Open Questions

Writers on nutrition, like medical doctors in general, tend to express themselves with a great deal of certainty. Since there are so many areas of disagreement and so much marketing noise, this just confuses the lay public and undermines trust in doctors and medical research. Virtually all such research is statistical in nature. Eating a pound of bacon each day does not guarantee you will have a heart attack in a year, but it does increase the odds quite a bit. We as individuals should be informed by these statistical results, but have to keep in mind that individual outcomes are not reliably predicted by statistical likelihoods.

Kaiser Permanente calculates my personal risk of heart attack or stroke in the next ten years to be 8.1 percent, which they call “moderate.” This means that out of 1000 men like me in all the relevant ways, roughly 919 of them will not have a heart attack or stroke for the next ten years. Here is what they say about it:

Your risk of having a heart attack or stroke is calculated from the following risk factors:

• Age, gender, race/ethnicity
• Smoking status
• Cholesterol levels
• Blood pressure
• Diabetes
• Use of medicines for blood pressure, or cholesterol

Healthy eating, exercise, quitting smoking, and controlling blood pressure help reduce risk. Statins reduce plaque in the arteries, help keep the arteries open and reduce the risk of heart attacks and strokes.

It is 2022. I am a 65 year old male nonsmoker. I am not overweight or diabetic, and I drink alcohol in very moderate amounts. Despite having eaten whole food, plant-based very strictly since 2009, and above average activity level, I have high blood pressure and high cholesterol. I take low dose blood pressure medications, but refuse to take statins to lower my cholesterol. My “risk assessment” does not take my diet into account. I suspect that is at least partially because there are not sufficient studies of the correlation between cholesterol and heart attack/stroke incidence among people who eat like me.

All my sources indicate that eating the way I do should have lowered my cholesterol and blood pressure more, but they didn’t. So, how worried should I really be? One of my medical heroes, Dr. Caldwell B. Esselstyn, Jr., once told me informally in person, that so long as I adhered to his whole food, plant-based program, I had no reason to worry. But his program excludes all nuts, avocados, and coconut, and I still eat those whole plants in small quantities. So it’s an open question.

Another of my medical heroes is Dr. John McDougall. I have seen him lecture in person more than once, had him sign books, and refer to his website often. Like most of my heroes, he implies that following the McDougall Program will automatically bring one’s cholesterol and blood pressure into the healthy range. However, in his article updated on September 12, 2022, Cholesterol – When and How to Treat It, he discusses his recommendations for people who, like me, can’t lower their cholesterol with diet alone. He lists some supplements he considers safe and effective. On the main question, “Who Should Get Medication?” he says “I’m not sure, but I am called upon to make my best guess with my patients every day.” Why is he not sure? I suspect there is no good study of the effect of lowering cholesterol on mortality and morbidity among people who strictly adhere to the McDougall Program.

Another of my medical heroes is Dr. Michael Greger. I have heard him lecture in person more than once, had him sign books, and watch his videos on NutritionFacts.org every week. His blog post of September 20, 2022, Paper-Filtered Coffee and Cholesterol, discusses how for over ten years, we have thought that paper-filtered coffee does not raise cholesterol, though other preparations do. But now, there is doubt about that result. Not all coffee raises cholesterol equally, but paper-filtered coffee still may raise it, more than previously thought. Does this matter if one eats whole food, plant-based? I still have higher cholesterol numbers than I should, despite the way I eat. I have one cup of strong, paper-filtered coffee every day. It seems the only way to find out if eliminating coffee would improve my cholesterol numbers is to try it for at least two weeks. But would lowering my cholesterol by that means actually reduce my chance of coronary vascular disease? I think that’s an open question, because the evidence correlating high lipids with CVD was collected from large populations, of whom very few individuals, maybe 1 in 10000, eat whole food plant-based.

By the way, these two doctors I admire greatly, do not agree in their recommendation about the best form of vitamin B-12 to take. Greger says cyanocobalamin, and McDougall says methylcobalamin. To me that makes it an open question.