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

For real science- we are juggling what we eat to find the best fit

Re-reading the study about red meat and its increase in mortality, I continue to go back to the gold standard of lifestyle epidemiology- smoking.  People who smoke one pack of cigarettes a day have a 20-fold increase in lung cancer. 86% of all lung cancers in the United States occur with smokers, or ex-smokers.  One can reverse prove this- people who quit smoking decreased their risk of heart disease as well as lung cancer for every year they had stopped. This was the gold standard that all other lifestyle researchers are trying to find. After smoking the next great one was second-hand smoke, and sadly the correlations between mortality and second-hand smoke fell apart – although that did not stop public statements.

Still others try to find that meat, or fat, or carbs, or something causes an increase in the rate of death. So what did is the real red meat of this study (sorry).

What this paper discovered was that the increased risk is that less than one person in one hundred died (less than 0.2% with heart disease and 0.32% with cancer – as opposed to the gold standard of a 20 fold difference).  Let us put this into the context that the article did not, and that most media did not – that one person in one hundred over a 28 year period who died also smoke more, drank more, had less physical activity, and was obese.

The article states they did a multivariate analysis to adjust for age, race, smoking, drinking, activity, caloric intake, and obesity – and removing those factors they still have, in the highest quartile, the increased rate of death with less than a 1.2 fold difference (compared to 20 fold for smoking and lung cancer).  For those of you not statistically or mathematically prone, this simply means they found a way to negate the influence of each of those factors so that the simple and singular analysis of each quartile (quartile one being the lowest meat eaters and quartile 5 being the largest consumers of meat) stands alone. They do not show us this data – we just take them at their word that this person who died, the one person in 100 in 28 years, who drank more, smoked more, was obese, did minimal physical activity, and ate more meat- died because they ate more meat.

Some nutritionists think we should graze on plants

Does this study really tell us that substituting one meat free meal a week will decrease mortality? Not really.  This was a statistical trick to take the people from one quartile to another- and in that they reduced risk.

If you examine the raw data, without statistical manipulations- you find that death rates go down with increased meat consumption until the fourth and fifth quartile.

Does this article shed light on how we should eat or what we should eat? No, it does not. In fact, this article is a statistical nightmare of a piece that gained attention because of its conclusions.

Take heart, there have been prospective studies of diets to see how they work, and these have been short-term studies, but they were corrected for variables. The diets examined include low-carbohydrate diets, Mediterranean diets, the Ornish diet, and others (Gardner CD, Kiazand A, Alhassan S, et al.: Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women. JAMA 297:969–977, 2007) and Comparison of the Atkins, Ornish, Weight Watchers, and Zone Diets for Weight Loss and Heart Disease Risk Reduction: A Randomized Trial Michael L. Dansinger, Joi Augustin Gleason, John L. Griffith, Harry P. Selker, Ernst J. SchaeferJAMA. 2005;293(1):43-53.)

We have moved beyond poorly done population studies – and are into trying to determine what is the best diet for people to consume.  We have more questions than answers – but the science tells us a few things:

Weight loss is good for all of us

(a) No matter which died patients are placed on, if it yields weight loss (probably meaning people are compliant on the diet)  reduced the cardiac risk factors including C-reactive protein, insulin levels, and reducing the low-density lipoprotein/high-density lipoprotein ratios.

(b) We really don’t know about fats, as much as we think we do

(c)  No one seems to like bread these days

(d) We all like grass fed beef, flaxseed fed chicken eggs, and anything that is free on a range (home on a range).

(e) We all like whole plants- but some of us like them more than others

(f)  Exercise is universally associated with better results, and you cannot exercise your way out of obesity.

To paraphrase Gary Taubes of “Good Calories, Bad Calories”- nutritional epidemiology is closer to pseudoscience than it is to science.

Who would have imagined that my patient, Evo, would have lost 14 pounds on the “beer and sausage” diet (now called the Evo diet).

From the medical side there are two other benefits — his triglyceride level dropped by half, his cholesterol dropped by a third, and his “good” cholesterol increased.  There was never an increase or a blip in any of the liver enzymes.  His fat mass dropped, the only non-fat mass of his that decreased was that tissue associated with and supporting the fat mass (I know, sounds complicated).  His muscle mass maintained itself.

One important lesson learned: we do not know enough about science and medicine and diets to be able to say anything to anyone about which diet is healthy and which is not. But let me give you an example – we had more data points for this one month of the Evo diet than Ornish had for his diet program.

The famous Ornish line is that his data showed a decrease in “Plaques” of patients who had heart disease. This was based on less than 20 patients, including the control group.  He has since gone on to show poor data with prostate cancer, as well as aging. The data that Ornish has isn’t good, and when you look at the data we generated in one month from the Evo diet, one could assume that we would find people would do better not doing the Ornish diet and following the Evo diet.  This is said with a smile, because never has a “lifestyle” and diet – such as Ornish, been propagated with less data and more press.  Ok- there is also the China Project (a single misuse of data to say the same thing).

The second important part of Evo’s diet was this: there was a simple and yet profound control of the portion sizes that he had. It was measured, it was regulated to around 1500 calories per day.  Based on that,  Evo lost more than we would expect him to have lost. Why? No clue.

What can you take away from this: First, if you want to have a diet begin by strictly regulating portions. Portion control is a key for any weight loss, including weight loss surgery.  Limit your portions, and thus your calories, and you should lose weight.  The advantage of beer and sausages is that they come in nice units that you can measure.

Processed meats appear to increase risk of colo-rectal cancer

What you should NOT take away from this: beer and sausage are not “diet foods.” Beer and sausage were, in this case, a tool for great portion control. And Evo ate more than just sausage. He ate what came with it.  When I cooked for him he had the peppers and onions that went with my famous recipe (recipe will be on terrysimpson.com later). He had bread (yes, I know some of you think bread is the devil’s tool) – if it came with the sausage.

The final message is most important- We don’t understand food as well as Ornish, Atkins, or pick some diet guru would have you believe.

The internet is full of claims of individuals living longer because of some diet, lifestyle, or supplement living longer.  So let us start with this disclaimer:

Anyone who gives absolute statements about one person living longer because they only drink Yak milk, or eat raw foods, or are a vegan, or a pescetarian, or eat raw lion meat – etc. – are making an opinion, not based on data.

The classic example is studies done on Seventh Day Adventists in the 1960’s and 1970’s.  Seventh Day Adventists are vegetarians by choice. They also do not drink alcohol, and they do not smoke tobacco.  Their lifespan was longer when compared to non-vegetarians. However, the study did not adjust for variables such as smoking, alcohol, lower body mass index, and what is called the “healthy volunteer effect.”

In 1999 a metastudy combined data from five western countries and reported mortality ratios.  This broad study showed fish eaters (pescetarians) had a the lowest ratio of 0.82, followed by vegetarians at 0.84.  Occasional meat eaters were at 0.84 and vegans as well as regular meat eaters had a ratio of 1.0.  (The lower the number the longer the lifespan.) – American Journal of Clinical Nutrition Vol 70 (3): 516S-524S – September 1999.

Fish eaters seem to live the longest

One of the most commonly cited studies is the “China Project” where blood samples were pooled from 65 rural counties in China.  Their conclusion was that meat eaters lived less long than those who ate animal proteins.  However, analysis of the raw data from that study leads to the opposite conclusion.  Ultimately the China Study became a best selling book. The books conclusions are the opinions of the author T Collin Campbell, many of those opinions have been refuted by peer-reviewed papers based on the raw data in the study.  One study example came from examination of the stomach cancer data showing that there was an inverse correlation between meat and stomach cancer.  Cancer Epidemiol Biomarkers Prev 1992, 1: 113-118.

Recently reported was the risk of meat consumption and colorectal cancers. Previous studies have been inconsistent so a metastudy was performed and there was an increase in risk of colo-rectal cancers with increased consumption of meat—however, this was “processed” meat- defined as cured or nitrate, or sausages.  The study did not adjust for other dietary habits, lifestyle, or genetic factors.  It should be noted that nitrate cured meats have higher associations with stomach and colo-rectal cancers.

Processed meats appear to increase risk of colo-rectal cancer

Population studies are flawed, and sometimes, the author’s conclusions may not agree with the raw data. There is not clear evidence that one dietary lifestyle is going to significantly increase lifespan if one does not include obesity, smoking, or consumption of fish.

While there are thousands of internet sites concluding that vegans live much longer- there is no study that agrees with that conclusion. What conclusion can you come to? Probably that eating fish is a good thing- eating too much processed food may not be a good thing. Best to pick great parents, don’t overeat, and a bit of red wine and chocolate are not bad things.

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.

There are about 150 species of asparagus,  but the most common in the US is Asparagus Officinalis.  Many of my favorite restaurants celebrate the return of asparagus with the white asparagus (which is grown by keeping the plants from getting all but UV light).  I remember well, picking wild asparagus from the roadsides in Illinois; there was nothing fresher.

Asparagus has a long medical history- even in the second century it was described as a cleansing (probably because it is a mild diuretic) and healing properties. It has been touted as a cure for cancer (it isn’t) to its anti-oxidant properties (see my previous post about anti-oxidants).

Some of the good things in asparagus are: 1) about half a dozen contain 50% of the daily recommended dose of folate; 2) it contains rutin, which may be an anti-inflammatory useful in fighting plaque in blood vessels (not proven, but interesting theory);  3) it contains some amino acids – which form the basis for proteins; 4) it contains glutathione, cysteine, glutamic acid, and glycine.

I must confess that until this last year I didn’t even think about eating asparagus, and then I tried it, and loved it once again.

So — asparagus is in season- and here are some easy things you can do with it that are so basic, even this busy surgeon can eat them.

First,  know that there is a woody end to the asparagus and you have to get rid of it. No matter how much you try to cook them, this part of the asparagus is more useful for making clothing or shelter, than it is for eating.

Second, the key to asparagus is that it is tender and delicate, so don’t over cook it. There are six simple methods for cooking it– and they are all pretty easy.

Boiling:
Boil the water in a medium sauce pan – add a pinch of salt and one T of olive oil  (whenever I see boiling water I think of the old western movies where someone was giving birth and the doctor or midwife would tell the husband – “we need hot water, and lots of it.”)  It takes four minutes to boil asparagus.   However, I prefer less time.

Blanche
In a medium sauce pan with water, salt, and olive oil- bring to a boil.  Add the asparagus until it is tender, or about two minutes.

Steaming
I like cookware. And, there are a lot of great steamers made just for asparagus. Asparagus needs to be steamed in the rack about one inch above the boiling water until just crisp – which is about four minutes.

Roasting
Put the asparagus in a large ziploc bag. Add some olive oil and a pinch of sea salt, and mix together until coated. Place on a baking sheet at 500 degrees for about 2 minutes. Turn once – and bake another two minutes. The asparagus should be tender.

Grilling
You can grill like I do on a big outdoor grill — which always raises my testosterone. You can also grill them over a gas grill on your stove. Brush the asparagus with olive oil, on medium high heat, turning once. This method takes about five to seven minutes.

Sous Vide
My favorite way to prepare the asparagus, or most food really, is Sous Vide. Coat the asparagus with olive oil and salt and pepper. Place in the sealed bag. Keep in a water bath at 183-185 degrees for 40 minutes to one hour.

I’m always looking for new ingredients to cook with that make an impact on flavor and calories. Spaghetti Squash is a great substitute for pasta. It has more flavor, fewer calories, more nutrients – and is just as easy to cook as pasta.

Making this is pretty easy. The hardest part is cutting the squash. There are two ways to do it: brute force, or heat. If you’re feeling really strong, you can use a serrated knife- cut off both ends and cut from the inside out. Or with a very sharp knife, pierce the skin with the tip- and pull toward you. All of which require being careful or you will need my surgical services to sew you up.

Not liking brute force when it comes to knives (we surgeons like a delicate touch) – I prefer this method: With a fork, pierce the skin of the squash. Pretend the squash is a rectangle and pierce it twice per side with the fork. Place in a microwave on high for two minutes. This will allow the squash skin to soften then you can cut it with minimal force.

Once it is cut in half- scoop out the seeds with a spoon. You can roast the seeds if you like. I like to drizzle olive oil over the squash as well as some Sea salt and pepper. Bake at 350 degrees for 30-45 minutes (its done when you can easily pierce the skin with a fork). Take it out of the oven- let it sit for ten minutes- then pull the pulp away from the skin and it will naturally form into noodles.

I like to use tongs to separate the squash from the skin. You can season the squash after you separate it from the skin. This can be used as the basis for its own dish- a much healthier and less fattening dish than any pasta.

My Favorite, And the Easiest Method

You can do it all in the microwave. Pierce the skin of the squash with the fork and place it into the microwave for 10 to 12 minutes. Once it is cooked let it rest for about five minutes. Cut the squash and scoop out the seeds (you can roast the seeds for a healthy snack). Drizzle on olive oil (with some a touch of truffle) and salt and pepper to taste (I like sea salt).

YourDoctorsOrders.com – the Juice and what it’s full of! from TweetMeTV on Vimeo.

Today in the supermarket there is a wide variety of juices available. Great combination of just about any juice you could imagine.  And, if you wanted even fresher juices, there are machines that will do it for you. One of my favorite devices is a juice press that I use for making fresh squeezed orange juice from the trees in my back yard.

But what about using juices for weight loss? For weight loss you want to have a lot of volume in your stomach of bulky high fiber items that are low in calories. For that, vegetables and fruits work well. But if you juice those fruits and vegetables, then the stomach doesn’t register the bulk with the brain.

Every time you eat something, especially something with bulk – the brain registers that sensation through a complex nerve network that begins in the top of the stomach. As bulky food goes through this area, your brain gets the sensation and when it reaches a certain amount it will hold off on sending out those hormones cause you to be hungry.

For example, if you eat a cup of broccoli you will have a lot of bulky foods, but only 12 calories! Your brain will sense that you have eaten a lot and as a result you will not feel hungry for hours. But if you juice all that broccoli you will drink about a cup of juice, and in two hours you will start to feel hungry again.

So while juicing allows you to concentrate a lot of good vitamins, minerals, and other nutrients, the juice doesn’t provide the bulk that the stomach needs to keep you from being hungry.

The other caution with juicing is this: don’t store the juice too long, and be sure to keep your juicer clean. There are a lot of bacteria that grow in juices – like salmonella and E. Coli, that can cause severe food poisoning. So, keep your juicer clean — and if you store the juice, be sure to drink it within a day or two — and keep it refrigerated.

So if you want weight loss– eat the vegetables and the fruits– they have plenty of bulk to keep you from being hungry – and provide a lot of nutrients for your body.