How Not to Die

Michael Greger with Gene Stone · 2015

Thesis

Most premature death and disability in the United States comes from diseases that diet and lifestyle can prevent, and in some cases slow or reverse, and a diet built on whole plant foods is the most effective single treatment for the leading causes of death.

Strength of evidence: mixed. Eating more fruit, vegetables, legumes and whole grains and less processed meat is clinical consensus; that a fully plant-based diet beats one with modest amounts of animal food, and that specific foods reverse specific diseases, is contested.

The main ideas

In the Global Burden of Disease estimates Greger cites, the American diet is the leading cause of death and disability in the United States, ahead of smoking.
The fifteen leading causes of death share a common dietary component, so one way of eating addresses most of them.
Foods can be sorted by a traffic light: unprocessed plant foods green, processed plant foods and unprocessed animal foods yellow, ultra-processed foods and processed meat red.
A daily checklist of twelve items, the Daily Dozen, turns the advice into servings of specific foods.
A diet without animal products needs a vitamin B12 supplement.

Diet as the leading risk

Greger's central claim is that the biggest cause of death in the United States is not a disease but a diet. He draws on the Global Burden of Disease study, a large international estimate of the causes of death and disability, which ranked the American diet as the leading risk factor, ahead of smoking. Most deaths from the leading killers, in his reading, come from chronic diseases that develop over decades and respond to what people eat every day.

His motivation is his grandmother, Frances Greger. At 65 she had end-stage heart disease. She had had so many bypass operations that, as Greger tells it, her surgeons ran out of plumbing, and she was sent home in a wheelchair to die. She then saw Nathan Pritikin on 60 Minutes and became one of the first patients at his center in Santa Barbara, which prescribed a diet of plant foods and graded exercise. Within three weeks she was walking ten miles a day.

The mechanism he proposes is that the same dietary pattern, rich in fiber, plants and unprocessed foods, and low in processed meat and refined foods, lowers the shared risk factors behind most chronic disease: high blood pressure, high cholesterol, inflammation and excess weight.

Implication: treat diet as the first intervention for chronic disease risk, not the last, and judge it by its effect on measurable risk factors such as blood pressure and cholesterol.

Fifteen ways not to die

The first half of the book takes the fifteen leading causes of death in the United States one chapter at a time. They are heart disease, lung diseases, brain diseases, digestive cancers, infections, diabetes, high blood pressure, liver diseases, blood cancers, kidney disease, breast cancer, suicidal depression, prostate cancer, Parkinson's disease, and iatrogenic causes, meaning harm from medical care itself.

In each chapter Greger reviews studies linking specific foods to the disease and argues that a whole-food, plant-based diet lowers risk. Heart disease, the leading cause, gets the strongest treatment. He draws on the work of physicians such as Dean Ornish, whose lifestyle program of a low-fat, largely plant-based diet, exercise and stress management was reported in 1990 to reverse narrowing of the coronary arteries in some patients. He also cites studies on cooked meat, including the carcinogens that form when meat is cooked at high temperature.

The structure carries the book's argument. Because the same dietary pattern appears as the recommendation in almost every chapter, the reader is meant to conclude that one way of eating addresses most of the leading killers at once, instead of requiring a different regimen for each disease.

The chapter on iatrogenic causes adds a second argument: medical treatment carries its own risks, which prevention avoids.

Implication: for a person at risk of several chronic diseases, a single sustained change in diet is a more efficient intervention than separate treatments for each.

The traffic light

The second half of the book turns the evidence into a way of choosing food. Greger sorts foods by color, like a traffic light. Green foods are unprocessed plant foods: vegetables, fruits, legumes, whole grains, nuts and seeds. Yellow foods are processed plant foods, such as refined flour or oils, and unprocessed animal foods. Red foods are ultra-processed plant foods and processed animal foods, such as processed meat.

The rule is to maximize green, minimize yellow and avoid red. The system is deliberately simple: it does not ask the reader to count calories or nutrients, only to shift the proportions of what they eat toward the green end.

The mechanism is that processing tends to remove fiber and nutrients and add salt, sugar and fat, while animal foods, especially processed meat, carry the risks Greger documents in the first half of the book. Ranking foods by both dimensions at once gives a single scale.

Implication: when choosing a meal or a grocery item, ask how processed it is and whether it is a plant or an animal food. Move each choice one step toward the unprocessed plant end instead of attempting a complete change at once.

The Daily Dozen

Greger's checklist specifies twelve things to eat or do every day. Beans and other legumes, 3 servings, with a serving being half a cup cooked or a quarter cup of hummus. Berries, 1 serving. Other fruits, 3. Cruciferous vegetables such as broccoli and cabbage, 1. Greens, 2. Other vegetables, 2. Ground flaxseeds, 1 tablespoon. Nuts and seeds, 1 serving. Herbs and spices, 1 serving, including a quarter teaspoon of turmeric. Whole grains, 3 servings. Beverages, 5 glasses. Exercise, 90 minutes of moderate activity or 40 minutes of vigorous activity.

The checklist turns the traffic light into specific targets, each a food group the first half of the book links to lower risk of one or more of the fifteen causes of death. Legumes, at three servings, carry the most weight, as the main protein source in a plant-based diet.

The book's appendix adds supplements, chief among them vitamin B12, which plants do not reliably provide. A fully plant-based diet cannot meet the body's B12 needs without a supplement or fortified foods.

Implication: use a checklist rather than willpower. Ticking off servings each day makes the diet concrete, and missing categories show where it is falling short.

Limits

Critics agree the diet is better than the typical Western diet but say the book overstates the evidence. The physician Harriet Hall, writing in Science-Based Medicine, said Greger often overstates benefits and leaves out contradicting evidence, citing his use of a ten-person study of animal fat and inflammation that had no control group. The writer Denise Minger, in a 2017 review, called repeated misrepresentation of research to fit a plant-based view the book's biggest liability, while crediting its extensive references.
Most of the evidence is observational, comparing people who eat differently, not trials that assign diets. John Ioannidis argued in JAMA in 2018 that confounding and measurement error in such studies often outweigh the small effects they report.
Professional bodies support plant-based diets without endorsing the book's strongest claims. The Academy of Nutrition and Dietetics stated in 2016 that appropriately planned vegetarian and vegan diets are healthful and nutritionally adequate and may provide health benefits; it does not say they are superior to diets with modest amounts of animal food.

The Good Gut — the gut microbes that explain part of why fiber-rich plant foods matter.
Starving to Heal in Siberia — the opposite intervention: a patient's account of treating disease by not eating at all.