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

Dr. Michael Greger’s “How Not to Die” has become a phenomenon in the health and nutrition world, selling millions of copies worldwide and inspiring countless individuals to reconsider their dietary choices. This comprehensive 562-page guide promises readers the tools to prevent and reverse our most common and deadly diseases through plant-based nutrition.

But does the science truly support these ambitious claims? This in-depth review examines both the strengths and weaknesses of “How Not to Die,” providing readers with the balanced perspective needed to make informed decisions about their health.

Understanding Dr. Greger’s Mission and Background

Dr. Michael Greger’s journey into nutrition advocacy began with a personal experience. As a child, he witnessed his grandmother’s remarkable recovery from heart disease through the Pritikin diet—a low-fat, plant-based approach. Medical professionals had sent her home to die, making her recovery all the more impactful for young Greger.

This formative experience launched Greger on a lifelong mission to promote food as medicine. Today, he operates NutritionFacts.org, a popular science-based website, and has established himself as an international speaker and medical doctor specializing in nutrition. His central thesis is straightforward: whole, plant-based foods can prevent and even reverse chronic diseases, while animal products and processed foods contribute to our health decline.

The Book’s Structure and Approach

“How Not to Die” is divided into two main sections. The first explores the top fifteen causes of premature death in America, examining how dietary choices influence each condition. The second section presents Dr. Greger’s “Daily Dozen”—a checklist of foods and behaviors he recommends incorporating into daily life.

Throughout the book, Greger maintains that plant-based eating represents the optimal dietary pattern for human health. He distinguishes his recommendations from strict veganism, acknowledging that occasional indulgences are part of being human. However, he firmly positions whole plant foods as health-promoting and most other foods as detrimental.

The Strengths: Valuable Insights and Research

Despite its biases, “How Not to Die” offers numerous valuable contributions to nutrition discourse. The book excels in several important areas that deserve recognition.

Comprehensive Research Documentation

Greger provides extensive references throughout the book, drawing from thousands of peer-reviewed studies. This commitment to evidence-based information sets “How Not to Die” apart from many popular diet books. Readers interested in exploring topics further have a roadmap for additional research.

Vindication of Whole Plant Foods

In an era of carbohydrate fear and fruit anxiety, Greger presents compelling evidence that whole plant foods—including fruits—can benefit health in numerous ways. He discusses studies showing that fruit consumption doesn’t harm diabetics and can even support blood sugar management when consumed in whole form.

The book also rehabilitates the reputation of legumes, which some dietary approaches wrongly demonize. Greger presents clinical evidence showing that beans, lentils, and other legumes support healthy weight management, improve cholesterol levels, and benefit blood sugar control.

Legitimate Concerns About Meat Quality and Preparation

One of the book’s most valuable sections addresses real risks associated with conventional meat production and high-temperature cooking methods. Greger discusses zoonotic diseases—illnesses transmitted from animals to humans—and presents evidence that some infections previously thought to originate within our bodies may actually come from contaminated meat.

For example, research suggests that urinary tract infections may sometimes result from E. coli strains found in chicken meat rather than our own gut bacteria. Additionally, pork products can harbor Yersinia bacteria and hepatitis E virus, particularly when undercooked.

The book also thoroughly examines heterocyclic amines (HCAs)—carcinogenic compounds formed when muscle meat is cooked at high temperatures. Multiple studies link HCAs to increased cancer risk, and Greger appropriately advises readers about safer cooking methods, such as lower-temperature preparation and moist-heat cooking techniques.

Questioning the Medical-Industrial Complex

“How Not to Die” encourages healthy skepticism about profit-driven healthcare systems that may prioritize pharmaceutical treatments over preventive nutrition. This perspective empowers readers to take control of their health through informed dietary choices.

The Weaknesses: Cherry-Picking and Misrepresentation

While “How Not to Die” contains valuable information, it suffers from a significant flaw: selective presentation of research to support predetermined conclusions. This practice, known as cherry-picking, appears throughout the book.

Selective Citation of Studies

In numerous instances, Greger cites studies that don’t actually support his claims or ignores findings within those studies that contradict his thesis. For example, when discussing kidney stones and oxalates in vegetables, he references a study examining total vegetable intake—not specifically high-oxalate vegetables like spinach and beets.

The researchers in that study actually expressed concern that high-oxalate vegetables might increase kidney stone risk and suggested that including such vegetables could have diluted the protective effects they observed from other vegetables.

The Omega-3 Controversy

Greger challenges the cardiovascular benefits of omega-3 fatty acids from fish by citing a controversial 2012 meta-analysis. He writes that researchers found no protective benefit for heart disease, heart attacks, or strokes.

However, this particular meta-analysis received substantial criticism from the scientific community. Critics noted that the average omega-3 intake in the analyzed studies was only 1.5 grams per day—half the amount recommended for heart disease prevention. The analysis also used an unnecessarily stringent statistical cutoff that may have obscured real benefits.

Other researchers pointed out that many participants in the reviewed trials were taking statin medications, which could mask the effects of omega-3s. More recent and methodologically sound reviews have confirmed cardiovascular benefits from omega-3 consumption, with many medical organizations continuing to recommend oily fish intake for heart health.

Asthma and Animal Foods: Incomplete Evidence

When discussing respiratory health, Greger presents studies showing that plant-based diets may reduce asthma symptoms. However, he omits findings within those same studies showing that fish consumption also demonstrated protective effects—often stronger than those associated with plant foods.

In one Taiwan study he cites regarding eggs and asthma, seafood actually showed negative associations with asthma diagnosis and breathing difficulties, performing better than soy, fruit, and vegetables. Multiple studies suggest omega-3 fats in seafood reduce inflammatory compounds that worsen asthma.

Greger also references a large Indian study linking meat consumption to asthma risk while failing to mention that the same study found regular milk consumption significantly reduced asthma risk.

Dementia, Diet, and Selective Geography

Greger discusses the “Nigerian paradox”—the observation that Nigerians have high rates of the Alzheimer’s-associated apoE4 gene variant but low Alzheimer’s rates. He attributes this protective effect to traditional plant-based Nigerian diets.

However, he doesn’t acknowledge that apoE4 prevalence is highest among many indigenous hunter-gatherer populations consuming substantial amounts of animal foods—including the Inuit, various African groups, and Australian Aborigines. These populations also show low Alzheimer’s rates when consuming traditional diets.

This suggests that protection against apoE4-related Alzheimer’s risk may relate more to general dietary patterns common among traditional populations—unprocessed foods, physical activity, and natural feast-famine cycles—rather than plant-based eating specifically.

The Soy and Breast Cancer Narrative

Greger presents soy as protective against breast cancer, citing studies showing reduced risk and improved survival among women who consume soy products. However, he doesn’t disclose how controversial and inconsistent the research on soy and breast cancer actually is.

The protective effects observed in some Asian populations often fail to appear in Western populations. Multiple meta-analyses have found no benefit from soy consumption for breast cancer risk among Western women. Some researchers believe genetic or gut bacteria differences between populations may explain these discrepancies, as many Asians harbor intestinal bacteria that convert soy isoflavones into equol—a compound potentially responsible for soy’s benefits.

The inconsistency in soy research makes definitive claims about its cancer-fighting properties premature, yet Greger presents these benefits as settled science.

Understanding the “Plant-Based” Definition

Another concern involves how Greger defines “plant-based” when citing studies. In some cases, he credits plant-based eating for health improvements achieved through dietary programs that don’t align with his recommendations.

For instance, he cites the Rice Diet as evidence that plant-based eating can reverse diabetic vision loss and kidney failure. However, the Rice Diet consisted primarily of white rice, refined sugar, and fruit juice—hardly representative of the whole-food, plant-based approach Greger advocates. This inconsistency in definitions can mislead readers about which dietary patterns truly produced the observed benefits.

The Importance of Context and Quality

One significant omission in “How Not to Die” is discussion of food quality beyond the plant-versus-animal dichotomy. While Greger thoroughly documents problems with conventionally raised livestock, he doesn’t acknowledge potential differences between factory-farmed animals and those raised in humane, sustainable conditions.

Similarly, the book doesn’t deeply explore the vast differences between ultra-processed plant foods and whole plant foods, though Greger generally advocates for minimal processing. A more nuanced discussion of food quality—across all categories—would strengthen the book’s practical value.

Who Will Benefit from This Book?

“How Not to Die” offers the most value to readers who approach it as a starting point for further investigation rather than absolute truth. Those who benefit most will:

• Fact-check claims against cited references and additional sources
• Recognize that nutrition science is complex and often contradictory
• Understand that individual responses to dietary patterns vary
• Appreciate the book’s strengths while remaining aware of its limitations
• Consult healthcare providers before making significant dietary changes, especially if managing chronic conditions

The book can inspire increased plant food consumption—a change that benefits most people—while its shortcomings remind us to maintain critical thinking about all nutrition information sources.

Practical Takeaways

Despite its biases, readers can extract valuable lessons from “How Not to Die”:

Increase Whole Plant Food Consumption

The overwhelming evidence supports eating more vegetables, fruits, whole grains, legumes, nuts, and seeds. These foods provide fiber, antioxidants, vitamins, minerals, and beneficial plant compounds that support health.

Minimize Ultra-Processed Foods

Greger’s emphasis on whole foods over processed options aligns with robust scientific evidence. Reducing consumption of highly processed items benefits health regardless of one’s overall dietary pattern.

Consider Cooking Methods

The book’s discussion of HCAs in high-temperature cooked meat highlights an important consideration for meat eaters. Using gentler cooking methods—such as steaming, boiling, slow-cooking, or lower-temperature roasting—can reduce exposure to potential carcinogens.

Question Commercial Food Systems

Greger’s skepticism about profit-driven food and healthcare industries is well-founded. Being informed consumers and patients serves our health interests better than passive acceptance of marketing messages or conventional wisdom.

Prioritize Prevention

Perhaps the book’s most important message is that dietary choices profoundly influence health outcomes. While not everyone can prevent every disease through diet alone, nutrition plays a crucial role in reducing risk for many chronic conditions.

Final Verdict: A Useful but Imperfect Resource

“How Not to Die” represents Dr. Michael Greger’s passionate attempt to democratize nutrition information and empower individuals to take control of their health. The book succeeds in presenting extensive research, challenging conventional medical approaches, and making a compelling case for increasing plant food consumption.

However, the systematic cherry-picking of evidence, misrepresentation of some studies, and failure to acknowledge complexity and nuance in nutrition science significantly limit the book’s credibility. Readers seeking unbiased, comprehensive nutrition guidance will need to supplement “How Not to Die” with additional resources and perspectives.

The book works best as one voice in a larger conversation about nutrition and health—a conversation that should include diverse viewpoints, acknowledge scientific uncertainty, and respect individual variations in optimal dietary patterns.

For those committed to critical thinking and willing to verify claims independently, “How Not to Die” offers valuable insights alongside its oversimplifications. The key is approaching it with both an open mind and a discerning eye, extracting wisdom while recognizing limitations.

Ultimately, whether you choose to follow Greger’s recommendations fully, partially, or not at all, the book serves as a reminder that food choices matter—and that we all benefit from eating more whole, minimally processed foods, particularly those from plant sources.

Before making significant dietary changes based on this or any nutrition book, consult with qualified healthcare providers who can consider your individual health status, medical history, and personal needs. Nutrition is not one-size-fits-all, and what works optimally for one person may not be ideal for another.

Sources:

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