Thursday, May 26, 2011

Forks Over Scalpels

[Correction: As I learned from a comment on today's post, from the creator and executive producer of "Forks Over Knives," there was no product placement in the movie by the Whole Foods Markets grocery store chain. My comments in the third-to-last paragraph below -- especially my use of the harsh term "sell out" -- were thus based on an incorrect assumption on my part. My apologies.]

-- Posted by Neil H. Buchanan

A new documentary film, "Forks Over Knives," discusses the connection between public health and the consumption of animal products. It is a brisk, lively movie experience, full of fascinating information, combining a clear-eyed description of depressing reality with an equally honest assessment of how much good people could do themselves by removing animal products from their diet. The film's title is a play on words, with the "knives" referring to surgeons' scalpels, which would be used much less often if people would pick up a fork and eat a healthy meal.

As I wrote in a Dorf on Law post last December, the case for veganism is over-determined, with four independent, individually sufficient reasons to become a vegan. It is possible to care only about the environment, or the economy, or animal rights, or human health, and conclude that our current practice of exploiting animals is a disaster. "Forks Over Knives" makes the case from the latter perspective.

The film is devoted mostly to describing the work of Drs. T. Colin Campbell and Caldwell Esselstyn, a nutritional researcher at Cornell and a surgeon at the Cleveland Clinic, respectively. Working independently, each of these men discovered through their research (starting in the 1970's) that people who eat animal products suffer much worse health outcomes than those who do not.

Their research cannot, of course, be described fully in a feature-length documentary, but the audience is given some very convincing results of their careful (and peer-reviewed) research. Among the more memorable statistics: in one year in Japan, there were 18 deaths from a particular kind of cancer, while in the US there were about 18,000. Even adjusting for population size, this is a 500-1 ratio, with the US on the losing end. Campbell and Esselstyn have spent decades demonstrating that such dramatic differences in health outcomes are the result of dietary differences, with consumption of animal products leading to much, more worse health outcomes (cancer, diabetes, heart disease, and so on).

These differences appear both at the individual and the societal level. For individuals, Dr. Esselstyn points out that the "radical" idea of changing what one eats is hardly as radical as splitting open a person's chest and inserting a blood vessel from that person's leg into his heart. Yet people opt for surgery (at great expense, and exposing themselves to risks of death during surgery and from hospital-based infections) rather than consider not eating animals. Esselstyn's patients who opt against surgery are able not only to arrest, but in many cases reverse, their surgery-eligible conditions by simply eating plant-based foods.

At the societal level, the Japan/US difference noted above is merely one small example (if 18,000 deaths per year can be considered small) of health differences among countries that are correlated with dietary differences. Most notably, Dr. Campbell's work has shown that the non-animal diet that has been common in China for millennia is associated with much better health outcomes than in countries that consume animals and their secretions. These "much better health outcomes" are not mere percentage reductions in various types of diseases, but their literal absence among the population. Moreover, while the movie cannot be expected to show how the research has controlled for other explanations (much less grapple with the causation/correlation problem), it does note that all of these "Western diseases" are showing up in the areas of China that are becoming more Western in their eating habits. Within a generation, a population that virtually never experienced obesity, heart disease, and all of the scourges of the Western world has become "just like us."

The movie thus makes a compelling case for action at both the individual and policy-making level to change what we eat, literally to save our lives. As a person who chose to become a vegan entirely for ethical reasons, this was good (but unnecessary) news. For the remainder of this post (and perhaps in one or more future posts), I will offer a few reactions to the movie that go beyond how the film presented Campbell's and Esselstyn's research.

-- Unsurprisingly, Campbell and Esselstyn report that they are often ridiculed by their colleagues for being anti-meat. Esslestyn reports that his colleagues took to mocking him as "Dr. Sprout." The general hostility of the American medical and scientific establishment to veganism is really quite shocking. For example, I recently saw a cardiologist about a potential problem (described in a DoL post in March). The prognosis was good. During our first meeting, however, as I was going through my medical history, I said, "Oh, and I'm a vegan." Did the cardiologist respond by noting the positive health effects of my refusal to eat animal products? Of course not. Instead, he immediately became grim and said, "Well, that's going to be a problem." When I asked why, he said that it is hard for vegans to lose weight because they eat too many starchy foods! I assured him that I am capable of losing weight on a vegan diet (which I am, in fact, currently doing), but he was unmoved. I changed the subject.

-- Indeed, one of the strengths of "Forks Over Knives" is its depiction of just how ill-informed the American public health community is about dietary issues. The filmmaker does a great job of debunking the widely-held myths about diet, such as the idea that we need meat for protein (wrong, because humans can easily get enough protein from plant-based food) and milk for calcium (ditto). Even so, the public believes these things, encouraged by supposed experts. The film includes two clips from an interview with the nutritionist at Washington University, who parrots the discredited nonsense about protein and calcium as if she were a character from the movie "Pleasantville."

-- One of my pet peeves about modern movies is product placement. I thus found "Forks Over Knives" a bit difficult to watch, because it was so obviously promoting the grocery-store chain Whole Foods. Characters are shown walking through Whole Foods, carrying Whole Foods bags, and so on. Nearly everyone uses the term "whole food, plant-based diet" to describe a vegan diet. At one point, Dr. Campbell said "plant-based diet," but immediately corrected himself, saying, "I mean, whole food, plant-based diet." In the same cineplex the previous week, I had seen Morgan Spurlock's new film, "Pom Wonderful Presents The Greatest Movie Ever Sold," which presents a subversive take on product placement. Given that Whole Foods makes its money by selling all manner of animal products, moreover, it was more than merely annoying to see the makers of "Forks Over Knives" sell out in this way.

-- Only one person in the entire film uses the word "vegan." That person happens to be an extreme fighting champion, who is deeply committed to veganism. Given the syllable-laden alternative favored by everyone else in the film, the filmmakers must have made a conscious decision to avoid the word vegan. Given the outright contempt for veganism even among some of the more enlightened elements of American society, this might well have been a sensible choice. Allowing a macho man -- a guy who beats people up for a living -- to use the V-word must, therefore, have seemed strategically sensible. I cannot help but think, however, that vegans do themselves little good by refusing to use the simple word that describes us. After all, Michael Dukakis's refusal to admit that he was a liberal (in response to George H. W. Bush's sneering reference to "the L-word") hardly made it easier to be a "progressive."

Notwithstanding these concerns, this is an important film. It presents facts that should be the basis for changing society. I hope that the world will change because of it.


Doug said...

The post you link to doesn't make the case for veganism on an economic basis - farm subsidies could be repealed with people still eating meat (if that is the argument).

Health-wise I believe the argument is there but so is it against smoking and we have a taste for meat. Not as convinced about milk as I have not seen any studies (or summaries thereof) though to be fair I have not really looked.

Ethically, there is a good case. Though not all animal products/byproducts are unethically obtained (wild game or breastfeeding infants being examples). As well, the arguments against humans eating meat could also be applied to non-human animals we keep as pets that can only eat meat and even wild animals (under a defense of others argument) though these are mostly intellectual objections (though to an intellectual argument).

Environmentally, again there is a good argument against farming of animals (though not against eating them - a slight distinction).

I am I guess one of the few that is pretty much intellectually convinced that I should cut down or stop eating meat but find it difficult to do for reasons of taste and availability of alternatives. What policies (if any) do you think could and/or should be put into place to make the transition to veganism easier for those who want to go there (or even just move in that direction)?

Brian W said...


I'm the creator and executive producer of Forks Over Knives and I thank you for this complimentary piece.

I would like to correct several errors you have made, that have been made by others as well. The production of Forks Over Knives had no corporate or organizational sponsor--including Whole Foods.

Individual Whole Foods stores sponsored advance screenings and mini-premieres only--and this was the extend of our partnership with the company. Our filming in Whole Foods stores was coincidental. WF is a large grocery chain that carries a lot of produce, and two local stores granted us permission with no hassle.

The fact that the term "whole food" plant-based diet is used has nothing do with the store. We use this because we are distinguishing it from a vegan or plant-based diet. There are a lot of vegan/plant-based "junk" foods, fragmented plant foods if you will like refined sugars and bleached flour that are not the basis of the diet that our experts are referring to.

When Colin Campbell "corrects" himself as you state and says "whole food" plant-based diet, he is on the Larry King show. This is a term he has been using for years, as evidenced in his writings. Further, at the time of the Larry King show, we had no formal relationship with Whole Foods, since the advance screenings weren't even contemplated at that time.

Finally, the term vegan is not used in Forks Over Knives because the film is about the science of health. Vegan diet means "never" consuming animal-based foods. The science doesn't suggest that there is a difference between consuming no animal products and a very small amount. So therefore we say plant-based diet. Having said this, on a personal level, I eat no animal products and recommend others consider the same, since there are valid reasons beyond health to adopt a 100% lifestyle.

Thank you again for writing this blog.

Brian Wendel

Neil H. Buchanan said...

I hope to respond to the question at the end of Doug's comment in a future post.

Naturally, I am delighted that Brian Wendel (the creator and executive producer of "Forks Over Knives") read (and mostly liked) my post. I am pleasantly surprised to learn that there was no product placement by Whole Foods Markets in the movie. Perhaps I'm hyper-sensitive about the issue of product placement. After I post this comment, I will add language to the beginning of the post, acknowledging my error. I will also note the clarification in my post tomorrow (in which I'll discuss another issue raised by the film).

I also appreciate the clarification about the use of the word vegan. I continue to think that the term vegan is the most useful that we have, and the distinction that Mr. Wendel draws does not necessitate an entirely different term of art. This difference of opinion is, however, a minor aside. The larger point is that the film is excellent and important.

Doug said...

I look forward to reading the future post.

LucienNicholson said...

Ethically, I don't think the case for veganism can be made. Veganism depends on large scale monocultures that necessitate wiping out large swaths of ecosystems. It isn't a jump in logic to suggest that plowing fields will result in killing more than one critter that has made its home there, much less irreparably changing the prairies and forests that were there previously.

Sure, factory-farmed meat is bad, but ethically raised, pastured meat is arguably better for natural habitats, and more humane.

The health benefits of veganism are also dubious. Humans are omnivores, and never ate grains until the advent of agriculture. Grains are not normally widely available most times of the year without agriculture, and are literally indigestible without processing by means of milling and cooking.

While I do believe that factory-farming should be stopped, I don't think veganism is superior from either a health perspective or an ethical perspective, unless you simply believe killing animals is wrong. Dr. Campbell based a good deal of his conclusions based on studies of mice that were fed casein from cow milk. To suggest from that and uncontrolled epidemiological data that humans shouldn't eat meat is a bit of a stretch in logic, and plain, bad science.

Michael C. Dorf said...

Here's a brief reply to Lucien Nicholson:

I can't speak for all vegans, but I start with the ethical principle that it is wrong to harm or kill sentient beings without good reason. If we as humans needed meat, dairy (which involves harm to mother cows whose calves are taken from them and to the calves themselves, who are slaughtered) or eggs (which involves similar harm to hens and male chicks) to survive, then it would not be wrong to eat these foods. To say that we are naturally omnivorous doesn't address the ethical question because we can thrive without animal products. For what it's worth, I have seen work (by Dr. Milton Milss, among others) that suggests we are either natural herbivores or, insofar as we are natural omnivores, the amount of meat in the hunter-gatherer diet is very small compared with the plant foods.

The claim of Drs. Campbell, Esselstyn, and others (like McDougall and Barnard) is that we can not only survive with little or no animal foods but that we do better that way. Campbell's conclusions are based on numerous, overlapping studies, including epidemiological ones that do not easily lend themselves to other explanations. Long-term large-n natural experiments are not inherently inferior to short-term relatively small-n controlled experiments. In many ways, they are superior--and absent better hypotheses, they strongly support Campbell's conclusions. Esselstyn arrived at his parallel clinical findings separately. The medical case for eating little or no animal products didn't have to be there, but it seems quite strong.

As to your interesting observation about pasture-raised animal foods, I think it raises a serious issue but only if raised by someone who takes the matter seriously. The vast majority of animal products sold in the U.S. are from grain-fed animals. Because of the energy-loss in conversion from plant to animal food, that means that producing these animal foods harms not only the animals whose products are consumed but also about ten times as many of the little critters that get killed in combines and the like, relative to direct consumption of grains, fruits, and vegetables. Unless Americans are willing to pay a lot more for their animal products, that is not about to change, and many of the pasture-raised animals are "finished" with grain in amounts that offsets most if not all of the advantage you describe. In any event, in my experience, most people who raise this sort of concern are not in fact interested in avoiding harm to the field critters, but do so simply as a means of concluding that it's impossible to survive without harming other creatures, so that they can eat whatever they want with a clean conscience. I will not assume you fall into that category, but I worry that comments like yours license that sort of thinking.

Thanks for reading and commenting.

LucienNicholson said...

We can both agree that grain feeding livestock is on net a bad thing. I'm not saying that it is impossible to eat without harming animals--there are raw vegans, who eat mostly fruit.

I am saying that consuming pastured animals, which admittedly does cost a lot more, is a better comparison.

True. Most people eat feedlot meat, but grain agriculture depends on fossil fuels for fertilizer and monocultures that deplete soil. I don't know how feasible, pastured animal husbandry is for most people, but ethically, I think it is at least on-par with veganism, given the necessary destruction of ecosystems and fossil fuels for fertilizers, transport, planting and harvesting. Joel Salatin suggests that grass-fed beef actually maintains grass lands and sequesters net amounts of carbon.

I'm looking forward now to seeing Forks Over Knives, though. Thanks for the post. Its all good food for thought.

Doug said...

@LucienNicholson - I think the proper comparison environmentally is the most economically farmed plant-based diet and the most economically farmed non-plant based diet. The latter, from all I have read, is much less harmful to the planet.

We could go to pastured animals but that is very expensive (just as we could go to eating more wild nuts and berries harvested from the forest but that would be expensive). Going from grain for meat (via feed) to grain for bread will have a significant, positive environmental impact at an affordable cost (in fact lower cost).

LucienNicholson said...

@Doug: I would point you to Michael Pollan's Omnivore's Dilemma where he goes to visit Joel Salatin's farm. As Salatin--as far as I can tell--rightly points out, ruminants and grass co-evolved, so pasture raising cows allows optimal treatment of cows, and optimal treatment of pastures. Cows are healthier on grass, and grass is actually healthier with cows eating it. The net effect is healthy grass lands with less erosion, more soil repletion and net carbon sequestration. The same cannot be said for mono-cultures, which are barren most of the year, and very susceptible to erosion.

But, yes, I agree that cost-wise, it is probably impractical for many folks to eat pasture raised animals. And it is a really bad idea to feed grain to cows on multiple levels. But modern monocultures are still unsustainable given their reliance on fossil fuels and the soil depletion.

My family raises its own chickens and cows, and buy grass-fed meat from local farmers, but given that even the cheap cuts are about $10/pound, that is probably not practical for most. I do wonder, though, about all the farmland around me in rural Wisconsin that could be used for pasture instead of corn and soybeans and how much meat it could raise, instead of going into my gas tank as ethanol; that's a totally separate issue, though.

Like I said above, I was not convinced by the China study, given that it was uncontrolled, and based in part on animal models. Feeding a single protein from bovine milk to mice is not a valid basis to condemn a total macro-nutrient and totally ignores evolutionary biology. Even with overlapping, long-term, large-n studies, correlation is not causation.

I'll look into Esselstyn and Dr. Milton Milss. I've been in the Loren Cordain camp, so I'd like to see a different opinion regarding plant food intake in ancestral populations.

Thanks for the comment and for the further reading material.

Michael C. Dorf said...

"Milss" was a typo. It's Mills. I've heard him give presentations on the topic of whether humans are natural omnivores/carnivores but he hasn't written the book yet. An excerpt of one of his presentations for a general audience is at

The full version is several hours long.

LucienNicholson said...

Thanks. I found a short article by him on I'll check out the video.

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