The Mediterranean Diet vs. a Completely Plant-Based Diet

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The Mediterranean Diet vs. a Completely Plant-Based Diet

Recent studies have shown that higher Mediterranean diet adherence scores are associated with a significant reduction of the risk of death, heart disease, cancer, and brain disease. The problem with such population studies is that people who eat healthier may also live healthier, and so how do we know it’s their diet?  I explore this question in The Mediterranean Diet or a Whole Food Plant-Based Diet?.

As the American Heart Association position states, “Before advising people to follow a Mediterranean diet, we need more studies to find out whether the diet itself or other lifestyle factors account for the lower deaths from heart disease.” How do you do that? There are ways you can control for obvious things like smoking and exercise—which many of the studies did—but ideally you’d do an interventional trial, the gold standard of nutritional science. You change people’s diets while trying to keep everything else the same and see what happens.

We got that kind of trial 20 years ago with the famous Lyon Diet Heart Study where about 600 folks who had just had their first heart attack were randomized into two groups. The control group received no dietary advice, apart from whatever their doctors were telling them, while the experimental group was told to eat more of a Mediterranean-type diet, supplemented with a canola-oil based spread to give them the plant-based omega-3’s they’d normally be getting from seeds and walnuts if they actually lived on a Greek isle in the 1950’s.

The Mediterranean diet group did end up taking some of the dietary advice to heart. They ate more bread, more fruit, less deli meat, less meat in general, and less butter and cream; other than that, no significant changes in diet were reported in terms of wine, olive oil, or fish consumption. So, they ate less saturated fat and cholesterol, more plant-based omega 3’s, but didn’t undergo huge dietary changes. Even so, at the end of about four years, 44 individuals from the control group had a second heart attack, either fatal or nonfatal, but only 14 suffered another attack in the group that changed their diet. So, they went from having a 4% chance of having a heart attack every year down to 1%.

A cynic might say that while there was less death and disease, the Mediterranean diet continued to feed their heart disease, so much so that 14 of them suffered new heart attacks while on the diet. Yes, their disease progressed, but a lot less than the regular diet group (about four times less). But what if there was a diet that could stop or even reverse heart disease?

Dr. Caldwell Esselstyn and colleagues at the Cleveland Clinic recently published a case series of 198 consecutive patients with cardiovascular disease counseled to switch to a diet composed entirely of whole plant foods. Of the 198, 177 stuck to the diet, whereas the other 21 fell off the wagon, setting up kind of a natural experiment. What happened to the 21? This was such a sick group of patients that more than half suffered from either a fatal heart attack or needed angioplasty or a heart transplant. In that same time period of about four years, of the 177 that stuck to the plant-based diet, only one had a major event as a result of worsening disease. As Dean Ornish noted in his response to the latest trial, “a Mediterranean diet is better than what most people are consuming”…but even better may be a diet based on whole plant foods.

Dr. Esselstyn’s was not a randomized trial; so, it can’t be directly compared to the Lyon study, and it included very determined patients. Not everyone is willing to dramatically change their diets, even if it may literally be a matter of life or death. In which case, rather than doing nothing, eating a more Mediterranean-type diet may cut risk for heart attack survivors by about two-thirds. Cutting 99% of risk would be better if Esselstyn’s results were replicated in a controlled trial, but even a 70% drop in risk could save tens of thousands of lives every year.

For more on the Mediterranean diet, check out:

For more on Dr. Esselstyn’s amazing work:

If the short-chain plant-based omega-3s in flax seeds and walnuts appear so beneficial, what about the long-chain omega-3’s found in fish and fish oil?  See Is Fish Oil Just Snake Oil? and Omega-3’s and the Eskimo Fish Tale.

In health,

Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live, year-in-review presentations:

Discuss

Michael Greger M.D., FACLM

Michael Greger, M.D. FACLM, is a physician, New York Times bestselling author, and internationally recognized professional speaker on a number of important public health issues. Dr. Greger has lectured at the Conference on World Affairs, the National Institutes of Health, and the International Bird Flu Summit, testified before Congress, appeared on The Dr. Oz Show and The Colbert Report, and was invited as an expert witness in defense of Oprah Winfrey at the infamous "meat defamation" trial.


76 responses to “The Mediterranean Diet vs. a Completely Plant-Based Diet

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  1. That’s a great picture of my VEGAN heart!!! I’m green with envy, how could you tell what it looked like ???
    Great article BTW… Similar results in Norway during and after WW2.. The Germans took all the animals to feed their army and the people only had the food they could grow, little to no meat or dairy.. As usual the rates of heart disease, stroke and diabetes dropped like a stone, only to rise again after the war when animals returned..
    m

      1. My great uncle was a doctor there under the war and in his journals he mentions , a very noticeable number of patients not needing his services , which he concedes is a positive thing . It was much talked about for some time after the war , some said it was because coffee was not available , but that would not explain why kids who normally don’t drink coffee were not getting sick as much either. this was WW two.
        My father would eat bread with sliced cold potatoes with salt and pepper for many years afterward , which was something they could get and he just continued until his passing in 2008.
        When they could get a bit of white bread they would put a slice of white on dark rye bread with a tiny bit of butter between , this was called a “millionaires Sandwich ” lol.

  2. While diet is important, somehow the word culture is missing from the picture. Lifestyle is not culture. While simulating a lifestyle could be simulated, simulating a culture in another culture cannot. There are things that cannot be quantitative measured. For example, ‘Mediterraneans’ did not drive that much. On the other hand, American walk from the house to the car and from the car to the supermarket, otherwise you could get robbed in certain areas. Americans live inside populated ‘parking lots,’ while Mediterraneans lived in small towns surrounded by nature. I could go on forever and rest my case.

    1. Panchito I would hate to think that people from around the world are reading your post and thinking America is like you describe above. Yes some cities might be as you describe but that is true for big cities in the Mediterranean as well.

      1. Point taken. Yes modern cities are all the same and have about the same problems. But in the ‘old Mediterranean diet,’ so called Mediterranean, there were no big cities. There were very small towns (probably extinct now) where the environment was different. People commuting to work in a car with anxiety is different than people walking to work breathing fresh air. And even if they were to eat the same, they may not get the same results. Thought something is better than nothing.

    2. Well except for all the Americans that live in small towns and the growing number of walkable and bikeable cities. Also the horrible traffic jams in Rome, Paris and London aren’t because every European is walking or riding their bikes everywhere. So while Europeans might on average walk or bike more than Americans, I don’t think it is fair nor accurate to overgeneralize.

  3. Does it go without saying that the Esselstyn diet eliminated all oils? For those 14 that had recurrent problems on a plant diet in the Lyon study, would they have had more success if no canola oil (or any other) was eliminated as well?

    1. Thanks for your comment Tommy,

      I may not be understanding your question entirely, but I believe all oils were eliminated from Dr Esselstyn trial (see here):

      “Foods prohibited. Initially the intervention avoided all added oils and processed foods that contain oils, sh, meat, fowl, dairy products, avocado, nuts, and excess salt. Patients were also asked to avoid sugary foods (sucrose, fructose, and drinks containing them, re ned carbohydrates, fruit juices, syrups, and molasses). Subsequently, we also excluded caffeine and fructose.”

      Hope this answer helps.

        1. Thanks for the response all!

          i guess what I really am asking is if elimination of added oil leads to a significant reduction of risk? From both Dr Esselstyn and Dr McDougall, they seem to treat added oil like poison and recommend zero consumption (similar to transfat) – While I try to reduce/minimize added oil it is very difficult to eliminate and sustain such a diet. Is there enough evidence to say that elimination of added oil results in a significant risk reduction?

          1. My working assumption is that the harm from any amount of fat, beyond the couple of grams of essential omega-3 and omega-6 fatty acids that we must consume, is proportional to the amount. Since refined oils have essentially zero positive micronutrients (at least as compared to an equal number of calories of whole food), then refined oils only have negative impacts on one’s health if for no other reason than the calories from refined oils displace an equal number of calories of other foods. In a WFPB diet that means that the food removed to make room for the refined oil calories are some of the most nutrient dense foods humans eat, and so in the context of one’s total diet, refined oils represent a substantial net reduction in total nutrient intake.

            But that absolute reduction of nutrients is proportional to the amount of fat consumed, so a very small amount of refined oil only reduces total nutrients a very tiny amount. Thus a teaspoon or two is probably not going to substantially affect one’s health especially if the remainder of one’s diet is whole plant foods. But do remember that for example romaine lettuce is only 8 calories a cup, so for each 40 calorie teaspoon of olive oil on your salad 5 cups of romaine lettuce has to be removed to keep the total calories constant. Doesn’t take much oil before there is no lettuce left in the bowl.

            Fats that come as part of a whole plant food represent a slightly more complex picture since they come with a number of other caloric and non-caloric nutrients. The net effect on the total diet thus depends on what the other nutrients are. If they are the lignans in flax seeds, then it is very much worth the “cost” of the fat (assuming that you are getting enough ALA from other foods).

            My feeling, and that is all it is, is that an otherwise whole plant food diet with lots of vegetables and especially leafy greens is so nutrient dense that there is room for a small amount of fatty foods, and so I enjoy a few nuts a day and half an avocado every week or two. But I see no nutritional reason to include any refined oils in my diet and so do not deliberately add them to my diet (I don’t cook everything myself from scratch, and so I can’t completely avoid refined fats).

          2. I agree with Jim.

            That said, the conventional mainstream view is that PUFAs do have positive benefits, even compared with wholegrain carbs
            “nvestigation of more than 127,000 cohort participants from the Nurses’ Health Study and Health Professionals Follow-up Study showed that replacing 5% of energy intake from saturated fats with an equivalent intake from PUFAs was associated with a 25% decreased risk of developing CHD; replacing with the equivalent intake from monounsaturated fats (MUFAs) was associated with a 15% lower risk.

            Although replacing with whole-grain carbs was associated with a 9% lower CHD risk, there was no risk decrease from replacing saturated fats with carbs from refined sugars.”
            http://www.medscape.com/viewarticle/851702

            This is usually interpreted as saying we should use high PUFA oils. However, we can get PUFAs from eg beans, nuts and seeds. The benefits come from the PUFAs not the oils as such. But if you get rid of the oils but don’t get your dietary PUFAs from eg flaxseeds, then your risk may even increase.

            Unfortunately, I don’t think that a head-to-head trial comparing obtaining PUFAs from oils vs obtaining PUFAs from whole foods has been conducted. However Jim’s arguments are compelling. Of course, I don’t enjoy oils or cook with them so it’s an easy decision for me. I really don’t understand why people think they are either enjoyable or hard to exclude from the diet.

    2. Our bodies need some fat in order for our cells to replicate and to absorb fat soluble vitamins, our fat calories should not exceed 10% of our total daily calories. Many studies have shown oil high in MUFA and low in saturated fats is good for our heart and our waistline. Cold-pressed canola oil is high in MUFA and has a perfect blend of Omega 3 & Omega 6, unfortunately canola oil gets a bad rap online.

      1. There are fats/oils in plant foods. Why use an unnatural extract when fats/oils are available in whole foods? I think adding more, (unnaturally obtained,) oils is unnecessary and unwise. Avocados, seeds, and nuts provide healthy fats, and in addition, they offer the added benefit of fiber and nutrients.

        1. While I agree with you in principle Johanna about wisely choosing whole foods and avoiding oils, I must admit I avoid avocados and many (most) nuts and seeds for much the same reasons. The first link shows nutrition data for avocado, .. high calorie, 16 % saturated fat , and a very poor omega 3 to omega 6 ratio. http://nutritiondata.self.com/facts/fruits-and-fruit-juices/1843/2 The canola oil also has about the same saturated fat content but much great pufa , and a very good omega 3 to 6 ratio. So if I HAD to use a small amount of fat, I’d go with organic canola oil, http://nutritiondata.self.com/facts/fats-and-oils/621/2

          1. I absolutely agree with you, Susan. I was replying to Jeff, who was advocating oil. I was suggesting whole food alternatives for him which would be healthier, (if he was worried about getting fats.)

          2. If you are looking for great O6:O3 ratios you can’t get better than flax seeds (1:4) or chia seeds (1:3). Canola oil has a ratio of 2.2:1. This is better than the 4:1 that we want to stay under. But it is greater than the 1:1 that it appears optimal.

            In vegetables cruciferous vegetables have not only great O6:O3 ratios but surprisingly percentage of calories from fat. The best O6:O3 ratio looks to be Brussels sprouts with a ratio of 1:2.2 (exactly the reverse of canola oil), 6% of calories from fat and 45 mg of LA and 99 mg of ALA per 100 g (from Self Nutrition Data</a?). Broccoli isn't too bad with a ratio of 1:1.2, 9% of calories from fat, and 21 mg of ALA and 17 mg of LA per 100 g.

            But even better is kale with a ratio of 1:1.3, 13% of calories from fat, and 138 mg of LA and 180 mg of ALA per 100 g. This is only about 1 1/2 cups chopped raw kale. My kale salads are usually four times this amount. So I am getting half of the ALA I need for a day in just one kale salad. What can't kale do!

      2. Oatmeal gets 16% of its calories from fat. In brown rice it is 8%, and in broccoli it is 10%. Seeds and nuts are of course much higher than this. If we are eating whole plant foods there is zero need to include refined liquid oils in our diet to get enough fat to aid fat soluble vitamin absorption. Also consider that the fat soluble vitamins tend to be highest in foods with relatively high fat content. For example the plant foods with the highest level of vitamin E are almonds (35% DV/ounce), spinach (18% DV/cup cooked), sunflower seeds (49% DV/ounce), avocado (20% DV/avocado), broccoli (10% DV/cup chopped). The only food that might not have enough fat in itself is the spinach with 0.47 g/cup. But I know that I never make a meal of nothing but cooked spinach, so it is likely that another food in the meal will contain enough fat to make sure that the vitamin E, beta carotene, and vitamin K are transported through the gut wall.

        Inside our bodies we absolutely needs fat to make things like cell walls, so much so in fact that nature couldn’t leave to chance that we would get enough fat in our diet and so the body can make all of the fat that it needs from the food that you do eat with the exception of two, the shortest chain omega-3 fatty acid, alpha linolenic acid (ALA) and the shortest chain omega-6, linoleic acid (LA). Whole foods with much better O6/O3 ratio than canola oil (2.2:1) are flax seeds (1:4), and chia seeds (1:3). Foods in the cabbage family also have a good ratio. For example Brussels sprouts contain 123 mg of O6 and 270 mg of O3 for a ratio of 1:2.2.

  4. The problems with Esselstyn’s diet are 1) that it makes it incredibly hard to meet your needs for vitamin E, given no nuts or vegetable oils are allowed; 2) We have little to no evidence that polyunsaturated and monounsaturated fats from plant foods cause heart disease; and 3) compliance with diets this low in fat is very poor in the long run. If you want people to eat healthier, you’ve got to make it doable AND enjoyable (i.e., meat substitutes that taste like meat.)

    1. Thanks for your comment Rick,

      This is a personal opinion and may not be in line with everyone but I will have to agree with you. However, I would like to emphasise that Dr Greger does recommend a whole food plant based diet that included nuts as you can see from this article about the Daily Dozen and you can see many videos on NF addressing the health benefits of nuts but not oils. The other point is that Dr Esselstyn’s diet was mainly focused on people who had CAD and therefore such steps could have been necessary in his point of view only to these specific group of people (see here).

      Hope this answer helps.

    2. hi Rick, not sure you caught yesterday’s video about the mediterranean diet, but the comment section there has a vigorous discussion going on about oils that might interest you. Also, I tend to agree with you about dr esselstyn’s diet, though I have heard him say that a small quantity of nuts would be alright, but he presumes people to be unable to control their intake. (I recall this from a youtube talk he gave in discussion with an audience member.. I found it off-putting) However , Dr Dean Ornish who has achieved reversal of heart disease, diabetes etc witn his program said he had to modify the reversal diet ti include nuts because he could not ignore the evidence of the benefits. https://www.ornish.com/proven-program/nutrition/ that is a link to the program description, with nut serving sizes listed . I take 1 tbsp flax seed and one walnut daily with my whole food plant based diet.

    3. Esselstyn’s hardline position on nuts is because he believes people will overeat them, not because he thinks they aren’t beneficial in small amounts. Keep in mind he is dealing with sick/cardiac patients, so dietary advice for those people who are trying for disease reversal, or to avoid progression, would naturally be more hardline than advice for people who are not sick.

    4. I don’t fully agree with Rick’s point about vit E.

      The World’s Healthiest Foods has a nice Nutrition Rating Chart
      http://www.whfoods.com/genpage.php?tname=nutrient&dbid=111#foodchart
      that shows the vit E content of various foods. If one eats a WFPB diet with amply amounts of dark green leafy vegetables and grains I fail to see how an otherwise healthy individual (no fat absorption disorders or genetic alterations that negatively affect vitamin E transport) would be vit E deficient.

      Additionally, in Dec of 2016 the Academy of Nutrition and Dietetics, published a position paper on vegetarian diets.
      http://www.andjrnl.org/article/S2212-2672(16)31192-3/fulltext
      A section of that paper is devoted to “Nutrition Considerations for Vegetarians”. Protein, n-3 fatty acids, iron, zinc, iodine, calcium, vitamin D, and vitamin B12 are discussed. Vit it E is not even mentioned as a concern.

      That said, according to the Linus Pauling Institute at Oregon State Univ
      http://lpi.oregonstate.edu/mic/vitamins/vitamin-E#LPI-recommendation
      “The current recommended dietary allowance (RDA) is 15 mg/day of α-tocopherol. It is estimated that more than 90% of Americans adults do not meet the estimated average requirement (EAR) of 12 mg/day of α-tocopherol.”
      Could it be that the reason for this vit E insufficiency is that most of the USA population is on the SAD diet and they don’t eat enough vegetables?

      Personally, I don’t have heart disease (that I am aware of) and I am going to continue to eat some nuts almost everyday along with lots of greens, but it is hard to keep track of the nuts if you snack on them out of the bag or can. One solution may be to aliquot the day’s allowance of nuts into a separate bag the night before. Or, limit yourself to a few walnuts on your morning oatmeal and call it a day. Now if I can only do that.

    5. Speaking only for myself as I address your 3rd point, Rick, I do not find that meat or meat analogs make my daily diet enjoyable: nutritious & palatable food (in that order!) is what I find pleasing—pleasing enough to look forward to my daily fare.

      1. Very well said thorn324, I was thinking along the same lines. I got into the wfpb adventure for medical reasons, but I stay in it for the food (and ethical reasons for sure). I did not try to make vegan copies of what I used to eat.. I kept an open mind to try various cuisines, and I love it.

      2. I agree with you, thorn324. However, in the first stages of eating a plant exclusive diet meat substitutes can be important for some people. As experience with a plant diet increases the reliance on meat substitutes seems less important. That’s my impression after talking to a handful of people who switched from an omnivore diet to a plant diet.

        The other point of Rick’s #3 is that “compliance with diets this low in fat is very poor in the long run.” Compliance could an interesting topic of discussion. I don’t think compliance was difficult for the traditional rural blue zone populations, although they probably had little choice. lol

        It seems obvious to me, although I may be wrong, that compliance to any healthy diet is more difficult if:
        1. Others in the household do not share the same diet.
        2. The society you live in promotes an unhealthy diet or makes it very easy or inexpensive to procure unhealthy food.
        4. The social situation(s) you are in require great willpower (or planning) to comply.
        5. The switch to a healthy diet is not a happy choice (forced by bad health or a nagging SO).
        6. The switch is made without understanding the benefits (i.e., the science).
        7. The diet is not started in early childhood.

  5. So, canola oil and bread were both allowed and recommended for the Mediterranean diet? These are both garbage non-foods with nearly no nutritional value, and potentially adverse effects. Especially when compared to olive oil, coconut oil, grass-fed butter, or starches like root vegetables & tubers. I’m not at all surprised they still had heart attack risk.

      1. Did it actually say they ate MORE canola oil and bread than the baseline? Perhaps you missed the fact that those eating canola and bread were compared against a “no dietary advice given” diet (which is, guess what, the standard American diet… more refined oils and refined carbs).
        Fewer adverse effects because of the antioxidant effects of the real foods which mitigate these problems. Eliminate the canola and refined wheat, and I bet the numbers would be closer to the plant-food based.

        1. Sigh

          “Subjects in the experimental group were instructed by the research cardiologist and dietitian to adopt a Mediterranean-type diet that contained more bread, more root vegetables and green vegetables, more fish, fruit at least once daily, less red meat (replaced with poultry), and margarine supplied by the study to replace butter and cream.”
          http://circ.ahajournals.org/content/103/13/1823

          1. Amazing, it does say “more”, the vaguest of terms! So I’ll thank you for pointing out that word and I’ll leave it at this – there is little quantification in this article of actually how much veggies vs oil vs bread is eaten. What do they quantify as “more” – this what is actually unclear without digging deeper. I would hesitate to say the canola oil and bread are causing the decrease in adverse effects, as you suggest, because there is no control group comparison. No group of people eating the same Mediterranean diet minus the bread and canola to compare against. Plenty of studies that show the detriments of canola out there. I’m not going to convince you to stop eating it, if it brings you pleasure and you believe it to positively impact your health. Namaste.

            1. Thanks . I don’t consume any oils or hard fats. It is unnecessary and almost certainly increases mortality and morbidity risk.

              However, there is pretty good evidence that replacing saturated fats – and butter (grass fed or not) and coconut oil are both high in saturated fat – decreases risk. There is also a reasonable amount of evidence that replacing olive oil with eg canola oil will also reduce risk. The Lyon Heart Study for example points in this direction.

        2. Coconut oil and grass-fed butter are both really bad for you. About all you can say for them is “It is better than the fat that comes with steak”. Olive oil is probably worse for you than canola, but I don’t know how well it has been studied. In any case if you are recommending olive oil you don’t get to call canola oil garbage.

          1. Plenty of scientific studies out there to back my point (to back either side, as there always seems to be in food science). However just the fact that canola was developed only in the last century, and 90% of the crops are GMO is enough for me to stay away from it. Do what works for you. I am at my fittest and healthiest while consuming oils of coconut, olive, avocado,and pasture raised butter.

            1. Are they GE or GMO? Also, is this pesticide GMO, yield GMO, or simply selection to reduce the Erucic Acid content? If the latter, then surely GMO is the healthier version in this case, right?

  6. I would to hear about the role of nutrition to proper jaw development in children to reduce orthodontic intervention. I spoke with Dr. Greger last year at the VegFest in Boston, MA who was a walking medical journal! He told me the pacifier was to blame, but I was not convinced that was the whole picture.

    1. Hi Matt- I’m guessing this issue is multifactorial, but I read a few years ago that one of the reasons we often now need orthodonture work (and especially removal of wisdom teeth) is that compared to the way very early humans ate, we hardly have to chew at all. The foods early humans gathered and ate were primarily very fibrous plants. Thus, from the time they first had teeth, they spent much of their time chewing. This developed the muscles of the jaw and jaw bone to a much greater extent and resulted in a larger mouth and more room for our teeth. I don’t know that there is anything to do about this and I’m not advocating making children spend their entire young lives chewing out in the garden. It would be interesting to see if children who eat more raw fruits and vegetables when they’re young have less need for orthodontists. Haven’t seen that study yet.

      1. Children who do eat a largely whole plant based diet do indeed seem to have better developed jaws with adequate room for wisdom teeth. I don’t agree with the people who have hijacked his work, but Dr. Weston Price, a Cleveland dentist, who in the 1930s traveled around the world looking at the jaw development and dental health of “primitive” people did find that those who ate their traditional plant based diet as children did seem to have more developed jaws with rounder dental arches and no problem fitting in their wisdom teeth. They also tended to straighter teeth without cavities and little or no plaque all without having brushed their teeth once in their life. But as these people began to adopt a western diet high in meats and refined plant foods during childhood their jaws didn’t develop fully to the point there was often not room for the wisdom teeth as well as many with crooked teeth and cavities were common if not universal.

        Now Dr. Price’s work was not the most scientifically rigorous, but there was some data there and it did point in the direction that diet did affect the development of the jaw as well as the structure and health of the teeth. As such, and in complete opposition to the frauds at the Weston A. Price Foundation, Dr. Price recommended a vegetarian diet for children as a way to make sure their jaws and teeth developed properly.

        @tom_goff:disqus @disqus_PhKM1GHehI:disqus I would love to see if there is other data from more rigorous researchers which can confirm or deny what Dr. Price observed. One would think that we could examine the skulls and jaws of people who have lived in different places at different times and physically measure jaw size and shape, whether the wisdom teeth successfully fit in the jaw, the amount of decay and other measure of dental health and see if that correlated with their diet. Tom Goff or Darryl, have you ever heard of such a study?

        1. Hi Jim

          No, I am not aware of any such study. It might in any case be subject to serious confounding.

          For example, to what extent does the degree of food processing affect the results? The more processed the foods (plant or animal), the less chewing is required and this would likely affect jaw development. The use of grindstones can result in high levels of grit in the diet and increase tooth wear. Even the precise composition of the diet may affect dental and oral health. For example, Eskimoes on a traditional diet were reputed to have excellent dental health but wild caught foods have more MUFA and PUFA fats, and less SFA, than farmed meats and fish available in Westernised societies. How does this affect outcomes? Does their practice of chewing leather to soften it also affect outcomes?
          If you want to explore a bit furthet
          Further, there may also be a survivorship bias in societies with high child mortality. Are children with poor oral/dental health more likely to die and would this affect observed rates of dental health in adults?

          However, I think it is fairly widely accepted that many modern Western foods high in added sugars, high in saturated fat and high in heavily processed foods do adversely affect dental and oral health which would suggest that Weston Price’s observations were probably broadly correct. Nonetheless, there are I understand examples of prehistoric skeletons where the individuals had lost all or many of their teeth before death. Of course, infection or injury as well as diet and/or starvation can also influence dental/oral health and might have played a role.

          If you want to explore a bit further you could check out papers on dentition and hominid evolution for example. Wikipedia has some good references. And regarding diet and oral health generally, I’d suggest Medscape is a good place to start.
          https://en.wikipedia.org/wiki/Hominid_dental_morphology_evolution
          http://emedicine.medscape.com/article/2066208-overview#a1

          And then there are genetic factors …………

          1. Thanks Tom! I agree about the confounders and all the factors that can affect dental health in general. Mostly though I was wondering in response to Matt K’s question and Cathleen’s response about whether the foods we feed our children affect how their jaws and teeth develop. I think a particularly good indicator might be whether the jaw developed with sufficient room for the wisdom teeth to fully erupt. A secondary one would be whether a person would have needed orthodontia to correct defects in tooth placement/alignment. I would be interested to see if the percentage of people without room for their wisdom teeth in their jaw has changed over the centuries and if so what was that trend line. The same for straight versus crooked teeth (where you can tell before they, as you said eroded down or fell out). Has it been a smooth steady trend going back centuries or even millennia or has it been a recent and rapid change.

            I did a little poking around and found reference to this paper. It concludes that reduced mechanical stress on jaws and teeth during development for why teeth are misaligned and why there is insufficient room for wisdom teeth rather than genetic difference (collectively termed malocclusion). As proof they point to the fact that the rates of malocclusion can change in a single generation when societies come into contact with the western diet. They seem to be saying it was because the traditional diet these societies ate put more stress on the teeth and jaw while teeth and jaws were developing and thus stimulated growth. However, the societies that were identified certainly cooked a large percentage of their food (save the Inuit). Also I think mechanical stimulation could play a role in jaw development, but I don’t see how it could be responsible to the greater average tooth crown size of the developing adult teeth prior to eruption. So I have doubts that it actually is a dramatic reduction in mechanical stress, at least not completely, but rather the nutrient shift when they moved from their traditional largely plant based diets to a western meat and refined plant food diet almost certainly played a role.

            1. Thanks Jim. That link is an interesting read.

              However, I am not sure that it is possible to easily disentangle the effects of nutrients from the effects of the physical properties of foods. It is also not just cooked versus raw food. The type of cooking can be relevant too. The physical properties of coarse bread versus modern wholegrain bread for example. Or a steak versus a burger pattie or sausage meat made from that same steak. Both are cooked but they have different physical properties .
              I also understand that permanent tooth crowns ( ie adult teeth) start to form when children are chewing not just swallowing food. Consequently, mechanical effects could be responsible either in full or part. This biomechanical explanation seems to be the most favoured at the moment (there have been some animal experiments which point in this direction) but there is no conclusive evidence yet. You might find this paper interesting (incidentally, the author is one of the three for the article you linked).
              https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3241821/

              I think the question is still open and it makes sense that nutrition plays a role. Tooth loss occurs with scurvy for example.

              But there is also infection to be considered – apparently sugar has no effect in caries in the absence of a specific bacterial infection
              https://www.nidcr.nih.gov/datastatistics/surgeongeneral/sgr/chap3.htm

              1. Tom, thanks in return for the link. I agree that it would be very tough to disentangle difference in nutrient intake and from mechanical stimulation. The nice thing is that raw plants represent the foods with both the highest mechanical stimulation (unless you cook your steaks to the equivalent of shoe leather) and nutrient density. So from the point of view of a diet that helps promote the proper development of the jaw and teeth in children, it doesn’t look like we in a modern society can do any better than a plant based diet with an appreciable fraction eaten raw.

                And thanks also for the link about dental caries. Since I changed to a plant based diet I no longer develop any plaque on my teeth. Just had my latest visit two days ago and the dental hygienist said that she literally had nothing to clean off my teeth. Since as the study you linked says, caries are caused by the bacteria that create a biofilm on the teeth that is the cause of tartar that harden into plaque, this would indicate to me that I no longer have substantial amounts of these bacteria in my mouth and as such a much reduced chance of subsequent bacteria mediated decay of my teeth. It also indicates that oral bacteria culture can be shifted from one that promotes decay (as evidence by my many fillings) to one that does not by a change to a plant based diet. I would think that would also be of great interest to parents of young children.

  7. A Harvard study 20 years ago showed that salmon oil helped to prevent second heart attack. An unintended offshoot showed that salmon oil also helped to decrease irregular heartbeat in the participants who had that condition.

    1. So was the healthier brains due to the fruit, vegetables or olive oil? And if was the olive oil, what was the biological processes/pathways that allowed olive oil to improve brain function? Or could it be that it wasn’t the olive oil per se but rather it replaced some of the artery clogging saturated fat from their diet that reduced plaque formation in the arteries in the brain and so maintained better blood supply that is the key to brain health.

      If it was this later case, which I suspect it was, then anything that replaced the saturated fat that was even marginally less damaging would appear to some degree beneficial. Olive oil has been shown experimentally to still cause damage to the endothelial cells lining the arteries, just not as badly as an equal number of calories of saturated fat. As such these pensioners were “better” because they weren’t getting as sick as fast as their peers eating more saturated fat (as well as less fruits and vegetables).

      Other research shows conclusively that whole plant foods actually improve endothelial function rather than just reduce the amount it is injured. Thus it is more likely that if these pensioners had consumed even more whole plant foods in place of the saturated fat rather than just doing a fat swap to olive oil that their arteries would have been even healthier, the blood supply to the brain even better, and their brain health improved even more.

  8. I have a question. From what I understand, Esselstyn and Ornish both recommend a whole foods, plant based diet, but without nuts, olives, avocado and coconut. But you present multiple videos and articles on the benefits of nuts and seeds. When would or wouldn’t one eat them?

    1. hi Kristen, Dr Greger has several videos on coconut products which generally are avoided by people eating to reverse heart disease or lose weight because of its high saturated fat content. http://nutritionfacts.org/video/is-coconut-oil-good-for-you/

      https://www.ornish.com/proven-program/nutrition/ Dr Dean Ornish includes nuts and seeds on his program though the quantities are limited. The link provided lists allowable portions. Dr Esselstyn also acknowledges the benefits of nuts /seeds, but discourages people from including them since he feels most people will eat them to excess.. he does encourage a tbsp of ground flax / day however, or chia seed. Avocado is a high calorie, high fat food, so someone seeking to lose weight or reverse heart disease would avoid them or include them only in very limited quantity.

      1. Thanks so much. Weight is definitely not a problem. Neither is cholesterol, the last I knew. Just trying to understand the more subtle points.

    2. Kristen: I have Esselstyn’s book on preventing and reversing heart disease, and even that book has a dressing recipe with a lot of walnuts in it. It just comes with a warning above that that recipe is not for people with heart disease. I think that’s where you can see some differences. *Some* nuts for some people can be health promoting. It’s just that if you have messed up your circulatory system so bad that you are in danger of killing yourself, you might need to be more extreme in limiting fat sources compared to other people. Dr. Greger is making recommendations for the population as a whole. Esselstyn and Ornish primarily serve the very sickest of us.
      .
      That’s how I generally see it, though to be more complete, I need to mention that I think that NutritionFacts has a video showing nuts in general may be health promoting for the heart, but I don’t have that video at my fingertips and am personally more likely to go with Esselstyn on that one.
      .
      I particularly appreciate susan’s point about weight gain also being an issue as I think that often gets overlooked.
      .
      For someone like you who sounds pretty healthy, I think eating nuts and seeds in the recommended amounts would be great. Dr. Greger recommends about 1 tablespoon of ground flaxseed every day, plus 1/4 cup whole nuts/seeds or 1/8 cup nut/seed butter.
      .
      What do you think?

      1. Thea — thank you for your feedback. I appreciate it. I knew that Esselstyn grudgingly allowed nuts, IF the cholesterol is low enough. That’s logical — if nuts have a deleterious effect on cholesterol. But what I am seeing here from Dr. Greger is not that. If I understand correctly. He’s showing that nuts (Brazil) lower cholesterol, that they don’t cause obesity, that they protect against cancer, that over and over again they are protective to our health. So … I have questions. Maybe, it’s as many of “them” are saying. It’s healthful to a point. Really? I’m not a nut fanatic, other than it is soooo much easier to not eat oils when I can make sauces and mayonnaise from nuts, but what happens if I “go nuts,” so to speak. Would I become insulin resistant? Would I eventually drive up my cholesterol despite the benefits seen at “low” levels of consumption?

        My mother is pushing 90. She has had low levels of inflammation in her joints since she was in her 50’s. Her hands look like she has rheumatoid arthritis, even with negative biomarkers, and she has had a hip replacement and both knees replaced. Something is not right. She has been living with enough daily pain that she generally requires medication twice a day, and not just Advil or Celebrex, either. I think she has had a leaky gut due to something for half her life. At my suggestion, she has been doing an eliminationn diet HEAVY on greens. In four days, she had no pain except her hands. As a careless lacto-ovo vegetarian, using oils, her cholesterol ran around 170. She LOVES nuts. Esselstyn includes a case history of a physician who was VEGAN and couldn’t get his cholesterol down without meds, until he gave up his small handful of nuts and avocado each night on his salad. Was he just one of those unlucky few who process fats exceptionally well?

        It seems that oils contribute to leaky gut. Are some people sensitive enough to fats that this condition is elicited with avocaodos and nuts, as well, causing inflammation and increased arthritis symptoms. Are these the same people who also have problems with cholesterol when they eat nuts, or is it an entirely different mechanism?

        I would love to tell my mom, enjoy your nuts! They are good for you. But I’m not sure. My questions are related to the differences of opinion in relation to their effect on cholesterol, the quantity (why if some is good, more isn’t better?), and the effect on the gut.

        1. Kristen: I am not an expert at this stuff. All I can do is share my thoughts with you.
          .
          First, I could be wrong, but I don’t think we have the definitive answers/studies you are looking for. So, we have to figure out how to proceed with imperfect information. None of the experts I follow think that people should go nuts on nuts. They have some differing opinions on who should eat nuts, but they all think that the general population would do best to limit nuts to a relatively small amount.
          .
          That amount of nuts that they do allow can be a good amount for someone like you (and me!) who wants to make some sauces that include nuts. One of my favorite vegan cookbooks is Vegan Casseroles. There are several sauces in the book that call for 1/2 cup cashews (among other ingredients such as soy milk, etc). That 1/2 cup is two servings if you ate all the sauce. But the way you use the sauce is you put it on a bunch of stuff (like broccoli and rice or pasta) so that you get at least 4 big servings out of the dish. That means that one super-creamy and rich meal has only half the allotted nut allowance for the day (according to Dr. Greger’s Daily Dozen). The point I’m making is that even within the restrictions of the experts, there is a fair amount of room for making those richer dishes that you crave.
          .
          I haven’t watched that video on nuts and weight gain/loss for some time. But if memory serves, there was a tricky phrase that I think most people over-look. It was something like “as much”. They didn’t gain “as much” weight as would have been expected based on the extra calories coming in. That doesn’t mean that people eating those extra nuts didn’t gain any weight from the experience. And we know from some high profile people like “Chef AJ” (you might want to look up her story) that nuts can very well be the cause of weight gain. My point here is that this website does paint nuts in a very positive light, but the devil is in the details and there is very good reason why the Daily Dozen only recommends 1/4 cup nuts and not more despite all the videos you are referencing.
          .
          I forwarded your post onto our medical moderators to see if they want to comment on the questions you pose. But I did have a response to “…the quantity (why if some is good, more isn’t better?)…” I really like this question because it is something that comes up all the time, though usually in a different context. There is a popular saying that goes: “the dose makes the poison.” This means that lots of things (everything) are perfectly safe or even beneficial at some levels, but detrimental above those levels. The classic example is: while water is not just a beneficial, but essential component of our diet, too much water can kill a person. So, it’s not surprising that some small amount of brazil nuts may be good, but other nuts or more brazil nuts may be overall bad for something like cholesterol. (I don’t know. I’m just making a point.)
          .
          One last thought for you: I am truly impressed that a) you came up with a great diet to help your mom address her health problems and b) she went a long with it. And it worked! That’s great. Now it seems like you want to know if it is OK to tell your mom if she can add back in nuts. My thought is: the diet was exactly what you described, an elimination diet. The purpose of an elimination diet is to eat an extremely restrictive diet in order to completely eliminate a health problem, and then to slowly add back in one food at a time to see if that food causes the problem to appear. It seems to me that you could have your mom tentatively add back in nuts and see what happens. Just be sure to educate your mom on what a reasonable daily nut intake looks like. And to not forget the 1 tablespoon flaxseed (which I understand would be good because omega 3 to 6 balance is important to combat inflammation? and many nuts have a whole lot of omega 6s) Again, I’m just a lay person sharing some thoughts.
          .
          Best of luck to both of you.

          1. Thanks, Thea. Again, I appreciate your thoughts. I think you’re right. We just don’t know all the details, yet. We’ll see how my mom does. I’m not ready to add the nuts back, yet, poor baby. :-/ And, yes, she is taking flaxseed. At least, from where I am (several thousand miles away), I believe she is taking flaxseed. She is still on a rather restricted diet. I’ve asked her to get her cholesterol checked. I think it will really encourage her. Then, as long as it’s down below 150 and her LDL is below 70, we’ll try no meds and check it again, and if it is STILL good, which I believe it will be if she adheres to the diet changes, we’ll add nuts and check it again a month later to see what impact the nuts had. That way we can see the effect on pain after being off them for quite some time and we can follow the impact on her cholesterol. She’ll never stay at 1/4 c nuts per day, so we’ll have to keep checking periodically, just to monitor. I really think the major problem, for both her pain and her cholesterol was free fats (oils) and butter and eggs, with a little cheese thrown in. At least, that’s what I’m hoping for. And of course, there was that ice cream. XD So I think there is hope that the nuts won’t be an issue for her, either for pain or for cholesterol. She has great genes.

            1. hi again Kristen.. I just wanted to add one thing., please note that Dr Ornish only ever spoke in positive terms about wal uts, ground flax and chia in any quotes I aw in the past. He did not insist on certain cholesterol either. Just one walnut a day , and /or the flax seed,… I only mention this because its the reason I only i clude these.. not almonds, peanuts or anything else. In your mom’s case the omega 6 excess from the other nut types might prove inflammatory (and pain inducing ?) .. thats why I avoid them entirely. walnuts , chia and flax are the ones with good omega 3 vs 6 ratio. Just a thought

              1. A very good thought! I’ll keep that in mind when we do introduce nuts. I knew that about flax and was catching on about chia, and I even knew that walnuts were the least inflammatory, but not specifially why. It stands to reason.

                BTW, I just watched a wonderful video of Dr. Greger’s on nuts and weight gain. Sorry. No weight gain. Not even with LOTS of extra nuts. So … what about cholesterol? What about the effect on the gut? I specifically looked this time on some of the studies Dr. Greger presented. On at least one study he flashed past, the upper category was like >= 2 servings per week! That would automatically include the people who ate >=2 servings per day! I think we need some more studies on the impact of higher nut consumption.

                Personally, I agree that there is intuitively a limit where your body just won’t thrive with that much fat. If noting else, you’re missing out on other plant products if all you eat are nuts. But I question where it is and what is happening — usually, not only with rare people — with the cholesterol. For example, could you actually induce insulin resistance from too many nuts?!

                I guess I’d like to be able to say to most people, especially my mom, don’t worry about the nuts. Just like don’t worry about the apples. All that said, 1/4 -1/2 cup per day seems more than enough. But see, I just doubled the recommendation! :-/

                1. your mom is lucky to have you Kristen, and I think thats what matters most ! I dont know if maybe each person is a little different, but I can hardly eat any and my cholesterol goes up. The benefit of the flax and the one walnut perday on oatmeal is worth the small inc in cholesterol. My aim is to reduce inflammation, so I try to avoid omega 6 (we get it in vegies anyway) and concentrate on omega 3 .. its working for me so far.

                  1. I appreciate you sharing. It really helps. Because what I hear the studies saying is nuts lower cholesterol. Nuts don’t cause weight gain. Nuts are great to help fight cancer. But the docs aren’t so enthusiastic. So they are obviously seeing something more along the lines of what you experience and what the physician in Esselystyn’s book experienced.

                    Also, I am so slow sometimes, but a light bulb went off finally regarding omega three vs. omega 6 and inflammation! What other words of wisdom do you have for inflammation? It sounds like you are ahead of me. XD

  9. Curious, what is the best method of cooking to retain the most nutrients out if foods like sweet potato, kale, broccoli etc, and how much is lost through different methods? E.g oven cooking, boiling, stir fry (without oil) and steaming

    1. Thanks for your question Darren.

      According to this review:

      “1. Onion׳s pungency is increased during food preparation, such as chopping and trimming.

      2. Steaming seems to be the best method to maintain the nutritional quality (TAC, carotenoids, glucosinolates, sulphorane, folate and phytochemicals).

      3. Onions should be cooked or baked to improve flavonols’ content.

      4.Sous vide cooking has shown good results in cooking potatoes and should be investigated further.

      5. Soaking and cooking peas and beans are effective in removing or reducing anti-nutrients such as tannins, TIA and acid phytic.

      6. Boiling seems to be the best method to retain folate in peas and should be further investigated.

      7. Soaking with salt, discarding water and cooking in fresh water is the best method to reduce cooking time, and to improve the protein quality, texture and appearance of beans, while reducing gastric issues.

      8. The absorption of Fe can be improved by heat processing.

      9. Other factors besides cooking – such as growth conditions and variety/cultivar – can affect sensory parameters.”

      This review is open access, therefore if you wish to further know about specific foods (peas, beans, broccoli, potatoes, onions), I highly recommend you to read it.

      Hope this answer helps.

    2. Hi, Darren. I see that Darchite, MSc, R.D. posted a terrific answer to your question. In addition to what he wrote, you might be interested in these videos, if you have not already seen them.
      https://nutritionfacts.org/video/second-strategy-to-cooking-broccoli/
      https://nutritionfacts.org/video/inhibiting-platelet-activation-with-garlic-and-onions/
      https://nutritionfacts.org/video/best-cooking-method/
      https://nutritionfacts.org/video/the-best-way-to-cook-sweet-potatoes/
      I hope that helps!

  10. I don’t get why Dr. Greger neglects the healthy aspect of oils from fish. I think a vegan + fish diet is the optimal one (fish is an important part of the Mediterranean diet as well).

    Source e.g.: Alexander et al.: A Meta-Analysis of Randomized Controlled Trials and Prospective Cohort Studies of Eicosapentaenoic and Docosahexaenoic Long-Chain Omega-3 Fatty Acids and Coronary Heart Disease Risk. Mayo Clin Proc. January 2017;92(1):15-29

    1. Michael Krause: Dr. Greger does not ignore the healthy aspect of oils from fish. What Dr. Greger always keeps in mind is that food is a package deal. You get the bad along with the good. The good along with the bad. So, to decide if a food is overall healthy, you have to figure out if the bad out weights the good or the good out weights the bad and figure out what the alternative food options are. Then, you can properly make decisions about the food. In the case of fish oils, the bad outweighs the good, especially in light of the fact that we have algae based DHA oil as an alternative with none of the bad that comes with fish oils. The same applies to fish itself. To learn more about fish and fish oil, check out the NutritionFacts topic pages: http://nutritionfacts.org/topics/fish and http://nutritionfacts.org/topics/fish-oil/

      1. Dear Thea,
        thank you for your answer. Could you hook me up with the associated journal articles that the pollution of fish (oil) is that high? I have problems with the thought that I should buy capsules of algae oil instead of eating organic fish.

        1. Michael Krause: All the videos on this site have a “Sources Cited” button. Click that button and a new section will appear below the video. So, all you have to do is find the videos on fish oil and contaminants and you can check for yourself.
          .
          Now I can’t remember what I said in my original post, but I’ll make a note about fish itself (as opposed to fish oil): When you eat fish, you not only get the omega 3 fat in the fish, but you also get the saturated fat, the cholesterol, the animal protein, the contaminants, etc. At the same time, you miss out on fiber and phytonutrients. Food is a package deal. When you eat fish, you get a *whole* lot of bad with a small amount of good.

    1. This site is scientifically biased against ingestion of anything that has been clearly shown in published clinical research to increase the risk of disease and premature death in humans. This includes animal products and refined fats and carbs as has been shown in 4000 unbiased clinical studies. Dr. G simply presents the unbiased evidence. What you eat and the risk you take with your life is totally up to you. No one is telling you what to eat.

      Dr. Ben

  11. Hi
    After watching ‘The Human Longevity Project ‘ I am not convinced that the Mediterranean diet is not healthy.
    I think you are out of touch with reality as the Mediterranean people thrived on their diet and they typically lived >100 years and did not suffer disease.
    It is the SAD diet and lack of exercise that is killing everyone. The low fat advice of the past few decades has resulted in escalating cases of chronic diseases as a result of a switch to refined carbs

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