Plant-Based Diets And Disease: The Current State Of The Evidence with Brenda Davis R.D.

thank you so much Stephen thank you all for being here and thank you for putting this amazing conference on and thank you for my cheering section over there you know how to make me feel very welcome I’m actually really excited about this presentation because I think it shares some of my favorite moments I’m going to talk a little bit about the Marshall Islands and a lot about the research what we know about the connection between plant-based diets and our risk of chronic disease so just a quick outline I’m going to talk about longevity cardiovascular disease cancer diabetes and that’s where I’ll tell you about the Marshall Islands and then just a little overview of other diseases and then the practical implications of these findings so what we know right now is that the number one killer globally is chronic disease about 70 percent of all deaths in the Western world are due to chronic diseases that are essentially lifestyle induced they’re induced by what we consider lifestyle norms within our culture it’s about 63 percent worldwide an estimated 90% of type 2 diabetes 80 to 90 percent of heart disease and about 50 to 70 percent of all cancers are considered entirely preventable think about that for a moment if you will it’s really unbelievable that the diseases that are killing us and the people we love are mostly entirely preventable by very simple lifestyle changes the four big lifestyle culprits according to the global status report from the World Health Organization are number one an unhealthy diet number two a sudden Herry lifestyle number three alcohol and number four tobacco the World Health Organization makes specific recommendations for a healthy diet and they are this is the World Health Organization this is not a vegetarian organization eat more fruits vegetables legumes nuts and seeds cut down on salt sugar and fat choose unsaturated fat instead of saturated fat and eliminate trans fatty acids the 2010 and I’m going to apologize right now because we had problems with getting my presentation on the screen so the pictures are totally messed up as you can see there’s things overtop of the writing and so forth so I apologize for that but the 2010 Dietary Guidelines Advisory Committee report had four main action points and they were eat fewer calories shift to a more plant-based diet significantly reduce intake of foods containing solid fats and added sugars and increase physical activity the 2015 Dietary Guidelines Advisory Committee report added the following for the first time ever eat less meat it’s the first time they’ve ever said eat less meat they’ve said eat less saturated fat they’ve said eat less cholesterol but they’ve never before come out and said eat less meat especially red and processed meat as it’s consumption is associated with increased disease risk and they also stated for the first time ever emphasize plant foods and D emphasized animal products to improve environmental sustainability can you imagine it’s really quite remarkable [Applause]

so how strong is the evidence plant-based diets confer a health advantage well here’s what we know about dietary patterns and disease risk and a lot of it comes predominantly from two large studies and you know what’s really neat about these studies is these studies they’re so valuable because they are comparing people who consume different dietary patterns non-vegetarian semi vegetarians pesco vegetarians lacto-ovo vegetarians and vegans but they’re all health-conscious so they’re trying to select for people that are similar health-conscious in their daily practices in their lifestyle practices so the first is the Adventist Health Study to 96,000 individuals and it began in 2002 and is ongoing and this is an American Canadian North American study and then epic Oxford with over 65,000 participants and it is out of the UK it began in 1993 and is ongoing so we’ve got a lot of information and a lot of this information has come out just in the last two three four years

so let’s talk first about longevity and we can’t talk about longevity with talking about the Blue Zones because there are places in the world where people commonly live to be 90 or 100 and even when they reach those advanced ages they are still very productive they feel good they’re out gardening they’re walking and so on there are 5 recognized Blue Zones Okinawa Sardinia Italy the seventh-day adventists the vegetarian seventh-day adventists of Loma Linda California Icaria Greece and the Nicoya Peninsula of Costa Rica and I talked a little bit yesterday but I’m just going to go over it again to remind you and for the for the benefit of those that didn’t hear yesterday’s presentations there there are actually six common lifestyle practices that that are sort of the things that we weave through all the blue zones strong families they’re socially engaged they do constant moderate physical activity they tend not to smoke and wear diet is concerned there are two things that they tend to do they all consume plant-based diets and they all consume legumes and the the researchers involved with the Blue Zones put together sort of the best from all of these Blue Zones and came up with what they call the Blue Zones longevity diet and here are the six principles number one eat less Harry Hachi Bou it’s called in in Okinawa stop eating when you’re 80% full number two move more be as active as possible in your daily activities number three eat primarily unprocessed foods so you want to minimize your intake of packaged foods fast foods fried foods eat more plants load up on vegetables fruits beans whole grains nuts and seeds and finally eat less or number five eat less meat and avoid processed meat and number six eat at home

so what do we know about vegetarians do vegetarians actually live longer and in a word yes they do the Adventist Health Study to found that vegetarians including vegans live on average about nine point one nine point five years longer for men and about six point one years longer for women and what’s really interesting is when you look at the percent of people in this population living to age 85 nearly half of men live to age 85 in this Adventist population compared to only 15 to 20 percent of men in the general population and over 60% of the women compared to about 30 to 40 percent of the women in the general population now when we look at vegetarian mortality and the Adventist Health Study too hair too similar this is not compared to the average Western eater but compared to similar health-conscious non-vegetarians mortality rates are reduced by about 28% for vegan men about 19% for pesco vegetarians 15% for vegans and 9% for lacto-ovo vegetarians and when I say vegans I’m talking about as a whole including women and the thing was is the women didn’t do as well as the men and the reason that I think that is and this is just a hypothesis I don’t really know for sure I think it’s because within the Adventist community even the non-vegetarian women eat really well they tend not to eat much meat they tend to eat a lot of fruits and vegetables even if they’re not vegetarian they’re very health conscious whereas there may be a greater discrepancy in the men so the vegan men have you know an even greater difference than the non-vegetarian men and so they would have that extra advantage

have have any of you ever watched the videos with dr. Ellsworth aware ham if you haven’t please look this guy up on the Internet he is absolutely amazing he was a practicing cardiothoracic surgeon till he was 95 years old he was doing surgeries and he said the only reason I retired was because I promised my family I would spend more time with them he said that a hundred I could still be doing this at a hundred he’s still you know mowing his lawn and driving everywhere and still speaking eloquently and very intelligently it’s really fun to listen to him so he’s one of the Blue Zone Adventists and there was also a meta-analysis in 2012 looking at seven prospective studies and this included about a hundred and twenty five thousand participants from the UK Germany the US the Netherlands and Japan and they found compared to non vegetarians vegetarians had a lower overall mortality of about 9 percent and that included vegetarians and vegans

so what do we know about red meat and mortality well there was a study that came out of Harvard looking at over 120 thousand participants and people consuming one serving of red meat per day increased their total mortality and before I tell you how much I want to tell you how much a serving equals a serving was three ounces of unprocessed red meat how many people do you know eat a three ounce steak Yeah right not very many it was a half an ounce of bacon actually less than and a half an ounce of bacon it was you know just under 13 grams is under a half an ounce then it was an ounce of sausage salami or Bologna and an ounce and a half or one wiener so that was a serving not a very big amount of meat one serving of unprocessed meat increased total mortality by 13% and one serving of processed red meat increased total mortality by 20% so triple the numbers if people are eating a nine ounce steak or three ounces of sausage or salami the author’s estimated that point five fewer servings of red meat per day would have reduced deaths by nine point three percent in men and seven point six percent in women

there was also a very interesting study that was released in 2014 on high protein intake in mortality and what it looked at was it looked at people who were consuming over 20% of calories from protein and what they found was participants who were 50 to 65 years of age who were followed for 18 years had seventy-four percent increase in overall mortality and a 400 percent or so four-fold increase in cancer and diabetes mortality with intakes of protein of over 20% of calories but what was really interesting is the associations were abolished or greatly attenuated which means there was very little association if the protein came from plant foods as opposed to animal foods now what’s the other interesting thing in this study is that those that were 66 years of age plus actually experienced benefits from higher protein except they had about 10 times increased risk of diabetes but they had less mortality and they had less cancer and they had less heart disease I believe so why you know it doesn’t make any sense well actually it makes a lot of sense when you consider that somebody who’s 50 to 65 a man especially would be eating maybe 2800 calories which is a hundred and forty grams of protein but a senior an older person might only be eating 1600 calories which would be about 80 grams of protein and as you get older your ability to actually absorb protein decreases so many people many countries recommend now a 25% increase in protein intake for seniors because they’re not digesting and absorbing it as well so that probably explains so a lot of seniors actually aren’t getting quite enough protein they need to up their protein intakes a little bit so that’s probably why the seniors did alright because they weren’t eating as much total protein even with 20% of calories from protein as compared to the younger people

so one thing that we know and I think this is absolutely fascinating research is that genes are responsible for an estimated 5 to 10% only of disease risk lifestyle Changez can actually alter our genes they can turn off disease promoting genes and turn on disease preventing genes they can increase telomerase by about 30% in telomerase is the enzyme that lengthens telomeres these are the ends of the chromosomes these red things on this picture that actually influence longevity and I don’t know if you’re familiar with Dean Ornish’s work on on well of course with heart disease but also with prostate cancer unbelievable he found that diet and lifestyle changes turned off about 500 disease promoting genes turned on about 50 disease preventing genes in fairly short order they actually looked at what was happening to the genes so what you eat not only can change your own destiny but it can change the destiny of your children as well and I thought this was an interesting time magazine why your gene DNA or why your DNA isn’t your destiny the take-home message here is plant-based diets are very positively linked to longevity the healthiest longest living people on the planet consume largely plant-based diets

so what about cardiovascular disease cardiovascular disease is the number one cause of death globally it’s responsible for about 30 percent of all deaths or at least it was in 2008 what we know about dietary patterns and cardiovascular disease well the Institute of Medicine says the following the Western dietary pattern characterized by high intakes of red and processed meat refined grains sweets and desserts and french fries is associated with an increased risk of cardiovascular disease in all regions of the world but a prudent dietary pattern characterized by a higher consumption of plant-based foods such as fruits and vegetables nuts and whole grains is associated with the significantly lower risk of cardiovascular disease and one of the reasons I want to I wanted to show you this slide is simply because I want you to be aware of the stance of mainstream organizations like the Institute of Medicine the American Heart Association they know this is the information they’re providing people with for some reason people still aren’t quite getting it the World Heart Federation says a person eating a low a diet low in saturated fats with plenty of fruits and vegetables has a 73 percent risk reduction for new major cardiac events compared to someone eating a western-style diet

so what about rates in vegetarian and vegan populations well epic Oxford forty five five thousand participants followed for twelve years found that vegetarians were less likely to develop heart disease than caught health-conscious meat or fish eaters this was really interesting they actually had were thirty two percent less likely when and this was vegetarians plus vegans lumped into one when all the variables were just at four except BMI which is body fatness and then twenty eight percent less likely when they also factored in body fatness so how overweight somebody was now this fish eater thing I thought this was a strangest finding because normally fish and most of the epidemiological studies have found to be somewhat cardioprotective relative to meat so when fish eaters are compared to meat eaters they tend to do better so I actually this was I I called one of the lead researchers on this on this study and I said what the heck how come the fish eaters didn’t do any better than the meat eaters and he said I don’t know and I said could it be because in the UK you tend to dip your fish in fat before you eat it as in fish and chips maybe that’s it so so it’s a possibility

the Adventist Health Study again over 73,000 participants and with men the vegans had 42 percent less cardiovascular disease and 55 percent less ischemic heart disease lacto-ovo vegetarians were 23% less cardiovascular disease 24% less ischemic heart disease and the the numbers that are bolded are significant the ones that aren’t wildered are non significant pesco vegetarians had 34 percent less cardiovascular disease and 23 percent less ischemic heart disease in the women there were no significant differences among the different dietary groups except the pesco the fish eating women had a 49 percent lower risk of ischemic heart disease and again i phone dr. Orlick who was the author on this and i said what’s up why are the women not doing as well as the men it doesn’t make sense and I he said I don’t know and I said could it be possible just what I told you before that the women have smaller differences the meat-eating Adventist verses the vegetarian Adventists than the men and he said that really is a possibility so but they’re not we really don’t know for sure

so why do vegetarians and vegans tend to do better where heart disease is concerned well they have more favorable risk factors so when we look at major modifiable risk factors like overweight and obesity elevated total and LDL cholesterol elevated triglycerides and high blood pressure vegetarians and vegans out a group are at lower risk for all of these things when we look at emerging risk factors like oxidized cholesterol inflammation poor antioxidant status greater IMT you know elevated TMAO I’m going to talk about all of these things but but again vegetarians are have a benefit for all of those emerging risk factors so let’s first talk a little bit about the major modifiable risk factors well here we’ve got epic Oxford if you look overweight and obesity the lowest BMI is in vegans you can see then lacto-ovo vegetarians about the same as fish eaters and both less than meat-eaters but what’s really interesting here is if you look at the BM eyes they’re all within the healthy BMI zone even the meat eaters this is a European study but the vegans have the healthiest BM eyes this is Adventist Health Study – here’s the vegans lacto-ovo pesco semi and non-vegetarian you can see the you know numbers the BMI is going up and a healthy BMI is is between eighteen point five and twenty four point nine right and so here within the United States the Adventists house study the only group that was in a healthy weight zone were the vegans everybody else was above the healthy weight numbers elevated blood lipids again as you go from vegan to lacto-ovo to non-vegetarian blood cholesterol go up LDLs go up HDLs are not much different they’re a little lower in the vegans but not a lot triglycerides are lowest in vegans are actually highest in the lacto-ovo vegetarians and this is based on about 20 studies and somewhere in between in non vegetarians and that would you know triglycerides tend to go up as your intake of carbohydrates especially refined carbohydrates goes up so these people may have been eating too many refined carbohydrates what about hypertension’s epic oxford shows lowest rates of hypertension among vegans like five point eight percent among men seven point seven percent among women and then going up and and 15 percent among meat-eating men and twelve percent among meat-eating women so really a very significant difference in the Adventist Health Study two hypertension was 75 percent lower among vegans and it was fifty five percent lower among lacto-ovo vegetarians than it was among health-conscious meat-eaters so very very significant finding

so what about the emerging risk factor inflammation chronic low-grade inflammation increases metabolic abnormalities that are associated with cardiovascular disease and it makes arterial plaque vulnerable to rupture and thrombosis so this is a serious issue in risk so vegetarians what we know is four out of five studies assessing CRP levels in CRP is your indicator for inflammation it’s a blood test you can do to test your levels of inflammation vegetarian showed significantly lower levels of inflammation compared to omnivores and there was only one study on vegans and this was actually on raw vegans but the vegans had a CRP of 0.57 compared to endurance athletes 0.75 compared to people eating a Western diet two point six one and a really healthy level is one or less so the vegans had the best level by far

what about oxidative stress well hyperlipidemia which is you know high cholesterol and high triglycerides causes oxidative stress and reduces our antioxidant defense system elevating levels of the sort of damaged fats in our bodies high intakes of Dietary heme iron that’s blood iron the iron from meat and fish and not all of the iron in meat and fish is heme iron but a you know probably 40 or 50 percent of it is and from saturated animal fats are associated with increased oxidative stress and dietary cholesterol actually increases acept ability of LDL to oxidation by nearly 40 percent limited evidence suggests that vegan and vegetarian diets decrease the oxidation of lipids probably owing to the high antioxidant and low well know heme iron content in these diets also vegetarians tend to have more favorable antioxidant status and and this is important to know food sources of antioxidants are protective supplement sources of antioxidants have not been shown to be protective okay so very important to know that a carotid IMT and here we’re looking at this kind of layer where plaque develops within the blood vessels sort of the outer layer and when you have a high IMT or carotid IMT it increases dramatically your risk of heart disease and diets high in meat and low in fiber can increase this carotid IMT well vegan diets and near vegan diets tend to reduce it

so what about this high TMAO which vegetarians tend to be protected against well high TMAO accelerates atherosclerosis especially in heart failure patients the highest TMAO levels increase their risk of dying by three point four times so this is really significant omnivores who regularly consume red meat our ideal hosts for the bacteria in the intestines that produce TMA and vegans have none of the TMA producing bacteria zero so even exactly even if you take carnitine from a supplement you won’t produce TMA because you don’t have the bacteria to make it so we don’t have those bad bacteria and then the TMA gets sent to the liver and it gets converted to TMAO which causes the damage and in fact it can also be produced from choline which is very high in eggs as well but we get choline from some plant foods but again we don’t have the bacteria to produce the TMA from it so this is good news

and then but there are some factors that are potentially unfavorable for vegans and we vegetarians so we need to be aware of those so what are they number one elevated homocysteine if you ignore vitamin b12 you are shooting yourself in the foot because your homocysteine shoots up your risk of heart disease potential we’re at risk of Alzheimer’s a birth defects and so on we’ll also shoot up okay so it’s really important to recognize that low omega-3 fatty acid status may also cause increased platelet aggregation or the stickiness of your blood cells it can elevate triglyceride levels and many vegetarians and vegans tend to have a lower omega-3 status so we need to take care of that it’s not difficult to take care of it but we need to take care of it so plant sources of omega-3s or taking microalgae which is the original source of DHA and EPA in the ocean which you can buy in a supplement form and oh this i won’t i won’t going to that high refined carbohydrate intakes are another problem potentially with vegetarian and vegan diets refined carbohydrate diets boost triglyceride levels and they increase the bad small dense LDL levels and this is the low-density lipoprotein which elevates your risk of heart disease so we what we don’t want to do is rely on refined carbohydrates as staples in our diet we should be eating unrefined carbohydrates instead low carbohydrates are not the answer and replacing saturated fat with refined carbohydrates does very little to alter our risk for cardiovascular disease replacing saturated fat however with unrefined carbohydrate is protective the Nurses Health Study in 2014 reported that long-term use of low carb diets rich in animal protein not in vegetable protein increased cardiovascular disease risk by 51% and all cause mortality by 33% so the high-protein plant-based diets did not increase risk at all

so the question is often asked how much red meat is safe and this question was posed to dr. Walter Willett from Harvard if you’re aware of dr. Willits work he’s one of the leading epidemiologists in the world and has been involved with the Nurses Health Study in the health physician study and so forth and here’s what he had to say like almost everything it’s frequency and amount that influence our risk there’s no sharp cutoff it’s like radiation we can’t say there’s any safe amount Harvard study found that red meat increased risk of cardiovascular disease by 18 percent for every serving of unprocessed red meat and 21 percent for every serving of processed red meat why saturated fat Hema iron neu5gc carnitine hormones and antibiotics and so on and so on and so on there have been three recent meta analyses on red meat intake and cardiovascular disease and they all showed four unprocessed red meat an increase of ten to fifteen percent in risk and for processed red meat an intake of more like twenty to forty percent increase in risk

so I want to address this really quickly because a lot of people say but wasn’t saturated fat vindicated did anybody see the headlines that saturated fat has been vindicated butter is back you don’t have to worry about saturated fat at all anymore well there were two studies that suggested we don’t have to worry about saturated fat and one was an analysis by Siri Torino and the other was an analysis by child hurry and I’ve highlighted in yellow here a few names that were involved with these trials Frank who Francesca crow dr. Massa Farion dr. Anjali I think Angela you know or something anyway we’ll see it and bigger and then I’ll be able to say it so I can’t read it so well there but here’s the headlines we saw saturated fat isn’t bad for your heart you know saturated fat may not cause heart disease not so bad after all etc etc etc well the people at Harvard said the media misrepresented and sensationalized these study results contributing to a haze of confusion among consumers and they brought together a group of nutrition experts to do a teach-in and in that were Frank who who was an author of the first study dr. Massa Farion who was an author of the second study Frank sax Ellis Lichtenstein who wrote the position paper for the American Heart Association and Walter Willett again and here’s what the panel consensus was cutting back on saturated fat is good for health if the saturated fat is replaced with good fats especially polyunsaturated fats if you replace saturated fats with refined carbohydrates like sugar there will be a detrimental effect food quality matters we’ve got to focus on food sources and dietary patterns rather than nutrients alone and they basically determined that saturated fat increases LDL and HDL but with an overall negative effect on cardio metabolic risk so they’re saying it’s not good replacing saturated fat with polyunsaturated fat lowers risk trans fat increases risk significantly refined carbs adverse effects monounsaturated fat uncertain effects and unrefined carbohydrates favorable effects and dr. Walter Willett did this little diagram you replace that trait of fat with trans fat the worst possible outcome with refined carbs the next worst with monounsaturated fat not so bad with unrefined carbohydrates much better and with polyunsaturated vegetable fat much better as well

here’s what dr. who said and remember he was an author of the first study that vindicated saturated fat dietary recommendations should be food based replacing high saturated fat foods such as red and processed meats with and butter with vegetable oils high in Manos and piu FFA’s or polyunsaturated fats nuts seeds legumes and whole grains there’s a world-renowned expert who was interviewed about this whole saturated fat fiasco and he says the fact that saturated fat raises cholesterol is beyond doubt that has been shown in hundreds of trials that fed people different types of fat the observational studies he’s talking about these two studies sometimes do not show a link for two main reasons reason number one the differences in saturated fat intake within populations are too small to produce an effect so if you compare someone eating 12% of calories from saturated fat with someone eating 14% of calories from saturated fat you won’t see huge differences the dietary data is inaccurate in a lot of these studies you know what they do they often do one 24-hour recall what did you eat yesterday and then follow the people for 10 years and don’t know other Dietary assessments none zero that’s shocking it’s shocking the meta-analysis and again the meta-analysis included in the second trial the shop Chowdhury trial gave people margarine that was high in trans fats when the authors omitted that trial they found that people who replace saturated fat with polyunsaturated fat actually had a 19 percent lower risk of heart disease but the meta-analysis buried that finding in a supplement after they were challenged that didn’t make the headlines 19 out of the 20 studies compared populations with almost no variation in saturated fat intake and very interesting the rate of cardiovascular disease in Finland where there’s very high saturated fat intake was four point time four point four times higher than that of Japan which was in this study in the same meta-analysis but they didn’t show that because they only looked at differences within each population so the Japanese people that some of were eating 6% of calories from saturated fat and some 8 they didn’t see any difference in Finland 15 vs. 17 they didn’t see any difference if they would have compared between the different populations they would have seen a huge difference okay an epic Oxford was the only study in that trial the only Madonna the only study used in the meta-analysis that included a wide range you know the wide range the non vegetarians vegetarians the vegans etc they found a 2 point 7 7 times greater risk in those with the lowest or the highest saturated fat intake versus the lowest saturated fat intake so that tells you something as well

now this is very interesting because I I actually emailed one of the authors of the Chowdhury study and I said what’s with this study there’s it just doesn’t make sense based on what we know she wrote me back and she explained to me that she had been very involved with the study when it was first done and she said they found a big difference in people eating the most saturated fat versus the least saturated fat but when they submitted it to a journal it was not accepted there was nothing new so the lead author took and reworked to the data taking out some of the studies like the one you saw in the last slide resubmitted it with a little different finding and it got accepted and she said when it was sent back to her she said it was within a week of being published and there was nothing she could do and here’s what she said the best available evidence from randomized control trials shows that saturated fat intake affects blood cholesterol levels which is an important risk factor for heart disease therefore current guidelines should still recommend that people minimize their intakes of saturated fat and what do people recommend well the American College of Cardiology and the American Heart Association recommend that people aim for a dietary pattern that achieves 5 to 6 percent of calories from saturated fat you’re basically talking a plant-based diet you cannot get down to 5 to 6 percent of calories from saturated fat if you’re not eating a plant-based diet and their level of evidence was the strongest level of evidence that exists ok and that you know that’s our conservative organizations

so what about heart disease reversal well we know and I won’t go into detail but you know dr. Caldwell Esselstyn has shown heart disease reversal using a low-fat plant-based diet as has dr. Dean Ornish both of dr. Esselstyn showing 72% of those tested getting reversal and and dr. Ornish finding 82% with reversal and a dr. Esselstyn just put out a study in 2014 that was quite interesting 198 patients with cardiac RDO vascular disease 177 adhered to his program 21 were non-adherent the recurrence rate was 0.6% among the adherent people and it was 62% among the non adherent and you know this study wasn’t a good study it wasn’t it was a self-selected group there was no control it wasn’t randomized all of that stuff but nonetheless it’s very interesting and very powerful findings this cartoon says heads you get a quadruple bypass tails you eat your veggies and I think the point here is you have a choice you know on in your treatment for cardiovascular disease and you have a choice in avoiding cardiovascular disease altogether the take-home message is whole food plant-based diets protect against cardiovascular disease and well-designed plant-based diet can provide more effective treatment than our most powerful medications and surgeries

cancer the World Cancer Research Fund and the American Institute for cancer research probably put out the most comprehensive documents ever written on diet and cancer and in 2007 they put out this food nutrition physical activity in the prevention of cancer a global perspective and it involved over a hundred scientists from 30 different countries around the world and what’s really interesting is they have an independent group of scientists that updates recommendations on an ongoing basis this is called the continuous update project so we’re getting you know they keep looking at the research and updating us on diet and cancer and they have a series of goals and recommendations and they basically say that they believe that populations and people who achieve these recommendations will not only reduce the risk of cancer but reduce the risk of many other diseases as well and there are two recommendations that have anything to do with our plant intake and our animal our intake of animal foods and plant foods and they are under plant foods eat mostly foods of plant origin eat at least five servings or 400 grams of a variety of non starchy vegetables and fruits every day eat relatively unprocessed cereal grains and/or pulses or legumes with every meal and limit refined starchy foods and people who consume starchy roots and tubers like potatoes make sure that they have sufficient non starchy vegetables fruits and pulses or legumes as well the justification for this recommendation most diets that are protective against cancer are made up of foods of plant origin and if you look at this list this is inside the book they list vegetables fruits pulses nuts seeds or spices and the risk of cancer you can see the decreases risk column and the increases risk column there is nothing in the increases risk column these foods don’t increase risk based on the studies we have but they seriously reduce risk and there was a one finding that was upgraded foods with fiber reduce risk of colon cancer colorectal cancer went from probable to convincing in 2011

animal foods what do they say limit intake of red meat and avoid avoid processed meat people who eat red meat to consume less than 500 grams a week very little if any to be processed justification red and processed meats are convincing or probable causes of some cancers and here’s meat poultry fish eggs in the risk of cancer you can see in the decreases risk column the only thing there is fish for colorectal cancer you can see in the increases risk convincing evidence for red and processed meat and colorectal cancer and probable or limited or suggestive evidence for several other cancers there have been several about seven meta analyses that have looked at unprocessed red meat and cancer in 2012 to 2014 and you can see basically this is unprocessed red meat increasing risk of a variety of cancers between about 10 and about 20 or 30% total red meat increasing risk about 45% here’s processed red meat in cancer increasing risk about 15 to 25 percent per serving the American Institute of cancer research estimated that about 45% of colorectal cases could be prevented if we all ate more fiber rich plant foods and less meat drank less alcohol moved more and stayed lean

so what are the rates among the populations vegetarians and vegans well epic Oxford compared to similar health-conscious non vegetarians cancer rates were 19% lower among vegans 12% lower among pesco vegetarians and 11% lower among lacto-ovo vegetarians so you can imagine this is compared to health-conscious meat-eaters imagine what it would be if it were compared to non health-conscious meteors the average Western diet eaters it would probably be 50 or 60% lower the Adventist Health Study – again almost 70,000 participants compared to non vegetarians cancer risk was 16% lower among vegans 12% lower among pesco vegetarians and 8% lower among lacto-ovo vegetarians 2012 meta-analysis the sames 12:7 studies that i talked about before the result showed cancer incidents and mortality rates were 18% lower among vegetarians compared with non vegetarians so why the veg advantage well plant-based diets have been shown to inhibit cancer cell growth reduce DNA damage improve DNA repair lower igf-1 levels or insulin-like growth factor-1 levels favorably alter fecal enzymes and gut microflora and reduce levels of a row of a variety of toxic metabolites

so what about soy and we talked a little bit about soy yesterday but I want to talk about the weight of the evidence for soy and cancer the American Institute of cancer research had a press release in 2012 and this is what the press relief said release said for all cancers human studies show soy foods do not increase cancer risk and in some cases may even lower it breast cancer patience and survivors need no longer worry about eating moderate amounts of soy foods so here’s what we know about soy and breast cancer in a 2014 meta-analysis soy consumers in Asia had a 41% risk reduction no association was noted in Western countries in this meta-analysis in 2012 there was a pooled analysis of Chinese and American women those with the highest intakes of isoflavones and that is the phytoestrogen in soy were 17% less likely to die from breast cancer and 25% less likely to have a recurrence of breast cancer I think this study is one of the most interesting this is a study from Korea 2013 people with the highest quartile of soy intake had a 61 percent lower risk if they were Braca one or bracha two carriers the people with the highest quartile of median take had a hundred and ninety-seven percent higher risk regardless of their bracha status whether or not they were Braca positive so very very interesting so soy was very protective and the highest quartile of soy was actually four to five servings a day soy intake in childhood moderate soy consumption in childhood adolescents and throughout puberty actually reduces lifetime breast cancer risk so what about soy and prostate cancer well a 2014 system systematic review and meta-analysis report reported that high soy that high risk men in high risk men intake of soy or soy isoflavones reduced risk of prostate cancer by 51% preliminary evidence suggests that soy actually reduces prostate cancer metastasis slows rise in PA reduces side effects so from radiation therapy the take-home message here is populations eating plant-based diets have lower cancer rates and plant-based diets have several lower or people eating plant-based diets lower several metabolic risk factors for cancer

so moving on to type 2 diabetes there was a study that looked at all kinds of dietary patterns and diabetes risk and the authors said in their summary together with maintenance of ideal body weight the promotion of a so-called prudent diet characterized by a high higher intake of plant-based foods and a lower intake of red meat meat products wheats high-fat dairy and refined grains or a Mediterranean dietary pattern appear to be the best strategies for decreasing diabetes risk so what are the rates among vegetarian or vegan populations well the Adventist Health Study 2 found that in health-conscious meat-eaters semi vegetarians pesco vegetarians lacto-ovo vegetarians and vegans as people consume less meat their their risk for diabetes decreased and so the rates were about seven point six percent among the health-conscious non vegetarians six point one amongst the semi vegetarians four point eight among pesco vegetarians and this is lacto-ovo vegetarians plus fish about 3.2 percent among lacto-ovo vegetarians and about two point nine percent among vegans and taking the same cohort and following them for another two years who develop diabetes well the risk was 62 percent lower for developing diabetes for vegans than for non vegetarians was about 32 percent lower among lacto-ovo vegetarians and this was adjusted for everything for age gender education income television watching physical activity smoking and body mass index so they actually adjusted for body weight so this is very interesting

there was a study looking at diabetes rates in Taiwanese Buddhists and for similar health-conscious near vegan and they looked at rates in similar health-conscious near vegan and omnivorous volunteers diabetes risk fully adjusted for all of these variables was 51% lower among near vegan men and about 75 percent lower for near vegan women and I want to tell you the pictures on this slide are very interesting because I was speaking at the sushi International Medical Association conference in Taiwan and there are seven of the most highly regarded hospitals in Taiwan they are all buddhist hospitals and they are all completely vegetarian this meal at the bottom was your typical cafeteria meal whole-grain rice and it’s just a whole huge buffet of vegetables and tofu dishes and so forth i went i was taken into the kitchen and you see that the garbage bags in that corner they’re all filled with greens for the patients fresh greens from the organic gardens that the Buddhist nuns were growing yeah I mean unbelievable can you imagine this concept of actually feeding sick people healthy food it’s just unbelievable I you know and we have so much to learn from others around the world I was stunned when I saw those bags of greens you would never see that in a hospital here

what about the diabetes rates among East Indians well over a hundred and fifty thousand adults twenty to forty nine years of age comparing non vegetarians and this again is fully adjusted including BMIs lacto-ovo vegetarians were 33% less likely to develop diabetes lacto-ovo vegetarian or lacto-vegetarian 31% less likely they didn’t consume the lacto-vegetarian were consuming milk but no eggs the lacto-ovo consuming both milk and eggs they didn’t have a vegan population but semi vegetarians were 24% less likely to develop diabetes so what do we know about red meat and diabetes risk again from the Harvard studies health professional follow-up study in the Nurses Health Study almost a hundred and fifty thousand participants participants adding just half a serving one and a half ounces of meat a day increased risk of diabetes by 48 percent unbelievable so we also have a study this is another arm of epic not not epic Oxford but epic Norfolk and they did a study looking at fruit and vegetable intake and diabetes risk and what they found was that that that basically there was a strong inverse association between fruit and vegetable intake and diabetes incidents compared with people eating though in the lowest quartile of vegetable intake risk was reduced 30% for the second quartile 66% for the third quartile and 81 percent for the highest quartile of vegetable intake so the the quarter of the group that we’re consuming the most vegetables 81 percent lower risk and remember we learned yesterday that only 2% of men and 3.5% of women actually get even the minimal amounts of fruits and vegetables recommended by the US government just unbelievable this is how much it would help if they improve their intakes

so we also know about treatment using plant-based diets from PCRM they’ve had a number of studies comparing low-fat vegan diets to an American Dietetic Association or sorry American diabetic Association diet for the treatment of diabetes and those eating vegan diets lost more weight and had greater blood glucose reductions than those eating the American diabetic Association diets we also have research from a Czech team that found near vegan diets more effective than calorie restricted conventional diets in increasing insulin sensitivity and reducing medications and body fat so there are also a lot of books that have been published on using plant-based diets to actually reverse diabetes or at least improve the you know the the risks of of complications of diabetes and the one on the Left defeating diabetes is a book that I wrote back in 2004 and this book was responsible for getting me invited to the Marshall Islands and that’s where we are now at the Marshall Islands story

so where are the Marshall Islands well you know where Hawaii is you know where New Zealand is the Marshall Islands are about 2,300 miles southwest of Hawaii and about 3,500 miles directly north of New Zealand they are about five to seven degrees north of the equator and they are it’s really interesting as you can imagine it’s summer year-round and it’s 82 degrees on average at midnight at 6:00 in the morning in the middle of the day hundred feet below the surface of the water in the ocean and wet and the coldest it ever gets is 77 degrees and the first week I was there it hit 77 because it was raining outside and people were shaking they were shot I’m not kidding you they were just shaking they were putting coats on and and and I have to tell you this story because it’s so funny a doctor in the Marshall Islands his daughter was going to come to Canada they were seventh-day Adventist and she was going to go to an Adventist college in Alberta and he said to me and this is in Lacombe Alberta it’s like minus 30 there in the wintertime minus 40 and he said to me he said you know I’ve heard it’s cold in your country he said you think she might need a sweater I told him to go into the kitchen enter the refrigerator stay there for a few hours and that’d help him decide if she needed a sweater I told them please do not send her to can’t send her to California but in the Marshall Islands diabetes is a state of emergency they have the highest death rates from diabetes on the planet the estimated prevalence is about 50% in those 35 plus pre-diabetes or type 2 diabetes almost all adults at least 90 percent of adults have either pre-diabetes or diabetes about half of all surgeries on the islands are amputations due to diabetes

so was diabetes a problem in the past not at all it was practically unheard of 70 or 80 years ago the people were slim they were physically active and they lived off the land so what was the traditional diet well they eat they ate plants 50 to 60 percent of their calories came from coconut they ate bread fruit bananas they pandanus green leaves and of course whatever they could catch out of the ocean period that’s all they ate they didn’t have anything in a box or a bag today what do they eat well the little girl on the far left is eating breakfast and I’m not kidding this with seven o’clock in the morning children eat whatever they want because parents have to still think that if they have a full belly they’re well nourished that’s the way it was for generations they didn’t understand that any food wouldn’t be nourishing they eat for lunch and dinner white rice sticky white rice and meat that’s often spam or some sort of canned meat or chicken they eat all the parts of the animals that we don’t want like turkey tails or any cheap animal parts you can see on the left hand corner it’s all bins of meat for a celebration and it’s bins of processed meat mostly the children’s favorite snack oh and I should say it’s all washed down with luau the number one ingredient for Lua luau is high-fructose corn syrup the meal on the right is a celebration meal and so you can see it’s white rice chicken ham sandwich a doughnut and some white soda biscuits so that’s the food they’re living on the favorite snack of the children is you know what ramen noodles are in those crinkly packages they’re deep fried noodles salted noodles well that’s the favorite snack and what they do is crack open a package they don’t cook it they pour a bag of Europe a package of kool-aid powder on top so all the artificial colors and preservatives in one day I was watching a kid they poured their kool-aid powder on top and then they took something out of their pocket a package of white stuff and they started sprinkling the white stuff and I thought they can’t be putting Salters yeah there’s 1,800 milligrams of sodium in one of those packages they can’t be putting something so I said to the person next to me I said are they putting on their ramen noodles and they said oh that’s a scene immortal you notice any motifs pure msg yeah so the top sources of calories and the marshalese diet are white rice white bread and rolls donuts and white flour baked goods spam and other canned meat chicken ramen noodles with kool-aid powder sprinkled on top sweetened beverages fish other meat salty snacks and that’s about it it would be difficult for me to design a diet to induce diabetes any better than the diet these people have adopted and that’s why they have such huge diabetes rates and that’s why they have the highest highest death rates from diabetes on the planet

so in 2006 we began the diabetes wellness project in the Marshall Islands and the founder of this project was canvasback missions a seventh-day Adventist medical mission group that had been providing medical teams to the Marshall Islands for 20 years plus bringing in teams of oncologist teams of ent dog there’s teams of dentists to try to help the people and they watched the diabetes epidemic really unfold and they were determined to do something so they got they applied for and were granted a grant got a grant a research grant from the US Department of Defense why because the US government the Marshall Islands were atomic bomb testing grounds after the Second World War and so there’s some sort of relation you know sort of a relationship between the Marshall Islands and the United States and the United States does give a lot back to the Marshall Islands now and so wanted to do this as another giving back and the partners were the Marshall Islands Ministry of Health and Loma Linda University and I was brought on because the doctor that was hired to be the sort of director the medical director of the project had just been to a conference that I was speaking out on diabetes and he said I think I think you know we could use the program from her book as our program to try in the Marshall Islands so that’s how I ended up getting involved

so what we did was we basically did a proper study where we work and we were comparing very aggressive lifestyle intervention with the usual care and we had a hundred and sixty nine participants with a1cs over eight so they were diabetic or they were taking diabetes medications and we used a random randomized parallel design with five overlapping cohorts and they were with us for 24 weeks and what that means is overlapping design means before one group has stopped we’re already starting another group okay so we did five groups and we did many others but only five were part of the actual research our goal was really simple our goal was to reverse the diabetes epidemic step one to prove that diabetes can be successfully treated with diet and lifestyle in the Marshall Islands and step two to get the government to adopt the programís under treatment for all marshalese people so here’s what we did weeks one two four and six there are with us for weekdays for six hours a day weeks three five seven and eight they were with us twice weekly for about five hours weeks nine to twelve they were with us weekly for about five hours and weeks twelve to twenty-four they were on their own but they would come for exercise and measure blood Sugar’s and all of that sort of thing and the guys you see here all of these men are ministers of health or senators so we put through the leaders of the communities we had the president we had you know all of the the you know princes and kings and all of those leaders because we wanted to educate the leaders it’s a it’s a quite a society where where there’s it’s a bit of a nepotistic society and and it’s and and I should also say it’s a beautiful society the people are absolutely incredible I have never heard people laugh as loud or you know sing is beautifully I one story I just have to tell you this doctor told me this story he first arrived to the Marshall Islands and he took a side road home to our hotel and and he said the first thing he saw was this gang of teenagers coming towards him and he got scared and he said it was a gang of teenage boys and as they approached and got closer he realized that they all had their arms around one another and they were all singing and as they got close to him they were so friendly and they were saying Yahweh Yahweh and and The Witches hello and love and all of that stuff and he knew he was in a very special place it’s a very special place

so they people would do a walk a blood glucose and breakfast on their own but we would provide their food this is in the intensive phase they come to the clinic for lunch and then they would be working during the day and then they would come at 3:00 and be with us till about 8:15 and that time they would do an exercise class a cooking class they’d have dinner they have an you know an education session in the evening it was very intense and our diet goal was very simple to restore insulin sensitivity and to accomplish that task we must produce weight loss in the overweight participants we’ve got to improve blood glucose control we’ve got to reduce oxidation and inflammation and we have to restore their nutritional health because they are as you can imagine extraordinarily malnourished so the diet design while it was a plant-based diet high in fiber it was a very low glycemic load I have to tell you this before I go on the high fiber thing the average fiber intake in the marshalese people was about 5 grams a day ok we got them to 40 to 50 grams a day so you can imagine what happened we had people that on average were going to the bathroom once every week or two yeah and so when they started going to the bathroom every day it scared them it scared them it was just so unusual for them and so it’s really quite quite interesting so it would very low glycemic load minimal refined carbohydrates if any minimal ground grains we didn’t use flour products we used intact whole grains moderate fat so we used some nuts and seeds low saturated fat zero trans fatty acids most of the saturated fat free coconut that we used and we did use coconut it’s a really important traditional food for them and sufficient essential fatty acids using flax seeds because they’re cheap we did allow them to eat some fish at home we’d never served any animal products at the clinic at all but they were allowed after the first few weeks if they wanted to have boiled fish not fried fish that was permitted because that’s a very important part of their cultural diet as well the diet was anti-inflammatory high in phytochemicals high in antioxidants low in accidents contain moderate levels of sodium a lot of people say well and these girls at the bottom these are these ladies are our cooks and they’re eating pandanus and pandanus is a really important source of vitamin A for these people and pandanus is so fibrous that you can’t really eat it you can only suck the juice out of it it’s like you need to have dental floss if you can go near it but they love it it’s quite flowery tasting

so so why not just return them to their local foods well of course it would be a great idea you know it would make sense from a health perspective and from a cultural perspective but from a practical perspective it’s impossible because the island might sustain like Majuro the main island that we worked on might sustain five hundred or a thousand people there are 30,000 people there so there’s no way you have to import food so the answer is to get them to import healthy foods and to eat as many local foods as they can so it’s just so important so the best choices are cheap imported foods but healthful ones like beans legumes barley low cost vegetables like cabbage and squash so what else did we do in the program well they did daily exercise their favorite was dancing men and women they loved to dance so they were khari and that you can see the women none of them have exercise clothes on because pants in their culture they’re starting a little bit now but when we arrived if you were pants as a woman you were a prostitute and it was only people from Asia that would ever wear pants and they were prostitutes so women wore long dresses period and we had to abide by that of course as well and so they exercised in their long dresses and every this if you take nothing away from this for diabetes if you know of family or friends walking after meals is one of the most potent things that you can do to keep your blood sugar down even if it’s only 5 minutes we had them walking about 20 or 30 minutes after meals we did cooking classes we did shopping tours we did education sessions and this man right here dr. Kamal was known as the butcher this is the man that cut the people’s legs off and everybody was scared of him and he was the sweetest man on the planet he was a vegetarian himself and I absolutely loved him he was just such a dear person and he said if only I could convince people to come in before they have gangrene going up their body and I have to cut their legs off to save their lives but what they would do in their culture if they got sores on their feet they would try to treat it with local medicine because they were scared if they went to the doctor he’d cut their leg off so they would wait until they you know their leg was everything was black and they had gangrene going in it that’s the only thing he could do so we brought him in to teach people about you know how to care for their feet and that he was he didn’t want to cut their legs off so you know and we would teach people about lifestyle and chronic disease food and nutrition exercise stress management dental health feet and eye care and and and gardening we tried to help people plant gardens even if only in buckets because the soil there you can imagine the a the atoll that they lived on is 30 miles long and three point seven square miles in area it’s this long strip of coral reef and there’s not good soil there at all so it’s very difficult

so I’ll tell you a little bit about the results in the first two weeks pain in the joints arms and legs was reduced or eliminated in almost everybody some of these people had intermittent claudication terrible pain in their legs it would disappear in the first week it was unbelievable they couldn’t believe it they’d be able to sleep through the night they had increased enter they of course were no longer constipated they could think more clearly and 90% of the participants were able to stop taking their medications in the first two weeks was unbelievable so and changes at two weeks in 12 weeks while you can see fasting blood sugar dropping 71 points in the first two weeks 48 and the first 12 because they were eating foods at home again a 1c dropped about two points by 12 weeks the insulin production went down which is wonderful because they were hyperinsulinemic BM eyes went down systolic blood pressure total cholesterol and the CRP the measure of inflammation went down about 1.2 points so this was all good and the committed participants the ones that really stuck to the program had the greatest success many of whom were able to reverse their disease completely the man on the top right this is Laura caloric his name is Laura caloric and he was a pilot and a lot of people in the Marshall Islands don’t get well-educated but he was actually able to become a pilot and and you know fly planes which was really quite remarkable he lost his pilot’s license because of diabetes and he came to the program and he completely reversed his disease he’s now flying again so it was really exciting for him you know these people are really pioneers of the Pacific the participants of this program provided hope amid a very deep sense of hopelessness they overcame insurmountable mountains of spam donuts ramen noodles and Cola they put together low-cost healthful meals despite the high cost and poor quality of their produce and their lack of resources they don’t have money they managed with little education and marginal English skills they succeeded with few gyms one to be exact no trails in a cultural taboo against women wearing exercise clothing the challenge in the Marshall Islands however is that even the best education program in the world is not enough because the marshalese culture is very group oriented everything shared there’s very few people with independent living units so community ownership is really key and until changes are embraced by the entire culture it’s very difficult for people to succeed long term

so what are we doing now our funding has run out so we are there doing what we can and we’ve shifted away from research to community efforts so we gave these little children this came from PCRM Carolyn Trapp came with me for a couple of weeks and handed these choose smart foods I choose smart foods bracelets to the children we we partnered with the Ministry of Health and the RMI government this is World Diabetes Day and the president and the Minister of Health and so forth are all there and we’re educating people we planted gardens in every single square inch of the hospital grounds we are teaching the children in the schools and getting them exercising as much as possible we reading community groups and church congregations we’ve partnered with restaurants and grocery stores and we’re still offering free lifestyle interventions free exercise classes and even and we keep going there every year in 2014 we went also to ebuy and ebuy has an area of 0.14 square miles it’s also part of the Marshall Islands the population is 15,000 people on point one four square miles it’s unbelievable we couldn’t do what we could do in Majuro we had a very small space we had to use little cooktop stoves but we did our best and we taught people to garden we brought a hundred and seventy seven earth boxes so people could could garden and of course things grow very very well we taught people to sprout we brought the hemp seed sprouting bags from the sprout man we got people walking we got people and they had a lot of fun we did grocery store tours and here’s the results in our mad row intervention last year fasting glucose average drop was a hundred and nineteen points after exercise 68 points and in ebuy it was the opposite average fasting glucose drop was fifty and after exercise a hundred and sixteen milligrams per deciliter

and people asked me could this program work at home and I say if there is hope in the Marshall Islands given the enormous barriers they face what is our excuse what is our excuse but the hope rests on demand from those affected and the integration of lifestyle medicine into our healthcare system it has got to be offered as a treatment option and so often physicians say to me all but my patients wouldn’t do that and I always say how do you know if you don’t offer it to them and I quickly want to introduce you to the vallejo family the vallejo family andreas right here was diagnosed with cancer at 36 years of age and he actually went to Hippocrates he came to a few conferences one of which I was speaking at and he asked me if I could help him to design a diet that would give him the best chance of survival he had a sub salivary gland tumor and it was not good put it that way and we put him on a very high raw very nutrient-dense diet but what just amazes me is everyone on his family said ondrea’s and he was a lawyer in Sanford he is a lawyer in San Francisco and he his favorite pastime was going to the best restaurant in whatever city he was buying the bit best steak and the best bottle of wine he wants he and his wife flew to Paris and spent $3,000 on one meal so they were really foodies okay and his whole family was like that but what really shocked me is his entire foodie family said ondrea’s whatever diet you’re put on we’re doing with you just amazing

and his father Carlos here’s what he was dealing with type-2 diabetic coronary heart disease he had just had a major heart attack he had uncontrollable high blood pressure high cholesterol peripheral artery disease his kidneys were failing and he had recurring doubt he was on 40 units of insulin and 17 pills a day he was told by his vision physician that he probably had less than two years to live he never expected that the diet would do anything for him you know why because his doctor told him he had a progressive irreversible disease and that nothing that he did would change anything after less than a year on a wholefoods plant-based diet Carlos took zero insulin and zero pills his fasting glucose was 4.4 24.8 his a1c 4.9 his blood pressure 115 over 70s his arteries open dot up based on a PET scan he did without surgical intervention the scar tissue is disappearing there is no longer any sign of peripheral artery disease his kidney function is now perfectly normal and he has not had a single recurrence of gout since he became vegetarian after four years his numbers are still the same and his health continues to improve Carlos said I used to spend my days in pain and suffering I took my insulin I was dizzy from my pills and I just knew I was going to die he said no I don’t even know what to do with all my time he said I spend two hours a day at the gym and he said I feel like I’m 25 years old he’s in his 70s

yeah the take-home message Whole Foods plant-based diets reduce risk of type 2 diabetes and provide the most effective therapeutic treatment for people with type 2 diabetes plant-based diets also protect against cataracts vegans have a 40 percent reduced risk kidney stones they have a 31 percent lower risk among lacto-ovo vegetarians and vegans diverticular disease 31 percent lower risk renal disease 52 percent lower risk why the advantage very simple because well-planned plant-based diets maximize protective dietary components and minimize pathogenic dietary components they maximize fiber phytochemicals enzymes antioxidants anti-inflammatories plant sterols and stanols pre and probiotics and they provide adequate micro nutrients and healthy macronutrients they minimize pathogenic factors the trans fats the excessive saturated fats the refined carbs the sodium and artificial food additives in neu5gc and chemical contaminants and all the products of high-temperature cooking and the TMAO and when we look at what Americans are eating 63% of the calories come from processed foods and 25% of the calories come from animal products only 12% from plant foods people get it this is you know you’ve heard of this heart attack grill anyone over 350 pounds eats for free all day every bit every day they even flaunt it you know here double bypass burger triple bypass burger quadruple bypass burger he was their mascot until he died at 29 and the bottom line is if you do not change directions you may end up where you’re headed and a 5% change in direction will not change anything you need to make an about-face lifestyle medicine is one powerful treatment option medications and surgeries cannot reverse lifestyle induced diseases because they do not address the root causes of those diseases only profound lifestyle changes have ever proven effective in reversing lifestyle induced diseases and the bottom line is the more we change the more we heal and I would like to make a call to action because it is time for food and nutrition policies to become a national priority and it is time but governments recognize that policies that may make healthy choices easier for people bring significant health economic social ecological and ethical advantages and with that I will close and say thank you so very much for your attention and I’m promoting my books which have all of this information in number thank you so much [Applause] thank you very much thank you