How Not to Die: Discover the Foods Scientifically Proven to Prevent and Reverse Disease

How Not to Die, published on December 8, 2015 by Flatiron Books, is the definitive popular guide to evidence-based plant-based nutrition. Dr. Michael Greger, a physician and founder of NutritionFacts.org, spent over a decade analyzing tens of thousands of peer-reviewed nutrition studies and translating them into accessible daily videos and articles. This book represents the culmination of that work: a comprehensive, fully referenced guide to using food to prevent, treat, and reverse the fifteen leading causes of death in America. The first half is organized by disease (heart disease, lung disease, brain disease, digestive cancers, infections, diabetes, high blood pressure, liver disease, kidney disease, breast cancer, prostate cancer, suicide/depression, Parkinson's disease, and doctor-induced death). The second half provides a practical framework (the Daily Dozen) for implementing the science. The book was an instant New York Times bestseller, has sold over five million copies, and has been translated into more than thirty languages. It is widely considered the foundational text of the evidence-based plant-based nutrition movement.

Structure Overview

The book is organized into two parts. Part I (chapters 1–15) covers the leading causes of death, with each chapter focusing on a specific disease and the foods that can help prevent or reverse it. Part II (chapters 16–17) provides the practical framework for implementation.

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Part I: How Not to Die from Disease

Chapter 1: How Not to Die from Heart Disease

Heart disease is the number one killer of Americans, claiming more than 400,000 lives annually. Yet Greger argues that it is almost entirely preventable and even reversible with dietary intervention. He presents the evidence from Dr. Dean Ornish's Lifestyle Heart Trial (1990), which showed that a plant-based diet combined with moderate exercise could reverse coronary atherosclerosis. Patients in the intervention group actually had less plaque after one year, while the control group got worse.

Greger explains the mechanism: cholesterol from animal products damages the endothelium (the inner lining of arteries), triggering an inflammatory response that leads to plaque formation. A plant-based diet, rich in dietary fiber and antioxidants, reduces cholesterol, improves endothelial function, and allows the body's natural repair mechanisms to clear plaque. Specifically, he recommends avoiding all animal products (especially meat, dairy, and eggs), minimizing added oils, and consuming a diet rich in whole grains, legumes, vegetables, and fruits.

The chapter introduces the concept of "artery ultrasound" or carotid intima-media thickness (CIMT) testing, which can detect early atherosclerosis before symptoms appear. Greger also discusses the role of nitric oxide in vascular health, explaining how a plant-based diet restores the endothelium's ability to produce this critical vasodilator.

Chapter 2: How Not to Die from Lung Disease

Lung cancer, COPD, and asthma are the focus. While smoking is the primary cause, diet plays a significant role in prevention and management. Greger reviews studies showing that higher consumption of fruits and vegetables is associated with lower lung cancer risk, even among smokers. Crucially, former smokers who adopt a plant-based diet can reduce their risk to almost that of never-smokers after several years.

The mechanism involves cruciferous vegetables (broccoli, kale, cabbage, Brussels sprouts), which contain sulforaphane, a compound that upregulates the body's detoxification enzymes and protects lung tissue from carcinogens. Apples, pears, and onions contain quercetin, a flavonoid with anti-inflammatory properties that may reduce asthma symptoms.

For COPD, Greger highlights evidence that a plant-based diet reduces systemic inflammation and improves lung function. He also addresses the role of antioxidants in protecting lung tissue from oxidative damage caused by pollution and smoking. He recommends at least one serving of cruciferous vegetables per day and a diet rich in colorful fruits and vegetables to maximize antioxidant intake.

Chapter 3: How Not to Die from Brain Disease

This chapter covers stroke and dementia. For stroke, the key dietary factors are blood pressure control and cholesterol reduction. Greger presents data showing that plant-based diets are more effective than any other intervention for lowering blood pressure, often achieving results comparable to medication.

For dementia, the focus is on Alzheimer's disease. Greger reviews the evidence that the same vascular risk factors that cause heart disease also contribute to Alzheimer's—leading to the "type 3 diabetes" hypothesis. He highlights foods that protect brain health: berries (especially blueberries) for their flavonoid content, turmeric for its anti-inflammatory curcumin, and green leafy vegetables for vitamin K and folate.

The concept of "brain angiogenesis" is introduced: a healthy diet promotes the growth of new blood vessels in the brain, improving circulation and oxygen delivery. Greger also discusses the role of homocysteine, an inflammatory amino acid that damages blood vessels and is elevated by animal protein consumption. B vitamins from plant sources can lower homocysteine levels and reduce brain shrinkage.

Chapter 4: How Not to Die from Digestive Cancers

Colorectal cancer is the third most common cancer and one of the most diet-responsive. Greger explains how dietary fiber from whole plant foods is the primary protective factor. Fiber speeds transit time through the colon, dilutes carcinogens, and feeds beneficial gut bacteria that produce short-chain fatty acids (butyrate) that protect colon cells from malignant transformation.

The chapter also covers stomach, pancreatic, and esophageal cancers. The common thread is that animal products and processed foods increase risk, while whole plant foods decrease it. Greger highlights the specific protective effects of legumes (beans, lentils, chickpeas) for colorectal cancer, attributing their potency to resistant starch and saponins.

Chapter 5: How Not to Die from Infections

A surprising chapter: Greger argues that diet affects immune function and susceptibility to infections. He reviews evidence that animal products can promote foodborne illness (E. coli, Salmonella, Campylobacter) and that plant-based diets strengthen immune function through enhanced antioxidant status and better gut microbiome health.

Specific foods highlighted for immune support: mushrooms (which enhance natural killer cell activity), garlic (which has antimicrobial properties), and berries (high in vitamin C and flavonoids). Greger also discusses the importance of avoiding antibiotic-resistant bacteria from factory-farmed meat.

Chapter 6: How Not to Die from Diabetes

Type 2 diabetes is presented as a reversible condition. Greger reviews studies showing that a plant-based diet can lower fasting blood glucose, improve insulin sensitivity, and reduce or eliminate the need for medication. The mechanism is multifactorial: weight loss, reduced intramyocellular fat (fat inside muscle cells that interferes with insulin signaling), and increased fiber intake (which slows glucose absorption).

The chapter features the work of Dr. Neal Barnard at the Physicians Committee for Responsible Medicine, whose studies have shown that a plant-based diet is superior to the American Diabetes Association's standard dietary recommendations for glycemic control. Greger emphasizes that diabetes reversal does not require calorie restriction or weight loss—some studies show improved glucose metabolism even before significant weight loss occurs.

Chapter 7: How Not to Die from High Blood Pressure

Hypertension affects one in three American adults and is the leading risk factor for death worldwide. Greger argues that the DASH diet (Dietary Approaches to Stop Hypertension) was a step in the right direction but did not go far enough. The sodium-potassium ratio is key: plant foods are naturally low in sodium and high in potassium, which relaxes blood vessels and reduces blood pressure.

Greger reviews studies showing that a whole-food plant-based diet lowers blood pressure more effectively than any other dietary pattern, often within weeks. He also discusses the specific role of nitric oxide, which plant-based diets enhance, in vasodilation.

Chapter 8: How Not to Die from Liver Disease

Non-alcoholic fatty liver disease (NAFLD) affects up to 25% of Americans and is the fastest-growing cause of liver failure. Greger explains that the primary cause is fructose metabolism in the liver, which generates fat through de novo lipogenesis. While fruit consumption is not the problem (the fiber and water content prevent fructose overload), concentrated sugars from HFCS, table sugar, and fruit juice can overwhelm the liver.

The treatment is a plant-based diet that eliminates added sugars and animal products, combined with exercise. Greger reviews studies showing that liver fat can be reduced by 30-50% within months of dietary change.

Chapter 9: How Not to Die from Kidney Disease

Chronic kidney disease affects 10% of the population and is strongly linked to animal protein consumption. Greger explains how animal protein increases the workload on the kidneys by creating acid load and requiring them to excrete nitrogenous waste. Plant-based diets reduce kidney workload and have been shown to slow or stop the progression of chronic kidney disease.

Chapter 10: How Not to Die from Breast Cancer

Breast cancer risk is heavily influenced by diet. Greger identifies three key dietary factors: (1) alcohol consumption increases risk, (2) animal protein consumption increases IGF-1 levels, which promote cancer cell growth, and (3) plant foods contain compounds that inhibit cancer growth. Flaxseeds are highlighted for their lignan content. Soy consumption is discussed and vindicated: rather than increasing risk, soy consumption is associated with reduced breast cancer recurrence and mortality.

Chapter 11: How Not to Die from Prostate Cancer

Prostate cancer is one of the most diet-responsive cancers. Greger reviews studies showing that plant-based diets slow cancer progression, that flaxseeds reduce tumor growth rates, and that the lycopene in cooked tomatoes is specifically protective. Cruciferous vegetables are highlighted for their sulforaphane content.

Chapter 12: How Not to Die from Suicide

Acknowledging that suicide is driven by complex psychological and social factors, Greger reviews evidence that diet can influence mood and mental health. He presents studies linking depression with inflammation, which is lowered by plant-based diets. He also highlights the role of omega-3 fatty acids (from flaxseeds and walnuts), folate (from leafy greens), and the gut-brain axis in mental health.

Chapter 13: How Not to Die from Parkinson's Disease

Parkinson's disease has been linked to dairy consumption. Greger reviews epidemiological studies showing that dairy consumers have higher rates of Parkinson's, possibly due to a contaminant in milk that crosses the blood-brain barrier. He also discusses evidence that berries, tea, and other flavonoid-rich foods are protective.

Chapter 14: How Not to Die from Doctor-Induced Death

A provocative chapter arguing that medical errors and unnecessary medical interventions kill hundreds of thousands of Americans annually. Greger is not anti-medicine but argues that prevention through diet and lifestyle is safer and more effective than waiting for disease to develop and then treating it with drugs and surgery.

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Part II: The Practical Framework

Chapter 15: The Daily Dozen

Greger introduces his signature framework: a checklist of foods to eat every day. The categories are: beans (3 servings), berries (1 serving), other fruits (3 servings), cruciferous vegetables (1 serving), greens (2 servings), other vegetables (2 servings), flaxseeds (1 serving), nuts and seeds (1 serving), herbs and spices (1 serving), whole grains (3 servings), and beverages (5 servings of water). He also recommends one serving of exercise and one serving of vitamin B12 supplementation daily.

Chapter 16: The Supplement Trap

Greger warns against the supplement industry's exaggerated claims. Most supplement studies have failed to show benefits and some (beta-carotene, vitamin E, calcium) have shown harm. He recommends only vitamin B12 (mandatory for anyone on a plant-based diet) and possibly vitamin D (depending on sun exposure and blood levels). Whole foods, not supplements, should be the source of nutrients.

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Reading Guide

Primary audience: General readers seeking evidence-based dietary guidance for disease prevention and reversal.

Recommended path: Read chapters 1 and 3 (heart disease and brain disease) as the most compelling evidence chapters, then chapter 6 (diabetes) for another strong case, then skip to part II (chapters 15-16) for the practical framework. Other chapters can be read as needed based on personal health concerns.

Sufficiency: The book is comprehensive as both an evidence review and a practical guide. The Daily Dozen provides a clear, actionable framework. The book is supported by extensive references available on NutritionFacts.org. For readers seeking deeper dives into specific diseases, the references provide an entry point to the primary literature.

1. Historical Context

How Not to Die was published in 2015 at a moment when plant-based eating was transitioning from a fringe movement to the mainstream. The previous decade had seen the publication of key research: the China Study (Campbell, 2005), the Adventist Health Studies showing lower mortality among vegetarians, and the European Prospective Investigation into Cancer and Nutrition (EPIC). Documentaries like Forks Over Knives (2011) had popularized the idea that diet could reverse chronic disease. Greger's contribution was to systematize the evidence, creating a comprehensive reference that could be cited—each claim backed by a link to the primary research on NutritionFacts.org. The book arrived just as the term "evidence-based medicine" was becoming a cultural touchstone, and it positioned plant-based nutrition within that framework.

2. Core Thesis

Greger argues that most of the leading causes of premature death can be prevented or reversed by a whole-food plant-based diet. The thesis rests on two claims: (1) the diseases that kill most people share common dietary roots, and (2) a single dietary pattern can address all of them simultaneously. The first claim is well-supported; the second is more ambitious but also supported by the common mechanism hypothesis: a plant-based diet reduces inflammation, improves lipid profiles, lowers blood pressure, normalizes blood glucose, and enhances antioxidant status—all of which affect multiple disease pathways.

3. Evidence and Methodology

Greger's methodology is systematic review: he has analyzed thousands of nutrition studies and presents what he considers the best evidence. The sources are overwhelmingly peer-reviewed and include large cohort studies, randomized trials, and meta-analyses. His approach to evidence is genuinely comprehensive for nutritional research.

However, the methodology has limitations. Greger selects studies that support his conclusions—a form of confirmation bias that is hard to avoid in such a sweeping project. He does not systematically search for contradictory evidence, and his presentation of individual studies sometimes glosses over methodological limitations. The same evidence base that Greger interprets as supporting a strict plant-based diet has been interpreted by others as supporting more moderate approaches.

A more significant issue: Greger's "evidence-based" brand creates an impression of objectivity that overstates the certainty of nutritional science. Many of the studies he cites are epidemiological (correlational) rather than experimental, and nutritional epidemiology is notoriously prone to confounding. Greger is aware of these limitations but does not always foreground them.

4. Strengths

Comprehensive scope: No other single book covers as many diseases with as much dietary evidence. This comprehensiveness is the book's greatest strength—it allows readers to see the common threads across different health conditions.

Actionable framework: The Daily Dozen is simple, memorable, and evidence-based. It provides clear guidance without being rigid. The checklist approach makes it easy for readers to track their compliance.

Transparent sourcing: Every claim is referenced to the primary literature, and readers can look up the original studies on NutritionFacts.org. This transparency is unprecedented in popular nutrition books.

Motivational writing: Greger writes with conviction and urgency. His tone is alarmist at times, but the underlying data are compelling. For readers who need motivation to make a significant dietary change, this tone can be effective.

Integrated lifestyle approach: The book addresses exercise, sleep, stress, and other lifestyle factors alongside diet, providing a complete health framework.

5. Weaknesses

Confirmation bias: Greger consistently selects studies that support his position and may give insufficient weight to contradictory evidence. The systematic review methodology on NutritionFacts.org is not truly systematic—it does not include pre-registered protocols or explicit search strategies.

Oversimplification: The claim that a single dietary pattern can prevent or reverse all leading causes of death oversimplifies the complexity of chronic disease. Genetics, environmental exposures, social determinants, and random chance all play important roles. Some diseases (certain cancers, neurodegenerative diseases) may not be as responsive to diet as the book suggests.

Alarmist tone: Greger's writing can be fear-based. The title itself ("How Not to Die") frames every food choice as a matter of life and death, which may create anxiety and an unhealthy relationship with food.

Dismissive of nuance: The book tends to present dietary choices in binary terms (plant foods good, animal foods bad). This oversimplification ignores the evidence about traditional diets that include some animal products, the nutritional challenges of strict plant-based diets (B12, iron, zinc, omega-3s), and the fact that not all people thrive on a completely plant-based diet.

Anti-doctor bias: Chapter 14's critique of medicine, while containing valid points, can undermine trust in healthcare providers. The framing that doctors are dangerous and diet is the only safe intervention may discourage readers from seeking appropriate medical care.

6. Named Critical Reception

The New York Times described the book as "a comprehensive and accessible guide to preventing and reversing disease through diet" but noted that "Greger's confidence occasionally exceeds what the evidence supports."

The British Medical Journal (BMJ) published a review praising the book's "meticulous referencing" and "commitment to evidence-based practice" while noting that "the dietary recommendations are more prescriptive than the evidence base for any individual intervention warrants."

The Guardian wrote that "How Not to Die makes a compelling case for plant-based eating, but its alarmist tone may put off the very readers who could benefit most."

Nutrition researcher Dr. David Katz offered qualified praise, calling the book "a valuable contribution to the public understanding of nutrition science" but cautioning that "the evidence supports a spectrum of healthy dietary patterns, not just one."

Critics from the low-carb/keto community have argued that Greger overstates the dangers of animal products and understates the potential benefits of carbohydrate restriction for certain populations, particularly those with diabetes or metabolic syndrome.

7. Similar Books

The China Study by T. Colin Campbell (2005) provides the epidemiological foundation for plant-based eating. Campbell's book is more research-focused and less practical; Greger provides the actionable framework.

Forks Over Knives by Gene Stone (2011) is the companion book to the documentary, covering similar ground with less scientific depth. Greger provides the references that Forks Over Knives lacks.

Prevent and Reverse Heart Disease by Caldwell Esselstyn (2007) is more focused and prescriptive, providing a specific protocol for reversing heart disease. Greger's book is broader.

The Starch Solution by John McDougall (2012) advocates a similar diet with more focus on starches and less on vegetables. Greger's Daily Dozen includes more vegetable servings.

8. Long-term Relevance

How Not to Die is likely to age well as a comprehensive reference for evidence-based plant-based nutrition. The core recommendations (eat more whole plant foods, fewer animal products and processed foods) are supported by a broad consensus in nutritional science that is unlikely to change. The specific claims about disease reversal may be refined by future research, and the absolute tone may moderate as the field advances. The book's legacy is likely to be the Daily Dozen framework, which has become a standard reference in plant-based nutrition.