Book SummaryHow Not to Die, by Michael Greger

1-Page Summary1-Page Book Summary of How Not to Die

Plant Diets Reduce Disease

Our genes only account for 10-20% of the risk for most leading causes of death, like high blood pressure, heart attacks, cancer. As evidence of this, when people move from low- to high-risk countries, their disease rates change to those of the new environment. For example, a Japanese person who moves to America raises her risk of heart disease, even though she is genetically Japanese.

But aren’t we dying less, and living longer? Not necessarily. Even though lifespan in America has increased slightly over the past decades, the quality of life at the end of life is worse.

The author Michael Greger argues diet is behind all of this. Specifically, that a diet heavy in meat, dairy, eggs, and processed foods is much less healthy than a diet based on whole foods and plants.

Here’s some evidence of how plant-based diets increase health:

• People who used to be vegetarians but who went back to eating meat increased their risk of disease significantly—they increase heart disease odds by 146%, stroke by 152%, diabetes by 166%, weight gain by 231%. Their life expectancy drops by 3.6 years.
• Women who eat more whole plant foods reduce odds of breast cancer by 90%.

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.

A plant-based, whole-food diet has been shown to decrease your likelihood of getting a large panel of diseases, from heart disease to Alzheimer’s. Here’s a selection of the many research results cited in the book:

• Drinking 3-4 shots of kale juice a day over 3 months lowers bad LDL cholesterol and boosts HDL cholesterol as much as running 300 miles does.
• Increasing fiber by 7 grams/day reduces risk of stroke by 7%. For the maximum reduction in stroke risk, eat 25 grams/day of soluble fiber and 47 grams/day of insoluble fiber.
• The more plant-based foods you eat, the lower your hypertension rates. Flexitarians show 23% reduced risk of hypertension; vegans show 75% reduced risk.
• Japanese men showed a 25x increase in prostate cancer risk after World War II. This is also associated with a 7x, 9x, and 20x increase in egg, meat, and dairy consumption respectively.
• Premenopausal women who ate 6g of fiber a day had 62% lower odds of breast cancer, compared to those eating <4g a day.

Diet can reverse disease, not just halt it. It's not too late if you already have heart disease or diabetes. Studies have shown that switching to a plant-based diet can reverse atherosclerotic plaques, reverse the influence of smoking on lung cancer, and decrease the inflammation that leads to many cancers.

Preventing disease is better than treating it. Drugs have side effects, and some disease is irreversible

Nuances...

How Not to Die Summary Shortform Introduction

Caveats

How Not to Die contains many good ideas, and it's one of the most rigorously cited mass-market books on nutrition out there.

That said, because it's written for a wide audience and doesn't want to bog readers down in scientifically precise language, Michael Greger sometimes cuts corners on his claims. Here are issues to note:

The magnitude of effects is important. Does eating organic blueberries have a 5% effect or a 50% improvement of health, compared to conventionally grown blueberries? Does meat-eating cost 1 year of life, or 5 years? Often Greger simply says the difference "is significant"—but this is a statistical term, which laymen may misconstrue as "the difference is huge." He often does this more when the difference is small (below 5%). When the difference is big, he'll use the actual number ("a 20% difference!"). This is misleading and over-represents the effects of some diet choices.

Whenever Greger says something has "up to a [X%] difference", this is misleading. When doing statistical analysis, science uses confidence intervals—"the effect can be as low as 1%, as high as 10%, and an average of 5%." Greger would sometimes represent this to...

How Not to Die Summary Preface

The US healthcare system runs on a fee-for-service model: doctors get paid for pills and procedures they perform, not for patient health outcomes. Thus, actually preventing disease and improving patients’ lifestyle is undervalued in medical care.

To wit, most medical schools don’t have any courses on nutrition. Doctors receive very little training on how diet can reduce the risk of serious disease and death. No wonder the medical establishment has paid so little attention to the value of nutrition.

Introduction

Our genes only account for 10-20% of the risk for most leading causes of death, like high blood pressure, heart attacks, cancer. As evidence of this, when people move from low- to high-risk countries, their disease rates change to those of the new environment. For example, a Japanese person who moves to America raises her risk of heart disease, even though she is genetically Japanese.

But...

How Not to Die Summary Part 1: How Not to Die from Disease | Heart Disease, Lung Disease

Heart Disease

Annual deaths from heart disease: 375,000

About Heart Disease

Coronary heart disease didn’t use to exist in some populations. It appears to be predominantly an environmental problem—when people move from low-risk areas to high-risk areas, their disease rates increase to match their new homes.

Atherosclerotic plaque—the hardening of blood vessels and a contributor to heart attacks—can start to be seen in childhood.

Elevated cholesterol and LDL is the only risk factor for atherosclerotic plaque. To reduce LDL, you need to reduce intake of trans fat, saturated fat, and dietary cholesterol

• A single unhealthy meal can stiffen your arteries within hours.

Ideally, your optimal LDL is 50-70 mg/dL, and your total cholesterol under 150 mg/dL. The usual recommendation from doctors is below 100 mg/dL and 200 mg/dL, respectively, but keep in mind this is the average recommendation in a country where heart disease is the #1 killer. It’s better to aim for better than average, if you want to beat the average statistics on heart disease deaths.

Heart disease itself is reversible—plaques can actually shrink in size! Your body actually wants to heal...

How Not to Die Summary Part 1-2: Brain Diseases, Digestive Cancers

Brain Diseases

Annual deaths from brain disease: 215,000

This includes:

• Stroke: 130,000 deaths per year
• Alzheimer’s: 85,000 deaths per year

Stroke

Strokes are caused by a clogged artery in the brain, leading to a lack of oxygenation of the brain and death of part of the brain. Like heart disease, hardening of the blood vessels through atherosclerotic plaques is a contributor to the risk of strokes.

How Not to Die from Strokes

Reduce your risk of strokes by 1) reducing cholesterol and blood pressure and 2) improving blood flow and antioxidants.

Fiber

• Increasing fiber by 7 grams/day reduces risk of stroke by 7%. For the maximum reduction in stroke risk, eat 25 grams/day of soluble fiber and 47 grams/day of insoluble fiber.
• It’s not known exactly why fiber reduces risk of stroke. It might help control cholesterol and blood sugar, which in turn reduces atherosclerotic plaque.
• It may also lower blood pressure, reducing risk of brain bleeds.

Potassium

• 1,640 mg increase of potassium is associated with a 21% reduction in stroke
  • Best source of potassium: greens, beans, sweet potatoes. Not bananas.

Citrus

• ...

How Not to Die Summary Part 1-3: Infections, Diabetes

Infectious Disease

Many infectious diseases resulted from human domestication of animals. We got tuberculosis from goats, measles and smallpox from cattle, typhoid fever from chickens, and the cold virus from horses.

Your immune system consists of a few types of cells:

• White blood cells
  • Neutrophils destroy pathogens like bacteria and parasites directly.
  • Natural killer cells kill your body’s cells that are infected.
• B cells
  • Produce antibodies that bind to a specific antigen (like a bacterial protein).
  • These antibodies then deactivate pathogens, or signal to natural killer cells that a cell is infected.

For some reason, people suffering from allergies have lower risk for some cancers. One theory is that an overactive immune system also protects against threats like cancer cells.

Reducing Infections and Boosting Immune System

Fruits and vegetables

• An evolutionary theory for the relationship between eating plants and the immune system: to reduce energy expenditure, the immune system activates itself periodically at times of greatest risk—including eating food with potential pathogens. As cavepeople, we evolved over...

How Not to Die Summary Part 1-4: High Blood Pressure, Liver Disease

High Blood Pressure

Annual deaths from high blood pressure: 65,000

The Disease

High blood pressure, or hypertension, is cited as the #1 risk factor for death in the world, leading to 9 million deaths worldwide annually (source: the Global Burden of Disease Study in the Lancet). 78 million Americans have hypertension.

Blood pressure consists of two numbers: systolic is the pressure when blood pumps through the artery, and diastolic is the pressure between beats.

• 110/70 is an ideal blood pressure, even though 120/80 is cited as normal
• 140/90 is hypertensive

Hypertension promotes atherosclerosis (which leads to heart attacks and strokes). It also puts strain on the heart leading to heart failure; it damages blood vessels and leads to kidney disease.

Blood pressure tends to increase with age—65% of Americans age 60 or above have hypertension. But Kenyans of that age eating a low-sodium diet based around whole plant foods had normal blood pressure.

Sodium

Evolutionarily, we ate plant-based diets consisting of 500mg of sodium a day.

Now, average daily consumption is 3,500mg, and the AHA recommends 1,500mg. (Remember that it might not be wise to...

How Not to Die Summary Part 1-5: Blood Cancers, Kidney Disease

Blood Cancers

Annual deaths from blood cancers: 56,000

This includes a range of diseases:

• Leukemia: 52,000 diagnosed each year, 24,000 die
  • In leukemia, bone marrow produces abnormal white blood cells, crowding out the ability to produce red blood cells and white blood cells. Leads to anemia, infection, death.
• Lymphoma: 70,000 diagnosed, 19,000 die
  • Lymphoma is the proliferation of lymphocytes, which are white blood cells.
  • These cells collect in lymph nodes and disrupt immunity.
• Myeloma: 24,000 diagnosed, 11,000 die
  • Myeloma is the proliferation of plasma cells, which are antibody-secreting white blood cells.
  • These cells displace bone marrow and make abnormal levels of antibodies that clog kidneys.
  • Multiple myeloma happens when cancer is discovered in multiple bones.
  • This is particularly resistant to treatment; most people diagnosed do not survive beyond 5 years.

Animal Viruses Causing Cancer

Of all foods in the large population EPIC study, poultry showed the greatest risk for blood cancers. For every 50g of poultry you consume daily, your risk of blood cancer increases between 56 and 280 percent....

How Not to Die Summary Part 1-6: Breast Cancer, Suicide

Annual deaths from breast cancer: 41,000

• 230,000 are diagnosed each year.

Risk Factors for Breast Cancer

Alcohol

• The metabolic product of alcohol, acetaldehyde, is the carcinogen.
• Even moderate drinking—one drink a day—shows a small increase in risk of breast cancer.
• Red wine is exempt from this effect, possibly because of compounds in grape skins that suppress estrogen synthase.

Decreased melatonin

• Melatonin regulates sleep and circadian rhythm and is secreted in the dark. Melatonin suppresses cancer growth.
• Blind women (who secrete melatonin constantly) shows half the odds of breast cancer.
• Women who work on night shifts show an increased relative risk (1.14) for breast cancer.
• Higher vegetable intake increases melatonin levels; meat lowers melatonin.

Heterocyclic amines (HCAs)

• HCAs are produced when cooking meat at high temperatures.
• Meat eaters who eat well-done meat eaters show 5x the odds of breast cancer compared to people who eat rare meat. Well-done meat eaters also show a higher risk of colon, esophagus, lung, pancreas, prostate, and stomach cancer.
• Mechanism of action: a particular HCA (PhIP)...

How Not to Die Summary Part 1-7: Prostate Cancer, Parkinson’s

Prostate Cancer

Annual deaths from prostate cancer: 28,000

Prostate Function and Disease

The prostate surrounds the urethra and secretes the fluid part of semen.

Half of men over 80 have prostate cancer, but most die with the disease.

Dietary Risks for Prostate Cancer

Milk and hormones

• High intake of dairy products increases total prostate cancer risk with a relative risk of 1.07.
• Overall, each daily glass of milk showed higher rates of premature death, heart disease, and cancer in women.
  • 3 or more glasses of milk a day show a mortality hazard ratio of 1.93!
• Women who drink milk have 5x the rate of twin births.
• Japanese men showed a 25x increase in prostate cancer risk after World War II. This is also associated with a 7x, 9x, and 20x increase in egg, meat, and dairy consumption respectively.
• Cow’s milk stimulates human prostate cancer cells in vitro by 30%.
• The culprit could be D-galactose, which induces premature aging in lab animals and causes acute symptoms in patients with galactosemia, possibly from oxidative stress.

Eggs and choline

• Men eating 2.5+...

How Not to Die Summary Part 1-8: Deaths from Medical Treatment

Annual deaths from iatrogenic causes: 225,000

Iatrogenic causes relate to illness caused by medical treatment. This includes:

• 106,000 deaths from side effects from medications
• 99,000 deaths from hospital-acquired infections
• 20,000 deaths from hospital errors
• 12,000 deaths from unnecessary surgery complications
• 7,000 deaths from wrong medication
• 199,000 deaths from drug side effects

How Not to Die from Medical Treatment

Reduce medical error.

• Residents used to have 36-hour shifts until they were shortened. Residents who undergo all-nighters increase serious medical errors by 36% and diagnostic errors by 5x.

Reduce radiation through diet and reducing exposure.

• Medical treatment and diagnose entail many sources of radiation:
  • A single CT scan for a baby girl could cause cancer at a rate of 1 out of 150.
  • A chest CT has the same cancer risk as 700 cigarettes.
  • An angiogram could cause cancer in 1 out of 270 women.
  • A cross-country flight could expose you to as much radiation as a chest x-ray.
• Reduce radiation damage through antioxidants in foods like spinach and kale. Vitamin C and E supplements...

Shortform Exercise: Reflect On Your Health Concerns

You’ve just read about the top 15 causes of death. Think about what you took away.

Which of the causes of death covered so far are you personally most worried about? Why?

How Not to Die Summary Part 2: What to Eat | Main Ideas

As you’ve seen throughout Part 1, the themes of How Not to Die include:

• Eating a plant-based diet decreases your risk of a host of diseases.
• Eating supplements that extract the active ingredient from fruits and vegetables leads to less benefit than eating the whole plants themselves.
• Meat and animal products increase your risk of disease, even after controlling for calories eaten and weight.

Even More Reasons to Eat Vegetables and Fruit

If the massive health benefits aren’t enough to convince you to eat more plant-based foods, here are a few more.

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...

How Not to Die Summary Part 2-2: Beans, Berries, and Other Fruits

Beans

Daily Recommendations

3 servings per day

Serving sizes

• ¼ cup of hummus or bean dip
• ½ cup cooked beans, tofu, tempeh
• 1 cup of fresh peas, sprouted lentils

What to eat: Black beans, black-eyed peas, butter beans, cannellini/garbanzo beans, chickpeas, edamame, kidney beans, lentils (beluga, French, red), miso, navy beans, peas, pinto beans, small red beans, tempeh

Nutrients and Benefits

Nutrients: protein, iron, zinc, fiber, folate, potassium

• Canned beans are as nutritious as boiled beans, except for the salt they contain.

Studies show:

• Beans drop LDL and total cholesterol.
• Every 20g increase in daily legume intake reduces premature death by 8%.

Specific Choices

Soy

• Half of nutrients are lost when soybeans are converted into tofu or soy milk.
  • For tofu, choose ones made with calcium.
• Tempeh or miso are whole soy foods that are preferable to tofu and soy milk.
  • Don’t boil miso since it has probiotics.
  • Despite its salt, miso may have protective effects that cancel...

How Not to Die Summary Part 2-3: Green, Leafy, and Other Vegetables

Cruciferous Vegetables

Daily Recommendations

1 serving per day

Serving sizes

• ½ cup chopped
• ¼ cup Brussels or broccoli sprouts
• 1 tablespoon horseradish

What to eat: Arugula, bok choy, broccoli, Brussels sprouts, cabbage, cauliflower, collard greens, horseradish, kale, mustard greens, radishes, turnip greens, watercress

Nutrients and Benefits

Nutrients: sulforaphane is thought to be the main beneficial component.

• Protects against DNA mutations and ability to form tumors
• Protects brain, eyesight, immunity
• May help with autism

Sulforaphane requires the enzyme myrosinase to be produced.

• Raw cruciferous vegetables suppress cancer cell growth in vitro, but not cooked vegetables.
• Michael Greger suggests a “hack and hold” technique—chop, then wait forty minutes while sulforaphane is produced.
• Frozen cruciferous vegetables lose much of the antiproliferative anti-cancer effect, because tyrosinase is destroyed before packaging. Powdered mustard seeds have tyrosinase and increase sulforaphane production.

Supplementing sulforaphane seems ineffective.

• ...

How Not to Die Summary Part 2-4: Nuts, Seeds, and Spices

Flaxseeds

Daily Recommendations

1 serving per day

Serving size

• 1 tablespoon ground

What to eat: Golden or brown flaxseeds

Nutrients and Benefits

Nutrients

• Contains lignans and omega-3 fatty acids
• It’s best to blend flaxseeds for better digestion. Ground flaxseed should last at least 4 months at room temperature.

Studies show:

• A double-blind, placebo-controlled, randomized trial showed blood pressure drop from 158/82 to 143/75 after eating a few tablespoons of flaxseed a day, compared to no change in control.
• Prostate cancer patients eating 3 tablespoons per day of flaxseed after a month show lower cancer proliferation rate.

Nuts and Seeds

Daily Recommendations

1 serving per day

Serving sizes

• ¼ cup nuts or seeds
• 2 tablespoons nut or seed butter

What to eat: Almonds, Brazil nuts, cashews, chia seeds, hazelnuts, hemp seeds, macadamia nuts, pecans, pistachios, pumpkin seeds, sesame seeds, sunflower seeds, walnuts

Nutrients and Benefits

Studies show:

• ¼ cup of nuts daily may lead to lifespan extension of 2 years+
• Nuts have high caloric density, but studies show that adding nuts to...

How Not to Die Summary Part 2-5: Whole Grains and Beverages

Whole Grains

Daily Recommendations

3 servings per day

Serving sizes

• ½ cup hot cereal or cooked grains, pasta
• 1 cup cold cereal
• 1 tortilla or slice of bread
• ½ bagel or English muffin
• 3 cups popcorn

What to eat: Barley, brown rice, buckwheat, millet, oats, popcorn, quinoa, rye, teff, whole-wheat pasta, wild rice

Nutrients and Benefits

Studies show:

• From the Nurses’ Health Study, the highest quintile of whole grain intake showed a reduced total mortality and reduced cardiovascular mortality.
• Whole grains reduce the risk of heart disease, type 2 diabetes, obesity, and stroke.
• Whole grains reduce inflammation across a panel of markers (e.g. CRP, interleukins, TNF-alpha).

Eat whole grains according to the Five-to-One rule:

• The ratio of grams of carbohydrates to dietary fiber should be 5 or less.
• When grains are processed into flour, they are digested more rapidly, and glycemic index increases.

Specific Choices

Gluten

• Outside of celiac disease, is gluten sensitivity real? Two randomized controlled trials show most people who claim to feel...

How Not to Die Summary Part 2-6: Exercise and Supplements

Exercise

Daily Recommendations

1 serving per day

Serving sizes

• 90 minutes of moderate-intensity activity
• 40 minutes of vigorous activity

What to do

• Moderate-intensity activity includes cycling, hiking, housework, ice skating, shoveling snow, walking briskly (4 mph), yard work, yoga.
• Vigorous activity includes basketball, jogging, rock climbing, running, vigorous swimming, tennis, and weightlifting.

Nutrients and Benefits

Is exercise more important than eating for body weight? No—eating is still the principal cause of obesity.

• Compared to past times, people may actually be increasing physical activity over time, but foods are more calorically dense now and cause a net increase in calories eaten.
• Compared to exercising away 100 calories, simply not eating those 100 calories is usually much easier.
• Diet is the #1 risk factor for decreasing lifespan, responsible for 26% of deaths and 14% disability-adjusted life years, compared to tobacco smoking at 22% and 12% respectively.
• Losing 1% of the nation’s body-mass index could reduce 2 million cases of diabetes, 1.5 million cases of heart disease, and 127,000 cases...