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

One of my favorite chefs – Gordon Ramsay, talking about eggs and a few other things.

Scrambled eggs:

When I first started out in life working in a kitchen one of my jobs was to crack eggs and put them into a large container and then when someone ordered eggs they would be ladled onto a hot griddle and in a minute an order of scrambled eggs would be ready. Turns out, most kitchens make eggs the same way — a hot griddle, very little time, and a fast breakfast.

Fast food eggs are made over too hot a griddle yielding rubbery consistency

Two problems- the eggs have been heated so fast, that the proteins have lost most of their water giving the eggs the consistency of rubber and second, the eggs don’t taste that great.

When my patients who had LAP-BAND surgery complained that eggs became stuck above there band – it was quite clear- they were either making them to hot and fast, or getting them from a restaurant that was doing the same.

Here is the secret to all eggs — think of eggs like sex – you want it slow. When you were a kid, fast may have been ok but now you are an adult- time to earn how to make them.

The perfect scrambled egg has the consistency of custard or yogurt. They are not hard, rubbery, or dried out. Egg whites are a protein called albumin – and like all proteins, when given a high heat they tend to denature (our scientific term) — or lose their water and become curdled, hard, and more akin to eating a wad of bubble gum than the nice custard we desire.

Ingredients:

4 large Eggs
1 T butter – UNSALTED

First DO NOT whisk the eggs together ahead of time. Do this under some heat – and gently. Whisking eggs together begins a mechanical breakdown of the proteins that will result in more rubbery consistency.

Place a non stick fry pan on a low heat. Take a teaspoon of butter and gently coat the bottom of the pan. If the butter can melt – then place four eggs in the pan. Using a silicone spatula gently break the yolks and fold the eggs together. Gently stir the eggs – and every minute take the pan off the heat and continue to stir the eggs. Once the eggs “set” – or are a wet consistency when they are giving off a bit of steam – take them off the heat for the last time. Take the remaining 2 teaspoons of butter and fold them into the eggs. You will see the heat from the pan will continue to SLOWLY cook the eggs. As you stir in the butter the creamy texture of the eggs will form- once they are to that point, remove them from the pan and serve them.

At this point add salt and pepper to taste – not before. If you add salt to the eggs before the mechanical action of the salt, combined with the drying property will pull the water out of the eggs.

There you have it- the pefect scrambled eggs. Want to add some ingredients – I recommend Salsa instead of cheese- more flavor, and far fewer calories than fat.

Two servings if you are trying to lose weight and one serving if you want to gain weight.

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

Dr. Esselstyn noted the risk of heart disease in rural China was low in the 1970’s – and presumed that they didn’t have a “western diet.” Now there are two flaws in his population statistics: First in the 1970’s in rural China most individuals were starving to death – it was the end of the cultural revolution and any source of food that could be found and eaten was. The second issue is if you examine data from The China Study you will see that heart disease mortality was lowest in the rural communities that were able to eat more meat. In The China Study (again, I promise this will be a topic later) – they used mortality statistics from the time during the end of the Cultural Revolution. Rural China was starving then, all trees had been used for fuel, there were virtually no birds left (combination of deforestation and hungry humans) and rice was used for the army.

Dr. Esselstyn then talks about Norway during World War 2, when they were occupied by the Nazi Germany, and how that heart disease diminished as the Norske were forced to eat a plant based diet. That was a great assumption to make, but when examining the data from Norway there are a few interesting factoids – Meat consumption dropped 60% but fish increased 200 per cent. Vegetables and potatoes increased but sugar decreased by half. And when the data is put to a microscope in 1942 and 1943 when mortality declined, animal proteins were still higher than before the war. It appears that Norway suffered from increasing fish (great source of Omega 3 fatty acids) and foraged for foods such as wild greens, grew and ate a lot of potatoes, but had a low amount of sugars and almost no margarine (I don’t know a respectable Norwegian today who cooks with margarine). The sad part of the war was the increase of mortality from infectious diseases – especially pneumonia (my mother’s cousin who fought for the resistance died of this, as did many of his comrades).

Norway in WW2 ate a lot of fish- and this roe was popular

He followed these patients for up to 12 years – his numbers are confusing as he started with 24 patients and six dropped out (leaving 18). One of the 18 died from his heart disease (leaving 17). At ten years there were 11 patients. They did angiography and reported a regression of 11 lesions with 14 remaining stable.

Angiogram- xray - of a plaque. Not enough to do surgery on though

When any study talks about a “cardiac event” it means to most of us a heart attack. If you have a small lesion in a coronary artery and then that lesion accumulates a blood clot that is what a heart attack is. The blood clot (from platelets – a sticky component of blood that helps you clot ) blocks the flow of blood to the heart muscle. If the clot blocks blood flow for a long time then the heart muscle dies and you have a myocardial infarction, if it opens up then all you have is a heart attack. This has little to do with the size of the lesion, and more to do with the complex chemistry of the coagulation system. Hence, taking aspirin a day or Plavix is more beneficial.

The other major problem with the study is that these individuals were on lipid lowering medications. Dietary reduction of lipid level (Cholesterol and lipoproteins such as VLDL, HDL) is about ten per cent on average, but never more than twenty per cent. However, lipid-lowering medications – such as Crestor – can remarkably lower levels of the lipids. In addition, lipid-lowering medications are best for reducing inflammation. They are anti-inflammatory to blood vessels, meaning in addition to lowering the lipids and cholesterol, their main effect is to reduce the chance of having a “coronary event.”

Crestor shown to be effective at decreasing the plaque in arteries

One of my cousins, preventing heart disease and eating fat

Mom prefers Sous Vide to the traditional roasted turkey

Thanksgiving is my favorite holiday- for so many reasons. But the turkey can be a pain — a pain to make properly, and then a pain because you have so much of it that one tires of turkey leftovers after a day or so.  The answer- making Turkey Sous Vide.

Sous Vide is a method of cooking that we have advocated for a while.  Don’t have a Sous Vide machine? Treat yourself and start changing the way you cook. It allows low temperature cooking, so that the meats are not overly dry. The most common reason people go to an emergency room on Thanksgiving is they get a piece of dry turkey caught in their throat. With Sous Vide, the turkey won’t be dry (of course, if you swallow too large a piece it can still get stuck).

The previous posts have talked about Sous Vide but there are a number of places that sell the equipment for the home cook to do Sous Vide cooking easily.  Most people need to get a water oven and a machine that does vacuum sealing of the food.  You can use the link above to purchase the Sous Vide machine, or you can find them at places like  Sur Le Table and William-Sonoma.  Mine was purchased from William-Sonoma and I have demonstrated its use at their stores.

Turkey

The first key is to butcher the turkey into its parts.  This makes the bird manageable.  As  you can see from the video, I love to do that myself, but if you have a good butcher they will do that for you. You can also purchase the pieces individually from the butcher if you like.  Some purchase just breast, some thighs.  It is cheaper to purchase the entire bird, though, and have the butcher break down the bird, including splitting the breasts.

This allows the turkey parts to be cooked at temperatures and times individually for them. It also allows you to cook the entire turkey Sous Vide and those parts you won’t use can be frozen for up to six months (avoiding those many recipes for turkey soups, turkey casseroles, and turkey curry).

To Brine or not Brine

Many talk about placing the turkey into a brine in order to help the turkey stay moist through cooking.  The brine has little to do with a turkey being moist. A brine is a solution of salty water, and some place other herbs and sugar in it- that draws water out of the turkey, especially the skin. It does not make the turkey more moist when cooking it.  Over cooking turkey in an oven is easy- over cooking turkey Sous Vide is impossible.

I find brines and marinades to be messy.  But having a turkey broken down into its parts makes it easier to handle.

Instead consider seasoning the turkey with Kosher Salt for a day. Less messy than making up a brine.  Salting the turkey helps the skin become crisp.

Seasoning the turkey:

A simple salt and pepper seasoning works well on the turkey. You won’t need olive oil on it, and we will take care of that great herb flavor with our cachet of herbs.  Salt and pepper the skin.  There are a number of poultry rubs available- and you may prefer those.

Herbs:

With Sous Vide the best way to permeate the turkey with sage, rosemary, thyme, and even basil if you like- is to roll these up in a plastic wrap. Cut off both ends and drop this into the bag.  If you put the herbs in directly there will be bits of turkey that will have intense flavor, and other bits that have none.

Duck Fat or Butter:

Placing either duck fat or butter in the bag will bathe the turkey during the time it is in the water oven. Some prefer one over the other- some even use a bit of olive oil. Butter is easy because it is solid at room temperature and melts nicely in the water oven.  Duck Fat, if kept in the refrigerator is solid at cool temperatures also.  Olive oil isn’t solid at room temperature and may be pulled out by the vacuum sealer, unless you are careful.

Water Oven Time:

Once sealed, they can be placed into the water bath kept at 150 degrees F.  Breast is done in 2.5 hours, thighs about 2 hours. They can stay in for longer- so if the guests are not quite ready, you can relax knowing that the turkey will not over cook.

Simple Sear:

When you are ready, have a hot grill to sear the turkey skin and provide that crispness to it. Whether you use a grill, grill pan, or hot oil – it is only two minutes a side.

Pre-Left overs:

If you find that you will have more turkey than you need- leave the turkey in the vacuum sealed bag. Put it into an ice bath immediately to stop the cooking and cool it down. Then freeze it. The turkey will be ok for up to six months.  Three months after last Thanksgiving we placed turkey breast back into the Sous Vide for 30 minutes to “re-warm” it (an oven, microwave, or stove will dry it out) – and had the most delicious, most amazing turkey breast — far better for sandwiches than anything you could purchase.
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Want to smell that stuffing– simple- make your favorite stuffing and bake it– the house will smell like thanksgiving and no choking on dry turkey!

Sometimes all you want for breakfast is a cup of coffee-- and that's ok

Everyone knows:  Always   eat Breakfast

There   are   a lot   of   variations   of   this   axiom.

“Breakfast   is   the   most   important   meal   of   the day.”

“Breakfast makes it so you won’t be hungry later.”

“Breakfast jump starts your metabolism”

“You need to eat a large breakfast”

“Breakfast   is   the   most   important   meal   of   the day.”

All of those are FALSE.

Breakfast is NOT the most important meal of the day- so don’t force it. The reality is that most people are not ready to eat breakfast when they first wake up.  So why does “everyone” say this? Some of this data was based on the Iowa Breakfast study- which was more than a single paper- but a group of observations made over a number of years and published. There have been a number of other studies showing that kids who eat breakfast do better in school than kids who do not. However, there are a lot of variables not accounted for in those studies.

In addition- a few other items were not taken into account: if you wake up at 4 am to do chores until 7 am, then have breakfast and go to school, you will do better in school than someone who wakes up at 4 am, does chores and doesn’t get breakfast.

Regarding most breakfast studies — funded by, and poor research  done, from cereal companies. Doesn’t mean they are bad studies- but they all fall into poor categories of evidenced based research.

“Breakfast makes it so you won’t be hungry later.”

A recent study showed that people who eat a large breakfast are not affected by how much they eat later in the day. Meaning that eating a large breakfast won’t keep you from snacking, or eating less the rest of the day.

You wonder where people come up with this idea– but when it is put to the scientific test- the breakfast you consume does not reduce food you consume later. Not one bit. No relation- no correlation.

Breafast buffet is not your friend

“Breakfast jump starts your metabolism”

They also found that eating less in the morning contributed to overall weight loss (if you eat less calories you will lose more weight).  There is a simple truth about weight loss – if you eat more calories than you burn, you will gain weight. If you eat big breakfasts and lots of other calories you will gain weight.  Breakfast does not jump start your metabolism- your body does that.

Again- how would you measure a “jump start” to metabolism? There are ways- but activity itself increases heart rate, breathing, and over all muscle activity. If you take comatose patients and measure their oxygen consumption and carbon dioxide production- and cycle feeds – the feeds do not increase metabolism. Another study took college football players and put them into a hospital and fed them. They were allowed to do a few walks- but not much more.  It was activity that increased metabolism- not food. Any food will increase some metabolism – but a breaking of the fast does NOT do any sort of jump start.

“You need to eat a large breakfast”

Want to just have a smoothie or yogurt or some oatmeal to start your day? Go ahead. You want to wait for a couple of hours after you get up before having something to eat- that works too. But if you eat a large breakfast – you still need to work off those calories.

You think this is an important meal?

The great thing about breakfast foods: You can eat them anytime! Who doesn’t like eggs for dinner? And after a long day- nothing is more refreshing than a blueberry smoothie to take the edge off hunger, and let you relax for a bit.  We have recipes for smoothies containing micronutrients, fibers, and supplements – a simple smoothie can be a pleasant treat after a long day of work, taking the edge off hunger so you can make a great dinner.

For the smoothie and other recipes go to terrysimpson.com

Artificial sweeteners are either the saving grace of America, or the devil. The first issue with artificial sweeteners came to light when cyclamates (the first marketed artificial sweeteners) 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 developed 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 and is generally easy to cook with – however; one package of Splenda is 600 times sweeter than an equal amount of sugar.

Two other sweeteners have joined the market in the United Sates. 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 function as sweeteners.

The issue with artificial sweeteners has been getting use to the sweet taste, and thus an 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 overly sweet taste is important. And there is 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 them. It is also no accident that once our patients get off artificial sweeteners, they lose more weight.

People who drink sodas that have artificial sweeteners have a sixty percent increase in stroke and heart disease. Sixty percent!

How do you gain weight with artificial sweeteners? Since they are so sweet, you naturally want food to balance out the sweetness. Increasing the quantity of food allows you to increase the bitter, sour, and other sensations to balance the sweet taste. Remember, your palate always wants to return to a balance.

Overall –avoid the artificial sweeteners. Still- what is better than artificial sweeteners in soda? Simple water. It is free (unless you are in a city where the water tastes bad) and is regulated more tightly than most things

Imagine a way that the government could reduce the level of obesity and it would cost nothing.  The government had that chance- and they blew it.

The US Department of Agriculture denied a request by New York State to run a pilot program where the city of New York would not allow people to purchase soda, or other sugar sweetened beverages, using food stamps. There are at least seven other states requesting such pilot programs.

It is not surprising that the opposition to this proposal came from the beverage industry who said, “It’s another attempt for government to tell people what they can and can’t drink. Singling out one specific item is discriminatory and unfair.”

Really? No one is saying they can’t drink soda – simply that the government won’t purchase items that are not in line with the intent of the food stamp program which is, “to provide for improved levels of nutrition among low-income people each month.”

The USDA said that city retailers would not be prepared to implement the new policy.  The food stamp program is run with a debit-style card. If a beneficiary is purchasing items from the grocery store not covered by food stamps, such as tobacco or alcohol, the cashier collects the money for those items after the food is deducted.

The original Food Stamp Act prohibited purchase of “soft drinks,” but that was changed because of regulatory issues-, which are now overcome thanks to technology. In fact, New York City officials stated that the “program’s electronic benefit card looks and acts like a credit or debit card” and that it only covers “some of the items in a typical s hopping cart, so program participants are already accustomed to supplementing their purchases with personal funds.”

The USDA also said “the proposal lacked rigorous methods to asses changes in sugar sweetened beverage consumption resulting from the new policy and the effects of those changes on obesity and health.”  A pilot program doesn’t have to prove that sugar sweetened beverages are not “food.” Even the original act prohibited these items.

The government purchases millions of gallons of sugar laden drinks for food stamp holders every day. Obesity is the number two killer in the United States – and by denying this simple pilot program are paying for obesity.  Preventing obesity costs nothing – paying for the effects of obesity costs everything.

References:

US Department of Agriculture. The Food Stampe Act of 1964. http://www.fns.usda.gov/snap/rules/Legislation/pdfs/PL_88-525.pdf.

Jessica Shahan, Associate-Administrator, Supplemental Nutrition Assistance Program, USDA, to Elizabeth Berlin, Executive Deputy Commissioner, New York State Office of Temporary Disability Assistance. August 19, 2011.

Scott-Thomas C. Food stamp soda exemption in NYC is discriminatory, says industry. Food Navigator-USA. May 5, 2011. http://www.foodnavgator-usa.com/Business/Food-Stamp-soda-exemption-in-NYC-is-discriminatory-syas-industry

JAMA, September 28, 2011 Vol 306, No. 12 page 1370-1371