Forks over Knives, a movie whose theme is in the title: food will replace surgical scalpels for cancer, heart disease, obesity, type 2 diabetes, and others.  Their answer is a “plant based” diet (Vegan).  The movie provides three live anecdotes to prove this, and star T. Colin Campbell and  Caldwell Esselstyn, Jr whose careers intersected with both having come to the same conclusion that a vegan lifestyle would eliminate heart disease, perhaps cancer, obesity, and other chronic illness.

The two stars of the movie, answering questions at its opening

The movie started with lots of video of obese people, and the movie ended with most of the people in the movie sitting down having a friendly, plant-based meal: great cinematic contrast as this small band of people fighting diseases by eating plants.

Some consider this movie  a documentary, especially those who advocate the whole plant (Vegan) lifestyle. It is not a documentary, a documentary is non-fiction, this is a movie, it is a hope, it is an unproven hypothesis.  As much as we (physicians) would love food to solve medical problems, and there is no doubt food can cause problems, but food, as medicine is another matter.

We are introduced to the narrator, Lee Fulkerson, who presents himself to a clinic while smoking a cigarette and having left behind two empty cans of an energy drink, and stating he earlier drank  a large cup of coffee.  The clinic is a family owned clinic  where the physicians, Drs. Matthew Lederman and Alona Pulde, promote a vegan lifestyle and will shop with the patients, cook with the patients, and watch their laboratory values improve. By the end of the film the narrator has lost weight, improved cholesterol, and improved his cardiac risk factors (they don’t tell you that the main reason for that improvement is he stopped smoking).

Lee Fulkerson looking over his lab results with Dr. Lederman

Much like the narrator doesn’t tell you that removing cigarettes, and weight loss were the primary improvement, the entire movie has a tendency to gloss over points, data, and misrepresent biology.

The good points of the movie are:

(1)  The doctors

It is great to see the physicians who take time with patients to change and impact their lives. Drs. Esselstyn, Matthew Lederman, and Alona Pulde whose fundamental belief in prevention is to impact what a patient eats. If you believe that food makes that fundamental impact on health, these physicians make a tremendous investment in their time to helping these patients. Many of us are teaching patients how to cook, and what to cook and more physicians are taking the course at Culinary Institute/Harvard to learn to these skills.  Changing lifestyle, spending time with patients, and having a positive impact is the ideal of primary care medicine.

Dr. Lederman and Pulde are a great team in this movie

(2)  Eating Healthier

Eating healthier is better than eating junk. No doubt the lady who ate her share of donuts into a heart attack helped herself by avoiding donuts. Whether she would have done just as well following a paleolithic diet as a vegan diet is debatable

Told she had to go to a rocker, Ms. Oswick found Dr. Esselstyn, and now lives without her donuts and chocolate

(3)   Feel Good Story

Watching a heartfelt good story: seeing people’s health improves, feeling better, and being more fit is a great story. Seeing physicians working to that end, as well as advocates of that position

The Incomplete Data
Cholesterol: The notions of cholesterol were not only out of date, but incorrect.  Early on the narrator states that cholesterol is what forms the plaques in the arteries of the body. To quote, “But when we consume dietary cholesterol, which is only found in animal foods like meat, eggs, and dairy products, it tends to stay in the bloodstream. This so-called plaque is what collects on the inside of our blood vessels and is the major cause of coronary artery disease.” This is not how plaque forms, and dietary cholesterol is far less important.  It may be that both T. Colin Campbell and Esselstyn were both trained in the era when cholesterol was thought to be the cause of the arterial plaques.  It isn’t and there are more discussions about this here.  Some people,  who have minor elevations of lipids,  can lower their lipid level (I avoid saying cholesterol because that is just not what we need to be talking about here)  through diet, exercise, and weight loss alone, but before throwing away medications and eating plants they should be  carefully monitored by their physician.

This is not a “minor slip up” in the movie- this is the first tenant of a plant based diet. It is also dangerously incorrect. Dietary cholesterol is avoided in a plant based diet, but a plant based diet does not avoid plaque in arteries.

The now clean arterial plaque:
One of Dr. Esselstyn associates had a heart attack- and they show the angiogram of his coronary arteries after the heart attack. You see the smooth arteries around this and then the ragged artery that caused the heart attack. After time on the plant based diet another angiogram was taken- and behold the artery is now clean.

Left is a clot, the artery on the right is free of clot - it is NOT reversed disease

This is misdirection to the viewers.  What they are seeing in that ragged artery is the remains of the clot in the artery that caused the heart attack. If a person survives, within a few days on aspirin that clot will disappear.  The associate credits Dr. Esselstyn with saving his life, by putting him on the plant based diet. But the misdirection is egregious, planned, and is often replicated on many websites that advocate a plant based diet — they will either show an artery of someone who had a heart attack with remaining clot, and then show a clean artery- or they will give you a slightly different two dimensional view of the artery that is more favorable.

The Norway Data
Dr. Esselstyn then shows the data of mortality from heart attacks and strokes of World War 2 Norway, which drops dramatically after the Nazi take over, and confiscate the meat supply.

The death rate dropped before the Nazi's took the Norwegians meats

The first question one would ask — if this is true, if by removing meat you immediately see a drop in strokes and heart attacks?  That is the implication. The problem is that Dr. Esselstyn’s conclusion about the data is missing a few points that might clarify the data:

The decrease in wartime heart disease and strokes was replaced with an increase in mortality from infectious disease, trauma (in war people tend to fire more bullets) – and in particular outbreaks of TB. The meats from the livestock were not taken by the Nazis until after this graph showed the dramatic decline (hence the drop was not because of less meat being consumed, in fact during this drop Norwegians consumed more meat  because the Nazis had told the Norwegians they were going to confiscate their livestock, so many Norwegians simply slaughtered their animals and didn’t raise new ones the following year. Meat consumption during this “fall in the graph” was almost double what it was during normal times.

The fish consumption during these times doubled. Not that eating more fish will decrease coronary disease (except in large population series this is a trend).

While others have pointed out that sugar consumption decreased, wheat consumption decreased and thus they became a paleo society with an emphasis on fish (thought Norwegians were Lutherans and turned out they were Pescatarians) – it is a long stretch that any single change in a diet would cause a single year dramatic decrease in cardiac mortality and strokes (but would be great if it did). It fits the theme of the movie that the change to a Vegan diet will, within a year, dramatically alter years of coronary artery accumulation of plaque – it won’t.

Dr. Campbell’s cancer study:
Rats given more milk protein have more “foci” of cancer than rats fed less milk protein. Several issues with this study, and those conclusions.  First, it wasn’t that the rats lived longer- they didn’t.  The rats died from being a part of an experiment, and some rats died before they were suppose to– those rats all were the rats getting less of “mothers milk protein.”

Campbell takes the one milk protein  and generalizes it to all animal proteins. Why? Proteins are chains of amino acids, and there is some magic about how a plant puts the amino acids together than an animal?  Casein is a bio-active group of proteins found in milk- it stimulates tissues to grow, which is what you want mother’s milk to do- it is not just a source of nutrition but is a “bioactive protein” meaning it helps to turn on certain proteins.  Take a rat liver, put it with a super high concentration of a protein that turns on proteins, and then add a cancer causing agent –well, it makes sense. But remember, these rats had better looking livers than the low protein rats (who died faster). Also  whey protein, another milk protein, has been demonstrated to have some opposite effect with tumor.  Some proteins are bio-active, and have effects when given in super concentrated form and isolated from their natural counter parts – like whey, they behave in not natural ways. Then to use this to make global conclusions about animal proteins is not science, it is prejudice. I discussed Dr. Campbell’s assumptions here.

Dr. Esselstyn’s patients:
Dr. Esselstyn took a bunch of patients with heart disease, convinced them to go on a Vegan diet (initially the group was allowed to have dairy til he met Dr Campbell then no dairy). Of this small group, six people dropped out. You can see more about his works on my previous post regarding him and this study.

While the study seems great, and they bring out two individuals who were a part of the original study (I think- they don’t really say that, and since the movie tends to gloss over details quite a bit one cannot make assumptions).

What is remarkable is that Dr. Esselstyn met with these patients every couple of weeks in his home. One sweet lady who had two heart attacks before 59 while eating a diet of chocolate and “every donut I could get my hands on and lots of gravy.” She also noted that Dr. Esselstyn, in spite of his “kind eyes” was quite strict “there’s the door.” That may explain why 6 of the original 24 dropped out.  Of the remaining 18 the math gets a bit fuzzy. 6 had “evidence of regression of disease” 11 stabilized.  But it turns out that Dr. Esselstyn’s math as presented was off, and not surprising, the data in this movie is driven by making a point, and not by precise details.

Esselstyn’s publication states he started with 22 patients, five dropped out, and six stayed on the diet but never came back for data collection—leaving Esselstyn with only 11 people in the study. The data from the  11 had  stabilization of their heart disease, but four people  had lesions that slightly progressed. The paper then looks at the method of regression of plaque, and these methods are now considered out-dated and of no use.

The high drop out rate could mean people either could not tolerate the diet, or died, or were asked to leave. The other issue is these patients had other interventions, such as statin agents that really do reduce arterial plaque formation. Esselstyn’s paper that does not rise to the evidence based medicine for major research. It is quite small, highly selective of the patients, not controlled for other interventions with heart disease (some patients had angioplasties, heart surgeries, and etc) – thus we cannot determine which intervention for this small group of individuals worked, if any. Why Esselstyn didn’t keep the other drop-outs on to serve as a control is deeply flawed.  Throughout the years on this diet variables changed – such as removing dairy products, and even if there was a dietary answer to heart disease, it would be lost in the details.

As a personal anecdote, my father had a heart attack in 1979, was forced to retire at age 55, did not have angioplasty (not available then) and loves sugar, ice cream, peanut butter, meat,  cheese, but he stopped smoking, retired, and 33 years later (and a few stents and an implantable defibrillator later). Looking at his previous angiograms- his disease has regressed (in spite of not being on a plant based diet, not being on a paleo diet, and not probably eating things that most diet zealots would shun). That is a series of 1, not 11 – but has as much validity as Esselstyn’s work.  The question is, was it diet that did this for these 11 people? What happened to the others? What does this mean? The answer is that this is as much of an anecdote as my dad is.

The China Project
T. Collin Campbell, a physiologist, calls this massive study the highlight of his career.  With his Chinese counterpart, Dr. Chen,  they took the simple hypothesis: diet effects disease rate.  By choosing rural villages with stable diets, and known health and mortality statistics assumptions could be made about how diet effects health.

Campbell and Chen with their monograph

The film shows the proud researchers, with reams of data, and the NY Times Jane Brody column (Brody is not an authority figure but the implication that the NY Times said this was a good study is another logical fallacy called “appeal to authority.”).

There are major problems with the China Study – the blood samples of all individuals was pooled and studied – avoiding individual variation. The statistics for heart disease in rural villages in the 1970′s (they used this data for their study) was imperfect at best, and if you ask Chinese cardiologists today the current statistics – 30 years later – are poor.  Heart disease is underestimated now, and even more 30 years ago. The same with cancer statistics, and most rural Chinese statistics.

The China Study has been uniquely reviewed and dissected by  Denise Menger of rawfoodsos.com.  She points out how the data sometimes shows the opposite of what is stated (much like this movie).  For example, the meat eaters of one village had lower levels of the diseases.

OVERALL
This is a movie, and not a documentary. This is a movie that advocates a plant based (Vegan) diet will solve heart disease, cancer, and other ailments- and presents inadequate and skewed data to that end. To be clear, there is no substantial data that proves their point, and the data they use is skewed if not outright incorrect.  It is a warm, feel good movie with some great people.

IF you wish to have a whole plant diet – then do so..  If you think you can throw your medicine away and just eat plants, do not do this without medical supervision – and by that I mean the MD or DO who prescribed the medication for you, or a physician that will monitor your blood levels of lipids, glucose, etc.

The Huffington Post is at it again- by promoting a nutrition quiz from the Physicians Committee for Responsible Medicine (PCRM).  One would think that a group like PCRM would be a responsible group, with a website that would have credible information. However, PCRM is a vegan organization that promotes an anti-dairy, anti-meat, anti-seafood, anti-egg diet, and the purpose of their quiz was to help evoke those ideas.  They have also sent out news releases that are bias to  a vegetarian diet and argues for it with half-truths that do little to advance their position, and a lot to reduce their credibility.

Recent breaking news quoted a paper in that indicated that fish oil did not prevent recurrence of heart problems and “evidence fails to support their use.”  PCRM did not include the conclusion:

“However, a diet high in fatty fish (≥2 servings of marine fish per week) should continue to be recommended for the general population and for patients with existing CVD because fish not only provides omega-3 fatty acids but also may replace less healthy protein sources, such as red meat.”

PCRM is anti-fish, as well as anti-dairy, and they fail to note that the American Heart Association recommendations for two meals a day being replaced by fish.

Recently PCRM released another study showing E. Coli was in 48% of chicken bought in 10 cities by their group. What they failed to state was that the E.Coli was not the type that causes humans illness.  Further, the major outbreaks of food-borne illness have recently come from produce and peanuts – as they are grown in soil that contains E. Coli. and can be contaminated with salmonella.  There are many types of bacteria in the soil, and E. coli is a common soil bacteria, but it is not the same type as that which comes from feces.

If you were a Vegan this might be your view of food

Here is their quiz with Science and Evidence based medicine rebuttal:

(1) Skim milk has the same amount of calories as cola

Yes, they are anti-dairy, and this is suppose to scare people into thinking that dairy is bad. For those who can tolerate milk, those who are not lactose intolerant, milk is a great source of nutrients.  Cola, not so much. They say all you need is water, nothing else – and we agree, however,  milk can have plenty of nutrients in them and should not be over looked.

(2) Cheese and steak have the same amount of cholesterol.

The first question you should ask is- so what? Dietary cholesterol has a minimal effect on the blood level of  the body’s cholesterol, we have known this since I was in medical school ( 1980’s). You can see my last post about fats to see more. That different amounts of cheese as well as a porterhouse steak have the same amount of cholesterol means nothing.  Very few physicians look simply at the cholesterol level, unless it is either very high >250 – and then we look at the underlying lipid profiles.

(3) Cheese is 70% fat.

Some cheese is, but again, cheese in moderation is not a bad thing. Some cheese is not  70% fat. By the way, most nuts, which this group advocates, are also 70% fat. They go on to say that Americans are eating three times the cheese we did in the 1970′s – probably not the case for some. Cheese is something that should be used in moderation – as it is dense with calories

(4) Frequent consumption of hot dogs and bacon makes it more likely you will get colon cancer.

In the one study, that has many flaws, if you eat a diet rich in processed meats your risk of cancer is higher- by a small amount. But that is a correlation, and not necessarily a causation, and when you work out the statistics, your chance of eating that much (a lot ) is not much, and your chance of getting cancer from it is – well, we don’t know. We don’t advocate eating a lot of processed any food. They state that the recommended amount of processed meats would be “none” – we would disagree, as do bacon lovers everywhere.  The correlation is so small with this as to be stretched.

(5) Women who regularly eat soy have a lower cancer risk.

This is not necessarily so.   Comparison studies have been mixed- so the answer is, we don’t know.  PCRM based their information about population studies from Asia- but other factors these women have include (a) less obesity (b) more physically active (c) drink less alcohol (d) eat more fruits and vegetables. Until the issue becomes clearer, many doctors recommend that women who take hormonal therapy or who have estrogen-receptor-positive breast cancer avoid soy supplements because they contain high concentrations of isoflavones. But in general, it’s fine to eat moderate amounts of soy foods as part of a balanced diet. One to 3 servings of soy a day (a serving is about a half cup) is similar to an average Japanese woman’s daily soy intake. If you are taking hormonal therapy to fight off a hormone-receptor-positive breast cancer, and you are concerned about any phytoestrogen effects, ask your doctor or registered dietitian about how much soy you can eat.

(6) Salmon has cholesterol and fat

Ah yes it does, and to repeat- consuming cholesterol is not the issue. Salmon fat is high in omega-3 fatty acids and quite healthy. Eskimos and maritime Native Americans had a diet rich in salmon and the lowest rate of heart disease on earth.  There is not convincing evidence to advocate taking fish-oil capsules, there is still evidence that replacing two meals a week with fish is protective for the heart.

(7) An egg has more cholesterol than a Big Mac

Cholesterol is not an issue in diet but the 540 calories in a Big Mac compared to the 90 calories in a large egg is. The calories in a Big Mac come from 29 grams of fat, while only 5 grams of fat from an egg. While PCRM has an issue with dairy, as do some from the Paleo diet, eggs are a healthy source of protein.  If you get rid of the yolk you can get rid of a lot of the calories also. The amount of cholesterol is less important than the lower calories- and you could always use egg whites which have less fat, much less cholesterol, but a great source of protein.

(8) Milk, Beans, and broccoli are all high in calcium

This is true, and for those who need a good source of calcium but do not drink milk, there are some good alternatives. They point out that the calcium in the beans and broccoli is absorbed at a rate of  50-60%, while milk is just  32%. What they fail to point out is that 1/2 cup of broccoli contains 21 mg of calcium while 8 oz of nonfat milk contains 300 mg. That means from broccoli you get 11 mg of Calcium which is about 1 percent of the daily requirement. If you get non-calcium enriched milk you are still getting 100 mg of calcium or ten times the amount you would with broccoli.

Vegetarians may absorb less calcium than omnivores because they consume more plant products containing oxalic and phytic acids . Lacto-ovo vegetarians (who consume eggs and dairy) and non-vegetarians have similar calcium intakes. However, vegans, who eat no animal products and ovo-vegetarians (who eat eggs but no dairy products), might not obtain sufficient calcium because of their avoidance of dairy foods.

In the Oxford cohort of the European Prospective Investigation into Cancer and Nutrition, bone fracture risk was similar in meat eaters, fish eaters and vegetarians, but higher in vegans, likely due to their lower mean calcium intake.  It is difficult to assess the impact of vegetarian diets on calcium status because of the wide variety of eating practices and thus should be considered on a case by case basis.

(9) Fish and Beef have no fiber

Quite true- there is no fiber in meats. This is why a balanced diet contains fruits and vegetables. However, fish and beef contain better sources of fat absorbable vitamins, calcium, B12, protein, and other nutrients than vegetables do.

(10)  A skinless roasted chicken breast has more calories per ounce than soda or white rice

This is quite true- and mainly because of the fat content of the chicken. But chicken has more nutrients than white rice and more than soda.

PCRM also was responsible for the comments that E. Coli was found in many of the chicken products.  What they didn’t say was that the E. Coli they found were not the same as responsible for food borne illness.  In fact, the E. Coli they found was the kind commonly found in the soil, where the very plants grow that they advocate consuming. The pro-Vegan group also neglected to mention that the majority of Salmonella infections that have caused major outbreaks have come from agricultural products, including peanuts, that they advocate for a healthy diet.

It appears that PCRM is more propaganda than science. If you are going to advocate for a position, your position is diminished when you don’t tell the full story. If cornered in press conferences they avoid the answers to the questions. This is not a place to get information at all.

In the case of diet and lifestyle, there is a lot we do not know- but PCRM as a source of nutritional information is less than adequate, in that often it does not tell the whole story.  As a website for health and information it is more like a political party than a resource for those looking for evidence based medicine or science based medicine.

One of the misleading advertisements from PCRM

Do you think you know which of these is best for you?

What do we really know about fat?  About how fats react in the human body when they are eaten?  Government agencies make a lot of assumptions about fat, and they base that on the popular opinions of physicians and scientists who serve on their advisory committees.  Those recommendations are published, and then are used by many physicians, dieticians, nurses, and other health care professionals as a basis of what to recommend to patients.

But what if those experts got it wrong? When the latest data about fats is examined critically we find out that the recommendations made by those government agencies has no basis in the literature.  However, you will find those recommendations repeated as gospel in almost every website about what to eat and what is healthy for you, even the highly respected websites such as WebMD.com

In the March issue of Nutrition, a highly respected, peer-reviewed, academic publication,  Robert Hoenselaar outlines how the advisory committees not only got their advice wrong, but how they cherry-picked the data (Nutrition 28 (2012) 118-123, Saturated fat and cardiovascular disease: The discrepancy between the scientific literature and dietary advice).

Recommendations from the United States Department of Agriculture (USDA) and European Food Safety Authority (EFSA) regarding consumption of fat are similar

(a) Consume less than 10% of calories from saturated fatty acids by replacing them with monounsaturated and polyunsaturated fatty acids

(b) Keep the intake of saturated fatty acids as low as possible while consuming a nutritionally adequate diet

(c)  Saturated fat intake should be as low as possible

In 2003, a meta-analysis of over 50 trials was published examining the relationship of dietary fat to serum cholesterol levels (Mensink RP, Zock PL, Kester AD, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serumlipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr 2003;77:1146–55.).  The conclusion was that saturated fat increases the levels of low-density lipoprotein (LDL) and high-density lipoprotein (HDL) but without changing the ratio of total to the HDL cholesterol.   They concluded that using cholesterol alone as a marker of risk was unreliable. This was because if you replace the saturated fat with carbohydrates or tropical oils if you examine the effects on HDL and apolipoprotein B. They concluded that “… we can never be sure what such fats and oils do to coronary artery disease risk.” To translate that from doctor-scientist language: we can improve some laboratory markers, but really not by any mechanism that makes a difference from what we know.

While a systematic review of randomized trials showed that when saturated fats are replaced by polyunsaturated fats there is a reduction in the laboratory marker for risk of heart disease, there was no association with mortality from heart disease.  To emphasize this: the laboratory values of the patients studied improved, but their mortality didn’t. The review also showed that monounsaturated fat intake significantly increased cardiac events, but no effect from the intake of saturated or polyunsaturated fat. Let me emphasize that: Monounsaturated fats, by at least one study, not only didn’t improve issues with the heart- the patients in that study did worse.

When examining other prospective studies about the risk of saturated fat and cardiovascular disease, there has been a consistent lack of an association between fat intake and heart disease, stroke, or total cardiac events.

Cohort studies show that by replacement of saturated fats with unsaturated fats, or carbohydrates – and examining the hazard ratios for heart attacks and deaths from heart disease were as follows: 0.87 for polyunsaturated fat, 1.19 for monounsaturated fat, and 1.07 for carbohydrates.  For those not familiar with statistics, these are essentially no difference, and if these small statistical numbers are accepted than polyunsaturated fat shows an alarming trend. So here is a study that indicates (with as much precision as most studies these days) that polyunsaturated fats are worse for you than saturated fats.

There is a difference between protection against what we define as risk of heart disease and death from heart disease.  Risk reduction means that we lower the laboratory values of factors we associate with risk – but the end point is death.  In a meta-analysis published in 2010 (Ramsden CE, Hibbeln JR, Majchrzak SF, Davis JM. N-6 fatty acid-specific and mixed polyunsaturated dietary interventions have different effects on CHD risk: a meta-analysis of randomised controlled trials. Br J Nutr 2010;104:1586–600.) examined seven different trials, they found that there was a risk reduction but no change in mortality.  Another study (Skeaff CM, Miller J. Dietary fat and coronary heart disease: summary of evidence from prospective cohort and randomized controlled trials. Ann Nutr Metab 2009;55:173–201.  ) had eight trials found “There is probably no direct relation between total fat intake and risk of CHD (heart disease).”
The advise of the USDA is reflected in places like WebMD, recounted in public service commercials, and recited as gospel by health care workers everywhere.  Giving false impressions about what an appropriate diet is.

Many of us constantly look for the right things to eat, the right food to feed ourselves and our families.  For that information we choose what we consider informed sources about risk reduction. What we discover is that there is not a clear answer, at least not yet. The differences between these ingredients are not large enough in the studies performed for a reasonable person to make blanket statements.

The only statements about fat that can be made are that trans-fats are bad for a person.  Trans-fats are the fats found in stick margarine, most pastries, and fast foods – but rapidly being eliminated because of their clearly demonstrated bad effects.

Here is what we do know: eating too many calories, be it of fat, carbohydrates, protein, or alcohol will lead to excess weight, and excess weight is a contributor to heart disease, diabetes, and joint problems.

Eat healthy, fresh, delicious food — all in moderation.

The Paleolithic diet presumes that foods eaten during the stone-age (Paleolithic era from 2.5 million years ago to 10 thousand years ago) are optimal foods for humans. The Paleolithic (Paleo) diet includes grass fed beef and other lean meats, fish, shellfish, fruits, vegetables,  eggs, nuts, but no grains, no dairy, no salt, no refined fats (butter or margarine) and no sugar or high fructose corn syrup.

Fanatical Diet (Lifestyle types)
There are three things one should never discuss in polite company, religion, politics, and diet. Getting into an argument with proponents of diets is like a democrat trying to convince a republican that Obama is ok. Each side will quote their own studies, statistics, and population studies. But the key to scientific study of the various diets is not what we presume from correlation, but from what we learn when that diet is placed into patients – in this case, the laboratory values of those who have the diet.

Diet proponents become fanatical about their diet (lifestyle) to the point of religious fervor. Seeking to prove that their diet is backed by science, proponents use population studies with associations that are only suggestive and not proof of causation. These associations become propaganda as the associations are repeated over and over, morphing from a suggestion to “proof.”

The Flaws of population studies or Correlation does not equal causation
The foundation of many diets are based on the correlation of what a population eats and what diseases they suffer from. In the Paleo diet the assumption about what they ate and the diseases they suffered from is a spurious correlation at best, and far from causation.

Population studies are flawed, as often we find that we don’t know as much about the population as the data might suggest. Take the Pima Indians of the Southwest. In 1990 a paper came out stating that the Pima Indians had a low incidence of fatal coronary heart attacks in spite of having a high rate of diabetes. The Pima Indians were called among the most studied populations, with an NIH post in Phoenix, and lots of studies showing the highest rate of diabetes in the world. When the population was examined more carefully, the Pima Indians had plenty of heart disease.

Step back from the most studied group in the United States with great statistics and physicians trained in modern medicine and then imagine making conclusions about what Chinese eat, or Mediterranean’s, or French. Those assumptions are more flawed, as are the statements about what diseases they do or do not have. Now step back further trying to determine what people of the Stone Age ate, what diseases they had, and we leave the tenuous role of suggestion and enter the role of outright guessing. Even if we have reasonable data (and often we don’t – even for the best studied people in the United States) the correlation between what people eat as a cause for what diseases they have is a fundamental flaw. Correlation does not equal causation.

The Best Diet or Lifestyle is?
When it comes to the best diet plan for a person – we just don’t know enough to say that one is better than another. There isn’t enough evidence to state that the Paleolithic (also called Paleo) diet is better than the Ornish, Southbeach, Pritiken, or pick one, or better than how you currently live your life.

We cannot broadly say that any given diet will prevent heart disease, cancer, arthritis, or even obesity. When someone tells you a diet can prevent such, they have gone from the realm of science to the realm of bs.

The Paleo Diet Premise:
The Paleo diet premise is that we should avoid certain foods because our body is not evolved to process those foods, and if it does process them it will lead to the chronic diseases of modern man – heart disease, strokes, cancer. Cavemen didn’t have those diseases, so we should eat like cave men. Of course, we don’t know about what diseases that cavemen had – especially when it comes to organ and soft tissue diseases, we just have a few fossils that we examine and look for evidence of known diseases. Would coronary artery disease show up in a fossil – nope? Would cancer show up in the fossil – bone cancer would (kind of a rare cancer) or cancer that went to the bone might – but it would be hard to tell if the fossil evidence.

We do know, from many hunter-gathering societies, that they live a short life, and not long enough to develop the diseases we associate with aging. All a person has to do to pass on their genes is make it into puberty, and to be effective to nurture the young, into the 30′s, and to see grandchildren and help child raising – into the early 40′s. That is what a simple civilization needs. After that, in any primitive society, the elderly become a burden – perhaps to be placed on an ice flow. People who live into their 40′s and 50′s may die of cancer, heart disease, or obesity- but they will have passed on their genetic code.

The Evolution of Homo Sapiens:
When Homo Erectus came out of Africa, they encountered a world that was much more varied in food sources than Africa. The brain of the human (H. sapiens) evolved, becoming much larger, and utilizing far more energy than the brains of the Australopithecus – about 10 percent more. More than any other species, humans evolved a brain that required more calories- and our brain metabolism accounts for up to 25% of our energy needs. Bigger brains and its increased requirements mean a richer diet- and modern hunter gathering species derive about half of the energy from animal foods – in contrast with other primates that have far fewer animal foods. While our ancestors the Australopithecus dined on plant foods, and had large mouths to grind up fibrous plants – humans are built, with smaller faces and jaws, to dine on energy rich animal foods.

The reconstructed skull of Lucy, Australopithecus- large jar and muscles for eating plants

The Human skull is larger, larger brain- and jaws for more energy rich foods

Humans were successful, as the fossil record shows, because they were “flexible” eaters, using a wide variety of dietary strategies. If there were a lot of Elk, then we ate elk- berries, we picked berries. To state that our digestive system evolved only to eat some few items found in the Stone Age – has been disproven on the face of it. Our ancestors in Africa didn’t encounter Arctic char, whales, seals, salmon – and yet when they moved from that warm climate to the frozen north, they adapted quite well to a very high fat diet of primarily animal based diet that was clearly not available in Africa. The findings of starch grains from wild plants in grinding tools from sites in Italy, Russia, and the Czech Republic from the mid-upper Paleolithic era suggest that the production of flour was present 30,000 years ago.

Contrary to what Paleo proponents state: people made flour 30,000 years ago

How to eat like a caveman
There are some things about the Paleo diet that people avoid:

Excess sugars including fructose
Excess Omega 6 oils – including soy
Processed wheat, grains, and gluten
Dairy

What is the scientific evidence for this? It’s the simple premise that modern man has lifestyle illness from altering food, taking in too many calories, and if we would return to our ancestors roots (pun intended) we would avoid these highly processed foods and not suffer from the holy trinity of diabetes, obesity, heart disease, and maybe even cancer. There is not a single shred of evidence to support the premise of this diet.

An entire dietary regimen has been formed with plenty of books and websites to guide you through this. It has become so popular that the question becomes not the flawed premise for the diet, but rather how the diet would compare to other diets. If you want to eat like a caveman, then shop on the outside of your grocery store.  Everything on the inside of your grocery store is generally processed foods, and everything on the periphery of the grocery store is generally not processed.  On the periphery you will find the vegetables, fruits, meat counter, fish counter – although you might get in trouble with dairy, and before you check out they might have a cookie or two – or there might be a bakery (a big no no among the non-Geico types). But lets be clear- whatever the caveman could get that they could eat- they would eat, and if a caveman were to be around today- wait, we have them – well, they eat Poptarts.

In one real scientific study patients with known heart disease who were randomized to either the Mediterranean-like diet (based on whole grains, low fat dairy products, fish, fruit, and vegetables) or the Paleolithic diet (no grains or dairy but plenty of lean meat, fish, fruits, vegetables, root vegetables, eggs, and nuts) and those who undertook the Paleolithic diet were satisfied with less food. There was also a decrease in leptin in the Paleolithic group by 31% and by 18% in the Mediterranean group.

There have been other studies that show that people who go with this diet have improved laboratory values – less triglycerides, lower blood pressure, some weight loss, that the diet has a better glycemic index (the food doesn’t increase blood glucose levels as much). This diet compared to a standard diabetic diet did better. Those studies are short term, with small numbers of individuals, and hints of laboratory values.

So before one assumes I am putting this diet plan into the trash bit along with Ornish- there is clearly some data here that shows good nutritional sense in the food.

While highly processed carbohydrates transiently increases blood glucose levels more than whole grains – it does not mean that bread is bad for a person. At least we don’t know enough about this to state that today. Clearly, people who eat a lot of flour based products can get fat quickly, and getting off the bread and bakery products will help reduce weight, decrease hemoglobin A1C levels, decrease triglycerides, and overall be healthy.  Some people need to be told to never eat them again – as some alcoholics must never drink again- and some people are able to moderate them so they do minimal damage to the body.

Only a few studies have examined the effects of the Paleolithic diet on laboratory values that we associate as increased risk for disease – but again, those were laboratory values, not a long-term follow up for disease.

The premise for the Paleo diet may be flawed, but here are the parts of the Paleo diet that most would agree with:

(a) Highly processed grains – white flour, rolled oats- do cause a rapid increase in blood glucose levels and the body responds to that by increasing triglycerides and ultimately fat.
(b) Fish – as long as it is not contaminated with mercury, is a protein source that is high in Omega 3 fatty acids, which have been shown to be beneficial. If you have some great fish three or four meals a week it works out well.
(c) Vegetables and fruits are the basis for most diets- thus a vegetarian could participate in a Paleo diet easily. Too many people do not eat enough fruits or vegetables or look to them as snacks.
(d) The trend away from cattle feedlots and desire to have grass fed rather than grain fed beef. Grain fed beef is fatter and more prone to being infected with Salmonella or E.Coli than grass fed beef.  There is a wider variety of taste with grass fed beef, and most who find grass fed beef end up preferring its flavor. Grass fed beef is best cooked with Sous Vide cooking.
(e) If you eat more calories than you burn you will gain weight. But it is more than just calories – it is also the types of calories. Eating high glycemic index foods mean you will spike glucose pushing it into cells, where it will be quickly transformed and stored as fat. Low glycemic index foods will be slowly burned  - thus, calorie for calorie with the Paleo diet plan you will tend to burn the fuel from the food as opposed to store it.
(f) If you eat a majority of your food with highly processed grains instead of whole grains you will have a faster rise in blood sugar. Some attribute this rise to increased obesity and an increased load on the pancreas.

Overall- this is not a bad diet program. Nothing in it would appear to cause nutrient deficiencies and there is some preliminary evidence that this diet keeps a person more satisfied with less food. It is a low-carbohydrate diet, and those diets, in comparison to other diets, tend to produce faster and longer weigh loss.

Here are a few scientific references- I’m sure we will add more as time goes on

Low incidence of fatal coronary heart disease in Pima Indians despite high prevalence of non-insulin-dependent diabetes. RG Nelson, ML Sievers, WC Knowler, BA Swinburn, DJ Pettitt, MF Saad, IM Liebow, BV Howard, and PH Bennett
Circulation. 1990;81:987-995

Food for Thought: Dietary change was a driving force in human evolution. Wm R Leonard. Scientific American. December 2002: 107-114.

A Paleolithic diet is more satiating per calorie than a Mediterranean-like diet in inviduals with ischemic heart disease. Jonsson, et. Al. Nutrition & Metabolism 2010, 7:85

Thirty thousand-year-old evidence of plant food processing. A Revedin, et al Proc. Nat. Acad. Sci, November 2010: 107:18815-18819

Heart disease happens when the arteries feeding the heart become infiltrated with plaques – and these plaques happen to contain fat, cholesterol, white blood cells. If the plaque builds up slowly the flow of blood to the heart diminishes and people develop chest pain or angina. If that plaque ruptures and causes the artery to close- that is a heart attack or myocardial infarction.

Plaque formation was thought to be because of a person’s diet – since the plaques had high levels of fat and cholesterol, it was thought that a diet that was low in fat and cholesterol would minimize a person’s risk of heart disease. Sometimes that is true- but not always- as the French have shown us- with a diet high in fat and cholesterol and one of the lowest levels of heart disease in the western world.

It turns out the instigator of plaque formation are the lipo-proteins that carry cholesterol and triglycerides. Think of LDL, HDL, VLDL, and IDL (low density lipoprotein, high density lipoprotein, very low density lipoprotein, and intermediate density lipoproteins) as boxcars that carry cholesterol and triglycerides. Those lipoproteins set off an inflammatory reaction in the blood vessel (they become oxidized) and that leads to plaque formation. The more of those proteins a person has, the higher the likelihood that they will develop heart disease.

Think of LDL as “lousy.” The HDL levels are associated with fewer tendencies for heart disease – but they still can cause inflammation of the artery, and a problem. Hence, artificially raising HDL levels causes more issues with heart disease (as was recently discovered in the niacin trials). HDL levels are seen in people who have more omega-3 fatty acids in their diets, but increasing their levels is still harmful.

The more lipoproteins your body makes the higher incidence of heart disease you will have.

It has only been recently that science has recognized that one must measure the lipoproteins directly. Not indirectly by measuring cholesterol – as the laboratories do today. In the recent article from the Journal of the American Medical Association, they measured LDL-cholesterol in people placed on diets rich in soy proteins, fiber, and walnuts – showing a decrease in the LDL-cholesterol – a classic mistake. LDL-cholesterol does not measure the total number of lipoproteins. The amount of lipoproteins one has depends on how much cholesterol and triglycerides the lipoproteins have to carry. If a person has a lot of cholesterol and/or triglycerides in the blood the body will make more lipoproteins. If you have too many, those lipoproteins will get into the wall of the artery and lay down their cholesterol and triglycerides (which are fats).

If you have a lot of triglycerides it will bump off the cholesterol and you will make more proteins to carry the triglycerides. Your cholesterol level will be low, but your number of lipoproteins will be high- and thus, even with low cholesterol you will have a high incidence of heart disease. This explains some of the seemingly contradictory data of people who had low LDL-cholesterol levels but a higher incidence of heart disease – when that blood was looked at later they were found to have a high level of the LDL proteins.

We still don’t understand everything about the biology of the formation of plaque but we do know this: genetics determines most of the level of cholesterol, and if your level is high reducing it with medication will reduce the incidence of heart attacks and strokes. If you have genetically high triglyceride levels, the same applies.

In terms of diet- dietary cholesterol has minimal impact on blood cholesterol. Triglyceride level can be greatly impacted by diet – however.

To reduce triglycerides in your diet, here are some suggestions:

* Eat fewer calories if you are overweight. Excess calories are converted into triglycerides and stored as fat.
* Avoid trans fats, found in some fried foods and commercial baked products.
* Replace saturated fat (found in animal fat and some tropical oils) for mono-unsaturated fat (found in olive/canola/peanut oils, etc.).
* Consume at least 2 servings of cold water fish each week, such as salmon, mackerel, tuna, lake trout, herring, and sardines (all of which are high in omega-3-fatty acid). *Include into your diet other foods high in omega-3 fatty acid, such as ground/milled flaxseed, walnuts, almonds, canola or soybean oil, etc.
* Avoid refined foods and foods that contain sugar (such as white flour, desserts, candy, juices, fruit drinks).
* Choose carbohydrates that have 2 grams fiber or more per serving, such as brown rice, whole wheat bread, and whole grain cereals.
* Consume at least 2-3 cups of vegetables and 1 cup of fruit each day.
* Follow your doctor’s advice regarding alcohol. Alcohol increases triglyceride levels for some individuals. If you have high triglycerides and do consume alcohol (such as red wine), it is recommended to limit intake to 5 ounces per day or limit it entirely.
* Exercise to burn excess calories, aiming for at least 30 minutes of physical activity on most days of the week.

Medications
People who have high triglycerides and low HDL or high LDL levels may require medications as well as diet modifications. Patients with triglycerides in the very high range (over 500 mg/dL) generally will require medications, because triglyceride levels this high may cause an acute inflammation of the pancreas.

Making changes in what you eat on a day-by-day basis can make a profound difference over time about how you eat. Here are a few examples of trading up for health:

Years ago I use to have a hamburger and French fries for lunch, almost every day. The first trade up was to get rid of the French Fries. That represented 600 calories a day. Over the course of 5 days that was 3000 calories – almost one pound of fat. In three months I lost five pounds. Eventually, the hamburger went, and was replaced with a home-made chicken salad, much healthier, because I was able to include items with increased micro-nutrients.

Another patient of mine struggled with weight loss and finally realized she was drinking wine every night: 3-4 glasses. First she dropped to no more than two glasses and over two months lost 6 pounds. This last year she changed her habit from having two glasses of wine a night. Here’s what she said:

“I would come home every night and want a glass to relax. Then you talked to me about smoothies, and making my own. So I started making a simple smoothie with berries, yogurt, some flax seed, and fiber. I noticed after I drank it I felt more refreshed, and was in a better place to make dinner. I had more energy – and best of all, I lost another 10 pounds in two months and have kept it off.”

She traded alcohol, and its calories, for berries rich in fiber, vitamins, antioxidants, and the flax seed with omega-3 fatty acids. It was also a way to get more fiber in her diet.

Trading up to better food, to better quality food, means that you can enjoy life more. It gives you a chance to incorporate some of the micro-nutrients that you might be missing. Ultimately you are empowering yourself for your own health.

Nothing tastes as good as healthy food, and nothing tastes as good as slender feels.

Smoothies make a great afternoon snack, too. Especially the time of day when you’ve just gotten home from work, you’re not ready for dinner, but your body needs a little “something.” Or an afternoon snack when you know you are not going to dinner for a while but want something that tastes pretty good.

I like making smoothies, because with them I know I can get into my body the things that I may not get in my daily diet. It allows me to pack in some healthy components, and here are a few things that I keep next to my blender that are important to my morning routine.

Fiber:

Fiber is material that the body does not digest in the guts. It helps keep people “regular” – and that means it will bulk things up. Fiber was once thought to prevent colon cancer, but that is not true. What it can prevent is diverticulosis (a disease of the colon where sometimes we have to perform a colostomy and remove part of the colon). Fiber can also prevent hemorrhoids (and if you have them it can help get rid of them).

The American Dietetic society recommends adults get 21 – 38 grams of fiber a day – and most get less than half of that amount. The best sources of fiber are vegetables, beans, fruits, and whole grains. Fiber adds bulk to the diet – and can make you feel satisfied for a long period of time.

I like adding fiber to supplement my diet, and there are a whole bunch of these products on the market. Some of them can cause gas – so I prefer those that do not – like Citrucel. Adding Citrucel to a smoothie gives me a boost of fiber and “keeps me going.” This type of fiber is called methyl-cellulose. It is found commonly in plants – and your body doesn’t digest it, but it acts as a broom to clean things out.

Flaxseed Grain:

Flaxseed is a grain that is high in Omega 3 fatty acids, that may help reduce the risk of heart disease. These are healthy fatty acids that help reduce total blood cholesterol and low-density lipoprotein (LDL, or “bad”) cholesterol. Think of your blood vessels like plumbing. Over time they get clogged with things like low-density lipoprotein (LDL). Think of Omega-3 fatty acids as the Drano for your plumbing. While you want to avoid putting things in that will clog those arteries, you also need some help getting rid of old bad habits. The whole grain is not always digested – so I prefer ground flaxseed. I typically add a tablespoon of this to the smoothie.

Whey Protein:

Protein isn’t always needed in a smoothie- especially if you are getting enough protein from your regular diet. But if you need some protein, a whey based protein is helpful. I use a product called Unjury. This is a medical protein that you can purchase online. We use that because it is the tastiest of the proteins out there (based on a taste test of my patients). It also has no added calories. Some of the flavored proteins also add a bit of different tastes to the smoothie, and the protein gives the smoothie a nice consistency and flavor.

Splenda:

Artificial sweeteners are either the saving grace of America, or the cause of evil. My basic take on sweeteners is that you should use natural food, and not artificial sweeteners. The first issue with artificial sweeteners came to light when cyclamates were found to cause cancer in rats. So in 1969 cyclamates were taken off the market. Saccharin was the next agent, but many didn’t like its after taste. Then came aspartame (Equal). This had no bitter after taste and became the favorite until someone started a rumor that aspartame killed ants, and was originally used as a rat poison. This is untrue on both counts. First, aspartame was developed as an artificial sweetener and second, it does not kill ants (I tried it, as have a lot of others – sadly it doesn’t work).

Splenda does contain calories (because of our FDA regulations it is allowed to be listed as “zero calories” but it is not). Splenda has 3.36 calories per packet (1 gram). It tastes like sugar- is made from sugar – and is generally easy to deal with. Two other sweeteners have joined the market in the United States. Stevia is a product of several plants and was recently approved as a food additive in the United States, and Truvia (a proprietary blend of Stevia made by Coca-Cola and Cargill the Pepsi produce it PureVia). These are essentially all the same. There are some other sugar-alcohols like Xylitol that work.

The issue with artificial sweeteners has been getting used to the sweet taste, and increase in appetite. In rats that are consuming artificial sweeteners, there is an increase in their body weight over time as they increase the amount of food they consume. Not that we are rats, but avoiding the sweet taste is important. And it’s no accident that while many of my weight loss patients consumes large quantities of “diet cola,” they still consume a lot of calories to go with the diet soda. It is also no accident that once our patients get off artificial sweeteners, they do much better.

Overall, avoid the artificial sweeteners. But when it comes to smoothies, you can add just a bit. Want to know what’s even better than Splenda (which I only use for very tart berries) ? BLUEBERRIES – a great natural sweetener.

Strawberry Smoothie

There is nothing like a smoothie to start the day, and sometimes when I first walk in the door from the office. Waking up after a night of sleep means you need some fluid – just like after a long day of work! So having a smoothie is quick and easy. The addition of some protein powder and fiber makes this a great start to the day (or end of the day).

1 ounce of Vanilla Whey (I use Unjury from unjury.com – it is a medical protein)

1 cup of frozen strawberries

4 ounces of plain Greek yogurt

1 tablespoon of sugar free Citrucel (fiber supplement)

1 cup of water

2 tablespoons of Splenda

Blend in a blender until smooth. It makes two servings

144 calories, 22 g protein, 0.1 g fat, 0 cholesterol, 4.15 gm of fiber

A word about blenders: There are lots of them on the market. Get a good one. Most professional chefs have a Vitamix in their kitchens at home and at work. They are expensive, but they are worth the extra money, and they have a wide range of things to do besides crush ice for the margarita.

For a while it seemed that everyone was talking about the importance of fiber,  and its role in preventing a variety of diseases.  After much speculation, we now have a few answers about  what fiber really does, and what makes it an  important component of good nutrition.

Fiber is simply things that humans cannot digest.  Many vegetables and fruit have methylcellulose – the stringy stuff– and we, as humans cannot digest it.  Cows can, horses can, deer can – but not humans.  This is why it is better to cook vegetables – because by breaking down some of the fiber our bodies can get to the nutrients that are locked into the vegetables.

What we do with it is simply pass the material through our body.  If you don’t have enough fiber you can become constipated – and develop things like hemorrhoids or diverticulosis.  Fiber is also good if you have chronically loose bowel movements – it will help bulk up the stools.

Years ago a group of people thought increased fiber would lead to less colon cancer – -with the theory that fiber acts as a broom to sweep out the colon and thus keep the colon from being in contact with toxic stool.  Well- that has been tested in a number of places and just isn’t the case.  Even people with high fiber diets have no lower incidence of colon cancer than those with an average fiber diet.

Some thought fiber would increase the metabolism – so by taking more fiber in you would be able to loose weight.  That was proved to be incorrect also.

What is known is that the more bulk fiber you have- from fruits and vegetables- with higher fiber — the longer the sense of feeling full is.

This is why we recommend to patients to increase green vegetables, or squash, or beans – to increase their fiber – and to keep them feeling full for a longer period of time.

So- if you want to lose weight- increase your fiber and decrease your processed food.  If you suffer from chronic hemorrhoids – see your doctor- but before then start on a high fiber diet (I recommend to my patients they take a scoop of fiber in 12 ounces of water followed by 12 more ounces of water).

Find yourself hungry mid-afternoon — consider a high fiber snack – like fruits.

So fiber has a lot of advantages – and the best source of fiber — vegetables

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