Wholefood Plant-Based Diet Reversed Angina without Medications or Procedures

Unfortunately, the standard medical practice for dealing with angina has been a dash to dish out the drugs1 . This may well relieve the symptoms, but it does not deal with the underlying causes. And what’s the main cause? You guessed it, diet. This blog deals with a case study 2  of a 60-year old male who, having been diagnosed with angina, refused both drug therapy and invasive testing in favour of making a dietary change to a WFPB diet. But did it work?

The study

The study subject reported a 12 month history of progressive severe mid-sternal chest discomfort after either walking only half a block, experiencing emotional stress or being out in cold weather. His family history included a mother who had coronary artery bypass surgery and a brother who had an acute myocardial infarction, both while they were in their early sixties.

With medical advice and counselling, he chose to adopt a wholefood plant-based diet (WFPB), which consisted primarily of the following:

  • vegetables
  • fruits
  • whole grains
  • potatoes
  • beans
  • legumes
  • nuts

Subject’s previous diet

He described his diet as having been a “healthy” diet of the following:

  • skinless chicken
  • fish
  • low-fat dairy
  • some vegetables, fruits, and nuts

Study results

Within just a few weeks of dietary change, his symptoms improved.

After four months, the following biometrics were recorded:

  • BMI fell from 26 kg/m2 to 22 kg/m2
  • blood pressure normalised
  • LDL (low-density lipoprotein) cholesterol decreased from 158 mg/dL to 69 mg/dL
  • ability to walk one mile without angina symptoms

Two years after starting the WFPB diet, he was able to jog more than 4 miles without incident and remained asymptomatic, off drug therapy for coronary artery disease, and has not required cardiac catheterisation 3 .

Study discussion

The study subject’s angina symptoms improved rapidly, as did his weight, blood pressure, and cholesterol levels. And this case study is supported by plenty of evidence that WFPB diets are strongly associated with:

  • improved plasma lipids 4
  • improved glycaemic control in patients with type 2 diabetes mellitus 5 6
  • weight reduction 7
  • blood pressure reduction 8 9 10
  • improved vascular function 11
  • profoundly improved coronary artery disease risk/symptoms 12 13 14 15
  • reduced overall mortality 16 17 18 19

The more the merrier

Studies 20  have shown a dose-response-like effect – that is, the greater the adherence to a healthy lifestyle (including a WFPB diet), the greater the apparent benefit.

When less is more

A growing body of evidence suggests that any and all animal-based foods may not be optimal for health 21 22 23 .

Coronary artery disease in plant-eating populations

This case reinforces research showing that great improvements in our “modern” Western NCDs (non-communicable diseases) can be achieved without the need for medications or medical procedures. Previous epidemiological studies24 have documented the near-absence of coronary artery disease in indigenous populations that eat largely or exclusively plant-based diets, including:

  • rural parts of China 25
  • a highland population of New Guinea 26
  • the Tarahumara Indians of Mexico 27
  • rural parts of South Africa 28
  • Norway during World War II 29

Study conclusion

A whole-food plant-based diet helped reverse angina without medical or invasive therapy. It appears prudent that this type of lifestyle be among the first recommendations for patients with atherosclerosis.

Final thoughts

Whilst some people might think it’s too difficult to live a “normal” life while eating a WFPB diet, it’s actually quite achievable within a real-world setting 30 and, with proper education and support, anyone can make the transition 31 .  Additionally, a WFPB diet is not associated with markedly increased food costs 32 ; and, in any case, what price can you put on a healthier and longer life?

Whilst the above research only covers one case study, its findings are completely in line with copious research data showing impressive results on the prevention and treatment of cardiovascular diseases through eating a WFPB diet, ideally – and optimally – without any added salt, oils or sugar. Take a look at some of the research links to find out more.

Finally, an excellent explanation of how simple dietary changes can effect such radical health improvements is presented in the following video, where Dr Caldwell B Esselstyn explains how you can make yourself “heart-attack proof”.

References & Notes

  1. Typical angina drugs: Clot-preventing drugs -clopidogrel (Plavix), prasugrel (Effient) ticagrelor (Brilinta); beta blockers – these work by blocking the effects of the hormone epinephrine, also known as adrenaline. As a result, the heart beats more slowly and with less force, thereby reducing blood pressure, they also help blood vessels relax and open up to improve blood flow, thus reducing or preventing angina; statins – these are drugs used to lower blood cholesterol, and work by blocking a substance the body needs to make cholesterol; calcium channel blockers – also called calcium antagonists, relax and widen blood vessels by affecting the muscle cells in the arterial walls. thereby increasing blood flow in the heart, reducing or preventing angina; blood pressure-lowering drugs – if you have high blood pressure, diabetes, signs of heart failure or chronic kidney disease, doctors tend to prescribe a drug to bring the blood pressure down. The two main classes of blood pressure drugs are angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs); finally, a drug called Ranolazine (Ranexa) may be used alone or with other angina medications, such as calcium channel blockers, beta blockers or nitroglycerin. []
  2. Case Rep Cardiol. 2015;2015:978906. doi: 10.1155/2015/978906. Epub 2015 Feb 10. A Whole-Food Plant-Based Diet Reversed Angina without Medications or Procedures. Massera D, Zaman T, Farren GE, Ostfeld RJ. []
  3. Cardiac catheterisation is the insertion of a catheter into a chamber or vessel of the heart. This is done both for diagnostic and interventional purposes. []
  4. Ferdowsian H. R., Barnard N. D. Effects of plant-based diets on plasma lipids. The American Journal of Cardiology. 2009;104(7):947–956. doi: 10.1016/j.amjcard.2009.05.032. []
  5. Barnard N. D., Cohen J., Jenkins D. J. A., et al. A low-fat vegan diet improves glycemic control and cardiovascular risk factors in a randomized clinical trial in individuals with type 2 diabetes. Diabetes Care. 2006;29(8):1777–1783. doi: 10.2337/dc06-0606. []
  6. Barnard N. D., Cohen J., Jenkins D. J. A., et al. A low-fat vegan diet and a conventional diabetes diet in the treatment of type 2 diabetes: a randomized, controlled, 74-wk clinical trial. The American Journal of Clinical Nutrition. 2009;89(5):1588S–1596S. doi: 10.3945/ajcn.2009.26736h []
  7. Mishra S., Xu J., Agarwal U., Gonzales J., Levin S., Barnard N. D. A multicenter randomized controlled trial of a plant-based nutrition program to reduce body weight and cardiovascular risk in the corporate setting: the GEICO study. European Journal of Clinical Nutrition. 2013;67(7):718–724. doi: 10.1038/ejcn.2013.92. []
  8. Jenkins D. J. A., Wong J. M. W., Kendall C. W. C., et al. The effect of a plant-based low-carbohydrate (‘Eco-Atkins’) diet on body weight and blood lipid concentrations in hyperlipidemic subjects. Archives of Internal Medicine. 2009;169(11):1046–1054. doi: 10.1001/archinternmed.2009.115. []
  9. McDougall J., Thomas L. E., McDougall C., et al. Effects of 7 days on an ad libitum low-fat vegan diet: the McDougall Program cohort. Nutrition Journal. 2014;13(1, article 99) doi: 10.1186/1475-2891-13-99. []
  10. Fraser G., Katuli S., Anousheh R., Knutsen S., Herring P., Fan J. Vegetarian diets and cardiovascular risk factors in black members of the adventist health study-2. Public Health Nutrition. 2015;18(3):537–545. doi: 10.1017/s1368980014000263. []
  11. Dod H. S., Bhardwaj R., Sajja V., et al. Effect of intensive lifestyle changes on endothelial function and on inflammatory markers of atherosclerosis. The American Journal of Cardiology. 2010;105(3):362–367. doi: 10.1016/j.amjcard.2009.09.038. []
  12. Ornish D., Brown S. E., Scherwitz L. W., et al. Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial. The Lancet. 1990;336(8708):129–133. doi: 10.1016/0140-6736(90)91656-u. []
  13. Esselstyn C. B., Jr., Ellis S. G., Medendorp S. V., Crowe T. D. A strategy to arrest and reverse coronary artery disease: a 5-year longitudinal study of a single physician’s practice. Journal of Family Practice. 1995;41(6):560–568. []
  14. Esselstyn C. B., Jr. Updating a 12-year experience with arrest and reversal therapy for coronary heart disease (an overdue requiem for palliative cardiology) The American Journal of Cardiology. 1999;84(3):339–341. doi: 10.1016/s0002-9149(99)00290-8. []
  15. Esselstyn C. B., Gendy G., Doyle J., Golubic M., Roizen M. F. A way to reverse CAD? The Journal of Family Practice. 2014;63(7):356–364. []
  16. Orlich M. J., Singh P. N., Sabaté J., et al. Vegetarian dietary patterns and mortality in adventist health study 2. JAMA Internal Medicine. 2013;173(13):1230–1238. doi: 10.1001/jamainternmed.2013.6473. []
  17. Bamia C., Trichopoulos D., Ferrari P., et al. Dietary patterns and survival of older Europeans: the EPIC-Elderly Study (European Prospective Investigation into Cancer and Nutrition) Public Health Nutrition. 2007;10(6):590–598. doi: 10.1017/s1368980007382487. []
  18. Wang X., Ouyang Y., Liu J., et al. Fruit and vegetable consumption and mortality from all causes, cardiovascular disease, and cancer: systematic review and dose-response meta-analysis of prospective cohort studies. The British Medical Journal. 2014;349 doi: 10.1136/bmj.g4490.g4490 []
  19. Bao Y., Han J., Hu F. B., et al. Association of nut consumption with total and cause-specific mortality. The New England Journal of Medicine. 2013;369(21):2001–2011. doi: 10.1056/nejmoa1307352. []
  20. Gupta S. K., Sawhney R. C., Rai L., et al. Regression of coronary atherosclerosis through healthy lifestyle in coronary artery disease patients—Mount Abu Open Heart Trial. Indian Heart Journal. 2011;63(5):461–469. []
  21. Michaelsson K., Wolk A., Langenskiold S., et al. Milk intake and risk of mortality and fractures in women and men: cohort studies. The British Medical Journal. 2014;349 doi: 10.1136/bmj.g6015.g6015 []
  22. Koeth R. A., Wang Z., Levison B. S., et al. Intestinal microbiota metabolism of L-carnitine, a nutrient in red meat, promotes atherosclerosis. Nature Medicine. 2013;19(5):576–585. doi: 10.1038/nm.3145. []
  23. Tang W. H. W., Wang Z., Levison B. S., et al. Intestinal microbial metabolism of phosphatidylcholine and cardiovascular risk. The New England Journal of Medicine. 2013;368(17):1575–1584. doi: 10.1056/nejmoa1109400. []
  24. Epidemiological studies look at the distribution and determinants of health and disease conditions in defined populations. Such research often forms the cornerstone of public health, and shapes policy decisions and evidence-based practice by identifying risk factors for disease and targets for preventive healthcare. []
  25. Campbell T. C., Parpia B., Chen J. Diet, lifestyle, and the etiology of coronary artery disease: the Cornell China study. The American Journal of Cardiology. 1998;82(10):18T–21T. []
  26. Sinnett P. F., Whyte H. M. Epidemiological studies in a total highland population, Tukisenta, New Guinea. Cardiovascular disease and relevant clinical, electrocardiographic, radiological and biochemical findings. Journal of Chronic Diseases. 1973;26(5):265–290. doi: 10.1016/0021-9681(73)90031-3. []
  27. Connor W. E., Cerqueira M. T., Connor R. W., Wallace R. B., Malinow M. R., Casdorph H. R. The plasma lipids, lipoproteins, and diet of the Tarahumara Indians of Mexico. The American Journal of Clinical Nutrition. 1978;31(7):1131–1142. []
  28. Trowell H., Painter N., Burkitt D. Aspects of the epidemiology of diverticular disease and ischemic heart disease. The American Journal of Digestive Diseases. 1974;19(9):864–873. doi: 10.1007/bf01071948. []
  29. Strom A., Jensen R. A. Mortality from circulatory diseases in Norway 1940–1945. The Lancet. 1951;1(6647):126–129. []
  30. Esselstyn C. B., Jr., Ellis S. G., Medendorp S. V., Crowe T. D. A strategy to arrest and reverse coronary artery disease: a 5-year longitudinal study of a single physician’s practice. Journal of Family Practice. 1995;41(6):560–568. []
  31. Peters N. C., Contento I. R., Kronenberg F., Coleton M. Adherence in a 1-year whole foods eating pattern intervention with healthy postmenopausal women. Public Health Nutrition. 2014;17(12):2806–2815. doi: 10.1017/s1368980014000044. []
  32. Hyder J. A., Thomson C. A., Natarajan L., et al. Adopting a plant-based diet minimally increased food costs in WHEL study. American Journal of Health Behavior. 2009;33(5):530–539. []

The Fat You Eat is the Fat You Wear

An April 2019 study 1 looked for dietary reasons that would account for the shockingly high rate of obesity and cardio-metabolic diseases within the US Hispanic and Latino population 2 .

The study

The Adventist Multi-ethnic Nutrition Study (AMEN) enrolled 74 Seventh-day Adventists from five Hispanic and Latino churches within a 20 mile radius of Loma Linda, CA into a cross-sectional study of diet and health. The information analysed was based on questionnaires, anthropometrics 3 and biomarkers 4 . By comparing US Hispanic and Latino omnivores with a similar plant-based population (namely, Hispanic and Latino vegetarian/vegan Seventh-day Adventists), the researchers hoped to find out whether better health generally found in the latter group could be attributed to their continued adherence to a plant-based diet. Particular attention was paid to differences in adiposity and adiposity-related biomarkers between the two groups.

Study findings

It appears that the reason US Hispanic and Latino populations experience such high rates of obesity and cardio-metabolic disease is largely down to their transition towards the SAD (Standard American Diet) and away from traditional Hispanic and Latino diets that emphasised whole plant foods, such as were still consumed by the vegetarian/vegan Seventh-day Adventists included in this study.

When compared with the general non-vegetarian Hispanic and Latino population, vegetarian/vegan dietary patterns within the Seventh-day Adventist Hispanic and Latino population were associated with:

  • significantly lower BMI (24.5 kg/m2 vs. 27.9 kg/m2, p = 0.006) 5
  • significantly lower waist circumference (34.8 cm vs. 37.5 cm, p = 0.01)
  • significantly lower fat mass (18.3 kg vs. 23.9 kg, p = 0.007)

Comparative results can be seen in the following table.

These findings are consistent with previous studies that have looked at other populations, including:

  • non-Hispanic white Adventists 6 7 8
  • black/African American Adventists 8 9 10
  • Asian Adventists 11

Traditional Latin American diets

There’s a rich cultural tradition of diverse regional plant foods within traditional Latin America cuisine:

  • the Mexican Tarahumara Indians traditionally ate a diet of beans, corn, and squash and very little meat – a pattern associated with lower risk of cardiometabolic disease 12 . The risks are significantly increased when the Tarahumara change to the typical US diet 13 .
  • Peruvian and Brazilian populations that follow traditional cultural choices which contain high amounts of plant foods have lower rates of hypertension, dyslipidemia, and obesity when compared to omnivores 14 .

The researchers consider that encouraging populations to re-introduce healthy plant foods, which have long-held and strong roots in their cultural heritage, is a potentially useful means of achieving high impact health interventions.

Study conclusions

Plant-based eating as practised by US-based Hispanic and Latino Seventh-day Adventists is associated with relatively healthy BMI15 . The study concludes that further research is needed to characterise the precise type of diet that should be recommended for use in obesity-related interventions among Hispanic and Latinos in the US.

Final thoughts

This study adds to the already considerable body of evidence suggesting that naturally-low-fat plant-based diets are the way to go if you want to remain healthy – particularly if you want to ensure that obesity and obesity-related diseases don’t reduce both the quality and length of your life. Of course, the more wholefood, non-processed the diet, the better. This would, I suspect, result in much improved biomarkers when compared, not only with the above omnivores, but also with the vegetarian/vegan group reviewed within this study – a group which included lacto-ovo vegetarians and pescotarians.

Additionally, I could not get a clear picture of whether and how this study drew distinctions between whole and processed plant foods, with the latter consistently failing to provide the health benefits of the former 16 .

From whatever perspective you may look, when it comes to obesity, there’s a weight of truth in the saying: “The fat you eat is the fat you wear.”

References & notes

  1. Plant-Based Diets Are Associated With Lower Adiposity Levels Among Hispanic/Latino Adults in the Adventist Multi-Ethnic Nutrition (AMEN) Study. Singh PN, Jaceldo-Siegl K, Shih W, Collado N, Le LT, Silguero K, Estevez D, Jordan M, Flores H, Hayes-Bautista DE, McCarthy WJ. Front Nutr. 2019 Apr 9;6:34. doi: 10.3389/fnut.2019.00034. eCollection 2019. PMID: 31024919. []
  2. Hispanic and Latino are often used interchangeably though they actually mean two different things. Hispanic refers to people who speak Spanish and/or are descended from Spanish-speaking populations, while Latino refers to people who are from or descended from people from Latin America. []
  3. Anthropometry refers to the measurement of the human individual. An early tool of physical anthropology, it has been used for identification, for the purposes of understanding human physical variation. []
  4. What are biomarkers? []
  5. The p-value is a number between 0 and 1 and os interpreted in the following way: A small p-value (typically ≤ 0.05) indicates strong evidence against the null hypothesis – that is, that there is no evidence to support a relationship, so you reject the null hypothesis and accept that there is a potentially causal relationship. Basically, the smaller the number, the more evidence there is for some form of relationship between the two or more elements under discussion. In this case, 0.006 indicates that there is a strong probability that a lower BMI is associated with a vegan/vegetarian diet. []
  6. Vang A, Singh PN, Lee JW, Haddad EH, Brinegar CH. Meats, processed meats, obesity, weight gain and occurrence of diabetes among adults: findings from Adventist Health Studies. Ann Nutr Metab. (2008) 52:96–104. doi: 10.1159/000121365 []
  7. Singh PN, Sabate J, Fraser GE. Does low meat consumption increase life expectancy in humans? Am J Clin Nutr. (2003) 78(Suppl. 3):526S−32S. doi: 10.1093/ajcn/78.3.526S []
  8. Tonstad S, Butler T, Yan R, Fraser GE. Type of vegetarian diet, body weight, and prevalence of type 2 diabetes. Diabetes Care. (2009) 32:791–6. doi: 10.2337/dc08-1886 [] []
  9. Singh PN, Clark RW, Herring P, Sabate J, Shavlik D, Fraser GE. Obesity and life expectancy among long-lived Black adults. J Gerontol A Biol Sci Med Sci. (2014) 69:63–72. doi: 10.1093/gerona/glt049 []
  10. Akbar JA, Jaceldo-Siegl K, Fraser G, Herring RP, Yancey A. The contribution of soul and Caribbean foods to nutrient intake in a sample of Blacks of US and Caribbean descent in the Adventist Health Study-2: a pilot study. Ethn Dis. (2007) 17:244–9. doi: 10.1093/aje/163.suppl_11.S31-c []
  11. Singh PN, Arthur KN, Orlich MJ, James W, Purty A, Job JS, et al. Global epidemiology of obesity, vegetarian dietary patterns, and noncommunicable disease in Asian Indians. Am J Clin Nutr. (2014) 100 (Suppl. 1):359S−64S. doi: 10.3945/ajcn.113.071571 []
  12. Connor WE, Cerqueira MT, Connor RW, Wallace RB, Malinow MR, Casdorph HR. The plasma lipids, lipoproteins, and diet of the Tarahumara indians of Mexico. Am J Clin Nutr. (1978) 31:1131–42. doi: 10.1093/ajcn/31.7.1131 []
  13. McMurry MP, Cerqueira MT, Connor SL, Connor WE. Changes in lipid and lipoprotein levels and body weight in Tarahumara Indians after consumption of an affluent diet. N Engl J Med. (1991) 325:1704–8. doi: 10.1056/NEJM199112123252405 []
  14. Navarro JA, Caramelli B. Vegetarians from latin america. Am J Cardiol. (2010) 105:902. doi: 10.1016/j.amjcard.2009.10.031 []
  15. The American Heart Association defines a healthy BMI as 18.5 kg/m² to 24.9 kg/m². []
  16. All Ultra-Processed Foods Linked to Increased Cancer Links []

Who Drinks & Smokes Most – Meat-Eaters or Plant-Eaters?

An April 2019 UK study 1 looked at the sort of food, drink and lifestyle choices made by meat-eaters and plant-eaters to see if differences in health outcomes of the two groups were partly the result of these choices.

The study

The researchers analysed data from FFQs (food frequency questionnaires) completed by 30,239 participants involved in the EPIC-Oxford study 2 . They assessed intakes of major protein-source foods and other food groups after dividing the participants into six groups of meat-eaters and non-meat-eaters:

  1. regular meat-eaters
  2. low meat-eaters
  3. poultry-eaters
  4. fish-eaters
  5. vegetarians
  6. vegans

The foods listed in the FFQs were categorised into 45 food groups and the results were analysed for variance in health outcomes between the 6 groups. Figures 1 (men) and 2 (women) give a rough idea of the results:

Study findings

There are large differences in dietary intakes between meat-eaters and non-meat-eaters:

non-meat-eaters consumed higher amounts of:

  • soy
  • legumes
  • pulses
  • nuts and seeds
  • whole grains
  • vegetables and fruits

non-meat-eaters consumed lower amounts of:

  • refined grains
  • refined carbohydrates
  • fried foods
  • alcohol
  • sugar-sweetened beverages (SSBs)
  • other foods high in free sugars (e.g. ice cream)

Contrary to expectations, vegetarians and vegans did not replace meat with higher intakes of animal-sourced protein alternatives (dairy and eggs) and non-animal protein alternatives (including legumes and nuts), respectively.

Vegetarians and vegans were found not to completely replace meat consumption with non-meat protein sources and high protein plant-sources but, rather, they increased their consumption of a large variety of plant-based foods and consumed lower amounts of high protein-sourced foods compared with meat-eaters.

The positive health benefits of lower protein intake (specifically, animal protein) have been discussed previously 3 4 5 6 .

The proportion of total energy from high protein-sourced foods:

  • regular meat-eaters – 33%
  • vegetarians – 25%
  • vegans – 20%

Compared with the 5 other groups, vegans consumed the highest amount of:

  • plant milk
  • nuts
  • brown rice
  • wholemeal pasta
  • couscous
  • wholemeal bread

Vegetarians consumed:

  • lower amount of dairy and eggs than meat-eaters
  • highest amount of cheese compared with other 5 groups

Egg consumption was low in all 6 groups, possibly because this study looked at a cohort that might be more ‘health conscious’ than the rest of the population. 7

Compared with regular meat-eaters, all the other groups:

  • were younger
  • had a higher education level
  • had a lower socio-economic status
  • were less likely to smoke and consume alcohol
  • had higher levels of physical activity
  • had lower BMI
  • had higher intakes of carbohydrates
  • had lower intakes of protein and fat

Table 1 shows more detail on the above:

Study conclusions

The findings suggest that non-meat-eaters might be consuming an overall “healthier” diet than meat-eaters.

In this large study of British men and women, we compared intakes of major protein-source foods and other food groups. …Our results show that meat-eaters and low and non-meat-eaters do not only differ in their meat consumption but in their overall dietary intake…The dietary intakes consumed by low and non-meat-eaters might explain the lower risk for some diseases in these diet groups and can be used as a real-life guide for future work assessing the health impacts of replacing meat intake with plant-based foods or dietary recommendations.

Final thoughts

On the whole, the results are what one would have expected. However, there were some surprises, particularly the findings that non-meat eaters tend to drink less booze, smoke less, and eat less processed and sweetened foods.

It’s often speculated, by those who are unfamiliar with plant-based diets, that life must be more boring when you stop eating animals – I mean, where’s the fun in eating grass?! However, if life were so dull when eating a supposedly buzz-free diet, wouldn’t you imagine that plant-eaters would eat a lot more comfort food 8 (sugary, fried, processed foods) and drink and/or smoke themselves silly whenever they could?

Some clarification is provided by research data showing that, not only does physical health generally improve on a plant-based diet, but mental health 9 10 11 and general outlook on life 12 also tends to improve – obviating the need to get caught in that “pleasure trap” 13 .

It was also interesting to note from this study, that the improved health outcomes for plant-eaters does not just derive from the fact that they eat more healthy foods – it’s also that they generally appear to eat less unhealthy food, exercise more, smoke and drink less. There was also variance by age, socio-economic and educational status between the groups – with the youngest group being vegan, highest socio-economic status being meat-eaters, and the most educated being fish-eaters. Food for thought…

Of course, this is not to say that there are no vegetarians and vegans eating horrendously unhealthy plant-based diets. This is something that’s been covered in previous blogs 14 15 16 . This can probably be seen by the surprisingly low amount of fruit and veg eaten by vegetarians and vegans, when compared with how much rice, pasta and bread they eat.

Since WFPB (especially when non-SOS) would guarantee a maximum amount of fruit and veg, with a minimum amount of the sort of junk foods that can find themselves included in a vegetarian or vegan diet, it would be interesting to see future studies which are able to include the WFPB diet within a list of food groups.


  1. Comparison of Major Protein-Source Foods and Other Food Groups in Meat-Eaters and Non-Meat-Eaters in the EPIC-Oxford Cohort. Papier K, Tong TY, Appleby PN, Bradbury KE, Fensom GK, Knuppel A, Perez-Cornago A, Schmidt JA, Travis RC, Key TJ. Nutrients. 2019 Apr 11;11(4). pii: E824. doi: 10.3390/nu11040824. []
  2. European Prospective Investigation into Cancer and Nutrition (EPIC)-Oxford study []
  3. The Problem with Protein []
  4. Eat Enough Food & You Eat Enough Protein []
  5. Animal Protein & Your Kidneys []
  6. Plant Protein, Fibre & Nuts Lower Cholesterol & Blood Pressure []
  7. Sobiecki, J.G.; Appleby, P.N.; Bradbury, K.E.; Key, T.J. High compliance with dietary recommendations in a cohort of meat eaters, fish eaters, vegetarians, and vegans: Results from the European Prospective Investigation into Cancer and Nutrition–Oxford study. Nutr. Res. 2016, 36, 464–477. []
  8. Ghrelin & Obesity – A Tentative Step Through the Minefield []
  9. Depression is Linked to Inflammation []
  10. Gut Microbiota & Depression []
  11. Depression & IBD / Crohn’s Disease / Ulcerative Colitis []
  12. What’s the Psychology of Plant-Eaters? []
  13. Bliss Points, Pleasure Traps & Wholefood Plant-Based Diets []
  14. Greggs’ Vegan Sausage Rolls – Why Veganism Can Fail []
  15. Vegan Pie Comes Top in British Pie Awards 2019 []
  16. Vegan Burgers – Healthy & Yum Yum? Forget it! []

Gout & Vegetarian Diets

A 2019 Taiwanese study 1  recently reported on the results of two large-scale cohort studies which were analysed in order to establish whether following a vegetarian diet reduces the risk of developing gout, when compared with following a non-vegetarian diet.

What is gout?

This subject has been covered extensively in a previous blog 2 so, in brief terms:

  • gout is the most common inflammatory joint disease and is an important risk factor for hypertension, diabetes, kidney diseases, cardiovascular diseases, and all-cause and cardiovascular mortality 3 4 5 6
  • gout pathogenesis begins with excess serum urate that forms monosodium urate crystals – a salt or ester of uric acid – in the joints, triggering gouty inflammation and resulting in excruciating pain 78
  • cases of gout have doubled or tripled in many countries in the past decades 9 10 making it a serious public health threat which desperately requires preventive strategies
  • Taiwan is particularly affected, with one of the highest incidences and prevalences of gout in the world 11

The study

Two cohort groups, representing almost 14,000 Taiwanese, were followed for between 7 and 9 years. They were divided into vegetarians (n=4684) and non-vegetarians (n=9251), and appropriate tests were undertaken to establish gout occurrence.

Study assumptions

  • the standard therapeutic diet aimed at preventing/managing gout restricts purine intake which is metabolised into urate and contributes to one-third of the body’s total urate pool 12
  • however, purine exclusion diets have only moderate urate-lowering effects and are generally regarded as an insufficient remedy 13
  • the researchers considered that the ideal diet for gout prevention/management should be able to simultaneously reduce uric acid and inflammation, while preventing gout-associated comorbidities
  • they conjectured that a vegetarian diet may be a promising dietary pattern to target multiple pathways in the gout pathogenesis, since:
    • vegetarians avoid purine-rich meat/seafood, while consuming increased amounts of vegetables, whole grains, seeds and nuts 14 15
    • plant foods contain polyphenols which potentially reduce uric acid via both an inhibition of xanthine oxidase16 activities and the enhancement of uric acid excretion 17
    • plant foods contain phytochemicals which potentially attenuate the NLRP3 18  inflammatory pathway 19 20
    • vegetarian diets have already been shown to reduce gout associated comorbidities, such as cardiovascular diseases 21 , diabetes 22 23 , and hypertension 24 25

Study results

In these two prospective cohort studies, a Taiwanese vegetarian diet is associated with lower risk of gout. This association persists after controlling for demographic, lifestyle, cardiometabolic risk factors, and baseline hyperuricemia. This finding does not differ across subgroups of sex, lifestyle factors, or comorbidities.

  • it’s most likely that vegetarians experienced a lower risk of gout simply because they had lower uric acid levels since their diets avoid purine-rich meat and seafood – a diet which in prospective studies has been shown to increase gout incidence and recurrence26 27 28 29
  • the results appear to go beyond the single effects of uric acid levels, since they were not consistently wide apart between all vegetarians and all non-vegetarians. The other potential factors influencing the reduction of gout in vegetarians may also be accounted for by the following:
    • vegetarian diets have higher alkalinity which has been shown to facilitate more effective uric acid excretion than an acidic diet – i.e. one that is fish/meat-based 30
    • vegetarian diets usually contain lower saturated fat, higher unsaturated fat and phytochemical-rich plant foods 14 15 31
    • the latter may prevent inflammatory responses which trigger gout attacks by dampening the inflammatory activation of NLRP3 inflammasome 32
    • fibre (high in plant-based diets) on its own, and when metabolised into short chain fatty acids by gut microbiota, has been shown to resolve inflammatory responses involved in gout attacks in mice 33  and in humans 34

Final thoughts

We saw in the previous gout blog 2 that there’s plenty of strong evidence to suggest that the best possible dietary option for gout-avoidance is a WFPB diet (with zero alcohol!). Of course, any diet which favours plant over animal foods will be of some benefit, and the more the latter is replaced with the former, the better in terms of gout-avoidance.

One interesting finding from this Taiwanese study relates to soy. Taiwanese vegetarian diets replace meat and seafood with soy products. But there appears to be a paradox here. Soy has a high purine content and has attracted an infamous reputation – even amongst health professionals – for causing gout 35 . However, contrary to this widely-held belief, the vegetarian diets with high soy content covered in this present Taiwanese study appear to lower gout risk.

And this is not the only study to show this. The researchers’ findings are consistent with the “Singapore Chinese Health Study” which found that soy was protective toward gout 27 .

A potential explanation for this rests in the fact that the potential of soy purines – mainly adenosine 36  and guanine 37 – to raise uric acid levels is considerably lower than those in meat and fish, which have a higher proportion of their purines in the form of hypoxanthine 38 39 40

A 2012 prospective study 41 of gout patients found that the impact of plant purine on gout attacks was significantly less than the purine from animal sources.

Finally, research suggests 42 that soy may have the ability to prevent gout through the inhibition of both the above-mentioned NLRP3 inflammatory pathway and the activity of the caspase-1 enzyme. The latter is an essential effector of inflammation, pyroptosis 43 , and septic shock 44 .

So, hurrah for the plants, boo hiss for meat and seafood, and don’t be shy about eating soy…

References & Notes

  1. Vegetarian diet and risk of gout in two separate prospective cohort studies. Chiu THT, Liu CH, Chang CC, Lin MN, Lin CL. Clin Nutr. 2019 Mar 27. pii: S0261-5614(19)30129-3. doi: 10.1016/j.clnu.2019.03.016. []
  2. Gout, Uric Acid, Urea, Purines & Plant-Based Diets [] []
  3. Bardin T, Richette P. Impact of comorbidities on gout and hyperuricaemia: an update on prevalence and treatment options. BMC Med 2017;15:123. []
  4. Kuo CF, See LC, Luo SF, Ko YS, Lin YS, Hwang JS, et al. Gout: an independent risk factor for all-cause and cardiovascular mortality. Rheumatology (Oxford) 2010;49:141e6. []
  5. Choi HK, Curhan G. Independent impact of gout on mortality and risk for coronary heart disease. Circulation 2007;116:894e900. []
  6. Teng GG, Ang LW, Saag KG, Yu MC, Yuan JM, Koh WP. Mortality due to coronary heart disease and kidney disease among middle-aged and elderly men and women with gout in the Singapore Chinese Health Study. Ann Rheum Dis 2012;71:924e8. []
  7. Desai J, Steiger S, Anders HJ. Molecular pathophysiology of gout. Trends Mol Med 2017;23:756e68. []
  8. So AK, Martinon F. Inflammation in gout: mechanisms and therapeutic targets. Nat Rev Rheumatol 2017;13:639e47. []
  9. Roddy E, Doherty M. Epidemiology of gout. Arthritis Res Ther 2010;12:223. []
  10. Kuo CF, Grainge MJ, Zhang W, Doherty M. Global epidemiology of gout: prevalence, incidence and risk factors. Nat Rev Rheumatol 2015;11:649e62. []
  11. Kuo CF, Grainge MJ, See LC, Yu KH, Luo SF, Zhang W, et al. Epidemiology and management of gout in Taiwan: a nationwide population study. Arthritis Res Ther 2015;17:13. []
  12. Fam AG. Gout: excess calories, purines, and alcohol intake and beyond. Response to a urate-lowering diet. J Rheumatol 2005;32:773e7. []
  13. Khanna D, Fitzgerald JD, Khanna PP, Bae S, Singh MK, Neogi T, et al. 2012 American College of Rheumatology guidelines for management of gout. Part 1: systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. Arthritis Care Res (Hoboken) 2012;64:1431e46. []
  14. Chiu TH, Huang HY, Chiu YF, Pan WH, Kao HY, Chiu JP, et al. Taiwanese vegetarians and omnivores: dietary composition, prevalence of diabetes and IFG. PLoS One 2014;9:e88547. [] []
  15. Orlich MJ, Jaceldo-Siegl K, Sabate J, Fan J, Singh PN, Fraser GE. Patterns of food consumption among vegetarians and non-vegetarians. Br J Nutr 2014;112:1644e53. [] []
  16. Xanthine oxidase is a type of enzyme that generates reactive oxygen species. These enzymes catalyse the oxidation of hypoxanthine to xanthine and can further catalyse the oxidation of xanthine to uric acid. []
  17. Mehmood A, Zhao L, Wang C, Nadeem M, Raza A, Ali N, et al. Management of hyperuricemia through dietary polyphenols as a natural medicament: a comprehensive review. Crit Rev Food Sci Nutr 2017:1e23. []
  18. J Inflamm Res. 2018 Sep 25;11:359-374. doi:10.2147/JIR.S141220. eCollection 2018. Spotlight on the NLRP3 inflammasome pathway. Groslambert M1,2,3,4,5, Py BF []
  19. Joseph SV, Edirisinghe I, Burton-Freeman BM. Fruit polyphenols: a review of anti-inflammatory effects in humans. Crit Rev Food Sci Nutr 2016;56:419e44. []
  20. Tozser J, Benko S. Natural compounds as regulators of NLRP3 inflammasomemediated IL-1beta production. Mediat Inflamm 2016;2016:5460302. []
  21. Crowe FL, Appleby PN, Travis RC, Key TJ. Risk of hospitalization or death from ischemic heart disease among British vegetarians and nonvegetarians: results from the EPIC-Oxford cohort study. Am J Clin Nutr 2013;97:597e603. []
  22. Chiu THT, Pan W-H, Lin M-N, Lin C-L. Vegetarian diet, change in dietary patterns, and diabetes risk: a prospective study. Nutr Diabetes 2018;8:12. []
  23. Tonstad S, Stewart K, Oda K, Batech M, Herring RP, Fraser GE. Vegetarian diets and incidence of diabetes in the adventist health study-2. Nutr Metab Cardiovasc Dis 2013;23:292e9. []
  24. Yokoyama Y, Nishimura K, Barnard ND, Takegami M, Watanabe M, Sekikawa A, et al. Vegetarian diets and blood pressure: a meta-analysis. JAMA Intern Med 2014;174:577e87. []
  25. Chuang SY, Chiu TH, Lee CY, Liu TT, Tsao CK, Hsiung CA, et al. Vegetarian diet reduces the risk of hypertension independent of abdominal obesity and inflammation: a prospective study. J Hypertens 2016;34:2164e71. []
  26. Choi HK, Atkinson K, Karlson EW, Willett W, Curhan G. Purine-rich foods, dairy and protein intake, and the risk of gout in men. N Engl J Med 2004;350: 1093e103. []
  27. Teng GG, Pan A, Yuan JM, Koh WP. Food sources of protein and risk of incident gout in the Singapore Chinese health study. Arthritis Rheum 2015;67:1933e42. [] []
  28. Williams PT. Effects of diet, physical activity and performance, and body weight on incident gout in ostensibly healthy, vigorously active men. Am J Clin Nutr 2008;87:1480e7. []
  29. Zhang Y, Chen C, Choi H, Chaisson C, Hunter D, Niu J, et al. Purine-rich foods intake and recurrent gout attacks. Ann Rheum Dis 2012;71:1448e53. []
  30. Kanbara A, Miura Y, Hyogo H, Chayama K, Seyama I. Effect of urine pH changed by dietary intervention on uric acid clearance mechanism of pHdependent excretion of urinary uric acid. Nutr J 2012;11:39. []
  31. Rizzo NS, Jaceldo-Siegl K, Sabate J, Fraser GE. Nutrient profiles of vegetarian and nonvegetarian dietary patterns. J Acad Nutr Diet 2013;113:1610e9. []
  32. Ralston JC, Lyons CL, Kennedy EB, Kirwan AM, Roche HM. Fatty acids and NLRP3 inflammasome-mediated inflammation in metabolic tissues. Annu Rev Nutr 2017;37:77e102. []
  33. Vieira AT, Galvao I, Macia LM, Sernaglia EM, Vinolo MA, Garcia CC, et al. Dietary fiber and the short-chain fatty acid acetate promote resolution of neutrophilic inflammation in a model of gout in mice. J Leukoc Biol 2017;101:275e84 []
  34. Lyu LC, Hsu CY, Yeh CY, Lee MS, Huang SH, Chen CL. A case-control study of the association of diet and obesity with gout in Taiwan. Am J Clin Nutr
    2003;78:690e701. []
  35. Messina M, Messina VL, Chan P. Soyfoods, hyperuricemia and gout: a review of the epidemiologic and clinical data. Asia Pac J Clin Nutr 2011;20:347e58. []
  36. Adenosine is a chemical that is present in all human cells. It readily combines with phosphate to form various chemical compounds including adenosine monophosphate (AMP) and adenosine triphosphate (ATP). []
  37. Guanine is one of the four main nucleobases found in the nucleic acids DNA and RNA, the others being adenine, cytosine, and thymine. []
  38. Hypoxanthine is a naturally occurring purine derivative. It is occasionally found as a constituent of nucleic acids, where it is present in the anticodon of tRNA in the form of its nucleoside inosine. []
  39. Kaneko K, Aoyagi Y, Fukuuchi T, Inazawa K, Yamaoka N. Total purine and purine base content of common foodstuffs for facilitating nutritional therapy for gout and hyperuricemia. Biol Pharm Bull 2014;37:709e21. []
  40. Clifford AJ, Riumallo JA, Young VR, Scrimshaw NS. Effect of oral purines on serum and urinary uric acid of normal, hyperuricemic and gouty humans. J Nutr 1976;106:428e50. []
  41. Zhang Y, Chen C, Choi H, Chaisson C, Hunter D, Niu J, et al. Purine-rich foods intake and recurrent gout attacks. Ann Rheum Dis 2012;71:1448e53. []
  42. Bitzer ZT, Wopperer AL, Chrisfield BJ, Tao L, Cooper TK, Vanamala J, et al. Soy protein concentrate mitigates markers of colonic inflammation and loss of gut barrier function in vitro and in vivo. J Nutr Biochem 2017;40:201e8. []
  43. (Pyroptosis is a highly inflammatory form of programmed cell death that occurs most frequently upon infection with intracellular pathogens and is likely to form part of the antimicrobial response. []
  44. Septic shock is a potentially fatal medical condition that occurs when sepsis, which is organ injury or damage in response to infection, leads to dangerously low blood pressure and abnormalities in cellular metabolism. []

Asthma and Plant-Based Diets

Asthma is a respiratory condition characterised by spasms in the bronchi of the lungs, resulting in breathing difficulties. It’s normally associated with allergic reactions or other forms of hypersensitivity. This blog will take a brief look at some evidence that suggests a central role for plant-based diets in the treatment of asthma and the prevention of asthmatic attacks.

Healthy body weight and asthma

  • two 2013 studies on asthma in children found that being overweight increases the risk of developing asthma by 35%, while being obese as a child increases the risk by 50% 1 and losing excess weight in children improves lung function2
  • this was further supported by a 2018 study: ““There are few preventable risk factors to reduce the incidence of asthma but our data show that reducing the onset of childhood obesity could significantly lower the public health burden of asthma.” 3

Fatty acid intake and asthma

Omega-6 fatty acids are mostly found in animal products. They are also found in margarines and other vegetable oils. The specific amounts of oil-based fats are shown in the chart below 4 . N.B. Consuming any form of oil or fat that’s been separated from its original food source is not to be advised, for reasons covered in previous blogs. 5 6 7 .

  • arachidonic acid (a long-chain omega-6 fatty acid) is found mainly in animal foods and has been shown to be a precursor of leukotrienes which have bronchoconstrictive effects 8 . Leukotrienes are a form of pro-inflammatory molecule released by mast cells during asthma attacks 9
  • omega-3 fatty acids, on the other hand, have been shown 10 to have anti-inflammatory effects
  • a higher ratio of omega-6 to omega-3 fatty acids in the diets of children has been shown 10 to have a significant association with an increased risk of asthma
  • omega-6 fatty acids have been shown 11 to hinder the incorporation of omega-3 fatty acids into tissue lipids and plasma
  • while some studies suggest 12 that fish-based omega-3 intake improves asthma symptoms in children, there are other studies 13 which contradict this and also suggest that such benefits in adults have not been proven
  • there are persuasive reasons for getting your omega-3 from walnuts, flaxseeds/chia seeds and/or plant-based omega-3 supplements rather than eating fish or using fish oil supplements 14 15

Saturated fat and asthma

  • evidence suggests 16 that when asthmatics eat diets containing high levels of total and saturated fat, there is an increase in the expression of those genes involved in airway inflammation
  • a 2010 study concluded 17 that high fat diets are able to inhibit the asthmatic’s response to the asthma medication Ventolin (albuterol)

Dairy products and asthma

  • a study 18 showed that pregnant women consuming low-fat yogurt once or more a day or low-fat milk 5.5 times or more a week had a 21% and 8% higher risk, respectively, for having a baby which would be diagnosed with asthma, as compared with women consuming no dairy
  • a 2015 study 19 found roughly 50% greater asthma prevalence in children who consumed butter 3 or more times a week, compared with those who either never consumed butter or only consumed it occasionally

Fast food and asthma

  • a 2013 study 20 found a ~40% increased risk of severe asthma developing in children and adolescents who consumed fast food 3 or more times a week, as compared with those who either never ate fast food or ate it only occasionally

Nuts, seeds and asthma

  • although tree nuts and peanuts can be allergenic to some people, a 2012 Danish study 21 found that nut intake during pregnancy was actually inversely related to an asthma diagnosis in their offspring at 18 months of age
  • a 2009 French study 22 looked at the risk that French women have of frequent asthma attacks (1 or more per week), and found that the risk was lower in women who consumed the highest amount of nuts and seeds (>5.3 g/day) when compared with those with the lowest consumption (≤ 1.0 g/day)

Salt and asthma

  • whilst there is evidence 23 that consuming a low-sodium (salt) diet appears to reduce bronchoconstriction in asthmatics in response to exercise, there is no strong evidence that a low-sodium diet (of itself) reduces the prevalence or severity of asthma 24
  • considering that salt is known 25  to be pro-inflammatory, it makes sense that it’s wise to avoid adding salt to your food and, of course, avoiding procesed foods which are known to be high in salt
  • a 2014 study concluded: “…our findings suggest that higher sodium consumption is associated with greater adiposity, leptin resistance, and inflammation independent of total energy intake and sugar-sweetened soft drink consumption.” 26

Fruits, vegetables and asthma

  • fruits, vegetables and other foods high in antioxidants have been shown 27 to produce ~45% lower risk for asthma in those children and adults who consume the most amount of fruits and vegetables, as compared with those who eat the least amount
  • a 2013 study 28 found that individuals who ate the lowest amount of fruit and vegetable (3 servings/day – typical of Western diets) had more than 50% increased risk of asthma exacerbation than those who ate 7 daily servings of fruits and vegetables
  • the European Academy of Allergy and Clinical Immunology (EAACI) recommended that clinical advice should be to increase the net intake of fruits and vegetables as a way of reducing the risk of asthma, particularly in children 29
  • a 2017 study concluded “higher intakes of fruits and vegetables may have a positive impact on asthma risk and asthma control.” 30 and provided an interesting schematic that compared the airway effects of the Western diet and a diet high in fruit and veg:

Vegetarian, vegan diets and asthma

  • a 1994 study 31 of almost 28,000 Seventh-day Adventists found that vegetarian women amongst the group reported a lower incidence of asthma, as compared to women who ate omnivore diets. “The theoretical basis for the value of vegan diets is the absence of potential triggers, particularly dairy products and eggs, as well as a relative lack of arachidonic acid.” 32
  • although the so-called Mediterranean diet is something of an anathema these days – with the spread of the modern Western diet across the continent – a 2014 review 33 found 7 out of 10 studies noted that there was a protective effect of a Mediterranean diet on the incidence of child asthma
  • a 1985 study used a vegan diet for 1 year as an alternative therapy to typical asthma drugs for a group of 35 asthma patients. They found a significant decrease in asthma symptoms as a result of this simple dietary intervention: “…71% reported improvement at 4 months and 92% at 1 yr. There was a significant improvement in a number of clinical variables; for example, vital capacity, forced expiratory volume at one sec and physical working capacity, as well as a significant change in various biochemical indices as haptoglobin, IgM, IgE, cholesterol, and triglycerides in blood. Selected patients, with a fear of side-effects of medication, who are interested in alternative health care, might get well and replace conventional medication with this regimen.” 34

Sugar-sweetened beverages and asthma

  • a 2009 US study 35 found an increased risk of developing asthma in those students who drank soda (fizzy drinks): 2 regular sodas a day meant a 28% increased risk, while 3 or more regular sodas a day meant a 64% increased risk. It was also pointed out that previous studies found asthma symptoms were worsened by regular soda consumption
  • a follow-up study 36 on non-obese adults found that those who consumed 2 or more sugar-sweetened beverages a day had ~65% increased risk of developing asthma, as compared to those who didn’t consume any such beverages
  • and it’s not just sodas that are the problem – a further 2016 US study 37 found that asthma risk in children between 2 and 9 years of age was significantly higher when they consumed apple juice or high fructose corn syrup-sweetened beverages 5 or more times a week, as compared to consuming only 1 or no such beverages per month

Alcohol and asthma

  • a 2012 study 38 found a U-shaped association between alcohol consumption and the development of new onset asthma in adults – that is, moderate weekly intake (1-6 units/week) showed a reduced risk, whilst those who never/rarely drank (<1 unit/month) and heavy drinkers (≥4 units/day) showed an increased risk. The risk of new-onset asthma was also shown to be lower for subjects with wine preference when compared with beer preference. However, the study authors admit that their findings were not statistically significant
  • contradictory information is provided by other authorities, including Asthma UK 39 , which claims that alcohol does exacerbate asthma symptoms, and a study in The Journal of Allergy and Clinical Immunology 40 , which states that wines are the greatest triggers for asthma attacks
  • whilst there’s obviously disagreement on this subject, and thus further research would be useful, previous blogs 41 42 have explained the reasons why any amount of alcohol intake has been shown to be potentially harmful

Vitamin D status and asthma

  • a 2014 meta-analysis 43 found that increased vitamin D deficiency was associated both with an increase in the incidence of asthma in general and with a decrease in lung function in asthmatic children in particular
  • whilst there is some disagreement on the benefits of vitamin D supplementation as a means of treating/preventing asthma in children 44 , an additional study 45 reported that those children who took vitamin D supplements reduced their risk of asthma by ~25%, as compared with children without supplemental vitamin D

Breastfeeding and asthma

  • a 2004 study 46 on the therapeutic measures for preventing the development of both allergic rhinitis and asthma, made the following suggestions for decreasing the the risk for developing asthma in babies during breastfeeding:
    • ensure that babies are breastfed for the first 4-6 months of life
    • avoid dairy products until at least 1 year old
    • avoid eggs until at least 2 years old
    • avoid nuts and fish until at least 3 years old

Inhalers and asthma

An interesting article appeared in The Telegraph today 47 entitled “Asthma inhalers as bad for the environment as 180-mile car journey, health chiefs say.” It points out the dangers to the environment of the hydrofluorocarbons (a powerful greenhouse gas) contained in the majority of the asthma inhalers (known as metered dose inhalers of MDI’s) used in the UK.

  • Nice (The National Institute for Health and Care Excellence) was reported to have calculated that “…five doses from an MDI have the same carbon emissions as a nine-mile trip in a typical car. The devices usually contain 100 doses. By contrast, dry powder inhalers are only around one fifth as bad for the environment.”
  • more than 5.4 million people in the UK receive treatment for asthma, including 1.1 million children
  • Britain has some of the highest rates in Europe, with around three people a day dying as a result of the condition

Whilst inhalers do, of course, save lives and users should only consider making changes in consultation with their doctor, they are known 48 to have side effects. Making dietary changes that help to prevent and treat asthma does seem to be a much better alternative, especially since the only side effects appear to be positive ones.

Final thoughts

The foregoing appears to suggest that there is, indeed, an important role for plant-based diets in the prevention and treatment of asthma. Such diets (so long as they are based on wholefood plants and avoid processed plant foods) are excellent for the maintenance of healthy weight and can provide the ideal fatty acid profile.

It’s clear that some particular foods are best avoided completely, including dairy products, fast food, sugar-sweetened beverages and, arguably, excessive amounts of salt – especially when contained in processed foods.

If you suffer from asthma, perhaps a useful way to check whether this dietary approach will alleviate your asthma is to stick with your current diet for a specific time, but keep a detailed daily record of asthma symptoms. After this, change to a non-SOS WFPB (no added sugar, salt or oil wholefood plant-based diet) for a similar specific period of time and maintain the daily diary. You would then be able to compare the frequency and intensity of symptoms between the two periods.

Should you decide to do this, and would like to share the results, please feel free to write to me with your findings and I will aim to publish them in a subsequent blog.

References & Notes

  1. Egan KB, Ettinger AS, Bracken MB: Childhood body mass index and subsequent physician-diagnosed asthma: a systematic review and meta-analysis of prospective cohort studies. BMC Pediatr 13:, 2013 []
  2. Moreira A et al: Weight loss interventions in asthma: EAACI evidence-based clinical practice guideline (part I). Allergy 68:425, 2013 []
  3. Obesity is linked to increased asthma risk in children, finds study BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k5001. 26 November 2018. []
  4. Comparison of Dietary Fats Chart []
  5. Surely Coconut Oil’s better than Butter?! []
  6. Olive Oil Injures Endothelial Cells []
  7. Coconut Oil is ‘Pure Poison’ says Harvard Professor []
  8. Pharmacotherapy. 1997 Jan-Feb;17(1 Pt 2):3S-12S. Arachidonic acid metabolites: mediators of inflammation in asthma. Wenzel SE []
  9. What are leukotrienes and how do they work in asthma? BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7202.90 BMJ 1999;319:90 []
  10. Wendell SG, Baffi C, Holguin F: Fatty acids, inflammation, and asthma. J Allergy Clin Immunol 133:1255, 2014 [] []
  11. Dias CB, Wood LG, Garg ML: Effects of dietary saturated and n-6 polyunsaturated fatty acids on the incorporation of long-chain n-3 polyunsaturated fatty acids into blood lipids. Eur J Clin Nutr 70:812, 2016 []
  12. Pediatr Allergy Immunol. 2018 Jun;294:350-360. doi: 10.1111/pai.12889. The role of fish intake on asthma in children: A meta-analysis of observational studies. Papamichael MM, Shrestha SK, Itsiopoulos C, Erbas B. []
  13. Brannan JD et al: The effect of omega-3 fatty acids on bronchial hyperresponsiveness, sputum eosinophilia, and mast cell mediators in asthma. Chest 147:397, 2015 []
  14. Omega 3 Supplements = Snake Oil []
  15. Nutritionfacts: Omega-3 Fatty Acids []
  16. Li Q et al: Changes in Expression of Genes Regulating Airway Inflammation Following a High-Fat Mixed Meal in Asthmatics. Nutrients 8:, 2016 []
  17. American Thoracic Society. “High-fat meals a no-no for asthma patients, researchers find.” ScienceDaily. ScienceDaily, 17 May 2010. []
  18. Maslova E et al: Low-fat yoghurt intake in pregnancy associated with increased child asthma and allergic rhinitis risk: a prospective cohort study. J Nutr Sci Jul 06 []
  19. Saadeh D et al: Prevalence and association of asthma and allergic sensitization with dietary factors in schoolchildren: data from the french six cities study. BMC Public Health 15:, 2015 []
  20. Ellwood P et al: Do fast foods cause asthma, rhinoconjunctivitis and eczema? Global findings from the International Study of Asthma and Allergies in Childhood (ISAAC) phase three. Thorax 68:351, 2013 []
  21. Maslova E et al: Peanut and tree nut consumption during pregnancy and allergic disease in children-should mothers decrease their intake? Longitudinal evidence from the Danish National Birth Cohort. J Allergy Clin Immunol 130:724, 2012 []
  22. Varraso R et al: Dietary patterns and asthma in the E3N study. Eur Respir J 33:33, 2009 []
  23. Mickleborough TD: Salt intake, asthma, and exercise-induced bronchoconstriction: a review. Phys Sportsmed 38:118, 2010 []
  24. Cochrane Database Syst Rev. 2004;(3):CD000436. Dietary salt reduction or exclusion for allergic asthma. Ardern KD. []
  25. Eur J Clin Nutr. 2012 Nov;66(11):1214-8. doi: 10.1038/ejcn.2012.110. Epub 2012 Aug 22. Dietary salt intake is related to inflammation and albuminuria in primary hypertensive patients. Yilmaz R, Akoglu H, Altun B, Yildirim T, Arici M, Erdem Y. []
  26. Pediatrics. 2014 Mar; 133(3): e635–e642. Dietary Sodium, Adiposity, and Inflammation in Healthy Adolescents. Haidong Zhu et al. []
  27. Seyedrezazadeh E et al: Fruit and vegetable intake and risk of wheezing and asthma: a systematic review and meta-analysis. Nutr Rev 72:411, 2014 []
  28. Grieger JA, Wood LG, Clifton VL: Improving asthma during pregnancy with dietary antioxidants: the current evidence. Nutrients 5:3212, 2013. []
  29. Asthma and dietary intake: an overview of systematic reviews. Garcia-Larsen V, Del Giacco SR, Moreira A, Bonini M, Charles D, Reeves T, Carlsen KH, Haahtela T, Bonini S, Fonseca J, Agache I, Papadopoulos NG, Delgado L. Allergy. 2016 Apr; 71(4):433-42. []
  30. Nutrients. 2017 Nov; 9(11): 1227. Published online 2017 Nov 8. doi: 10.3390/nu9111227. Diet and Asthma: Is It Time to Adapt Our Message? Laurent Guilleminault et al. []
  31. Knutsen SF: Lifestyle and the use of health services. Am J Clin Nutr 59:1171S, 1994. []
  32. PCRM: Nutrition Guide for Clinicians: Asthma. []
  33. Lv N, Xiao L, Ma J: Dietary pattern and asthma: a systematic review and meta-analysis. J Asthma Allergy 7:105, 2014 []
  34. J Asthma. 1985;22(1):45-55. Vegan regimen with reduced medication in the treatment of bronchial asthma. Lindahl O, Lindwall L, Spångberg A, Stenram A, Ockerman PA. []
  35. Park S et al: Regular-soda intake independent of weight status is associated with asthma among US high school students. J Acad Nutr Diet 113:106, 2013 []
  36. Park S et al: Association of sugar-sweetened beverage intake frequency and asthma among U.S. adults, 2013. Prev Med 91:58, 2016. []
  37. DeChristopher LR, Uribarri J, Tucker KL: Intakes of apple juice, fruit drinks and soda are associated with prevalent asthma in US children aged 2-9 years. Public Health Nutr 19:123, 2016 []
  38. Lieberoth S et al: Intake of alcohol and risk of adult-onset asthma. Respir Med 106:184, 2012 []
  39. Asthma UK: Asthma and alcohol []
  40. JACI: Alcoholic drinks: Important triggers for asthma. Hassan Vally, BSc (Hons), Nicholas de Klerk, PhD, Philip J. Thompson, FRACP []
  41. No Amount of Alcohol Consumption is Safe []
  42. Alcohol – Bad News for Good Bacteria []
  43. Zhang LL, Gong J, Liu CT: Vitamin D with asthma and COPD: not a false hope? A systematic review and meta-analysis. Genet Mol Res 13:7607, 2014 []
  44. Fares MM et al: Vitamin D supplementation in children with asthma: a systematic review and meta-analysis. BMC Res Notes 8:, 2015 []
  45. Xiao L et al: Vitamin D supplementation for the prevention of childhood acute respiratory infections: a systematic review of randomised controlled trials. Br J Nutr 114:1026, 2015 []
  46. Stanaland BE: Therapeutic measures for prevention of allergic rhinitis/asthma development. Allergy Asthma Proc 25:11, 2004 Jan-Feb []
  47. The Telegraph: Asthma inhalers as bad for the environment as 180-mile car journey, health chiefs say. []
  48. Medicinenet.com: What Are the Side Effects of Asthma Inhalers? Medical Editor: William C. Shiel Jr., MD, FACP, FACR []

Heart Surgery or Plant-Based Diet?

In previous blogs, I shared two documentary films produced by the H.O.P.E. project 1 : “What You Eat Matters” 2 and “From Cancer Patient to Plant-Based Strong Man” 3 . H.O.P.E. have just released another short documentary film about Paul Chatlin, a man with heart disease who was saved from surgery by changing to a plant-based diet.

Paul Chatlin’s Story

Paul Chatlin

In 2013, after being diagnosed with heart disease, Paul’s doctor gave him a simple choice – change his diet or undergo major heart surgery.

At the time, Paul was eating a typical Western diet, with cheese and meat being his favourite foods. Having loved pretty much anything fried in oil, he was given a “nutrition prescription” which required him to give up all these foods and cut out the oil – replacing his habitual diet with a low fat, whole food, plant-based diet.

Having spent his whole life eating one way, he found it a struggle to know what he could now eat and how he could prepare it without using oil. Luckily, he came across and attended a seminar on plant-based nutrition by the world-renowned physician and researcher Dr. Caldwell B. Esselstyn 4, a major player in the famous WFPB documentary film, “Forks Over Knives” 5 and author of his must-read book, “Prevent and Reverse Heart Disease: The Revolutionary, Scientifically Proven, Nutrition-Based Cure.” 6 .

As a result of the seminar, Paul was better equipped and motivated to strike out with his new diet and lifestyle. One month on, his heart pain went away completely. Within a year, his cholesterol levels had dropped from 309 to 122. He also lost over 40 lbs (18 kg).

Paul was so amazed with the health impacts of changing to a plant-based diet, that he started The Plant Based Nutrition Support Group (PBNSG) 7 to help others make the transition to the optimally health WFPB diet.

The film

In this second in the series of H.O.P.E. ‘Plant Power Stories’, Paul shares his journey back to health and encourages us all to give back to our communities.

Final thoughts

If you consider that plant-based eating is of value to the health and well-being of your friends and family, perhaps you could consider sharing this blog with them.

So many people are facing a lifetime on medications and/or having invasive surgery for conditions that could be avoided and treated with simple dietary changes. But, of course, they have to know that such an alternative exists in the first place!

Whilst anecdotal success stories such as Paul’s are likely to inspire hope, all nutritional claims made on this website are always backed up by peer-reviewed, scientific research.


  1. The H.O.P.E. Project. []
  2. I H.O.P.E. You Watch & Share This Film []
  3. The Healing Power of Plants []
  4. Dr Caldwell B Esselstyn’s website. []
  5. Forks Over Knives – The Film []
  6. Prevent and Reverse Heart Disease: The Revolutionary, Scientifically Proven, Nutrition-Based Cure []
  7. The Plant Based Nutrition Support Group []

Diverticulitis and Plant-Based Diets

Diverticulitis is a very unpleasant and potentially lethal condition which is increasingly afflicting populations eating the modern Western diet. This blog will look in some detail at its symptoms, causes and history, as well as potential ways in which you can avoid allowing this often hidden-until-too-late condition to creep up on you.


What are the symptoms of diverticulitis?

The really dangerous thing about this disease is that there can be no symptoms at all until you drop dead. Indeed, it’s reported 1 that nine out of ten people who die of diverticulitis did so without ever even knowing they had it!

Although it can be an asymptomatic disease, there are a range of symptoms that may appear 2 3 , including:

  • cramping
  • bloating
  • abdominal pain, normally on the left side (ranging from slight to excruciating)
  • fever
  • nausea
  • vomiting
  • chills
  • constipation
  • abscesses (the formation of puss)
  • fistula 4
  • intestinal perforation (the formation of a hole in the wall of the colon)
  • sepsis 5

What is diverticulitis?

The clue is in the word itself – the Latin word dīverticulum means turn aside or divert. This diversion is exactly what can happen to some of the food (called chyme) as it passes through the intestines (usually in the colon – also known as the bowel), the muscular walls of which are “diverted” outwards into the abdomen. Peristalsis is a process where the muscles of the intestinal walls contract and relax so that the chyme gradually gets pushed along to the anus and out of the body.

If weak spots are formed in the outer layer of the intestinal wall, the muscles can push outwards laterally, forming pouches or diverticula (diverticulosis). Although the plural is “diverticuli”, many authorities still use “diverticula” for singular and plural. These diverticula can then become inflamed, infected, and start bleeding (diverticulitis). The greatest danger is that infected diverticula will eventually burst, seeping intestinal contents into the bloodstream. This can lead to sudden death.

It’s obvious, then, that diverticulosis occurs first. This condition is usually completely unnoticed and most people never know they have it unless it’s found on a routine colonoscopy. Diverticulitis comes next, and it’s the reason people end up in hospital. It’s reported that 10-25% of individuals with diverticular disease end up developing symptoms such as abdominal pain, bloating, irregular bowel movements, bleeding, or signs of infection. 6 7

Doctors often use the analogy of an over-inflated inner tube poking out through the wall of a tyre. Similarly, increased internal pressure can force the gut to balloon out through weak spots in the intestinal wall. The results are pretty obvious and rather unpleasant:

If the pressure builds up so much and the diverticula rupture, intestinal contents can be pushed into the abdomen and end up in the blood stream. 8

The reason internal pressure can increase so much within the intestines (usually in the colon) is related to the type and quantity of food (chyme) that’s passing through. Continuing the inner tube for intestine analogy – imagine your fingers doing the peristalsis movement and squeezing along a lump of soft mashed potato inside the tube. Should be pretty easy. However, replace the mashed potato with thick gooey molasses and it would be much harder to squeeze it along, resulting in increased internal pressure. If, over a long period of time, your colon is having to squeeze small and compacted lumps, rather than gently contract and dilate around large and soft lumps, damage is pretty inevitable. 9

Most diverticula are not particularly large – around 1-2 centimetres in diameter – but, nevertheless, even at this size they can be big enough to cause symptoms and complications in some people. 10

Dietary fibre & diverticulitis

Just as in the previous blog on constipation 11 , it comes down to the amount of fibre in your diet – too little, and our faeces become small and firm. The same thing is happening within our intestines. If there’s not enough ‘bulk’, the intestines have to squeeze really hard to move the chyme along, and this pressure buildup can force out those bulges and eventually lead to the colon literally rupturing itself.

High-fibre diets make for larger and easier movements through the colon. Plant-based diets contribute a considerable range of intestinal health benefits: adding huge amounts of natural prebiotics and probiotics that permit the gut bacteria (the microbiome) to do their magic: providing anti-inflammatory, anti-cancer, anti-obesity and blood sugar control effects; reducing the risk of stroke, high cholesterol and heart disease; helping to prevent hiatal hernia, brain loss, kidney stones, COPD, Parkinson’s disease, and diabetes; aiding weight loss; improving immunity, and ultimately increasing healthy longevity 12 . That our bodies are able to produce sufficient nitric oxide (a powerful antioxidant) is another factor that is of vital importance to the maintenance of health; and, as previous blogs have considered 13 14 , the quality and quantity of plant foods within our diet dictates the type of microbiome inhabiting all parts of our bodies – from our mouths and intestines to our bladder.

I came across a nice Australian site which stated the following: “We evolved in tandem with our gut microbiome, the bacteria and other microbes that inhabit our gut. They are just as much a part of our digestive system as our own cells. They feed on dietary components that are not absorbed in the small intestine, such as dietary fibre and resistant starch. The microbiome pays its fare by providing us with energy and nutrients that would otherwise have been lost. The large bowel or colon is essentially a fermentation vat. This explains the gas.” 15  It’s always good to see that on the other side of the planet, these WFPB websites are quoting the likes of Drs McDougall, Greger, Popper and Klaper.

Low-fibre diets are not the only risk factor for diverticulitis. Additional contributing factors include smoking, being obese, and eating a diet which is high in red meat and animal fat. One study on meat intake and risk of diverticulitis in men, concluded: “Red meat intake, particularly unprocessed red meat, was associated with an increased risk of diverticulitis.” 16

This is backed up by a 2017 study:

During 894,468 person years of follow-up, we identified 1063 incident cases of diverticulitis….The association between dietary patterns and diverticulitis was predominantly attributable to intake of fiber and red meat.” 17

The modern Western diet contains high levels of animal-based and processed foods. Whilst it’s obvious that animal foods are completely devoid of fibre, some people need to be gently reminded that most processed foods are also very fibre-poor, with most fibre being stripped out during the manufacturing process. 18

Diverticulitis diagnosis

Medical advice should always be sought if you have any symptoms of diverticulitis. Most diagnoses are during an acute attack of abdominal pain.

Your doctor will normally want to give you a physical examination (checking abdominal tenderness) in order to establish the cause of the pain – and there can be a wide range of causes other than diverticulitis.

Women would also normally have a pelvic examination to rule out pelvic disease. After this, the following are possible diagnostic tests:

  • blood and urine tests (checking for signs of infection)
  • pregnancy test for women of childbearing age (ruling out pregnancy as a cause of abdominal pain)
  • liver enzyme test (ruling out liver-related causes of abdominal pain)
  • stool test (ruling out infection in patients with diarrhoea)
  • CT scan (identifying inflamed/infected pouches and to confirm a diagnosis of diverticulitis)

Diverticulitis treatment

The severity of symptoms will determined the treatment. There are two broad classifications used: uncomplicated diverticulitis (usually mild symptoms treated at home) and complicated diverticulitis (usually severe symptoms treated at hospital):

  • uncomplicated diverticulitis
    • antibiotics to fight any detected bacterial infection
    • a liquid diet for a few days until intestines heal naturally
    • when symptoms improve, gradually add solid food to the diet
    • over-the-counter pain relief
  • complicated diverticulitis
    • intravenous antibiotics
    • a tube inserted to drain away any abdominal abscess (if formed)
    • surgery – this would normally be needed if:
      • certain complications occurred, such as:
        • bowel abscess
        • fistula
        • obstruction
        • puncture (perforation) in the colon wall
      • you have a history of multiple episodes of uncomplicated diverticulitis (flare-ups – see below)
      • you have a weakened immune system

Acute flare-ups are not uncommon. It’s reported 19 that 20% of people with diverticula develop a bout of diverticulitis at some stage in their lives.  Best advice – eat lots of fibre and keep hydrated so that you can avoid them developing in the first place.

Two types of surgery for diverticulitis

The two main types of surgery involved with diverticulitis are:

  • primary bowel resection (removing diseased intestinal sections and reconnecting healthy sections)
  • bowel resection with colostomy (when inflammation has been too severe to connect the colon to the rectum, a colostomy will be the option. This involves making an opening in your abdominal wall and connecting it to the still-healthy part of the colon. Waste then passes through the opening into a bag. It’s possible in some cases that the inflammation will reduce and the colostomy can be reversed and the bowel reconnected)

A colonoscopy may be recommended at no less than six weeks after recovering from diverticulitis, particularly if no test was done in the previous year. This might be done in order to exclude any cancer. Some authorities consider 20  that there is no direct link between diverticular disease and colon or rectal cancer. Naturally, a colonoscopy cannot be risked during a diverticulitis attack.

When is eating fibre & a WFPB diet not recommended?

When there’s a flare-up of diverticular disease, especially when hospitalisation was required, it’s generally recommended that a low fibre/liquid-like diet is used as a short-term intervention. Primarily advised as a means of managing gut motility and acute pain, this period of so-called “bowel rest” usually involves abstaining from all solid foods for 2-3 days and consuming only a clear liquid diet, with water or other clear beverages usually being all that’s advised. Once the symptoms have disappeared (that is, when acute pain has subsided) and, of course, under the advice of their doctor, the patient would then be advised to transition to a high-fibre plant diet – ideally of the non-SOS WFPB type.

An absolute must in treating acute diverticulitis is a high-fibre diet if patients wish to prevent complications and recurrences of disease.” 18

Can diverticulitis be reversed by diet?

Once you’ve been diagnosed with diverticulitis, you are strongly recommended to always liaise with your doctor about any dietary changes. However, to avoid recurrence of symptoms, there is little doubt that reducing the pressure within your intestinal tract is key. This is best achieved through eating a diet high in fibre and ensuring you are always fully hydrated.

How much water and fibre is enough? This is a well-debated topic, and was covered in the previous blog 21 , but my research shows that a person eating a balanced WFPB diet is likely to consume up to 100 grams of fibre daily. This is definitely a healthy level. One UK study suggested 22 that for every 5 gram increase in fibre consumed each day, the result was a 15% reduction in disease risk. The same study found that some whole plant fibre sources were especially protective against the disease, namely whole grains and fruits.

However, if a person chooses not to eat an exclusively WFPB diet, it’s generally advised that over 30 grams of fibre is the lower recommended limit. Personally, I would always suggest that WFPB is the way to go. Best be safe than sorry with something that can kill you quickly without you even knowing you had it in the first place.

In terms of daily liquid (ideally water, or black/green tea) consumption, a minimum of around 7 cups (1.75 litres) of water for women and ll cups (2.75 litres) for men is recommended. Plant foods contain mostly water, and so this will add to liquid intake to make it up to the WHO recommendation of 11 cups (2.75 litres) for women and 15 cups (3.75 litres) for men. 23

It’s been shown 2 that even eating just a standard vegetarian diet (with a high intake of dietary fibre compared with the standard meat-based Western diet), is associated with lowering the risk of getting the disease in the first place, of being admitted to hospital, and of dying from the disease. How much more for a WFPB diet with its higher fibre content? Other studies have shown similar results, stating: “Consuming a vegetarian diet and a high intake of dietary fibre were both associated with a lower risk of admission to hospital or death from diverticular disease.” 24

Dr John McDougall considers that it’s certainly worth changing to a high-fibre diet in order to relieve symptoms and prevent further diverticuli: “Contrary to what was once popular opinion, the addition of fibers in the form of brans or high fiber foods has relieved symptoms in 90% of cases of severe colon disease, even with recurrent pain and bleeding. A high fiber diet will also decrease the likelihood of developing new diverticuli. The diverticuli already formed are permanent herniations of the colon, and will not disappear except by surgical removal, which is rarely indicated.” 25

In the following short video, Dr McDougall also reassures us that the bleeding and infection within diverticuli can, in most cases, disappear by making simple dietary changes. The diverticuli themselves remain, although he considers that they would no longer be a problem, so long as a high-fibre diet is maintained.

Diverticulitis rises as fruit & veg consumption drops

Major studies have shown 6 26 beyond any doubt that the risk of developing diverticular disease goes down as fruit and vegetable consumption goes up – and, of course, vise versa. These studies produced the following results:

  • increased diverticular disease is associated with consumption of:
    • beef
    • lamb
    • pork
    • processed meats
    • cookies
    • potato/corn crisps (chips in the US)
    • French fries (chips in the UK!), and
    • white bread
  • physical activity (running/jogging) reduces disease risk
  • decreased diverticular disease is associated with
    • increased fibre intake
  • the strongest correlation of disease reduction is associated with consumption of:
    • fruit, and
    • cereal fibre
  • consumption of all vegetable fibre also reduces disease risk

A further study 7 looked at the effects of using a high-fibre diet in the cases of 100 patients who had been previously diagnosed with acute diverticulitis. After 5-7 years on this diet, 91% of the patients remained completely symptom-free. The authors pointed out that the following respected organisations endorse and encourage the use of a high-fibre diet to prevent diverticular disease:

  • American College of Gastroenterology 27
  • European Association for Endoscopic Surgery 28
  • American Society of Colon and Rectal Surgeons 29
  • World Gastroenterology Organisation 30

Can you eat nuts and seeds if you have diverticulitis?

The usual medical advice around people who have had diverticulitis is that they should avoid eating nuts, seeds, corn, and popcorn. Indeed, some doctors advise that everyone should avoid these foods as a means of avoiding the disease. However, there are at least two recent studies that have blown this unfounded advice out of the water.

A 2009 study 10 stated: “Without any good evidence, certain foodstuffs such as nuts, seeds, popcorn, and corn have long been implicated in the development of diverticulitis and are often advised against by physicians. They were thought to provoke diverticulitis or diverticular bleeding by causing luminal trauma. In a large prospective study of men without known diverticular disease, Strate et al found 31 that nut, corn, and popcorn consumption did not increase the risk of diverticulosis, diverticulitis, or diverticular bleeding.”

A 2012 study 32 stated: “Residue refers to any indigestible food substance that remains in the intestinal tract and contributes to stool bulk. Historically, low-residue diets have been recommended for diverticulosis because of a concern that indigestible nuts, seeds, corn, and popcorn could enter, block, or irritate a diverticulum and result in diverticulitis and possibly increase the risk of perforation. To date, there is no evidence supporting such a practice. In contrast, dietary fiber supplementation has been advocated to prevent diverticula formation and recurrence of symptomatic diverticulosis, although this is based mostly on low-quality observational studies.

Whilst further research is useful, any advice to avoid nuts & seeds does not appear to be based on anything but unfounded conjecture. And, as shown in the 12-year long Seventh Day Adventist Study published in 2001, vegans who didn’t eat any nuts and seeds didn’t live as long as those vegans who did. This is because of the essential fats that nuts and seeds contain – allowing effective absorption of the phytochemicals and anti-oxidants that both groups are eating 33 34

How common is diverticulitis?

Diverticular disease [including diverticulitis] is the most common intestinal disorder.” 35

One study states: “In industrialized nations, diverticular disease affects up to 70% of individuals by 60 years of age, with symptoms that can range from mild gastrointestinal disturbance to incapacitating pain.” 36

Is diverticulitis age-related?

Whilst it’s been conventionally thought that it is an inevitable age-related condition – with the theory being that the intestinal walls tend to weaken as the years and decades pass – this theory can be shown to be untrue. Back in 1907, guess how many cases were recorded? 25! 36 That’s not 25% of the population, but 25 individual cases had been reported in the medical literature. And, as you can see from the graphic photograph above, any autopsy would have had little difficulty in missing diverticulitis if it had been present.

Development of diverticular disease is not an inevitable part of growing older. The colons of people living in underdeveloped countries show a virtual absence of diverticular disease. Healthy, low, pressures in the colon happen when the diet is high in starches, vegetables, and fruits, with their generous content of fiber.” 25

Even in 1916, a study 37 reported that diverticulitis was still not sufficiently documented as a morbid disease in medical literature for it to merit medical recognition.

Diverticulitis – a late 20th Century disease

But in a 1971 study, by the WFPB pioneer Denis Burkitt and his team 38 , it was already recognised as the most common intestinal disease in the US population.

How could this have happened so quickly?

Denis Burkitt showed incredible insight by pointing out that it was most probably down to the fact that even by the 1970’s the Western diet had become low in fibre and high in animal products, processed and highly refined foods. Indeed, it took just half a century from the introduction of rolling milling of flour (which greatly reduced the natural fibre content) in the late 1800’s for diverticulitis to become common in the UK by the 1920’s.

Since then, things have gone from bad to worse.

A number of the first researchers to study diverticulitis nicknamed it a “20th century problem” and a “disease of Western civilisation.” 6

Denis Burkitt’s team back in the 1970’s included in their report 38 a simple diagram which they thought explained the process by which diverticula are formed:

It’s probably no surprise that the US and European populations have the highest rates of diverticular disease in the world, whilst it is rarely found in developing countries before, that is, they adopt the Western diet. 39 7

A 1985 study 40 , again by Denis Burkitt, compared Americans and Africans to see if there were differences in their rates of diverticulitis and other intestinal diseases related to low-fibre diets  – namely, hiatus hernia and pelvic phleboliths 41 . As Dr Greger pointed out in a video on this subject 42 , Burkitt found a huge difference in diverticulitis rates between the Africans eating the high-fibre diet (less than 1% of the population) and the Americans eating the low-fibre diet (more than 50% of the population):

Your poo can give a clue

This might not be the most tasteful subject, but you can tell a lot about the likely state of your intestines by checking on what your poo (stool or faeces) looks like.  If you’re regularly constipated, and diverticula have already formed in the colon, stagnant faecal matter ends up clogged in the diverticula “bubbles”. 39 This can, in turn, trigger inflammation of the intestinal wall, resulting in the above-mentioned symptoms. The following chart is one of the standard charts used to get clues from your poos:

The Bristol Stool Chart provides a graphic version of various stool samples.

Developed by Dr. Ken Heaton from the University of Bristol in the late 1990’s, it’s used primarily as a clinical communication aid in categorising stool types 43 .

It’s only meant to be an unofficial guide, but does allow us to get a general idea of the classification of our poo, providing, thereby, a reasonably good indicator of both the diet we’re eating and the likely state of our intestines.

  • types 1 and 2 are typical of a constipated individual
  • type 3 is borderline normal
  • type 4 is the “gold standard for the perfect stool”
  • type 5 is heading in the direction of diarrhoea
  • types 6 and 7 reflect an individual in diarrhoea distress

If you want to delve deeper into the subject of bowel movements and constipation, Dustin Rudolph, PharmD has written a useful article44

It’s worth repeating that the balance of gut bacteria can be altered by chronic constipation and eating a low-fibre diet. Rather than a colon full of “good” (healthy) bacteria, there’s an increase in “bad” (infectious) bacteria that populate the colon. And it’s the presence of the latter bacteria that can further increase the chances of an infection developing.

Low-fibre diets do NOT cause diverticulitis!

Just to confuse the issue, a 2012 North Carolina study 45 came up with completely different conclusions than everything else that’s been said above about diverticulitis (and, of course, constipation) being powerfully linked to low-fibre diets. The study concluded:

In our cross-sectional, colonoscopy-based study, neither constipation nor a low-fiber diet was associated with an increased risk of diverticulosis.

By understanding the reason that they found no association, we can learn something about the quantity of fibre necessary to make a significant difference to your risk of developing chronic constipation and/or diverticulitis, plus we can learn a lot about how clinical trials can come up with misleading information.

In this study, they took two groups and carefully ensured that one group received only 8 grams of fibre a day while the other group received 25 grams of fibre a day. When they compared the results, there was no significant difference in the rates of diverticulosis and, thus they announced to the world that we do not need to bother eating a high-fibre diet in order to maintain good gut health.

The story was taken up all over the world, with headlines like:

“Diets high in fiber won’t protect against diverticulosis, study finds.46 47

“High-fibre diet may not protect against diverticulosis.” 48

“Paleo Diet: More Evidence That Fiber is Not A Good Thing.” 49

And not only did the Paleo crowd get involved and believe the study findings, even medical journals jumped on the band wagon, quoting the conclusions of the above study:

“Diverticulosis and dietary fiber: rethinking the relationship…A high-fiber diet does not protect against asymptomatic diverticulosis.” 50

So, what’s going on here?

Firstly, good news about bad habits is always attractive for those who want to justify their own bad dietary habits – tucking into a juicy beefburger and fries with impunity, rather than having to worry about eating all that rabbit food!

However, the fatal flaw in the study was identified pretty quickly by other studies, including the following:

Most importantly, how this study is interpreted is limited by the overall low-fiber intake within the study population. Although the authors performed analyses stratified by fiber intake and found no significant difference between those in the lowest (2.5–10.1 g) and highest quartiles (18.4–50.3 g) of fiber intake, few patients in the uppermost quartile had a true high fiber intake. An analysis reflecting clinical recommendations of high-fiber (>25 g) vs low-fiber (<14 g) diets may have yielded different results.” 51

To clarify just what this flaw of the study was, Dr Greger 52  drew an excellent analogy with early vitamin C studies. It takes around 10 mg of vitamin C a day to avoid developing scurvy 53 .

Back in the 1700’s, James Lind 54  wondered if scurvy in sailors could be avoided if they were given wedges of lemon each day. So he tested his theory. One group were given one wedge of lemon, and the other group were given three wedges of lemon a day. He found no difference at all between the groups, and the same ratio came down with scurvy.

So, did this prove that low vitamin C levels are not associated with the development of scurvy? Of course not. In order to prevent scurvy, it’s necessary to ingest at least 10 mg of vitamin C, and a single wedge of lemon only has around 2 mg. So, even with three wedges of lemon, you’re still only getting around 6 mg.

See the analogy?

The group eating the highest amount of fibre in the above North Caroline study 45 were only eating around 25 grams of fibre a day, which is less than the US minimum recommended daily allowance of around 32 grams. As Dr Greger says: “They didn’t even make the minimum. So they compared one fiber-deficient diet to another fiber-deficient diet—no wonder there was no difference in diverticulosis rates.

Whenever looking at any study results that appear “too good to be true”, it’s always worth checking on what was compared with what – after all, even a McDonald’s Big Breakfast is healthy when compared with…smoking tobacco or inhaling asbestos!

Final thoughts

As with many things in life, simple is best. The best form of cure for diverticular disease is prevention. And the best form of prevention is undoubtedly provided by eating a high-fibre diet, keeping well-hydrated, and getting plenty of regular daily exercise.

I can’t really think of a better way of ending than by quoting a closing comment by Dustin Rudolph, PharmD, writing for T Colin Campbell’s Center for Nutrition Studies (CNS), made at the end of his article on diverticular disease:

Eat plants. Get lots of fiber. Live happy. And avoid doctors and pharmacists if at all possible by adopting a whole food, plant-based lifestyle. Your body will thank you for many years to come.” 18

References & Notes

  1. J Chapman, M Davies, B Wolff, E Dozois, D Tessier, J Harrington, D Larson. Complicated diverticulitis: is it time to rethink the rules? Ann Surg. 2005 Oct;242(4):576-81; discussion 581-3. []
  2. Spiller, R. C. (2015). Changing views on diverticular disease: impact of aging, obesity, diet, and microbiota. Neurogastroenterology & Motility, 27(3), 305-312. [] []
  3. Health Navigator New Zealand. Diverticular disease and diverticulitis. Retrieved from https://www.healthnavigator.org .nz/health-a-z/d/diverticular-disease-diverticulitis/ []
  4. A fistula, in this case, is an abnormal passage between a hollow or tubular organ and the body surface, or between two hollow or tubular organs. In this case, it is more commonly between the intestine and the bladder. []
  5. Diverticulitis: Causes, Symptoms & Treatment. By Alina Bradford. June 12, 2018. []
  6. Aldoori W, Ryan-Harshman M. Preventing diverticular disease. Review of recent evidence on high-fibre diets. Can Fam Physician. 2002 Oct;48:1632-7. [] [] []
  7. Unlu C. Daniels L, et al. A systemic review of high-fibre dietary therapy in diverticular disease. Int J Colorectal Dis. 2012;27:419-427. [] [] []
  8. N S Painter. Diverticular disease of the colon. The first of the Western diseases shown to be due to a deficiency of dietary fibre. S Afr Med J. 1982 Jun 26;61(26):1016-20. []
  9. Painter N, Truelove S, et al. Segmentation and the localization of intraluminal pressure in the human colon, with special reference to the pathogenesis of colonic diverticula. Gastroenterology. 1968;54(Suppl):778-780. []
  10. Beckham H, Whitlow CB. The Medical and Nonoperative Treatment of Diverticulitis. Clin Colon Rectal Surg. 2009;22:156-160. [] []
  11. Constipation & Plant-Based Diets []
  12. Nutritionfacts.org. Topic: Fibre. []
  13. Are Nitrates & Nitrites Bad For Us? []
  14. Greens: Chewing vs Juicing []
  15. wholefoodsplantbasedhealth.com: Gut Health. []
  16. Cao, Y., Strate, L. L., Keeley, B. R., Tam, I., Wu, K., Giovannucci, E. L., & Chan, A. T. (2017). Meat intake and risk of diverticulitis among men. Gut, gutjnl-2016. []
  17. Gastroenterology. 2017 Apr;152(5):1023-1030.e2. doi: 10.1053/j.gastro.2016.12.038. Epub 2017 Jan 5. Western Dietary Pattern Increases, and Prudent Dietary Pattern Decreases, Risk of Incident Diverticulitis in a Prospective Cohort Study. Strate LL et al. []
  18. CNS: What Is Diverticular Disease and How to Treat It. By Dustin Rudolph, PharmD. February 14, 2019. [] [] []
  19. Patient. Diverticula (including Diverticulosis, Diverticular Disease and Diverticulitis). Retrieved from http:// patient.info/health/diverticula-including-diverticulosis-diverticular-disease-and-diverticulitis []
  20. Mayo Clinic: Patient Care & Health Information Diseases & Conditions: Diverticulitis []
  21. Constipation & Plant-Based Diets []
  22. Crowe, F., Appleby, P., Allen, N., & Key, T. (2011). P2-54 Diet and risk of diverticular disease in the European prospective investigation into cancer and nutrition (EPIC)-Oxford cohort, a prospective study of British vegetarians and non-vegetarians. Journal of Epidemiology and Community Health, 65(Suppl 1), A234-A234. []
  23. How Many Glasses of Water Should We Drink a Day? Michael Greger M.D. FACLM May 25th, 2015 Volume 24. []
  24. Diet and risk of diverticular disease in Oxford cohort of European Prospective Investigation into Cancer and Nutrition (EPIC): prospective study of British vegetarians and non-vegetarians. BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d4131 []
  25. Dr John McDougall: Diverticular Disease – Diverticulosis & Diverticulitis. [] []
  26. Crowe FL, Balkwill A, et al. Source of dietary fibre and diverticular disease incidence: a prospective study of UK women. Gut. 2014;63:1450-1456. []
  27. ACG: Diverticulosis and Diverticulitis []
  28. European Association for Endoscopic Surgery and other Interventional Techniques []
  29. American Society of Colon and Rectal Surgeons: Treatment of Sigmoid Diverticulitis (Revised). []
  30. World Gastroenterology Organisation: Diverticular Disease. []
  31. Strate L L, Liu Y L, Syngal S, Aldoori W H, Giovannucci E L. Nut, corn, and popcorn consumption and the incidence of diverticular disease. JAMA. 2008;300(8):907–914. []
  32. Tarleton S, DiBaise JK. Low-residue diet in diverticular disease: putting an end to a myth. Nutr Clin Pract. 2011 Apr;26(2):137-42. []
  33. Adventist Health Study-1 Publication Database []
  34. Why Vegans Need Fats And DHA by Joel Fuhrman, M.D. []
  35. Diverticulosis: When Our Most Common Gut Disorder Hardly Existed. Michael Greger M.D. FACLM July 17th, 2015 Volume 25 []
  36. J Y Wick. Diverticular disease: eat your fiber! Consult Pharm. 2012 Sep;27(9):613-8. doi: 10.4140/TCP.n.2012.613. [] []
  37. W H M Telling, O C Gruner. Acquired diverticula, diverticulitis, and peridiverticulitis of the large intestine. Brit J Surg. 4:468-530, 1917. []
  38. N S Painter, D P Burkitt. Diverticular disease of the colon: a deficiency disease of Western civilization. Br Med J. 1971 May 22;2(5759):450-4. [] []
  39. Boynton W, Floch M. New strategies for the management of diverticular disease: insights for the clinician. Ther Adv Gastroenterol. 2013;6(3):205-213. [] []
  40. D P Burkitt, J L Clements Jr, S B Eaton. Prevalence of diverticular disease, hiatus hernia, and pelvic phleboliths in black and white Americans. Lancet. 1985 Oct 19;2(8460):880-1. []
  41. Pelvic phleboliths are are round clusters of calcium that develop in the walls of a vein. They can vary in size but are usually around 5 mm across. They most commonly appear in the veins surrounding the pelvis. They can be caused by constipation and straining, which can damage pelvic veins. []
  42. Diverticulosis: When Our Most Common Gut Disorder Hardly Existed. Michael Greger M.D. FACLM July 17th, 2015 Volume 25. []
  43. Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol. 1997. []
  44. Dustin Rudolph, PharmD. The Anatomy Of A Bowel Movement (And How To Cure Constipation).  August 14, 2013. []
  45. A F Peery, R S Sandler, D J Ahnen, J A Galanko, A N Holm, A Shaukat, L A Mott, E L Barry, D A Fried, J A Baron. Constipation and a low-fiber diet are not associated with diverticulosis. Clin Gastroenterol Hepatol. 2013 Dec;11(12):1622-7. doi: 10.1016/j.cgh.2013.06.033. [] []
  46. ScienceDaily: Diets high in fiber won’t protect against diverticulosis, study finds []
  47. UHC HealthTalk: Diets high in fiber won’t protect against diverticulosis. January 23, 2012. []
  48. The Washington Post: High-fibre diet may not protect against diverticulosis. []
  49. Paleo Diet News: Paleo Diet: More Evidence That Fiber is Not A Good Thing. Posted on February 1, 2012. []
  50. L L Strate. Diverticulosis and dietary fiber: rethinking the relationship. Gastroenterology. 2012 Feb;142(2):205-7. []
  51. R E Burgell, J G Muir, P R Gibson. Pathogenesis of colonic diverticulosis: repainting the picture. Clin Gastroenterol Hepatol. 2013 Dec;11(12):1628-30. doi: 10.1016/j.cgh.2013.08.046. []
  52. Does Fiber Really Prevent Diverticulosis? Michael Greger M.D. FACLM July 20th, 2015 Volume 25 []
  53. Scurvy is a disease resulting from a lack of vitamin C (ascorbic acid). Early symptoms include weakness, feeling tired, and sore arms and legs. Without treatment, decreased red blood cells, gum disease, changes to hair, and bleeding from the skin may occur. As scurvy worsens there can be poor wound healing, personality changes, and finally death from infection or bleeding. []
  54. Tröhler U (2003). James Lind and scurvy: 1747 to 1795. []

Constipation & Plant-Based Diets

Studies suggest 1 2 that around 20% of people in Westernised countries suffer from constipation. That’s a lot of unpleasant and largely unnecessary toilet trouble by any standards. But is there a simple, drug-free remedy? You can bet your beans and greens there is!

Fibre, fibre, fibre

The most common lifestyle choice associated with the development of constipation is eating a low-fibre diet.

It still comes as something as a surprise just how many people are completely unaware that fibre can only be found in foods derived from plants – fruit and veg, beans, whole grains, etc – and that there is ZERO fibre in meat, dairy products, and eggs.

The average daily fibre intake in the UK is 17.2 grams/day for women and 20.1 grams/day for men, with a government recommendation of a minimum of 30 grams/day 3 . In the US, the recommendations vary from 19-38 grams/day, whilst US fibre intake is even less than the UK, at around 16 grams/day 4 5 . And, because these are averages, it means there are plenty of people eating considerably less than this.

A previous blog 6 discussed fibre in more detail, and pointed out that eating as much as 100 grams of fibre daily was quite normal in earlier human evolution.

In those countries where traditional diets contain much more fibre, it’s no surprise to find that constipation is much less common. But how can we know that it’s the fibre that’s making so much difference? Well, studies have looked at the changes that occur when such countries adopt the modern Western diet, which is much lower in fibre content. And what they’ve found is that constipation prevalence increases. 7 8

Constipation by country

There’s a very detailed list of reported constipation cases available at cureresearch.com 9 , but the following selective chart from a 2008 study 10  shows a common finding: namely, that women tend to suffer more than men.

Key: United States (US), United Kingdom (UK), France (FR), Germany (GE), Italy (IT), Brazil (BR) and South Korea (SK).

Problems arising from constipation

There are a number of complications which may arise from constipation 11 12 , including:

  • haemorrhoids (from “straining at the stool”)
  • anal fissures
  • rectal prolapse
  • faecal impaction (also called malignant constipation), which may lead to:
    • bowel obstruction
    • nausea
    • vomiting
    • tender abdomen
  • encopresis (where soft stool from the small intestine bypasses the impacted faecal mass in the colon)

How to prevent and alleviate constipation

It’s pretty obvious that the most sensible and natural method will involve increasing fibre content in the diet.

In children, studies show 13 14 that a lower intake of dietary fibre differentiates children with chronic constipation from those who have regular bowel movements. It’s so sad that children have to undergo such suffering simply because their parents and carers fail (whether through ignorance or conscious choice) to feed them a diet that maintains their gut health. Of course, it’s not just the problem of constipation that’s at issue here; maintaining a healthy gut microbiome from early life is vital for overall health through childhood and into old age 15 16 17 18 . And it’s such an obvious yet largely unappreciated fact 19 that our GI tract (along with all the trillions of essential bacteria, fungi and other microbes therein) is best maintained by a whole food plant-based diet rather than a diet of processed and/or animal foods.

As would be expected, therefore, additional studies show that increasing dietary fibre improves constipation and significantly reduces the need for laxatives in all societal groups:

  • children 20
  • young adults 21
  • elderly people 22 , and
  • post-surgery patients 23

When fibre supplementation may be necessary

Naturally, the first and best option is to increase the consumption of high-fibre foods. This is because, by eating whole plant foods, we don’t just facilitate easier gut transit, but the fibre itself and the natural healthy bacteria included with plants act as probiotics and prebiotics for our gut bacteria, and a variety of plants provides a vast array of minerals, vitamins, and an almost inestimable number of beneficial phytochemicals.

However, there are situations where chewing away on fibrous plant food is not an option, and so, in the following cases, fibre supplements may be the best option:

  • individuals lacking teeth (edentulism)
  • patients who can’t swallow easily or at all (dysphagia)

Prescribing laxatives is a very general knee-jerk reaction of medical professionals. They seem to choose this because they don’t appear to believe their patients have the wherewithal to significantly alter their diets. However, suggesting fibre supplements, in the case of the above two conditions, or changing to a high-fibre diet, in the case of most patients, is far more successful than merely pouring laxatives down your throat while still eating the same constipating diet. When the second best alternative (fibre supplements) are offered, evidence suggests 24  that around 60% of constipated patients can dispense with the laxatives they had been previously taking.

Different types of fibre supplements

The following have been shown to be effective for constipation relief:

  • psyllium (Metamucil) 25 (although prunes have been shown 26  to be more effective than psyllium)
  • methylcellulose (Citrucel) 27
  • Japanese konjac root (glucomannan) 28

But, I repeat, the first and best option is to transition to a plant-based diet (ideally non-SOS WFPB) unless, of course, you have no teeth or cannot swallow easily. And, even the latter two cases, I would suspect that there may be some way found to ensure whole plant foods are eaten, even if they have to be pulped or liquidised to some extent. I have some personal experience of this situation, since my father developed COPD 29 and dysphagia. Being crippled and having to be cared for my my mother, she was told that he would only ever be able to eat pureed food. However, she found that with some careful selection of foods, he was able to eat “solid” food almost until the time of his eventual death.

Dehydration & constipation

Even mild dehydration is a very common factor in cases of constipation 30 31 . This has also been found 20  to be the case in young constipated children. And it’s easy to understand why this is the case, and how it links inextricably with diet, when you realise that whole plant foods contain loads of water, while processed and animal foods can contain considerably less – and also usually contain loads of dehydrating salt.

Becoming dehydrated, without being aware of it, is much easier and more widespread than most of us realise. This can be seen from a US study 32 which found a shocking 75% of US citizens were chronically dehydrated.

In patients with functional chronic constipation, it’s been shown 33  that combining fibre and fluid (25 grams and 1.5-2.0 litres, respectively) on a daily basis was more effective for constipation relief than simply taking fibre alone.

It’s no surprise, then, that Dr Greger includes water consumption as one of the essential items in his Daily Dozen list 34 , stating that “…authorities from Europe, the U.S. Institute of Medicine, and the World Health Organization recommend between 2 to 2.7 liters of water a day for women. That’s 8 to 11 cups a day for women, and 10 to 15 cups a day for men. Now but that’s water from all sources–not just beverages–and we get about a liter from food and the water our body actually makes. So these translate into a recommendation for women to drink 4 to 7 cups of water a day, and men 6 to 11 cups, assuming only moderate physical activity at moderate ambient temperatures.” 35 .

Constipation & cow’s milk

Many children with chronic constipation are found 36 to be allergic to cow’s milk, manifesting IgE antibodies 37 to cow’s milk antigens38 . It’s always worthwhile for parents to ensure that any difficulties occurring during potty training are not associated with constipation resulting from the child drinking cow’s milk.

This is no insignificant matter, since consumption of cow’s milk has been found 39 to be significantly higher in infants and children with constipation and anal fissure than in those without these disorders.

And it gets even worse. Colonoscopies revealed 40  that around 50% of constipated, cow’s milk-allergic children and adolescents had lymphoid nodular hyperplasia 41 , compared with 20% of controls. The same study also found that around 33% of all cow’s milk-allergic individuals had a significantly higher number of intraepithelial T cells 42 , indicating an enhancement of local immune responses against food antigens. Another study of children with lymphoid modular hyperplasia found 43  that in 43 of the 52 individuals a diagnosis of cow’s milk or multiple food hypersensitivity was made.

Such activation of the immune system is known 44 to affect gastric motility 45 , thus indicating a likely role for an immune response to food antigens in cases of constipation.

Cow’s milk or soy milk?

Cutting out cow’s milk totally, in the diets of those children with cow’s milk sensitivity and constipation, has been shown 46  to result in significant improvement in up to 66% of cases.

In a small-scale study 47 of children with constipation, 100% of the participants had full resolution of chronic functional constipation when soy milk was used as a replacement for cow’s milk.

A further study found 48 that when cow’s milk was reintroduced, constipation returned within 5-10 days.

Previous blogs 49 50 have discussed in much more detail the range of health issues associated with cow’s milk. In basic terms, for all humans, irrespective of age, there’s absolutely no nutritional need for “baby calf growth fluid” 51 to be included in the diet. And, for a significant number of both children and adults who experience constipation, it would seem a sensible plan to try cutting out cow’s milk completely to see whether relief of symptoms follows.

Final thoughts

So, getting lots of fibre, drinking plenty of fluids and avoiding cow’s milk seem to be the major routes towards non-drug prevention and treatment of constipation in all age groups. One area we haven’t covered is regular physical exercise, which, counter to popular belief, does not have any overwhelming study evidence to support its value for constipation treatment or avoidance. Some studies consider that it can be an important adjunct for males 52 and females 53  of all age groups in the prevention and treatment of constipation. However, other studies, including the following 2017 French study, question whether increasing exercise per se has any positive effect:

The benefi[t] of increasing water intake or daily physical exercise in the treatment of chronic constipation have a lack of evidence, except specific situations such as elderly, hospitalized, institutionalized, dehydrated people or people consuming fluids less than 500mL/day. Change in environmental defecation conditions or bowel habits are probably anecdotal recommendations.” 54

Yet other authorities consider 55 that, in some cases of particularly intense exercise, constipation can be worsened. More research is needed on which level of activity (stationary yoga movements, gentle walking or marathon running, for instance) has what effect on constipation.

Whilst lack of exercise is particularly important as we age and run the risk of becoming too sedentary 56 , the increasing rates of childhood obesity – and the associated reduction in physical exercise – are reported by some studies as revealing a worrying increase in cases of constipation and other GI health concerns 57 58 .

My personal experience is that the effects of exercise appear to be determined, at least to some extent, on the quality of diet you are consuming. If you’re already eating a low-fibre diet and then exercise, I have no doubt that it might lead to increased constipation; however, when a high-fibre diet is your norm, exercise may not have the same effect. A comparison study would be of interest in this respect.

What all studies agree on, however, is that the main and overreaching factor of importance in avoiding and treating constipation is fibre, fibre and more fibre.

So, in conclusion, whilst it’s easy to say that best means of achieving healthy GI tract activity is to follow a varied WFPB diet, keep hydrated and ensure that you get plenty of daily exercise, when we have had a lifetime of practising ingrained and unquestioned habits, it can be really difficult to make such lifestyle and dietary changes.  However, ensuring that our children do not fall into bad habits will both protect them and encourage us to embrace healthier practices ourselves.

References & Notes

  1. Higgins PD, Johanson JF. Epidemiology of constipation in North America: a systematic review . Am J Gastroenterol . 2004; 99: 750–759. []
  2. Chiarelli P, Brown W, McElduff P: Constipation in Australian women: prevalence and associated factors. Int Urogynecol J Pelvic Floor Dysfunct 11:71, 2000 []
  3. British Nutrition Foundation: Dietary fibre. []
  4. Hoy MK, Goldman JD. Fiber intake of the U.S. population: What We Eat in America, NHANES 2009–2010. United States Department of Agriculture website. []
  5. U.S. Department of Agriculture and Agricultural Research Service. What We Eat in America: Dietary Fiber (g): Usual Intakes from Food and Water, 2003-2006, Compared to Adequate Intakes. National Health and Nutrition Examination Survey (NHANES) 2003-2006. United States Department of Agriculture website. []
  6. Fibre! Fibre! Fibre! []
  7. Yang XJ et al: Epidemiological study: Correlation between diet habits and constipation among elderly in Beijing region. World J Gastroenterol 22:8806, 2016 []
  8. Holmboe-Ottesen G, Wandel M. Changes in dietary habits after migration and consequences for health: a focus on South Asians in Europe. Food Nutr Res . 2012;56. []
  9. cureresearch.com:Statistics by Country for Constipation []
  10. AP&T. A multinational survey of prevalence and patterns of laxative use among adults with self‐defined constipation. A. WALD C. SCARPIGNATO S. MUELLER‐LISSNER M. A. KAMM U. HINKEL I. HELFRICH C. SCHUIJT K. G. MANDEL. First published: 01 September 2008 https://doi.org/10.1111/j.1365-2036.2008.03806.x []
  11. Walia R, Mahajan L, Steffen R (October 2009). “Recent advances in chronic constipation”. Curr Opin Pediatr. 21 (5): 661–6. []
  12. McCallum IJ, Ong S, Mercer-Jones M (2009). “Chronic constipation in adults”. BMJ. 338: b831. []
  13. Kranz S et al: What do we know about dietary fiber intake in children and health? The effects of fiber intake on constipation, obesity, and diabetes in children. Adv Nutr 3:47, 2012. []
  14. Castillejo G et al: A controlled, randomized, double-blind trial to evaluate the effect of a supplement of cocoa husk that is rich in dietary fiber on colonic transit in constipated pediatric patients. Pediatrics 118:e641, 2006. []
  15. Gut Microbiota & Depression []
  16. Fibromyalgia, Probiotics & Gut Microbiota []
  17. Physical Activity for Disease Prevention & Healthy Gut Microbiome []
  18. Multiple Sclerosis (MS), Serotonin & Gut Microbiota []
  19. Two Types of Gut Bacteria: Plant Eaters’ & Meat Eaters’ []
  20. Castillejo G et al: A controlled, randomized, double-blind trial to evaluate the effect of a supplement of cocoa husk that is rich in dietary fiber on colonic transit in constipated pediatric patients. Pediatrics 118:e641, 2006 [] []
  21. Woo HI et al: A Controlled, Randomized, Double-blind Trial to Evaluate the Effect of Vegetables and Whole Grain Powder That Is Rich in Dietary Fibers on Bowel Functions and Defecation in Constipated Young Adults. J Cancer Prev 20:64, 2015 []
  22. Howard LV, West D, Ossip-Klein DJ: Chronic constipation management for institutionalized older adults. Geriatr Nurs 21:78, 2000 Mar-Apr []
  23. Griffenberg L et al: The effect of dietary fiber on bowel function following radical hysterectomy: a randomized trial. Gynecol Oncol 66:417, 1997 []
  24. Sturtzel B et al: Use of fiber instead of laxative treatment in a geriatric hospital to improve the wellbeing of seniors. J Nutr Health Aging 13:136, 2009 []
  25. Ramkumar D, Rao SS: Efficacy and safety of traditional medical therapies for chronic constipation: systematic review. Am J Gastroenterol 100:936, 2005 []
  26. Prunes vs. Metamucil vs. Vegan Diet. Michael Greger M.D. FACLM March 15th, 2013 Volume 12 []
  27. Mounsey A, Raleigh M, Wilson A: Management of Constipation in Older Adults. Am Fam Physician 92:500, 2015 []
  28. Yen CH et al: Long-term supplementation of isomalto-oligosaccharides improved colonic microflora profile, bowel function, and blood cholesterol levels in constipated elderly people–a placebo-controlled, diet-controlled trial. Nutrition 27:445, 2011 []
  29. Chronic Obstructive Pulmonary Disease (COPD) is an umbrella term used to describe progressive lung diseases including emphysema, chronic bronchitis, and refractory (non-reversible) asthma. This disease is characterised by increasing breathlessness. []
  30. Eur J Clin Nutr. 2003 Dec;57 Suppl 2:S88-95. Mild dehydration: a risk factor of constipation? Arnaud MJ []
  31. Murakami K et al: Association between dietary fiber, water and magnesium intake and functional constipation among young Japanese women. Eur J Clin Nutr 61:616, 2007 []
  32. Survey of 3003 Americans, Nutrition Information Center, New York Hospital-Cornell Medical Center. April 14, 1998. []
  33. Anti M et al: Water supplementation enhances the effect of high-fiber diet on stool frequency and laxative consumption in adult patients with functional constipation. Hepatogastroenterology 45:727, 1998 May-Jun []
  34. Dr. Greger’s Daily Dozen Checklist. Michael Greger M.D. FACLM September 11th, 2017 Volume 38 []
  35. How Many Glasses of Water Should We Drink a Day? Michael Greger M.D. FACLM May 25th, 2015 Volume 24 []
  36. Cow’s milk protein allergy in children: identification and treatment. The Pharmaceutical Journal15 MAY 2018. By Hetal Dhruve, Joanne Walsh, David Mass, Adam Fox. []
  37. IgE antibodies: If you have an allergy, your immune system overreacts to an allergen by producing antibodies called Immunoglobulin E (IgE). These antibodies travel to cells that release chemicals, causing an allergic reaction. This reaction usually causes symptoms in the nose, lungs, throat, or on the skin. []
  38. Antigens are toxins or other foreign substances which induce an immune response in the body, especially the production of antibodies. []
  39. Andiran F, Dayi S, Mete E: Cows milk consumption in constipation and anal fissure in infants and young children. J Paediatr Child Health 39:329, 2003 []
  40. Turunen S, Karttunen TJ, Kokkonen J: Lymphoid nodular hyperplasia and cow’s milk hypersensitivity in children with chronic constipation. J Pediatr 145:606, 2004 []
  41. Lymphoid nodular hyperplasia (LNH) generally presents as an asymptomatic disease, but it may cause gastrointestinal symptoms like abdominal pain, chronic diarrhoea, bleeding or intestinal obstruction. []
  42. Intraepithelial T cells (IETs), residing at the epithelial barrier in the gastrointestinal tract, are an epitome of tissue-resident T cells. Tissue-resident T cells are long-lived, nonrecirculating T cells that provide rapid immune responses independent of peripheral T cell recruitment. []
  43. Clin Gastroenterol Hepatol. 2007 Mar;5(3):361-6. Colonic lymphoid nodular hyperplasia in children: relationship to food hypersensitivity. Iacono G, Ravelli A, Di Prima L, Scalici C, Bolognini S, Chiappa S, Pirrone G, Licastri G, Carroccio A. []
  44. Hermann GE, Tovar CA, Rogers RC: Induction of endogenous tumor necrosis factor-alpha: suppression of centrally stimulated gastric motility. Am J Physiol 276:R59, 1999 []
  45. Gastric Motility: contractions of gastric smooth muscle that serves two basic functions: ingested food is crushed, ground and mixed, liquefying it to form what is called chyme. Chyme is then forced through the pyloric canal into the small intestine, a process called gastric emptying. []
  46. Carroccio A et al: Chronic constipation and food intolerance: a model of proctitis causing constipation. Scand J Gastroenterol 40:33, 2005 []
  47. Crowley ET et al: Does milk cause constipation? A crossover dietary trial. Nutrients 5:253, 2013 []
  48. Iacono G et al: Intolerance of cow’s milk and chronic constipation in children. N Engl J Med 339:1100, 1998 []
  49. If You Want Enough Calcium, Forget Milk []
  50. Cow’s Milk – But It Looks So Innocent… []
  51. ‘Cow’s milk’ as baby calf growth fluid: video with Michael Klaper. []
  52. Harvard Men’s Health Watch. Chronic constipation: A strain for men. Published: September, 2008 []
  53. Diabetes Metab Syndr Obes. 2017; 10: 513–519. Effects of a proposed physical activity and diet control to manage constipation in middle-aged obese women. Sayed A Tantawy, Dalia M Kamel, Walid Kamal Abdelbasset, and Hany M Elgohary []
  54. Presse Med. 2017 . Jan;46(1):23-30. doi: 10.1016/j.lpm.2016.03.019. Epub 2017 Jan 5. [Diet and lifestyle rules in chronic constipation in adults: From fantasy to reality…]. [Article in French]. Fathallah N, Bouchard D, de Parades V. []
  55. Exercise Causes Constipation! By Ashok T Jaisinghani, October 4, 2016 in Diet & holistic health []
  56. NIH: Concerned About Constipation? []
  57. PLoS One. 2014; 9(2): e90193. Physical Activity and Constipation in Hong Kong Adolescents. Rong Huang, Sai-Yin Ho, Wing-Sze Lo, and Tai-Hing Lam []
  58. Hippokratia. 2015 Jan-Mar; 19(1): 11–19. Constipation in Childhood. An update on evaluation and management. I Xinias and A Mavroudi []

How Can Parents Get Toddlers To Eat Healthily?

There are a number of methods to ensure that toddlers eat healthily, and there’s probably been no other time in human history when it’s been more important to do so. Child obesity and all its associated metabolic diseases are hitting children at ever younger ages 1 2 3 . Whilst it’s so easy to blame Big Business and national governments, the primary responsibility for ensuring our children grown up healthy is now, as it always has been, mostly in the hands of their own parents and carers.

Definition of terms

Although not written in stone, the stages of early childhood are conventionally understood as the following:

  • newborn – between 0 and 2 months
  • infant – between 2 and 12 months
  • toddler – between 12 months and 4 years

Getting it right from the start

The most important time to ensure the development of healthy eating habits is arguably during the early weaning process – that is, the period when the baby is transitioning from mother’s breast milk to solid food. I am taking for granted that we would all agree the newborn’s ideal first nutrition (for around the first 6 months) should always be exclusively mother’s breast milk whenever possible. All the evidence points in this direction 4 5 6 .

Bad habits are hard to break

Between around 6 and 12 months of age, the infant will be introduced to “solid” food. It’s during this stage that major mistakes can be made, and bad eating habits (food high in calories and low in nutrients) can be set in motion.

If, however, appropriate food (high in nutrients and sufficient in calories for growth) is introduced, ingrained bad habits within the infant and toddler stages can be avoided, with the remaining years of childhood (and probably adulthood) thus standing a much better chance of being free from the need to put endless effort into undoing such habits – yo-yo dieting, continual fighting to escape the pleasure trap, with all its tempting and addictive bliss points 7.

The importance of good example

Whether or not less-favourable eating habits have been established, parents and carers need to ensure that they act as good examples. This means:

  • eating a healthy and varied balance of foods themselves
  • eating at regular times
  • sharing meals – making each meal a special family event, rather than simply eating separately in front of the TV
  • encouraging toddlers to eat 3 meals a day plus 2 healthy snacks. This can avoid those hunger pangs that can result in unhealthy ‘grazing’ between meals and then overeating during meals

Children who grow up seeing their parents and carers forever on diets or bingeing on unhealthy foods is not something that will act as a good example.

One recent story I heard was of a nutritionist who was asked to intervene in a family where the young child refused to eat anything that even appeared to be a vegetable or a fruit, preferring instead to eat a diet existing more or less solely of sweets, crisps and cakes. The nutritionist advised that containers of bite-sized carrots and celery be left around the kitchen for the child to be attracted to eat. The nutritionist then walked past the veg and said something along the lines of “Oh look! How lovely! Carrots. I love them” and then tucked into them with glee. When the father was asked to do the same, as a means of giving positive feedback to the child, he picked up a carrot, bit into it and pulled a face that would have been better suited to a person who had just swallowed a bumble bee. Naturally, the child saw his father’s reaction and the nutritionist could immediately identify the major reason that the child had developed such unhealthy habits.

Toddlers in the kitchen

Even from the youngest age, infants will be influenced by the sorts of foods they encounter. This isn’t just a matter of flavours, but also of smell, texture, colour, and general variety – the colours of the rainbow.

The relationship parents and carers have to matters relating to food preparation itself will have an effect on the growing child. Involving the toddler from an early age in making meals and understanding the nature of different foods can be of great help in ensuring the child grows up with knowledge about and control over dietary matters.

Any parent will find that toddlers simply love experimenting with the selection and preparation of food. This playful experience is a great way for them to try different foods in the kitchen. It, along with meal times, should be a fun way to spend time with the family. The idea of simply placing already-prepared meals in front of a toddler may be attractive in terms of saving preparation time; however, doing so would tend to miss the exciting and productive times when he or she (or a group of toddlers, be they friends or siblings) could be involved in handling, selecting, chopping, peeling, and even cooking (with careful supervision, of course).

I remember that when I was young I asked my mother what tongue was – you know, those greyish-red slices of meat that bear no resemblance to that huge, dripping muscular organ lolling out of the mouths of cows. I’d been eating it for years and it hadn’t dawned on me that what we called slices of tongue was actually part of a dead animal. I mean, they called candyfloss candyfloss, but you don’t floss candy with it! Anyway, once I discovered what it was, I never touched it again. Had I been responsible for cutting it out of the mouth of the dead cow and then slicing and boiling it, perhaps I would have developed an aversion to it at an even earlier age. Who knows?


Toddler or parent temptation?

Avoiding the temptation to give in to a toddler’s potential demands for sweets and treats is increasingly difficult for parents, what with the ubiquitous advertising campaigns and availability in toddler-height shelves in most shops these days. Even when it comes to those special times, it’s still so important to avoid making unhealthy junk foods a treat or a central part of festivals, birthdays and other celebrations.

If a toddler grows up thinking that a real treat is enjoying a healthy salad rather than being thrown a bag of prawn cocktail crisps or a bag of Haribo Starmix, it’s a pretty good indication that something has been done right!

Of course, parents themselves have to engage in the same fight with sweet and junky temptations that they may well have had since their own childhoods. In this case, fighting one’s own natural desires for sweet indulgence is a preface to allowing one’s children to grow up with more freedom from cravings and learned preferences associated with such toxic foods.

And it hardly needs saying saying that using foods in any way to establish or maintain emotional control is to be avoided. As soon as emotional states (positive or negative) are inextricably linked to food, problems can arise. The art of developing a sense of well-being which is separate from the need for oral satisfaction is something that one would wish all children to learn at an early age. It allows them freedom to seek emotional satisfaction and achievement in other more productive spheres of life.

Eat when hungry

Thus, it’s useful for toddlers to grow up learning that they eat when they are hungry – not when they are forced to do so or because they are bored or depressed.

In any case, toddlers have tiny stomachs which, if filled with unhealthy foods, will leave no room for more essential nutrients. This is where portion control comes into its own. In order to ensure that the toddler does not get used to over-eating, the type and quantity of foods they are presented with should be taken into consideration. Just as there should be no justification for “forcing” an infant or toddler to eat something that he or she does not want to eat, it is equally unhelpful for them to force food down when their body is telling them that they have eaten enough.

Allowing infants and toddlers to exercise some choice in the foods they put into their mouths is advisable – so long as the selection is from healthy and interesting foods. If they don’t want to eat at the moment, fine – be patient and wait until they feel hungry. In the meantime, they can see their parents enjoying the same sorts of food, without having made a big issue of the child’s not eating at that moment. A relaxed atmosphere around the dining table is always likely to produce healthy and easy-going dietary habits in the child.

When hunger hits and ‘seconds’ are required, they should be from a selection of vegetables or fruit. If the toddler wants more immediately after having eaten their meal, it might be a good idea to encourage them to wait for a little while in order to let the food “settle” – allowing leptin to do its job 8 – before they have extra portions.

Learning portion control early in life is a useful means of preventing over-eating in future years. This is not usually a problem, however, with those who eat a non-SOS WFPB diet, since the range of foods within this dietary regime tend to be self-limiting. It’s only when the stomach is filled with high calorie/low nutrient alternatives 9 that over-eating is something that parents should be really concerned about – both for themselves and their children – being that processed foods are carefully manufactured to be addictive “pleasure traps” as they hit those “bliss points” 10 .

Anticipation can be better than participation

Learning ‘satisfaction-delay’ is a really good skill for children to learn young. If a toddler gets what he or she wants immediately upon request, they don’t learn how to delay pleasurable experiences, and learning how to live with the delayed pleasure of eating is a useful skill that spills over into most aspects of child and adult life.

Delaying gratification isn’t a new concept. Back in 300 BC, Aristotle saw that the reason so many people were unhappy was that they confused pleasure for true happiness. True happiness, according to Aristotle, is about developing habits and surrounding yourself with people who grow your soul.” 11

Variety (within reason) matters

Introducing a variety of foods is important and, as stated before, not forcing a child to eat a particular food, if they feel a strong dislike for it, is a sensible move. The chances are that they will change their minds later and try the foods if they see adults enjoying them and not making an issue of them. Patience is the key. This planet of ours grows so many wonderful edible plants that finding alternatives should never be a problem for the attentive parent.

Whilst toddlers are, of course, too young to receive pocket money and run the risk of spending it on sweets etc, any food choices they are able to make at this young age should be from as healthy a range of options as possible. This means keeping only healthy foods in the house and trying to avoid the aisles in supermarkets which draw their attention to unhealthy foods – unfortunately, this is virtually impossible in the modern Western food shopping experience.

Take care with carers

Parents should make their dietary rules very clear to any carers who take responsibility for the toddler. Bad habits learned from carers can cause conflict in the child when they return to their parents and find that they are being told a different story about what dietary habits are or are not acceptable. This applies to both the type and quantity of foods themselves and the regularity and form of dining habits.

Thinking before drinking

In terms of drinks, toddlers should not get used to filling up on sugary drinks. It should go without saying that infants receive their best source of liquids from their mother’s breast milk. Providing drinking fluids during weening is, of course, a natural and essential route, so long as the liquid provided is plain water.

It’s hard to find any authority that would advise parents to give their toddlers fizzy/sugary drinks. The best thing is to avoid all sugary drinks completely so that the child becomes accustomed and perfectly content with simple tap water.

Parents would be wise to do a bit of careful research before deciding to follow the crowd in giving their toddlers cow’s milk. Parents usually feed cow’s milk to their children because they had it themselves and it’s something that is, well, just done! However, much of this is based on an arguably inaccurate belief that cow’s milk is necessary to ensure children get enough calcium 12 . There are some pretty convincing arguments, based on solid research 13 12 , that would caution against feeding cow’s milk to your child, especially when there are plenty of fortified plant milk alternatives 14 to choose from.

It may come as a surprise to some people, but even fruit juices are not an ideal drink 15 , especially if they have added sugar or artificial sweeteners. If, however, they are to be given to toddlers, they should be diluted with water.

Final thoughts

The foregoing is by no means a comprehensive overview of the many ways in which parents can encourage healthy eating habits in their children during the earliest stages of their lives. For my part, I wish my parents had followed even a few of the ideas outlined above. My overly sweet childhood diet resulted in countless rotten teeth and fillings during my adolescent years. This has been accompanied with a life-long struggle against using sweet and fatty junk foods as a reward for a tiring day, a pick-me-up when feeling a little low, and a treat whenever there’s a “y” in the day!

This is why engendering good dietary habits from a young age is so very important. It’s easier to do the right thing when you don’t have to continually undo the wrong.

I wouldn’t wish on anyone a lifetime of being good at bad habits.


  1. Can The UK Government Really Combat Child Obesity? []
  2. England’s Obesity Hotspots []
  3. The State of Childhood Obesity in the US []
  4. Research on Breastfeeding & Breast Milk at the NICHD []
  5. British Nutrition Foundation: SACN’s ‘Feeding in the First Year of Life’. []
  6. NHS: Benefits of Breastfeeding []
  7. Bliss Points, Pleasure Traps & Wholefood Plant-Based Diets. []
  8. Leptin – The “Fat” Hormone? []
  9. Toxic Hunger vs Real Hunger []
  10. Bliss Points, Pleasure Traps & Wholefood Plant-Based Diets []
  11. Psychology Today: The Benefits of Delaying Gratification. Are You Avoiding Pain or Living With Purpose? Dec 26, 2017. []
  12. If You Want Enough Calcium, Forget Milk [] []
  13. Cow’s Milk – But It Looks So Innocent… []
  14. Plant Milks Are Churning Up The Ground []
  15. Fruit Juice by Nutritionfacts.org []

Improve Blood Flow By Hanging Upside Down?

It might sound a bit odd, but apparently it’s possible to improve metabolic measures related to blood flow simply by hanging upside down. However, get it wrong and you might end up killing yourself.

It’s well-known that regular aerobic exercise is good for the heart. But various yoga positions also appear to do a similar trick without the need for so much sweating.

One particular yoga pose of specific interest is the upside down position. Of course, as you can see below, there are plenty of different ways of achieving this.

What are the upside down benefits?

A 2011 review 1  into the benefits of yoga in general considered that upside down (or inverted) yoga poses were of benefit to the cardiovascular system:

Inverted poses encourage venous blood flow from the legs and pelvis back to the heart and then pumped through the lungs where it becomes freshly oxygenated. Many studies 2 3 4 show yoga lowers the resting heart rate, increases endurance, and can improve the maximum uptake and utilisation of oxygen during exercise.

There are plenty of yoga websites 5 6 7 8 that give advice on the best way to achieve this inverted pose – variously called supported headstand, sirsasana, inversions, and so forth.

Any yoga’s good yoga

Naturally, this is not the only yoga pose that studies have shown has health benefits. Studies suggest a wide range of benefits, such as:

  • neurological disorders 9 , including:
    • multiple sclerosis 10
    • stroke 11
    • epilepsy 12
    • Parkinson’s disease 13
    • dementia 14
    • Alzheimer’s 15
  • hypertension 16
  • obesity 17
  • diabetes 18
  • depression 19

The list goes on and on…

Dying to be upside down

However, you should be warned that this is not one of those things where a little is good and a lot is even better. Too much inversion can kill 20 .

In 2009, a guy called John Jones, who lived in Utah, died after spending 28 hours stuck upside down in a cave 21 , most likely from asphyxiation.

Upside down lungs

It transpires that our lungs evolved to sit on top of all the other organs for a very good reason. They are such delicate organs that it doesn’t take them long to get squashed by the larger and heavier organs such as the liver and intestines that usually sit below them. 22

This isn’t a problem for sloths, since they have their lungs “taped” to their ribs 23 .

But for us mere humans, having our heads directly underneath our feet for extended periods of time means that the lungs simply can’t absorb enough oxygen given the restricted space they have to work within.

Upside down brain

And it’s not just our lungs that have difficulty. Our bodies are set up to move blood around when we’re upright. Our blood vessels are customised to make sure blood doesn’t pool in our feet. This system is a “one-way street”, since our bodies didn’t evolve to prevent blood from pooling in the brain. This is patently not the case with bats. They have one-way valves in their arteries that prevent blood from flowing backwards. This is why they are able to hang upside down without the blood rushing to their heads 24 .

However, unlike bats, Batman would get into all sorts of vascular trouble (with or without the help of Robin) – ruptured blood vessels and potential brain haemorrhage included.

Upside down heart

And the heart is no lover of too much life down under 25 . It’s thought that heart failure accounts for most upside down fatalities. Just as with the brain, when the heart is above the head, it pumps more slowly and starts to receive more blood than it has the capacity to deal with at any one time. The result is that it begins to have a hard time maintaining blood pressure. Eventually, it will lose its ability to move sufficient blood around to maintain all the body’s essential functions.

Hanging around for too long will eventually kill you – a risk which increases as we age or if we are sick.

Inversion can be torture

It should be remembered that inversion was used as a torture method is ye olde days. It combined pain with a smattering of humiliation. Often the torture of choice for those sinners with unorthodox beliefs, it was used by the Romans with Christians and the Spanish with Jews and Muslims 26 27  . The Japanese even have a word for it – Tsurushi or “reverse hanging” 28 .

Nice to see how relaxed that monk-like executioner appears!

Another thing they used to do was to keep the victim inverted for some time and then make them stand upright again. Apparently, this is very painful as the blood pools to the feet again. Of course, they’re then hung upside down again. This process usually kills them within 8 to 10 hours.

Oh how inventive we humans are…

Final thoughts

It’s probably the case that any exercise is good exercise – whether it’s resistance training with weights, aerobic, or yoga. The important thing is to ensure you get plenty of regular daily exercise – either 90 mins low-moderate intensity (e.g. walking) or 45 mins of high-intensity exercise (e.g cycling, running, or rowing). It’s generally suggested 29 that you can work out your maximum heart rate by simply subtracting your age from 220. Then you can think of low-moderate intensity as being 50 – 70% of the resulting figure, whilst high-intensity would be 70-85%.

Spending a little time upside down appears to be something worth considering – however, some methods of achieving this are better than others…


  1. Int J Yoga. 2011 Jul-Dec; 4(2): 49–54. Exploring the therapeutic effects of yoga and its ability to increase quality of life. Catherine Woodyard. []
  2. Effect of yoga on cardiovascular system in subjects above 40 years. Bharshankar JR, Bharshankar RN, Deshpande VN, Kaore SB, Gosavi GB. Indian J Physiol Pharmacol. 2003 Apr; 47(2):202-6. []
  3. Hatha yoga: improved vital capacity of college students. Birkel DA, Edgren L Altern Ther Health Med. 2000 Nov; 6(6):55-63. []
  4. Effects of Hatha yoga and Omkar meditation on cardiorespiratory performance, psychologic profile, and melatonin secretion. Harinath K, Malhotra AS, Pal K, Prasad R, Kumar R, Kain TC, Rai L, Sawhney RC J Altern Complement Med. 2004 Apr; 10(2):261-8. []
  5. Yoga Journal: Supported Headstand []
  6. Yoga Journal: Everybody Upside-Down []
  7. YouTube video: How to Do a Headstand (Sirsasana) Yoga []
  8. DoYouYoga: 10 Most Popular Yoga Inversions []
  9. J Clin Neurosci. 2017 Sep;43:61-67. doi: 10.1016/j.jocn.2017.05.012. Epub 2017 Jun 7. Evidence based effects of yoga in neurological disorders. Mooventhan A, Nivethitha L. []
  10. PLoS One. 2014 Nov 12;9(11):e112414. doi: 10.1371/journal.pone.0112414. eCollection 2014. Yoga for multiple sclerosis: a systematic review and meta-analysis. Cramer H, Lauche R, Azizi H, Dobos G, Langhorst J. []
  11. Cochrane Database Syst Rev. 2017 Dec 8;12:CD011483. doi: 10.1002/14651858.CD011483.pub2. Yoga for stroke rehabilitation. Lawrence M, Celestino Junior FT, Matozinho HH, Govan L, Booth J, Beecher J. []
  12. Cochrane Database Syst Rev. 2017 Oct 5;10:CD001524. doi: 10.1002/14651858.CD001524.pub3. Yoga for epilepsy. Panebianco M, Sridharan K, Ramaratnam S. []
  13. Trials. 2017 Nov 2;18(1):509. doi: 10.1186/s13063-017-2223-x. The effects of yoga versus stretching and resistance training exercises on psychological distress for people with mild-to-moderate Parkinson’s disease: study prxotocol for a  randomized controlled trial. Kwok JYY, Kwan JCY, Auyeung M, Mok VCT, Chan HYL. []
  14. Int J Geriatr Psychiatry. 2017 Jan;32(1):118. doi: 10.1002/gps.4538. The therapeutic effects of yoga in people with dementia: a systematic review. Du Q, Wei Z. []
  15. Res Gerontol Nurs. 2014 Jul-Aug;7(4):171-7. doi: 10.3928/19404921-20140218-01. Epub 2014 Feb 26. The effect of chair yoga in older adults with moderate and severe Alzheimer’s disease. McCaffrey R, Park J, Newman D, Hagen D. []
  16. Exp Clin Endocrinol Diabetes. 2016 Feb;124(2):65-70. doi: 10.1055/s-0035-1565062. Epub 2015 Nov 17. The Efficacy and Safety of Yoga in Managing Hypertension. Cramer H. []
  17. Prev Med. 2016 Jun;87:213-232. doi: 10.1016/j.ypmed.2016.03.013. Epub 2016 Apr 4. A systematic review and meta-analysis on the effects of yoga on weight-related outcomes. Lauche R, Langhorst J, Lee MS, Dobos G, Cramer H. []
  18. Prev Med. 2017 Dec;105:116-126. doi: 10.1016/j.ypmed.2017.08.017. Epub 2017 Sep 4. The effects of yoga among adults with type 2 diabetes: A systematic review and meta-analysis. Thind H et al. []
  19. Depress Anxiety. 2013 Nov;30(11):1068-83. doi: 10.1002/da.22166. Epub 2013 Aug 6. Yoga for depression: a systematic review and meta-analysis. Cramer H, Lauche R, Langhorst J, Dobos G. []
  20. Quora: How long could a human being survive hanging upside down if they’re being fed, hydrated, etc. Would spending one’s life hanging upside down shorten one’s lifespan? Amandi Dilshara. Oct 24 2019. []
  21. ABC News: Man in Utah Cave Faced Tough Odds, Doctors Say John Jones’ upside down position in the cave left rescue workers little time. By LAUREN COX. Nov. 26, 2009. []
  22. HowStuffWorks: How Your Lungs Work. BY CRAIG FREUDENRICH, PH.D. []
  23. National Geographic: SCIENCE & INNOVATION. To Breathe Upside-Down, Sloths Tape Organs To Their Ribs. BY ED YONG. PUBLISHED APRIL 23, 2014. []
  24. Bat Worlds: Bat Anatomy. Nov 5, 2013. []
  25. How StuffWorks: How Your Heart Works. CARL BIANCO. []
  26. The Marseille Tarot Revealed: A Complete Guide to Symbolism, Meanings & Methods. By Yoav Ben-Dov. []
  27. Bustle: 7 Incredibly Disturbing Execution Methods From The Middle Ages (You Really Should Not Read This) By LARA RUTHERFORD-MORRISON. May 14 2015. []
  28. Wikipedia: Tsurushi. []
  29. Mayo Clinic: Exercise intensity: How to measure it. []