PDF Summary:How Not to Die, by Michael Greger
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1-Page PDF Summary of How Not to Die
Picture the end of your life. Do you want to die from heart disease? Cancer? Diabetes?
In How Not to Die, Michael Greger argues that a plant-based, whole-food diet has been scientifically shown to reduce the most common diseases leading to death. He then gives his recommendation for "The Daily Dozen" foods to eat to maximize health benefits.
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Why does plant-based diet improve health? Humans evolved over millions of years eating primarily vegetables, so many of our biological responses to food were wired to prehistoric diets.
Today’s modern environment is unnatural, in the sense that we haven’t evolved to handle the new types of food available to us, as well as the quantity available.
- Processed foods now contain much more fat, sodium, and caloric density than we evolved eating. Our normal biological processes haven't adapted to surviving on modern diets.
- Modern foods are so nutrient dense that they amplify the dopamine reward circuit. After eating ice cream, ordinary mangos are nowhere near as enjoyable. By eating whole foods, you can reset this sensitivity.
Regulation of food is often strongly influenced by industry. Just like how the tobacco industry fought to show smoking didn't cause cancer, there is a strong agriculture lobby promoting meat and processed foods.
Why Plants Help and Meat Hurts
Meat itself seems negatively correlated with health and mortality, even controlling for vegetable intake. In other words, if group 1 eats vegetables, and group 2 eats the same amount of vegetables but adds meat, group 2 shows higher mortality and risk of disease.
In these research studies, are vegetarians healthier simply because they tend to be skinnier? No—in population studies, plant-based diets show lower mortality even controlling for BMI, wealth, and other confounding factors.
In research studies, eating health supplements doesn’t have as positive an effect as whole foods. This might be because whole foods contain many other benefits, such as fiber and other micronutrients. Supplement extracts also introduce risk of contaminants and toxicity.
Even More Reasons to Eat Vegetables and Fruit
Think of your diet everyday as a bank account of 2000 calories you can spend everyday. Eating one 800 calorie hamburger displaces eating 7 sweet potatoes or 26 cups of broccoli. Which one would benefit your body more?
Some might shy away from a plant-based diet because it seems expensive. This is partly true—on a calories-per-dollar basis, junk food and fat are the cheapest. But on a nutrients-per-dollar basis, vegetables offer 6x more nutrition compared to processed food.
- Meat costs 3x more than vegetables but deliver 16x less nutrition. Thus, meat is 48x more expensive on a nutrient basis than vegetables.
Diet by Traffic Light
Eating a plant-based diet doesn’t have to be complicated. Michael Greger suggests thinking of food as a traffic light system:
Green Foods: Unprocessed plant foods
- Unprocessed means nothing bad is added, and nothing good is taken away.
- Sometimes, processing actually makes food healthier. Tomato juice may be healthier than whole fruit because the nutrient lycopene is more available. Similarly, cocoa powder is processed to remove saturated fat.
- You can eat unlimited amounts of green foods.
Yellow Foods: Processed plant foods, Unprocessed animal foods
- Processed means something bad is added, or something good is taken away.
- For example, almond milk is worse than eating pure almonds.
- Ideally you’d replace yellow foods with their corresponding green foods, which are more nutritious.
Red Foods: Ultra-processed plant foods, Processed animal foods
- Eat red foods sparingly. In driving, you might run a red light once in a while, but you don’t make a habit of it. The same is true of red foods.
- It’s OK to eat these in small amounts, if they help you eat more green foods (such as bacon bits or hot sauce with vegetables).
Dr. Greger’s Daily Dozen
As a simple checklist for what to eat everyday, Dr. Greger recommends these 12 components. Each box represents one serving.
- Beans: 3 Servings [ ] [ ] [ ]
- Berries: 1 Serving [ ]
- Other Fruits: 3 Servings [ ] [ ] [ ]
- Cruciferous Vegetables: 1 Serving [ ]
- Greens: 2 Servings [ ] [ ]
- Other Vegetables: 2 Servings [ ] [ ]
- Flaxseeds: 1 Serving [ ]
- Nuts: 1 Serving [ ]
- Spices: 1 Serving [ ]
- Whole Grains: 3 Servings [ ] [ ] [ ]
- Beverages: 5 Servings [ ] [ ] [ ] [ ] [ ]
- Exercise: 1 Serving [ ]
These 12 recommendations form “Dr. Greger’s Daily Dozen.”
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PDF Summary Shortform Introduction
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Occasionally his interpretations of research is questionable. For instance, to promote organic foods, he says “organic fruits and vegetables do appear to have more nontraditional nutrients like polyphenol antioxidants.” However, his cited study found “no consistent differences in plasma or urine carotenoids, polyphenols, vitamins E and C content, LDL cholesterol, antioxidant activity, ability to protect against DNA damage, immune system markers between participants consuming organic and conventional diets.” Now, they do say slightly different things—he’s talking about nutrient density in foods, and the study is talking about blood levels. But it’s disingenuous to use this citation to back up his point. By far he says what most of his references say, but this error occurred more often than expected, thus possibly requiring a slight downweighting of his recommendations down a notch.
The Most Convincing Studies
How Not to Die features hundreds of nutritional studies to back up its claims. While many of them suffer from the issues discussed above, a...
PDF Summary Preface
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In total, lifestyle accounts for 78% of risk of chronic disease. Not smoking, having normal body weight, exercising half an hour a day, and maintaining a healthy diet can reduce the risk of chronic disease by a huge margin.
But wait—can’t we just take medication to reduce our risk of disease? Not really. Drugs can’t protect you fully from disease, and they have side effects. Here’s an analogy—you have a running faucet that is causing a sink to overflow. Taking drugs is like mopping up the floor around the overflowing sink constantly, instead of turning off the faucet.
Preventing the disease is often far better than treating it over years and decades. And diet is the way this book recommends you prevent disease.
PDF Summary Part 1: How Not to Die from Disease | Heart Disease, Lung Disease
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Things that don’t reduce heart disease:
- Fish oil shows no proven benefit for overall mortality, heart attack, or stroke.
- Statin medications are good for patients who won’t comply with diet, but they have side effects of liver and muscle damage, as well as diabetes.
Why doesn’t the idea that diet can reverse heart disease get more public attention? It likely has to do with lobbying interests by powerful industry groups.
- In 1977, the US Senate committee released dietary guidelines advising that the population cut down on animal-based foods. But the meat, milk, and egg industries successfully lobbied to remove this recommendation from the report.
- Professional medical organizations are often funded by food companies, which aim to influence doctor recommendations.
Lung Disease
Annual deaths from lung disease: 296,000
Within lung disease are three sub-diseases:
- Lung cancer: 160,000 deaths per year
- Chronic obstructive pulmonary disease (also known as emphysema): 140,000 deaths per year
- Asthma: 3,000 deaths per year
Lung Cancer
Smoking is the most serious risk factor for lung cancer.
- Male smokers are 23x more likely to get...
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Learn more about our summaries →PDF Summary Part 1-2: Brain Diseases, Digestive Cancers
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Sleep
- Those at lowest risk of stroke sleep 7-8 hours a night. Much more or much less sleep than this increases risk of stroke.
Antioxidants
- Your body needs energy to function, and oxygen normally plays a critical role. Because oxygen is very reactive, it also tends to steal electrons from other chemicals, becomes a radical oxygen species, and oxidizes substances like DNA, causing mutations (which can lead to cancer). Antioxidants slow this down by placating oxygen and reacting with it instead of your DNA.
- Physiologically, antioxidants prevent circulation of oxidized fats that can damage blood vessels. Antioxidants decrease artery stiffness, prevent blood clots from forming, lower blood pressure, lower inflammation
- In population studies, people who eat the most antioxidant-rich foods had the lowest health risks.
- Plant foods contain 64x more antioxidants than animal foods
- (Shortform note: Why do plant foods contain so much more antioxidants than animal foods? One theory suggests that antioxidants are needed to protect against sun damage. Plants spend much of their time in the sun, immobile, getting energy for photosynthesis. In contrast,...
PDF Summary Part 1-3: Infections, Diabetes
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* Blueberries (1.5 cups per day for 6 weeks) doubled natural killer counts in athletes after intense exercise, when normally exercise cuts those cell counts in half.
Other diet
- Cardamom activated the activity of natural killer cells against lymphoma cancer by 10x in vitro.
- Probiotics: Babies delivered via C-section have increased risk for allergies. The theory is that natural birth babies are exposed to the mother’s vaginal bacteria, which then reside in the baby’s gut.
- There isn’t enough evidence yet to suggest that supplementation of probiotics is necessary.
- Mushrooms: Eating button mushrooms daily over a week increased IgA antibody levels in saliva by 50%.
Exercise
- Exercise may activate IgA antibody production in saliva, eyes, and nostrils.
- Aerobic exercise for 30 minutes a day, 3 times a week for 12 weeks increased IgA levels in saliva by 50%, compared to control.
- Elderly sedentary women have a 50% chance of getting a cold in the fall. 0.5 hours per day of walking reduces the risk to 20%. Conditioned runners have just an 8% risk.
- Overtraining, like with marathons, increases risk of infection. This can be addressed...
PDF Summary Part 1-4: High Blood Pressure, Liver Disease
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- Sodium suppresses an antioxidant enzyme called superoxide dismutase.
How to Reduce Sodium Intake
Understand the major dietary sources of sodium:
- ¾ of salt in the average diet comes from processed foods.
- For kids, the major source of sodium is pizza; for people aged 20-50, it’s chicken; for ages 50+, it’s bread.
Why is there so much salt in food?
- Partly it’s for preservation of food.
- Adding sodium to meat increases water retention, increasing the weight of meat that’s sold.
- Saltier food tastes better than unsalty food, so competition with other products increases sodium across the board.
How to cut back on sodium:
- Adjust your taste buds back to normalcy.
- Your taste buds adapt to whatever food you give it. Cut sodium, fat, and sugar from your diet for a few weeks—food will taste bland at first, but eventually your taste buds will revert to normal. Food will taste more flavorful, and you will actively dislike aggressively salty and fatty foods.
- Don’t add salt at the table.
- Don’t add salt when cooking.
- Stop eating out so much.
- Avoid processed foods.
- Buy foods with fewer milligrams of sodium than there...
PDF Summary Part 1-5: Blood Cancers, Kidney Disease
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- There’s still no smoking gun yet on viruses directly causing cancer through infection and genetic mutation. This is an area of active research.
How Not to Die from Blood Cancers
Besides reducing your consumption of poultry, eating specific things helps protect against blood cancers:
Greens
- A plant-based diet reduces all cancer forms, lowering risk of blood cancer by half.
- Patients with lymphoma that eat >3 vegetable servings a day show a 42% improved survival rate. Green, leafy vegetables and citrus showed the most protective effects.
- It’s not clear whether the diet reduced cancer effects, or it improved tolerance to chemotherapy.
- In healthy patients, >5 servings of green, leafy vegetables per week showed half the odds of lymphoma.
- Sulforaphane in cruciferous vegetables kills cancer in vitro while ignoring healthy cells.
- Vitamin C and carotenoid in diet lowers lymphoma risk, but supplementing vitamin C doesn’t do anything.
- High-dose supplements actually increase the risk of death. Why? A large dose may disrupt the natural balance of antioxidants that reduce disease
Acai Berries
- An extract of acai triggers...
PDF Summary Part 1-6: Breast Cancer, Suicide
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- Every 20g fiber/day showed a 15% lower risk of breast cancer.
- Getting up to a minimum of 25g/day may be required to show an effect. The average vegetarian may only get 20g/day.
Apples
- Daily apple eaters show 24% lower odds of breast cancer (and also of ovarian, laryngeal, and colorectal cancers).
- Apples contain antioxidants in skin that seem to suppress breast cancer cell growth in vitro.
- Compounds in skin reactivate maspin (mammary serine protease inhibitor) which reduces cancer growth.
Cruciferous Vegetables
- 250g each of broccoli and brussels sprouts per day reduced heterocyclic amine (HCA) levels in urine by around 22%.
- Mechanism of action: may improve liver function to detoxify HCAs.
- Sulforaphane suppresses the ability to form tumors. To match the levels of sulforaphane used in in vitro studies, you would need to eat ¼ cup of broccoli sprouts a day
Flaxseeds
- Contain lignans and phytoestrogens that dampen the effects of human-made estrogen.
- 1 tbsp of flaxseeds can extend a woman’s menstrual cycle by a day.
- A study of cancer patients showed that eating a 25g flaxseed muffin caused a 31% increase in...
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PDF Summary Part 1-7: Prostate Cancer, Parkinson’s
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* After 11 days of avoiding animal protein, IGF-1 levels drop by 20%, and IGF-1 binding protein levels increase by 50%.
- An increase in animal protein consumption of 3% is associated with a 15% increased risk of bladder cancer.
- Vegetarians who include eggs and dairy in diets don’t achieve significant reduction in IGF-1.
How Not to Die from Prostate Cancer
Vegetarian diet
- In vitro, blood from a standard diet slowed down prostate cancer cell growth by 9%. Blood from men placed on a plant-based diet for a year reduced cancer cell growth by 70%.
- Cruciferous vegetables are especially helpful, cutting cancer progression by over 50%.
- Increasing plant protein intake of 2% is associated with a 23% decreased risk of cancer.
- Vegetarian diets can reverse prostate cancer. PSA levels in people on a plant-based diet decrease, while levels increase in a control group.
Exercise vs Diet
- Exercise is helpful, but not as helpful as a plant-based diet.
- This was shown by comparing 3 groups: 1) the control, which was sedentary, 2)...
PDF Summary Part 1-8: Deaths from Medical Treatment
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- Patients who overtrust drugs may be less likely to adopt lifestyle changes.
Reconsider taking aspirin.
- Salicylic acid (the active ingredient in aspirin) acts as a blood thinner by inhibiting pro-coagulant enzymes. It also suppresses proinflammatory prostaglandins. People at risk of heart attacks take it regularly.
- Aspirin is not generally recommended for people who haven’t had the first heart attack, because of the side effects it causes.
- Fruits and vegetables contain salicylic acid—blood levels of salicylic acid in people on plant-based diets are comparable to that in people who take low-dose aspirin.
- Cumin, chili powder, paprika, and turmeric have the highest concentration of salicylic acid. As suggestive evidence, India has very low rates of colon cancer, which is the most sensitive cancer to aspirin.
- Organic produce seems to have more salicylic acid, possibly because salicylic acid is used as a defense mechanism against bugs. Produce that rely on pesticides don’t have a need for this defense mechanism.
- Fruit and vegetables may cause fewer side effects than taking aspirin. Furthermore, if you take it naturally in diet, salicylic...
PDF Summary Part 2: What to Eat | Main Ideas
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- Remember how the meat, milk, and egg industries successfully lobbied to remove a federal recommendation to eat less animal-based foods.
Today’s Foods Work Against Us
Modern foods are optimized to develop unhealthy eating habits.
Our primate brains have evolved to have natural drives for food, water, and sex. Modern industries exploit and amplify this in ways we don’t consciously perceive. Processing foods takes them into an unnaturally addictive state. As we eat more of these hyper-rewarding foods, we raise the barrier for enjoying other foods, and we decrease dopamine sensitivity.
As an analogy, natural coca leaves have not been shown to be addictive over millennia of consumption, but it does become addictive when processed into cocaine
Similarly, ice cream gives such an intense dopamine response (to both sugar and fat) that it deadens your response to natural foods like fruits. Then, because fruits are not rewarding and ice cream is what you’ve come to expect, you start seeking an even greater dopamine high than what ice cream provides.
The good news is, eating normal whole foods for a period of time can return dopamine sensitivity to normal levels.
Diet...
PDF Summary Part 2-2: Beans, Berries, and Other Fruits
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Nutrients and Benefits
Nutrients: 10x more antioxidants than other fruits and vegetables by density
- Compared to fresh berries, frozen berries are roughly the same in nutrition or about 20% less nutritious in antioxidant activity, but tend to last longer and are cheaper.
- However, berry jams lose the majority of nutrients.
Studies show:
- Protection against cancer
- Immune system boost
- 1.5 cups/day of blueberries for 6 weeks doubled natural killer counts in athletes after intense exercise, when normally it drops by half
- Protection for the brain
- Women who ate one serving of blueberries and two servings of strawberries a week had slower rates of cognitive decline, by as much as 2.5 years.
- Fructose in fruit is less harmful than added fructose
- Fiber, antioxidants, and phytonutrients in berries may cancel out the harmful effects of fructose, such as by lowering the rate of absorption.
- A small trial found that feeding a diet that included 20 servings of fruit per day had no effect on weight,...
PDF Summary Part 2-3: Green, Leafy, and Other Vegetables
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Nutrients and Benefits
Nutrients:
- Chlorophyll blocks carcinogen activity, possibly by regenerating coenzyme Q10
- Warning: Greens contain vitamin K. If taking warfarin or blood-thinners, can nullify the drug
Studies show:
- Greens decrease cancer risk
- An increase of 1 serving a day is associated with 4% lower risk for coronary heart disease.
- Vitamin C-rich foods contributed most to the effect.
- People who were in the highest quintile in fruit and vegetable intake showed a much lower relative risk (0.69) for ischemic stroke, compared to those in the lowest quintile.
Eat greens with fat to better absorb nutrients.
- Fat-soluble compounds like beta-carotene, lutein, vitamin K, zeaxanthin are better absorbed when paired with fat.
Method of preparation—fresh is better.
- Fresh kale showed much better antiproliferative effects than frozen and heated-in-bag kale (in some assays, cooked kale showed no antiproliferation while fresh did).
- Boiling broccoli [removes 50% of...
PDF Summary Part 2-4: Nuts, Seeds, and Spices
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Peanuts
- Women at high risk for heart disease who eat nuts or peanut butter daily halve their risk of heart attack compared to non-eaters.
Pistachios
- Erectile dysfunction is an early sign of vascular disease and can predict heart disease.
- 40 over 40 rule: 40% of men over age 40 have erectile dysfunction.
- 3 to 4 handfuls of pistachios a day for 3 weeks show improvement of erectile function by 50%
- The Nurses’ Health Study show pistachios can also improve female lifespan.
Herbs and Spices
Daily Recommendations
1 serving per day
Serving sizes
- ¼ teaspoon turmeric
- any other you enjoy
What to eat: Allspice, barberries, basil, bay leaves, cardamom, chili powder, cilantro, cinnamon, cloves, coriander, cumin, curry powder, dill, fenugreek, garlic, ginger, horseradish, lemongrass, marjoram, mustard powder, nutmeg, oregano, smoked paprika, parsley, pepper, peppermint, rosemary, saffron, sage, thyme, turmeric, vanilla
Nutrients and Benefits
Nutrients: Spices have high antioxidant density.
This can be too much of a good thing
- Poppy seeds contain opium, and you can overdose—the safe dose is below 1...
PDF Summary Part 2-5: Whole Grains and Beverages
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Pigmented grains
- Pigmented rice (red, purple) may have antioxidant benefits over brown rice.
Oats
- Contain avenanthramides, which are anti-inflammatory compounds.
- They suppress inflammation for skin rashes.
Beverages
Daily Recommendations
5 servings per day
Serving sizes
- One glass
What to drink : Black tea, chai tea, chamomile tea, coffee, earl grey tea, green tea, hibiscus tea, hot chocolate, jasmine tea, lemon balm tea, matcha tea, oolong tea, peppermint tea, rooibos tea, water, white tea
Nutrients and Benefits
The common “8 glasses a day” recommendation seems to originate from a 1921 paper measuring urine and sweat output.
The new recommendation is 10-15 cups of water a day for men, and 8-11 for women, including liquid from foods. Net of food, this translates to 6-11 cups for men and 4-7 for women.
Studies show:
- Low liquid intake is associated with heart disease, kidney disease, urinary tract infections, and other diseases. But it’s unclear whether low fluid drinking is to blame—it’s associated with other unhealthy behaviors like lack of exercise and poor diet.
- Each extra daily cup of fluid reduced risk of...
PDF Summary Part 2-6: Exercise and Supplements
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Other options for activity:
- Switch to a standing desk—this causes an extra 30,000 calories burned per year.
- Have walking meetings or stand-up meetings instead of sit-down meetings.
- Take short breaks from work, taking just 1 minute to walk or climb stairs.
- Turmeric can improve endothelial function, along with 1 hour per day of exercise.
Reduce muscle soreness and oxidative stress from exercise.
- Reduce lactic acid with bioflavonoids from citrus.
- Reduce inflammation with anthocyanin flavonoids in berries.
- Whole-food antioxidants reduce DNA damage from exercise, whereas vitamin C supplements promote even more oxidative stress.
Supplements
While Dr. Greger recommends that all your nutrients come from whole foods, he does suggest that a few nutrients be supplemented when on a plant-based diet.
Vitamin B12
- B12 is made only by microbes, and is present in meat but not plants.
- B12 deficiency can lead to paralysis, psychosis, and blindness.
- Dosing
- If you’re under 65: 2,500 micrograms of cyanocobalamin once a week, or 250 micrograms a day
- If you’re over 65: up to 1,000 micrograms daily
Vitamin D
- ...