EP. 143: HOW NOT TO DIE

Feb 1

WITH MICHAEL GREGER, MD

A prominent expert on evidence-based lifestyle medicine shares surprising facts behind why the American diet is the leading cause of death among Americans — and what we can do to make food work for us.

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Episode Summary

The American diet is the leading cause of death among Americans. Accumulating medical evidence now shows that poor diet not only contributes to heart disease, diabetes, and stroke, but also to cancer, Alzheimer's disease, liver disease, and much more. Despite its direct and indirect roles in causing half or more of all deaths, food is not something doctors learn about in their training, nor is it something that's emphasized enough to patients by the medical establishment.

Our guest on this episode is Michael Greger, MD, a specialist in lifestyle medicine and one of the most trusted voices in evidence based nutrition and public health. He is the internationally best selling author of How Not to Die (2015), How Not to Diet (2019), and How Not to Age (2023).

Over the course of our conversation, Dr. Greger shares his approach to healthy living, focusing on the surprising power of whole-food, largely plant-based diets in transforming our bodies at a molecular level. He discusses strategies for helping patients and ourselves achieve behavioral change and explores how our brains and palates are rewired by processed foods, how we can reverse this, the ethics of patient counseling around lifestyle interventions, why there is such a mismatch between nutrition beliefs and behaviors among physicians, and his most high-yield recommendations for starting your journey to eating well.

Michael Greger, MD, FACLM is a physician, New York Times best-selling 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, among countless other symposia and institutions; testified before Congress; has appeared on shows such as The Colbert Report; and was invited as an expert witness in defense of Oprah Winfrey at the infamous "meat defamation" trial. In 2017, he was honored with the American College of Lifestyle Medicine with its Lifestyle Medicine Trailblazer Award.
Dr. Greger is also licensed as a general practitioner specializing in clinical nutrition and is a founding member and Fellow of the American College of Lifestyle Medicine. Dr. Greger's nutrition work can be found at NutritionFacts.org , which is a registered 501(c)3 nonprofit charity.

Four of his books — How Not to Die, The How Not to Die Cookbook, How Not to Diet, and How Not to Age — became instant New York Times Bestsellers. He is also the author of Bird Flu: A Virus of Our Own Hatching and Carbophobia: The Scary Truth Behind America's Low Carb Craze. Dr. Greger is a graduate of the Cornell University School of Agriculture and the Tufts University School of Medicine.
In this episode, you will hear about:
• 2:45 - How Dr. Greger’s grandmother’s miraculous recovery due to diet change inspired him to build a career in nutrition science
• 6:58 - The disconnect that exists between the American medical system and the science of nutrition
• 13:57 - Why nutrition education is lacking in American medical training
• 21:31 - Issues with compliance among patients trying to adopt a lifestyle of healthy eating
• 28:00 - Supporting patients who are not interested in preventative healthcare measures
• 35:15 - Navigating the confusing and often conflicting landscape of nutritional studies
• 43:20 - Whether there is a universal dietary recommendation
• 46:49 - Simple ways to improve your diet, starting today
Henry Bair: [00:00:01] Hi. I'm Henry Bair.
Tyler Johnson: [00:00:03] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build health care institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and healthcare executives. Those who have collected a career's worth of hard earned wisdom, probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging, and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:02] What is the leading cause of death among Americans? Smoking? Accidents? Actually, it's the American diet. Accumulating medical evidence now shows that poor diet not only contributes to heart disease, diabetes, and stroke, but also to cancer, Alzheimer's disease, liver disease, and so much more. Despite its direct and indirect roles in causing half or more of all deaths, food is just not something doctors learn about in their training, nor is it something that's emphasized enough to patients by the medical establishment. Our guest on this episode is Doctor Michael Greger, a specialist in lifestyle medicine and one of the most trusted voices in evidence based nutrition and public health. He is the internationally best selling author of How Not to Die, How Not to Diet, and How Not to Age. Over the course of our conversation, Dr Greger shares his approach to healthy living. Focusing on the surprising power of whole foods, largely plant based diets, in transforming our bodies at a molecular level. Preventative health is hard because, as you will hear him say, when it's done well, nothing happens. Still, he'll discuss strategies for helping patients and ourselves achieve behavioral change along the way, exploring how our brains and palates are rewired by processed foods. How we can reverse this. The ethics of patient counseling around lifestyle interventions. Why there is such a mismatch between nutrition beliefs and behaviors among physicians, and his most high yield recommendations for starting your journey to eating well.
Henry Bair: [00:02:40] Michael, welcome to the show and thanks for being here.
Dr. Michael Greger: [00:02:43] I'm so glad to be here. It's an honor.
Henry Bair: [00:02:46] As a preface, I have to mention how much your writings have helped me personally. Last year as a first year resident, I was sleeping poorly, not exercising and eating what I thought was a serviceable diet. You know, I was subsisting off of a lot of convenient and packaged foods, but it wasn't like I was guzzling burgers and fries on a daily or weekly basis. But during a routine blood test, I found out that not only was I pre-diabetic, but my LDL and triglyceride levels were also way above the upper limits of normal. Something had to change. But when it came to diet, I realized I didn't even know where to start. That's when I found your book. I've been implementing many of your recommendations, focusing on a mostly, but not exclusively plant based whole food diet on a daily basis for the past ten months. And in the interim, my lab values have normalized quite drastically. So I have been looking forward to this conversation. We'll get into all the specifics of all that, but first, can you tell us what initially brought you to medicine and to the world of lifestyle medicine.
Dr. Michael Greger: [00:03:56] You know, it all started with my grandmother. Actually, I was I was just a kid when the doctors sent my grandma home in a wheelchair to die. Basically, she was diagnosed with end stage heart disease. She already had so many bypass operations that, you know, you get so scarred up inside. The surgeon is basically run out of plumbing, you know, confined to a wheelchair, crushing chest pain. Her life was over at age 65. But then she heard about this guy, Nathan Pritikin, one of our early lifestyle medicine pioneers. And what happened next is actually detailed in biography. It talks about Francis Greger, my grandmother. They wheeled her in and she walked out, though she was given a medical death sentence at age 65 thanks to a healthy diet, went on to live another 31 years till age 96 to continue to enjoy her six grandkids, including me. So that's why I went into medicine. That's why I practice lifestyle medicine, where I started the website nutritionfacts.org, where I wrote the book How Not to Die. Why 100% of the proceeds I get from all my books are donated directly to charity. I just want to do for everyone's family what Pritikin did for my family.
Henry Bair: [00:05:06] So as you were observing this happen, this was before medical school. Was this dream medical school after?
Dr. Michael Greger: [00:05:12] Oh, yeah. Yeah, yeah, yeah, this is this is way back. And, you know, at the time, it was no big deal. I mean, that's what happened. You know, that's what happens when you go to the doctor. They make you better. And all of a sudden grandma was better. But at the time we had no idea how revolutionary this was. You know, back then in the 70s, the, you know, heart disease, progression of heart disease, maybe we could slow it down, but the thought that it could be stopped or reversed, I mean, that was completely unknown. The they just expected people to get worse, worse, worse than they died. And, you know, Pritikin was doing this, you know, by the thousands. But it wasn't until Ornish came along.
Henry Bair: [00:05:44] This is doctor Dean Ornish. For the listeners who might not be aware.
Dr. Michael Greger: [00:05:48] Doctor Dean Ornish and, you know, The Lancet. In 1990, the the first randomized controlled trial to actually put people on a healthy diet and lifestyle and show using quantitative angiography that indeed you can start reversing the course of the disease. There wasn't black and white. And then you have, you know, nuclear imaging after that showing this reversal of heart disease, this disease thought to be irreversible. The number one killer of men and women. That is what really kind of inspired me down this path. I already had seen it in my own, you know, in my own life. But here it was in black and white, publishing some of the most prestigious medical journals in the world. Yet I looked around and like nothing happened. You know, it's like, here we are. We you know, hundreds of thousands continue to die of this preventable arrestable disease, heart disease. And I just felt that we weren't exercising all the tools in our medical toolbox to do all we could for our patients. And so that's what really drove me to not just pursue preventive medicine, preventing disease with lifestyle approaches, but actually treatment and potentially reversal with lifestyle approaches.
Tyler Johnson: [00:06:58] I think it's an interesting observation in terms of the paradigm that we use in medicine in the United States. I mean, I'm a medical oncologist, right? So I and I finished residency a good number of years ago, but not that long ago. And what was really striking to me when I would work, particularly in the cardiac critical care unit at Stanford. So, you know, a pretty common scenario on that service is that you'd have a patient who comes in with what we call an Nstemi. So for early trainees or those who are not medical folks, and Nstemi is sort of a moderately severe heart attack, let's think about it like that. And the thing that is interesting about an end Stemi. So if you come in with a Stemi, which is a very severe heart attack, you get whisked away to the cath lab, you know, basically the second you walk in the door. But for a moderately severe heart attack, that doesn't happen. And often you are going to go to the catheterization lab, which is a place where they can try to clear up the clot in your artery by putting in a little sort of a metal cage to prop the artery open in a moderately severe heart attack. Usually you will go to the lab to have that done, let's say in 24 or 48, 72 hours, depending on the circumstances and the day of the week, and a bunch of other things.
Tyler Johnson: [00:08:03] So the thing that's just so interesting to me is that if you have a patient who's on the floor for 48 hours, there is this pretty complicated decision tree that has to do with first, you're going to start them on aspirin and give them oxygen and pain control and whatever. And then you're probably going to start them on Plavix. And then you're probably going to think about something like A2B3 inhibitor and then and then and then. But the thing that's so interesting is that as you look, you know, giving someone an aspirin if they're having a heart attack has an enormous mortality benefit and is very consequential and beneficial for them. But then when you go to Plavix on top of aspirin, never mind other anticoagulant or antiplatelet agents on top of that, which they may not even use two B3 three and three inhibitors anymore. I don't know because I'm not a cardiologist, but the point is to say that the marginal benefit of each of those interventions at the time that the person is having the moderate heart attack gets to be smaller and smaller and smaller and smaller, right. So that with aspirin it's pretty big. But then everything beyond that, it gets to be to where it's almost vanishingly small.
Tyler Johnson: [00:09:04] And of course, the newer the drug, the more expensive it is. So that you have this sort of strange situation where you are paying more and more for less and less benefit. But if it has any sort of, you know, what is an accepted benefit in a randomized controlled trial, then it will often become a standard part of the workflow. But what is so interesting to me is that to sort of at least the philosophical point, I mean, I'm not an expert in nutritional science either, and so it's hard for me to comment on the nitty gritty specifics of any given trial, but at least paradigmatically or philosophically, it would seem to be inarguable that there are things that we could do far upstream of the moderate heart attack, which would cost effectively nothing, or at least much less, and would have much greater benefits. And yet, the US health care system is just not set up to deliver or focus on those kinds of interventions in the same way that there is this sort of a laser focus on the kind of intervention that we would deliver in the 24 to 48 hours between when a person comes into the emergency department and when they actually then get into the cath lab.
Dr. Michael Greger: [00:10:15] Well, you know, it's even worse than that. It's not just that, you know, if we find some incremental benefit, then, you know, we can charge Medicare for it. But even where you don't see the incremental benefit, like those that same kind of angioplasty in a context not of an acute MI, but in the context of kind of stable angina, which hasn't been shown to improve, not only shown to improve your survival, but not even compared to sham procedures, not even improve pain. So we have this situation where we're doing thousands of these super expensive procedures where the benefits may not even way outweigh the risks, which really kind of the most extreme side of the equation versus write some of these absolute lowest tech solutions that just don't make anybody money. They don't make the medical instrumentation companies money, they make hospitals money, you know. And so it's like, where are we going to learn about this, you know, when's the last time we were taken out to dinner by Big broccoli? It's probably been a while. I mean, it's just the system is set up in a way that just incentivizes some of the wrong treatments. Obviously, some of these high tech solutions can be extraordinarily life saving.
Dr. Michael Greger: [00:11:27] And but you know, about what, 80% of what comes into a primary care office these days are these lifestyle diseases. And unless we're treating the underlying cause, you know, we can slow down the rate at which our diabetics, you know, lose their sight and kidney function and lower limbs. But if we actually want to reverse the disease, we really have to treat the cause, which in most cases are these diet and lifestyle behaviors, which we as physicians are just simply not taught about yet. If you look at the Global Burden of Disease study, which is the largest systemic analysis of risk factors in history, funded by the Gates Foundation, the number one cause of death in these United States is the American diet. Bumping tobacco, smoking to number two. Cigarettes only kill about a half a million Americans every year, whereas our diet kills many more. The leading cause of disability as well. And so you'd think if what we really cared about in medicine is saving people's lives, then obviously nutrition. The number one thing taught in medical school. Right. Obviously, it's the number one thing your doctor talks to you about at every single visit, right? But see, there's this disconnect right between the science and the mainstream practice of medicine.
Dr. Michael Greger: [00:12:38] And I really harken it back. You can kind of make this comparison to, like, smoking in the 50s. We already had decades of science starting in the 30s, linking smoking with lung cancer, but it was ignored because smoking was normal. Two thirds of Americans smoked. Most doctors smoked. The average per capita cigarette consumption 4000 cigarettes a year. The average person walking around smoked half a pack a day. The American Medical Association was reassuring everyone that smoking in moderation, that's totally fine. So there was this similar disconnect between science and public policy, and it took more than 25 years, 7000 studies, before the first Surgeon General's report against smoking came out in the 60s. And since then, one of the greatest public health victories of all time. Down came smoking rates, essentially every single year since that first Surgeon General's report in 1964. And then came tumbling down lung cancer rates, this extraordinary Accomplishment. And I think we find ourselves in a similar situation now where we have this overwhelming body of evidence, but it just has not really connected with policy. It has not connected with medical education in ways that's really, you know, neglecting opportunities to make worlds of difference.
Henry Bair: [00:13:57] Earlier on, you talked about how there isn't really a big broccoli sort of countering big tobacco. Or, you know, or Big pharma, for example. And sure, that makes sense from the private side. But what is the explanation, you know, for for medical education? I mean, us doctors, we like to think of ourselves as outside the realm of thinking about profits and return on investment and things like that. And yet, you know, I mean, some of the things I mean, I have a copy of your book, How Not to Age right Here with me. And it's interesting that the title is provocative, but you're not actually talking about how to live forever. And that's not the point. I think your point is that the title How Not to Age, implies that there is a better way to age than other ways to age, and you're trying to advocate for a way to age such that you maintain your optimal health such that you can live your life according to your values until the very end, basically. But, you know, your book basically goes through all the different organ systems and functions in the human body that can be improved by diet, you know, and going all the way from immune system to musculoskeletal system to decreasing cancer, to improving bone health to cognitive function.
Henry Bair: [00:15:07] And as I read this, I have to think to myself, why is it that we had maybe four hours of nutrition per week for four weeks in the first quarter of medical school, and that was it. Why is it that in residency training, you know, every day we have an hour of lectures, like noontime lectures, and it's always focused on the latest pharmaceutical developments or common disease pathologies and never. I don't think I had a single one on nutrition. And when we counsel patients in the hospital as residents, it's almost like a cursory gesture. We ask them about their diet. Oh, do you eat healthily? And the patient says, yeah, yeah, I eat pretty healthily. And you just kind of like roll with it. It's like, okay, great. You know, we don't really drill down on exactly what they're eating. Contrast that with when a patient says that they don't really take their statins, you know, as scheduled. You get so upset. All the cardiologists that come fired up and they come into the room, you know, and they'll do whatever it takes so that the patient will take their statins. So what is the disparity there if it's not profit, if it's not, you know, return on investment motives. Why do you think at the medical education level, at how we train future doctors, this is still lagging behind what you would like to see?
Dr. Michael Greger: [00:16:16] I mean, certainly some of it's ignorance, although a quarter of medical schools these days don't have a single course in nutrition. So, you know, we have this severe nutrition deficiency in education. You know, most doctors just never taught about the impact health and health and nutrition can have on the course of illness. And so we graduate without this kind of powerful tool in our toolbox. Of course, there's institutional barriers, time restraints, lack of reimbursement. You know, if they're not going to test for it on the boards, we're not going to teach for it. And you know, you know, pharma plays a role in influencing medical education and practice as well. And I think doctors like to like we are such highly trained specialists. We're like the fighter pilots. It's like asking a fighter pilot who's spent years with this high tech equipment, perfecting their craft, asking them to go on some wishy washy diplomatic mission, you know, and just, you know, talk about, you know, I mean, it's like almost kind of beneath us as specialists to talk about. So, you know, you know, would you eat this morning kind of blah, blah, blah. Like, that's somehow for somebody else. And of course, there's nothing wrong with delegating that responsibility to having, you know, uh, you know, a dietician in the practice and someone who can talk about these things, you know, just like, look, we don't take our own labs.
Dr. Michael Greger: [00:17:32] We don't do our own x rays. Look, we have someone who talked to them about diet, but unfortunately, that piece just is not reimbursed. You know, in general, we aren't really paid for counseling people on how to take better care of ourselves. So this system is just not kind of set up to incentivize, you know, some new drug comes out splashed all over some new surgical procedure. There's press releases, you know, there's paid CME over it. And it's just like otherwise it just kind of gets buried in some journal and some basement of some, you know, medical library. And it's just not kind of put into practice, even though it could potentially have a huge impact on a population scale. You know, if you think about these, you know, kind of the golden goose of big pharma, which are these lifestyle medications like antihypertensives or these statin drugs, the absolute risk reduction, even for something like secondary prevention, someone at high risk for heart disease, you know, is on the on the order of maybe 2% over five years. We, both doctors and patients alike, I think, overestimate the power of these drugs, whether we're talking about the anti-osteoporosis drugs or whatever, to actually affect outcomes and such that it's like, look, I, you know, I take a statin, you know, why, you know, so I can go through the drive through on my way to the drug store to pick up my prescription.
Dr. Michael Greger: [00:18:51] But when you actually drill down, in fact, if you ask people what is the kind of absolute risk reduction they would accept to take a pill every day for the rest of their life, I mean, it's just completely off the charts. If people actually knew how little these drugs actually benefited them, you know, almost nobody would take them. Of course, that would be a disaster because these drugs on a population scale are extraordinarily life saving, but on an individual basis. Right. I mean, you know, the number needed to, you know, to treat is, you know, I don't know if you're like the 1 in 67 people or something that's going to benefit. So it's a difficult sell kind of within the system. And of course, look, we as physicians are continuing to eat the foods that are contributing to these epidemics of dietary disease. You know, it's just like
Henry Bair: [00:19:37] look at any hospital cafeteria. Look at the food right there.
Dr. Michael Greger: [00:19:40] Oh my god. It's like the worst food. Like, we look what we're feeding people. Like, I mean, it's just we're just swimming in it, like, you know, the smoking, you know? But at the same time, you know, the first workplaces to get rid of smoking vending machines were the hospitals. You know, in many ways, medicine actually led the way in the fight against smoking. And similarly, we could do the same here. And there are places that are doing it in New York City. You know, all 11 public health hospitals in New York City. Every lunch and dinner is healthy, plant based by default. And if the patient, you know doesn't want it, then they're offered another plant based default. And only after refusing it twice Are they actually offered? You know, they can get the steak and eggs or whatever else is on the meal on the menu, but it's like, you know, healthy food in a hospital. Like what a concept, you know. So this role modeling behavior that I think can have a big impact, you know, just simply telling people, you know, the ICRC, this is the the official account of World Health Organization body that determines what is and is not cancer causing determined years ago that processed meat, bacon, ham, hot dogs, lunch meat, sausage, etc.
Dr. Michael Greger: [00:20:47] is a known human carcinogen class one carcinogen. We know it causes cancer, yet you know, we try not to smoke around our kids, but we're sending them to school with a baloney sandwich. It's like, why is it part of school lunches? Why are we allowing advertising of some of these foods in the way they are? You know, why are we kind of shouting from the rooftops? There's things we can actually do to reduce people's risk of some of the leading killers. But, you know, prevention isn't sexy. When prevention works, nothing happens. You know, it's just it's just such a such a hard sell versus oh my God, we have some procedure. And all of a sudden, you know, you can, you know, jump out of the hospital bed and walk home. I mean, that's exciting. Um, it's less exciting when you don't end up in the hospital in the first place.
Tyler Johnson: [00:21:31] So I totally grant the distinction that wait is not a perfect surrogate measure for the healthiness of your diet. Right. You can be thin and eat unhealthily, and you can be heavier and eat healthily. So I stipulate that. But nonetheless, if you look at weight as at least a, you know, sort of a rough measure, at least most people who carry a lot of excess weight probably have healthier things that they could do in their diet. The reason that I bring this up is to say that there have been many, many, many studies over the years before the GLP one antagonist. There have been many studies that have looked at all sorts of lifestyle interventions. Whether you want to talk about extreme diets, which I know that those have their own problems, I'm not saying that's like a, you know, the load store we should look to. But I'm just saying, whether you want to look at whatever kind of diet you want to look at or whether you want to look at just a program for sort of general nutritional counseling and encouragement of exercise and, you know, all those kinds of things. Even in very well-designed randomized controlled studies, those have shown very reliably over the course of many years that if you take a sort of generalized population of patients and you put them in a group, even where you're going to do relatively intense lifestyle modification, types of interventions where you try to get them onto an exercise program and try to get them to change their diet and all the rest of it. It just at least insofar as weight is a, you know, at least some rough measure of at least how effective those programs are, the programs either make no apparent difference, at least in terms of people losing weight, or they make a little bit of a difference that lasts for a little while, and then people tend to sort of revert to their own mean weight, whatever that was, after the lifestyle intervention is done.
Tyler Johnson: [00:23:20] The intensive part of it. And so all of that is just to say, you know, and I don't mean to be nihilistic, but I guess that some people might say from at least a public health standpoint or a sort of, you know, what's going to work for the population, that even if, as you said before, the number needed to treat or whatever, you know, test characteristic you want to use is relatively high for something like taking a statin or taking a baby aspirin or whatever. The thing is, at least that's a thing where the substance of the intervention is. You take, in most cases, a single pill a day, whereas if it's someone who has become accustomed to carrying a lot of weight, for example, and accustomed to eating basically whatever they want, then it amounts to sort of teaching them to refuse a thing that they feel like they want all day, every day. Maybe not every time it's offered to them, but at least the majority of the times that it's offered to them. And that just seems like a big lift, right? Like from a public health standpoint, I could imagine a skeptic or a critic saying, well, yeah, of course it would be great if we could get everybody to eat a plant based diet and only whole foods and whatever, whatever. But we can't do that. We've tried and it just doesn't work. What would you say in response to those kinds of ideas?
Dr. Michael Greger: [00:24:35] No, I think that is a critical point to bring up. The controversy is not so much in the science, but rather in the compliance. I mean, there's such this enormous mountain of evidence. Now, it's not that people are questioning, you know, there's healthy things to do, but whether people will actually comply. And that's why if you look at like the Uspstf, for example, um, you know, which is kind of the body that determines what is useful in terms of prevention, something like, um, advising people on a healthy diet to lose weight is not considered effective. And so that's a perfect example of a. Wait a second. Obesity is a Hundred percent diet related disease. Like you lock anybody in a closet, they'll lose weight, period, with no exceptions, like it's 100%. So it's not that we're questioning whether, you know, overeating calories is going to get people to, to, to gain weight. But it is indeed that critical compliance piece. And I think my response would be, is that too often I think we as physicians have this patronizing attitude that, look, I can't even get my patients to stop smoking. There's no way I'm going to bring up diet or something like this. But it's not our decision to make, right.
Dr. Michael Greger: [00:25:46] It's our role, I believe, is to lay out the available options and tell people, okay, look, we can put you on this drug and this are the, the, the likely benefits. Or if you did this with your diet, these would be the likely benefits outcomes someone in your position. And then it's their body their choice. They want to keep smoking cigarettes. They want to go bungee jumping. They want to disconnect the smoke alarms in their house. They want to want to not put their seatbelt on. That's completely up to them. As long as they as long as they're fully informed. It's up to each of us to make our own decisions as to what to eat and how to live. But we should make these choices consciously educating ourselves about the predictable consequences of our actions. So that's what we can do as physicians, is inform people. And so that's all I'm calling for is fully informed consent. And then what the patient does with that is completely up to them. Unfortunately, that patient has been bombarded since birth with ads for fast food and junk food and a kind of tobacco playbook like misinformation campaign from these food companies, which actually originally were the tobacco companies.
Dr. Michael Greger: [00:26:54] Right? Philip Morris, the biggest food company in the world with Kraft and General Mills. R.j. Reynolds bought Nabisco the entire rise of ultra processed foods. It was all traced back to when the tobacco industry bought all these companies, all of a sudden made them three times as profitable. And that's where Kool-Aid came from, and that's where. I mean, all this, I mean, and so people are confused. People don't. It's not like, oh, people are fully informed and they know how much power they have over their health, destiny and longevity. They know the power of diet and they just choose not to. I mean, I think we're really in a situation where people are confused, just like the tobacco industry tried to instill doubt about whether or not tobacco was difficult. And so then they're not making a fully informed choice. Similarly, I think people just don't know the power they have. And once they do, which is, I think our role as physicians, as guardians of their health, and then they can do what they want. But unfortunately, I don't think either doctors nor patients are fully informed about the power that a healthy lifestyle can have in terms of decreasing risk of premature death and disability.
Henry Bair: [00:27:59] Yeah, I understand where you're coming from. When you say that, you know, you offer the patient the best information possible, communicating the clearest way possible, and then after that it's up to them. You just have to wonder though, because I face this all the time now. Or you know, last year when I was an internal medicine intern towards the second half of the year, really after coming across some of your work and seeing it work on myself, we can get into that later. Um, I started being a little bit more proactive with counseling patients about their diet, especially on services like cardiology, for example. And I would get a version of this response a lot, right? Patients would listen and they would say, okay, I understand it. They understand the benefits of a plant based diet, but they just don't like it. And they would far prefer to just eat whatever foods give them the most joy and whatever happens to my body. Sure, I might live a shorter life, but at least I'll have a great time while I get to the end. How do you respond to that?
Dr. Michael Greger: [00:28:56] Oh well, I mean, unfortunately, if they're in the hospital, they probably understand that they're not living such a great time that it's not just about the years of your life, but the life in your years. But it's right. It's the it's that motivational interview technique which is like, okay, what are your goals in life? And how can I help you fulfill them? And they're like, oh yeah. Oh, you do want to see your kids grow up. Oh, you do want to go see your granddaughter's wedding. Oh, you do want to, you know, on down the list. Okay, well, this is the best way you can do it. And then it's totally up to you. But it's not this paternalistic, you know, it's their body, their choice. You know, they have a right to refuse medication. They have right to refuse surgery. They have a right to refuse food. Right? I mean, they have a right to do anything they want. And so what I would say to them, I was like, well, you know, if you ever get, you know, diabetes or come back to me, I'm here all the time. Here's some great resources, here's some great, you know, websites and documentaries and books and go to your local public library. Check these out. And if you're not convinced, all right. You know, and there is tremendous power to reverse some of these lifestyle diseases like hypertension, type two diabetes if caught early enough. Unfortunately, you know, about half the people that die from heart disease die from sudden cardiac death, right? So it's not like they have like, oh well, oh, heart disease. We can reverse the progression of heart disease. No problem. I'll just eat whatever I want and then I get a little pressure in my chest. I'll just, you know, I'll just get with the program. The problem is about half, you know, particularly women, that's death within, you know, first symptoms in someone without known heart disease, your first symptom may be your last. So an ounce of prevention is worth way more than a pound of cure because there is no cure for dead.
Tyler Johnson: [00:30:36] You know, listening to you, there are two thoughts that come to my mind talking about this. One is, you know, we have talked with many guests on the program over the years about the science and the, you know, philosophy is the right word, I guess, the psychology, the science and psychology of addiction. And I would be interested to know, like I, I imagine that there are some Patients who would tell Henry or tell me or tell you or anybody that. Well, I just want to keep eating the way that I'm eating because it brings me joy. But I imagine that if you really dug down underneath that, at least in many cases, it would not so much be that it brings them joy as it would be, that it just sort of is what they do, or it is what they're used to, or it may be associated with things that bring them joy, right? If they have particular restaurants that they go to or, you know, things that they eat with their friends or, you know, around the football game on Sundays or whatever, the thing is. But it would be interesting to know whether eating large amounts of ultra processed foods really brings people more joy than eating healthier foods would bring if they were put in a context where they were able to do that in a way that was consistent and could come to be associated with psychologically positive experiences.
Dr. Michael Greger: [00:31:59] You know. The problem is that our palates have been so deadened, numbed by this hyper sweet, hyper salty, hyper fatty, you know, plethora of foods that, like, you know, the ripest peach in the world is going to taste sour after a bowl of Froot Loops. Right. And so, you know, someone will, you know, someone will come, you know, coming up to me and see, you know, I'm eating like some, you know, sweet potato with some cinnamon or something on it for lunch and, you know, and stare over my cubicle and be like, oh, and look at me as if I'm some, like, esthetic monk. It's like, oh, it's amazing. You can do that. But like, I could never do that. But what they don't realize is that actually tastes delicious. And you do these studies, the original studies were done on salt reduction. You put people on a low salt diet and initially they say everything tastes like cardboard. And you put them on a low salt diet and then you follow them within a few weeks, the original soup they sold, the taste is too salty. They actually prefer a lower salt diet. You know, our taste buds are replaced about every two weeks or so. And the same thing. There's less research on this, but you put people on a on a cut out added sugars from the diet.
Dr. Michael Greger: [00:33:03] There's kind of a similar phenomenon where all of a sudden normal natural, healthy foods actually taste good, like the thought of corn on the cob without salt, without butter, like it's just like mind blowing to people. But no, you don't realize if you cut out these, you know, ultra processed foods, all of a sudden natural foods actually taste good and eventually you end up in this best of both worlds scenario where food tastes amazing and you know you love the food. The food kind of loves you back, and you start experiencing some of the short term benefits like maybe sleeping better, better digestion, less painful periods, more energy, whatever of starting to eat healthier. And so then you have your own body telling you that it feels good, blah blah blah. But it's that activation energy. It's that initial hump where you start, you eat healthy and you're like, there's no way I would rather die early in pain than to eat this kind of, you know, those twigs or whatever for the rest of my life. But that's, of course, exactly how these foods are designed. These are just, you know, natural. The food tastes good. Same reason sex feels good.
Dr. Michael Greger: [00:34:07] We wouldn't last very long as a species without both. Without these pleasure centers, these reward pathways incentivizing our efforts, then you know, we're not going to get along very far. And so we evolved in a, in a, you know, environment where sodium was scarce, we have this taste for saltiness gives us a survival advantage. Now it's the opposite. The food industry has hijacked these natural drives, turned them against us. Calories were scarce okay. So taste for sweetness. We get the ripe fruit. Taste for fat gets us the nuts and seeds. Whatever. Okay, but the food industry says, ah, you like that? We can make sure you don't just eat one and we can design foods to be so-called, you know, hyper palatable, you know, and fits all the classic criteria of substance use disorders, from compulsive use to reinforcement to, you know, withdrawal symptoms. On down the list. And so it's like what? What am I saying? You should stop eating really good food. No, it's just a matter of kind of reestablishing a healthy palate such that healthy foods actually taste good. And you get the best of both worlds. But it takes a little while to get there. And so you just got to handhold your patients through that tough period.
Henry Bair: [00:35:16] So I want to pivot a little bit. Earlier on you were talking about how the science is there. I'm not going to say I'm pushing back on that. But I do want to say that, first of all, I genuinely despise going into nutrition science, going into the weeds. And here's why. Here's why I know that it's not like I don't. I don't hate nutrition science. I hate going into the literature behind it because it's so messy.
Dr. Michael Greger: [00:35:38] It's a mess.
Henry Bair: [00:35:39] You know, remember, one of the things that your books advocate for are things like cutting out dairy, cutting out eggs, for example, and you look online. Are eggs healthy? You You'd probably get equal 50 over 50. You would get the same number of robust, clinically validated studies that say eggs are fine as those that say eggs are not fine, right? It's just it's super confusing and I can't tell you the number of times I've tried to research a question. Right. Are red meats like whole foods but red meats? Are they healthy? Are they not? Are high protein diets, you know, healthy or not? And I get so frustrated. I just like I have to take a break because I find so much conflicting evidence. And I have to ask you, you know, because your books are very robustly cited. In fact, in all of your books, there's so much, so many citations that you don't even include it in your book. You just refer it. You have like hyperlinks, you know, to this online database of thousands of references. So clearly you have gone really deep into the science behind nutrition. How do you navigate this conflicting evidence?
Dr. Michael Greger: [00:36:45] Okay. Well, the conflicting evidence is conflicting on purpose. So if you look at those two sets of studies, it's not that one says eggs are good for you and one says eggs aren't good for you. It's really more like eggs are negative. Eggs are neutral. But if you look at funding buys, if you look at who actually funds the studies, and much of it is the checkoff program such that egg producers by law actually have to contribute to a fund which is tens of millions of dollars used in advertising. Same thing with the dairy industry. Same with the cattlemen's industry where there's this fund set up and managed by the government to advertise the whole milk mustache campaign and all this egg nutrition board. That's the. And so if you look at like an umbrella analysis, looking at the meta analysis of meta analysis, even without the funding bias, even without seeing who cites what, you know, about 80% of the studies on Whole Foods show that there are beneficial or neutral at worst, and the opposite is found for animal foods found there. You know, 89% negative or neutral. And so that just gives you a taste. And of course, if you can look I like what David Katz did. Who is the head of the Yale's Nutrition Prevention Research Center. He brought together hundreds of the top nutrition scientists in the world to come up with, kind of like the IPCC of nutrition.
Dr. Michael Greger: [00:37:57] Right. You know, you go online, there's all sorts of crazy, you know, climate, whatever. So who are you going to trust? You're going to trust the climate scientists who have dedicated their lives to this work. Okay, well, let's get the nutrition scientists together to agree to a consensus statement as to what is the healthy diet for the human species. So this you can go to True Health Initiative org, which is the organization was set up to reflect this work. And, you know, spoiler alert, the healthiest diet is this diet centered around whole plant foods. And so that is the consensus going back decades nutrition literature as to the core tenets of healthy eating and healthy living. The food industry likes to stoke these like, oh, it's you know, it's so controversial. The coffee's good, coffee's bad. In hopes that you just kind of throw up your hands and eat whatever crap is put in front of you. But there really is if you do kind of an in-depth analysis of what's out there in the literature, we really know an extraordinary amount of what the healthiest diet is. Of course, we're learning stuff all the time, but it's not as, uh, it's not as controversial as I think the lay, uh, clickbait headlines will have us believe.
Tyler Johnson: [00:39:04] I think also, I've been influenced in this regard to some degree by Michael Pollan's writing, particularly in a defense of food or the defense.
Dr. Michael Greger: [00:39:11] In defense of food.
Tyler Johnson: [00:39:12] Yeah. Yeah. So he makes sort of two points that I think are really valuable. One is specifically about what we should eat. And then one is sort of how we think about what we should eat. So his formulation for what we should eat is he says it can basically all of the science can be reduced down to seven words, which is eat food. And I'll come back to the word food in a second. But eat food mostly plants. Not too much. And he says that that is sort of the distillation of all of the science about nutrition. And then he has this whole chapter about what the word food means, where he says in order to count for food, it has to have like fewer than six ingredients your mother has, or your grandmother has to be able to pronounce all of them, or some things she has to like. Recognize that it would be an actual food. Et cetera, et cetera. But in another way, the point that he makes that, I think is almost more important even than his formulation of the distillation of nutrition science is that he makes the point that one of the biggest problems with the way that we think about eating and nutrition and diet, and the whole thing is specifically that we have over medicalized it in the sense that it's like we want to not believe that a donut is bad for us unless we have a large scale, randomized, controlled trial showing that people who eat donuts on Saturday mornings are significantly, statistically, significantly more likely to die than people who don't. Right. And like at some point, it sort of becomes a reductio ad absurdum because it's like, you know, you just can't produce a randomized controlled trial about every single part of nutrition, right? Like, at some point there has to be a recognition that while there may be, in a sense, conflicting science and, you know, some sort of detailed aspects, at least the overall preponderance of evidence is that certain things are better and certain things are worse.
Dr. Michael Greger: [00:40:59] I mean, and that was the big tobacco industry argument. You know, they started this whole sound science campaign, quote unquote, questioning the epidemiology because they're making the point. There has never been a randomized controlled trial showing that smoking is bad for you. In fact, there was one RCT done in Britain of smoking cessation, and all cause mortality showed no effect. Why? Because it's compliance. Right. You know, you tell people to quit, you randomize people to quit for the rest of their lives or continue to smoke. And what happens? Well, you know, they don't do it. And so there's no difference in mortality between the two. But that, of course, doesn't mean that smoking is okay for you. And so. Right. We need to draw on a greater body of evidence that we would normally have with these kind of big pharma funded trials where it's very easy to do these placebo controlled trials, but you can't demand the same level of evidence. But you certainly would want to demand that level of evidence for drugs because of the downsides. Right. Because drugs kill an estimated 100,000 Americans every year. That's not overdoses. That's not opioids, that's not prescribed. That's drugs deaths as prescribed. Because there's such a tremendous potential downside. You need this tremendous high level of gold standard evidence. But when you're telling someone to like, you know, eat broccoli, it's like and like I said, there's some new study that was only done on 50 people.
Dr. Michael Greger: [00:42:14] And it was and it was, you know, some intermediate measure like drop in blood pressure, don't even have heart outcomes. And it showed that, oh, you drink hibiscus tea and, you know, fine. You know, and you showed, you know, this this remarkable drop in blood pressure okay. And so I tell people, oh, try some hibiscus tea and someone looks at me. How how could you possibly change your clinical practice based on one single study that 50 people in it like, are you crazy? Yeah. Yeah. But what's the downside? It's like, okay, let's say this completely fraudulent, falsified, fabricated P hacked whatever. Like what's the worst that can happen? You have like a, you know, a tasty smoothie or something. Like just the the bar for evidence needed to have people make common sense. Simple recommendations like stop smoking, move more, eat more fruits and vegetables. The level the bar of evidence, I think has to be set at a level that can be met just because the worst thing that can happen is, is yeah, it may not help that thing, but you know, we have so much evidence that helps so many other different outcomes.
Henry Bair: [00:43:20] So, you know, your books advocate for a whole foods plant based diet. Do you objectively think this is the best diet for every person?
Dr. Michael Greger: [00:43:30] I think we should try to eat primarily plants, not necessarily exclusively plants or plant based diets. Really more just about maximizing the intake of the healthiest foods, right? Right. As physicians like, you know, labels like vegetarian, vegan, right. That just tell us what you don't eat. I mean, do you actually eat vegetables? I mean, you know, and of course, it doesn't matter what you eat in your birthdays, the holiday special occasion, it's the day to day stuff that really adds up. And on a day to day basis, you really should try to center our diets around natural foods from fields, not factories, unprocessed plant foods. You know, the real food that grows out of the ground. These are really our healthiest choices. And so we should try to not only for the benefits that they provide, but you're also kind of, you know, needling out any of some of the less healthy options in our diet. And, yeah, I mean, I mean, I do think that without exception, that is the healthiest diet. You know, there's this obsession over personalized nutrition, just like, you know, precision medicine, personalized medicine. You know, this concept that one size does not fit all. And who does not want to think that they're special, right. It was just so appealing to our ego. And so, you know, there is this just this proliferation of services online where you get a cheek swab or you get some blood and they do some analysis and they can, you know, give you personalized foods and supplements and blah, blah, blah. And look, certainly there are legitimate differences. Some people have peanut allergies, some people don't. Some people are better at digesting lactose or not or metabolizing caffeine. Some people have to avoid gluten. Et cetera. Et cetera. Some people don't metabolize alcohol the same way, but it's not like some foods are good for some people and some, with the exception of these kind of allergies things and bad for other people, it's usually like something's good for someone or really good for them because they have a certain way they metabolism or something is bad for them or really bad for them.
Dr. Michael Greger: [00:45:21] It causes, you know, a bad triglyceride spike. And most people are really bad, but it's not like this food, oh my God, it's good for you and kind of bad for somebody else. But there's this, you know, astonishing number these direct to consumer testing companies offering this device, you know, based on genome wide association studies where, you know, it's really just kind of statistical association between diseases and particular stretches of DNA. But we're talking about tiny few percent differences, you know, so, you know, a slightly increase or decrease risk of disease. And so fine, let's say your genetic analysis says that you're slightly more at risk for some, you know, grave condition. What advice are you going to give? You're going to give the same advice for everybody else. Keep your weight down. Don't drink too much exercise. You know, eat healthy foods, right. That's regardless of your, you know, genetic risk. Having said that, much of the personalized nutrition space is just, you know, scammy, overpriced nonsense. But if getting that analysis back or some fancy digital readout get you to eat healthier than you otherwise might. It's like, how much is that test worth? Well, I mean, that may actually be a really good investment, obviously, but they didn't need that. You know, so it's really again, about the kind of compliance piece rather than, you know, actually some differences because of who you are that, you know, you need colors more than the next dude.
Tyler Johnson: [00:46:49] Usually at the end of our discussions, we ask some version of what advice would you have had for a younger version of yourself? Or, you know, how can people be a better doctor or whatever? But I want to ask a variation on that for today. Like we have many people who listen to the program, from what we can gather, who are trainees or relatively young doctors or what have you. And I can imagine that many of those people would listen to this and they might say to themselves, okay. I mean, sure, in some fantasy land where I had an extra ten hours a week to, like, sit home and, you know, chop my homegrown vegetables before I come on to my 30 hour shift in the ICU. Yeah, I would make it. Or if I had a personal chef who could, you know, cook me wonderfully savory vegetarian dishes and put them in, you know, Tupperware so that I could bring them to the hospital and warm them up for my lunch in the ICU? Yeah, absolutely. I would do that. But I don't live in that world. I live in the real world and in the real world. There's a vending machine at the end of the hallway in the hospital where I work, and there's a cafeteria that has mostly unhealthy food, unlike apparently some in New York that has that stuff on offer. And I can go to, you know, Trader Joe's or Safeway or whatever the thing is and buy, you know, and there's all of this readily packaged, highly processed, but easily edible foods that I can just grab stuff in my backpack and take with me to work. So if that person were listening to this and they said, okay, I want to eat a more plant based, more whole foods based, whatever diet, but how in the heck am I actually supposed to do that in the treadmill of my regular everyday life? What is some no pun intended, low hanging fruit that that person could go to? That would be something that Something that they can actually get to and do.
Dr. Michael Greger: [00:48:28] Yes. Well, you've answered your own question. Anyone who doesn't think healthy foods can be convenient has never met an apple. I mean, right? I mean, we're talking you could even eat the packaging. It's like like, I mean, it's like ridiculous, right? I mean, but, you know, that is definitely the ultra processed food industry propaganda. It's like, who's got time? It's unrealistic to advise people to avoid, you know, these foods. But I mean, some of the healthiest foods are some of the cheapest foods, some of the healthiest foods and the most convenient foods. You can microwave a sweet potato, throw it in your pocket, munch it on the way to work. Trail mix. I mean, it's just like healthy foods can be just as convenient, cheaper and, you know, healthier and keep you more focused and blah, blah, blah. I mean, all the all the kind of benefits, all the, the kind of ancillary benefits that we really should not let that be an excuse to not shop more in the produce aisle.
Henry Bair: [00:49:19] I want to sort of add on to that, and which is, I think, plant based diet. It is a fad. There are lots of people doing it, but I think everyone has heard of it and I've definitely encountered it, myself included. I think like a year ago, if I had heard about if someone had recommended, oh, you should eat a plant based diet, I'd be like, yeah, okay, fine, whatever. Rolled my eyes and I get that response a lot from patients too, because it just seems I don't know either. People are skeptical because they see it as a trend, or it's almost daunting because it feels like it's a it's a big, big, big change to maybe even your identity. So it can be very hard to engender that kind of lifestyle alteration. This might be an unfair question, but I'm going to posit it in case you have great insights for us. If there were a few most high impact, most beneficial changes to your diet, specific foods to incorporate, or to get rid of, what would you say and why?
Dr. Michael Greger: [00:50:12] Yeah, no. And I'm glad you put it that way. Right. You don't I mean, you want to make it as unintimidating as possible. So it's like. And so that's what I always start with. I mean, you got to know the psychology of patients. Some patients. Some people are like, you know, all or nothing kind of people, and they really thrive in that kind of. But, you know, for most people it is you know, I'm often first having people add food to their diet. They think I'm going to start taking away food. No, no, let's add food. So we want people to eat berries every day. The healthiest fruits, greens every day, dark green leafy vegetables, particularly cruciferous vegetables, the healthiest type of vegetables, and also legumes, beans, split peas, chickpeas, lentils. Those would be the three foods I encourage people to add to their diet. If there were just three foods I would remove from their diet, number one being anything with trans fats, these partially hydrogenated oils, which thankfully have been removed from the US food supply but continue to kill hundreds of thousands of people around the world. Number two processed meat, bacon, ham, hot dogs, lunch meat increasing risk of colorectal cancer, the number one cancer killer of nonsmokers.
Dr. Michael Greger: [00:51:02] And number three, soda basically liquid candy. We shouldn't be drinking our calories like that. Those would be the three things that are removed. The three things that and that would go a long way. And, you know, so you have these studies that suggest that even if people make just these barest of minimum improvements in their diet and lifestyle, like five servings of fruits and vegetables a day, maintaining a healthy weight, not smoking, walking even like 20 minutes a day dropped their risk 40% of dying over the subsequent four years. For people making that midlife switch between 45 and 64, I mean, that's just absolutely a story that'll get you like 80% of the way there. Now, if you want to tweak your diet and, you know, get all body hacky and, you know, find out, oh, I want to know what the best sweetener is or the best. Fine. You know, you can go down endless rabbit holes, but you can get, you know, 89%. They're just these really basic common sense lifestyle practices. We really have tremendous power over our health, destiny and longevity with these simple changes in our diet and lifestyle that anybody can do.
Tyler Johnson: [00:51:59] It is just in closing, I have to say, it's so funny because I had a discussion with a person last week who is in touch with the sort of I live in Palo Alto, right? And so there's this whole like super longevity movement, right? People who want to live till their 180. And this person was telling me that they went to some, you know, like Super elite conference with people who are like investing billions of dollars in technology to lengthen their lives this way. And he was astounded at how many of them you can just sort of tell by being at a party with them, have no interest in eating healthy. No interest in exercising and investing billions of dollars. And then like two days later, there was a prominent story in the New York Times about how people who have that same goal are using rapamycin, which is this, like super serious immunomodulatory drug that we give to people who have had like solid organ transplants, and they're taking it to try to increase their longevity, as you said, because apparently there is no big broccoli. But anyway, just to say, sometimes truth is stranger than fiction or something.
Henry Bair: [00:53:04] Yeah, sometimes the most effective things, as you've shown us, are things we can start doing for ourselves now. We don't need a prescription. So with that, we want to thank you again, Michael, for coming on the show, for sharing your insights. It's really quite empowering because so much of it is. Again, it's you can start applying these lessons today. Thank you very much.
Dr. Michael Greger: [00:53:23] Awesome. Thanks so much. Had a blast.
Henry Bair: [00:53:29] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at the Doctor's Art.com. If you enjoyed the episode, please subscribe, rate, and review our show. Available for free on Spotify, Apple Podcasts, or wherever you get your podcasts.
Tyler Johnson: [00:53:48] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient, or anyone working in healthcare who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:54:02] I'm Henry Bair.
Tyler Johnson: [00:54:02] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.