To my doctor Steven Flier, and our mutual explorations of health and well-being

Acknowledgments

I would like to express my gratitude to many people, among them:

·My wife, Sonya, for having lovingly explored a new way of life with me, not to mention having participated in many enjoyable collaborations on the recipes in this book

·My son, Ethan, and my daughter, Amy, for their patience through hundreds of dinnertime conversations on nutrition and for putting up with some of the less-than-successful culinary experiments

·My mother, Hannah, and my sister, Enid, for, many pleasurable conversations on nutrition and life-style

·Alison Roberts for her wonderfully proficient and exhaustive research and irreplaceable assistance with many aspects of this project

·My medical advisory team-Steven Flier, Robert Bauer, and Peter Kurzweil-for generously contributing their time and expertise, discussing extensively relevant issues, and supplying highly detailed commentaries to review the medical and scientific accuracy of this work

·My editor, Erica Marcus, and the team at Crown: Kim Hertlein, June Bennett-Tantillo, Bill Peabody, Etya Pinker,and Ken Sansone

·Nancy Mulford for her expert assistance with the research, glossary, and food charts

·Warren Stewart for his culinary insights and enhancement of the recipes with flavorful spices and herbs

·Jill Jacobs for her valuable administrative support and ideas

·Don Gonson for his ideas, support, and encouragement

·Aaron Kleiner for hundreds of discussions on nutrition and health

·My readers-Loretta Barrett, Harry George, George Gilder, Don Gonson, Jill Jacobs, George King, M.D., Aaron Kleiner, Ethan Kurzweil, Hannah Kurzweil, Sonya Kurzweil, Erica Marcus, Nancy Mulford, Steve Rabinowitz, Mitch Rabkin, M.D., Alison Roberts, Martin Schneider, Enid Kurzweil Sterling, Warren Stewart, and Laura Viola-for their many valuable comments and criticisms

·And, finally, all of my friends and associates and the many engaging discussions we have had that have helped to shape my perspective on health and well-being versus the “civilized” diet

Author’s Note

Medical research has shown that the nutrition, exercise, and other life-style principles described in this book can help control weight and diseases, including heart disease, stroke, cancer, hypertension, and type II diabetes, and reduce the risk factors associated with these diseases.

However, neither the author nor the medical advisers for this book make any representation or warranty of any kind whatsoever regarding the effectiveness or appropriateness of this program, principles, or information for any individual.

· No person should engage in this or any other dietary, exercise, or health program without advice from his or her physician.

· In particular, persons who have or believe they may have a disease, including but not limited to heart disease, cardiovascular disease (such as stroke), hypertension, diabetes, or cancer, or who are taking medication for such conditions, should take particular care to be monitored by a doctor when undertaking this or any other nutritional, life-style, or health program.

Introduction

Shortly after World War II, the idea that cigarette usage may be damaging to one’s health was controversial. Yet when my father’s doctor suggested that there may be some benefit to cutting down on smoking, my father stopped immediately and never thought about it again. In 1961, he had his first heart attack. It was suggested that he cut down on salt to reduce the strain on his heart, so he simply cut out salt from his diet. In 1970, at the age of 58, he died of heart disease. I was 22, ten years older than my father was when his father died of the same cause.

I carried two feelings that stemmed from my father’s experience. One was the sense of a cloud in my future. The trend, indicated by the only two data points I had, suggested that I might only live to see my own son reach the age of 32. On the other hand, I also had a vague sense of confidence that somehow I would figure out a way to overcome this problem. That latter feeling was typical of my optimistic orientation, but it was nonetheless a strongly held conviction. As it turned out, I had some help along the way.

Thus began my interest in heart disease. I am not a doctor, although I do consider myself to be a scientist and consequently I began to approach this issue from the perspective of the available scientific literature. I tried to engage my doctor in a discussion of the issues, with only limited success. While he talked to me about it to some extent, he clearly had only limited interest in doing so, and, admittedly, I was unusually demanding. Finally, exasperated with my persistent questions, he said, “Look, I just don’t have time for this, I have patients who are dying that I have to attend to.” Not one to be easily put off by attempts to appeal to my sense of guilt, I couldn’t help but wonder whether any of these patients now dying might possibly have benefited from earlier explorations of ways to prevent disease. I decided to change doctors and find one who had an interest in preventive medicine. It also wouldn’t hurt if he had sometime on his hands.

As it turns out, I heard about a new doctor who was just setting up a practice. He had a reputation for a brilliant mind, an engaging curiosity in new medical frontiers, and, most important the willingness to struggle with issues of prevention with his patients. I became Steven Flier’s patient in 1982. It turned out to be a good decision. Just recently, Boston Magazine recognized him as one of the leading physicians in the city.

Most significant, he had the time and the patience to engage in my extensive interrogations on medical issues. One of his early discoveries was that I had a glucose intolerance, an early form of type II diabetes (a major risk factor for heart disease). This only intensified my interest in understanding what was known about heart disease and its prevention.

We decided I should lose about 25 to 40 pounds, so there followed a number of years of largely futile efforts in this direction. I tried numerous diets of various kinds (low-calorie, low-carbohydrate, and others) and while some worked temporarily, I kept gravitating back to the same weight. I began to despair that I didn’t have the willpower to take this vital first step.

In late 1987, on Dr. Flier’s advice, I decided to adopt the recommendations of the American Heart Association and reduce fat intake to 30 percent of calories and cholesterol intake to no more than 300 milligrams per day. This had a modest positive effect. My cholesterol went down from 234 to 193. According to the Framingham Study-a massive longitudinal (long-term) study of more than 5,000 Americans with a view toward understanding the factors underlying heart disease-one can obtain an estimate of one’s risk of heart disease by considering the ratio of total serum (blood) cholesterol to high-density lipoprotein (HDL) cholesterol, the so-called good cholesterol. The lower the ratio, the lower one’s risk. My ratio fell from 8.7 to 6.9, which, according to the Framingham Study, means that my risk fell from 175 percent of “normal” risk to 143 percent of “normal.”¹ That’s a shift in the right direction, but not entirely comforting when you consider that “normal” (i.e., average) risk for Americans is a 75 percent chance of a heart attack in one’s lifetime!²

In 1988, I ran across the writings of Nathan Pritikin I had heard of his approach before but had always dismissed it as too radical and too Spartan. Pritikin maintained that by adopting a diet that was very low in fat and cholesterol (specifically 10 percent of calories from fat and 100 milligrams of cholesterol per day), one can obtain dramatic reductions in the risk of heart disease and other diseases. With my heightened interest in preventing heart disease, I decided to take a closer look.

Nathan Pritikin’s own story is interesting.³ In 1957, at the age of 40, he was diagnosed as having coronary insufficiency caused by advanced atherosclerosis. He was prescribed a variety of drugs and told to restrict his mobility. Distressed with these recommendations, he decided instead to examine the scientific literature and discovered extensive evidence that atherosclerosis could be reversed in animals if they were given diets very low in fat and cholesterol. With this and other clues, Pritikin went on to pioneer an approach to treating heart disease using diet and exercise. Using himself as his first test subject, all of his symptoms of heart disease disappeared.

Paradoxically, Pritikin also made a profound mistake in 1957. His doctor had prescribed a series of X-ray treatments to destroy a fungus infection that was causing anal itching. Pritikin was very concerned that the X rays would hit parts of his body that would be damaged by this radiation, but his doctor assured him that it was a safe procedure. Today, we would recognize the procedure as irresponsible, but Pritikin reluctantly went along with the recommendation and underwent the treatment, which involved receiving 220 rads of unfiltered X rays. Two days later, a blood test revealed a seriously elevated white blood cell count, which was subsequently diagnosed as monoclonal macroglobulinemia, a blood disorder caused by excessive radiation and an early stage of leukemia. Twenty-eight years later, Nathan Pritikin died of leukemia. An autopsy revealed that he had the heart and arteries of a young man, completely clear of any signs of heart disease or atherosclerosis.⁴

I examined Pritikin’s evidence and became impressed with the extensive documentation establishing a link between nutrition and disease. Despite the medical profession’s early resistance to Pritikin’s advocacy of nutrition and other life-style modifications as a treatment for heart disease, there has been increasing interest in this approach in the medical community since Pritikin’s death. Some of the best evidence has been fairly recent, including the first concrete evidence of atherosclerotic reversal in humans brought about entirely by life-style modification.

I discussed what I had read with Dr. Flier and he thought that it made sense. I was still concerned about my ability to undergo such an apparently radical change in my eating habits, given my rather dismal efforts through more than five years of attempted weight loss. Nonetheless, in October of 1988, I decided to give it a try. Since I had found much more moderate changes to be difficult to sustain, I braced myself for a significant discipline. The results were rather surprising.

It turned out to be a lot easier than I had expected. In fact it felt rather natural. I discovered a new world of foods that were very tasty, diverse, and satisfying. I never felt deprived and, unlike my experiences with other “diets” I had been on, I never felt hungry. Gradually my tastes and orientation to food changed and my desire for the higher-fat foods I had been used to went away.

Within 3 months, I had lost 25 pounds. More surprising were the results of my cholesterol test. “I’m stunned” was Dr. Flier’s response, to which he added that he was going to start the diet himself the next day. My total serum cholesterol was now 110. My HDL had also gone up (primarily from increased exercise), so my ratio (of total cholesterol to HDL) was now 2.5. According to the Framingham Study statistics, my risk of heart disease was now only 5 percent of normal (down from an original 175 percent of normal). Altogether, that represented a 97 percent reduction in my risk. Extensive testing also indicated that my glucose intolerance had vanished as well. I went on to lose another 15 pounds to put me at my ideal weight. I felt that the cloud had disappeared.

A BRIEF MEDICAL HISTORYFurther extensive research of the literature during this period revealed a rich tapestry of scientific and medical evidence, including extensive animal studies and human intervention and population studies, that revealed nutrition and other life-style factors as much more significant influences on health than I had previously realized. The common wisdom was that “taking care of yourself” (i.e., moderating fat and cholesterol intake, exercise, etc.) was worth doing, but that your genetic heritage was a bigger factor. The respective influences of these two factors were often estimated at a ratio of 70 to 30 in favor of genetics over life-style. It became clear to me, however, that this was only true if one restricted oneself to the compromised nutritional recommendations that still comprise the official position of American health agencies.

Indeed, my own experience bore this out. By following the recommendations of the American Heart Association, I had reduced my heart risk by about 20 percent. But by going down further, to the level of fat and cholesterol characteristic of societies in which heart disease is virtually unheard of. I reduced my risk by 97 percent. Extensive human population studies show the same pattern. Those societies that eat 30 percent of calories from fat have heart disease rates about 30 percent lower than those that eat 40 percent of calories from fat. But societies that eat diets characterized by whole grains, vegetables, and fruits with, about 10 percent of calories come from fat, have heart disease rates that are at least 90 percent lower than the societies that eat about 40 percent calories from fat. The primary reason put forth by the medical community for putting out the highly compromised recommendation of 30 percent calories from fat is that people will resist bigger changes, that these are too difficult for an American palate wedded to a high-fat diet. Ironically, the more complete change is, I believe, easier to make and maintain. For a variety of reasons that I detail in the rest of the book, following the nutritional recommendations that I call the 10% solution eliminates food urges and is self-sustaining in ways that other, more limited, approaches are not.

There were a number of bonuses that I had not expected. The pattern that exists for heart disease exists also for the most common cancers. Cancer of the breast, ovaries, colon, prostate, and even of the lung are very rare in societies that eat very little fat. Also, if you follow a low-salt dietary plan, you can virtually eliminate hypertension and stroke. We can greatly ameliorate many other conditions, including osteoporosis and most forms of arthritis. Indeed, there are a wide range of these “diseases of affluence” that are caused by our “civilized” diet (in particular, the Western civilized diet). But perhaps of greater significance was the way I felt in terms of increased energy, improved ability to sleep and relax, and a deeper sense of well-being.

I then encountered two unexpected conflicts. If you see someone standing precariously on a ledge oblivious to the fact that they are in danger of a great fall, you feel a sense of obligation to inform them of their unrealized plight. If the person is someone you care about then the urgency is even greater. I did not have to look very far to find others that were desperately in need of this knowledge I had gained. Typical were adult male friends with elevated cholesterol, strong family histories of heart disease, and perhaps a few extra inches around the middle. Others included adult female friends with family histories of breast cancer. There were many variations of concern.

So invariably I got drawn into extended conversations on the topic of preserving health and well-being through nutrition and life-style These turned out to be longer conversations than I had expected. To make the case, I felt compelled to go through a lot of the evidence. Then there were more subtle issues. Why aren’t the American Heart Association recommendations good enough? This is mostly genetics anyway, isn’t it? What happened to moderation?

If I made it through these issues, there was always the big one of palatability. Sure, you’ll live a long time, but who wants to live that way? If you eat this way, maybe it just seems like a long time! That this could be an enjoyable, even liberating way to eat and live took a bit of explanation.

Then if someone was still interested, there was the core issue of the recommendations of the 10% solution. And scores of follow-up questions: How do I shop? Can I convert my recipes? Is walking better than jogging? What about restaurants? How about parties, functions, airplanes, traveling?

Things were getting out of hand. I had developed a reputation for having accumulated knowledge on this subject, so I was getting calls from many friends and colleagues. I needed a more efficient way to share this knowledge. None of the books available on the subject was quite right. Nathan Pritikin’s books, while having made a major contribution in their time, did not include enough of the scientific evidence to make an optimally persuasive case for the audience I had in mind. Besides, some of the best evidence had become available since his death. Other books, such as The Eight-Day Cholesterol Cure, put too much evidence on such over-the-counter drugs as niacin and did not represent an optimal diet. Many others stuck to the compromised 30-percent-calories-from-fat recommendation and were definitely not satisfactory.

I decided to write my own essay and put down my thoughts, accumulated research, evidence, and experience so that I could share this material in an effective way with what was apparently a growing audience. The essay also got out of hand and turned into a book. In this, I again had the guidance of Dr. Flier and several other devoted and insightful physicians.

The second conflict had to do with proselytizing. Being a scientist and a trained skeptic, I was always turned off by people with strong singular agendas. People out to save my soul or even just my health and well-being were strongly suspect. I felt very uncomfortable, therefore, in this role myself, telling other people how they should eat or live. Recognizing my own resistance to these types of messages, I also realized what I was up against in terms of getting people to take ideas such as these seriously.

After some lively internal debate, I finally decided that I had a responsibility to share my knowledge on this issue, but that I should strive for a certain loving detachment when it came to people choosing their own eating and living styles. This is not an easy balance to achieve. It is hard not to feel some pride if someone accepts my ideas and then shares with me their excitement at 30 lost pounds or 50 lost cholesterol points. If nothing else, such experiences demonstrate that I was successful in communicating my thoughts.

I have come to consider my responsibility to be that of effectively communicating a set of messages-empowering people to set their own priorities and to make their own compromises. That is what I object to in the public-health recommendations. They come precompromised, as if the American people were incapable of making their own decisions on these matters.

Having written a book on the subject makes this objective of objectivity easier for me to achieve. I can deliver someone a complete message, and people can consider it on their own terms and on their own time. Any follow-up is up to the reader.

Even this limited goal of effective communication is a challenging one. If you wanted to deliver a message to a king, it would probably not be fully effective to scribble down a note on a piece of paper and throw it onto the royal lawn. Any self-respecting king will have many layers of obstacles to prevent stray messages from penetrating the royal solitude. Similarly, we have all erected formidable barriers to messages. We have little choice. We could hardly survive if we allowed all of the thousands of messages that bombard us daily to get through. Penetrating the subtle, yet common, misconceptions, fears, and folklore that underlie public understanding of nutrition is particularly difficult. Eating is an activity to which people devote a large portion of their time and effort. Food and its images are deeply interwoven in our myths, our rituals, our fantasies, and our relationships. While most people profess ignorance of nutrition, virtually everyone nonetheless maintains strongly held views on the subject and its relationship to the rest of our lives. Getting people’s attention, let alone truly broadening someone’s perspective, is not an easy task. But that is the challenge of any writer.

I have now influenced hundreds of people to adopt this approach to health. Consistently, people report back to me that once they made a commitment to it they found that adopting it was “no big deal.” People will say that they anticipated having to employ significant discipline, that it would be a formidable undertaking, only to discover that it was surprisingly easy. Sure, they cut out butter, mayonnaise, and other fats, cut down significantly on meat and so on, but they also discovered that when they were done cutting things out, there was a great deal left that they enjoyed, and many substitutions that made the process much easier today than ever before. The physical and medical results that my friends, relatives, associates, and many others have achieved have been very gratifying for me. People have expressed gratitude for enormous improvements in cholesterol levels, weight, blood pressure, and their general sense of well-being. Many have thanked me for saving their lives.

As for myself, I have happily kept up the “diet” and the benefits. I really will have to find a better word here, because “diet” is associated with being onerous and temporary and my new eating habits are neither.

It is too bad that I cannot go back and share this knowledge with my father. Unlike many people, he accepted health and nutritional advice readily and easily. Six simple words-eat 10 percent calories from fat-could have saved his life. He could be alive today.

Foreword

A doctor’s activities center on diagnosis (finding and defining conditions or problems that exist), prognosis (what one can expect for the future), and treatment of those that are treatable. These were the steps I went through when I first met Ray Kurzweil many years ago. I am his doctor. I practice internal medicine in Boston, and I am an instructor at the Harvard Medical School.

Making the diagnosis was easy: a simple blood test, a routine examination. And the diagnosis was clear-high cholesterol and a glucose intolerance, an early stage of adult-onset (type II diabetes). A cholesterol level in the mid-200s, a triglyceride level of more than 600, and an abnormal glucose tolerance test were readily defined by routine laboratory tests. The prognosis was also easy. These were chronic conditions-not amenable to cure, only to management, the term doctors often use to describe the regular testing and follow-up of medical conditions. We manage diabetes with insulin or oral medications, we treat high cholesterol with diets and medications, but we never cure them. Ray would be a “patient” for life-always on some sort of therapy for these conditions. Of this I was sure.

I reviewed his family history: Ray’s father died of coronary artery disease at the age of 58. I went through the list of other risk factors, and Ray had a host of them, including excess weight, high levels of stress, and only occasional exercise. Thank goodness he wasn’t a smoker. When added to his high cholesterol and diabetes, these risk factors placed his likelihood of future coronary artery disease at a very high level. Even at high levels of risk, however, prognostication is imprecise. Would he have a myocardial infarction (heart attack), and if so, when? Anything less than 100 percent is not certainty. Most of us feel uncomfortable with uncertainty. It is especially difficult for doctor and patient. Our inability to predict who among those at risk will, in fact, develop specific diseases-which smoker gets lung cancer, for instance-is frustrating. It also enables some people to continue with unhealthy behaviors. People often believe that a serious disease won’t happen to them, and they take some comfort in the fact that they might be right. How silly to have wasted all that energy on diet, or exercise, or medications for that matter, when it might not be needed after all. For greater certainty about disease we turn to published studies. The medical literature contains case reports, reviews, and controlled clinical trials designed to help define the natural history of disease. Unfortunately, the complexities of individual cases (specifics of their history) often differ from published reports of combined data. It is hard to infer one specific individual’s risk from combined population studies. But despite these impressions, weighing all the known factors, it was clear that Ray had a higher than normal risk of future coronary artery disease, which would most likely strike him at an early age.

Next was the issue of treatment. There are uncertainties with medication, too. Risk benefit ratio is the term we apply to the quantification of these questions: How likely is a good therapeutic benefit compared to the likelihood of a side effect or a complication? With these questions (as with prognosis) we turn to published studies. As physicians and as scientists, we are taught that controlled studies, those where test conditions are carefully designed to eliminate the effects of chance, placebo, and bias, are the only ones to value. Testimonials and anecdotal reports are of limited interest, since their scientific validity is doubtful. It is impossible to infer cause and effect from what could be chance occurrences. Faith healers and charlatans throughout history have pointed to cases where they claim success. The trouble is that the ideal medical investigation-a randomized, controlled clinical trial-is costly; time consuming, and difficult to do, and often misses the exact circumstances of a particular patient problem. Nevertheless, decisions need to be made and treatments prescribed. With Rays conditions, two types of treatments were available: life-style changes in diet, exercise, and weight; and medications, such as insulin, oral antidiabetic medications, and cholesterol lowering medications. It was not necessarily an either-or decision. Both could be tried.

The sad truth is that most doctors are terrible at teaching people about changing their life-styles, mostly because it takes time and it is frustrating. A prescription can be written out in seconds, but teaching and explaining require time, often more than a busy doctor can spare. The frustration comes from repeated failure. Despite the best advice, people rarely change. Of every twenty smokers intensively counseled by their doctor on how to quit and why, nineteen of them will still be smokers a year later. From a doctor’s point of view, this is a major failure. It feels as though the benefit is not worth the effort. It is hard for doctors to acquire the skills needed to help their patients. Medical schools have no courses in behavior modification or patient education. Nutrition is a largely ignored subject. Therefore, most often, doctors relegate education and motivation for life-style change to others-dietitians, commercial weight-loss programs, smoke cessation programs, and psychotherapists, But even here, it is usually a piecemeal effort, without the full force and impact of a well-defined and clearly thought-out program. It is also hard to find the facts, since scientifically sound studies centered on life-style modification have been few and far between. Last, doctors have the same failings as their patients. They, too, can be seduced into the seemingly easy path of high-fat diets, high-stress lives, and inadequate exercise and the quick fixes of fad diets and fast acting medications.

I am grateful that these failings did not deter Raymond Kurzweil. He forced me, through the power of his intellect and his dogged enthusiasm for life and knowledge, to reach deeper than I had before. I, too, was overweight. I, too, had little time or inclination for exercise. My cholesterol, though not as high as Ray’s, was more than 200. I, too, had been doing nothing about it. Ray asked questions that I could not answer, and he proposed alternatives that I had not considered. Ray took the approach of an engineer and a scientist, the approach of a problem solver and a creator. He looked deep into the medical literature. He amassed scientific, medical, demographic, sociological, anthropological, and historical data and synthesized a coherent plan for changing his life. The scientific foundations were there, and to Ray the uncertainties were not sufficient to deter him from change. He did change. In doing so he proved to himself and to me the profound physical and emotional benefits of gaining control over one’s life. I saw his cholesterol plummet, his weight melt, and his glucose intolerance disappear. Though his case was not a randomized, controlled clinical trial, it proved to me what can be done by a motivated and intelligent person who values life and health. It proved to me that compromises based upon ease and convenience are not adequate, and that knowledge is power for patients and physicians.

I began to incorporate the changes of a low-fat near-vegetarian diet into my life. I began to exercise on a daily basis, and I saw my weight fall from 244 pounds to its current level of 185. I saw my cholesterol fall from 210 to 150. I experienced the thrill of self-discovery and self-control, the improvement in my sense of well-being and level of energy, and I found this in a context not of self-deprivation or restriction, but rather of expansion and self-awareness. I found that my changes were inspirational and motivational for my patients as well. Seeing me change my ways proved to them that they could change their ways and experience the same benefits.

I am happy to report that my prognostications for Ray were wrong. Despite my certainty that Ray would be a “patient” for life, he is not. He is no longer diabetic, he is no longer overweight, and he is no longer at risk for coronary artery disease. He has gone from being a patient whose illness is “managed” to being a person with mastery over his fate. He has also become a colleague and a teacher, instructing me in the value of curiosity, an open mind, and intellectual honesty. Ray and his family have already benefited from the synthesis of these issues you are about to read-so have I and so have scores of my patients. My hope is that the millions of Americans who need this information learn from it, too.

Steven R. Flier, M.D., Associate in Medicine, Boston’s Beth Israel Hospital; Clinical Instructor in Medicine, Harvard Medical School, Boston, Massachusetts