How Not to Die

  Aspirin

  How well do over-the-counter drugs perform? For example, take aspirin. Perhaps the most commonly used medication in the world,57 it’s been around in pill form for over a century. Its active ingredient, salicylic acid, has been used in its natural form (as an extract of willow tree bark) to ease pain and fever for thousands of years.58 One of the reasons it remains so popular—despite the fact that better anti-inflammatory painkillers exist now—is that it’s used by millions of people on a daily basis as a blood thinner to reduce the risk of a heart attack. As we saw in chapter 1, heart attacks often occur when a blood clot forms in response to a ruptured atherosclerotic plaque in one of your coronary arteries. Taking aspirin may help stop this from happening.

  Aspirin may also lower the risk of cancer.59 It works by suppressing an enzyme within your body that creates pro-clotting factors, thereby thinning your blood. At the same time, aspirin suppresses proinflammatory compounds called prostaglandins, which in turn reduces pain, swelling, and fever. Prostaglandins may also dilate the lymph vessels inside tumors, potentially allowing cancer cells to spread. One of the ways scientists think aspirin helps prevent cancer deaths is by counteracting a tumor’s attempts to pry open the lymphatic bars on its cage and spread throughout the body.60

  So should everyone take a “baby”-strength aspirin a day? (Note that aspirin should never actually be given to infants or children.)61 No. The problem is that aspirin can cause side effects. The same blood-thinning benefit that can prevent a heart attack can also cause a hemorrhagic stroke, in which you bleed into your brain. Aspirin can also damage the lining of the digestive tract. For those who’ve already had a heart attack and continue to eat the same diet that led to the first one (and are therefore at exceedingly high risk of having another one), the risk-benefit analysis seems clear: Taking aspirin would probably prevent about six times more serious problems than it causes you. But among the general population who have yet to have their first heart attack, the risks and benefits are more closely matched.62 Thus, taking an aspirin a day is generally not recommended.63 Throw in even a 10 percent reduction in cancer mortality, though, and it could tip the risk-benefit balance in favor of aspirin.64 Given that regular, low-dose aspirin use may reduce the risk of cancer mortality by one-third,65 it is tempting to recommend it for nearly everyone. If only you could get the benefits without the risks.

  Well, maybe you can.

  The willow tree isn’t the only plant that contains salicylic acid. It’s widely found in many of the fruits and vegetables in the plant kingdom.66 That’s why you often find the active ingredient of aspirin in the bloodstreams of people who aren’t taking it.67 The more fruits and vegetables you eat, the higher your level of salicylic acid may rise.68 In fact, the levels of people eating plant-based diets actually overlap with those of some people taking low-dose aspirin.69

  With all that salicylic acid flowing through their systems, you might think plant eaters would have higher ulcer rates, because aspirin is known to chew away at the gut. But those following plant-based diets actually appear to have a significantly lower risk of ulcers.70 How is that possible? Because in plants, the salicylic acid may come naturally prepackaged with gut-protective nutrients. For example, nitric oxide from dietary nitrates exerts stomach-protective effects by boosting blood flow and protective mucus production in the lining of the stomach, effects which demonstrably oppose the proulcerative impact of aspirin.71 So, for the general population, by eating plants instead of taking aspirin, individuals may not only get aspirin’s benefits without its risks but also get the benefits—with benefits.

  People who have had a heart attack should follow their physician’s advice, which probably includes taking aspirin every day. But what about everyone else? I think everyone should take aspirin—but in the form of produce, not a pill.

  The salicylic acid content in plants may help explain why traditional, plant-based diets were so protective. For instance, before their diets were Westernized, animal products made up only about 5 percent of the average Japanese diet.72 During this period in the 1950s, age-adjusted death rates from colon, prostate, breast, and ovarian cancers were five to ten times lower in Japan than in the United States, while incidences of pancreatic cancer, leukemia, and lymphoma were three to four times lower. This phenomenon was not unique to the Japanese. As we’ve seen throughout this book, Western rates of cancers and heart disease have been found to be dramatically lower among populations whose diets are centered around plant foods.73

  If part of this protection arises from the aspirin phytonutrients, which plants in particular are packed with the stuff? While salicylic acid is ubiquitously present in fruits and vegetables, herbs and spices contain the highest concentrations.74 Chili powder, paprika, and turmeric are rich in the compound, but cumin has the most per serving. Indeed, just one teaspoon of ground cumin may be about the equivalent of a baby aspirin. This may help explain why India, with its spice-rich diets, has among the lowest worldwide rates of colorectal cancer75—the cancer that appears most sensitive to the effects of aspirin.76

  And the spicier, the better! A spicy vegetable vindaloo has been calculated to contain four times the salicylic acid content of a milder madras-style veggie dish. Eat a single meal, and you can get the same spike in salicylic acid in your bloodstream as if you took an aspirin.77

  The benefits of salicylic acid are another reason you should strive to choose organic produce. Because the plant uses the compound as a defense hormone, its concentration may be increased when that plant is bitten by bugs. Pesticide-laden plants aren’t nibbled as much and, perhaps as a result, appear to produce less salicylic acid. For example, in one study, soup made from organic vegetables was found to contain nearly six times more salicylic acid than soup prepared from conventional, nonorganically grown ingredients.78

  Another way to get more salicylic acid value for money is by opting for whole foods. Whole-grain breads, for example, not only offer more salicylic acid but may contain one hundred times more phytochemicals in general than white bread—reportedly eight hundred compared with approximately eight.79

  Attention has been focused on salicylic acid because of the voluminous data on aspirin, but hundreds of the other phytonutrients have been found to have anti-inflammatory and antioxidant activity as well. Still, given the strength of the aspirin evidence, there are those in the public health community who talk of a widespread “salicylic acid deficiency,” proposing that the compound be classed as an essential vitamin: “Vitamin S.”80 Whether it’s the salicylic acid or a combination of other phytonutrients that account for the benefits of whole plant foods, the solution is the same: Eat more of them.

  Colonoscopies

  The colonoscopy. You’ll be hard pressed to find a more dreaded routine procedure. Every year, U.S. doctors may perform more than fourteen million colonoscopies,81 an exam used to detect abnormal changes in the large intestine (colon) and rectum. During the procedure, doctors insert a five-foot-long flexible tube fitted with a tiny video camera and inflate the colon with air to visualize the colon lining. Any suspicious polyps or other abnormal tissue can be biopsied during the procedure. Colonoscopies can help doctors diagnose causes of rectal bleeding or chronic diarrhea, but routine colon cancer screenings may be the most common reason they are performed.

  The reasons doctors often find it difficult to convince their patients to keep coming back for colonoscopies include the necessary bowel prep, during which you have to drink liters of a powerful liquid laxative before the procedure to completely clean yourself out. There’s also the pain and discomfort of the procedure itself82 (though you’re purposefully given drugs with amnesiac effects so you won’t remember how it felt),83 feelings of embarrassment and vulnerability, and the fear of complications.84 These fears are not unfounded. Despite how routinely colonoscopies are performed, serious complications occur in about 1 out of every 350 cases, including such issues as perforations and fatal bleeding.85 Perforations can occur when
the tip of the colonoscope punctures the wall of the colon, when the colon is overinflated, or when a doctor cauterizes a bleeding biopsy site. In extremely rare cases, this cautery can ignite some residual gas and cause the colon to literally explode.86

  Death from colonoscopy is rare, occurring in only about 1 in every 2,500 procedures.87 Yet this means colonoscopies may be killing thousands of Americans every year, raising the question: Do the benefits outweigh the risks?

  Colonoscopies are not the only screening technique for colon cancer. The U.S. Preventive Services Task Force (USPSTF), the official prevention guidelines body, considers colonoscopies just one of three acceptable colon-cancer screening strategies. Starting at age fifty, everyone should get either a colonoscopy once a decade, have their stool tested for hidden blood every year (which involves no scoping at all), or have a sigmoidoscopy every five years, along with stool testing every three. The evidence supporting “virtual” colonoscopies or DNA stool testing was judged insufficient.88 Though routine screenings are no longer recommended at age seventy-five, this assumes you’ve been testing negative for twenty-five years. If you’re now seventy-five and have never been screened, then it’s probably a good idea to get screened at least into your eighties.89

  Sigmoidoscopy uses a much smaller scope than in a colonoscopy and has ten times fewer complications.90 However, because the scope may only go about two feet inside your body, it might miss tumors farther inside. So which is better overall? We won’t know until randomized controlled colonoscopy trials are published in the mid-2020s.91 Most other developed countries do not recommend either scoping procedure, though. For routine colon cancer screening, they still endorse the noninvasive stool blood testing.92

  Which of the three options is best for you? The USPSTF recommends that the decision should be made on an individualized basis after weighing the benefits and risks with your doctor.

  To what extent, though, do doctors inform patients of their options? Researchers audiotaped clinic visits to find out. They were looking for the nine essential elements of informed decision making, which include explaining the pros and cons of each option, describing the alternatives, and making sure the patient understands these options.93

  Unfortunately, when it came to colon cancer screening, in most cases, the doctors and nurse practitioners studied communicated none of this vital information, zero out of nine elements.94 As an editorial in the Journal of the American Medical Association put it: “There are too many probabilities and uncertainties for patients to consider and too little time for clinicians to discuss them with patients.”95 So doctors tend to just make up patients’ minds for them. What do they choose? A National Cancer Institute-funded survey of more than one thousand physicians found that nearly all doctors (94.8 percent) recommended a colonoscopy.96 Why do doctors push colonoscopies in the United States when most of the rest of the world appears to prefer noninvasive alternatives?97 It may be because most doctors in the rest of the world don’t get paid by procedure.98 As one U.S. gastroenterologist put it, “Colonoscopy . . . is the goose that has laid the golden egg.”99

  An exposé in the New York Times on spiraling health care costs noted that in many other developed countries, colonoscopies cost just a few hundred pounds. In the United States? The procedure may cost thousands, which the journalists concluded has less to do with providing top-notch medical care and more with business plans aimed at maximizing revenue, marketing, and lobbying.100 Who’s in charge of setting the prices? The American Medical Association. A Washington Post investigation exposed that each year, a secretive AMA committee determines billing standards for common procedures. The result is gross overestimates for the time it takes to perform common services like colonoscopies. As the Post pointed out, if AMA standards are to be believed, some doctors would have to work more than twenty-four hours a day to perform all the procedures they report to Medicare and private insurers. Is it any wonder that gastroenterologists bank nearly $500,000 (over £300,000) per year?101

  But why would your family doctor or internist push the procedure if they’re not the ones doing it? Many doctors who refer their patients to gastroenterologists receive what are essentially financial kickbacks. The U.S. Government Accountability Office (GAO) reported on this practice of so-called self-referrals, a scheme where providers refer patients to entities in which they have a financial interest. The GAO estimated that doctors make nearly a million more referrals every year than they would have if they were not personally profiting.102

  What to Take Before a Colonoscopy

  Ever taken one of those breath mints after a big meal at a restaurant? Peppermint doesn’t just make your breath smell better; it also helps to reduce the gastrocolic reflex—the urge to defecate following a meal. Nerves in your stomach stretch after eating, which triggers spasms in the colon to enable your body to make room for more food coming down the pike. Peppermint can reduce these spasms by relaxing the muscles that line your colon.103

  What does this have to do with colonoscopies? If you take circular strips of human colons removed during surgery and lay them on a table, they spontaneously contract about three times per minute. Isn’t that kind of creepy? But if you drip menthol (found in peppermint) onto the colon strips, the strength of the contractions diminishes significantly.104 During a colonoscopy, such spasms can hinder the progress of the scope and cause the patient discomfort. By relaxing colon muscles, peppermint can make the procedure easier for both doctor and patient.

  Doctors have experimented with spraying peppermint oil from the tip of the colonoscope,105 as well as using a hand pump to flood the colon with a peppermint solution prior to the procedure.106 The simplest solution might be the best, though: asking the patient to swallow peppermint oil capsules. Premedicating with eight drops’ worth of peppermint essential oil four hours before a colonoscopy was found to significantly reduce colon spasms, patient pain, and make the scope easier to insert and withdraw compared with a placebo.107

  If you do need a colonoscopy, ask your doctor about using this simple plant remedy. It might make it easier on both of you.

  Clearly, patients in America may be getting more medical care than they really need. So said Dr. Barbara Starfield, who literally wrote the book on primary care.108 One of our nation’s most prestigious physicians, she composed the scathing commentary in the Journal of the American Medical Association naming medical care as the third-leading cause of death in the United States.109

  Her primary-care work has been widely embraced, but her findings on the potentially ineffective and even harmful nature of U.S. health care received almost no attention. “The American public appears to have been hoodwinked into believing that more interventions lead to better health,” she later said in an interview.110 As one health care quality advisor noted, the widespread disregard of Dr. Starfield’s evidence “recalls the dark dystopia of George Orwell’s 1984, where awkward facts swallowed up by the ‘memory hole’ become as if they had never existed at all.”111

  Sadly, Dr. Starfield is no longer with us. Ironically, she may have died from one of the adverse drug reactions she so vociferously warned us about. After she was placed on two blood thinners to prevent a stent in her heart from clogging up, she told her cardiologist she was bruising more and bleeding longer—that’s the drug risk you hope doesn’t outweigh the benefits. Then Dr. Starfield died after apparently hitting her head while swimming and bleeding into her brain.112

  The question I ask myself is not whether she should have been put on two blood thinners for as long as she was—or whether she should have had the stent inserted to begin with. Rather, I wonder if she could have avoided the medication and the surgery both by avoiding the heart disease in the first place. Heart attacks are considered 96 percent avoidable in women who eat a wholesome diet and engage in other healthy lifestyle behaviors.113 The number-one killer of women need almost never happen.

  PART 2

  Introduction

  In part 1 of this book, I explor
ed the science that demonstrates the role a plant-based diet rich in certain foods may play in helping to prevent, treat, and even reverse the fifteen leading causes of death. For those who may have already been diagnosed with one or more of these diseases, the information in part 1 can be lifesaving. But for everyone else—perhaps those worried about inheriting their family history of illness or those who simply want their diet to promote health and longevity—the primary question might concern food choices to make day in and day out. I have given more than a thousand presentations, and one of the most common questions I get is, “What do you eat every day, Dr. Greger?”

  This, part 2 of How Not to Die, is my response to that question.

  I’ve never had so much a sweet tooth as a grease tooth. Pepperoni pizza. Chicken wings by the basket. Sour cream-and-onion crisps. A bacon cheeseburger nearly every day during high school. Anything oily and fatty—and all washed down with an ice-cold Dr Pepper. Okay, so maybe a little sweet tooth. I also really liked strawberry-iced doughnuts.

  Even though my grandma’s miraculous recovery from heart disease inspired me to pursue a career in medicine, I didn’t clean up my own diet until the publication of Dr. Ornish’s landmark Lifestyle Heart Trial in 1990. I was such a nerd in high school that I would spend my summer holidays hanging out in the science library at the local university. And there it was, published in the most prestigious medical journal in the world—proof that my family’s story was not a fluke: Heart disease could be reversed. Dr. Ornish and his team had taken before-and-after x-rays of people’s arteries and demonstrated how they could be opened up without angioplasty. No surgery. No miracle drug. Just a plant-based diet and other healthy lifestyle changes. That’s what motivated me to change my own diet and ignited my twenty-five-year love affair with nutritional science. From that point forward, I have been determined to spread the word about food’s power to make you healthy, keep you healthy, and, if necessary, return you to health.