How Not to Die by Dr. Michael Greger: An In-Depth Review and Analysis

Dr. Michael Greger’s “How Not to Die” has become a phenomenon in the health and wellness world, selling millions of copies worldwide and inspiring countless individuals to reconsider their dietary choices. But does this 562-page guide to disease prevention live up to its bold promises? This comprehensive review examines both the valuable insights and potential pitfalls of this influential work.

The Foundation: Dr. Greger’s Personal Mission

The genesis of “How Not to Die” stems from Dr. Greger’s childhood experience watching his grandmother recover from severe heart disease through dietary intervention. Sent home by doctors with no hope of survival, she defied expectations by following the low-fat Pritikin diet. This remarkable recovery planted the seeds for Greger’s lifelong mission to promote food as medicine.

Today, Dr. Greger serves as an international lecturer, physician, and the voice behind the popular website Nutrition Facts, where he analyzes nutrition research for public consumption. His book aims to democratize health information, empowering readers to take control of their wellbeing through dietary choices.

The Core Philosophy: Plant-Based Eating as Medicine

At its heart, “How Not to Die” advocates for a whole-food, plant-based diet as the primary defense against the leading causes of death in developed nations. Greger distinguishes his approach from strict veganism or vegetarianism, allowing for some flexibility while maintaining that unprocessed plant foods represent the optimal choice for human health.

The book covers fifteen of the most common causes of premature death, including heart disease, lung disease, brain disease, digestive cancers, infections, diabetes, high blood pressure, liver disease, blood cancers, kidney disease, breast cancer, suicidal depression, prostate cancer, Parkinson’s disease, and iatrogenic causes.

Strengths: What the Book Gets Right

Comprehensive Research and References

One of the book’s most impressive features is its extensive citation of scientific literature. With sprawling references spanning numerous studies and clinical trials, Greger demonstrates significant effort in compiling evidence to support his recommendations. The scope is genuinely vast, covering topics from cardiovascular health to cognitive function.

Legitimizing Medical Skepticism

“How Not to Die” effectively validates readers’ concerns about profit-driven healthcare systems. Greger makes a compelling case that questioning the medical-industrial complex isn’t conspiracy theory territory but rather a reasonable stance given conflicts of interest in modern medicine.

Defending Misunderstood Foods

The book successfully rehabilitates several foods that have been unfairly maligned in popular nutrition discourse:

• Fruit: Greger presents evidence showing that fruit consumption doesn’t harm blood sugar control in diabetics and that even high fruit intake (up to 20 servings daily in one study) doesn’t negatively impact metabolic markers.
• Phytates: Rather than being anti-nutrients to avoid, Greger explains how these compounds in plant foods offer protective effects against various cancers.
• Legumes: The book explores clinical evidence showing that beans and lentils support weight maintenance, insulin sensitivity, and cardiovascular health.

Valid Concerns About Meat Consumption

Beyond outdated fears about saturated fat and cholesterol, Greger highlights legitimate risks associated with meat consumption:

Zoonotic Infections: The book presents compelling evidence that certain infections, including urinary tract infections from E. coli in chicken and Yersinia from pork, may be transmitted through meat consumption. Research suggests that chicken-derived E. coli shows resistance to many antibiotics, making resulting infections particularly challenging to treat.

Hepatitis E: Greger notes that this potentially serious virus is found in approximately one in ten pig livers in American grocery stores and can survive the temperatures reached in undercooked pork.

Heterocyclic Amines (HCAs): High-temperature cooking of muscle meat creates these carcinogenic compounds, which research has linked to increased risks of breast, colon, esophageal, lung, pancreatic, prostate, and stomach cancers. The book correctly identifies cooking method as a crucial factor in meat-related cancer risk.

Critical Weaknesses: Where the Book Falls Short

Systematic Cherry-Picking of Evidence

The most significant flaw in “How Not to Die” is its selective presentation of research. While Greger cites numerous studies, he often omits findings that contradict his plant-based thesis or misrepresents what cited research actually demonstrates.

Example: Kidney Stones and Oxalates

When arguing that high-oxalate vegetables don’t increase kidney stone risk, Greger cites a study examining total vegetable intake—not specifically high-oxalate vegetables. The researchers actually expressed concern that high-oxalate vegetables “might increase the risk of stone formation” and suggested these foods could have “offset some of the protective association” found for vegetables generally.

Example: Animal Protein and Kidney Stones

Greger states that meat eaters have higher kidney stone risk and claims “the more they ate, the higher their associated risks.” However, the cited EPIC-Oxford study actually found that people eating small amounts of meat had lower risk than vegetarians (hazard ratio of 0.52 versus 0.69).

Questionable Plant-Based Classifications

In some instances, Greger attributes health benefits to “plant-based diets” that were actually achieved through programs bearing little resemblance to his recommendations. For example, he credits Walter Kempner’s Rice Diet with reversing diabetic vision loss and treating kidney failure, despite this diet consisting primarily of white rice, refined sugar, and fruit juice—hardly the whole-food, vegetable-rich approach Greger advocates.

Asthma and Dietary Patterns: A Selective Narrative

The book’s discussion of asthma illustrates how Greger constructs narratives by emphasizing certain findings while ignoring others. He cites studies showing that plant foods reduce asthma symptoms, but fails to mention that the same research found seafood consumption was inversely associated with asthma diagnosis, wheezing, and shortness of breath—often more strongly than plant foods.

Similarly, while noting that meat consumption correlated with increased asthma risk in one Indian study, Greger omits that the same research found milk consumption significantly reduced asthma risk, with those never consuming dairy being more likely to report asthma.

Dementia, Diet, and Incomplete Evidence

Greger presents plant-based eating as protective against Alzheimer’s disease, citing lower dementia rates among Nigerians eating traditional plant-based diets compared to African Americans. However, he doesn’t mention that the same analysis found fish consumption to be protective against Alzheimer’s, particularly in European and American populations.

When discussing increased Alzheimer’s rates in Japan correlating with increased animal food consumption, Greger doesn’t acknowledge research showing that much of this increase resulted from changes in diagnostic criteria rather than actual prevalence increases. After accounting for these diagnostic changes, the positive relationship between animal fat and dementia disappeared.

The ApoE4 Question

Greger attributes the “Nigerian paradox”—high ApoE4 prevalence but low Alzheimer’s rates—to Nigeria’s plant-based diet. However, many hunter-gatherer populations worldwide share this pattern despite consuming significant amounts of animal foods. This suggests that protection against ApoE4-related dementia may relate more to lifestyle factors common among traditional populations (physical activity, feast-famine cycles, unprocessed foods) rather than plant-based eating specifically.

Soy and Breast Cancer: An Outdated Narrative

The book’s treatment of soy as a breast cancer preventive resurrects claims that have become increasingly controversial in scientific circles. While Greger provides references suggesting soy protects against breast cancer and improves outcomes after diagnosis, he doesn’t disclose how polarized and inconclusive the soy research actually is.

Geographic Limitations

Studies showing protective effects of soy are largely limited to Asian populations. Multiple meta-analyses have found that protective associations observed in Asian women don’t exist among Western women. This may relate to differences in gut bacteria (more Asians harbor bacteria that convert soy isoflavones into equol), timing of exposure (childhood versus adult), or types of soy products consumed.

Conflicting Laboratory Evidence

While Greger cites cell studies suggesting soy isoflavones can reactivate cancer-suppressing BRCA genes, other laboratory and animal research has shown soy isoflavones can enhance breast cancer growth. This contradiction highlights the limitations of extrapolating from isolated cell studies to real-world dietary recommendations.

The Omega-3 Controversy

Greger challenges the cardiovascular benefits of omega-3 fatty acids by citing a 2012 meta-analysis finding no protective effects from fish oil. However, this particular analysis became one of the most criticized publications in omega-3 research, with numerous experts identifying significant flaws:

• The average omega-3 intake across included studies was only 1.5g daily—half the amount recommended for heart disease prevention
• An unnecessarily stringent cutoff for statistical significance may have obscured real benefits
• Many participants were taking statin drugs, which might mask omega-3 effects

More recent, methodologically sound reviews support omega-3 consumption for cardiovascular protection, with physicians continuing to recommend two to three servings of oily fish weekly for high-risk patients.

Practical Takeaways for Readers

Despite its limitations, “How Not to Die” offers valuable information for anyone interested in using diet to support health:

What to Embrace

• Increase whole plant foods: The evidence supporting increased consumption of vegetables, fruits, legumes, whole grains, nuts, and seeds is robust across dietary patterns.
• Be cautious with cooking methods: If you eat meat, lower-temperature cooking methods like boiling, steaming, or slow-cooking significantly reduce formation of harmful compounds compared to grilling, frying, or high-heat roasting.
• Source quality matters: For meat eaters, choosing properly raised animals and ensuring thorough cooking can reduce infection risks.
• Question profit-driven health advice: Greger’s skepticism toward medical industry conflicts of interest is well-founded and worth maintaining.

What to Question

• Absolute dietary prescriptions: The book’s black-and-white stance on animal foods isn’t fully supported by the complexity of nutrition science.
• Single studies as proof: Be wary of strong claims based on individual studies, especially when the broader literature is mixed.
• Population-specific findings: Research findings in one population (like Asian soy studies) don’t necessarily apply universally.
• Mechanistic assumptions: Cell studies and animal research, while interesting, don’t always translate to effects in whole humans eating whole foods.

Who Should Read This Book?

“How Not to Die” serves different audiences in different ways:

Ideal for: Individuals interested in plant-based eating, those seeking motivation to increase whole food consumption, readers who enjoy diving into nutrition research, and people looking to understand potential dietary influences on chronic disease.

Less ideal for: Those seeking perfectly balanced, unbiased nutrition information, readers unable to critically evaluate health claims, or individuals prone to dietary extremes.

Conclusion: A Useful Resource With Important Caveats

“How Not to Die” represents Dr. Michael Greger’s passionate mission to empower individuals with health information. The book succeeds in presenting a comprehensive case for food as medicine and challenges readers to think critically about conventional medical approaches.

However, the systematic cherry-picking of evidence and misrepresentation of research to fit a predetermined narrative significantly undermines the book’s credibility. Readers who approach it as a starting point for exploration rather than definitive truth will benefit most.

The ideal approach to “How Not to Die” involves:

• Appreciating the extensive research compilation while recognizing its selective nature
• Embracing evidence-based recommendations for increasing whole plant food consumption
• Questioning absolute claims and investigating the cited research independently
• Recognizing that optimal nutrition likely exists on a spectrum rather than at extremes
• Consulting healthcare providers before making significant dietary changes, especially if managing chronic conditions

Ultimately, “How Not to Die” offers treasures for readers willing to navigate its weaknesses. The book’s greatest contribution may not be providing all the answers, but rather inspiring readers to ask better questions about how food influences health—and to seek those answers with the same critical thinking that should be applied to the book itself.

For those considering the plant-based approach advocated by Dr. Greger, discussing dietary changes with a qualified healthcare provider or registered dietitian can help ensure nutritional adequacy while pursuing health goals. This is particularly important for individuals with existing health conditions or those taking medications, as dietary changes can affect treatment effectiveness and nutritional requirements.

Sources:

• Nutrition Facts – Dr. Michael Greger’s Official Website
• PubMed Central – National Institutes of Health
• JAMA Network – Journal of the American Medical Association
• Nature – International Journal of Science
• Centers for Disease Control and Prevention