The China Study

A book by Colin Campbell and Thomas M. Campbell II advocating a whole-food, plant-based diet on the basis of large-scale epidemiological and nutritional research. Alongside claims that animal foods increase chronic disease risks, it criticizes the ways food and medical industry interests distort nutritional information.

Preface (from the first edition)

A preface and endorsement by Howard Lyman, an American farmer turned lobbyist and animal rights activist.

Author Colin Campbell first discovered dioxin, published hundreds of academic papers, served on government expert panels, contributed to international organizations, and helped establish the American Institute for Cancer Research and World Cancer Research Fund.

Lyman admires how Campbell, despite becoming a successful and influential mainstream scientist, sought problems and improvements rather than settling into the system. Part IV exposes problems and corruption in government, pharmaceutical/medical industries, and academia—something possible because Campbell held key positions within the system without compromising.

Foreword

An endorsement by John Robbins.

(The son of Irma Robbins, a cofounder of Baskin-Robbins, he is a writer and environmental/animal rights activist. He also wrote the foreword to Why We Love Dogs, Eat Pigs, and Wear Cows.)

Robbins denounces companies that make enormous profits deliberately spreading misinformation through advertising, magazines, broadcasting, and other media. He recommends the book as particularly valuable for presenting not only useful conclusions but also many trustworthy studies, calling its content “revolutionary.”

Introduction

Information about nutrition abounds and everyone is curious, yet few feel confident about what to eat for good health. The author wrote this book to address that problem. Based on more than 800 credible studies, it offers a new framework for understanding nutrition and health.

His doctoral research at Cornell University studied animal protein to promote livestock growth. Everyone then believed animal protein was a “good nutrient.”

At the MIT, he contributed to discovering and understanding dioxin and aflatoxin, both well-known carcinogens.

At Virginia Tech, with US Agency for International Development support, he studied nutritional problems among poor children in the Philippines. Ten years of research yielded an unexpected finding: liver cancer was more common among wealthy children consuming abundant protein. Similar research was being conducted in India. This could mean protein consumption sometimes assists carcinogens.

This prompted serious research into cancer and protein intake. Animal experiments revealed that however much aflatoxin was administered, cancer did not develop on a low-protein diet. Casein promoted every stage of cancer, whereas plant protein did not carry that risk.

He subsequently began the large-scale China Study, conducted over several years in China and Taiwan jointly by Cornell University, Oxford University, and the Chinese Academy of Preventive Medicine. It found roughly 8,000 statistically significant relationships between diet and health.

Over subsequent decades, he participated in scientific research, government panels, and policymaking, learning of numerous systemic problems. In the United States, boundaries between government, industry, academia, and medicine are blurred, as are those between improving public health and increasing corporate revenue. He argues that this produces and circulates vast quantities of inaccurate information. Part IV elaborates.

Part I. The China Study

Chapter 1. Problems We Face, Solutions We Need

Sickness, anyone?

Americans’ death rate from cancer rises annually. Other health problems, including obesity and diabetes, are increasing too. Both relate to heart disease, the leading cause of death. Yet recent research suggests healthy diets can prevent almost all heart disease and even reverse its progression.

• [11] Ornish D, Brown SE, Scherwitz LW, et al. “Can lifestyle changes reverse coronary heart disease?” Lancet 336 (1990): 129–133.
• [12] Esselstyn CB, Ellis SG, Medendorp SV, et al. “A strategy to arrest and reverse coronary artery disease: a 5-year longitudinal study of a single physician’s practice.” J. Family Practice 41 (1995): 560-568.

Oops… We didn’t mean to have that happen!

Medical treatment is Americans’ third leading cause of death, with unintended drug deaths particularly prominent. Better understanding of nutrition and broader medical acceptance could reduce prescriptions, increase natural healing through food and other means, and ultimately lower mortality. The author calls for a broader approach to health.

An expensive grave

Americans spend more on health than anyone else, and medical expenditure as a proportion of GDP keeps increasing. Yet physicians’ prescriptions are influenced more by insurance reimbursement than by patients’ health. The US medical system has serious problems.

A system meant to improve public health instead damages it.

Working to lessen confusion

Americans’ health problems are complex, but the solution is cheap and simple: choose food well. One reason for confusion about food and nutrition is scientists’ excessive focus on small details rather than the broader context.

The book’s prescription is simple: avoid all animal flesh (meat), cows’ milk (dairy), and chickens’ eggs, and eat a whole-food, plant-based diet instead. This is unrelated to any philosophical position such as veganism. The author liked meat, spent years in mainstream academia, and even lamented the views of some vegetarian students in his classes.

Almost every claim rests on large-scale human studies conducted directly by the author, his students, and colleagues over decades. These studies received many awards from prestigious organizations.

The promise of the future

A whole-food, plant-based diet offers more diverse and impressive benefits than any drug or surgery. It helps prevent chronic conditions including heart disease, cancer, diabetes, stroke, hypertension, arthritis, cataracts, dementia, and lethargy.

Evidence is also accumulating that it reverses some degenerative diseases, and it is known to help prevent some conditions arising from genetic predispositions.

Chapter 2. A House of Proteins

Discussions of protein mix science, culture, and mythology. Since its discovery in 1839, protein has always been considered the foremost nutrient. Much confusion rests on the myth that “protein is meat and meat is protein.”

(According to The Sexual Politics of Meat, getting protein through meat eating also connects to myths of masculinity. In many domestic violence cases, husbands’ common excuse was that their wives had not prepared proper food—meat. “Real men” supposedly must eat meat. In cultures accepting this masculine mythology, men who abstain are considered to reject masculine privileges. —ak)

Pressing for quality

Dietary protein is broken down into amino acids that serve various functions. Eight cannot be synthesized in the body and must come from food: the essential amino acids. High-quality protein merely means protein yielding suitable proportions of essential amino acids after digestion and absorption; amino acids themselves have no “quality.”

As later explained, supposedly “low-quality” plant proteins are actually the healthiest, supporting slow but steady synthesis of new proteins. Numerous studies also show that the remarkably complex human metabolic system allows sufficient protein intake from plants alone.

The protein gap

The author spent three graduate-school years studying how high-quality protein promotes livestock growth, part of research addressing the global “protein problem.” Discussion of “the protein gap in developing countries” was prominent in the 1960s and 1970s.

A 1976 study called protein deficiency the most important global food problem and recommended abundant cows’ milk (milk), chickens’ eggs (eggs), cattle (beef), and aquatic animals (fish). The UN Food and Agriculture Organization held similar views.

• Scrimshaw NS, and Young VR. “Nutritional evaluation and the utilization of protein resources.” In: C. E. Bodwell (ed.), Evaluation of Proteins for Humans, pp. 1–10. Westport, CT: The Avi Publishing Co., 1976.
• Jalil ME, and Tahir WM. “World supplies of plant proteins.” In: J. W. G. Porter and B. A. Rolls (eds.), Proteins in Human Nutrition, pp. 35–46. London: Academic Press, 1973.

Additional protein might matter if a population obtains all its calories from a single plant. Otherwise, the author recommends plant-based protein sources. Animal protein is not the best long-term choice.

Feeding the children

From 1965, the author participated in research improving child nutrition in the Philippines. Project leader Charlie Engel was interested in “mothercraft”: teaching mothers nutrition.

His research chose peanuts as a protein source because they grow easily almost anywhere. However, mold sometimes contaminates them with carcinogenic aflatoxin, leading him to study both protein supply and aflatoxin.

Liver cancer was unusually prevalent among Filipino children under ten. Investigation revealed that highly contaminated peanuts were used in peanut butter, which children ate frequently. Surprisingly, liver cancer mainly affected wealthy children consuming abundant protein, including animal protein.

A similar Indian study appeared at the time but received little attention. Rats given aflatoxin were split between diets with 20% and 5% protein. Cancer developed in 100% of the former group and 0% of the latter.

• Madhavan TV, and Gopalan C. “The effect of dietary protein on carcinogenesis of aflatoxin.” Arch. Path. 85 (1968): 133–137.

The nature of science: what you need to know to follow the research

Definitive proof is almost impossible in medicine or health. Science is inherently statistical, identifying highly plausible facts rather than absolute truths. It uses both observational studies and intervention studies, but interventions in health and nutrition are difficult: people cannot be confined to laboratories.

Readers seeking conclusions from one or two definitive studies may be disappointed. Those willing to weigh evidence from many studies and approach truth gradually will find value here.

(The following material provides background in scientific methods: correlation versus causation, statistical significance, how biological mechanisms increase confidence in causality, meta-analysis, and so forth. Omitted. —ak)

Chapter 3. Turning Off Cancer

Because cancer is frightening, the public reacts sensitively to information about carcinogens. Much media coverage, however, relies on studies administering excessive amounts—equivalent to eating only one food for decades—so fear is inflated. Exaggerated fear of nitrites is a prime example.

How would people react if a substance caused cancer in 100% of subjects in animal experiments, even at everyday intake levels? It would attract more concern than nitrites or aflatoxin. The Indian study in chapter 2 reported precisely such results.

Before proceeding, the author briefly states his view of animal experiments:

“

I understand concerns about animal experiments. But without them, obtaining such firm evidence supporting a whole-food, plant-based diet would have been difficult. As far as I know, there is still no alternative to the animal experiments I conducted.

Three stages of cancer

Cancer proceeds through initiation, promotion, and progression. In a garden analogy, initiation is sowing seeds; promotion is growth; progression is uncontrolled growth spreading everywhere.

In initiation, carcinogens such as aflatoxin act as seeds. Some arise naturally, but most are manufacturing byproducts. They alter ordinary cells’ genes, making them susceptible to cancer. Initiation can happen within minutes and, with rare exceptions, is irreversible.

During promotion, cancer-prone cells begin growing and dividing over several years. Once large enough to be clinically visible, they are called tumors. Crucially, promotion requires “suitable conditions” and, unlike initiation, is reversible.

In progression, tumors spread to other bodily tissues. Metastasis of malignant tumors ultimately causes death. Little was known about cancer when the author began, but much more is understood now, allowing more questions to be studied systematically.

Protein and initiation

Experiments showed that reducing protein suppresses tumors through various mechanisms: less aflatoxin enters cells, susceptible cells divide more slowly, and enzymes involved in aflatoxin’s harmful effects become less active.

Protein and promotion

Studying fully developed tumors takes much time and money, so the researchers studied small foci appearing shortly after initiation. Their development was determined almost entirely by protein intake rather than the amount of aflatoxin.

A group receiving little aflatoxin and 20% dietary protein developed far more foci than a group receiving much aflatoxin and 5% protein. In a twelve-week experiment changing protein levels every three weeks, foci development responded immediately. Reducing protein reversed development at every stage. Once exposure to a carcinogen had initiated cancer, however, excessive protein later could restart foci development even if reducing protein had previously stopped it.

Humans reportedly need only about 5–6% of energy from protein. Allowing individual variation, the American recommended intake is 10%, yet the average American gets 15–16%. The preceding research suggests such diets are likely to promote cancer foci.

Not all proteins are alike

Those studies all used casein from cows’ milk. Wheat protein, however, did not promote cancer growth however much was consumed. The same held for soy protein.

The Grand Finale

After studying foci immediately following initiation, the researchers conducted a two-year study with hundreds of rats. All received aflatoxin, with diets containing either 20% or 5% protein. Every rat in the former group developed cancer; none in the latter did.

Some changed diets after forty or sixty weeks, roughly halfway through life. Switching from 20% to 5% protein reduced tumor growth by 35–40%; switching from 5% to 20% started tumor growth. The conclusion: nutrition can turn cancer “off” or “on.”

Other cancers, other carcinogens

Alongside the rat research, the author studied HBV’s effects on liver cancer. HBV likewise caused cancer only in groups consuming high casein levels. Studies of breast cancer in rats produced the same results.

Larger implications

Excessive casein caused cancer across different organs (liver and breast), carcinogens, and species (rats and mice). This is important because humans and rodents share very similar protein functions and stages of cancer development.

Follow-up research expanded nutrition to fish protein and dairy fat, and cancer to pancreatic cancer as well as liver cancer. Consistently, nutrition mattered far more than carcinogens in cancer development. Animal foods also promoted tumors, while plant foods reduced them.

These findings are very likely applicable to humans, but quantitative as well as qualitative relationships needed establishing. The China Study, begun in 1980, helped address this.

Chapter 4. Lessons from China

The cancer atlas

In the early 1970s, Chinese leader Zhou Enlai was battling cancer. He ordered a large-scale study, mobilizing 650,000 people to investigate 880 million residents.

Regional differences stood out more than genetic ones, sometimes exceeding a hundredfold. In the United States, regional variation is at most two- or threefold. China’s enormous regional differences, despite less genetic variation within its population than in the US, suggest environmental factors may matter more than genetic ones.

Pulling it together

Science, politics, and capital occasionally converge on one goal. This project was such a case, bringing together leading researchers and collecting large quantities of blood and urine samples and disease data to analyze correlations among numerous variables.

The Chinese dietary experience

In the United States, protein supplies about 15% of calories, up to 80% of it animal protein. In China then, protein supplied 9% of calories, only about 10% of it from animals.

These data are important because the overall pattern differs greatly from the US. Substantial regional differences within China were also extremely useful. The press called the study “monumental.”

Diseases of poverty and affluence

Analysis separated diseases associated with overnutrition from those associated with undernutrition or hygiene. Cancer, heart disease, and diabetes mainly accompanied overnutrition; parasitic infections and digestive disorders accompanied deficiency and poor hygiene.

Blood cholesterol and disease

Blood cholesterol was the most important predictor of heart disease, cancer, and related diseases. Lower was safer, even below levels considered “adequate.” Interpretation requires care, however: dietary cholesterol (or fat) does not translate directly into blood cholesterol (or body fat).

Blood cholesterol and diet

Animal foods almost invariably increased blood cholesterol, and plant foods almost invariably reduced it. (Roman numerals i, ii, iii indicate statistical significance of 95%, 99%, and 99.9%, respectively.)

• Greater consumption of meat (i), milk, eggs, fish (i, ii), fat (i), and animal protein increased blood cholesterol.
• Greater consumption of plant protein (i), dietary fiber (ii), cellulose (ii), hemicellulose (i), soluble carbohydrates (ii), plant-derived vitamin B (i), legumes, brightly colored vegetables, fruit, carrots, potatoes, and some grains reduced it.

Many doctors still say saturated fat and dietary cholesterol strongly affect blood cholesterol, but ample evidence that animal food intake is the largest factor was already known in the early 1980s.

• Sirtori CR, Noseda G, and Descovich GC. “Studies on the use of a soybean protein diet for the management of human hyperlipoproteinemias.” In: MJ Gibney and D Kritchevsky (eds.), Current Topics in Nutrition and Disease, Volume 8: Animal and Vegetable Proteins in Lipid Metabolism and Atherosclerosis, pp. 135–148. New York: Alan R. Liss, 1983.

Fat and breast cancer

Despite forty years of research, both the public and scholars remain confused about fat. Fat’s bodily effects are extremely complex, yet many studies focus on isolated mechanisms. Popular books full of inaccurate information by assorted “doctors” also contribute.

Fat and a focus on cancer

The National Academy of Sciences published a diet, nutrition, and cancer report in 1982, with the author’s participation. It recommended limiting fat to under 30% of total calories to prevent cancer. Earlier similar recommendations for heart disease prevention drew little response, but cancer attracted considerable attention.

Research shows strong correlations between national dietary fat intake and breast cancer mortality. It may seem that reducing fat reduces this risk, but that is oversimplified: the correlation does not appear for plant-derived dietary fat.

The importance of fiber

Dietary fiber supplies no nutrients itself but importantly supports digestion. Chinese people consume three times as much fiber as Americans on average.

Some “experts” recommend restricting fiber because it impedes iron absorption. The China Study, however, found no correlation between fiber intake and iron absorption. More fiber instead reduced rectal cancer and colon cancer risks and lowered blood cholesterol.

Antioxidants, beautiful collections

Fruit’s varied colors come from antioxidants, chemicals found almost exclusively in plants. Eating the widest possible variety of whole plant foods provides a harmonious combination of vitamin C, beta-carotene, dietary fiber, and many other beneficial chemicals.

The Atkins crisis

Around the first edition’s publication (2004), the Atkins diet, a low-carbohydrate, high-fat diet, was hugely popular. It remains so now (2016). The author addresses it thoroughly in The Low-Carb Fraud, so only summarizes here.

Criticism of refined carbohydrates may partly be justified, but most low-carb authors barely distinguish them from other carbohydrates. Low-carb, high-fat diets recommend 15–20% of calories from carbohydrates and the rest from fat and protein—the opposite of the author’s position.

Such books usually begin by claiming Americans followed expert advice to eat low-fat for decades, yet kept gaining weight. Statistics show they never ate low-fat diets. These books contain few sound claims, but short-term weight loss may explain their popularity.

In an Atkins Center experiment, a group lost weight over twenty-four weeks on low-carb, high-fat diets, but because intake fell to 1,450 kcal/day. Humans cannot live this way for more than several years. Moreover, 68% experienced constipation, 51% headaches, and 10% hair loss; other cases revealed further health problems.

• Noakes M, and Clifton PM. “Weight loss and plasma lipids.” Curr. Opin. Lipidol. 11 (2000): 65–70.
• Bilsborough SA, and Crowe TC. “Low-carbohydrate diets: what are the potential short-and long-term health implications?” Asia Pac. J. Clin. Nutr. 12 (2003): 396–404.
• Stevens A, Robinson DP, Turpin J, et al. “Sudden cardiac death of an adolescent during dieting.” South. Med. J. 95 (2002): 1047–1049.

Undernutrition or illness naturally causes weight loss. Eating paper, heroin addiction, or chemotherapy also reduces weight, but is not recommended as weight-loss therapy. Low-carb, high-fat diets are similar: they do cause weight loss, by damaging health. The Paleo diet differs little.

The truth about carbohydrates

Less-refined complex carbohydrates benefit the body in various ways, while more refining brings more disadvantages. Most Americans consume excessive refined carbohydrates. Eating carbohydrates directly as whole grains, fruit, and vegetables offers many benefits.

The China Study weighs in

Chinese people consume more calories than Americans yet have lower obesity rates. They are more active on average, and low-fat, low-protein diets change their metabolism. Such diets cause calories to be expended in other forms rather than stored as body fat.

Diet and body size

Low-fat, low-protein diets help with weight loss. But what if one wants greater height and weight? Protein matters, whether animal or plant. Animal protein, however, increases risks of various diseases, including heart disease and cancer.

Why, then, are people in “poor,” predominantly plant-eating countries relatively small? The problem is insufficient quantity and variety of food, rather than plant-based eating itself.

Pulling it together

The China Study and numerous studies by the author and colleagues demonstrate diet’s importance. He has eaten vegetarian for twenty-five years and says he is healthier than before. (As of 2021, he is 87 and still healthy. —ak)

Part II. Diseases of Affluence

Chapter 5. Broken Hearts

(The title means both emotional heartbreak and damaged hearts. —ak)

In 1953, autopsies of 300 US soldiers killed in the Korean War found heart disease in 77%. This is deeply concerning given their average age of 22, above-average physical activity as soldiers, and absence of diagnosed heart problems during life.

Heart attack

Plaque made of protein, fat (including cholesterol), and other substances forms in the coronary arteries, but does not itself immediately block blood flow. When the thin cap separating plaque from blood detaches—unpredictably—plaque and blood clot around it and rapidly obstruct the artery.

Framingham

Heart attacks were once considered unpreventable: the heart gradually deteriorated and suddenly failed. After World War II, the US National Heart Institute studied 5,000 Framingham residents over several years, establishing blood cholesterol as a risk factor.

Outside our borders

Are genetic differences responsible for Americans’ unusually high heart disease rates? Cases including Japanese people raised in America suggest otherwise. Smoking also shows little association. The problem was diet: heavy meat consumption and too little plant food. Attention focused excessively on fat and protein, yet plant protein did not cause heart disease. Fat and protein were ultimately merely indicators of meat-centered diets.

• Kannel WB, Dawber TR, Kagan A, et al. “Factors of risk in the development of coronary heart disease—six-year follow-up experience.” Ann. Internal Med. 55 (1961): 33–50.

Dr. Dean Ornish

Dr. Dean Ornish ran a dietary program for patients with heart disease severe enough to require surgery. Of 200 participants between 1993 and 1998, 65% reportedly lost their chest pain within a year. By 2011, roughly 4,000 patients had improved.

Chapter 6. Obesity

The children

BMI is widely used to measure obesity, and childhood obesity by this standard is rising. Obese children face social prejudice and psychological difficulties, along with strong associations with sleep apnea, musculoskeletal disorders, hypertension, diabetes, and other illnesses.

The solution

Two-thirds of Americans are overweight and one-third obese. The solution is lasting habit change: a whole-food, plant-based diet and sufficient exercise. Numerous intervention and follow-up studies agree.

• Ellis FR, and Montegriffo VME. “Veganism, clinical findings and investigations.” Am. J. Clin. Nutr. 23 (1970): 249–255.
• Berenson G, Srinivasan S, Bao W, Newman WPR, Tracy, RE, and Wattigney WA. “Association between multiple cardiovascular risk factors and atherosclerosis to children and young adults. The Bogalusa Heart Study.” New Engl. J. Med. 338 (1998): 1650–1656.
• Key TJ, Fraser GE, Thorogood M, et al. “Mortality in vegetarians and nonvegetarians: detailed findings from a collaborative analysis of 5 prospective studies.” Am. J. Clin. Nutr. 70 (Suppl.) (1999): 516S–524S.
• Bergan JG, and Brown PT. “Nutritional status of ‘new’ vegetarians.” J. Am. Diet. Assoc. 76 (1980): 151–155.
• Appleby PN, Thorogood M, Mann J, et al. “Low body mass index in non-meat eaters: the possible roles of animal fat, dietary fibre, and alcohol.” Int J. Obes. 22 (1998): 454–460.
• Dwyer JT. “Health aspects of vegetarian diets.” Am. J. Clin. Nutr. 48 (1988): 712–738.
• Key TJ, and Davey G. “Prevalence of obesity is low in people who do not eat meat.” Brit. Med. J. 313 (1996): 816–817.
• Shintani TT, Hughes CK, Beckham S, et al. “Obesity and cardiovascular risk intervention through the ad libitum feeding of traditional Hawaiian diet.” Am. J. Clin. Nutr. 53 (1991): 1647S–1651S.
• Barnard RJ. “Effects of life-style modification on serum lipids.” Arch. Intern. Med. 151 (1991): 1389–1394.
• McDougall J, Litzau K, Haver E, et al. “Rapid reduction of serum cholesterol and blood pressure by a twelve-day, very low fat, strictly vegetarian diet.” J. Am. Coll. Nutr. 14 (1995): 491–496.
• Ornish D, Scherwitz LW, Doody RS, et al. “Effects of stress management training and dietary changes in treating ischemic heart disease.” JAMA 249 (1983): 54–59.
• Shintani TT, Beckham S, Brown AC, et al. “The Hawaii diet: ad libitum high carbohydrate, low fat multi-cultural diet for the reduction of chronic disease risk factors: obesity, hypertension, hypercholesterolemia, and hyperglycemia.” Hawaii Med. J. 60 (2001): 69–73.
• Nicholson AS, Sklar M, Barnard ND, et al. “Toward improved management of NIDDM: a randomized, controlled, pilot intervention using a lowfat, vegetarian diet.” Prev. Med. 29 (1999): 87–91.
• Ornish D, Scherwitz LW, Billings JH, et al. “Intensive lifestyle changes for reversal of coronary heart disease.” JAMA 280 (1998): 2001–2007.

A whole-food, plant-based diet is not always identical to a strict vegan diet. Some people are junk vegetarians or junk vegans, consuming excessive refined carbohydrates and otherwise nutritionally poor diets.

Hunger signals something wrong and is undesirable long-term. Whole plant foods allow more eating with relatively fewer calories, eliminating the need to count calories and eat tiny portions. Plant foods tend to be burned as heat rather than stored as body fat.

Exercise

Exercise is well established as effective for weight loss. Consistent daily exercise works better than temporary programs. Fifteen to forty-five minutes daily can reduce weight by roughly 5–8 kg. Animal experiments also found greater activity with lower animal protein intake.

Going in the right direction

Be wary of exercise programs or drugs promising weight loss in weeks or months. Research claiming to find an “obesity gene” also requires context, since countless genes contribute. The solution is simple: consistent long-term exercise and predominantly whole plant foods.

Chapter 7. Diabetes

Two faces of the same devil

Type 2 diabetes often accompanies obesity and affected 9.3% of US adults as of 2012. Most diabetes is type 1 or type 2. Type 1 usually begins in childhood and represents 5–10% of cases; almost all the rest are type 2. Rapidly rising type 2 prevalence in teenagers means age is no longer used to distinguish them as before.

Without diabetes, eating breaks carbohydrates into glucose (blood sugar), and the pancreas produces insulin to distribute it throughout the body. Some glucose is used immediately for energy; the rest is stored as fat for later. Diabetes disrupts this process.

Type 1 diabetes is an autoimmune disease: insulin-producing cells are destroyed or fail to function. In type 2 diabetes, insulin is produced but cells do not readily absorb glucose: insulin resistance.

Complications are extremely diverse: heart disease, stroke, hypertension, blindness, kidney disease, neurological, foot, and dental disorders, and pregnancy complications. Existing drugs and surgery manage but cannot cure diabetes. Correct eating, however, is known to make cure possible.

Many cases link diabetes and diet: dramatically increasing prevalence among Japanese immigrants to the United States; simultaneous rapid increases in meat consumption and diabetes in Japan over the past fifteen years; and reduced diabetes prevalence in England and Wales as meat consumption fell during World War II.

Curing the incurable

These observational studies show correlation rather than causation. James Anderson conducted an intervention with patients. Switching to predominantly plant-based diets reduced blood sugar and blood cholesterol in both type 1 and type 2 diabetes. Twenty-four of twenty-five type 2 patients stopped taking insulin within weeks.

• Anderson JW. “Dietary fiber in nutrition management of diabetes.” In: GV Vahouny, and D. Kritchevsky (eds.), Dietary Fiber: Basic and Clinical Aspects, pp. 343–360. New York: Plenum Press, 1986.

A further seventy-four-week study followed the first edition. A vegan-diet group did better than one following the American Diabetes Association’s recommended diet. A whole-food, plant-based diet, rather than simply vegan eating, would probably have produced still better results.

• Barnard N, Cohen J, and Ferdowsian H. “A low-fat vegan diet and a conventional diabetes diet in the treatment of type 2 diabetes: a randomized, controlled, 74-wk clinical trial.” Am. J. Clin. Nutr. 89 (2009): 1588S–1596S.

Chapter 8. Common Cancers: Breast, Prostate, Large Bowel (Colon and Rectal)

The author’s lifelong cancer research earned an American Institute for Cancer Research award in 1998. His conclusion was that, at least regarding nutrition, all cancers are essentially alike, whatever the site or initiating cause.

Breast cancer

One in eight American women develops breast cancer. Discovery of “breast cancer genes” such as BRCA-1 and BRCA-2 has led to excessive emphasis on heredity. Conversations with patients revealed strikingly little public awareness of nutrition’s relationship to breast cancer.

Risk factors

Major risks are early menstruation, late menopause, high blood estrogen, and high blood cholesterol. Diets centered on meat and refined carbohydrates increase all four. These findings need broader publicity.

Mutations in BRCA-1 and BRCA-2 do increase breast and uterine cancer prevalence, but consider that 1) only 0.2% carry them (about sixty times fewer than the 12.5% of American women diagnosed with breast cancer); 2) countless other genetic factors remain undiscovered; and 3) nutrition and environment strongly influence gene activation.

Those diagnosed are currently advised to 1) watch and wait, 2) depend on drugs for life, or 3) undergo mastectomy. But there is a fourth option: avoid animal foods, refined carbohydrates, and alcohol, and exercise consistently. High-risk people also need regular screening. Changing diet and exercising remain important even after removal of one breast.

Dioxin, PCBs, PAHs, and other endocrine disruptors pose real dangers. The author’s point is that excessive focus on them should not obscure the more important factor of diet.

Large bowel cancer (including colon and rectum)

People in wealthy countries have long been known to suffer more large bowel cancer. Colon cancer is especially prevalent in countries consuming much meat, animal protein, and sugar, and little grain.

Dietary fiber is particularly important. A 2003 study of half a million Europeans found a 40% difference in rectal and colon cancer prevalence between the highest and lowest fifths of fiber intake.

• Bingham SA, Day NE, Luben R, et al. “Dietary fibre in food and protection against colorectal cancer in the European Prospective Investigation into Cancer and Nutrition (EPIC): an observational study.” Lancet 361 (2003): 1496–1501.

Prostate cancer

National variation in prostate cancer prevalence exceeds that of breast cancer. Western diets or migration to the West increase prevalence. High dairy consumption particularly raises it two- to fourfold.

Bringing it together

Sufficient evidence has accumulated, but medical and nutritional experts remain insufficiently aware or reluctant to accept it. Academia and government must discuss whole-food, plant-based diets more actively.

Chapter 9. Autoimmune Diseases

Seven to ten percent of humans have autoimmune diseases, with women affected more than twice as often as men. These occur when the immune system attacks one’s own body: the pancreas in type 1 diabetes, or joint tissue in arthritis.

Immunity from invaders

Proteins from invading bacteria, viruses, and other agents are called antigens. Since proteins are amino-acid chains, infinitely many antigens are possible. The immune system creates tailored antibodies for each antigen.

Immunity from ourselves

One underlying mechanism in autoimmune diseases is molecular mimicry. If an invading molecule resembles bodily cells, the immune system may learn incorrectly and attack those cells. Milk is a representative example.

Partly digested milk absorbed through the intestine into blood can disrupt immunity. Usually no problem arises, but some cases develop into autoimmune disease. The immune system’s complexity means the specific circumstances remain unclear.

Type I diabetes

The mechanism by which milk causes childhood type 1 diabetes is well understood. Undigested protein fragments enter blood through the small intestine; some exactly match cells in the pancreas producing insulin. If the immune system makes antibodies and attacks the pancreas, insulin production stops for life.

Children with genetic predispositions, or intestinal immune systems damaged by viruses, who absorb cows’ milk too early have eleven to thirteen times the type 1 diabetes risk of those adequately breastfed. Compare smoking’s threefold increase in lung cancer: eleven- to thirteenfold is enormous.

The commonality of autoimmune diseases

Shared features:

1. Abnormal immunity attacks one’s own body.
2. More frequent in regions with little sunlight.
3. Some autoimmune diseases often occur together.
4. Associated with animal foods such as milk.
5. Sometimes triggered by viruses.
6. Considerably similar mechanisms.

Chapter 10. Wide-Ranging Effects: Bone, Kidney, Eye, and Brain Diseases

Osteoporosis

Unlike plant protein, animal protein is highly acidic. Neutralizing it draws calcium from bones, ultimately weakening them. Excessive long-term dietary calcium also harms bodily calcium regulation. Milk is particularly dangerous because it is rich in both animal protein and calcium.

Kidney stones

Kidney stones cause headaches, motion sickness, fatigue, frequent urination, and blood in urine. Animal protein intake is strongly associated with them.

Eye problems

Macular degeneration is the leading cause of irreversible vision loss after age sixty. Eating abundant green vegetables, carrots, and so forth reduces risk by 88%. Cataracts, often removable surgically, occur more frequently than macular degeneration and can be prevented through foods such as spinach.

Mind-altering diet

Problems range from relatively mild cognitive impairment and cognitive dysfunction to severe mental dysfunction and dementia. These relate to hypertension and high blood cholesterol. Research on 260 older adults found that reducing saturated fat and cholesterol while increasing carbohydrates, dietary fiber, vitamins, and minerals benefits physical health and cognitive function.

• Acheson ED, Bachrach CA, and Wright FM. “Some comments on the relationship of the distribution of multiple sclerosis to latitude solar radiation and other variables.” Acta Psychiatrica Neurologica Scand. 35 (Suppl. 147) (1960): 132–147.

A whole-food, plant-based diet also helps prevent severe mental illnesses such as Alzheimer’s disease, largely through positive vascular effects. Aged 82 when writing the revised edition, the author remains healthy, enjoying walking, running, golf, and skiing.

Part III. The Good Nutrition Guide

Chapter 11. Eating Right: Eight Principles of Food and Health

• Principle 1. Nutrition represents the combined activities of countless food constituents. The whole exceeds the sum of its parts. Overemphasizing a single nutrient or chemical is inappropriate.
• Principle 2. Supplements are not a panacea for health. The supplement industry has grown enormously, but effects are absent or minimal. Vitamin B12 and vitamin D are exceptions. B12 cannot be produced in the body, deficiency causes disorders, and supplements have no known adverse effects. Although research on their effectiveness is insufficient, supplementation is recommended. Vitamin D is actually a hormone, not a vitamin, produced through fifteen to thirty minutes of adequate daily sunlight. People in low-sunlight regions or unable to go outside may lack it. Evidence for supplement effectiveness is limited. Excess vitamin D can also harm, so consult a doctor before taking it.
• Principle 3. Virtually no nutrients are better supplied by animal foods than plants. Plants are rich in antioxidants, fiber, vitamins, and minerals. Animals contain much cholesterol, fat, and protein, but plant fats and proteins are healthier. Cholesterol and vitamins A, B12, and D occur mainly in animals, but all except B12 can be produced in the body, so eating animals to obtain them is unnecessary.
• Principle 4. Genes alone do not cause disease. Food importantly affects gene activity.
• Principle 5. Nutrition can substantially control the adverse effects of harmful chemicals.
• Principle 6. Nutrition that prevents a disease can also halt or reverse its progression. Not every disease is reversible. Autoimmune diseases such as type 1 diabetes are considered irreversible, yet food can still reduce medication needs and provide other benefits.
• Principle 7. Nutrition effective against a particular chronic disease benefits overall health in many ways. Early planning discussions proposed organizing the book around foods recommended for each disease. This might market well, but would not match scientific facts.
• Principle 8. Good nutrition promotes health across all areas. Everything connects. For health and nutrition, holism fits better than reductionism. This is central to the author’s Whole: Rethinking the Science of Nutrition.

Chapter 12. How to Eat

Supplements

Take vitamin B12. If you get almost no sunlight, take vitamin D, never exceeding the recommended amount. These two are all that science establishes about supplements; the rest lack supporting evidence.

Eat All You Want (While Getting Lots of Variety) of Any Whole, Unrefined, Plant-Based Food

Eat a varied whole-food, plant-based diet. Reduce refined foods and avoid cattle, pigs, birds, fish, chickens’ eggs, cows’ milk, and similar foods as much as possible.

Can you do this?

Giving up meat completely may seem impossible. Try just one month. Even that reveals vegetarian dishes you never knew, shows it is easier than expected, improves body and mood, and demonstrates that you can do it.

Vegetarian and vegan vs. WFPB diet

Vegetarians avoid meat but may consume milk and eggs, making their diets less healthy. Vegans eat plants alone but do not avoid processed foods, making their diets less healthy too. Usually motivated by beliefs, these diets improve on meat eating but fall short of a whole-food, plant-based diet.

Part IV. Why Haven’t You Heard This Before?

Chapter 13. Science: The Dark Side

Fraud for personal gain has always existed, but in health it is deadly. Problems range from unverified alternative medicine to medical policies and government guidelines distorted by interest-group lobbying.

Big surprise

In the late 1970s, Food and Nutrition Board (FNB) leaders Bob Olson and Alf Harper, under the Food and Drug Administration, received livestock, dairy, and poultry industry funding. At the author’s first meeting in 1980, every one of the eighteen committee members except him received industry money.

An agenda item addressed “food fraud,” surprisingly including the McGovern Report, which recommended less meat and more plant food based on contemporary scientific findings. His objection postponed discussion, but weeks later he saw Olson on television arguing that a high-fat, meat-centered diet posed no problem.

Falling on my petard

In June 1982, the author published a review of research linking diet, nutrition, and cancer as an official National Academy of Sciences report. Industry-funded scientists such as Olson and Harper, and livestock/dairy/poultry interests, rushed to criticize it. A senior colleague sneered that he had ruined a promising career and been “hoist with his own petard.”

American Institute for Cancer Research

The American Institute for Cancer Research was founded with his help. Immediately afterward, it sent the National Academy of Sciences report to 50,000 US physicians, again drawing criticism from interested parties. The American Cancer Society even circulated an official document falsely claiming AICR’s scientific chair—the author—had gathered eight or nine quacks, some formerly imprisoned. Criticism and lobbying made the first two years difficult, but the institute gradually built credibility and now operates well.

These personal experiences concern public issues as well as individual careers and lives. Experts and government organizations using authority selectively in collusion with business are dangerous. Unethical scholars are few but enormously influential.

Large medical companies recommend drugs and surgery, while the American Cancer Society says on television that food and cancer are unrelated. American Institute for Cancer Research papers say they are related. How can people know whom to trust? Without insider or expert knowledge, judgment is difficult. Science involves money, power, ego, and protection of personal interests as well as the common good.

Chapter 14. Scientific Reductionism

The 1982 National Academy of Sciences report analyzed individual nutrients but also stressed obtaining them through food rather than drugs or supplements. Companies ignored this emphasis, citing the rest to promote supplements.

Focus on fat

Organizing the report by nutrient was, in retrospect, a major mistake. Thinking centered on isolated nutrients became fashionable for decades, particularly regarding fat. The report linked cancer to animal foods generally, not fat alone, yet attention focused only on fat.

Carnivorous nurses

The well-known Nurses’ Health Study linked high-fat diets to heart disease and cancer. It popularized low-fat meat eating, which remained generally high in protein and cholesterol. But meat eating, rather than fat, was the problem. The study’s design was flawed from the outset.

Many such studies preserve typical American meat-centered diets while reducing particular nutrients such as fat. They cannot establish anything about whole-food, plant-based diets, merely exposing scientific reductionism’s limitations.

In the ten years following the first edition, supplement studies generally found no benefit or some adverse effects. Nevertheless, the industry grows substantially.

• Gaziano JM, Glynn RJ, Christen WG, et al. “Vitamins E and C in the prevention of prostate and total cancer in men: the Physicians’ Health Study II randomized controlled trial.” JAMA 301 (2009): 52–62.
• Christen WG, Glynn RJ, Sesso HD, et al. “Age-related cataract in a randomized trial of vitamins E and C in men.” Arch. Ophthalmol. 128 (2010): 1397–1405.
• Christen WG, Glynn RJ, Manson JE, et al. “Effects of multivitamin supplement on cataract and age-related macular degeneration in a randomized trial of male physicians.” Ophthalmol. 121 (2014): 525–534.
• Sesso HD, Christen WG, Bubes V, et al. “Multivitamins in the prevention of cardiovascular disease in men: the Physicians’ Health Study II randomized controlled trial.” JAMA 17 (2012): 1751–1760.
• Gaziano JM, Sesso HD, Christen WG, et al. “Multivitamins in the prevention of cancer in men: the Physicians’ Health Study II randomized controlled trial.” JAMA 308 (2012): 1871–1880.
• Wang L, Sesso HD, Glynn L, et al. “Vitamin E and C supplementation and risk of cancer in men: posttrial follow-up in the Physicians’ Health Study II randomized trial.” Am. J. Clin. Nutr. 100 (2014): 915–923.
• Wang J, Eliassen AH, Spiegelman D, et al. “Plasma free 25-hydroxyvitamin D, vitamin D binding protein, and risk of breast cancer in the Nurses’ Health Study II.” Cancer Causes & Control 25 (2014): 819–827; Bertrand KA, Rosner B, Eliassen AH, et al. “Premenopausal plasma 25-hydroxyvitamin D, mammographic density, and risk of breast cancer.” Breast Cancer Res. Treat. 149 (2015): 479–487.
• Massa J, Cho E, Orav EJ, et al. “Long-term use of multivitamins and risk of colorectal adenoma in women.” Brit. J. Cancer 110 (2014): 249–255.

Chapter 15. The “Science” of Industry

Food and pharmaceutical companies earn enormous profits and do not want their products linked to harmful effects, cancer, or heart disease. Through associations and other means, they use science for marketing.

The Airport Club

It later emerged that while the author conducted the China Study, seven prominent scholars connected to the National Dairy Council and American Meat Institute monitored research continually for “uncomfortable” findings. They included E. M. Foster and Professor Michael Pariza at the University of Wisconsin-Madison (where Alf Harper worked). The author was, of course, on their watch list.

Powerful groups

Founded in 1915, the National Dairy Council is particularly powerful. It funds favorable research, sells milk to children through schools nationwide, and creates and promotes health education encouraging milk consumption. Its 2003 promotional budget was an astounding $165M (roughly two billion won).

Fruit claims

The fruit industry differs little. The “common knowledge” that vitamin C is antioxidant and oranges contain much of it has little basis. Oranges contain less vitamin C than assumed, and it accounts for only a tiny fraction of their antioxidant effects. This is merely scientific reductionism and marketing that distorts science.

The misuse of science continues unabated

Companies naturally pursue profit: managers who fail to maximize shareholder interests are replaced. Health-related businesses, however, should prioritize accurate consumer information above everything. The author declares that marketers’ “science” differs from the science he knows.

Chapter 16. Government: Is It for the People?

Dietary ranges: the last assault

The Food and Nutrition Board (FNB), under the National Academy of Sciences, periodically reports maximum nutrient intakes for preventing chronic disease. Recommendations such as allowing up to 35% of calories from protein let entirely unhealthy diets fall within the recommended ranges.

Protein

Americans get roughly 11–21% of calories from protein. The claim that the FNB report’s 35% reduces heart disease risk is absurd. Asked where 35% came from, an acquaintance on the committee said he had never heard that number and suspected an unexplained change just before printing. Suspiciously, the standing chair was replaced by an industry representative shortly before publication.

A sugarcoated report

The FAO under the World Health Organization limits added sugars to 10%, while FNB allows 25%. According to The Guardian and other sources, the US Sugar Association and World Sugar Research Organisation threatened and otherwise pressured WHO personnel.

• Boseley S. “Sugar industry threatens to scupper WHO.” The Guardian April 21, 2003.
• Brundtland GH. “Sweet and sour; The WHO is accused by the sugar industry of giving unscientific nutrition advice. But its recommendations are based on solid evidence, says Gro Harlem Brundtland.” New Scientist, May 3, 2003: 23.

WHO resisted and retained 10%. The author suspects FNB accepted industry demands in adopting 25%. Some panel members received funding from M&M’s and similar sources.

Industry subsequently cited the FNB report whose figures it had influenced and distorted to criticize WHO’s report.

The influence of industry

How did industry gain such power? Typically, companies hire prominent scholars as consultants, hold symposia and workshops through them, broaden contacts through recruiting speakers, identify “suitable” people, and extend their connections.

Government should regulate industry, yet some government-funded scholars also receive industry commissions. They use connections with government scientists to influence policy favorably for industry, bringing the entire system under its control. The FNB chair at the time received money from dairy interests including Nestlé.

Banning corporate funding for individual scholars is not the answer, the author says: it would merely drive relationships underground. Instead, disclose which companies support which scholars, making this public discussion. Everyone should have access without going to court, as is currently necessary.

The industry-distorted 2002 FNB report affected public-school meals nationwide and nutrition education programs. It will therefore seriously damage Americans’ health for years. Based on over twenty years on government panels, the author finds it very difficult to believe government policy serves public health.

Unfunded nutrition

The National Institutes of Health has twenty-seven divisions addressing cancer, the heart, and so forth, but none devoted solely to nutrition. Individual divisions allocate very little to nutrition, and most of that concerns pharmaceutical, supplement, and other commercial interests.

Chapter 17. Big Medicine: Whose Health Are They Protecting?

Dr. Sprouts

Caldwell B. Esselstyn Jr., named among America’s best doctors in 1994–1995, is an outstanding physician. Despite his skill, cancer patients’ postsurgical outcomes were generally poor. Doubting available treatments, he studied alternatives and encountered Dr. John McDougall’s research.

He then studied eighteen patients on low-fat plant-based diets with minimal cholesterol medication (see chapter 5). Their results became among the best outcomes in medical history. Strong data have since won recognition, but other doctors initially mocked him as “Dr. Sprouts.”

Lack of training

Doctors essentially do not study nutrition in formal education: an average of just twenty-one hours across four medical-school years. Industry also deeply influences teaching materials, producing biased resources and distributing them to universities free.

Dr. McDougall’s challenge

McDougall is among the longest-standing advocates of a whole-food, plant-based diet. He has written ten books, keeps a home collection of research on diet and disease, and spends hours daily searching online for recent papers.

Early in his medical career in Hawaii, poor patient outcomes made him question his practice. Feeling he needed more study, he entered Honolulu’s Queen’s Medical Center, only to find experienced doctors’ patients generally did poorly too. Colleagues dismissed dietary research he mentioned as “controversial,” yet however much he read, the conclusions were clear.

Hooked on drugs

McDougall also points out that medical education is aligned with pharmaceutical companies. The pharmaceutical industry endlessly supplies students with free gifts, travel, accommodation, meals, and educational-event tickets. Sales representatives’ distorted information profoundly influences prescriptions.

Companies, rather than researchers, design much research, fund only suitable studies, retain raw data, selectively provide some to researchers, and sometimes seek researchers merely to lend names to papers already written to suit company interests. Major journals have become pharmaceutical promotional publications.

Since the first edition: from Thomas M. Campbell, MD

Coauthor Thomas M. Campbell II became a physician after the first edition. The medical-education/pharmaceutical connections described then have improved considerably. Universities introduced rules against improper relationships. Medical foundations and associations began teaching links between whole-food, plant-based diets and health. Through the University of Rochester’s nutrition-in-medicine program, he and his spouse, who works in preventive medicine, systematically recommend plant-based diets to patients.

Chapter 18. Academia

Although the first edition addressed science’s dark side, it said too little about academia itself, prompting this additional chapter. Industry, medicine, media, and government exploit available information to their advantage; ultimately, academia produces it.

“Academia” here includes government advisory expert committees as well as universities. To function properly, it must allow individual researchers freedom, expand knowledge through original research, and share results with independent learners, including the public. Current academia does nothing of the sort.

The challenge to academic freedom: Cornell as case study

From 1975, full support from Cornell University enabled much research. But after the China Study attracted attention around 1990, suppression began: his vegetarian nutrition course was canceled, his achievements were excluded from university publicity, and other restrictions followed.

Dr. Cutberto Garza, then head of his nutritional sciences division, was a vice president of multinational food company Dannon. He also chaired the USDA dairy-guidelines committee. Litigation later revealed that six of its eleven members secretly received industry support.

Chapter 19. Repeating Histories

A hundred and fifty years ago, George Macilwain advocated a constitutional theory of disease. He attributed cancer to grease, fat, and alcohol and became vegetarian at forty. Disease, he assumed, arose from the body’s overall constitution rather than localized problems. His terminology differed, but his ideas closely resembled the author’s.

Twenty-five hundred years ago, Socrates warned that affluent cities’ meat eating and livestock would cause land shortages, violence, war, and disease. Americans now suffer diseases of affluence on an unprecedented scale. Tropical forests have shrunk and the climate changed rapidly. Humanity has built so-called civilization for 2,500 years, but may not have even 250 more, let alone 2,500.

We now know a great deal about food, health, and disease. Abundant evidence shows a whole-food, plant-based diet can prevent diseases and aid recovery. Evidence of animal-food risks also overflows. We must change, and can.

Afterword to the revised edition

The current system is both illogical and immoral. Nutrition should be studied holistically, yet almost purely commercial motives drive reductionist research. Oligarchic leaders actively prevent the public from learning findings of research funded through its taxes.

Holistic research into whole-food, plant-based diets remains scarce. Colleagues say “there is insufficient evidence”—a self-fulfilling prophecy.

There is hopeful news nevertheless. Since the first edition, the author has given about 600 talks worldwide, 200 at medical schools or conferences. Young researchers interested in this subject will begin occupying important positions.

Scholars doubting the book should conduct proper research to refute it. National institutions such as NIH should reduce spending on absurd television advertising and invest in holistic nutrition research.

Discoveries about whole-food, plant-based diets’ health effects are the most important advance in Western medical history. There is no alternative.

Notes

Since the 1970s, Colin Campbell has researched relationships among food, nutrition, health, and disease, especially cancer. He led the China Study and other large studies, helped found the American Institute for Cancer Research, and served for years on expert panels advising US policy.

Thomas M. Campbell II is cofounder and director of the University of Rochester Program for Nutrition in Medicine.

The extensive citation of trustworthy research stands out. The author supports a whole-food, plant-based diet, rather than veganism, criticizing “junk vegans” on health grounds. Paradoxically, this makes his arguments more credible to me.