How Not to Die by Dr. Michael Greger: An Evidence-Based Review

Dr. Michael Greger’s “How Not to Die” has become a worldwide phenomenon since its publication, inspiring millions to reconsider their relationship with food and health. As a physician, researcher, and founder of the popular website NutritionFacts.org, Greger presents a compelling case for plant-based nutrition as the ultimate defense against chronic disease.

But does the science truly support his bold claims? This comprehensive review examines both the strengths and weaknesses of “How Not to Die,” providing readers with an honest assessment of what this influential book gets right—and where it falls short.

The Foundation: Dr. Greger’s Personal Mission

The book’s origin story is deeply personal. As a young boy, Greger witnessed his grandmother’s remarkable recovery from terminal heart disease through the Pritikin diet—a low-fat, plant-based approach that defied her doctors’ grim prognosis. This transformative experience set him on a lifelong mission to promote food as medicine.

Spanning 562 pages, “How Not to Die” tackles the leading causes of death in developed nations, from heart disease and diabetes to various cancers. Greger’s central thesis is straightforward: a whole-food, plant-based diet can prevent, arrest, and even reverse many of our most feared diseases.

The book distinguishes itself by focusing on “plant-based” eating rather than strict veganism, acknowledging that dietary perfection is neither realistic nor necessary for most people.

What “How Not to Die” Gets Right

Despite its biases, the book offers valuable insights that deserve attention from readers of all dietary backgrounds.

Empowering Patient Knowledge

Greger champions the democratization of medical information, arguing that patients shouldn’t rely solely on doctors as gatekeepers of health knowledge. This perspective is particularly relevant in an era where medical appointments are often rushed and focused on pharmaceutical interventions rather than lifestyle modifications.

His skepticism toward the “medical-industrial complex” isn’t conspiracy theory—it’s a justified concern backed by documented conflicts of interest in medical research and practice.

Comprehensive Research References

The book’s extensive bibliography demonstrates Greger’s commitment to evidence-based recommendations. With hundreds of scientific citations, readers have ample opportunity to verify claims and explore topics in greater depth.

Rehabilitation of Misunderstood Plant Foods

Greger effectively counters several common misconceptions about plant-based eating:

Fruit and Sugar: In an era of sugar-phobia, he presents compelling evidence that whole fruits don’t contribute to diabetes or weight gain the way refined sugars do. He even cites studies where participants consumed up to 20 servings of fruit daily without adverse metabolic effects.

Phytates as Protectors: Rather than viewing phytates as mere “anti-nutrients” that bind minerals, Greger explores their potential cancer-fighting properties, providing a more nuanced perspective on these compounds.

Legumes for Metabolic Health: The book examines clinical evidence showing that beans and lentils can improve insulin sensitivity, blood sugar control, and cholesterol levels—countering fears about their carbohydrate content.

Legitimate Concerns About Meat Safety

While some of Greger’s meat-related warnings rely on questionable evidence, others highlight genuine food safety issues:

Zoonotic Infections: The book discusses emerging research linking certain urinary tract infections to chicken-derived E. coli strains, suggesting that foodborne illness may be more common than traditionally believed. The antibiotic resistance of these bacteria compounds the concern.

Pork and Pathogens: Greger presents evidence connecting pork consumption to Yersinia infections (which may trigger autoimmune conditions) and hepatitis E virus, particularly in undercooked products.

High-Temperature Cooking Risks: The book thoroughly examines heterocyclic amines (HCAs)—carcinogenic compounds formed when muscle meat is cooked at high temperatures. The evidence linking grilled, fried, and well-done meat to increased cancer risk is substantial and well-documented.

Where the Evidence Gets Cherry-Picked

The book’s most significant weakness is its selective use of scientific literature—presenting research that supports plant-based eating while ignoring or misrepresenting studies that don’t.

The Oxalate Contradiction

When addressing kidney stone concerns about high-oxalate vegetables, Greger cites a study that doesn’t actually examine high-oxalate vegetable intake—only total vegetable consumption. Moreover, the researchers themselves suggested that high-oxalate vegetables in participants’ diets might have diminished the protective effects they observed.

Similarly, his citation of the EPIC-Oxford study on animal protein and kidney stones omits a crucial finding: people consuming small amounts of meat had lower kidney stone risk than strict vegetarians.

The Omega-3 Controversy

Greger challenges the cardiovascular benefits of fish-based omega-3 fats by citing a heavily criticized 2012 meta-analysis. What he doesn’t mention:

• The average omega-3 intake in the analyzed studies was only half the recommended dose for heart disease prevention
• Multiple experts published critiques pointing out statistical and methodological flaws
• More rigorous subsequent reviews have supported omega-3’s cardiovascular benefits, with researchers recommending regular oily fish consumption

Asthma and Animal Foods: The Missing Context

While Greger emphasizes associations between animal products and respiratory problems, he consistently omits findings showing protective effects from certain animal foods:

A 56-country study he cites found that seafood consumption was inversely associated with wheezing, allergic symptoms, and asthma—with fish offering more protection than any plant food measured. A Taiwanese study similarly showed seafood protecting against asthma diagnosis and breathing difficulties, outperforming soy, fruits, and vegetables.

Furthermore, an Indian study he references found that regular milk consumption was associated with lower asthma risk, while avoiding dairy was identified as a risk factor alongside smoking and alcohol use.

The Alzheimer’s Oversimplification

Greger attributes rising dementia rates in Japan and China to increased animal food consumption. However, he fails to mention that diagnostic criteria changes artificially inflated these statistics. When researchers adjusted for these changes, the correlation between animal fat and dementia disappeared.

His discussion of apoE4—a genetic variant that dramatically increases Alzheimer’s risk—selectively focuses on plant-eating Nigerians while ignoring that hunter-gatherer populations worldwide (who consume substantial animal foods) also show high apoE4 prevalence with low dementia rates.

The Soy and Breast Cancer Debate

Greger presents soy as a breast cancer fighter, citing studies showing protective effects in Asian populations. What he doesn’t adequately disclose:

• The evidence for soy’s cancer-protective effects is highly controversial and inconsistent
• Protective effects observed in Asia rarely replicate in Western populations
• Clinical trials have generally failed to demonstrate significant benefits from soy isoflavones on breast cancer risk factors
• Some research suggests soy may actually enhance breast cancer growth under certain conditions

The Japan-focused review he cites used cautious language (“possibly” decreases risk, “suggested in some but not all studies”) that his summary doesn’t reflect.

Understanding the Broader Context

The pattern of evidence selection in “How Not to Die” reveals an important lesson: nutrition science is rarely black and white. Most foods exist on a spectrum of effects that vary based on quality, preparation, quantity, individual genetics, and overall dietary context.

For instance, while Greger correctly identifies risks from conventionally raised livestock in industrial operations, he remains silent on potential benefits from pasture-raised, humanely treated animals. Similarly, his focus on isolated nutrients or food groups often overlooks the complexity of whole dietary patterns.

The Rice Diet Paradox

One of the book’s more puzzling moments involves Walter Kempner’s Rice Diet. Greger credits this program with reversing diabetic vision loss and treating kidney failure, presenting it as evidence for plant-based eating’s healing power.

The problem? The Rice Diet consisted primarily of white rice, refined sugar, and fruit juice—highly processed foods that contradict everything else Greger recommends. This disconnect highlights the challenge of maintaining a consistent narrative when cherry-picking from diverse research.

Who Should Read This Book?

“How Not to Die” serves different purposes for different readers:

For those new to nutrition science: The book provides an accessible introduction to how diet affects health, though readers should verify claims and seek additional perspectives.

For committed plant-based eaters: It offers validation and extensive references to support dietary choices, along with practical tips for optimizing plant-focused nutrition.

For omnivores: The book raises legitimate questions about food quality, preparation methods, and the potential benefits of increasing plant food consumption—even if total animal food elimination isn’t the goal.

For health professionals: It serves as a reminder of nutrition’s powerful role in disease prevention and treatment, though clinical recommendations should draw from broader, less biased sources.

Making the Most of Greger’s Research

To benefit from “How Not to Die” while avoiding its pitfalls:

Verify bold claims: Use the book’s extensive references as a starting point, but examine the original studies yourself. Check whether Greger’s interpretation aligns with the researchers’ conclusions.

Look for missing context: When a claim seems too good to be true, investigate what contrary evidence might exist. Nutrition science is rarely unanimous.

Focus on principles over ideology: The book’s strongest message—that whole, minimally processed plant foods offer substantial health benefits—doesn’t require demonizing all animal products or ignoring their potential role in a healthy diet.

Consider individual factors: Genetic variations, gut microbiome composition, existing health conditions, and personal preferences all influence optimal nutrition. One-size-fits-all approaches rarely work.

The Bigger Picture: Food Quality Matters

An often-overlooked aspect of the plant-versus-animal debate is that food quality may matter more than food category. Industrial agriculture—whether producing soybeans or chickens—raises concerns about pesticide residues, antibiotic resistance, environmental degradation, and nutrient density.

Meanwhile, both carefully sourced animal products and organic plant foods can contribute to health. The false dichotomy between “all plants good, all animal foods bad” prevents more nuanced discussions about sustainable agriculture, ethical animal husbandry, and personalized nutrition.

Final Verdict: A Valuable but Imperfect Resource

“How Not to Die” succeeds in its primary mission: demonstrating that diet powerfully influences health outcomes and that increasing whole plant food consumption benefits most people.

Greger’s passion for nutrition education is evident on every page, and his commitment to making scientific information accessible deserves recognition. The book’s extensive research compilation, even with its selective nature, provides valuable starting points for further investigation.

However, the systematic cherry-picking of evidence undermines the book’s credibility and does a disservice to readers seeking unbiased guidance. Science communication requires presenting the full picture—including uncertainties, contradictions, and limitations—not just data points supporting a predetermined conclusion.

For readers approaching the book as an introduction to plant-based nutrition rather than the final word on dietary health, “How Not to Die” offers considerable value. Those willing to fact-check claims, seek additional perspectives, and think critically about nutritional recommendations will gain the most from Greger’s work.

Ultimately, the book’s greatest contribution may be inspiring readers to take control of their health through dietary choices—even if the specific path forward looks different from Greger’s strict plant-based prescription.

Practical Takeaways

Regardless of your dietary philosophy, certain principles from “How Not to Die” deserve consideration:

• Increase consumption of vegetables, fruits, legumes, nuts, and whole grains
• Minimize processed foods, refined sugars, and excessive salt
• Choose cooking methods that reduce carcinogen formation (lower temperatures, shorter times, moist heat)
• Prioritize food quality and sourcing when possible
• View food as a powerful preventive medicine, not just fuel
• Maintain skepticism toward oversimplified nutritional narratives from any source

Before making significant dietary changes, especially if you have existing health conditions, consult with qualified healthcare providers who can offer personalized guidance based on your individual circumstances.

The quest for optimal nutrition is ongoing, and “How Not to Die” represents one voice in a complex, evolving conversation. By approaching it with both open-mindedness and critical thinking, readers can extract valuable insights while avoiding dogmatic thinking about food and health.

Sources:

• NutritionFacts.org – Dr. Michael Greger’s Research Website
• PubMed Central – National Institutes of Health Database
• JAMA Network – Medical Research Journal
• European Respiratory Journal
• Thorax – BMJ Respiratory Medicine Journal
• Nature – International Journal of Science