Tag Archives: Forks over Knives

What Is A Plant-Based Diet (And Should I Be On One)?

The phrase “plant-based diet” is being tossed around a lot these days. The skeptical cardiologist never knows what people mean when they use it and so must assume that most of the world is also puzzled by this trendy term.

Is A Plant-Based Diet Code For Veganism?

For some, a “plant-based diet” (PBD) is what vegans eat.

Veganism combines a diet free of animal products, plus a moral philosophy that reject the “commodity status of animals.” Vegans are the strictest of vegetarians, eschewing milk, fish and eggs.

One PBD advocate in the introduction to a Special Issue of the Journal of Geriatric Cardiology,  defines it as follows:

“a plant-based diet consists of all minimally processed fruits, vegetables, whole grains, legumes, nuts and seeds, herbs, and spices and excludes all animal products, including red meat, poultry, fish, eggs, and dairy products.”

You will notice that this cardiologist “excludes all animal products”  and that the qualifying phrase “minimally processed” has crept into the definition.

Forks Over Knives-Whole-food, plant-based diet

The “documentary” Forks Over Knives brought the phrase “whole food, plant-based diet” to national prominence. The movie focused on the diets espoused by Caldwell Esselstyn and T. Colin Campbell. Since its release in 2011 a whole industry based on the Forks Over Knives (FON) brand has been launched. FON uses the following definition:

 “A whole-food, plant-based diet is centered on whole, unrefined, or minimally refined plants. It’s a diet based on fruits, vegetables, tubers, whole grains, and legumes; and it excludes or minimizes meat (including chicken and fish), dairy products, and eggs, as well as highly refined foods like bleached flour, refined sugar, and oil.”

I’ve written detailed posts on the Esselstyn diet here and here. I think it is needlessly restrictive and not supported by scientific evidence. (Esselstyn’s website and book state unequivocally “you may not eat anything with a mother or a face (no meat, poultry, or fish” and “you cannot eat dairy products” which differs from the FON definition.)

The key new terms in the FON approach to note are:

Whole Food. The Oxford English Dictionary (OED) defines whole food as “food  that has been processed or refined as little as possible and is free from additives or other artificial substances.”

Unrefined or minimally refined. The OED defines refined as:

“With impurities or unwanted elements having been removed by processing.”

The FON definition for a PBD then is similar to our first definition-minimally processed vegan-but allows (at least theoretically)  minimal meat, dairy and eggs. The FON Esselstyn/Campbell diets choose to define vegetable oil, including olive oil, as highly refined foods and do not allow any oils.

U.S. News and World Report Definition Of Plant-Based Diets

U.S. News and World Report publishes an annual rating of diets based on the opinion of a panel of nationally recognized experts in diet, nutrition, obesity, food psychology, diabetes and heart disease.

US News defines a plant-based diet as “an approach that emphasizes minimally processed foods from plants, with modest amounts of fish, lean meat and low-fat dairy, and red meat only sparingly.”

This definition is radically different from the first two. Notice now that you can have “modest amounts” of meat and dairy, foods which are anathema to vegans. Also, note that “low-fat dairy” is being recommended, a food which (in my opinion) is highly processed and that lean meat is to be preferred and red meat avoided.

I was happy to see that for the first time, the Mediterranean Diet ranked as  Best Diet Overall, but shocked to find that the Mediterranean diet came out on top of the US News list of “Best Plant-Based Diets.”

Readers will recognize that this is the diet I recommend and follow (with slight modifications). On this diet I regularly consume hamburgers, steak, fish and whole egg omelettes.

The plant-based diet of vegans or of Forks Over Knives is drastically different from the Mediterranean Diet.

For example, olive oil consumption is emphasized in the Mediterranean Diet, whereas the Esselstyn diet featured in FON forbids any oil consumption.

The FON/Esselstyn diets are very low in any fats, typically <10%, whereas the Mediterranean Diet is typically 30-35% fat.

Esselstyn really doesn’t want you to eat nuts and avocados because he thinks the oil in them is bad for you. This is nuts! I’m handing out nuts to my patients just as they were given to the participants in the PREDIMED randomized trial showing the benefits of the Med diet.

Dr. Pearson’s Plant-Based Diet

Since the term “plant-based diet” apparently means whatever a writer would like it to mean, I have come up with my own definition.

With the  Dr. P Plant-Based Diet© your primary focus in meal planning is to make sure that you are regularly consuming a large and diverse amount of healthy foods that come from plants.

If you don’t make it your focus, it is too easy to succumb to all the cookies, donuts, pies, cakes, pretzels, chips, French fries,  breakfast bars and other  calorie-dense but nutrient-light products that are cheap and readily available.

In Dr. P’s Plant-Based Diet© meat, eggs, and full fat dairy are on the table. They are consumed in moderation and they don’t come from plants (i.e. factory farms).

I, like the PBD  definers of yore, have taken the liberty of including many vague terms in my definition. Let me see if I can be more precise:

Regularly = at least daily.

Large amount = 3 to 4 servings daily.

Healthy = a highly contentious term and one, like “plant-based” that one can twist to mean whatever one likes. My take on “healthy” can be seen on this blog. I’m not a fan of plant-based margarines, added sugar, whether from a plant or not, should be avoided, and the best way to avoid added sugar is to avoid ultra-processed foods.

Ultra-processed foods (formulations of several ingredients which, besides salt, sugar, oils and fats, include food substances not used in culinary preparations, in particular, flavours, colours, sweeteners, emulsifiers and other additives used to imitate sensorial qualities of unprocessed or minimally processed foods and their culinary preparations or to disguise undesirable qualities of the final product).

Ultra-processed foods account for 58% of all calories in the US diet, and contribute nearly 90% of all added sugars.

I do like the food writer Michael Pollan’s simple rules to “Eat Food. Mostly Plants. Not Too Much.” and this NY Times piece summarizes much of what is in his short, funny and helpful Food Rules book:

you’re much better off eating whole fresh foods than processed food products. That’s what I mean by the recommendation to eat “food.” Once, food was all you could eat, but today there are lots of other edible foodlike substances in the supermarket. These novel products of food science often come in packages festooned with health claims, which brings me to a related rule of thumb: if you’re concerned about your health, you should probably avoid food products that make health claims. Why? Because a health claim on a food product is a good indication that it’s not really food, and food is what you want to eat.

On Dr. P’s Plant-Based Diet© you can add butter to your leeks and green onions.You can add eggs to your onions, tomatoes and peppersAnd you can eat salads full of lots of cool different plants for lunch.

To answer my titular question-if you are using Dr. P’s definition of a plant-based diet then you definitely should be on one.

Viva La Plant!

-ACP

More Incredibly Bad Science From Dr. Esselstyn’s Plant-Based (Vegan) Diet Study

A while back the skeptical cardiologist exposed “The incredibly bad science behind Dr. Esselstyn’s plant-based diet.

The diet has the catchy slogan “eat nothing with a face or a mother” and Esselstyn was featured in the vegan propaganda film “Forks Over Knives.”

After detailing the lack of science I concluded:

Any patients who were not intensely motivated to radically change their diet would have avoided this crazy "study" like the plague.

This "study" is merely a collection of 18 anecdotes, none of which would be worthy of publication in any current legitimate medical journal.

Three of the 18 patients have died, one from pulmonary fibrosis, one presumably from a GI bleed, and one from depression. Could these deaths be related to the diet in some way? We can't know because there is no comparison group.

The post garned little attention initially but in the last few months several hundred visitors per day apparently read it and Essesltyn followers have started leaving me testimonials to the diet along with nasty comments.

Here’s are some typical ones (with my comments in red)

“If your (sic) not backed by some meat industry or cardiac bypass group I would be much surprised.”

I am completely free of bias. Nobody is paying me anything to do the research and writing I do. My only purpose is to find the truth about diet in order to educate my patients properly. I have  saved many more patients from bypass surgery than I have referred for the procedure.

“it is so arrogant to think the only science could come from clinical studies which may be funded by an interested party.”

Doctors like randomized (and preferably blinded) clinical studies because they minimize the bias introduced by interested parties like patients and zealous investigators (like Dr. E)  motivated to see positive outcomes. Small, non-randomized studies can only generate ideas and hypotheses which larger, randomized studies can prove with a greater degree of certainty.

“the entire nentire western medical system is skewed due to the big pharma influence…unfortunately western medicine believes the only science is the pen and the scalpel..whereas …history is the best teacher of all…”

By pen I assume you mean medications. If we examine history as  you suggest we see that life expectancy was 50 years in 1945  but today in developed countries it is around 80 years. This advance corresponds to (among other things) advances in vaccines, antibiotics, anti-cancer drugs, cardiac and blood pressure medications and surgery: the pen and the scalpel. It does not correspond to following a vegan diet.

“Your foolishness is the embarrassment.”

Thank you for this insightful comment! I’m considering it as my epitaph.

One man felt that changing to the Esselstyn diet dramatically improved his cardiac situation and commented:

“Nothing like bashing something that works just because you want to eat meat. .”

I do enjoy meat in moderation but I also really enjoy vegetables, nuts, fish, legumes, olive oil and avocados. I looked into Esselstyn’s diet in detail because it stands out as particularly misguided in banning nuts, avocados, fish and olive oil to heart patients.

..”.So sicking (sic) to see people talk trash about something that works so well… It saved my life…”

I’m happy you are doing well with your cardiac condition but it is impossible to know what would have happened to you on a more reasonable diet such as the Mediterranean diet (which actually has legitimate scientific studies supporting it). And again criticizing Esselstyn’s ideas and “study” can hardly be considered trash talk.

“I personally have followed dr. esselstyn’s program for what will be 5 years in 11/17 and have made tremendous gains in my cardio pulmonary function….my cardiologist looks at me in wonder…why are you here? and often says , if everyone did what you have…Id be out of business…so…isnt that telling and sad?”

I’m glad you’re doing well with the program, most patients can’t follow this kind of diet for more than a few months.  But perhaps we shouldn’t judge its effectiveness until  we make sure you don’t suffer a heart attack next week. Your cardiologist is wrong: see what I wrote about “dealing with the cardiovascular cards you’ve been dealt.” Some individuals inherit genes that guarantee progressive and accelerated atherosclerosis that will kill them at an early age despite the best lifestyle.

“…the phrase “follow the money” comes to mind…and since theres no big money to be made….science will attempt to dispell the results and thousands of years of history that proves this dietary system works…”

Using a scientific approach to analyze Esselstyn’s diet (which tries to claim a scientific basis) seemed appropriate to me but I wasn’t motivated by money. I’m looking for what is best for my patients, pure and simple.

The Plural of Anecdote Is Not Data

One man wrote:

“But since this is only anecdotal evidence – it must be junk science…”

Esseslstyn devotees like to post what their personal experience is with the diet but as skeptical medicine has pointed out “the plural of anecdote is not data.” 

One woman described in detail a good response her husband had after starting the diet following a heart attack:

I’m concerned about the skeptical cardiologist going after the person of dr. Esselstyn versus the science, such as quoting how you States dr. Esselstyn came up with the diet. So there may be a personal bias there. I’m sure there are more people out there on the esselstyn diet that are not noted in the study years ago. I hope there is another book coming out

I’ve reviewed in detail my comments about how Esselstyn came up with the diet but I am at a loss to find any ad hominem attack.

This woman went on to say

We will keep you posted, as my husband is willing to get another cardiac Cath and 12 months to visually see the difference after the diet.

I have to point out that if his cardiologist performs a cardiac cath (which carries risks of stroke, heart attack and death) for the sole purpose of checking the effect of the diet he is engaging in unethical medical behavior and likely insurance fraud. By the way, I hope that your husband is on a statin like most of Dr. Esselstyn’s are!:)

and a man wrote

Calling Essylstein ilk shows a little too much biased hatred on your part

Please note the definition of ilk “a type of people or things similar to those already referred to.” No pejorative there. And no ad hominem attack.  I wrote:

 It is possible that the type of vegan/ultra-low fat diets espoused by Esselstyn and his ilk have some beneficial effects on preventing CAD, but there is nothing in the scientific literature which proves it.

I should be able to criticize the methods and ideas of Dr. E without it being considered an attack on his person

Completely wrong. Esselstyn has saved my life. His book explains it all, how the endothelium cells get ruined, inflammation … heart attack proof (his words). One does not continue as head of the Cleveland Wellness Center if one is a quack.

Words are easy to come by on the interweb but Dr. E’s are not supported by science and as for the “Cleveland Wellness Center” it is probably not wise to get me started. Dr. E ‘s program is listed as being part of the Cleveland Clinic Wellness Center which is an attempt to capitalize on the market for pseudoscientific enterprises. He is not the director. The director recently came under intense criticism for promoting anti vaccine quackery. (See here).

The Wellness Center promotes so-called functional, integrative, complementary and alternative approaches. (Functional medicine is fake medicine!) These are approaches that have not been proven to work and could arguably be called quackery. (Let me be clear, however, I am not calling Dr. Esselstyn a quack but the fact that he is part of the Wellness Center does not add any scientific validity to his work.)

“I’m sure there are more people out there on the esselstyn diet that are not noted in the study years ago. I hope there is another book coming out”

Fake News, Fake Science

As a matter of fact, Dr. E has been hard at work over the last 30 years and has added a grand total of 176 patients who are considered “adherent” to the diet: about 6 per year. The “original research” was published in The Journal of Family Practice in 2014. Unfortunately the bad science present in the original publication has only been amplified.

In addition to any randomization or suitable control group for comparison, the data collection techniques are unacceptable:

“In 2011 and 2012 we contacted all participants by telephone to gather data. If a participant had died, we obtained follow-up medical and dietary information from the spouse, sibling, off-spring or responsible representative.”

In other words, there was no actual systematic review of medical records, autopsies or death certificates, just word of mouth from whomever answered the phone.

“Patients who avoided all meat, fish, dairy, and knowingly, any added oils throughout the program were considered adherent.”

Imagine, if you will, that your husband died 10 years ago and you received a call from Dr. E’s office or perhaps Dr. E himself and he asks you if your husband “avoided all meat, fish, dairy and added oils.”  For one thing, it would be very difficult for you to answer that question with any degree of accuracy: was your husband cheating on Dr. E’s diet when you weren’t looking, do you remember his entire diet from 10 years ago?

For another thing, you know that the caller has an agenda. If your husband died of a heart problem the caller is not going to be happy until he/she gets you to admit that your husband had some guacamole on Cinco de Mayo in 2002. If he’s alive and doing well, the caller is likely to be satisfied with a simple answer that , yes, he’s following the diet.

Yes, we have more data from Dr. E but it turns out to be even more incredibly bad than the first lot.

Let the anecdotes and ad hominem attacks begin!

-ACP