Radiation & Incurability

To radiate or not to radiate

On the 13^th of February, I met with a radiation oncologist.  My expectations of this appointment were that the doctor would have reviewed my recent scans and my past radiation treatment file from 2010 before I met with him.  This did not happen.  Instead, I discovered this doctor was acquainting himself with my health history for the first time as he sat before me.  My husband commented later that it was most likely done this way in order to avoid his not being compensated for his time if I did not show up for the appointment.  I see this as a possibility though it did not soften my annoyance. 

He began by starting from the beginning, my 2005 diagnosis.  I was perturbed a bit that we had to start from the beginning.  All of that doesn’t matter now.  Not only was he unfamiliar with my case, he further annoyed me when he said “Tell me about your first diagnosis in 2005 when you were in high school”.  Really, I look that young?  Oh yeah, and I look like a model too.  This type of talk may have at one time flattered me, but no longer.  I know better.  Cancer and its treatment does not make someone look young and vivacious, just the opposite. I have seen myself in the mirror.

With my health history covered, he next wanted to see my scans.  I thought how could he give me a valid opinion today about possible radiation when he is so clearly unprepared to do so?  He did do something no other doctor has done.  He invited me to look at my CAT scans.  I have been curious as to what those scans looked like.  My oncologist in Chapel Hill has never looked at them so I have never asked her to show them to me.  The scans looked exactly like those I have seen on TV or on the internet with one exception.  The radiation oncologist pointed out a black area on my right lung. 

“That is showing where your lung has scarring from your past radiation”, he said. 

The lungs looked great otherwise.  Soon the image of the area where the 1.2 cm tumor is located was reached.  The tumor was not easily revealed, at least in that image.  He did not look any further for a better image.  I guess he decided he had seen enough.  He turned to me and said he wanted to speak to Dr. Z, radiation oncologist in Chapel Hill, before he would give his opinion.  He said that I had had a great deal of radiation in that area.  The tumor would need a lot more than what I have had already to produce the result we would want.   The appointment ended without his opinion on treatment with radiation which was good because he did need some time to think things over, obviously.  I left with the understanding that he would call me on Wednesday. 

I went home with doubt that he would recommend radiation treatment.  There was something about his demeanor and the way he said, “This is a difficult area to treat”.  I also thought about what I would do if he said, “Yes”.  Would I want to take the risk of losing the function of my right arm?  (My tumor is close to the right clavicle bone deep within my chest.  The radiation would pass through motor neurons responsible for muscle movement to my right arm and might damage them permanently.)  Ever since the radiation oncologist in Chapel Hill let me know of the possibility of this particular side-effect I had been thinking about what I would do.  I was leaning toward taking that risk if it was possible to completely eradicate the cancer.

Wednesday came and Wednesday went.  I know I am not the only patient that this doctor sees, but when he said, “I will call you Wednesday”, I expected a phone call.    Late Thursday morning, I called his office.  A nurse said she would contact him and then call me back.  Not too many minutes later the doctor called.

Somehow I imagined that I would be given a choice about my being treated with radiation.  I thought the doctor would call me and tell me about side-effects and what the likely hood the treatment would work with his opinion included. Then I would go home and discuss it with my family and make a decision about this treatment.  This didn’t happen.  I won’t have to make a decision.  The radiation oncologist I saw on the 13^th made that decision for me.  He will not treat me.  The possible side-effects, due to my having had radiation in 2010 to the same area, could be so severe that the doctor felt the risk of damage to me was greater than the benefit.  D---! But, I am grateful that my treatment is about what benefits me and not how much money a doctor can make by treating me.

Incurability 

This life I lead with metastatic breast cancer can be so discouraging.  I am constantly reminded on the internet and in my oncologist’s office of the incurability of stage IV breast cancer.  In talking to the radiation oncologist on the phone, the words that my oncologist has said more than once raced through my brain yet again, “Your cancer is probably in other places, but can’t be seen yet”.  Another way to put what he said is . . . even if we get rid of that tumor in your chest, you are still going to die of breast cancer.  This reaffirms how impossible my situation is.  It explains why once breast cancer metastasizes doctors don’t go after it aggressively.  The goal is stability or shrinkage, nothing more.  According to my oncologist, studies have shown that getting rid of the tumor(s) that can be seen doesn’t save lives-- sneaky horrible breast cancer cells.

I did not truly understand how deadly metastatic breast cancer was until my cells found their way to this point of no return.  I thought that if it ever metastasized to an organ, if it was caught early, there would still be a chance to save me or anyone else.  Apparently, almost 100% of the time, this is wrong.  Nor did I know that 30% of early breast cancer patients will eventually be diagnosed with stage IV.  No wonder so many bloggers with stage IV breast cancer are sick of Pinktober because it creates beautiful images and stories of early-stage breast cancer patients all smiling because they beat the disease.  There is nothing happy in the pink party for people like me.   

OK, so radiation is out for now.  There may be a need to use it in the future if the cancer grows in such a way that it is necessary for my comfort to reduce it.  At least I have Perjeta and Herceptin.  I hope these targeted therapies continue to do their magic. 

Life without Taxotere

Life without Taxotere for this three week cycle of treatment has been wonderful.  I have felt tremendously better. 

·        The neuopathy caused by this drug was starting to make my feet hurt when I stood for any length of time. My feet did swell and pain was felt, but there was a definite improvement. 

·       The scalp sores I have enjoyed (ha ha) at the end of week two after treatment did not appear.   

·        I did not feel anxious by the end of the first week from the steroids taken because I did not have to take those pills.  Those steroids were responsible for lessening any nausea symptoms and reducing inflammation.  My body did not like it.  I could not concentrate on any one thing for very long.  The drug made me feel like I needed to jump out of my skin to find relief from the anxiousness. 

·        Mentally I was and am so much happier.  I didn’t go through the horrible sadness I have felt after Taxotere.

·       My mouth feels so much better. No more destruction to the cells of my mouth. Yipee! I couldn’t taste food very well for the whole week after my infusion.  Salsa would set my mouth on fire.  No amount of milk could alleviate the pain.  Now eating is fun again.  My teeth had even begun to hurt. 

·        I still feel tired at times, physically weak, and sometimes I can’t figure out why I don’t feel right, but overall this cycle has been the best since I started treatment.  There are moments when I feel almost normal – well, almost.

·        Diarrhea still plagues me.

Tomorrow is infusion day.  That will be the time for herceptin and Perjeta to attach to the receptors on the outside of my cancer cells and stop them from growing and dividing. 

Thanks for reading.      

Healthy Exercise: Begin Now & Keep Moving

Exercise is one of the four roots of optimum wellness, but too few of us treat exercise as important for health. How many tell themselves they are too old to start exercise—that's for young people. Well… tell that to Olga Kotelko, who, at 94, began exercising at the age of 77 and hasn't stopped. She is so into exercise that she competes in senior track and field events and has amassed a collection of 200 medals.

Exercise is a key part of a healthy lifestyle. Along with diet, sleep and attitude it's a root to good health. Exercise contributes to being and staying healthy. So what motivates you to get out and exercise? For me, its knowing I feel so much better when I exercise.

My main source of exercise is running. I really don't like running, but I know its a quick way to get exercise with the most benefit. I currently run at a small lake about a mile from my house. The residents keep it interesting—copious Canada geese, a few mallard ducks and groups of coots are visited regularly by several swans, a couple of cranes and sometimes a bald eagle.

Benefits of Exercise

1. Reduces your risk of disease such as cancer, osteoporosis and diabetes, even colds and flus. It prevents or manages high blood pressure and boosts good cholesterol (HDL) while reducing bad cholesterol (LDL) and triglycerides.
2. Improves your mood by stimulating brain chemicals such as endorphins that leave you more relaxed and happy. Endorphins are powerful natural stress and pain reducers. Had a bad day at work and your muscles ache? Nothing that a brisk bike ride wouldn't fix.
3. Manages weight by burning calories. More importantly you build lean muscle mass that burns calories even at rest. Covert Bailey called it "being a better butter burner."
4. Boosts you energy level. Exercise helps your entire cardiovascular system, delivering more oxygen and nutrients to your tissues. Your heart and lungs work more efficiently so you become less winded when you climb a flight of stairs.
5. Promotes better sleep. If you struggle with not sleeping well, tossing and turning in the night, get some exercise and you'll sleep better. You'll get to sleep faster and sleep deeper when you exercise regularly. Caution: exercising too close to bedtime might cause disruption in going to sleep.
6. Puts the spark back in your sex life.
   If you're feeling too out of shape for intimate activity or don't have the energy, regular exercise can change that. Feeling energized and looking better from regular exercise can have a positive effect on your sex life. It can also help elevate a women's libido and decrease the possibility of erectile dysfunction in men.
7. It's fun! There are all sorts of fun physical activities. Like ballroom dancing, rock and wall climbing, belly dancing or basketball. Next time you take your kids or grandkids to the park, chase them around the jungle gym and push them on the swing. Keep it moving, no matter what you find to do. And make sure you exercise at least 30 minutes, three times per week.

There! Now that wasn't too bad, was it?

Check out tips on starting out when you don't like to exercise at the Summer Tomato.

What do you like to do for exercise? And how do you stay motivated to do it?

Black Bean Salad (or Salsa)

Ingredients:

• 1 15.5-ounce can no-salt-added or low-sodium black beans, drained
• 1 15-ounce can no-salt added or low-sodium kernel corn, drained or ¾ cup frozen corn, thawed
• 1 medium red bell pepper or 1 tomato diced
• 1/2 cup red onion, diced
• 1 teaspoon minced garlic from jar
• 2 tablespoon chopped cilantro
• 2 tablespoons cider vinegar
• 3 teaspoons extra virgin olive oil 
• Juice of 1 lime

Instructions:

• Toss all ingredients together
• Chill for at least one hour

Tip: Serve this as a side salad to a meal or warm in microwave and use as a filling for tacos!

Nutrition:
Servings: 6
Calories: 142
Fat: 2.5g
Saturated fat: 0.5g
Protein: 6g
Carbohydrate: 26g
Fiber: 5g
Cholesterol: 0mg
Sodium: 11mg

Recipe copyright © 2011 American Heart Association

Preventive Procedure Helps Patient Rest Easy

Allen Woods in the recovery room after 
his last radiofrequency ablation treatment.

If it weren’t for a routine endoscopy, Allen Woods, 68, wouldn’t have known there was a silent disease afflicting his esophagus. Mr. Woods had struggled with gastroesophageal reflux disease (GERD) for years and had been taking prescription medications to alleviate symptoms. However, as it does in approximately 15 percent of chronic GERD patients, the condition led to a more serious disease called Barrett’s esophagus (BE). That’s why he turned to Niraj Jani, MD, Division Head of Gastroenterology at GBMC.

BE causes damage to the lining of the esophagus and can increase a person’s risk of developing esophageal cancer. This realization was of extra concern to Mr. Woods, as he is an oropharyngeal cancer survivor, putting him at higher risk of developing esophageal cancer. “Often, BE doesn’t show any warning signs besides GERD, so the timing of his endoscopy was fortunate. Factors that increase risk of developing BE include a long history of GERD or being older in age, overweight or a Caucasian male,” says Dr. Jani. 

In some cases, the only necessary treatment is lifestyle and diet changes to help manage GERD in an effort to prevent BE from developing further. These include limiting or eliminating certain foods and beverages, like fatty foods and caffeine that aggravate reflux symptoms, and maintaining a healthy weight. 

In Mr. Woods’ case, to prevent his BE from developing into cancer, he underwent a series of three simple procedures to eradicate the affected area. This procedure, called an EGD (esophagogastroduodenoscopy), uses a long, thin tube with a light and camera at the end, to visualize and biopsy abnormalities in the lining of the esophagus. During his EGD, Mr. Woods underwent a procedure called radiofrequency ablation (RFA), which is a highly effective method for eradicating BE. “During the procedure, heat energy generated by current is used to burn abnormal cells,” explains Dr. Jani, who adds that GBMC was the first community hospital in the Baltimore area to offer this treatment option.

“I feel fortunate that this treatment option is available,” Mr. Woods says. “Rather than removing whole sections of my esophagus, Dr. Jani was able to remove only the abnormal cells in the lining.” Mr. Woods hasn’t had any adverse side effects from treatment and feels it’s impacted his life in a major way: “Knowing that I’m being closely monitored greatly reduces my anxiety about cancer. The peace of mind is priceless,” he says. Mr. Woods will undergo routine surveillance, but at the present time no longer has BE. 

For additional information about GBMC’s Gastroenterology services, call 443-849-GBMC (4262) or visit www.gbmc.org/gi.

Vacationing with Little Ones

As new parents become more accustomed to having a baby, they might start thinking about traveling as a family. Planning for a child’s safety during vacation is of utmost importance. With spring and summer approaching, below are some items parents should remember for health and safety’s sake:

1. If you’re going to be spending time in motor vehicles while you’re on vacation, a car seat is a must. If you’re flying to your destination, this might be an easy item to overlook, but whether you’re renting a car or taking a taxi during your vacation, a car seat will keep your child as safe as possible during transport.
2. Be sure to include a first aid kit in your suitcase that contains medications, such as baby/child acetaminophen or ibuprofen, and an oral syringe. If your child takes vitamins, pack those as well. Some children require medications like asthma inhalers or injectable epinephrine for life-threatening allergies. A thermometer, sterile bandages, antibiotic ointment, tweezers and a cold pack are also helpful.
3. If you’ll be spending time in the sun, bring baby- or child-friendly sunscreen and wide-brimmed hats.
4. Remember to pack childproofing items for your vacation rental, such as outlet covers, door knob covers, and pipe cleaners or twist ties to secure cords and draperies. Tip: duct tape can do several of these jobs if you need to pack lightly.
5. Your baby is likely to experience the same ear-popping sensation that adults do when traveling by plane, but doesn't know how to yawn on cue and can’t chew gum to help. Breastfeeding or sucking on a bottle, pacifier or sippy cup can alleviate pressure.
6. Another key to a happy baby (and happy parents) during vacation is good sleep. Try to maintain the usual naptime and bedtime routines if possible. If your baby depends on white noise when sleeping, bring along a white noise CD or small sound machine. Make sure your baby has a safe place to sleep, whether you are bringing your own portable crib or relying on one that is available through your vacation rental.
7. Remember all the essentials: formula, baby food, snacks, diapers, wipes, a potty seat if your child is in potty training, your child’s favorite comfort toy or blanket, and other items, such as a lightweight umbrella stroller to make your trip more convenient.

Most of all, be flexible! It may take your baby a few days to get accustomed to the new environment.

Commonly Used Cooking Oils

If you are health-conscious and like to cook or bake, you have likely stood in the aisle of the supermarket, glancing at the many types of oils, trying to select the best one. There are more than 20 types of cooking oils and since they are derived from plants, such as nuts, olives and seeds, they all have different characteristics.

Things to Consider When Choosing Oils

Smoke Point

Each type of oil has its own unique “smoke point,” and it’s best to select an oil with the right smoke point for the dish you are preparing. Once oil exceeds its smoke point, the temperature at which it begins to chemically break down and produce smoke, it emits cancer-causing carcinogens into the air and a strong foul smell. 

Fat Content

Oil is a form of fat, carrying 14 grams in a single tablespoon, so it should be consumed in moderation. Not all fat is created equally, however. There are two types of fat: saturated and unsaturated. Unsaturated fat, whether monounsaturated or polyunsaturated, is considered to be heart-healthy, or “good” fat. Saturated fat, found in fatty meats and vegetable oil, can increase cholesterol and increase the risk of heart disease, heart attack and stroke. While vegetable oil is commonly used, its high fat content from partially hydrogenated oils is bad for the heart.

Flavor

Some types of oils are flavorless, some have mild flavor and certain types have rich, distinct flavoring. The flavor factor is worth considering when using the oil in baking or when you want to pack some punch to a recipe.

Pros and Cons of Commonly Used Cooking Oils

Olive Oil

Depending on the type you choose, olive oil has many uses. Light olive oil has a high smoke point, making it preferable for cooking foods at a high temperature, such as pan-frying. Extra virgin olive oil has a strong, grassy flavor and a lower smoke point, so choose that when whipping up a marinade, dip or dressing. It also is considered one of the healthiest oils, with 75 percent monounsaturated fat.

Canola Oil

With a high smoke point, no distinct flavoring and only seven percent saturated fat, canola is one of the most versatile, healthy oils. Canola can be used instead of vegetable oil when baking and when cooking foods at a high heat. 

Sesame Oil

With a strong, intense flavor, sesame oil is a key ingredient in many Asian dishes, and its 350 degree Fahrenheit smoke point makes it perfect for stir-frying. The dense flavor of sesame oil allows you to use a minimal amount - usually less than a tablespoon - which helps to reduce calories. Additionally, it has high unsaturated fat content and low saturated fat. 

Sunflower Oil

Sunflower oil is high in monounsaturated fat. This heart-healthy oil is similar to light olive oil and canola oil; it carries a light, almost unnoticeable flavor and can be used up to 440 degrees Fahrenheit. 

Coconut Oil

Coconut oil has gained popularity lately for its rich flavor and versatility. Natasia Tomlinson, RD, LDN, a clinical dietitian at GBMC, does not recommend the use of coconut oil for its high saturated fat content. Its health benefits are limited and largely unproven, so it’s better to opt for a more heart-healthy choice. 

Vegetable Oil

Containing hydrogenated oils and saturated fat, vegetable oil can raise cholesterol and increase risk of blood clots. If you have to use vegetable oil, use sparingly when possible. Canola oil is a great substitute for vegetable oil.

Which Healthcare Setting is Right for You?

Knowing where to turn for healthcare can be confusing because there are many options available, all offering what seem to be similar services. People might wonder if it is necessary to have a primary care physician (PCP) versus going to an urgent care or convenience care clinic. They may also struggle with deciding when an issue warrants a visit to a hospital’s emergency department. Listed below are descriptions for different types of care to help minimize the confusion.

A primary care physician’s office, which usually includes physician assistants, nurses, nurse practitioners, technicians and clerical staff, builds relationships with patients, truly getting to know their healthcare goals and needs. The most valuable benefit of having a primary care doctor is that he or she concentrates on health maintenance and managing chronic illnesses like diabetes. GBMC PCP offices offer extended weekday hours and morning office hours on Saturdays. All of GBMC’s PCP offices function as patient-centered medical homes, emphasizing prevention and wellness rather than treating patients when they’re already sick. Although PCPs are very focused on wellness, they also build time into their schedules to accommodate patients when they are sick as well as to treat minor urgencies, such as sprains. Additionally, nurse practitioners act as extensions of the physicians to offer convenient, timely healthcare access.

Urgent care clinics are staffed by a team similar to that of a PCP office, but they typically treat conditions such as sprained ankles, cuts and fevers. They are more focused on episodic care (when a person is already sick or has a minor injury) rather than prevention or overall wellness. Urgent care clinics have late hours, are open on weekends, accept walk-ins and often have other service capabilities such as X-rays, lab work and prescriptions available onsite for patient convenience.

Convenience care clinics are located in pharmacies or grocery stores. They are not always staffed by a physician, but instead by nurses or assistants who treat conditions like earaches, sore throats and flu-like symptoms. These clinics typically also offer common vaccinations, like the flu shot, on a walk-in basis. 

Hospital emergency departments are meant to treat more critical health problems, which may include heart attack, stroke, allergic reaction, major injury, etc. If someone is experiencing symptoms consistent with the above conditions, or has suffered a severe injury, it’s important to call 911 and get to the closest ED. 

“Finding a PCP is often a good place to start. This will ensure patients have a go-to person who is aware of their overall health status and maintains all of this information on their electronic health record,” explains Mark Lamos, MD, President and Medical Director of Greater Baltimore Medical Associates and Internal Medicine physician at GBMC. “Fortunately for patients, there is always a healthcare option available to handle their individual situation.” 

Interested in finding a primary care physician who is right for you? Visit www.gbmc.org/mydoctor or call 443-849-GBMC (4262) for a listing of GBMC’s PCP office locations. Videos of many physicians are available for viewing on the website and appointments can also be requested online.

Healthy Wisdom Wednesday

Tip:
For Valentine's Day, don't fall for chocolates that are loaded with sugar, which contributes to the risk of dying from heart disease. Love your sweetheart by making them healthy, yummy chocolates for Valentine's Day:

Red Velvet Chocolate Squares Recipe

Do Vegetarians Live Longer Than Health Conscious Omnivores?

Proponents of Paleo and Low-Carb diets suggest that plant-based diets, particularly those rich in grains and legumes, promote disease, ultimately resulting in premature death. However, there is a substantial amount of evidence casting doubt on such suggestions, with many studies providing evidence that plant-based diets increase longevity. This review will focus on studies examining the longevity of plant-based populations, and some of the criticisms of these studies, particularly in reference to Denise Minger's recently published book, Death By Food Pyramid.

It is not news that Denise Minger has a tendency to downplay the health benefits of plant foods and plant-based diets. In her critique of the China Study, Minger claimed that “as a plant-nosher”, she was hoping to find evidence to support Dr. T. Colin Campbell's findings from the China Study linking dietary fiber to lower rates of colorectal cancer.1 Somehow, however, despite her vegan bias apparently creeping into her critique, Minger suggested that she was unable to find sufficient evidence outside of the China Study supporting the hypothesis that dietary fiber protects against colorectal cancer. And yet, several months later the omnivorous panel of experts of the World Cancer Research Fund concluded based on a review of over 1,000 publications that there was convincing evidence that dietary fiber protects against colorectal cancer.2 In Death By Food Pyramid, Minger continues this trend of downplaying the health benefits of plant-based diets. 

Failing to Equal the Seventh-day Adventists

In the chapter of her book, Herbivore’s Dilemma, Denise Minger provides a brief overview of the history and the growth of the popularity of vegetarian diets, bringing into picture the earliest of the studies on the Californian Seventh-day Adventists. Loma Linda, California which is highly concentrated by Adventists is considered to be a Blue Zone because of the greater life expectancy compared to other parts of North America. Loma Linda shares the title of Blue Zone with four other populations which are all characterized by traditionally consuming plant-based diets, typically rich in legumes and grains.3 These other Blue Zones include, Ikaria, Greece; Nicoya, Costa Rica; Okinawa, Japan; and Sardinia, Italy. It seems that Minger was not even able to get these simple details right in her book, claiming that the Greek island of Crete is considered a Blue Zone, while citing an article that clearly refers to Ikaria.

Minger hypothesizes that the longevity of the Adventists maybe unrelated to their low meat diet, and may rather reflect the discouraged use of tobacco and alcohol. To illustrate this, Minger points out that the Mormons who are also discouraged from the use of tobacco and alcohol, "but whose founder never endured any meat-abstinence visions"[p.194] have a greater life expectancy than the average population. Although Joseph Smith, Jr., the founder of Mormonism may not have demanded followers to completely abstain from meat, the Word of Wisdom (section 89 in The Doctrine and Covenants) which he delivered, apparently received as a revelation from god, states that:4

Yea, flesh also of beasts and of the fowls of the air, I, the Lord, have ordained for the use of man with thanksgiving; nevertheless they are to be used sparingly;

In regards to longevity, Minger then goes onto state that:

But what’s even more telling is the fact that meat-eating Mormons and vegetarian Adventists tend to live equally as long. When compared to ethnically matched folks outside their religious groups, both Adventist and Mormon men—once their birthday-cake candles start numbering in the thirties—can expect to live about seven years longer than the rest of the population.[p.194]

Unlike what Minger appears to have the reader believe, the 7 years greater life expectancy referred to in the study she cites is for the average Adventist male, and not specifically for vegetarian Adventist men. Less than one third of the men in the cited study were considered vegetarians, with more than half considered regular meat eaters.5 What these studies specifically found was that the life expectancy for active Mormon men who reached the age of 35 was about 7.5 years greater than the average U.S. white male, whereas the life expectancy of the average Californian Seventh-day Adventist male who reached the age of 30 was about 7.3 years greater than the average Californian white male.5 6 When specifically looking at the average vegetarian Californian Adventist male, their life expectancy was found to be about 9.5 years greater than the average Californian white male. It is important to note that the Californian whites that the Adventists were compared to have one of the highest life expectancies of any American state, and are expected to live up to a year longer than the average U.S. white that the Mormons were compared to.7

The more recent 25 year follow-up of the Mormons may allow for a more informative comparison, as like the Adventist study, it included both men and women from California, and examined the effects of other lifestyle factors on mortality. Mormon men and women over the age of 25 with four favorable lifestyle factors associated with significantly reduced mortality were expected to live about 9.8 and 5.6 years longer, respectively, compared to U.S. whites.8 In comparison, vegetarian Adventist men and women over the age of 30 with three favorable lifestyle factors were expected to live about 13.2 and 8.9 years longer, respectively, compared to non-Adventist Californians whites.5 9 Compared to the average U.S. white however, this difference in life expectancy would be expected to be closer to about 14 and 10 years.7 However, and more importantly, a later paper on the Californian Adventists found that those who adhered to a vegetarian diet for at least 17 years were expected to live 3.6 years longer than those who adhered for fewer years.10 This suggests that when restricting the analysis to long-term vegetarian Adventists, the difference in life expectancy compared to the Mormons would be even greater.

There are also other lines of evidence lending support to the observed greater life expectancy of the vegetarian Seventh-day Adventists compared to health conscious Mormons. For example, one study in which vegetarian Adventists and Mormons were matched for strength of religious affiliation, and consumption of tobacco, alcohol, tea and coffee, the vegetarian Adventists were found to have significantly lower levels of serum cholesterol, blood pressure and rates of obesity (Fig. 1).11 12 The difference in blood pressure remained significant even after controlling for BMI, and could not be explained by differences in sodium intake. Another study also found that vegetarian Adventists had lower blood pressure than Mormons, and that the difference increased with age, suggesting a greater favorable effect of long-term adherence to a flesh-free diet.12 

Figure 1. All percentiles of distribution of blood pressure were found to be lower in the vegetarian Adventists compared to health conscious omnivorous Mormons.

Although some of the many factual errors in Minger’s book may be passed off as sloppy research rather than as being intentional (one example perhaps being when she confuses Crete for Ikaria), given the number of occasions she has discussed the Adventist studies previously, it is difficult to believe that she was truly being honest and simply was not even aware of the data in the very studies she cites. Furthermore, Minger acknowledges in this book that she had others with knowledge in this field review her manuscript and assist her with the completion of this book (almost exclusively individuals who have demonstrated an anti-vegetarian stance), allowing for little excuse for these misleading statements.

Mortality in Vegetarians and Health Conscious Omnivores

As there are no published meta-analyses examining all of the current available prospective cohort studies comparing mortality in vegetarians and health conscious non-vegetarians, I performed a simple meta-analysis using the results for the fully adjusted model from the most recent follow-up of each cohort. For mortality from all-causes, based on 7 cohorts, the vegetarian group had a statistically significant 7%, and a borderline significant 6% reduced risk, using the fixed effects and random effects models, respectively (Fig. 2).10 13 14 15 16 The 6 cohorts that stratified data by sex suggested an even stronger protective effect of a vegetarian diet for men.16 17

Figure 2. All-cause mortality for vegetarians compared to health conscious non-vegetarians in a meta-analysis using the fixed effects model. 

*Indicates that participants classified as semi-vegetarians were included in the vegetarian group

It should be stressed that the meat intake in the non-vegetarian group in most of these studies was significantly lower than that of the general population. As described in a different review, the selection criteria for the non-vegetarians in these studies generally included being affiliated with vegetarians in some way or another, likely explaining their relatively low meat intakes. Furthermore, evidence suggests that many of the self-proclaimed vegetarians in these studies actually consumed meat on a regular basis, resulting in minimal differences in meat intake between the groups.10

Considering the lack of difference in meat intake between the vegetarian and non-vegetarian groups, it would only be expected that these studies would not have the statistical power to demonstrate a significant benefit of a vegetarian diet. Two studies which may be considered as especially having limited statistical power due to such limitations were the Heidelberg Study and Health Food Shoppers Study. In the Heidelberg Study, the non-vegetarian group were predominantly semi-vegetarians, while in the Health Food Shoppers Study, a validity assessment of the survey used to classify the participants vegetarian status suggested that 34% of the participants classified as vegetarians actually consumed meat. In fact, a slightly greater percentage of participants classified as vegetarians in the Health Food Shoppers Study were found to consume meat 3 or more times a week than the non-vegetarians in the Heidelberg Study (7.6% and 6.9%, respectively).14 18 Taking this into consideration, I performed a sensitivity analysis excluding either the Heidelberg Study or Health Food Shoppers Study from the meta-analysis. Excluding the Health Food Shopper Study alone reduced heterogeneity and strengthened the association between vegetarian status and a reduced risk of mortality from all-causes (RR 0.91 [95% CI, 0.87-0.94], and 0.92 [95% CI, 0.86-0.98] using the fixed effects and random effects model, respectively).

Most of these studies did not provide separate data for length of adherence to a vegetarian diet. As already described earlier in this review, evidence from several of these studies suggest a stronger effect on mortality would have been observed if the analysis was restricted to long-term vegetarians.10 Another important limitation was that most studies also did not verify changes to vegetarian status of the participants throughout the follow-up, which may in part explain why the association between a vegetarian diet and a reduced risk of mortality weakened over time in several of the studies.9 10

Another important potential limitation of these studies described in detail in the next section, is that some of the participants likely adopted a vegetarian diet in order to improve poor health, such as symptoms of an undiagnosed or developing illness that would ultimately became fatal. Each of these limitations described are expected to have either biased these findings towards null, or even in favor of the non-vegetarian group, suggesting that the findings of this meta-analysis may have significantly underestimated the benefits of an appropriately planned vegetarian diet.

In order to determine which factors may have contributed to the observed reduced risk of death in vegetarians, I also performed separate meta-analyses for the major causes of death. This included mortality from coronary heart disease and cardiovascular disease, and the incidence of all cancers combined. For mortality from coronary heart disease, based on 7 cohorts, the vegetarian group had a statistically significant 25% and 24% reduced risk, using the fixed effects and random effects models, respectively (Fig. 3).13 14 15 16 17 For mortality from cardiovascular disease, based on 7 cohorts, the vegetarian group had a statistically significant 17% and 14% reduced risk, using the fixed effects and random effects models, respectively (Fig. 4).13 14 15 16 17 For the Adventist Mortality Study and Adventist Health Study, mortality from cardiovascular disease was derived from pooling the relative risk for mortality from coronary heart disease and stroke.17 Excluding the Adventist Mortality Study and the Adventist Health Study, the vegetarian group had a statistically significant 8% reduced risk of mortality from cardiovascular disease, using both the fixed effects or random effects model (0.92 [95% CI, 0.85-0.99]).

Figure 3. Coronary heart disease mortality for vegetarians compared to health conscious non-vegetarians in a meta-analysis using the fixed effects model. 

*Indicates that participants classified as semi-vegetarians were included in the vegetarian group

Figure 4. Cardiovascular disease mortality for vegetarians compared to health conscious non-vegetarians in a meta-analysis using the fixed effects model. 

*Indicates that participants classified as semi-vegetarians were included in the vegetation group

As described in a previous review, the degree of reduction in risk of mortality from coronary heart disease observed in vegetarians in these cohort studies was generally in proportion to the expected reduced risk based on the differences in levels of total and non-HDL cholesterol, and blood pressure. There is a plethora of evidence, not only from epidemiological studies, but also clinical trials that plant-based diets and nutrients have favorable effects on total and LDL cholesterol, blood pressure, among several other factors which are established risk factors for cardiovascular and all-cause mortality.19 20 21 22

In the Oxford Vegetarian Study, high compared to low intake of saturated animal fat was associated with a nearly 3-fold increased risk of coronary heart disease mortality.23 Similarly, in a meta-analysis of 11 cohort studies, high compared to low intake of saturated fat was associated with a 32% increased risk of coronary heart disease mortality, despite the inclusion of over-adjustments for dietary and serum lipids.24 It was also found in the Oxford Vegetarian Study that high compared to low intake of total animal fat and dietary cholesterol was associated with a greater than 3-fold increased risk of coronary heart disease mortality.23 Furthermore, evidence from thousands of experiments carried out over the last century have shown that the feeding of dietary cholesterol and saturated fat has accelerated the development of atherosclerosis in virtually every animal species in which researchers were able to find a method to sufficiently elevate cholesterol concentrations. This includes herbivores, omnivores and carnivores from mammalian, avian and fish species, and over one dozen different species of nonhuman primates.

In both the Oxford Vegetarian Study and the Adventist Mortality Study, high compared to low intake of eggs was associated with an increased risk of coronary heart disease mortality.23 25 However, for ill-defined reasons, these studies were excluded from several recent meta-analyses. In the Adventist Mortality Study and Heidelberg Study, high compared to no intake of meat was associated with a 50% and almost 5-fold increased risk of coronary heart disease mortality, respectively.14 25 Similarly, in the Adventist Health Study, high compared to no intake of beef was associated with a greater than 2-fold increased risk for men.26 In addition, recent meta-analyses of prospective cohorts found that an increment of 1 mg/day of heme iron, found only in animal tissue, is associated with a 16% and 27% increased risk increased risk of type II diabetes and coronary heart disease, respectively.27 28 Therefore, the totality of evidence strongly suggests that the observed greater longevity of vegetarians can be explained, at least in part, by the reduced risk of cardiovascular disease as the result of the replacement of animal foods with minimally processed plant foods.

For incidence of all cancers combined, based on 5 cohorts, the vegetarian group had a statistically significant 8%, and borderline significant 6% reduced risk, using the fixed effects and random effects model, respectively (Fig. 5).13 14 29 30 Excluding the Health Food Shoppers Study removed evidence of heterogeneity and strengthened these findings (RR 0.90 [95% CI, 0.85-0.99] using both the fixed effects and random effects models).

Figure 5. Cancer incidence for vegetarians compared to health conscious non-vegetarians in a meta-analysis using the fixed effects model. 

*Indicates that participants classified as semi-vegetarians were included in the vegetation group

The finding of a decreased risk of cancer in vegetarians may also be explained, in part, by a diet devoid in heme iron. Controlled feeding trials have established that NOCs (N-nitroso compounds) arising from heme iron in meat forms potentially cancerous DNA adducts in the human digestive tract, likely in part, explaining the significant association between heme iron and an increased risk of colorectal cancer in recent meta-analyses of prospective cohort studies.31 32 33 Heme iron has also been associated with numerous other cancers. These lines of evidence also provide confidence in the validity of the findings of greater longevity in vegetarians.

Why Some People Choose to Become Health Conscious

Which came first,
vegetarianism or ill health?

In health research, the reasons why some people chose to become health conscious is critically important when interpreting data from observational studies. This is because it is possible that it may not have been the health conscious lifestyle that caused the examined outcome, but rather the outcome that caused the health conscious lifestyle, ie. reverse causality. As previously described in a different review, reverse causality occurs when the studied effect precedes the cause. An example in health research is the frequent paradoxical observation that former smokers have worse health outcomes than current smokers. These unfavorable outcomes are not explained as being caused by smoking cessation, but rather that those who quit smoking tend to have done so because they were showing symptoms of illness, illnesses that ultimately resulted in the observed unfavorable health outcomes. A similar phenomenon has been observed in nutritional research where sick people tend to adopt a more plant-based diet, suggesting that this would bias observational studies towards showing an unfavorable effect of plant-based diets and nutrients, and therefore a favorable effect of animal based diets and nutrients.34

Although Denise Minger suggests that the favorable health outcomes for vegetarians observed in many studies maybe unrelated to dietary factors, but rather explained by other healthy habits associated with vegetarianism, she fails to consider the possibility that these vegetarians may have become health conscious, including adopting a vegetarian diet, in order to improve poor health. The results of a recent study from the Netherlands illustrates the critical importance of considering reverse causality in research on plant-based diets. The researchers found that 75% of the vegetarian participants with cancer adopted a vegetarian diet after diagnosis, consistent with previous research which found that cancer survivors are highly motivated to adopt a more plant-based diet with the intention of improving poor health.35 36

Although health researchers often attempt to partially control for reverse causality by excluding participants who were diagnosed with cancer, cardiovascular disease and other life threatening conditions prior to baseline of a study, it is nearly impossible to fully control for reverse causality, as participants may make dietary changes due to symptoms or unfavorable risk factors that act as markers of an undiagnosed or developing disease. For example, it is known that in studies carried out as far back as the late 1950s, participants with unfavorable blood cholesterol levels tended to reduce the intake of dietary cholesterol and saturated fat (ie. in part, by abstaining from animal foods). This resulted in paradoxical findings where participants who consumed more dietary cholesterol and saturated fat actually had lower serum cholesterol levels. These paradoxical findings were produced, in part, because those participants who continued to consume a diet rich in these lipids were choosing to do so because they were able to maintain lower cholesterol levels despite consuming such a diet (ie. due to favorable genetics).37 Many individuals who attempt to downplay the harmful effects of these lipids, such as Minger has done in her book have chosen to ignore this critical factor when reviewing research on the diet-heart hypothesis.24

In the chapter Herbivore’s Dilemma, Minger reviews several prospective cohort studies that compared the mortality rates of vegetarians to health conscious non-vegetarians, carefully selecting only those studies in which vegetarians were not found to live longer. These studies were the Oxford Vegetarian Study, the Health Food Shoppers Study and the Heidelberg Study, all included in my meta-analysis. Minger emphasizes the lack of reduced risk of mortality in the vegetarian groups, while neglecting to mention that the difference in intake of meat between the groups was relatively small. Minger especially focuses on the Heidelberg Study, happening to be the smallest study, which found a non-significant increased risk of all-cause mortality in the vegetarian group. Minger points out that in this particular cohort, the vegetarians had greater levels of physical activity, consumed less alcohol and smoked less. Minger then states “Mortality and disease rates, in this case, might be expected to turn up in favor of the vegetarian crowd, even though the opposite ended up happening”[p.270]. This statement is outright misleading as all these factors were controlled for in the analysis. One could also correctly point out that the vegetarians tended to be older than the meat eaters, but suggesting that this would be expected to turn up in favor of the meat eaters would also be misleading, as age was also controlled for. Either way, the differences in mortality between the groups did not even come close to being statistically significant.

There are several important findings that Minger neglected to mention that cast doubt on the suggestion that a vegetarian diet had a harmful effect on the participants in the Heidelberg Study. For example, it was shown in an earlier follow-up of this study that, similar to the Adventist studies, the participants who adhered to a very low meat diet for at least 20 years had a 29% lower risk of all-cause mortality compared to those who adhered to such a diet for fewer years.10 Excluding the first 5 years of follow-up significantly strengthened this association, resulting in a 45% lower risk of all-cause mortality, suggesting that reverse causation may have attenuated the results for the entire follow-up.38 This difference in mortality was considerably stronger than the mortality difference between vegetarians and non-vegetarians. Unfortunately the researchers appear to not have provided any data comparing mortality in long-term vegetarians and non-vegetarians. Indeed, in other cohorts it has been observed that compared to non-vegetarians, short-term vegetarians had a higher rate, whereas long-term vegetarians had a lower rate of all-cause mortality.34 These findings suggest that those who adopted a vegetarian diet more recently had done so due to deteriorating health, biasing the results in favor of the non-vegetarians. 

Also as already briefly mentioned, in this study it was also found that intake of meat 3 or more time per week was associated with an almost 5-fold increased risk of mortality from ischemic heart disease, whereas there was a greater than 2-fold risk increase for those who consumed fish more than once per month. One of the reasons that this did not translate into an increased risk of all-cause mortality in the non-vegetarian group may have been due to the very low intake of meat, with less than 7% of the non-vegetarians consuming meat 3 or more times a week.14 Another important finding was that there was a trend towards a favorable effect of a vegetarian diet on mortality in the early years of follow-up, which declined over time (Fig. 6).14 This suggests the likelihood of undocumented changes in vegetarian status in a portion of the participants throughout the follow-up, which would be expected to have attenuated a possible favorable effect of a vegetarian diet. A similar phenomenon was also observed in several other studies included in my meta-analysis.9

Figure 6. Standard Mortality Rates (SMRs) and their 95% CIs for all-cause mortality, dietary group, and 5-year follow-up period, separately for males and females. (○, female vegetarians; •, female nonvegetarians; □, male vegetarians; ▪, male nonvegetarians).

Minger also points out that there was a trend towards a higher rate of mortality among the vegans in the Heidelberg Study, which included only 60 vegans, while neglecting to mention that in the Adventist Health Study 2, which included almost 100 times many vegans found that compared to the non-vegetarians, the vegans, especially male vegans experienced a lower rate of mortality.16 In the Heidelberg Study, while current smokers had the same mortality rate from cancer as never smokers, past smokers suffered from a 70% greater risk of cancer mortality than current smokers. This strongly suggests that many of the past smokers in this cohort quit smoking because they had deteriorating health.14 This raises the question as to whether the participants in this cohort also had a tendency to adopt a vegetarian diet after becoming ill, possibly explaining the unfavorable mortality rates in the vegetarian group. Perhaps the reason why the vegetarians in this group tended to be older, was not because they were becoming more ethical with old age, but because they were becoming more health conscious, which included adopting a vegetarian diet due to deteriorating health with old age. As these lines of evidence described suggest, the trends towards elevated mortality in the vegetarian groups in the Heidelberg Study may be explained by reverse causation. It is more than possible that it was not the vegetarian diet that caused these unfavorable outcomes, but deteriorating health, which would ultimately resulted in these unfavorable outcomes that caused a portion of the participants to adopt a vegetarian diet.

Ignoring the difficult

There is strong evidence that plant-based diets, including those rich in whole-grains and legumes reduces the risk of premature death from chronic and degenerative diseases, which in-turn helps explain the longevity of a number of plant-based populations. Contrary to the findings for plant-based diets, there is a plethora of evidence demonstrating the harms of popular carbohydrate restricted diets. For example, meta-analyses of clinical trials have found that low-carbohydrate diets elevate LDL cholesterol and impair endothelial function.39 Furthermore, a recent meta-analysis of prospective cohort studies with more than 272,000 participants found that low-carbohydrate diets, particularly those rich in animal foods are associated with an increased risk of all-cause mortality.40 Evidence also shows that the hazardous effects of diets rich in animal foods are also applicable to that of organic, grass-fed animal foods. These, and other lines of evidence described throughout this review appear to have been almost entirely ignored by proponents of these diets, perhaps because they find it too difficult to explain. 

Although there is strong evidence that plant-based diets promote longevity, it is important to replace animal foods with minimally refined plant foods in order to achieve the maximum benefits. This may in part explain why the benefits of a vegetarian diet were more evident in the Adventists than other populations.9 In conclusion, the totality of evidence supports the hypothesis that appropriately planned whole foods, plant-based diets promote longevity. 


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