You	told	me	yourself	that	most
neurologists	don’t	like	to	take	care	of	MS	patients.”	John	could	not	believewhat	he	had	just	heard. In	a	very	tense	moment,	he	said:
Wait	a	minute. I’m	a	doctor. This	is	a	hospital. As	far	as	I	know	our	job
is	to	relieve	the	suffering	of	the	sick. These	are	sick	people. Just
because	other	doctors	can’t	help	them	in	their	suffering	doesn’t	mean
that	we	can’t. Here’s	the	evidence	that	says	we	can. I	have	an	effective
treatment	for	people	who	need	my	care	and	this	is	a	hospital. Will	you
explain	to	me	why	we	don’t	want	to	take	care	of	those	kinds	of
patients? He	continued:
I	want	to	talk	to	the	head	of	the	hospital. I	want	to	explain	to	her	why	I
need	this	program	and	why	the	hospital	needs	this	program	and	why
the	patients	need	this	program. I	want	you	to	get	me	an	appointment. Ultimately	though,	the	head	of	the	hospital	proved	to	be	just	as	difficult. John	reflected	on	the	situation	with	his	wife. He	was	supposed	to	renew	his
contract	with	the	hospital	in	a	couple	of	weeks,	and	he	decided	not	to	do	it. He	left	on	cordial	terms,	and	to	this	day	he	does	not	hold	personal	grudges. He	just	explains	it	by	saying	that	their	directions	in	life	were	different. John
would	prefer	to	remember	St.	Helena	for	what	it	was:	a	good	home	to	him	for
sixteen	years,	but	a	place	nonetheless	that	was	“just	into	that	whole	drug
money	thing.”
Now,	John	runs	a	highly	successful	“lifestyle	medicine”	program	with	his
family’s	help,	writes	a	popular	newsletter	that	he	makes	freely	available
(
http://www.drmcdougall.com
),	organizes	group	trips	with	past	patients	and
new	friends	and	has	more	time	to	go	windsurfing	when	the	wind	picks	up	on
Bodega	Bay. This	is	a	man	with	a	wealth	of	knowledge	and	qualifications,
who	could	benefit	the	health	of	millions	of	Americans. He	has	never	been
challenged	by	any	of	his	colleagues	for	physician	“misbehavior,”	and	yet	the
medical	establishment	does	not	want	his	services. He	is	reminded	of	this	fact
all	the	time:
Patients	will	come	in	with	rheumatoid	arthritis. They’ll	be	in
wheelchairs,	they	can’t	even	turn	the	key	on	their	car. And	I’ll	take	care
of	them	and	three	or	four	weeks	later,	they’ll	go	back	to	see	their
doctor. They’ll	walk	up	to	their	doctor,	grab	their	hand	and	shake	it
hard. Doctor	will	say,	“Wonderful.”	The	patient,	all	excited,	will	say,
“Well,	I	want	to	tell	you	what	I	did. I	went	to	see	this	Dr.	McDougall,	I
changed	my	diet,	and	now	my	arthritis	is	gone.”	Their	doctor	simplyresponds,	“Oh	my	goodness. That’s	great. Whatever	you’re	doing,	just
keep	doing	it. I’ll	see	you	later.”	That’s	always	the	response. It’s	not,
“Please,	my	god,	tell	me	what	you	did	so	I	can	tell	the	next	patient.”
It’s,	“Whatever	you’re	doing,	that’s	just	great.”	If	the	patient	starts	to
tell	them	they	changed	to	a	vegetarian	diet,	the	doctor	will	cut	in	with,
“Yeah	okay,	fine,	you’re	really	a	strong	person. Thanks	a	lot. See	you
later.”	Get	them	out	of	the	office	as	quickly	as	they	can. It’s	very
threatening…	very	threatening.ESSELSTYN’S	REWARD
Back	in	Ohio,	Dr.	Esselstyn	retired	from	active	surgery	in	June	of	2000	and
assumed	the	position	of	preventive	cardiology	consultant	in	the	department	of
general	surgery	at	the	Cleveland	Clinic. He	has	continued	
to	do	research	and
to	visit	with	patients. He	holds	three-hour	counseling	sessions	in	his	home
with	new	heart	disease	patients,	gives	them	research	evidence	and	provides	a
delicious	“heart-safe”	meal. In	addition,	he	gives	talks	around	the	country	and
abroad. In	March	of	2002,	Ess	and	his	wife	Ann,	whose	grandfather	founded	the
Cleveland	Clinic,	drafted	a	letter	to	the	head	of	the	cardiology	department	and
the	head	of	the	hospital	at	the	Cleveland	Clinic. The	letter	started	off	by
saying	how	proud	they	were	of	the	reputation	and	excellence	of	the	Clinic	and
the	innovation	of	the	surgical	procedures,	but	that	everyone	recognized	that
surgery	was	never	going	to	be	the	answer	to	this	epidemic	of	heart	disease. Ess	formally	proposed	the	idea	that	he	could	help	set	up	an	arrest	and	reversal
dietary	program	in	the	department	of	preventive	cardiology	at	the	Cleveland
Clinic. The	program	would	mirror	his	own	and	could	be	administered	by
nurse	clinicians	and	physician	assistants. Ideally,	a	young	physician	with
passion	for	the	idea	would	head	the	program. Ultimately,	every	patient	with
heart	disease	at	the	Clinic	would	be	offered	the	option	of	arrest	and	reversal
therapy	using	dietary	means,	which	costs	very	little,	harbors	no	risks	and	puts
the	control	back	into	the	patients’	hands. You’d	think	that	if	an	opportunity	arose	to	profoundly	heal	sick	people,
and	one	of	the	most	reputable	people	in	the	country	was	going	to	help	you,	a
hospital	would	jump	at	the	opportunity. But	after	being	one	of	the	star
surgeons	at	the	Cleveland	Clinic	for	decades,	after	initiating	a	heart	reversal
study	that	had	greater	success	than	anything	ever	done	at	the	Clinic,	and	after
graciously	offering	a	plan	to	help	heal	even	more	people,	neither	the	head	of
the	hospital	nor	the	department	head	had	the	respect	to	even	acknowledge	that
Ess	had	written	to	them. They	didn’t	call. They	didn’t	write. They	completely
ignored	him. Seven	weeks	passed,	and	finally	Ess	called	the	department	head	and	the
hospital	head,	and	neither	of	them	would	take	his	call. Finally,	after	seven
calls,	the	head	of	the	hospital	got	on	the	phone. This	man	had	praised	Ess	for
years	for	his	research	and	seemed	excited	by	his	results,	but	now	he	was
singing	a	different	tune. He	obviously	knew	exactly	what	Ess	was	calling
about,	and	told	Ess	that	the	head	of	the	cardiology	department	didn’t	want	to
do	it. In	other	words,	he	just	passed	the	buck. If	the	head	of	the	hospital
wanted	it	to	be	done,	it	would	be	done,	regardless	of	what	the	head	ofcardiology	wanted. So	Ess	called	the	head	of	cardiology,	who	finally	took	his
call. The	man	was	abrasive	and	rude. He	made	it	clear	he	had	no	interest	in
what	Ess	was	trying	to	do. Ess	hasn’t	talked	to	either	of	these	doctors	since,	but	he	still	has	hope	that
he	can	change	their	minds	as	more	and	more	research	supports	what	he	has
been	saying. Meanwhile,	many	people	at	the	Clinic	are	still	excited	about
Ess’s	work. Many	of	them	want	to	see	a	wider	application	of	his	program,	but
the	powers	that	be	will	not	let	it	happen. They	get	frustrated,	and	Ess	is
frustrated	because	the	current	program	in	preventive	cardiology	is	a	disaster:
They	still	eat	meat,	they	still	eat	dairy,	and	they	don’t	have	any
cholesterol	goal. It’s	all	just	so	vague. Preventive	cardiology	takes
great	pride	when	they	are	able	to	slow	the	rate	of	progression	of	this
disease. This	isn’t	cancer	for	God’s	sake! An	interesting	situation	is	now	developing:	just	as	with	Dr.	McDougall,
many	of	the	Clinic	“bigwigs”	with	heart	disease	have	themselves	gone	to
Esselstyn	for	treatment	and	lifestyle	counseling. They	know	it	works,	and
they	seek	out	the	program	on	their	own. As	Ess	says,	this	could	be	developing
into	a	very	interesting	crisis:
I	have	now	treated	a	number	of	senior	staff	with	coronary	disease	at	the
Clinic—senior	staff	physicians. I	have	also	treated	a	number	of	senior
staff	trustees. One	of	the	trustees	knows	about	the	frustrations	that
we’ve	had	trying	to	get	this	into	the	Clinic,	and	he	says,	“I	think,	if	the
word	gets	out	that	Esselstyn	has	this	treatment	that	arrests	and	reverses
this	disease	at	the	Cleveland	Clinic,	and	it’s	been	used	by	senior	staff
and	he’s	treated	senior	trustees,	but	he’s	not	permitted	to	treat	the
common	herd,	we	could	be	open	for	a	lawsuit.”
For	the	time	being,	Ess,	with	his	wife’s	help,	will	continue	to	run
counseling	sessions	out	of	his	own	home	because	the	institution	to	which	he
gave	the	greater	part	of	his	life	does	not	want	to	endorse	a	dietary	approach
that	competes	with	its	standard	menu	of	pills	and	procedures. This	past
summer	Ess	spent	much	more	time	than	usual	at	his	upstate	New	York	farm,
making	hay. As	much	as	Ess	likes	a	more	relaxed	life,	he	would	also	love	to
continue	to	help	diseased	people	get	better	with	the	aid	of	the	Cleveland
Clinic. But	they	won’t	allow	him	to
. As	far	as	I	am	concerned,	this	is	nothing
short	of	criminal. We,	the	public,	turn	to	doctors	and	hospitals	in	times	of
great	need. For	them	to	provide	care	that	is	knowingly	less	than	optimal,	that
doesn’t	protect	our	health,	doesn’t	heal	our	disease	and	costs	us	tens	ofthousands	of	dollars	is	morally	inexcusable. Ess	sums	up	the	situation:
The	Clinic	is	now	injecting	stem	cells	to	try	to	make	new	heart	vessels
grow. Wouldn’t	it	be	easier	to	stop	the	disease? It’s	appalling,	isn’t	it? It’s	just	so	grippingly	unbelievable	to	think	that	we’re	being	led	around
by	people	who	refuse	to	believe	the	obvious! Both	Esselstyn	and	McDougall	have	now	been	denied	reentry	into	the
establishment,	after	headline-making	success	at	healing	people	with	a
nutritional	approach. You	can	focus	on	the	money—according	to	John	and
Ess,	80%	of	St.	Helena’s	and	65%	of	the	Cleveland	Clinic’s	respective
incomes	were	generated	by	traditional	heart	disease	treatments,	surgical
interventions—but	it’s	something	more	than	just	money. It	may	also	be	the
intellectual	threat	that	the	patient	should	be	in	control,	and	not	the	doctor;	that
something	as	simple	as	food	could	be	more	powerful	than	all	the	knowledge
of	pills	and	high-tech	procedures;	it	may	be	the	lack	of	credible	nutrition
education	in	medical	school;	it	may	be	the	influence	of	the	drug	industry. Whatever	it	is,	it	has	become	clear	that	the	medical	industry	in	this	country	is
not	protecting	our	health	as	it	should. As	McDougall	reaches	his	arms	out,
palms	up,	and	scrunches	his	shoulders	up,	he	simply	says,	“It’s	beyond
comprehension.”18
Repeating	Histories
I
N
	1985,	when	I	was	on	sabbatical	in	Oxford,	England,	I	had	the	opportunity
to	study	the	history	of	diet	and	disease	at	some	of	the	great	medical	history
libraries	in	the	Western	world. I	made	use	of	the	famous	Bodlean	Library	in
Oxford	and	the	London	libraries	of	the	Royal	College	of	Surgeons	and	the
Imperial	Cancer	Research	Fund. In	the	quiet	recesses	of	these	marble-lined
sanctuaries,	I	was	thrilled	to	find	authors	who	wrote	eloquently	on	the	topic	of
diet	and	cancer,	among	other	diseases,	over	150	years	ago. One	such	author	was	George	Macilwain,	who	wrote	fourteen	books	on
medicine	and	health. Macilwain	was	born	and	raised	in	Northern	Ireland. He
later	moved	to	London	where	he	became	a	prominent	surgeon	in	the	early
1800s. He	was	to	become	a	member,	and	later,	an	honorary	fellow,	of	the
Royal	College	of	Surgeons. He	became	vegetarian	at	the	age	of	forty,	after
identifying	“grease,	fat	and	alcohol”	as	being	the	chief	causes	of	cancer. 1
Macilwain	also	popularized	the	theory	of	the	“constitutional	nature	of
disease,”	mostly	in	reference	to	the	origins	and	treatment	of	cancer. The	constitutional	nature	of	disease	concept	meant	that	disease	is	not	the
result	of	one	organ,	one	cell	or	one	reaction	gone	awry	or	the	result	of	one
external	cause	acting	independently. It	is	the	result	of	
multiple	systems
throughout	the	body	breaking	down
. Opposing	this	view	was	the	local	theory
of	disease,	which	said	that	disease	is	caused	by	a	single	external	agent	acting
at	a	specific	site	in	the	body. At	that	time,	a	fierce	fight	was	under	way
between	those	who	believed	in	diet	and	those	who	
supported	surgery	and	the
emerging	use	of	drugs. The	“local	disease”	proponents	argued	that	disease
was	locally	caused	and	could	be	cut	out	or	locally	treated	with	isolated
chemicals. In	contrast,	those	who	favored	diet	and	lifestyle	believed	thatdisease	was	a	symptom	resulting	from	the	“constitutional”	characteristics	of
the	whole	body. I	was	impressed	that	these	old	books	contained	the	same	ideas	about	diet
and	disease	that	had	resurfaced	in	the	health	battles	of	the	1980s. As	I	learned
more	about	Macilwain,	I	came	to	realize	that	he	was	a	relative	of	mine. My
paternal	grandmother’s	maiden	name	was	Macilwain,	and	that	“branch”	of	the
family	had	lived	in	the	same	part	of	Northern	Ireland	that	George	Macilwain
had	come	from. Furthermore,	there	were	family	stories	about	a	famous
Macilwain	who	had	left	the	family	farm	in	Ireland	to	become	a	very	well-
known	doctor	in	London	in	the	early	1800s. My	father,	who	had	emigrated
from	Northern	Ireland,	had	referred	to	an	Uncle	George	when	I	was	young,
but	I	never	was	aware	of	who	this	man	was. Through	further	genealogical
research,	I	have	come	to	the	near	certain	conclusion	that	George	Macilwain
was	my	great-great	uncle. This	discovery	has	been	one	of	the	more	remarkable	stories	of	my	life. My
wife	Karen	says,	“If	there’s	such	a	thing	as	reincarnation.…”	I	agree:	if	I	ever
lived	a	past	life,	it	was	as	George	Macilwain. He	and	I	had	similar	careers;
both	of	us	became	acutely	aware	of	the	importance	of	diet	in	disease,	and	both
of	us	became	vegetarian. Some	of	his	ideas,	written	over	150	years	ago,	were
so	close	to	what	I	believed	that	I	felt	they	could	have	come	from	my	own
mouth. I	discovered	more	than	my	family	history	while	reading	in	these	august,
history-laden	libraries. I	found	out	that	scholars	have	been	arguing	over	the
nature	of	health	for	centuries,	even	millennia. Almost	2,500	years	ago,	Plato
wrote	a	dialogue	between	two	characters,	Socrates	and	Glaucon,	in	which
they	discuss	the	future	of	their	cities. Socrates	says	the	cities	should	be
simple,	and	the	citizens	should	subsist	on	barley	and	wheat,	with	“relishes”	of
salt,	olives,	cheese	and	“country	fare	of	boiled	onions	and	cabbage,”	with
desserts	of	“figs,	pease,	beans,”	roasted	myrtle-berries	and	beechnuts,	and
wine	in	moderation. 2
	Socrates	says,	“And	thus,	passing	their	days	in
tranquility	and	sound	health,	they	will,	in	all	probability,	live	to	an	advanced
age.…”
But	Glaucon	replies	that	such	a	diet	would	only	be	appropriate	for	“a
community	of	swine,”	and	that	the	citizens	should	live	“in	a	civilized
manner.”	He	continues,	“They	ought	to	recline	on	couches…	and	have	the
usual	dishes	and	dessert	of	a	modern	dinner.”	In	other	words,	the	
citizens
should	have	the	“luxury”	of	eating	meat. Socrates	replies,	“if	you	wish	us	also
to	contemplate	a	city	that	is	suffering	from	inflammation	
We	shall	also	need
great	quantities	of	all	kinds	of	cattle	for	those	who	may	wish	to	eat	them,	shall
we	not?”Glaucon	says,	“Of	course	we	shall.”	Socrates	then	says,	“Then	shall	we
not	experience	the	need	of	medical	men	also	to	a	much	greater	extent	under
this	than	under	the	former	regime?”	Glaucon	can’t	deny	it. “Yes,	indeed,”	he
says. Socrates	goes	on	to	say	that	this	luxurious	city	will	be	short	of	land
because	of	the	extra	acreage	required	to	raise	animals	for	food. This	shortage
will	lead	the	citizens	to	take	land	from	others,	which	could	precipitate
violence	and	war,	thus	a	need	for	justice. Furthermore,	Socrates	writes,	“when
dissoluteness	and	diseases	abound	in	a	city,	are	not	law	courts	and	surgeries
opened	in	abundance,	and	do	not	Law	and	Physic	begin	to	hold	their	heads
high,	when	numbers	even	of	well-born	persons	devote	themselves	with
eagerness	to	these	professions?”	In	other	words,	in	this	luxurious	city	of
sickness	and	disease,	lawyers	and	doctors	will	become	the	norm. 2
Plato,	in	this	passage,	made	it	perfectly	clear:	we	shall	eat	animals	only	at
our	own	peril. Though	it	is	indeed	remarkable	that	one	of	the	greatest
intellectuals	in	the	history	of	the	Western	world	condemned	meat	eating
almost	2,500	years	ago,	I	find	it	even	more	remarkable	that	few	know	about
this	history. Hardly	anybody	knows,	for	example,	that	the	father	of	Western
medicine,	Hippocrates,	advocated	diet	as	the	chief	way	to	prevent	and	treat
disease	or	that	George	Macilwain	knew	that	diet	was	the	way	to	prevent	and
treat	disease	or	that	the	man	instrumental	in	founding	the	American	Cancer
Society,	Frederick	L.	Hoffman,	knew	that	diet	was	the	way	to	prevent	and
treat	disease. How	did	Plato	predict	the	future	so	accurately? He	knew	that	consuming
animal	foods	would	not	lead	to	true	health	and	prosperity. Instead,	the	false
sense	of	rich	luxury	granted	by	being	able	to	eat	animals	would	only	lead	to	a
culture	of	sickness,	disease,	land	disputes,	lawyers	and	doctors. This	is	a
pretty	good	description	of	some	of	the	challenges	faced	by	modern	America! How	did	Seneca,	one	of	the	great	scholars	2,000	years	ago,	a	tutor	and
advisor	to	Roman	Emperor	Nero,	know	with	such	certainty	the	trouble	with
consuming	animals	when	he	wrote
2
:
An	Ox	is	satisfied	with	the	pasture	of	an	acre	or	two:	one	wood	suffices
for	several	Elephants. Man	alone	supports	himself	by	the	
pillage	of	the
whole	earth	and	sea. What! Has	Nature	indeed	given	us	so	insatiable	a
stomach,	while	she	has	given	us	so	insignificant	bodies?…	The	slaves
of	the	belly	(as	says	Sallust)	are	to	be	counted	in	the	number	of	the
lower	animals,	not	of	men. Nay,	not	of	them,	but	rather	of	the	dead.…
You	might	inscribe	on	their	doors,	“These	have	anticipated	death.”
How	did	George	Macilwain	predict	the	future	when	he	said	that	the	localtheory	of	disease	would	not	lead	to	health? Even	today,	we	don’t	have	any
pills	or	procedures	that	effectively	prevent,	eliminate	or	even	treat	the	causes
of	any	chronic	diseases. The	most	promising	preventions	and	treatments	have
now	been	shown	to	be	diet	and	lifestyle	changes,	a	constitutional	approach	to
health. How	did	we	forget	these	lessons	from	the	past? How	did	we	go	from
knowing	that	the	best	athletes	in	the	ancient	Greek	Olympics	must	consume	a
plant-based	diet	to	fearing	that	vegetarians	don’t	get	enough	protein? How	did
we	get	to	a	place	where	the	healers	of	our	society,	our	doctors,	know	little,	if
anything,	about	nutrition;	where	our	medical	institutions	denigrate	the
subject;	where	using	prescription	drugs	and	going	to	hospitals	is	the	third
leading	cause	of	death? How	did	we	get	to	a	place	where	advocating	a	plant-
based	diet	can	jeopardize	a	professional	career,	where	scientists	spend	more
time	mastering	nature	than	respecting	it? How	did	we	get	to	a	place	where	the
companies	that	profit	from	our	sickness	are	the	ones	telling	us	how	to	be
healthy;	where	the	companies	that	profit	from	our	food	choices	are	the	ones
telling	us	what	to	eat;	where	the	public’s	hard-earned	money	is	being	spent	by
the	government	to	boost	the	drug	industry’s	profits;	and	where	there	is	more
distrust	than	trust	of	our	government’s	policies	on	foods,	drugs	and	health? How	did	we	get	to	a	place	where	Americans	are	so	confused	about	what	is
healthy	that	they	no	longer	care? Our	country’s	population,	which	numbers	almost	300	million	people,
3
	is
sick. 82%	of	American	adults	have	at	least	one	risk	factor	for	heart	disease
4
81%	of	Americans	take	at	least	one	medication	during	any	given	week
5
50%	of	Americans	take	at	least	one	prescription	drug	during	any	given
week
5
65%	of	American	adults	are	overweight
6
31%	of	American	adults	are	obese
6
Roughly	one	in	three	youths	in	America	(ages	six	to	nineteen)	is	already
overweight	or	at	risk	of	becoming	overweight
About	105	million	American	adults	have	dangerously	high	cholesterol
levels
7
	(defined	as	200	mg/dL	or	higher—heart-safe	cholesterol	level	is
under	150	mg/dL)
About	50	million	Americans	have	high	blood	pressure
8
Over	63	million	American	adults	have	pain	in	the	lower	back
(considerably	related	to	circulation	and	excess	body	weight,	both
influenced	by	diet	and	aggravated	by	physical	inactivity)	during	anygiven	three-month	period
9
Over	33	million	American	adults	have	a	migraine	or	severe	headache
during	any	given	three-month	period
9
23	million	Americans	had	heart	disease	in	2001
9
At	least	16	million	Americans	have	diabetes
Over	700,000	Americans	died	from	heart	disease	in	2000
Over	550,000	Americans	died	from	cancer	in	2000
Over	280,000	Americans	died	from	cerebro-vascular	diseases	(stroke),
diabetes	or	Alzheimer’s	in	2000
At	the	great	peril	of	ignoring	the	warnings	of	Plato	and	others,	America
has,	in	the	words	of	Seneca,	“anticipated	death.”	Starvation,	poor	sanitation
and	communicable	diseases,	symbols	of	impoverishment,	have	been	largely
minimized	in	the	Western	world. Now	we	have	an	urgency	of	excess,	and
some	of	the	previously	less	developed	countries	are	racing	to	get	where	we
are. Never	before	have	such	large	percentages	of	the	population	died	from
diseases	of	“affluence.”	Is	this	the	affluence	that	Socrates	predicted	2,500
years	ago—a	society	full	of	doctors	and	lawyers	wrestling	with	the	problems
caused	by	people	living	luxuriously	and	eating	cattle? Never	before	have	so
many	people	suffered	such	high	levels	of	obesity	and	diabetes. Never	before
has	the	financial	strain	of	health	care	distressed	every	sector	of	our	society,
from	business	to	education	to	government	to	everyday	families	with
inadequate	insurance. If	we	have	to	decide	between	health	insurance	for	our
teachers	and	textbooks	for	our	kids,	which	will	we	choose? Never	before	have	we	affected	the	natural	environment	to	such	an	extent
that	we	are	losing	our	topsoil,	our	massive	North	American	aquifers,	and	our
world’s	rainforests. 10
	We	are	changing	our	climate	so	rapidly	that	many	of	the
world’s	best-informed	scientists	fear	the	future. Never	before	
have	we	been
eliminating	plant	and	animal	species	from	the	face	of	the	earth	as	we	are
doing	now. Never	before	have	we	introduced,	on	such	a	large	scale,
genetically	altered	varieties	of	plants	into	the	environment	without	knowing
what	the	repercussions	will	be. All	of	these	changes	in	our	environment	are
strongly	affected	by	what	we	choose	to	eat. 11
As	the	billions	of	people	in	the	developing	world	are	accumulating	more
wealth	and	adopting	the	Western	diet	and	lifestyle,	problems	created	by
nutritional	excess	are	becoming	exponentially	more	urgent	with	each	passing
year. In	1997,	the	director-general	of	the	World	Health	Organization,	Dr.
Hiroshi	Nakajima,	referred	to	the	future	chronic	disease	burden	in	developing
countries	as	“a	crisis	of	suffering	on	a	global	scale.”
12
We’ve	fumbled	around	for	the	past	2,500	years,	building	up	theunsustainable	behemoth	that	we	now	call	modern	society. We	certainly	won’t
have	another	2,500	years	to	remember	the	teachings	of	Plato,	Pythagoras,
Seneca	and	Macilwain;	we	won’t	even	have	250	years. From	this	urgency
arises	great	opportunity,	and	because	of	that	I	am	filled	with	hope. People	are
beginning	to	sense	the	need	for	change	and	are	beginning	to	question	some	of
the	most	basic	assumptions	that	we	have	about	food	and	health. People	are
beginning	to	understand	the	conclusions	of	scientific	literature	and	are
changing	their	lives	for	the	better. Never	before	has	there	been	such	a	mountain	of	empirical	research
supporting	a	whole	foods,	plant-based	diet. Now,	for	example,	we	can	obtain
images	of	the	arteries	in	the	heart,	and	then	show	conclusively,	as	Drs. Dean
Ornish	and	Caldwell	Esselstyn,	Jr.,	have	done,	that	a	whole	foods,	plant-based
diet	reverses	heart	disease. 13
	We	now	have	the	knowledge	to	understand	how
this	actually	works. Animal	protein,	even	more	than	saturated	fat	and	dietary
cholesterol,	raises	blood	cholesterol	levels	in	experimental	animals,	individual
humans	and	entire	populations. International	comparisons	between	countries
show	that	populations	subsisting	on	traditional	plant-based	diets	have	far	less
heart	disease,	and	studies	of	individuals	within	single	populations	show	that
those	who	eat	more	whole,	plant-based	foods	not	only	have	lower	cholesterol
levels,	but	have	less	heart	disease. We	now	have	a	deep	and	broad	range	of
evidence	showing	that	a	whole	foods,	plant-based	diet	is	best	for	the	heart
. Never	before	have	we	had	such	a	depth	of	understanding	of	how	diet
affects	cancer	both	on	a	cellular	level	as	well	as	a	population	level. Published
data	show	that	animal	protein	promotes	the	growth	of	tumors. Animal	protein
increases	the	levels	of	a	hormone,	IGF-1,	which	is	a	risk	factor	for	cancer,	and
high-casein	(the	main	protein	of	cow’s	milk)	diets	allow	more	carcinogens
into	cells,	which	allow	more	dangerous	carcinogen	
products	to	bind	to	DNA,
which	allow	more	mutagenic	reactions	that	give	rise	to	cancer	cells,	which
allow	more	rapid	growth	of	tumors	once	they	are	initially	formed. Data	show
that	a	diet	based	on	animal-based	foods	increases	a	female’s	production	of
reproductive	hormones	over	her	lifetime,	which	may	lead	to	breast	cancer. We
now	have	a	deep	and	broad	range	of	evidence	showing	that	a	whole	foods,
plant-based	diet	is	best	for	cancer
. Never	before	have	we	had	technology	to	measure	the	biomarkers
associated	with	diabetes,	and	the	evidence	to	show	that	blood	sugar,	blood
cholesterol	and	insulin	levels	improve	more	with	a	whole	foods,	plant-based
diet	than	with	any	other	treatment. Intervention	studies	show	that	Type	2
diabetics	treated	with	a	whole	foods,	plant-based	diet	may	reverse	their
disease	and	go	off	their	medications. A	broad	range	of	international	studies
shows	that	Type	1	diabetes,	a	serious	autoimmune	disease,	is	related	to	cow’smilk	consumption	and	premature	weaning. We	now	know	how	our
autoimmune	system	can	attack	our	own	bodies	through	a	process	of	molecular
mimicry	induced	by	animal	proteins	that	find	their	way	into	our	bloodstream. We	also	have	tantalizing	evidence	linking	multiple	sclerosis	with	animal	food
consumption,	and	especially	dairy	consumption. Dietary	intervention	studies
have	shown	that	diet	can	help	slow,	and	perhaps	even	halt,	multiple	sclerosis. We	now	have	a	deep	and	broad	range	of	evidence	showing	that	a	whole	foods,
plant-based	diet	is	best	for	diabetes	and	autoimmune	diseases
. Never	before	have	we	had	such	a	broad	range	of	evidence	showing	that
diets	containing	excess	animal	protein	can	destroy	our	kidneys. Kidney	stones
arise	because	the	consumption	of	animal	protein	creates	excessive	calcium
and	oxalate	in	the	kidney. We	know	now	that	cataracts	and	age-related
macular	degeneration	can	be	prevented	by	foods	containing	large	amounts	of
antioxidants. In	addition,	research	has	shown	that	cognitive	dysfunction,
vascular	dementia	caused	by	small	strokes	and	Alzheimer’s	are	all	related	to
the	food	we	eat. Investigations	of	human	populations	show	that	our	risk	of	hip
fracture	and	osteoporosis	is	made	worse	by	diets	high	in	animal-based	foods. Animal	protein	leeches	calcium	from	the	bones	by	creating	an	acidic
environment	in	the	blood. We	now	have	a	deep	and	broad	range	of	evidence
showing	that	a	whole	foods,	plant-based	diet	is	best	for	our	kidneys,	bones,
eyes	and	brains
. More	research	can	and	should	be	done,	but	the	idea	that	whole	foods,
plant-based	diets	can	protect	against	and	even	treat	a	wide	variety	of	chronic
diseases	can	no	longer	be	denied. No	longer	are	there	just	a	few	people
making	claims	about	a	plant-based	diet	based	on	their	personal	
experience,
philosophy	or	the	occasional	supporting	scientific	study. Now	there	are
hundreds	of	detailed,	comprehensive,	well-done	research	studies	that	point	in
the	same	direction. Furthermore,	I	have	hope	for	the	future	because	of	our	new	ability	to
exchange	information	across	the	country	and	around	the	world. A	much
greater	proportion	of	the	world	population	is	literate,	and	a	much	greater
proportion	of	that	population	has	the	luxury	of	choosing	what	they	eat	from	a
wide	variety	of	readily	accessible	foods. People	can	make	a	whole	foods,
plant-based	diet	varied,	interesting,	tasty	and	convenient. I	have	hope	because
people	in	small	towns	and	in	previously	isolated	parts	of	the	country	can	now
readily	access	cutting	edge	health	information	and	put	it	into	practice. All	of	these	things	together	create	an	atmosphere	unlike	any	other,	an
atmosphere	that	demands	change. Contrary	to	the	situation	in	1982,	when	a
few	colleagues	tried	to	destroy	the	reputations	of	scientists	who	suggested	that
diet	had	anything	to	do	with	cancer,	it	is	now	more	commonly	accepted	thatwhat	you	eat	can	determine	your	risk	of	multiple	cancers. I	have	also	seen	the
public	image	of	vegetarianism	emerge	from	being	considered	a	dangerous,
passing	fad	to	a	healthful,	enduring	lifestyle	choice. The	popularity	of	plant-
based	diets	has	been	increasing,	and	both	the	variety	and	availability	of
convenient	vegetarian	foods	have	been	skyrocketing. 14
	Restaurants	around
the	country	now	regularly	offer	meat-free	and	dairy-free	options. 15
	Scientists
are	publishing	more	articles	about	vegetarianism	and	writing	more	about	the
health	potential	of	a	plant-based	diet. 16
	Now,	over	150	years	after	my	great-
great	uncle	George	Macilwain	wrote	books	about	diet	and	disease,	I	am
writing	a	book	about	diet	and	disease	with	the	help	of	my	youngest	son	Tom. Tom’s	middle	name	is	McIlwain	(the	family	changed	the	spelling	over	the
past	couple	of	generations),	which	means	that	not	only	am	I	writing	about
many	of	the	same	ideas	Macilwain	wrote	about,	but	a	relative	bearing	his
name	is	the	co-author. History	can	repeat	itself. This	time,	however,	instead	of
the	message	being	forgotten	and	confined	to	library	stacks,	I	believe	that	the
world	is	finally	ready	to	accept	it. More	than	that,	I	believe	the	world	is
finally	ready	to	change. We	have	reached	a	point	in	our	history	where	our	bad
habits	can	no	longer	be	tolerated. We,	as	a	society,	are	on	the	edge	of	a	great
precipice:	we	can	fall	to	sickness,	poverty	and	degradation,	or	we	can
embrace	health,	longevity	and	bounty. And	all	it	takes	is	the	courage	to
change. How	will	our	grandchildren	find	themselves	in	100	years? Only	time
will	tell,	but	I	hope	that	the	history	we	are	witnessing	and	the	future	that	lies
ahead	will	be	to	the	benefit	of	us	all.APPENDIX	A
Q&A:	Protein	Effect	in	Experimental	Rat	Studies
COULD	THE	DIETARY	PROTEIN	EFFECT	BE
DUE	TO	OTHER	NUTRIENTS	IN	THE	RAT
DIET? Decreasing	dietary	protein	from	20%	to	5%	means	finding	something	to
replace	the	missing	15%. We	used	a	carbohydrate	to	replace	the	casein
because	it	had	the	same	energy	content. As	dietary	protein	decreased,	a	1:1
mixture	of	starch	and	glucose	increased	by	the	same	amount. The	extra	starch
and	glucose	in	the	low-protein	diets	could	not	have	been	responsible	for	the
lower	development	of	foci	because	these	carbohydrates,	when	tested	alone,
actually	increase	foci	development. 1
	If	anything,	a	little	extra	carbohydrate	in
the	low-protein	diet	would	only	increase	cancer	incidence	and	offset	the	low-
protein	effect. This	makes	prevention	of	cancer	by	low-protein	diets	even
more	impressive.MIGHT	THE	PROTEIN	EFFECT	BE	DUE	TO
THE	RATS	ON	A	LOW-PROTEIN	DIET	EATING
LESS	FOOD	(I.E.,	LESS	CALORIES)? Many	studies	done	in	the	1930s,	1940s	and	1950s
2
	had	shown	that	decreasing
total	food	intake,	or	total	calories,	decreased	tumor	development. A	review	of
our	many	experiments,	however,	showed	that	animals	led	the	low-protein
diets	did	not	consume	less	calories	but,	on	
average,	actually	consumed	more
calories. 3,	4
	Again,	this	only	reinforced	the	tumor-promoting	effect	observed
for	casein.WHAT	WAS	THE	OVERALL	HEALTH	OF	THE
RATS	ON	A	LOW-PROTEIN	DIET? Many	researchers	have	long	assumed	that	animals	fed	diets	this	low	in	protein
would	not	be	healthy. However,	the	low-protein	animals	were	healthier	by
every	indication. They	lived	longer,	were	more	physically	active,	were
slimmer	and	had	healthy	hair	coats	at	100	weeks	while	the	high-protein
counterpart	rats	were	all	dead. Also,	animals	consuming	less	dietary	casein
not	only	ate	more	calories,	but	they	also	burned	off	more	calories. Low-
protein	animals	consumed	more	oxygen,	which	is	required	for	the	burning	of
these	calories,	and	had	higher	levels	of	a	special	tissue	called	brown	adipose
tissue,
5,	6
	which	is	especially	effective	in	burning	off	calories. This	occurs
through	a	process	of	“thermogenesis,”	i.e.,	the	expenditure	of	calories	as	body
heat. This	phenomenon	had	already	been	demonstrated	many	years	before. 7–
11
	
Low-protein	diets	enhance	the	burning	off	of	calories,	thus	leaving	less
calories	for	body	weight	gain	and	perhaps	also	less	for	tumor	growth	as	well
.WAS	PHYSICAL	ACTIVITY	RELATED	TO	THE
CONSUMPTION	OF	THE	LOW-PROTEIN	DIET? To	measure	the	physical	activity	of	each	group	of	rats,	we	compared	how
much	they	voluntarily	operated	an	exercise	wheel	attached	to	their	cages. A
monitor	recorded	the	number	of	times	the	animals	turned	the	exercise	wheel. The	low-casein	animals
12
	exercised	about	twice	as	much,	when	measured
over	a	two-week	period! This	observation	seems	to	be	very	similar	to	how
one	feels	after	eating	a	high-protein	meal:	sluggish	and	sleepy. I	have	heard
that	a	side	effect	of	the	protein-drenched	Atkins	Diet	is	fatigue. Have	you	ever
noticed	this	feeling	in	yourself	after	a	high-protein	meal?APPENDIX	B
Experimental	Design	of	the	China	Study
S
IXTY-FIVE	COUNTIES
	in	twenty-four	different	provinces	(out	of	twenty-seven)
were	selected	for	the	survey. They	represented	the	full	range	of	mortality	rates
for	seven	of	the	more	common	cancers. They	also	provided	broad	geographic
coverage	and	were	within	four	hours’	travel	time	of	a	central	laboratory. The
survey	counties	represented:
semitropical	coastal	areas	of	southeast	China;
frigid	wintry	areas	in	northeast	China,	near	Siberia;
areas	near	the	Great	Gobi	desert	and	the	northern	steppes;
and	areas	near	or	in	the	Himalaya	Mountains	ranging	from	the	far
northwest	to	the	far	southwest	part	of	the	country
Except	for	suburban	areas	near	Shanghai,	most	counties	were	located	in
rural	China	where	people	lived	in	the	same	place	their	entire	lives	and
consumed	locally	produced	food. Population	densities	varied	widely,	from
20,000	nomadic	residents	for	the	most	remote	county	near	the	Great	Gobi
desert,	to	1.3	million	people	for	the	county	on	the	outskirts	of	Shanghai. This	survey	is	referred	to	as	an	ecological	or	correlation	study	design,
meaning	that	we	are	comparing	diet,	lifestyle	and	disease	characteristics	of	a
number	of	sample	populations,	in	this	case	the	sixy-five	counties. We
determine	how	these	characteristics,	as	county	averages,	correlate	
or	associate
with	each	other. For	example,	how	does	dietary	fat	relate	to	breast	cancer
rates? Or	how	does	blood	cholesterol	relate	to	coronary	heart	disease? How
does	a	certain	kind	of	fatty	acid	in	red	blood	cells	relate	to	rice	consumption? We	could	also	compare	blood	testosterone	levels	or	estrogen	levels	with
breast	cancer	risk. We	did	thousands	of	different	comparisons	of	this	type. In	a	study	of	this	kind,	it	is	important	to	note	that	only	the	average	values
for	county	populations	are	being	compared. Individuals	are	not	being
compared	with	individuals	(in	reality,	neither	does	any	other	epidemiological
study	design). As	ecological	studies	go,	this	study,	with	its	sixy-five	counties,
was	unusually	large. Most	such	studies	only	have	ten	to	twenty	such
population	units,	at	most.Each	of	the	sixty-five	counties	provided	100	adults	for	the	survey. One-
half	were	male	and	one-half	female,	all	aged	thirty-five	to	sixty-four	years. The	data	were	collected	in	the	following	manner:
each	person	volunteered	a	blood	sample	and	completed	a	diet	and
lifestyle	questionnaire;
one-half	of	the	people	provided	a	urine	sample;
the	survey	teams	went	to	30%	of	the	homes	to	carefully	measure	food
consumed	by	the	family	over	a	three-day	period;
samples	of	food	representing	the	typical	diets	at	each	survey	site	were
collected	at	the	local	marketplace	and	were	later	analyzed	for	dietary	and
nutritional	factors. One	of	the	more	important	questions	during	the	early	planning	stages	was
how	to	survey	for	diet	and	nutrition	information. Estimating	consumption	of
food	and	nutrients	from	memory	is	a	common	method,	but	this	is	very
imprecise,	especially	when	mixed	dishes	are	consumed. Can	you	remember
what	foods	you	ate	last	week,	or	even	yesterday? Can	you	remember	how
much? Another	even	more	crude	method	of	estimating	food	intake	is	to	see
how	much	of	each	food	is	sold	in	the	marketplace. These	findings	can	give
reasonable	estimates	of	diet	trends	over	time	for	whole	populations,	but	they
do	not	account	for	food	waste	or	measure	individual	amounts	of	consumption. Although	each	of	these	relatively	crude	methods	can	be	useful	for	certain
purposes,	they	still	are	subject	to	considerable	technical	error	and	personal
bias. And	the	bigger	the	technical	error,	the	more	difficult	it	is	to	detect
significant	cause-effect	associations. We	wanted	to	do	better	than	crudely	measure	which	foods	and	how	
much
of	these	foods	were	being	consumed. Thus	we	decided	to	evaluate	nutritional
conditions	by	analyzing	blood	and	urine	samples	for	indicators	(biomarkers)
of	multiple	nutrient	intakes. These	analyses	would	be	far	more	objective	than
having	people	recall	what	they	ate. Collecting	and	analyzing	blood,	however,	was	not	easy	to	arrange,	at	least
not	in	the	way	that	we	preferred. The	initial	problem	was	getting	
enough
blood. For	cultural	reasons,	rural	Chinese	were	reluctant	to	provide	blood
samples. A	finger	prick	seemed	to	be	the	only	possibility	but	this	was	not
good	enough. A	regular	vial	of	blood	would	give	100	times	as	much	blood
and	allow	for	analyses	of	many	more	factors. Dr.	Junshi	Chen	of	our	team,	at	the	Institute	of	Nutrition	and	Food
Hygiene	in	the	Ministry	of	Health,	had	the	unenviable	task	of	convincing
these	volunteers	to	give	a	regular	vial	of	blood. He	succeeded. Sir	Richard
Peto	at	the	University	of	Oxford	of	our	team	then	made	the	very	practicalsuggestion	of	combining	the	individual	blood	samples	to	make	a	big	pool	of
blood	for	each	village	for	each	sex. This	strategy	gave	more	than	1,200–1,300
times	more	blood	when	compared	with	the	finger	prick	method. Making	big	pools	of	blood	had	enormous	implications	and	made	possible
the	China	Study,	as	it	later	became	known. It	allowed	analyses	of	far	more
indicators	of	diet	and	health. This	allowed	us	to	consider	relationships	in	a	far
more	comprehensive	manner	than	would	have	otherwise	been	possible. For
more	detail	on	the	theoretical	and	practical	basis	for	collecting	and	analyzing
blood	in	this	way	the	reader	is	referred	to	the	original	monograph	of	the
study. 1
After	collecting	the	blood,	we	then	had	to	decide	who	would	do	the	many
analyses	that	were	possible. We	wanted	nothing	but	the	best. While	some
analyses	were	conducted	at	our	Cornell	lab	and	at	Dr.	Chen’s	Beijing	lab,	the
rest	of	the	analyses,	especially	the	more	specialized	types,	were	done	in	about
two	dozen	laboratories	located	in	six	countries	and	in	four	continents. Laboratories	were	selected	because	of	their	demonstrated	expertise	and
interest. The	laboratory	participants	are	listed	in	the	original	monograph. 1HOW	GOOD	IS	THIS	STUDY? Because	this	survey	was	a	one-of-a-kind	opportunity,	we	intended	that	it	be
the	best	of	its	kind	ever	undertaken. It	was	comprehensive;	it	was	high
quality;	and	its	uniqueness	allowed	new	opportunities	to	investigate	diet	and
disease	that	were	never	before	possible. These	features	
of	comprehensiveness,
quality	and	uniqueness	greatly	improved	the	credibility	and	reliability	of	the
findings—by	far. Indeed,	the	
New	York	Times
,	in	a	lead	story	in	its	Science
Section,	called	the	study	“The	Grand	Prix”	of	epidemiological	studies.COMPREHENSIVENESS	OF	DATA
This	survey	was,	and	still	is,	the	most	comprehensive	of	its	kind	ever
undertaken. After	all	the	blood,	urine	and	food	samples	were	collected,	stored
and	analyzed,	and	after	the	final	results	were	tabulated	and	evaluated	for
quality	(a	few	suspect	results	were	not	included	in	the	final	publication),	we
were	able	to	study	367	variables. These	represented	a	wide	variety	of	dietary,
lifestyle	and	disease	characteristics,	now	included	in	a	dense	896-page
monograph. 1
	There	were:
disease	mortality	rates	on	more	than	forty-eight	different	kinds	of
disease
2
;
109	nutritional,	viral,	hormonal	and	other	indicators	in	blood;
over	twenty-four	urinary	factors;
almost	thirty-six	food	constituents	(nutrients,	pesticides,	heavy	metals);
more	than	thirty-six	specific	nutrient	and	food	intakes	measured	in	the
household	survey;
sixty	diet	and	lifestyle	factors	obtained	from	questionnaires;
and	seventeen	geographic	and	climatic	factors. The	study	was	comprehensive,	not	only	because	of	the	sheer	number	of
variables,	but	also	because	most	of	these	variables	varied	over	broad	ranges,
as	with	the	cancer	mortality	rates. Broad	ranges	strengthened	our	ability	to
detect	important	previously	undiscovered	associations	of	variables.QUALITY	OF	DATA
A	number	of	features	added	quality	to	this	study. The	adults	chosen	for	this	survey	were	limited	to	those	who	were	thirty-
five	to	sixty-four	years	of	age. This	is	the	age	range	in	which	the	diseases
being	investigated	are	more	common. Information	on	death	certificates
of	people	older	than	sixty-four	years	was	not	included	in	the	survey
because	this	information	was	considered	less	reliable. In	each	of	the	sixty-five	counties	in	the	study	two	villages	were	selected
for	the	collection	of	the	information. Having	two	villages	in	each	county
rather	than	one	gives	a	more	reliable	county	average. When	the	values	of
two	villages	are	more	similar	to	each	other	than	to	all	the	other	counties,
then	this	means	higher-quality	data. 3
When	possible,	variables	were	measured	by	more	than	one	kind	of
method. For	example,	iron	status	was	measured	in	six	different	ways,
riboflavin	(vitamin	B
2
)	in	three	ways,	and	so	forth. Also,	in	many	cases,
we	could	assess	the	quality	and	reliability	of	data	by	comparing	variables
known	to	have	plausible	biological	relationships. The	populations	under	study	proved	to	be	very	stable. An	average	of	93–
94%	of	the	men	in	the	survey	were	born	in	the	county	where	they	lived
at	the	time	of	the	survey;	for	women	it	was	89%. Also,	according	to	data
published	by	the	World	Bank,
4
	the	diets	at	the	time	of	our	survey	were
very	similar	to	those	consumed	in	earlier	years. This	was	ideal	because
those	earlier	years	represented	the	time	when	the	diseases	were	initially
forming.UNIQUENESS	OF	DATA
One	idea	that	makes	our	study	unique	is	our	use	of	the	ecologic	study	design. Critics	of	the	ecologic	study	design	correctly	assume	that	it	is	a	weak	design
for	determining	cause-and-effect	associations	when	one	is	interested	in	the
effects	of	single	causes	acting	on	single	outcomes. But	this	is	not	the	way	that
nutrition	works. Rather,	nutrition	causes	or	prevents	disease	by	multiple
nutrients	and	other	chemicals	acting	together,	as	in	foods. An	ecologic	study
is	almost	ideal	if	we	wish	to	learn	how	an	array	of	dietary	factors	act	together
to	cause	disease. It	is	the	comprehensive	effects	of	nutrients	and	other	factors
on	disease	occurrence	where	the	most	important	lessons	are	to	be	learned. To
investigate	these	comprehensive	causes	of	disease,	it	was	therefore	necessary
to	record	as	many	dietary	and	other	lifestyle	factors	as	possible,	then
formulate	hypotheses	and	interpret	data	that	represent	comprehensiveness. Perhaps	the	most	unique	characteristic	that	set	this	study	apart	concerned
the	nutritional	characteristics	of	the	diets	consumed	in	rural	China. Virtually
every	other	human	study	on	diet	and	health,	of	whatever	design,	has	involved
subjects	who	were	consuming	a	rich	Western	
diet. This	is	true	even	when
vegetarians	are	included	in	the	study	because	90%	of	vegetarians	still
consume	rather	large	amounts	of	milk,	cheese	and	eggs,	while	a	significant
number	still	consume	some	fish	and	poultry. As	is	shown	in	the
accompanying	chart	(
Chart	B.1
),
5
	there	is	only	a	small	difference	in	the
nutritional	properties	of	non-vegetarian	and	vegetarian	diets	as	consumed	in
Western	countries. CHART	B.1:	VEGETARIAN	AND	NON-VEGETARIAN	DIET
COMPARISONS	AMONG	WESTERNERS
Nutrient
Vegetarian
Non	-	vegetarian
Fat	(%	of	calories)
30–36
34–38
Cholesterol	(g/day)
150–300
300–500
Carbohydrates	(%	of	calories)
50–55
<50
Total	protein	(%	of	calories)
12–14
14–18
Animal	protein	(%	of	total	protein)
40–60
60–70
A	strikingly	different	dietary	situation	existed	in	China. In	America,	15–
17%	of	our	total	calories	is	provided	by	protein,	and	upwards	of	80%	of	this
amount	is	animal-based. In	other	words,	we	gorge	on	protein	and	we	get	most
of	it	from	meat	and	dairy	products. But	in	rural	China,	they	consume	less
protein	overall	(9–10%	of	total	calories),	and	only	10%	of	it	comes	fromanimal-based	foods. This	means	that	there	are	many	other	major	nutritional
differences	in	the	Chinese	and	American	diets,	as	shown	in	
Chart	B.2
. 1
CHART	B.2:	CHINESE	AND	AMERICAN	DIETARY	INTAKES
Nutrient
China
United	States
Calories	(kcal/kg	body	wt./day)
40.6
30.6
Total	fat	(%	of	calories)
14.5
34–38
Dietary	fiber	(g/day)
33
12
Total	protein	(g/day)
64
91
Animal	protein	(%	of	total	calories)
0.8*
10–11
Total	iron	(mg/day)
34
18
*Non-fish	animal	protein
This	was	the	first	and	only	large	study	that	investigated	this	range	of
dietary	experience	and	its	health	consequences. Chinese	diets	ranged	from
rich	to	very	rich	in	plant-based	foods. In	all	other	studies	done	on	Western
subjects,	diets	ranged	from	rich	to	very	rich	in	animal-based	foods. It	was	this
distinction	that	made	the	China	Study	so	different	from	other	studies.MAKING	IT	HAPPEN
Organization	and	conduct	of	a	study	of	this	size,	scope	and	quality	was
possible	because	of	the	exceptional	skills	of	Dr.	Junshi	Chen. Survey	sites
were	scattered	across	the	far	reaches	of	China. In	American	travel	distances,
they	ranged	from	the	Florida	Keys	to	Seattle,	Washington,	and	from	San
Diego,	California,	to	Bangor,	Maine. Travel	between	these	places	was	more
difficult	than	in	the	United	States,	and	supplies	and	instructions	for	the	survey
had	to	be	in	place	and	standardized	for	all	collection	sites. And	this	was	done
before	e-mails,	fax	machines	and	cellular	phones	were	available. It	was	important	that	the	twenty-four	provincial	health	teams,	each
comprised	of	twelve	to	fifteen	health	workers,	be	trained	to	carry	out	the
blood,	food	and	urine	collections	and	complete	the	questionnaires	in	a
systematic	and	standardized	manner. To	standardize	the	collection	of
information,	Dr.	Chen	divided	the	country	into	regions. Each	region	sent
trainers	to	Beijing	for	the	senior	training	session. They,	in	turn,	returned	to
their	home	provinces	to	train	the	provincial	health	teams. Although	the	U.S.	National	Cancer	Institute	(NCI)	of	the	National
Institutes	of	Health	(NIH)	provided	the	initial	funding	for	this	project,	the
Chinese	Ministry	of	Health	paid	the	salaries	of	the	approximately	350	health
workers. It	is	my	estimate	that	the	Chinese	contribution	to	the	project	was
approximately	$5–6	million. This	compares	with	the	U.S.	contribution	of
about	$2.9	million	over	a	ten-year	period. Were	the	U.S.	government	to	have
paid	for	this	service	in	a	similar	project	in	the	U.S.,	it	would	have	cost	at	least
ten	times	this	amount,	or	$50–60	million.APPENDIX	C
The	“Vitamin”	D	Connection
T
HE	MOST	IMPRESSIVE	EVIDENCE
	favoring	plant-based	diets	is	the	way	that	so
many	food	factors	and	biological	events	are	integrated	to	maximize	health	and
minimize	disease. Although	the	biological	processes	are	exceptionally
complex,	these	factors	still	work	together	as	a	beautifully	choreographed,
self-correcting	network. It	is	exceptionally	impressive,	especially	the
coordination	and	control	of	this	network. Perhaps	a	couple	of	analogies	might	help	to	illustrate	such	a	process. Flocks	of	birds	in	flight	or	schools	of	fish	darting	about	are	able	to	shift
direction	in	a	microsecond	without	bumping	into	each	other. They	seem	to
have	a	collective	consciousness	that	knows	where	they	are	going	and	when
they	will	rest. Colonies	of	ants	and	swarms	of	bees	also	integrate	varying
labor	chores	with	great	proficiency. But	as	amazing	as	these	animal	activities
are,	have	you	ever	thought	about	how	their	behaviors	are	coordinated	with
such	finesse? I	see	these	same	characteristics,	and	more,	in	the	way	that	the
countless	factors	of	plant-based	foods	work	their	magic	to	create	health	at	all
levels	within	our	body,	among	our	organs	and	between	our	cells	and	among
the	enzymes	and	other	sub-cellular	particles	within	our	cells. For	those	unfamiliar	with	biomedical	research	laboratories,	the	walls	of
these	labs	are	often	covered	with	large	posters	showing	thousands	of
biochemical	reactions	operating	within	our	bodies. These	are	reactions	that
are	known;	far	more	remain	to	be	discovered. The	interdependence	of	these
reactions	with	each	other	is	especially	informative,	even	awesome	in	its
implications. An	example	of	a	very	small	portion	of	this	enormous	network	of	reactions
is	the	effect	of	vitamin	D	and	its	metabolites	on	several	of	the	diseases
discussed	in	this	book. This	particular	network	illustrates	a	complex
interconnection	between	the	inner	workings	of	our	cells,	the	food	we	eat	and
the	environment	in	which	we	live	(
Chart	C.1
). Although	some	of	the	vitamin
D	present	in	our	bodies	may	come	from	food,	we	can	usually	get	all	that	we
need	from	a	few	hours	of	sunshine	each	week. In	fact,	it	is	our	ability	to	make
our	vitamin	D	that	leads	to	the	idea	that	it	is	not	a	vitamin;	it	is	a	hormone(i.e.,	made	in	one	part	of	our	body	but	functioning	in	another	part). The	sun’s
UV	rays	make	vitamin	D	from	a	precursor	chemical	located	in	our	skin. Provided	we	get	adequate	sunshine,	this	is	all	the	vitamin	D	we	need. 1
	We
can,	of	course,	also	get	vitamin	D	from	fortified	milk,	certain	fish	oils	and
some	vitamin	supplements. The	vitamin	D	made	in	our	skin	then	travels	to	our	liver,	where	it	is
converted	by	an	enzyme	to	a	vitamin	D	metabolite. This	metabolite’s	main
function	is	to	serve	as	the	body’s	storage	form	of	vitamin	D	(while	remaining
mostly	in	the	liver	but	also	in	body	fat). The	next	step	is	the	crucial	one. When	needed,	some	of	the	storage	form	of
vitamin	D	in	the	liver	is	transported	to	the	kidney,	where	another	enzyme
converts	it	into	a	supercharged	vitamin	D	metabolite,	which	is	called	1,25	D.
The	rate	at	which	the	storage	form	of	vitamin	D	is	converted	to	the
supercharged	1,25	D	is	a	crucial	reaction	in	this	network. The	1,25	D
metabolite	does	most	of	the	important	work	of	vitamin	D	in	our	bodies. This	supercharged	1,25	D	is	about	1,000	times	more	active	than	the
storage	vitamin	D.	Supercharged	1,25	D	only	survives	for	six	to	eight	hours
once	it	is	made. In	contrast,	our	storage	vitamin	D	survives	for	twenty	days	or
more. 2,	3
	This	demonstrates	an	important	principle	typically	found	in
networks	like	this:	the	far	greater	activity,	the	far	shorter	lifetime	and	the	far
lower	amounts	of	the	1,25	D	end	product	provide	a	very	responsive	system
wherein	the	1,25	D	can	quickly	adjust	its	activity	minute-by-minute	and
microsecond-by-microsecond	as	long	as	there	is	sufficient	storage	vitamin	D
to	draw	from. Small	changes,	making	a	big	difference,	can	occur	quickly. The	relationship	between	the	storage	form	of	vitamin	D	and	the
supercharged	1,25	D	is	like	having	a	large	tank	of	natural	gas	buried	in	our
yard	(storage	vitamin	D)	but	carefully	using	only	a	very	tiny	amount	of	gas	to
light	the	burner	at	our	stovetop. It	is	critical	that	the	amount	and	timing	of	gas
(1,25	D)	coming	to	our	stovetop	be	carefully	
regulated,	regardless	of	how
much	there	may	be	in	the	tank,	whether	it	is	low	or	whether	it	is	full. However,	it	is	also	useful	that	we	maintain	an	adequate	supply	in	our	storage
tank. In	the	same	way,	it	is	critical	that	the	kidney	enzyme	in	this	reaction	has
a	soft,	sensitive	touch,	so	to	speak,	as	it	produces	the	right	amount	of	the	1,25
D	at	the	right	time	for	its	very	important	work.CHART	C.1:	THE	VITAMIN	D	NETWORK
One	of	the	more	important	things	that	vitamin	D	does,	mostly	through	its
conversion	to	supercharged	1,25	D,	is	to	control	the	development	of	a	wide
variety	of	serious	diseases. For	the	sake	of	simplicity,	this	is	schematically
represented	by	showing	the	inhibition	of	the	conversion	of	healthy	tissue	to
diseased	tissue	by	1,25	D.
4–12
So	far,	we	can	see	how	adequate	sunshine	exposure,	by	ensuring	enough
storage	form	of	vitamin	D,	helps	to	prevent	cells	from	becoming	diseased. This	suggests	that	certain	diseases	might	be	more	common	in	areas	of	the
world	where	there	is	less	sunshine,	in	countries	nearer	the	North	and	South
Poles. Indeed	there	is	such	evidence. To	be	more	specific:	
in	the	northern
hemisphere,	communities	that	are	farther	north	tend	to	have	more	Type	1
diabetes,	multiple	sclerosis,	rheumatoid	arthritis,	osteoporosis,	breast	cancer,
prostate	cancer	and	colon	cancer,	in	addition	to	other	diseases
. Researchers	have	known	for	eighty	years	that	multiple	sclerosis,	for
example,	is	associated	with	increasing	latitude. 13
	As	you	can	see	in	
Chart	C.2
,
there	is	a	huge	difference	in	MS	prevalence	as	one	goes	away	from	the
equator,	being	over	100	times	more	prevalent	in	the	far	north	than	at	the
equator. 14
	Similarly,	in	Australia,	there	is	less	sunshine	and	
more	MS	as	one
goes	farther	south	(r=91%). 15
	MS	is	about	sevenfold	greater	in	southern
(43°S)	than	in	northern	Australia	(19°S). 16CHART	C.2:	WORLDWIDE	DISTRIBUTION	OF	MS	FOR	120
COUNTRIES
A	lack	of	sunshine,	however,	is	not	the	only	factor	related	to	these
diseases. There	is	a	larger	context. The	first	thing	to	note	is	the	control	and
coordination	of	these	vitamin	D-related	reactions. Control	operates	at	several
places	in	this	network,	but,	as	I	already	said,	it	is	the	conversion	of	storage
vitamin	D	into	the	supercharged	1,25	D	in	the	kidneys	that	is	especially
critical. In	considerable	measure,	this	control	is	exercised	by	another	complex
network	of	reactions	involving	a	“manager”-type	hormone	produced	by	the
parathyroid	gland	located	in	our	neck	(
Chart	C.3
). When,	for	example,	we	need	more	1,25	D,	parathyroid	hormone	induces
the	kidney	enzyme	activity	to	produce	more	1,25	D.	When	there	is	enough
1,25	D,	parathyroid	hormone	slows	down	the	kidney	enzyme	
activity. Within
seconds,	parathyroid	hormone	manages	how	much	1,25	D	there	will	be	at
each	time	and	place. Parathyroid	hormone	also	acts	as	a	conductor	at	several
other	places	in	this	network,	as	shown	by	the	several	arrows. By	being	aware
of	the	role	of	each	player	in	its	“orchestra,”	it	coordinates,	controls	and	finely
tunes	these	reactions	as	a	conductor	would	a	symphony	orchestra. Under	optimal	conditions,	sunshine	exposure	alone	can	supply	all	the
vitamin	D	that	we	need	to	produce	the	all-important	1,25	D	at	the	right	time.Even	the	elderly,	who	are	not	able	to	produce	as	much	vitamin	D	from
sunshine,	have	nothing	to	worry	about	if	there	is	enough	sunshine. 17
	How
much	is	“enough”? If	you	know	how	much	sunshine	causes	a	slight	redness	of
your	skin,	then	one-fourth	of	this	amount,	provided	two	to	three	times	per
week,	is	more	than	adequate	to	meet	our	vitamin	D	needs	and	to	store	some	in
our	liver	and	body	fat. 17
	If	your	skin	becomes	slightly	red	after	about	thirty
minutes	in	the	sun,	then	ten	minutes,	three	times	per	week	will	be	enough
exposure	to	get	plenty	of	vitamin	D.
When	and	if	we	don’t	get	enough	sunshine,	it	may	be	helpful	to	consume
vitamin	D	from	our	diets. Almost	all	of	the	vitamin	D	found	in	our	diet	has
been	artificially	added	to	foods	like	milk	and	breakfast	cereals. Along	with
vitamin	supplements,	this	amount	of	vitamin	D	can	be	quite	significant	and,
under	certain	circumstances,	there	is	some	evidence	that	this	practice	may	be
beneficial. 18–21
In	this	scheme,	sunshine	and	parathyroid	hormone	work	together	in	a
marvelously	coordinated	way	to	keep	this	system	running	smoothly,	both	in
filling	our	vitamin	D	tank	and	in	helping	to	produce	from	moment	to	moment
the	exact	amount	of	1,25	D	that	we	need. When	it	comes	to	getting	sufficient
sunshine	or	getting	vitamin	D	in	food,	taking	light	from	the	sun	makes	far
more	sense.THROWING	WRENCHES	INTO	THE	SYSTEM
There	are	several	studies	now	showing	that	if	1,25	D	remains	at	consistently
low	levels,	the	risk	of	several	diseases	increases. So	then	the	question	is:	what
causes	low	levels	of	1,25	D? Animal	protein-containing	foods	cause	a
significant	decrease	in	1,25	D.
22
	These	proteins	create	an	acidic	environment
in	the	blood	that	blocks	the	kidney	enzyme	from	producing	this	very
important	metabolite. 23
A	second	factor	that	influences	this	process	is	calcium. Calcium	in	our
blood	is	crucial	for	optimum	muscle	and	nerve	functioning,	and	it	
must	be
maintained	within	a	fairly	narrow	range. The	1,25	D	keeps	the	blood	levels	of
calcium	operating	within	this	narrow	range	by	monitoring	and	regulating	how
much	calcium	is	absorbed	from	food	being	digested	in	the	intestine,	how
much	calcium	is	excreted	in	the	urine	and	feces	and	how	much	is	exchanged
with	the	bone,	the	big	supply	tank	for	the	body’s	calcium. For	example,	if
there	is	too	much	calcium	in	the	blood,	1,25	D	becomes	less	active,	less
calcium	is	absorbed	and	more	calcium	is	excreted. It	is	a	very	sensitive
balancing	act	in	our	bodies. As	blood	calcium	goes	up,	1,25	D	goes	down,
and	when	blood	calcium	goes	down,	1,25	D	goes	up. 10,	24
	Here’s	the	kicker:	if
calcium	consumption	is	unnecessarily	high,	it	lowers	the	activity	of	the
kidney	enzyme	and,	as	a	consequence,	the	level	of	1,25	D.
1,	25
	In	other	words,
routinely	consuming	high-calcium	diets	is	not	in	our	best	interests. CHART	C.3:	ROLE	OF	THE	PARATHYROID	HORMONE	IN	THE
REGULATION	OF	SUPERCHARGED	1,25	D
The	blood	levels	of	1,25	D	therefore	are	depressed	both	by	consuming	too
much	animal	protein	and	too	much	calcium. Animal-based	food,	with	its
protein,	depresses	1,25	D.	Cow’s	milk,	however,	is	high	both	in	protein	andcalcium. In	fact,	in	one	of	the	more	extensive	studies	on	MS	that	is	associated
with	lower	levels	of	1,25	D,	cow’s	milk	was	found	to	be	as	important	a	factor
as	latitude	mentioned	earlier. 26
	For	example,	the	association	of	MS	with
latitude	and	sunshine	shown	in	
Chart	C.2
	also	is	seen	with	animal-based	foods
shown	in	
Chart	C.4
. 14
One	could	hypothesize	that	diseases	like	MS	are	due,	at	least	in	part,	to	a
lack	of	sunshine	and	lower	vitamin	D	status. This	is	supported	by	the
observation	that	northern	people	living	along	coastlines	(e.g.,	Norway	
and
Japan)
26
	who	consume	lots	of	vitamin	D-rich	fish	have	less	MS	than	people
living	inland. However,	in	these	fish-eating	communities	with	lower	rates	of
disease,	much	less	cow’s	milk	is	consumed. Consuming	cow’s	milk	has	been
shown	to	associate	with	MS
26
	and	Type	1	diabetes
27
	independent	of	fish
intake. In	another	reaction	associated	with	this	network,	increased	intakes	of
animal	protein	also	enhance	the	production	of	insulin-like	growth	factor	(IGF-
1,	first	introduced	in	chapter	eight)	and	this	enhances	cancer	cell	growth. 5
	In
effect,	there	are	many	reactions	acting	in	a	co-ordinated	and	mutually
consistent	way	to	cause	disease	when	a	diet	high	in	animal	protein	is
consumed. When	blood	levels	of	1,25	D	are	depressed,	IGF-1	simultaneously
becomes	more	active. Together,	these	factors	increase	the	birth	of	new	cells
while	simultaneously	inhibiting	the	removal	of	old	cells,	both	favoring	the
development	of	cancer	(seven	studies	cited	by
28
). For	example,	people	with
higher-than-normal	blood	levels	of	IGF-I	have	been	shown	to	have	5.1	times
the	risk	of	advanced-stage	prostate	cancer. 28
	If	combined	with	low	blood
levels	of	a	protein	that	inactivates	IGF-I
29
	(i.e.,	more	IGF-1	activity),	there	is
9.5	times	the	risk	of	advanced-stage	prostate	cancer
. 28
	This	level	of	disease
risk	is	alarming. Fundamental	to	it	all	is	the	fact	that	animal-based	foods	like
meat	and	dairy
30–32
	lead	to	more	IGF-I	and	less	1,25	D,	both	of	which
increase	cancer	risk.CHART	C.4:	WORLDWIDE	DISTRIBUTION	OF	CALORIE
CONSUMPTION	FROM	ANIMAL-BASED	FOODS	FOR	120
COUNTRIES
14
These	are	only	a	few	of	the	factors	and	events	associated	with	this	vitamin
D	network. With	the	right	food	and	environment,	these	events	and	reactions
cooperate	in	an	integrated	manner	to	produce	health	benefits. In	contrast,
when	the	wrong	food	is	consumed,	its	adverse	effects	are	mediated	by	not
one,	but	many,	of	the	reactions	within	this	network. Also,	many	factors	in
such	foods,	even	beyond	the	protein	and	calcium,	participate	in	causing	the
problem. And,	finally,	it	often	is	not	one	disease	but	many	that	are	likely	to
occur. What	impresses	me	about	this	and	other	networks	is	the	convergence	of	so
many	disease-causing	factors	operating	through	so	many	different	reactions	to
produce	a	common	result. When	that	common	result	is	more	than	one	disease,
it	is	even	more	impressive. When	these	various	factors	are	found	in	one	type
of	food	and	this	food	is	epidemiologically	related	to	one	or	more	of	these
diseases,	the	associations	become	still	more	impressive. This	example	begins
to	explain	why	dairy	foods	would	be	expected	to	increase	the	risk	of	these
diseases. There	is	no	way	that	so	many	intricate	mechanisms,	operating	in
such	synchrony	to	produce	the	same	result,	are	only	a	random	unimportanthappenstance. Nature	would	not	have	been	so	devious	as	to	refine	such	a
useless	internally	conflicting	maze. Networks	like	this	exist	throughout	the
body	and	within	the	cells. But	of	even	more	importance,	they	are	highly
integrated	into	a	far	larger	dynamic	called	“life.”ReferencesPART	IChapter	1
1
. American	Cancer	Society. “Cancer	Facts	and	Figures—1998.”	Atlanta,
GA:	American	Cancer	Society	1998. 2
. Flegal	KM,	Carroll	MD,	Ogden	CL,	et	al. “Prevalence	and	trends	in
obesity	among	U.S.	adults,	1999–2000.”	
JAMA
	288	(2002):	1723–1727. 3
. National	Center	for	Health	Statistics. “Obesity	still	on	the	rise,	new	data
show. The	U.S.	Department	of	Health	and	Human	Services	News
Release.”	October	10,	2003. Washington,	DC:	2002. Accessed	at
http://www.cdc.gov/nchs/releases/02news/obesityonrise.htm
4
. Lin	B-H,	Guthrie	J,	and	Frazao	E.	“Nutrient	Contribution	of	Food	Away
from	Home.”	
In:
	E.	Frazao	(ed. ),	
America’s	Eating	Habits:	Changes	and
Consequences
. Washington,	DC:	Economic	Research	Service,	USDA,
1999. Cited	on	p.	138	in:	Information	Plus. Nutrition:	a	key	to	good
health
. Wylie,	TX:	Information	Plus,	1999. 5
. Mokdad	AH,	Ford	ES,	Bowman	BA,	et	al. “Diabetes	trends	in	the	U.S.:
1990–1998.”	
Diabetes
	Care	23	(2000):	1278–1283. 6
. Centers	for	Disease	Control	and	Prevention. “National	Diabetes	Fact
Sheet:	National	Estimates	and	General	Information	on	Diabetes	in	the
United	States,	Revised	Edition.”	Atlanta,	GA:	Centers	for	Disease
Control	and	Prevention,	1998. 7
. American	Diabetes	Association. “Economic	consequences	of	diabetes
mellitus	in	the	U.S.	in	1997.”	
Diabetes	Care
	21	(1998):	296–309. Cited
In:	Mokdad	AH,	Ford	ES,	Bowman	BA,	et	al. “Diabetes	trends	in	the
U.S.:	1990–1998.”	
Diabetes	Care
	23	(2000):	1278–1283. 8
. American	Heart	Association. “Heart	Disease	and	Stroke	Statistics—2003
Update.”	Dallas,	TX:	American	Heart	Association,	2002. 9
. Ornish	D,	Brown	SE,	Scherwitz	LW,	et	al. “Can	lifestyle	changes	reverse
coronary	heart	disease?”	
Lancet
	336	(1990):	129–133. 10
. Esselstyn	CB,	Ellis	SG,	Medendorp	SV,	et	al. “A	strategy	to	arrest	and
reverse	coronary	artery	disease:	a	5-year	longitudinal	study	of	a	single
physician’s	practice.”	
J. Family	Practice
	41	(1995):	560–568. 11
. Starfield	B. “Is	U.S.	health	really	the	best	in	the	world?”	
JAMA
	284
(2000):	483–485. 12
. Anderson	RN. “Deaths:	leading	causes	for	2000.”	
National	Vital
Statistics	Reports
	50(16)	(2002):
13
. Phillips	D,	Christenfeld	N,	and	Glynn	L.	“Increase	in	U.S.	medication-
error	death	between	1983	and	1993.”	
Lancet
	351	(1998):	643–644. 14
. U.S.	Congressional	House	Subcommittee	Oversight	Investigation. “Costand	quality	of	health	care:	unnecessary	surgery.”	Washington,	DC:	1976. Cited	by:	Leape,	L.	“Unnecessary	surgery.”	
Ann. Rev. Publ. Health
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(1992):	363–383. 15
. Lazarou	J,	Pomeranz	B,	and	Corey	PN. “Incidence	of	adverse	drug
reactions	in	hospitalized	patients.”	JAMA	279	(1998):	1200–1205. 16
. World	Health	Organization. Technical	Report	Series	No. 425. “International	Drug	Monitoring:	the	Role	of	the	Hospital.”	Geneva,
Switzerland:	World	Health	Organization,	1966. 17
. Health	Insurance	Association	of	America. Source	Book	of	Health
Insurance	Data:	1999—2000
. Washington,	DC,	1999. 18
. National	Center	for	Health	Statistics. Health,	United	States,	2000	with
Adolescent	Health	Chart-book
. Hyattsville,	MD:	National	Center	for
Health	Statistics,	2000. 19
. Starfield	B. Primary	Care:	Balancing	Health	Needs,	Services,	and
Technology
. New	York,	NY:	Oxford	University	Press,	1998. 20
. World	Health	Organization. World	Health	Report	2000:	Press	release. “World	Health	Organization	assesses	the	world’s	health	systems.”	June
21,	2000. Geneva. Accessed	at	
http://www.who.int
21
. Coble	YD. American	Medical	Association	press	release. “AMA	decries
rise	in	number	of	uninsured	Americans.”	September	30,	2003. Chicago,
IL. Accessed	at	
http://www.ama-assn.org/ama/pub/article/1617–
8064.html
22
. Campbell	TC. “Present	day	knowledge	on	aflatoxin.”	
Phil	J	Nutr
	20
(1967):	193–201. 23
. Campbell	TC,	Caedo	JP,	Jr.,	Bulatao-Jayme	J,	et	al. “Aflatoxin	M
1
	in
human	urine.”	
Nature
	227	(1970):	403–404. 24
. This	program	was	conducted	in	collaboration	with	the	Philippine
Department	of	Health	and	was	funded	by	the	United	States	Agency	for
International	Development	(USAID). USAID	paid	my	full	salary	for	six
years	and	resulted	in	110	“mother	craft	centers”	distributed	around	much
of	the	Philippines. Progress	on	this	contract	was	prepared	as	monthly
reports	to	USAID	by	Associate	Dean	C.W. Engel	at	Virginia	Tech. 25
. Hu	J,	Zhao	X,	Jia	J,	et	al. “Dietary	calcium	and	bone	density	among
middle-aged	and	elderly	women	in	China.”	
Am. J.	Clin. Nutr. 58	(1993):
219–227. 26
. Hu	J,	Zhao	X,	Parpia	B,	et	al. “Dietary	intakes	and	urinary	excretion	of
calcium	and	acids:	a	cross-sectional	study	of	women	in	China.”	
Am. J.
Clin. Nutr. 58	(1993):	398–406. 27
. Hu	J,	Zhao	X,	Parpia	B,	et	al.
_OceanofPDF.com_The_China_Study__The_Most_Comprehensive_St_-_T_Colin_Campbell.txt
Summarize the following text section accurately and concisely. Maintain specific details and numerical information, and use anti-repetition mechanisms:

        You	told	me	yourself	that	most
neurologists	don’t	like	to	take	care	of	MS	patients. ”	John	could	not	believewhat	he	had	just	heard. In	a	very	tense	moment,	he	said:
Wait	a	minute. I’m	a	doctor. This	is	a	hospital. As	far	as	I	know	our	job
is	to	relieve	the	suffering	of	the	sick. These	are	sick	people. Just
because	other	doctors	can’t	help	them	in	their	suffering	doesn’t	mean
that	we	can’t. Here’s	the	evidence	that	says	we	can. I	have	an	effective
treatment	for	people	who	need	my	care	and	this	is	a	hospital. Will	you
explain	to	me	why	we	don’t	want	to	take	care	of	those	kinds	of
patients. He	continued:
I	want	to	talk	to	the	head	of	the	hospital. I	want	to	explain	to	her	why	I
need	this	program	and	why	the	hospital	needs	this	program	and	why
the	patients	need	this	program. I	want	you	to	get	me	an	appointment. Ultimately	though,	the	head	of	the	hospital	proved	to	be	just	as	difficult. John	reflected	on	the	situation	with	his	wife. He	was	supposed	to	renew	his
contract	with	the	hospital	in	a	couple	of	weeks,	and	he	decided	not	to	do	it. He	left	on	cordial	terms,	and	to	this	day	he	does	not	hold	personal	grudges. He	just	explains	it	by	saying	that	their	directions	in	life	were	different. John
would	prefer	to	remember	St. Helena	for	what	it	was:	a	good	home	to	him	for
sixteen	years,	but	a	place	nonetheless	that	was	“just	into	that	whole	drug
money	thing. ”
Now,	John	runs	a	highly	successful	“lifestyle	medicine”	program	with	his
family’s	help,	writes	a	popular	newsletter	that	he	makes	freely	available
(
http://www. drmcdougall. com
),	organizes	group	trips	with	past	patients	and
new	friends	and	has	more	time	to	go	windsurfing	when	the	wind	picks	up	on
Bodega	Bay. This	is	a	man	with	a	wealth	of	knowledge	and	qualifications,
who	could	benefit	the	health	of	millions	of	Americans. He	has	never	been
challenged	by	any	of	his	colleagues	for	physician	“misbehavior,”	and	yet	the
medical	establishment	does	not	want	his	services. He	is	reminded	of	this	fact
all	the	time:
Patients	will	come	in	with	rheumatoid	arthritis. They’ll	be	in
wheelchairs,	they	can’t	even	turn	the	key	on	their	car. And	I’ll	take	care
of	them	and	three	or	four	weeks	later,	they’ll	go	back	to	see	their
doctor. They’ll	walk	up	to	their	doctor,	grab	their	hand	and	shake	it
hard. Doctor	will	say,	“Wonderful. ”	The	patient,	all	excited,	will	say,
“Well,	I	want	to	tell	you	what	I	did. I	went	to	see	this	Dr. McDougall,	I
changed	my	diet,	and	now	my	arthritis	is	gone. ”	Their	doctor	simplyresponds,	“Oh	my	goodness. That’s	great. Whatever	you’re	doing,	just
keep	doing	it. I’ll	see	you	later. ”	That’s	always	the	response. It’s	not,
“Please,	my	god,	tell	me	what	you	did	so	I	can	tell	the	next	patient. ”
It’s,	“Whatever	you’re	doing,	that’s	just	great. ”	If	the	patient	starts	to
tell	them	they	changed	to	a	vegetarian	diet,	the	doctor	will	cut	in	with,
“Yeah	okay,	fine,	you’re	really	a	strong	person. Thanks	a	lot. See	you
later. ”	Get	them	out	of	the	office	as	quickly	as	they	can. It’s	very
threatening…	very	threatening. ESSELSTYN’S	REWARD
Back	in	Ohio,	Dr. Esselstyn	retired	from	active	surgery	in	June	of	2000	and
assumed	the	position	of	preventive	cardiology	consultant	in	the	department	of
general	surgery	at	the	Cleveland	Clinic. He	has	continued	
to	do	research	and
to	visit	with	patients. He	holds	three-hour	counseling	sessions	in	his	home
with	new	heart	disease	patients,	gives	them	research	evidence	and	provides	a
delicious	“heart-safe”	meal. In	addition,	he	gives	talks	around	the	country	and
abroad. In	March	of	2002,	Ess	and	his	wife	Ann,	whose	grandfather	founded	the
Cleveland	Clinic,	drafted	a	letter	to	the	head	of	the	cardiology	department	and
the	head	of	the	hospital	at	the	Cleveland	Clinic. The	letter	started	off	by
saying	how	proud	they	were	of	the	reputation	and	excellence	of	the	Clinic	and
the	innovation	of	the	surgical	procedures,	but	that	everyone	recognized	that
surgery	was	never	going	to	be	the	answer	to	this	epidemic	of	heart	disease. Ess	formally	proposed	the	idea	that	he	could	help	set	up	an	arrest	and	reversal
dietary	program	in	the	department	of	preventive	cardiology	at	the	Cleveland
Clinic. The	program	would	mirror	his	own	and	could	be	administered	by
nurse	clinicians	and	physician	assistants. Ideally,	a	young	physician	with
passion	for	the	idea	would	head	the	program. Ultimately,	every	patient	with
heart	disease	at	the	Clinic	would	be	offered	the	option	of	arrest	and	reversal
therapy	using	dietary	means,	which	costs	very	little,	harbors	no	risks	and	puts
the	control	back	into	the	patients’	hands. You’d	think	that	if	an	opportunity	arose	to	profoundly	heal	sick	people,
and	one	of	the	most	reputable	people	in	the	country	was	going	to	help	you,	a
hospital	would	jump	at	the	opportunity. But	after	being	one	of	the	star
surgeons	at	the	Cleveland	Clinic	for	decades,	after	initiating	a	heart	reversal
study	that	had	greater	success	than	anything	ever	done	at	the	Clinic,	and	after
graciously	offering	a	plan	to	help	heal	even	more	people,	neither	the	head	of
the	hospital	nor	the	department	head	had	the	respect	to	even	acknowledge	that
Ess	had	written	to	them. They	didn’t	call. They	didn’t	write. They	completely
ignored	him. Seven	weeks	passed,	and	finally	Ess	called	the	department	head	and	the
hospital	head,	and	neither	of	them	would	take	his	call. Finally,	after	seven
calls,	the	head	of	the	hospital	got	on	the	phone. This	man	had	praised	Ess	for
years	for	his	research	and	seemed	excited	by	his	results,	but	now	he	was
singing	a	different	tune. He	obviously	knew	exactly	what	Ess	was	calling
about,	and	told	Ess	that	the	head	of	the	cardiology	department	didn’t	want	to
do	it. In	other	words,	he	just	passed	the	buck. If	the	head	of	the	hospital
wanted	it	to	be	done,	it	would	be	done,	regardless	of	what	the	head	ofcardiology	wanted. So	Ess	called	the	head	of	cardiology,	who	finally	took	his
call. The	man	was	abrasive	and	rude. He	made	it	clear	he	had	no	interest	in
what	Ess	was	trying	to	do. Ess	hasn’t	talked	to	either	of	these	doctors	since,	but	he	still	has	hope	that
he	can	change	their	minds	as	more	and	more	research	supports	what	he	has
been	saying. Meanwhile,	many	people	at	the	Clinic	are	still	excited	about
Ess’s	work. Many	of	them	want	to	see	a	wider	application	of	his	program,	but
the	powers	that	be	will	not	let	it	happen. They	get	frustrated,	and	Ess	is
frustrated	because	the	current	program	in	preventive	cardiology	is	a	disaster:
They	still	eat	meat,	they	still	eat	dairy,	and	they	don’t	have	any
cholesterol	goal. It’s	all	just	so	vague. Preventive	cardiology	takes
great	pride	when	they	are	able	to	slow	the	rate	of	progression	of	this
disease. This	isn’t	cancer	for	God’s	sake. An	interesting	situation	is	now	developing:	just	as	with	Dr. McDougall,
many	of	the	Clinic	“bigwigs”	with	heart	disease	have	themselves	gone	to
Esselstyn	for	treatment	and	lifestyle	counseling. They	know	it	works,	and
they	seek	out	the	program	on	their	own. As	Ess	says,	this	could	be	developing
into	a	very	interesting	crisis:
I	have	now	treated	a	number	of	senior	staff	with	coronary	disease	at	the
Clinic—senior	staff	physicians. I	have	also	treated	a	number	of	senior
staff	trustees. One	of	the	trustees	knows	about	the	frustrations	that
we’ve	had	trying	to	get	this	into	the	Clinic,	and	he	says,	“I	think,	if	the
word	gets	out	that	Esselstyn	has	this	treatment	that	arrests	and	reverses
this	disease	at	the	Cleveland	Clinic,	and	it’s	been	used	by	senior	staff
and	he’s	treated	senior	trustees,	but	he’s	not	permitted	to	treat	the
common	herd,	we	could	be	open	for	a	lawsuit. ”
For	the	time	being,	Ess,	with	his	wife’s	help,	will	continue	to	run
counseling	sessions	out	of	his	own	home	because	the	institution	to	which	he
gave	the	greater	part	of	his	life	does	not	want	to	endorse	a	dietary	approach
that	competes	with	its	standard	menu	of	pills	and	procedures. This	past
summer	Ess	spent	much	more	time	than	usual	at	his	upstate	New	York	farm,
making	hay. As	much	as	Ess	likes	a	more	relaxed	life,	he	would	also	love	to
continue	to	help	diseased	people	get	better	with	the	aid	of	the	Cleveland
Clinic. But	they	won’t	allow	him	to. As	far	as	I	am	concerned,	this	is	nothing
short	of	criminal. We,	the	public,	turn	to	doctors	and	hospitals	in	times	of
great	need. For	them	to	provide	care	that	is	knowingly	less	than	optimal,	that
doesn’t	protect	our	health,	doesn’t	heal	our	disease	and	costs	us	tens	ofthousands	of	dollars	is	morally	inexcusable. Ess	sums	up	the	situation:
The	Clinic	is	now	injecting	stem	cells	to	try	to	make	new	heart	vessels
grow. Wouldn’t	it	be	easier	to	stop	the	disease. It’s	appalling,	isn’t	it. It’s	just	so	grippingly	unbelievable	to	think	that	we’re	being	led	around
by	people	who	refuse	to	believe	the	obvious. Both	Esselstyn	and	McDougall	have	now	been	denied	reentry	into	the
establishment,	after	headline-making	success	at	healing	people	with	a
nutritional	approach. You	can	focus	on	the	money—according	to	John	and
Ess,	80%	of	St. Helena’s	and	65%	of	the	Cleveland	Clinic’s	respective
incomes	were	generated	by	traditional	heart	disease	treatments,	surgical
interventions—but	it’s	something	more	than	just	money. It	may	also	be	the
intellectual	threat	that	the	patient	should	be	in	control,	and	not	the	doctor;	that
something	as	simple	as	food	could	be	more	powerful	than	all	the	knowledge
of	pills	and	high-tech	procedures;	it	may	be	the	lack	of	credible	nutrition
education	in	medical	school;	it	may	be	the	influence	of	the	drug	industry. Whatever	it	is,	it	has	become	clear	that	the	medical	industry	in	this	country	is
not	protecting	our	health	as	it	should. As	McDougall	reaches	his	arms	out,
palms	up,	and	scrunches	his	shoulders	up,	he	simply	says,	“It’s	beyond
comprehension. ”18
Repeating	Histories
I
N
	1985,	when	I	was	on	sabbatical	in	Oxford,	England,	I	had	the	opportunity
to	study	the	history	of	diet	and	disease	at	some	of	the	great	medical	history
libraries	in	the	Western	world. I	made	use	of	the	famous	Bodlean	Library	in
Oxford	and	the	London	libraries	of	the	Royal	College	of	Surgeons	and	the
Imperial	Cancer	Research	Fund. In	the	quiet	recesses	of	these	marble-lined
sanctuaries,	I	was	thrilled	to	find	authors	who	wrote	eloquently	on	the	topic	of
diet	and	cancer,	among	other	diseases,	over	150	years	ago. One	such	author	was	George	Macilwain,	who	wrote	fourteen	books	on
medicine	and	health. Macilwain	was	born	and	raised	in	Northern	Ireland. He
later	moved	to	London	where	he	became	a	prominent	surgeon	in	the	early
1800s. He	was	to	become	a	member,	and	later,	an	honorary	fellow,	of	the
Royal	College	of	Surgeons. He	became	vegetarian	at	the	age	of	forty,	after
identifying	“grease,	fat	and	alcohol”	as	being	the	chief	causes	of	cancer. 1
Macilwain	also	popularized	the	theory	of	the	“constitutional	nature	of
disease,”	mostly	in	reference	to	the	origins	and	treatment	of	cancer. The	constitutional	nature	of	disease	concept	meant	that	disease	is	not	the
result	of	one	organ,	one	cell	or	one	reaction	gone	awry	or	the	result	of	one
external	cause	acting	independently. It	is	the	result	of	
multiple	systems
throughout	the	body	breaking	down. Opposing	this	view	was	the	local	theory
of	disease,	which	said	that	disease	is	caused	by	a	single	external	agent	acting
at	a	specific	site	in	the	body. At	that	time,	a	fierce	fight	was	under	way
between	those	who	believed	in	diet	and	those	who	
supported	surgery	and	the
emerging	use	of	drugs. The	“local	disease”	proponents	argued	that	disease
was	locally	caused	and	could	be	cut	out	or	locally	treated	with	isolated
chemicals. In	contrast,	those	who	favored	diet	and	lifestyle	believed	thatdisease	was	a	symptom	resulting	from	the	“constitutional”	characteristics	of
the	whole	body. I	was	impressed	that	these	old	books	contained	the	same	ideas	about	diet
and	disease	that	had	resurfaced	in	the	health	battles	of	the	1980s. As	I	learned
more	about	Macilwain,	I	came	to	realize	that	he	was	a	relative	of	mine. My
paternal	grandmother’s	maiden	name	was	Macilwain,	and	that	“branch”	of	the
family	had	lived	in	the	same	part	of	Northern	Ireland	that	George	Macilwain
had	come	from. Furthermore,	there	were	family	stories	about	a	famous
Macilwain	who	had	left	the	family	farm	in	Ireland	to	become	a	very	well-
known	doctor	in	London	in	the	early	1800s. My	father,	who	had	emigrated
from	Northern	Ireland,	had	referred	to	an	Uncle	George	when	I	was	young,
but	I	never	was	aware	of	who	this	man	was. Through	further	genealogical
research,	I	have	come	to	the	near	certain	conclusion	that	George	Macilwain
was	my	great-great	uncle. This	discovery	has	been	one	of	the	more	remarkable	stories	of	my	life. My
wife	Karen	says,	“If	there’s	such	a	thing	as	reincarnation. …”	I	agree:	if	I	ever
lived	a	past	life,	it	was	as	George	Macilwain. He	and	I	had	similar	careers;
both	of	us	became	acutely	aware	of	the	importance	of	diet	in	disease,	and	both
of	us	became	vegetarian. Some	of	his	ideas,	written	over	150	years	ago,	were
so	close	to	what	I	believed	that	I	felt	they	could	have	come	from	my	own
mouth. I	discovered	more	than	my	family	history	while	reading	in	these	august,
history-laden	libraries. I	found	out	that	scholars	have	been	arguing	over	the
nature	of	health	for	centuries,	even	millennia. Almost	2,500	years	ago,	Plato
wrote	a	dialogue	between	two	characters,	Socrates	and	Glaucon,	in	which
they	discuss	the	future	of	their	cities. Socrates	says	the	cities	should	be
simple,	and	the	citizens	should	subsist	on	barley	and	wheat,	with	“relishes”	of
salt,	olives,	cheese	and	“country	fare	of	boiled	onions	and	cabbage,”	with
desserts	of	“figs,	pease,	beans,”	roasted	myrtle-berries	and	beechnuts,	and
wine	in	moderation. 2
	Socrates	says,	“And	thus,	passing	their	days	in
tranquility	and	sound	health,	they	will,	in	all	probability,	live	to	an	advanced
age. …”
But	Glaucon	replies	that	such	a	diet	would	only	be	appropriate	for	“a
community	of	swine,”	and	that	the	citizens	should	live	“in	a	civilized
manner. ”	He	continues,	“They	ought	to	recline	on	couches…	and	have	the
usual	dishes	and	dessert	of	a	modern	dinner. ”	In	other	words,	the	
citizens
should	have	the	“luxury”	of	eating	meat. Socrates	replies,	“if	you	wish	us	also
to	contemplate	a	city	that	is	suffering	from	inflammation	
We	shall	also	need
great	quantities	of	all	kinds	of	cattle	for	those	who	may	wish	to	eat	them,	shall
we	not. ”Glaucon	says,	“Of	course	we	shall. ”	Socrates	then	says,	“Then	shall	we
not	experience	the	need	of	medical	men	also	to	a	much	greater	extent	under
this	than	under	the	former	regime. ”	Glaucon	can’t	deny	it. “Yes,	indeed,”	he
says. Socrates	goes	on	to	say	that	this	luxurious	city	will	be	short	of	land
because	of	the	extra	acreage	required	to	raise	animals	for	food. This	shortage
will	lead	the	citizens	to	take	land	from	others,	which	could	precipitate
violence	and	war,	thus	a	need	for	justice. Furthermore,	Socrates	writes,	“when
dissoluteness	and	diseases	abound	in	a	city,	are	not	law	courts	and	surgeries
opened	in	abundance,	and	do	not	Law	and	Physic	begin	to	hold	their	heads
high,	when	numbers	even	of	well-born	persons	devote	themselves	with
eagerness	to	these	professions. ”	In	other	words,	in	this	luxurious	city	of
sickness	and	disease,	lawyers	and	doctors	will	become	the	norm. 2
Plato,	in	this	passage,	made	it	perfectly	clear:	we	shall	eat	animals	only	at
our	own	peril. Though	it	is	indeed	remarkable	that	one	of	the	greatest
intellectuals	in	the	history	of	the	Western	world	condemned	meat	eating
almost	2,500	years	ago,	I	find	it	even	more	remarkable	that	few	know	about
this	history. Hardly	anybody	knows,	for	example,	that	the	father	of	Western
medicine,	Hippocrates,	advocated	diet	as	the	chief	way	to	prevent	and	treat
disease	or	that	George	Macilwain	knew	that	diet	was	the	way	to	prevent	and
treat	disease	or	that	the	man	instrumental	in	founding	the	American	Cancer
Society,	Frederick	L. Hoffman,	knew	that	diet	was	the	way	to	prevent	and
treat	disease. How	did	Plato	predict	the	future	so	accurately. He	knew	that	consuming
animal	foods	would	not	lead	to	true	health	and	prosperity. Instead,	the	false
sense	of	rich	luxury	granted	by	being	able	to	eat	animals	would	only	lead	to	a
culture	of	sickness,	disease,	land	disputes,	lawyers	and	doctors. This	is	a
pretty	good	description	of	some	of	the	challenges	faced	by	modern	America. How	did	Seneca,	one	of	the	great	scholars	2,000	years	ago,	a	tutor	and
advisor	to	Roman	Emperor	Nero,	know	with	such	certainty	the	trouble	with
consuming	animals	when	he	wrote
2
:
An	Ox	is	satisfied	with	the	pasture	of	an	acre	or	two:	one	wood	suffices
for	several	Elephants. Man	alone	supports	himself	by	the	
pillage	of	the
whole	earth	and	sea. What. Has	Nature	indeed	given	us	so	insatiable	a
stomach,	while	she	has	given	us	so	insignificant	bodies. …	The	slaves
of	the	belly	(as	says	Sallust)	are	to	be	counted	in	the	number	of	the
lower	animals,	not	of	men. Nay,	not	of	them,	but	rather	of	the	dead. …
You	might	inscribe	on	their	doors,	“These	have	anticipated	death. ”
How	did	George	Macilwain	predict	the	future	when	he	said	that	the	localtheory	of	disease	would	not	lead	to	health. Even	today,	we	don’t	have	any
pills	or	procedures	that	effectively	prevent,	eliminate	or	even	treat	the	causes
of	any	chronic	diseases. The	most	promising	preventions	and	treatments	have
now	been	shown	to	be	diet	and	lifestyle	changes,	a	constitutional	approach	to
health. How	did	we	forget	these	lessons	from	the	past. How	did	we	go	from
knowing	that	the	best	athletes	in	the	ancient	Greek	Olympics	must	consume	a
plant-based	diet	to	fearing	that	vegetarians	don’t	get	enough	protein. How	did
we	get	to	a	place	where	the	healers	of	our	society,	our	doctors,	know	little,	if
anything,	about	nutrition;	where	our	medical	institutions	denigrate	the
subject;	where	using	prescription	drugs	and	going	to	hospitals	is	the	third
leading	cause	of	death. How	did	we	get	to	a	place	where	advocating	a	plant-
based	diet	can	jeopardize	a	professional	career,	where	scientists	spend	more
time	mastering	nature	than	respecting	it. How	did	we	get	to	a	place	where	the
companies	that	profit	from	our	sickness	are	the	ones	telling	us	how	to	be
healthy;	where	the	companies	that	profit	from	our	food	choices	are	the	ones
telling	us	what	to	eat;	where	the	public’s	hard-earned	money	is	being	spent	by
the	government	to	boost	the	drug	industry’s	profits;	and	where	there	is	more
distrust	than	trust	of	our	government’s	policies	on	foods,	drugs	and	health. How	did	we	get	to	a	place	where	Americans	are	so	confused	about	what	is
healthy	that	they	no	longer	care. Our	country’s	population,	which	numbers	almost	300	million	people,
3
	is
sick. 82%	of	American	adults	have	at	least	one	risk	factor	for	heart	disease
4
81%	of	Americans	take	at	least	one	medication	during	any	given	week
5
50%	of	Americans	take	at	least	one	prescription	drug	during	any	given
week
5
65%	of	American	adults	are	overweight
6
31%	of	American	adults	are	obese
6
Roughly	one	in	three	youths	in	America	(ages	six	to	nineteen)	is	already
overweight	or	at	risk	of	becoming	overweight
About	105	million	American	adults	have	dangerously	high	cholesterol
levels
7
	(defined	as	200	mg/dL	or	higher—heart-safe	cholesterol	level	is
under	150	mg/dL)
About	50	million	Americans	have	high	blood	pressure
8
Over	63	million	American	adults	have	pain	in	the	lower	back
(considerably	related	to	circulation	and	excess	body	weight,	both
influenced	by	diet	and	aggravated	by	physical	inactivity)	during	anygiven	three-month	period
9
Over	33	million	American	adults	have	a	migraine	or	severe	headache
during	any	given	three-month	period
9
23	million	Americans	had	heart	disease	in	2001
9
At	least	16	million	Americans	have	diabetes
Over	700,000	Americans	died	from	heart	disease	in	2000
Over	550,000	Americans	died	from	cancer	in	2000
Over	280,000	Americans	died	from	cerebro-vascular	diseases	(stroke),
diabetes	or	Alzheimer’s	in	2000
At	the	great	peril	of	ignoring	the	warnings	of	Plato	and	others,	America
has,	in	the	words	of	Seneca,	“anticipated	death. ”	Starvation,	poor	sanitation
and	communicable	diseases,	symbols	of	impoverishment,	have	been	largely
minimized	in	the	Western	world. Now	we	have	an	urgency	of	excess,	and
some	of	the	previously	less	developed	countries	are	racing	to	get	where	we
are. Never	before	have	such	large	percentages	of	the	population	died	from
diseases	of	“affluence. ”	Is	this	the	affluence	that	Socrates	predicted	2,500
years	ago—a	society	full	of	doctors	and	lawyers	wrestling	with	the	problems
caused	by	people	living	luxuriously	and	eating	cattle. Never	before	have	so
many	people	suffered	such	high	levels	of	obesity	and	diabetes. Never	before
has	the	financial	strain	of	health	care	distressed	every	sector	of	our	society,
from	business	to	education	to	government	to	everyday	families	with
inadequate	insurance. If	we	have	to	decide	between	health	insurance	for	our
teachers	and	textbooks	for	our	kids,	which	will	we	choose. Never	before	have	we	affected	the	natural	environment	to	such	an	extent
that	we	are	losing	our	topsoil,	our	massive	North	American	aquifers,	and	our
world’s	rainforests. 10
	We	are	changing	our	climate	so	rapidly	that	many	of	the
world’s	best-informed	scientists	fear	the	future. Never	before	
have	we	been
eliminating	plant	and	animal	species	from	the	face	of	the	earth	as	we	are
doing	now. Never	before	have	we	introduced,	on	such	a	large	scale,
genetically	altered	varieties	of	plants	into	the	environment	without	knowing
what	the	repercussions	will	be. All	of	these	changes	in	our	environment	are
strongly	affected	by	what	we	choose	to	eat. 11
As	the	billions	of	people	in	the	developing	world	are	accumulating	more
wealth	and	adopting	the	Western	diet	and	lifestyle,	problems	created	by
nutritional	excess	are	becoming	exponentially	more	urgent	with	each	passing
year. In	1997,	the	director-general	of	the	World	Health	Organization,	Dr. Hiroshi	Nakajima,	referred	to	the	future	chronic	disease	burden	in	developing
countries	as	“a	crisis	of	suffering	on	a	global	scale. ”
12
We’ve	fumbled	around	for	the	past	2,500	years,	building	up	theunsustainable	behemoth	that	we	now	call	modern	society. We	certainly	won’t
have	another	2,500	years	to	remember	the	teachings	of	Plato,	Pythagoras,
Seneca	and	Macilwain;	we	won’t	even	have	250	years. From	this	urgency
arises	great	opportunity,	and	because	of	that	I	am	filled	with	hope. People	are
beginning	to	sense	the	need	for	change	and	are	beginning	to	question	some	of
the	most	basic	assumptions	that	we	have	about	food	and	health. People	are
beginning	to	understand	the	conclusions	of	scientific	literature	and	are
changing	their	lives	for	the	better. Never	before	has	there	been	such	a	mountain	of	empirical	research
supporting	a	whole	foods,	plant-based	diet. Now,	for	example,	we	can	obtain
images	of	the	arteries	in	the	heart,	and	then	show	conclusively,	as	Drs. Dean
Ornish	and	Caldwell	Esselstyn,	Jr. ,	have	done,	that	a	whole	foods,	plant-based
diet	reverses	heart	disease. 13
	We	now	have	the	knowledge	to	understand	how
this	actually	works. Animal	protein,	even	more	than	saturated	fat	and	dietary
cholesterol,	raises	blood	cholesterol	levels	in	experimental	animals,	individual
humans	and	entire	populations. International	comparisons	between	countries
show	that	populations	subsisting	on	traditional	plant-based	diets	have	far	less
heart	disease,	and	studies	of	individuals	within	single	populations	show	that
those	who	eat	more	whole,	plant-based	foods	not	only	have	lower	cholesterol
levels,	but	have	less	heart	disease. We	now	have	a	deep	and	broad	range	of
evidence	showing	that	a	whole	foods,	plant-based	diet	is	best	for	the	heart. Never	before	have	we	had	such	a	depth	of	understanding	of	how	diet
affects	cancer	both	on	a	cellular	level	as	well	as	a	population	level. Published
data	show	that	animal	protein	promotes	the	growth	of	tumors. Animal	protein
increases	the	levels	of	a	hormone,	IGF-1,	which	is	a	risk	factor	for	cancer,	and
high-casein	(the	main	protein	of	cow’s	milk)	diets	allow	more	carcinogens
into	cells,	which	allow	more	dangerous	carcinogen	
products	to	bind	to	DNA,
which	allow	more	mutagenic	reactions	that	give	rise	to	cancer	cells,	which
allow	more	rapid	growth	of	tumors	once	they	are	initially	formed. Data	show
that	a	diet	based	on	animal-based	foods	increases	a	female’s	production	of
reproductive	hormones	over	her	lifetime,	which	may	lead	to	breast	cancer. We
now	have	a	deep	and	broad	range	of	evidence	showing	that	a	whole	foods,
plant-based	diet	is	best	for	cancer. Never	before	have	we	had	technology	to	measure	the	biomarkers
associated	with	diabetes,	and	the	evidence	to	show	that	blood	sugar,	blood
cholesterol	and	insulin	levels	improve	more	with	a	whole	foods,	plant-based
diet	than	with	any	other	treatment. Intervention	studies	show	that	Type	2
diabetics	treated	with	a	whole	foods,	plant-based	diet	may	reverse	their
disease	and	go	off	their	medications. A	broad	range	of	international	studies
shows	that	Type	1	diabetes,	a	serious	autoimmune	disease,	is	related	to	cow’smilk	consumption	and	premature	weaning. We	now	know	how	our
autoimmune	system	can	attack	our	own	bodies	through	a	process	of	molecular
mimicry	induced	by	animal	proteins	that	find	their	way	into	our	bloodstream. We	also	have	tantalizing	evidence	linking	multiple	sclerosis	with	animal	food
consumption,	and	especially	dairy	consumption. Dietary	intervention	studies
have	shown	that	diet	can	help	slow,	and	perhaps	even	halt,	multiple	sclerosis. We	now	have	a	deep	and	broad	range	of	evidence	showing	that	a	whole	foods,
plant-based	diet	is	best	for	diabetes	and	autoimmune	diseases. Never	before	have	we	had	such	a	broad	range	of	evidence	showing	that
diets	containing	excess	animal	protein	can	destroy	our	kidneys. Kidney	stones
arise	because	the	consumption	of	animal	protein	creates	excessive	calcium
and	oxalate	in	the	kidney. We	know	now	that	cataracts	and	age-related
macular	degeneration	can	be	prevented	by	foods	containing	large	amounts	of
antioxidants. In	addition,	research	has	shown	that	cognitive	dysfunction,
vascular	dementia	caused	by	small	strokes	and	Alzheimer’s	are	all	related	to
the	food	we	eat. Investigations	of	human	populations	show	that	our	risk	of	hip
fracture	and	osteoporosis	is	made	worse	by	diets	high	in	animal-based	foods. Animal	protein	leeches	calcium	from	the	bones	by	creating	an	acidic
environment	in	the	blood. We	now	have	a	deep	and	broad	range	of	evidence
showing	that	a	whole	foods,	plant-based	diet	is	best	for	our	kidneys,	bones,
eyes	and	brains. More	research	can	and	should	be	done,	but	the	idea	that	whole	foods,
plant-based	diets	can	protect	against	and	even	treat	a	wide	variety	of	chronic
diseases	can	no	longer	be	denied. No	longer	are	there	just	a	few	people
making	claims	about	a	plant-based	diet	based	on	their	personal	
experience,
philosophy	or	the	occasional	supporting	scientific	study. Now	there	are
hundreds	of	detailed,	comprehensive,	well-done	research	studies	that	point	in
the	same	direction. Furthermore,	I	have	hope	for	the	future	because	of	our	new	ability	to
exchange	information	across	the	country	and	around	the	world. A	much
greater	proportion	of	the	world	population	is	literate,	and	a	much	greater
proportion	of	that	population	has	the	luxury	of	choosing	what	they	eat	from	a
wide	variety	of	readily	accessible	foods. People	can	make	a	whole	foods,
plant-based	diet	varied,	interesting,	tasty	and	convenient. I	have	hope	because
people	in	small	towns	and	in	previously	isolated	parts	of	the	country	can	now
readily	access	cutting	edge	health	information	and	put	it	into	practice. All	of	these	things	together	create	an	atmosphere	unlike	any	other,	an
atmosphere	that	demands	change. Contrary	to	the	situation	in	1982,	when	a
few	colleagues	tried	to	destroy	the	reputations	of	scientists	who	suggested	that
diet	had	anything	to	do	with	cancer,	it	is	now	more	commonly	accepted	thatwhat	you	eat	can	determine	your	risk	of	multiple	cancers. I	have	also	seen	the
public	image	of	vegetarianism	emerge	from	being	considered	a	dangerous,
passing	fad	to	a	healthful,	enduring	lifestyle	choice. The	popularity	of	plant-
based	diets	has	been	increasing,	and	both	the	variety	and	availability	of
convenient	vegetarian	foods	have	been	skyrocketing. 14
	Restaurants	around
the	country	now	regularly	offer	meat-free	and	dairy-free	options. 15
	Scientists
are	publishing	more	articles	about	vegetarianism	and	writing	more	about	the
health	potential	of	a	plant-based	diet. 16
	Now,	over	150	years	after	my	great-
great	uncle	George	Macilwain	wrote	books	about	diet	and	disease,	I	am
writing	a	book	about	diet	and	disease	with	the	help	of	my	youngest	son	Tom. Tom’s	middle	name	is	McIlwain	(the	family	changed	the	spelling	over	the
past	couple	of	generations),	which	means	that	not	only	am	I	writing	about
many	of	the	same	ideas	Macilwain	wrote	about,	but	a	relative	bearing	his
name	is	the	co-author. History	can	repeat	itself. This	time,	however,	instead	of
the	message	being	forgotten	and	confined	to	library	stacks,	I	believe	that	the
world	is	finally	ready	to	accept	it. More	than	that,	I	believe	the	world	is
finally	ready	to	change. We	have	reached	a	point	in	our	history	where	our	bad
habits	can	no	longer	be	tolerated. We,	as	a	society,	are	on	the	edge	of	a	great
precipice:	we	can	fall	to	sickness,	poverty	and	degradation,	or	we	can
embrace	health,	longevity	and	bounty. And	all	it	takes	is	the	courage	to
change. How	will	our	grandchildren	find	themselves	in	100	years. Only	time
will	tell,	but	I	hope	that	the	history	we	are	witnessing	and	the	future	that	lies
ahead	will	be	to	the	benefit	of	us	all. APPENDIX	A
Q&A:	Protein	Effect	in	Experimental	Rat	Studies
COULD	THE	DIETARY	PROTEIN	EFFECT	BE
DUE	TO	OTHER	NUTRIENTS	IN	THE	RAT
DIET. Decreasing	dietary	protein	from	20%	to	5%	means	finding	something	to
replace	the	missing	15%. We	used	a	carbohydrate	to	replace	the	casein
because	it	had	the	same	energy	content. As	dietary	protein	decreased,	a	1:1
mixture	of	starch	and	glucose	increased	by	the	same	amount. The	extra	starch
and	glucose	in	the	low-protein	diets	could	not	have	been	responsible	for	the
lower	development	of	foci	because	these	carbohydrates,	when	tested	alone,
actually	increase	foci	development. 1
	If	anything,	a	little	extra	carbohydrate	in
the	low-protein	diet	would	only	increase	cancer	incidence	and	offset	the	low-
protein	effect. This	makes	prevention	of	cancer	by	low-protein	diets	even
more	impressive. MIGHT	THE	PROTEIN	EFFECT	BE	DUE	TO
THE	RATS	ON	A	LOW-PROTEIN	DIET	EATING
LESS	FOOD	(I. E. ,	LESS	CALORIES). Many	studies	done	in	the	1930s,	1940s	and	1950s
2
	had	shown	that	decreasing
total	food	intake,	or	total	calories,	decreased	tumor	development. A	review	of
our	many	experiments,	however,	showed	that	animals	led	the	low-protein
diets	did	not	consume	less	calories	but,	on	
average,	actually	consumed	more
calories. 3,	4
	Again,	this	only	reinforced	the	tumor-promoting	effect	observed
for	casein. WHAT	WAS	THE	OVERALL	HEALTH	OF	THE
RATS	ON	A	LOW-PROTEIN	DIET. Many	researchers	have	long	assumed	that	animals	fed	diets	this	low	in	protein
would	not	be	healthy. However,	the	low-protein	animals	were	healthier	by
every	indication. They	lived	longer,	were	more	physically	active,	were
slimmer	and	had	healthy	hair	coats	at	100	weeks	while	the	high-protein
counterpart	rats	were	all	dead. Also,	animals	consuming	less	dietary	casein
not	only	ate	more	calories,	but	they	also	burned	off	more	calories. Low-
protein	animals	consumed	more	oxygen,	which	is	required	for	the	burning	of
these	calories,	and	had	higher	levels	of	a	special	tissue	called	brown	adipose
tissue,
5,	6
	which	is	especially	effective	in	burning	off	calories. This	occurs
through	a	process	of	“thermogenesis,”	i. e. ,	the	expenditure	of	calories	as	body
heat. This	phenomenon	had	already	been	demonstrated	many	years	before. 7–
11
	
Low-protein	diets	enhance	the	burning	off	of	calories,	thus	leaving	less
calories	for	body	weight	gain	and	perhaps	also	less	for	tumor	growth	as	well. WAS	PHYSICAL	ACTIVITY	RELATED	TO	THE
CONSUMPTION	OF	THE	LOW-PROTEIN	DIET. To	measure	the	physical	activity	of	each	group	of	rats,	we	compared	how
much	they	voluntarily	operated	an	exercise	wheel	attached	to	their	cages. A
monitor	recorded	the	number	of	times	the	animals	turned	the	exercise	wheel. The	low-casein	animals
12
	exercised	about	twice	as	much,	when	measured
over	a	two-week	period. This	observation	seems	to	be	very	similar	to	how
one	feels	after	eating	a	high-protein	meal:	sluggish	and	sleepy. I	have	heard
that	a	side	effect	of	the	protein-drenched	Atkins	Diet	is	fatigue. Have	you	ever
noticed	this	feeling	in	yourself	after	a	high-protein	meal. APPENDIX	B
Experimental	Design	of	the	China	Study
S
IXTY-FIVE	COUNTIES
	in	twenty-four	different	provinces	(out	of	twenty-seven)
were	selected	for	the	survey. They	represented	the	full	range	of	mortality	rates
for	seven	of	the	more	common	cancers. They	also	provided	broad	geographic
coverage	and	were	within	four	hours’	travel	time	of	a	central	laboratory. The
survey	counties	represented:
semitropical	coastal	areas	of	southeast	China;
frigid	wintry	areas	in	northeast	China,	near	Siberia;
areas	near	the	Great	Gobi	desert	and	the	northern	steppes;
and	areas	near	or	in	the	Himalaya	Mountains	ranging	from	the	far
northwest	to	the	far	southwest	part	of	the	country
Except	for	suburban	areas	near	Shanghai,	most	counties	were	located	in
rural	China	where	people	lived	in	the	same	place	their	entire	lives	and
consumed	locally	produced	food. Population	densities	varied	widely,	from
20,000	nomadic	residents	for	the	most	remote	county	near	the	Great	Gobi
desert,	to	1. 3	million	people	for	the	county	on	the	outskirts	of	Shanghai. This	survey	is	referred	to	as	an	ecological	or	correlation	study	design,
meaning	that	we	are	comparing	diet,	lifestyle	and	disease	characteristics	of	a
number	of	sample	populations,	in	this	case	the	sixy-five	counties. We
determine	how	these	characteristics,	as	county	averages,	correlate	
or	associate
with	each	other. For	example,	how	does	dietary	fat	relate	to	breast	cancer
rates. Or	how	does	blood	cholesterol	relate	to	coronary	heart	disease. How
does	a	certain	kind	of	fatty	acid	in	red	blood	cells	relate	to	rice	consumption. We	could	also	compare	blood	testosterone	levels	or	estrogen	levels	with
breast	cancer	risk. We	did	thousands	of	different	comparisons	of	this	type. In	a	study	of	this	kind,	it	is	important	to	note	that	only	the	average	values
for	county	populations	are	being	compared. Individuals	are	not	being
compared	with	individuals	(in	reality,	neither	does	any	other	epidemiological
study	design). As	ecological	studies	go,	this	study,	with	its	sixy-five	counties,
was	unusually	large. Most	such	studies	only	have	ten	to	twenty	such
population	units,	at	most. Each	of	the	sixty-five	counties	provided	100	adults	for	the	survey. One-
half	were	male	and	one-half	female,	all	aged	thirty-five	to	sixty-four	years. The	data	were	collected	in	the	following	manner:
each	person	volunteered	a	blood	sample	and	completed	a	diet	and
lifestyle	questionnaire;
one-half	of	the	people	provided	a	urine	sample;
the	survey	teams	went	to	30%	of	the	homes	to	carefully	measure	food
consumed	by	the	family	over	a	three-day	period;
samples	of	food	representing	the	typical	diets	at	each	survey	site	were
collected	at	the	local	marketplace	and	were	later	analyzed	for	dietary	and
nutritional	factors. One	of	the	more	important	questions	during	the	early	planning	stages	was
how	to	survey	for	diet	and	nutrition	information. Estimating	consumption	of
food	and	nutrients	from	memory	is	a	common	method,	but	this	is	very
imprecise,	especially	when	mixed	dishes	are	consumed. Can	you	remember
what	foods	you	ate	last	week,	or	even	yesterday. Can	you	remember	how
much. Another	even	more	crude	method	of	estimating	food	intake	is	to	see
how	much	of	each	food	is	sold	in	the	marketplace. These	findings	can	give
reasonable	estimates	of	diet	trends	over	time	for	whole	populations,	but	they
do	not	account	for	food	waste	or	measure	individual	amounts	of	consumption. Although	each	of	these	relatively	crude	methods	can	be	useful	for	certain
purposes,	they	still	are	subject	to	considerable	technical	error	and	personal
bias. And	the	bigger	the	technical	error,	the	more	difficult	it	is	to	detect
significant	cause-effect	associations. We	wanted	to	do	better	than	crudely	measure	which	foods	and	how	
much
of	these	foods	were	being	consumed. Thus	we	decided	to	evaluate	nutritional
conditions	by	analyzing	blood	and	urine	samples	for	indicators	(biomarkers)
of	multiple	nutrient	intakes. These	analyses	would	be	far	more	objective	than
having	people	recall	what	they	ate. Collecting	and	analyzing	blood,	however,	was	not	easy	to	arrange,	at	least
not	in	the	way	that	we	preferred. The	initial	problem	was	getting	
enough
blood. For	cultural	reasons,	rural	Chinese	were	reluctant	to	provide	blood
samples. A	finger	prick	seemed	to	be	the	only	possibility	but	this	was	not
good	enough. A	regular	vial	of	blood	would	give	100	times	as	much	blood
and	allow	for	analyses	of	many	more	factors. Dr. Junshi	Chen	of	our	team,	at	the	Institute	of	Nutrition	and	Food
Hygiene	in	the	Ministry	of	Health,	had	the	unenviable	task	of	convincing
these	volunteers	to	give	a	regular	vial	of	blood. He	succeeded. Sir	Richard
Peto	at	the	University	of	Oxford	of	our	team	then	made	the	very	practicalsuggestion	of	combining	the	individual	blood	samples	to	make	a	big	pool	of
blood	for	each	village	for	each	sex. This	strategy	gave	more	than	1,200–1,300
times	more	blood	when	compared	with	the	finger	prick	method. Making	big	pools	of	blood	had	enormous	implications	and	made	possible
the	China	Study,	as	it	later	became	known. It	allowed	analyses	of	far	more
indicators	of	diet	and	health. This	allowed	us	to	consider	relationships	in	a	far
more	comprehensive	manner	than	would	have	otherwise	been	possible. For
more	detail	on	the	theoretical	and	practical	basis	for	collecting	and	analyzing
blood	in	this	way	the	reader	is	referred	to	the	original	monograph	of	the
study. 1
After	collecting	the	blood,	we	then	had	to	decide	who	would	do	the	many
analyses	that	were	possible. We	wanted	nothing	but	the	best. While	some
analyses	were	conducted	at	our	Cornell	lab	and	at	Dr. Chen’s	Beijing	lab,	the
rest	of	the	analyses,	especially	the	more	specialized	types,	were	done	in	about
two	dozen	laboratories	located	in	six	countries	and	in	four	continents. Laboratories	were	selected	because	of	their	demonstrated	expertise	and
interest. The	laboratory	participants	are	listed	in	the	original	monograph. 1HOW	GOOD	IS	THIS	STUDY. Because	this	survey	was	a	one-of-a-kind	opportunity,	we	intended	that	it	be
the	best	of	its	kind	ever	undertaken. It	was	comprehensive;	it	was	high
quality;	and	its	uniqueness	allowed	new	opportunities	to	investigate	diet	and
disease	that	were	never	before	possible. These	features	
of	comprehensiveness,
quality	and	uniqueness	greatly	improved	the	credibility	and	reliability	of	the
findings—by	far. Indeed,	the	
New	York	Times
,	in	a	lead	story	in	its	Science
Section,	called	the	study	“The	Grand	Prix”	of	epidemiological	studies. COMPREHENSIVENESS	OF	DATA
This	survey	was,	and	still	is,	the	most	comprehensive	of	its	kind	ever
undertaken. After	all	the	blood,	urine	and	food	samples	were	collected,	stored
and	analyzed,	and	after	the	final	results	were	tabulated	and	evaluated	for
quality	(a	few	suspect	results	were	not	included	in	the	final	publication),	we
were	able	to	study	367	variables. These	represented	a	wide	variety	of	dietary,
lifestyle	and	disease	characteristics,	now	included	in	a	dense	896-page
monograph. 1
	There	were:
disease	mortality	rates	on	more	than	forty-eight	different	kinds	of
disease
2
;
109	nutritional,	viral,	hormonal	and	other	indicators	in	blood;
over	twenty-four	urinary	factors;
almost	thirty-six	food	constituents	(nutrients,	pesticides,	heavy	metals);
more	than	thirty-six	specific	nutrient	and	food	intakes	measured	in	the
household	survey;
sixty	diet	and	lifestyle	factors	obtained	from	questionnaires;
and	seventeen	geographic	and	climatic	factors. The	study	was	comprehensive,	not	only	because	of	the	sheer	number	of
variables,	but	also	because	most	of	these	variables	varied	over	broad	ranges,
as	with	the	cancer	mortality	rates. Broad	ranges	strengthened	our	ability	to
detect	important	previously	undiscovered	associations	of	variables. QUALITY	OF	DATA
A	number	of	features	added	quality	to	this	study. The	adults	chosen	for	this	survey	were	limited	to	those	who	were	thirty-
five	to	sixty-four	years	of	age. This	is	the	age	range	in	which	the	diseases
being	investigated	are	more	common. Information	on	death	certificates
of	people	older	than	sixty-four	years	was	not	included	in	the	survey
because	this	information	was	considered	less	reliable. In	each	of	the	sixty-five	counties	in	the	study	two	villages	were	selected
for	the	collection	of	the	information. Having	two	villages	in	each	county
rather	than	one	gives	a	more	reliable	county	average. When	the	values	of
two	villages	are	more	similar	to	each	other	than	to	all	the	other	counties,
then	this	means	higher-quality	data. 3
When	possible,	variables	were	measured	by	more	than	one	kind	of
method. For	example,	iron	status	was	measured	in	six	different	ways,
riboflavin	(vitamin	B
2
)	in	three	ways,	and	so	forth. Also,	in	many	cases,
we	could	assess	the	quality	and	reliability	of	data	by	comparing	variables
known	to	have	plausible	biological	relationships. The	populations	under	study	proved	to	be	very	stable. An	average	of	93–
94%	of	the	men	in	the	survey	were	born	in	the	county	where	they	lived
at	the	time	of	the	survey;	for	women	it	was	89%. Also,	according	to	data
published	by	the	World	Bank,
4
	the	diets	at	the	time	of	our	survey	were
very	similar	to	those	consumed	in	earlier	years. This	was	ideal	because
those	earlier	years	represented	the	time	when	the	diseases	were	initially
forming. UNIQUENESS	OF	DATA
One	idea	that	makes	our	study	unique	is	our	use	of	the	ecologic	study	design. Critics	of	the	ecologic	study	design	correctly	assume	that	it	is	a	weak	design
for	determining	cause-and-effect	associations	when	one	is	interested	in	the
effects	of	single	causes	acting	on	single	outcomes. But	this	is	not	the	way	that
nutrition	works. Rather,	nutrition	causes	or	prevents	disease	by	multiple
nutrients	and	other	chemicals	acting	together,	as	in	foods. An	ecologic	study
is	almost	ideal	if	we	wish	to	learn	how	an	array	of	dietary	factors	act	together
to	cause	disease. It	is	the	comprehensive	effects	of	nutrients	and	other	factors
on	disease	occurrence	where	the	most	important	lessons	are	to	be	learned. To
investigate	these	comprehensive	causes	of	disease,	it	was	therefore	necessary
to	record	as	many	dietary	and	other	lifestyle	factors	as	possible,	then
formulate	hypotheses	and	interpret	data	that	represent	comprehensiveness. Perhaps	the	most	unique	characteristic	that	set	this	study	apart	concerned
the	nutritional	characteristics	of	the	diets	consumed	in	rural	China. Virtually
every	other	human	study	on	diet	and	health,	of	whatever	design,	has	involved
subjects	who	were	consuming	a	rich	Western	
diet. This	is	true	even	when
vegetarians	are	included	in	the	study	because	90%	of	vegetarians	still
consume	rather	large	amounts	of	milk,	cheese	and	eggs,	while	a	significant
number	still	consume	some	fish	and	poultry. As	is	shown	in	the
accompanying	chart	(
Chart	B. 1
),
5
	there	is	only	a	small	difference	in	the
nutritional	properties	of	non-vegetarian	and	vegetarian	diets	as	consumed	in
Western	countries. CHART	B. 1:	VEGETARIAN	AND	NON-VEGETARIAN	DIET
COMPARISONS	AMONG	WESTERNERS
Nutrient
Vegetarian
Non	-	vegetarian
Fat	(%	of	calories)
30–36
34–38
Cholesterol	(g/day)
150–300
300–500
Carbohydrates	(%	of	calories)
50–55
<50
Total	protein	(%	of	calories)
12–14
14–18
Animal	protein	(%	of	total	protein)
40–60
60–70
A	strikingly	different	dietary	situation	existed	in	China. In	America,	15–
17%	of	our	total	calories	is	provided	by	protein,	and	upwards	of	80%	of	this
amount	is	animal-based. In	other	words,	we	gorge	on	protein	and	we	get	most
of	it	from	meat	and	dairy	products. But	in	rural	China,	they	consume	less
protein	overall	(9–10%	of	total	calories),	and	only	10%	of	it	comes	fromanimal-based	foods. This	means	that	there	are	many	other	major	nutritional
differences	in	the	Chinese	and	American	diets,	as	shown	in	
Chart	B. 2. 1
CHART	B. 2:	CHINESE	AND	AMERICAN	DIETARY	INTAKES
Nutrient
China
United	States
Calories	(kcal/kg	body	wt. /day)
40. 6
30. 6
Total	fat	(%	of	calories)
14. 5
34–38
Dietary	fiber	(g/day)
33
12
Total	protein	(g/day)
64
91
Animal	protein	(%	of	total	calories)
0. 8*
10–11
Total	iron	(mg/day)
34
18
*Non-fish	animal	protein
This	was	the	first	and	only	large	study	that	investigated	this	range	of
dietary	experience	and	its	health	consequences. Chinese	diets	ranged	from
rich	to	very	rich	in	plant-based	foods. In	all	other	studies	done	on	Western
subjects,	diets	ranged	from	rich	to	very	rich	in	animal-based	foods. It	was	this
distinction	that	made	the	China	Study	so	different	from	other	studies. MAKING	IT	HAPPEN
Organization	and	conduct	of	a	study	of	this	size,	scope	and	quality	was
possible	because	of	the	exceptional	skills	of	Dr. Junshi	Chen. Survey	sites
were	scattered	across	the	far	reaches	of	China. In	American	travel	distances,
they	ranged	from	the	Florida	Keys	to	Seattle,	Washington,	and	from	San
Diego,	California,	to	Bangor,	Maine. Travel	between	these	places	was	more
difficult	than	in	the	United	States,	and	supplies	and	instructions	for	the	survey
had	to	be	in	place	and	standardized	for	all	collection	sites. And	this	was	done
before	e-mails,	fax	machines	and	cellular	phones	were	available. It	was	important	that	the	twenty-four	provincial	health	teams,	each
comprised	of	twelve	to	fifteen	health	workers,	be	trained	to	carry	out	the
blood,	food	and	urine	collections	and	complete	the	questionnaires	in	a
systematic	and	standardized	manner. To	standardize	the	collection	of
information,	Dr. Chen	divided	the	country	into	regions. Each	region	sent
trainers	to	Beijing	for	the	senior	training	session. They,	in	turn,	returned	to
their	home	provinces	to	train	the	provincial	health	teams. Although	the	U. S. National	Cancer	Institute	(NCI)	of	the	National
Institutes	of	Health	(NIH)	provided	the	initial	funding	for	this	project,	the
Chinese	Ministry	of	Health	paid	the	salaries	of	the	approximately	350	health
workers. It	is	my	estimate	that	the	Chinese	contribution	to	the	project	was
approximately	$5–6	million. This	compares	with	the	U.
He said that the head of the hospital was just as difficult to deal with.
What did John say in response to the head of the hospital's refusal to consider his proposal?
Dr. Esselstyn is writing a book with his youngest son, Tom.
Who is the author of the book that Dr. Esselstyn is writing with his youngest son?
The author of the dialogue is Plato.
What is the name of the doctor who wrote a dialogue between two characters, Socrates and Glaucon, in which they discuss the effects of diet on health?
The U.S. National Cancer Institute provided the initial funding for the China Study.
What is the name of the organization that provided funding for the China Study?
There is no information in the text about a book written by George Macilwain.
What is the name of the book written by Dr. Esselstyn's great-great-uncle, George Macilwain?