more readily digestible.

          In addition, the wheat used in breads and bakery is of the soft variety (referred to as common wheat, or bread wheat), different from the durum wheat (actually, they are different hybrid species), from which the semolina is obtained to make he pasta, or it’s directly eaten as grains.

          • Markus

            Do you really mean one should eat the whole, ungrinded grain as a single piece? How do you digest that, with which enzyme?

            I’ m sure you will see the grains allmost untouched in your feces, so why to ingest it at all?

            Regarding the durum wheat: as long as you not tell us what a differerent outcome it will have this is just a acedemical note without any value to this discussion. So please explicate more!

        • Guest

          In fact i

        • Péter Miklós

          In fact it is the Glycemic Load that you should look at. GI just tells you the quality of the food, GL considers quantities as well. GL draws a quite different picture about how much different food raise blood glucose level.

          • Markus

            I disagree, too. A snickers bar has a GI of 68 while potato has a GI of 104. If a take a a serving size of 2 oz for a snickers bar and 3 oz for a potato dish (as starter) we hava g glyc. load of 136 for the snickers vs a whopping 312 for the potatoes!

            So a snickers bar is much better that potato!

            But is this really what you would use to measure the quality of a given food?

          • Péter Miklós

            Markus, your values are incorrect. 1 serving (60g, ~2oz) Snickers bar has GL 18, 1 serving (150g, ~5oz) boiled white potato has GL 21.

            http://www.health.harvard.edu/newsweek/Glycemic_index_and_glycemic_load_for_100_foods.htm

          • Raw and Cooked Vegan

            You’re also neglecting the negative affects of fat. It is high fat in the blood which leads to sugar problems. Get rid of the fat and watch your sugar problems disappear. Our cells run on sugar. You need not fear it.

        • Raw and Cooked Vegan

          Yes but the more important point is that ice cream and snickers have tremendous quantities of fat. Reduce the fat in your diet to 10% and watch your glycemic issues disappear.

    • b00mer

      I had never heard of combining high-GI foods with fat, and it sounded so intuitively wrong to me given the inhibitory nature of fat on insulin, that I had to look it up. What struck me were the instructions (per diabetes.org) to combine high-GI foods with low-GI foods, low-GI meaning either FIBER or fat. It sounds like you’re familiar with Dr. Barnard’s work on dietary fat and diabetes, but if you’re still concerned with glycemic index values, I would definitely concentrate on combining with fiber and limiting the fat.

      • DanielFaster

        This is right; fat is wrong. If you get your sweet from whole foods like dates, figs, apples, oranges, etc. it already has the fiber built in. Deconstructing food and trying to reconstruct it with isolated nutrients rarely has the same effect. Fat clogs the cells up from the inside and is associated with inflammation that also clogs from the outside, so as to promote insulin resistance and make diabetes worse.

        • b00mer

          Everything I’ve read about the GI makes it seem either useless or worse than useless: eating pure fat is a-okay since it doesn’t have carbohydrate, pineapple is equal to swedish fish, oatmeal is higher than chocolate… can’t believe mainstream medicine still promotes such an obviously ridiculous concept, though I guess if someone is trying to “mop the floor” rather than “turn off the faucet”, it’s a great paper towel!

          • Raw and Cooked Vegan

            Believing this is the sad result of the success of low carb diet huxters. Your cells run on sugar. Get the fat low in your diet. Your body loves carbs. As long as you deprive it of them your body will rebel. Read 80/10/10 by Dr. Graham or anything by Dr. McDougal and have your eyes opened.

        • Israel Navas Duran

          Nonsense. You do realize that are many plant foods are rich in fat, right? Plant foods such as flaxseeds, sesame seeds, walnuts, hazelnuts, almonds, pistachios, macadamias, cashews, pumpkin seeds, avocados, ripe olives, etc.

          • DanielFaster

            Saturated fat is code for pro-inflammatory animal products, but if you eat too much of it, especially in an ad hoc isolated or refined form for the purpose of gratuitously increasing fat intake which is what this thread is about, regardless of where it comes from it will in fact cause problems for a lot of folks.

    • SeedyCharacter

      Rice cakes have an extremely high GI (82/100). Probably best to choose a whole grain cracker lower on the index. And spread with a bit of nut butter. Yum. Good luck!

    • John Galt

      I am in our local teaching hospital’s “Cardiac Research Institute” (Medical University of the Soviet Republic of South Carolina) right now where they spend millions each year trying to find a cure for heart disease! I find it hard to believe these doctors are either stupid or ignorant.

    • dandy

      i also eat plain 100% whole grain brown rice cakes(unsalted) daily with slices of tomato and cucumber. is this ok??

      • Ann

        me to with peanut butter or almond butter

  • DH

    What a great video, Dr Greger! I think this is the one to share with my patients in my vascular medicine practice. I will also check out the links in the ‘Doctor’s Note’, some of which I have read before.

    You are performing a great and heroic public service for many patients at risk for heart disease as well as those with established heart disease, peripheral arterial disease and cerebrovascular disease. Your video here is brief enough that I can watch it with my patients and answer any questions that come up.

    I am at a real loss why a plant-based diet is not more widespread among practicing physicians, even physician-patients. Do you have any thoughts on that? When I talk about plant-based diets with my colleagues, their eyes roll over; same thing with patients. Scientists tend to think this is ‘wackaloon’ stuff. I’ve read great criticism of Ornish in a New York Times article published 15 years ago by Gina Kolata in which she quotes many eminent and respected names in preventive cardiology who take turns criticizing plant-based diets and Ornish in particular. Why is that?

    • b00mer

      Human nature, tale as old as time. I remember the story my mom told me about the doctor back in the seventies who rested his ashtray on her pregnant belly. If you were against smoking would you have been considered a wackaloon back then?

      Doctors like you are awesome!!! And – according to the American Physical Society, only ten percent of a population has to become convinced to reach the “tipping point”, where an idea becomes the majority consensus. http://pre.aps.org/abstract/PRE/v84/i1/e011130

      • DH

        So it comes down to maverick opinions vs. the mainstream. There are just too few plant-based physicians, nutritionists and other “thought and opinion” leaders — i.e. well under 10% of the population is vegan. We are reaching more critical mass – I heard yesterday Al Gore has gone vegan. But the trend seems to be restricted to liberals and democrats, although I’m sure there’s a few political conservatives. Medicine is extremely conservative in that majority opinion sets the guidelines, reimbursement schedules and publication policies (at both editorial and peer review levels). For many years, bloodletting was the norm. Just because something is the norm, does not mean it is ok. If everyone wanted to jump off the Brooklyn bridge, would you…? etc

        Thanks for the compliment, by the way.

        Also, you mentioned elsewhere about balsamic glaze. Where do you buy this stuff? I’ve never heard of it. Same thing as balsamic vinegar?

        • b00mer

          True, majority opinions aren’t always a good thing! But I have hope that our current one will be slowly replaced by a better [plant-based/preventative] one. And obviously the profits associated with the current model is an additional hurdle when it comes to healthcare. Perhaps change will come less from the healthcare system itself and more from the general public educating themselves and actually forgoing many of our modern healthcare practices. But people have to get that education somewhere; some people will get it from nutritionfacts and FoK, but some lucky ones will hear it from their healthcare professionals, and as a bonus, get the additional counseling and assistance that some people really need to make the change.

          Balsamic glaze, my favorite! I get mine from our local ethnic foods store (cheapest option), but I’ve also seen it at the local co-op. Don’t think I’ve seen it at our ‘normal’ grocery store, but ours is kind of small; I would imagine a TJ or WF would have it.

          It’s basically balsamic vinegar, reduced way way down. So technically you could make your own but life’s too short in my opinion! Mine is sugar-free, but I’ve noticed some recipes use a whopping amount and I’m betting some commercial varieties do too, so something to look out for.

          • DH

            Very cool. “but life’s too short in my opinion!” Sounds like something the Buddha would say (WWBS). We have a local olive oil and balsamic vinegar ‘tasting room’ store, and I’m going to ask them if they sell it. Yes a low sugar version would be ideal as I’ve noticed alot of balsamic vinegars are heavy on carbs. I’ve been trying to whip up low-fat salad dressings and it sounds like balsamic glaze cannot be beat for simplicity, speed-of-use, and the fact it is fat-free.

          • John J. Mulrooney

            Just a quick note. If you start with a fine Balsamic Vinegar and add nothing, you simply have to heat it so it barely reaches a simmer for as long as you want to get the thickness of reduction you like the most!! Incredibly simple, cheap and wonderfully flavorful.

        • Ernest Mayberry

          There are notable conservative businessmen who are vegan: Steve Wynn, Michael Eisner, Tom Freston, John Mackey to name a few.

        • SeaBreeze

          You may be a fine physician, but your understanding of ideology and your characterization of those of us who don’t share your political/economic philosophies is truly offensive — not to mention naive and clearly based in ignorance. Ernest Mayberry offered you a handful of names of Republican businessmen who are also vegan. I would add that these are also highly creative & visionary entrepreneurs. Notably, Wynn & Mackey are downright plant-based nutrition ACTIVISTS with whom you are obviously unfamiliar. (Do you live under a rock?) Your false characterization and false analogies (allopathic medicine is “conservative” = political affiliation with Republican = what? meat eaters?, etc.) are parochial and inaccurate. Stick to medicine.

          Beyond the marquee-name vegans mentioned, there are many of us who are proudly die-hard economic/political “conservatives” & libertarians who much appreciate Dr. Gregor’s research-based educational outreach. You clearly equate people who support limited government, free-market economics, respect for private property & individual liberties, etc. with close-mindedness & rigidity.

          I think it YOU who displays close-minded bias & bigotry with your politicization of nutrition. I (a pro-2nd Amendment Tea Party vegan) am working very hard to persuade a radically left-wing dear friend with cancer to change her diet. It’s an uphill slog. It would never occur to me to slam her politics because of her receptiveness (or, rather, lack thereof) to making these nutritional changes.

          With your insight into human nature, it’s a fine thing, too, that your branch of medicine is not psychiatry. Do you actually believe everyone who works with Dr’s MacDougal, Esselstyn, Fuhrman, etc. vote Democrat? Do you actually believe that only people who vote Democrat display flexibility & creativity? Google “Crunchy Cons” and learn something.

          • DH

            Thanks, SeaBreeze! I enjoyed your post. It did put me in my place. True, I made a number of unfounded assumptions. But I am worse than a liberal, I am actually a Canadian! And while we learn so much about your politics on the nightly news, many Americans learn nothing about Canadian politics (we have a right-wing Conservative Party government which is still to the left wing of Ralph Nader). Oh boy. I probably just offended someone else! :-)

      • Dikaiosyne

        “…according to the American Physical Society, only ten percent of a population has to become convinced to reach the “tipping point”, where an idea becomes the majority consensus.”

        Those committed change-agents need to be homogeneously (randomly) distributed throughout a population. We’re not seeing that in proselytizing a vegetarian diet, as there’s primarily a clustering of those agents, e.g., at this site.

        • b00mer

          I know I look like just a bunch of letters on a computer screen, but turns out I’m a real human with real human friends and family! Parents, one sibling, and three close friends plus two of their husbands already adopting a plant based diet. I am fairly certain I know no one else who comments on this site regularly in real life. …but I bet they’re real humans too! And many of them doctors with practices and patients to boot. And even though our comments look really close together on the screen, I’m betting we live pretty far apart in real life too. p.s. interesting use of the word proselytizing, I’m sure you didn’t mean any negative connotation with that. I tend to regard promotion of proven public health strategies as ‘advocacy’, but hey, to-may-to, to-mah-to as they say.

          • Dikaiosyne

            The word “proselytizing” was used in the study’s abstract: their word, not mine.

        • DH

          “as there’s primarily a clustering of those agents, e.g., at this site.”

          Is that really surprising? Go to a paleo site and yo u will see paleo diet advocates. Go to a raw foods site and you will largely see raw foods advocates. Are you at all surprised there are people proselytizing a plant-based diet here? I would be surprised if you were surprised. There’s huge self-selection and referral bias with all these sites.

          • Dikaiosyne

            It has nothing to do with my reaction to clustering, but it has everything to do with the study’s claim of the need for change-agent homogeneity within a population in order to effect a population-wide social change. Clustering is not a homogenous distribution.

    • http://nutritionfacts.org/ Michael Greger M.D.

      Thanks! I was curious about the article you mentioned. Here it is I think: http://www.nytimes.com/1998/12/29/health/scientist-at-work-dean-ornish-a-promoter-of-programs-to-foster-heart-health.html?pagewanted=all&src=pm Seems most of the criticism was based on how few patients he had studied, but now that he’s published on thousands we can be confident in his remarkable results.

  • VegAtHeart

    In connection with the previous video’s discussion on DHA/EPA supplementation, I wonder if we follow your reasoning and maintain our LDL levels at the heart-attack proof level, then why is DHA/EPA supplementation necessary (above of course the minimum amount that can be manufactured by the body from ALA (taken from flax, chia, hemp, walnuts, etc.))? The context of my question is that it seems the main argument for recommendation algae oil supplementation has been to reduce inflammation that leads to an increased likelihood of atherosclerosis. But, if LDL is “the cause” of atherosclerosis and inflammation is only secondary, then why not focus on the root problem (by avoiding trans fats, dietary cholesterol and saturated fat) and thereby skip taking the DHA/EPA supplements?

    • guest

      Exactly! Seems like these supplements wouldn’t even be needed if we eliminated the wrong things (you’ve mentioned them) and added in the right foods. I hear of no mention of this by Dr. Greger and I am confused why not.

      • GaryGiovino

        Great video, as always and a great discussion. What would be the best algae-based DHA/EPA product to buy? I am looking for a brand name.

        • am95

          If you want to go that route, I’ve found Ovega-3 to be the best value.
          You want to not only look at the number of capsules per bottle but also
          the amount of DHA/EPA per capsule.

      • b00mer

        Dr. Greger seems to stick to simply reporting published findings; connecting the dots as VegAtHeart has indeed seems plausible, but it may still be conjecture at this point. And unfortunately even studies looking at “vegans” aren’t necessarily looking at people with diets based on whole foods that are high in omega 3 and low in omega 6/trans/saturated fats. I look forward to studies specifically on the wfpb oil-free community in the future.

  • mykamakiri

    Dr Greger,

    As always – thank you for the continuing inspiration.

    Do you have any plans to address the cannabis issue in the near or distant future? Humanity has such a long history with this plant.

    Keep up the amazing work.

  • Laloofah

    Great video! But the last bit compels me to add that I think it’s important to recognize that choices we make with harmful impacts that extend beyond ourselves cease to be “personal.” Certain food choices come at great cost not just to our own health, quality of life and longevity, but to non-human animals, the world’s hungry, the environment, and the human toll and health care costs borne by society.

  • Kaspar

    Can we really use the Ugandan population to study diet’s connection with heart disease, though? We have to keep in mind that life expectancy in Uganda right now is only about 54 years, not to mention 50 years ago when it was even 10 years less. According to Wikipedia, it is estimated that 87% of the people who die of coronary heart disease are 60 and older. Now, I’m not saying that plant-based diets shouldn’t be the way to go in order to prevent heart disease. I’m just saying that the study mentioned in the video should be taken with a grain of salt.

    • Dikaiosyne

      No, we can’t. At best, it’s poor ‘science’ to do so–and this video exemplifies that poor science. There are simply too many confounding factors that are not controlled for, such as genetics, lifestyle, amount of daily exercise, etc.

      A controlled study would resolve this issue. Thus, be *very careful* with the prescriptive diet advice based upon a descriptive study, as offered in this video.

    • DH

      True, ecological comparisons are confounded, but the two populations being compared both lived in Uganda (one was native, the other were Indians of the Ismaili class – Gujaratis from India). And in these types of cross-cultural comparisons, the outcome was not necessarily MI after the age of 60 but rather how much coronary plaque was present at postmortem. We know from studies of Korean and Vietnam War casualties that most people in the general Western population already have advanced atherosclerosis by their 20′s, and the study in question Dr G is mentioning actually adjusts for age effects in that it was an age-matched study.

      • Dikaiosyne

        “…one was native, the other were Indians of the Ismaili class – Gujaratis from India…”

        Factors are still confounded. How much did the Gujaratis’ diet while in India contribute to atherosclerosis? Was their lifestyle, daily exercise, total diet the same? What about genetic differences between the populations? Adjusting for age merely adjusts for one factor.

        There’s nothing wrong with sharing the study’s findings, but generalizing those findings to other populations is unjustifiable and irresponsible.

        • Karl Young

          Well sure, you’ve seen one clinical study, you’ve seen one clinical study… I certainly agree that generalizations must be done with care, but unless populations are born and raised in hermetically sealed environments and shifted infinitely slowly, in exactly the same atmospheric conditions, between separate hermetically sealed environments in exactly the same atmospheric conditions…

          • Dikaiosyne

            The issue’s not simply tautological; the issue’s a matter of a study being well designed such that high-confidence generalizations can be made from it.

          • Karl Young

            Yes, but there are always many confounding factors in a clinical study (i.e. done on anything as complicated as human beings). And certainly some studies are designed better than others (and even apparently well designed studies can be shown to be flawed when better understanding develops). But you’re implication that because there were many confounding factors that this study produced virtually no evidence of the effect of a plant based diet on the incidence of coronary heart disease seems as unwarranted as concluding that it’s an open and shut case.

          • DH

            Please see my comment to Dikaiosyne above.

          • Dikaiosyne

            “Yes, but there are always many confounding factors in a clinical study…”

            No, not always. Some use matched populations (controlled variables) except for the populations’ target independent variable, and then gather data on the study’s dependent variable’s delta. The statistical heuristics mentioned can help normalize the results for making justifiable study generalizations.

            The Uganda study may provide a glimpse of a *trend*, but making prescriptive diet claims from it is folly.

          • Karl Young

            Mixed effects models and other statistical tools are very useful but it’s simply incorrect to say that one can eliminate confounding factors. One can control, using those statistical methods, for what one is aware of and this can be done more or less effectively. But there still could be a host of confounding factors for which the researchers are unaware (and which might come to light subsequently, as has happened on a number of occasions).

            It wasn’t my impression that Greger was basing his prescriptive diet claims on the Uganda study, only arguing that they provided additional evidence for the prescriptive claims he was already making based on a host of other evidence.

          • DH

            This is but one study among many different types and lines of research that are converging on the same conclusion. Yes you can take any study out of context and say it is flawed and biased. It is an imperfect puzzle piece, on its own does not tell us much. But fit it into the larger jigsaw puzzle and take a bird’s eye view of the entire landscape – randomized trials, cohort studies, ecological studies, case-control studies, in vivo and ex vivo animal studies, in vitro studies, expert opinion. There are multiple lines of research that satisfy most, if not all, of the gold standard Bradford-Hill criteria for causality here, with respect to plant-based diet and coronary risk. But people take one study, like the China Study, and criticize it to tear down the entire concept that plant-based nutrition is heart-healthy. When they do this, they are ignoring every other line of research, both converging and diverging. In virtually all evidence that I have seen, the data converge on one conclusion. In any field of medicine or public health, you are going to get some outliers and yes there are some negative studies too (for example, a subgroup analysis of a secondary endpoint of one single vegetarian study suggested higher rates of mortality for ONE type of cause of death among Oxford vegetarians). Do 20 analyses and 1 will be a false positive due to chance alone. I urge you to look at the entire, gestalt evidence landscape before concluding that this study should be taken with several large pounds of salt. Please.

          • Dikaiosyne

            It would have been better to cite a well-designed meta-analysis to make the point here than to cite a single, poorly-designed study. The onus of proof resides with the good Dr. Why, then, weren’t his claims sufficiently grounded?

          • DH

            Interesting discussion. There is no such thing as a meta-analysis which combines data from in vitro studies, animal studies, cohorts, case-control studies, ecological comparisons, randomized trials, etc. But there have been a lot of background briefing papers on this in the literature, e.g. by Ornish, Esselstyn, Pritikin, Barnard, MacDougall and their ilk. Most readers of this website are well aware of the background. Most videos are short enough to elaborate on a single or maybe two important scientific studies. He could have picked any of them…. information overload would mean picking all of them. And I for one would prefer that an original research paper be discussed than someone else’s synthesis/opinion piece. That way, we all learn. Most epidemiologists, nutritionists and public health physicians accept the diet-heart hypothesis because it has stood the test of time, meaning more than 65 years. A very small but vocal group despite it but have had no success in positing an alternative that is evidence-based and has led to treatment success (for example, the Atkins diet).

            Also you can follow the links on the “Doctor’s Note” to read other contributory evidence.

            And again, there will always be outliers. Science moves us closer to the truth – no one study is perfect though. We can certainly learn from outliers so long as their methodology is not the cause of the problem.

          • Dikaiosyne

            “There is no such thing as a meta-analysis which combines data from in vitro studies, animal studies, cohorts, case-control studies, ecological comparisons, randomized trials, etc.”

            Nor was I expecting such a meta-analysis. However, a meta-analysis of similar studies from which results can be aggregated and analyzed for trends is a reasonable expectation.

            “Most epidemiologists, nutritionists and public health physicians accept the diet-heart hypothesis because it has stood the test of time, meaning more than 65 years.”

            Empirical claims are not justified by standing the “test of time”–and I suspect you didn’t literally mean that. Empirical claims must stand the test of scientific inquiry, sans any agenda. Even then, those claims are always epistemologically tentative, as that’s the nature of a posteriori assertions.

            Please don’t misinterpret my challenging this article’s cited study…

            Just image that you’re a Judge hearing evidence for a case before you w/o bringing in prior knowledge on the issue. The cited study–and accompanying, anecdotal information–simply doesn’t get the job done in favor of the plaintiff, unless one’s preaching to the choir. If the goal of this article is to get the word out about plant-based diets, why not put time into creating a high-quality publication? Doing so doesn’t mean “information overload,” but it does mean offering well-justified claims.

          • DH

            Some of the language you use is a bit above my pay grade. However, I’ll humor you, since it’s nice to see a dissident voice and keeps the discussion lively. Yes I did mean that diet-heart has stood the test of time – 65 years – meaning all the scientific inquiries over those years, “survival of the fittest” [theory] if you will. And finally, this article was judged important enough to warrant re-republication after 60 years in the leading global epidemiology journal, plus an accompanying opinion piece by the [now]-96-year old author. Sure I’m using a “resort to authority” argument here, but I rely on journals all the time to do my work for me in terms of selecting appropriate peer-reviewed epidemiological data – I don’t have time to re-peer review each and every manuscript. This was published in the world’s leading medical journal 60 years ago (The Lancet), so in a sense, it’s been peer-reviewed twice (Lancet and Int. J. Epidemiol.).

            Do you want to get into other examples? Take, for instance, the migration studies on epidemiological transition. Asians who move to the West – such as the Japanese to Hawaii – get breast cancer, prostate cancer and heart disease rates that match their locale. Now you can’t make the argument that the genetic comparison (to those who stayed back) is confounded. What is the most common change in such people? They adopt the local fare, meaning diet. Similar things happen when people move from rural areas to the city – they adopt a meat-based, western diet. You might still say it’s exercise-related, or that they all start smoking, or industrial pollution, but again you have not looked at the full database of studies. Each study draws a quibble. Put them together and we call that science.

          • Dikaiosyne

            “Asians who move to the West – such as the Japanese to Hawaii – get breast cancer, prostate cancer and heart disease rates that match their locale.”

            Interesting that you would mention this, as I was thinking of this, too, when crafting my last reply to you. This is certainly good evidence of the impact of diet on health. It can also be good evidence of the impact of a western lifestyle, in general, on health.

            Our western diet is generally very pro-inflammatory and terribly lacking in anti-inflammatory phyto-nutrients and omega-3s. It’s also *much more* sedentary than the Japanese.

            When I visited Japan a few years ago, I suddenly noticed that I was only seeing a very few overweight Japanese. It was absolutely stunning! This was while waiting to board a train–a part of most Japanese’s daily routine. Generally speaking, they get much more exercise each day than most in the west do in weeks.

            The Japanese typically consume good amounts of seafood–and some red meat–but this is usually accompanied by generous amounts of plants–including soy bean products. They also eat tons of rice–a high-GI food.

            I’m not the “dissident voice” you may think I am. My diet it primarily plant based; haven’t eaten red meat for almost 30 years, but have seafood now and then. Have also cut way back on dairy products. I go absolutely nuts for nuts!

            My only point here was to encourage well-founded claims by change agents, so little work is left for the readers/viewers.

            It’s evident that you have a good background in this area, so you bring that context into this reading. However, those who have no background in this diet issue who are also skeptics will leave as skeptics after viewing this poorly-done video.

          • DH

            When I ate a diet rich in red meat, butter, eggs, fish, poultry and green leafy vegetables, my cholesterol and apoB soared to levels seen in familial hypercholesterolemia patients (who often succumb to complications of atherosclerosis in their 30′s and 40′s). This seems to be a constant theme on paleo and LCHF websites – people continuously experiencing the same effect, often written off as ‘bouyant LDL’ (I did a VAP too at the time, which suggested the LDL was not buoyant, despite major weight losses and insulin resensitization).

            I then went to a pesco-vegetarian diet with dairy – very similar to what you are eating. During this time I became a Buddhist and for ethical reasons, stopped eating either fish or dairy. While a difficult transition, I am happy to avoid the saturated fat and cholesterol in these products, even if, in moderation, they would not have harmed me. The literature does suggest that small differences in lipid concentrations, especially over long periods of follow-up and populations, do account for more cardiovascular events. This may not apply to a specific individual, who could have protective genes. Or it could apply, especially if that individual had other risk factors or say was a cholesterol hyper-absorber.

            The Japanese are interesting in that they have always had much higher rates of stroke than heart disease, and there have been a couple of explanations for that (including their sensitivity to dietary salt, the steepness of their BP-stroke risk gradient, and the relative predominance of hemorrhagic stroke vs. ischemic stroke in their cerebrovascular disease burden). However, as their diets have westernized, and come to resemble ours more and more, their has been a significant ‘catch-up’ in coronary artery disease to their (falling) stroke rates. In other words, CAD has not dropped as steeply as stroke has in their population. I call this the McDonaldization of their diet and certainly non-marine animal products are a major portion of this problem.

            But if you want to look at the impact of a western diet on population health, look no further than Mexico, our neighbor to the south (I am in Canada) – a country with the fastest-growing rate of type 2 diabetes in the world. The traditional Mexican diet – legume and maize-rich, largely agricultural/agrarian – has been replaced by fast food, junk food, processed food – sugar, salt, fat. Their consumption of meat during this time has skyrocketed – it’s not all about junk carbs. The result is a ticking time bomb for public health.

            I will view the video again but I really don’t think it was poorly done. It is simply impossible to cover all the epidemiological basics of diet-heart in a single less than 10 minute piece. The good doctor provides links to background information on the side. If your contention is that he could have picked a better study that was not confounded and prone to ecological fallacy, many other videos on this site look at well-designed prospective cohort studies. I, personally, also like videos and talks on historical epidemiological articles – it is fascinating to me that people were actively working on this 2-3 generations ago, and here we are, still arguing about their findings! Ansel Keys would probably be depressed by how infamous he has become.

          • Thea

            DH: I’ve enjoyed your posts. Thanks for participating on this site.

          • DH

            :-) You’re most welcome! I’ve enjoyed yours too.

          • Veganrunner

            Very well said DH.

    • Coacervate

      The video was about the historical source of Mr. Pritikin’s inspiration. It explains that we’ve had solid evidence for this diet-disease connection for some 50 years but somehow we just don’t get it. Dr G’s point at the end is most relevant. The data is now in, the INFORMED choice is yours. May you live long and prosper.

  • Kathryn

    Hello Dr. Gregor, Have you ever commented on the italian immigrants who built the town of Roseto in Pennsylvania? it seems their lifestyle and not the food impacted their health in a very positive way. it would be interesting to hear your perspective on this interesting town.

  • Wendy

    What is the life expectancy of the people in Uganda? What is the thing that kills them most?

  • Animal Rescuer

    What do we make of Dr. Mark Hyman’s reporting of things–one being that 70% of people who have heart disease/go in for surgery (I believe that’s what he said) have “normal” cholesterol . . . that saturated fats like coconut oil are good, and even lean meats are fine to eat . . . the the “real” problem is our consumption of sugar? I’ve been eating a vegan diet for nearly 20 years, and I’m not planning on changing that–but as I pick up pre-med coursework and work with patients on their diets in an internship, I want to be sure I really understand what’s what.

    • DH

      Of course you do. Bear in mind that these studies were measuring fasting lipids, which are not physiological, and not postprandial lipids, which are physiological. In other words, we normally don’t go fasting for 14 hours every day – we have multiple cholesterol and triglyceride spikes on the basis of food consumption. So measuring a fasting cholesterol is like only seeing the carrot rather than the snowman (Dr D. Spence’s analogy – http://www.researchgate.net/publication/10647774_Fasting_lipids_the_carrot_in_the_snowman). Anyone’s cholesterol can be “normal” if measured in a fasting state where nothing but water has been consumed for 14 hours. But the postprandial spikes from the chylomicronemia of omnivores far exceed those of vegans.

    • b00mer

      “Normal” cholesterol levels (<200) as quantified by mainstream medicine are *not low enough* to successfully prevent heart disease based on epidemiological evidence. Among whole foods plant based physician advocates, you will always see a recommendation of <150, which *is low enough* to prevent disease based on epidemiological evidence. It is also known in mainstream cardiology that the only way to achieve <150 is through statins or a pure vegetarian/vegan diet.

  • guest

    I am curious where these people in the study got their B12?
    I’m guessing they got their vitamin D from the sunshine and
    not a pill.

  • Merio

    Dear Dr Greger, thanks for another great video… the more i follow this site, the more i want to know about nutrition… i’ll try to spread your message even in Italy… cancer and hearth disease are the two major causes of death even in my country…

  • Thinkabouddit

    I wish it were so simple as to just follow the rules and all would be fine. But how come so many raw fooders who eat only a plant based diet have so many problems with teeth and erosion of enamel, etc. Did the Bantu eat any fruit?

    • b00mer

      I don’t really see where your question is stemming from, since nowhere in this video or on this site, is a raw food/fruitarian diet promoted.

      Raw fooders/fruitarians – teeth problems (don’t know about this myself, taking your word for it)

      vs

      Bantu whole food plant based (definitively *not* raw) eaters – perfect teeth.

      If you want the teeth (and the arteries) of the Bantu, “plantains and sweet potatoes, other vegetables, corn, millet, pumpkins, tomatoes and, green leafy vegetables”.

      I don’t see the conflict. Apologies if I’m misunderstanding your question.

      • Thinkabouddit

        I may have misunderstood, but I thought the point was to eat a healthy plant-based diet to protect health and teeth. It seems that those who eat so many fruits and vegetables have concerns about enamel erosion, etc. When I became a vegan over 40 years ago, I ate predominantly raw fruits and vegetables, with some cooked potatoes and grains, etc. I encountered problems with enamel erosion. Admittedly, I was in law school at the time and focused on study and neglected to rinse after every mono-meal of fruit. But I hear many say that excessive fruit consumption leads to problems with teeth. Is this about the Bantu diet or plant based in general?

        • DanielFaster

          Erosion is apparently a problem if you brush right after eating acidic foods that soften your enamel, addressed by Dr. Greger in another video. http://nutritionfacts.org/video/plant-based-diets-dental-health/

          • Thinkabouddit

            It’s confusing because google gives an article showing the Bantu diet: “Their food acquisition was primarily limited to agriculture and hunting, where generally the women were responsible for agriculture and the men drew for the hunt. Except with the Tsonga (and partially the Mpondo), fishing was surprisingly of little importance. The diet consisted of corn (introduced from South-East Asia), meat (mostly wild game and beef), vegetables; and milk, water and grain beer (which contained very little alcohol compared with European beer).”

            Also, it’s my understanding that fruit sugar feeds bacteria in the mouth that poops, and the bacterial poop is what demineralizes the teeth, causes erosion, and dental carries. So a diet of fruit could be more threatening.

            The best advice does seem to be rinsing right after a meal and brushing well after a pause of about 45 minutes.

  • Derrek

    What’s your opinion on fasting for 2
    18-24 hours? Is it helpful? I heard it has health benefits. Is have to the studies though.

  • Ann

    I have always had cavities, even after 10 years of being vegetarian and then vegan, and after years on a plant based fully healthy diet (according to this website and other science scources). BUT I do clench my teeth in my sleep, I think that damages them and creates cavities.

    • Markus

      Hi Ann,

      clenching one’s teeth is quite often a symptome of low magnesium. Do you also have muscle cramps or Migraine sometimes? Make a test for your blood serum Magnesium, it should be >0,9 umol/l, optimum would be 1,0 umol/l.

      If too low, look out either for Magnesium citrate or for the Sango coral.

      • Ann

        Hi Markus! Thx for replying to me :)

        My magnesium is fine. I get a yearly bloodtest and everytime my magnesium is high. I dont have headaches or muscle cramps.
        I think I have a sleep disorder, since I often wake up tired, especially after I dreamed a lot. And I sleepwalk almost every night. Nothing major, usually I end up opening my curtains or something. But I feel it causes my quality of sleep to decrease. Maybe the clenching has something to do with it. Once I broke a back tooth that way.
        I am actually thinking about doing a sleep study in the hospital to see whats up.

        My magnesium was 2.2 , and the reference range here is: 1.6-2.6 mg/dL

  • Derrek

    Is fasting for 18-24 hours healthy? I heard it has health benefits.

  • leo

    life expentency in uganda is 54 years

  • Julie Someone

    i would love to know ‘who knows who’ …eeerrrrrr! “I’m like, wtf?!?” …then i read the tiny green writing… hope u r up and running soon!

  • Markus

    A Canadian study has challenged the use of corn and safflower oils as
    healthy substitutes for saturated animal fats, saying the oils may
    increase the risk of heart disease.

    In a paper published Monday in the Canadian Medical Assn. Journal,
    researchers concluded that polyunsaturated vegetable oils that were rich
    in omega-6 linoleic acid, but relatively poor in omega-3
    alpha-linolenic acid, were not associated with beneficial effects on
    heart health.

    Specifically, authors said a review of recent research suggested that
    though omega-6 linoleic acid lowered serum cholesterol levels, it also
    seemed to increase the risk of coronary artery diseases.

    Study authors Richard Bazinet, a professor of nutrition at the
    University of Toronto, and Dr. Michael Chu, a heart surgeon at the
    London Cardiac Institute in Ontario, said it was unclear why the oils
    increased health risks. However, they said it might have to do with the
    chemical process known as oxidation.

    “The detrimental effects of linoleic acid were seen in participants
    who were smokers and those who consumed alcohol, people likely to be
    under increased oxidative stress,” the authors wrote.

    In Canada, corn and safflower oil are used in foods such as mayonnaise, creamy dressings, margarine and chips.

    The federal Food Directorate allows the food industry to label
    products with corn and safflower oil as healthy replacements for
    saturated fats. Study authors are now asking the government to
    reconsider its labeling eligibility.

    The authors note that canola oil and soybean oil, which are consumed
    to a far greater degree, are associated with health benefits. Those
    vegetable oils contain more omega-3 alpha-linoleic acids, which lower
    cholesterol and lower the risk of coronary artery disease.

    http://www.latimes.com

  • om

    I find it interesting that Dr. Greger correlates sugar/cavities to saturated fat/cholesterol. While it is true that the Ugandans ate a low fat plant based diet, they also ate a low refined sugar diet. Humans have been eating foods high in saturated fats for thousands of years, yet refined sugars have entered our diets in only the past several hundreds of years, and even then only the rich had access to abundance amounts of sugars until the 20th century.

    As Dr. Lustig would say, it ain’t the fat people, its our over consumption of refined fructose for the heart disease epidemic that has plagued western society for the past hundred years.