Thursday, September 29, 2011

Forks Over Knives: A Pictorial Review

 My Dinner Tonight.  Typical Wednesday Fare.
(The salad is dressed in macadamia nut oil and coconut vinegar.)
The plantains I sauteed in coconut oil jumped ship and swam
to the bottom of my belly as soon as they saw the camera coming.

by Chris Masterjohn

I don't buy bacon very often, but when I went to Whole Foods this past Thursday, I couldn't resist.  After all, I was there to pick up the new Forks Over Knives DVD, and it lured me right over to the Campbell & Co. corner, where the complete works of Drs. Campbell, Esselstyn, Fuhrman, McDougall and friends lie directly perpendicular to all the most delicious meats.

Here's a rough layout of my local Whole Foods:

I finally watched Forks Over Knives today, and I have to say I enjoyed it.  The producers have a good sense of humor, and the movie gave me a few good laughs.  I enjoyed the testimonials of people regaining their health, because I prefer to rejoice when others rejoice.  And I agree with the overall spirit of exalting the food fork over the medical knife.
You all know I disagree with the dietary conclusions of the movie — which can be summed up in the phrase "veganism" "whole-foods, plant-based diet" — not because I deny that whole plant foods are healthy, but because the people pushing this phrase invariably deny the health-promoting value of whole animal foods.

Denise Minger wrote a stellar critique of the dietary arguments in the movie.  I'm not going to try to duplicate the irreplaceable, so here I'm just going to stick to the pictures, explaining why I liked some of them and why I found some of them misleading.

Nature's Perfect Food 

Kudo's to them for not being bashful about breastfeeding.  I think modesty is important, but I wholeheartedly support any attempts to "normalize" breastfeeding, and it really bothers me that women in our society need to choose between working and rearing children when women in times past could work with their infants on their backs and breastfeed on demand.

Convenience Foods


Will anyone here deny that the "legendary foil-wrapped TV dinner" was one of the worst developments since sliced bread?  

"Processed Foods, Like Bleached Flour, Refined Sugars, and Oil" 


Not many of these in my cabinet.  Yours?


And you bet there ain't none of this.

Don't Tread on Me, Genes

"If you go through life thinking that what happens to you from a health perspective is based on your genes, you're a helpless victim."  

Preach it, sista!  I couldn't agree more. 

Shark Love

My favorite part of the movie was when evolutionary psychologist Doug Lisle took a brief foray into the intimacies intricacies of the mating behavior of great white sharks.

When the sharks first meet, it's love at first sight.  It's like when Jacob first beheld Rachel in all her beauty, and could not help but kiss her.  Within moments, we are sure that Cupid's arrow has struck, and the two seek refuge in a more private place.



I really appreciated the producers' modesty.  You and I both know what's going on here, but this is a movie I'd like to be able to watch with my family.  I think they did a fantastic job hitting the point home without needlessly offending anyone.

Dr. Lisle explained how a key point of the "motivational triad" is seeking pleasure, like food and sex.  Nevertheless, there are key differences between the ways males and females relate to these stimuli.  I know what you're thinking.  Male sharks want to feel competent, while female sharks want to feel cherished.  In the more difficult moments, male sharks go into their ocean-caves while female sharks talk about their problems.  But Dr. Lisle is having none of this nansy pansy relationship nonsense, and just gives us the simple facts, straight up:


Male and female sharks both care about food and sex, but the way to a male shark's heart is first through sex, and the way to a female shark's heart is first through food.  Who wudda thunk it!  I certainly learned something.

Dr. Lisle goes on to explain how when we have access to unlimited pleasurable stimuli — like modern pornographic junk food — we wind up swimming our way right into the "pleasure trap."  


It was like Jacob meeting Rachel's father.  Boy was he in for trouble.

Arteries Are Like Pipes?

Despite all of these fantastic themes, some of the pictures were misleading.  Consider this depiction of the atherosclerotic process, which comes on the screen as we begin learning of Dr. Esselstyn's work:

It shows cholesterol flowing through the blood and just glomming on to the inner lining of a blood vessel as if it were grease clogging up a pipe.  Is that how it happens?  Not at all.

First of all, the plaque grows behind the layer of the blood vessel in contact with the blood, not on top of it.  The plaque develops inside the blood vessel:

Second, the plaque doesn't initially progress inward to obstruct the blood vessel.  It initially progresses outward, pushing backwards into the middle of the blood vessel:

It doesn't begin occluding the blood vessel until it's already occupying about 40 percent of the blood vessel wall.  What happens to make it start occluding the blood vessel?  It appears to be the successive rupturing and re-healing of highly inflamed plaques:
On the left we see a secondary plaque forming on the surface of an initial plaque that had ruptured.  On the right we see that the worst plaques may have as many as four sites of rupture and re-healing.

There is little doubt in my mind that an eminent surgeon like Dr. Esselstyn knows this, and no doubt the producers chose to simplify the process so non-scientists could understand it.  Nevertheless, the depiction in Forks Over Knives is misleading.  It gives the audience the impression that a high concentration of cholesterol is the prime mover in atherosclerotic progression, when in fact the prime mover in the initiation of plaque is the oxidation of lipids and the immune system's effort to protect the blood vessel from these oxidized lipids, and the prime mover in coronary occlusion is the inflammatory process that degrades the plaque, causing it to rupture and re-heal.

Campbell's Magical Graphs

The movie did a good job covering Dr. Campbell's rat research. . . . sort of.  Let's start with the "revelation to die for" that led Campbell to begin this research.

I'm glad they mentioned this study, and it is certainly of interest for the audience to learn that the rats fed 20 percent casein in this experiment developed cancer, but I wish they would have mentioned that half the animals fed the low-protein diet died, as alluded to in the screen shot, which Denise already pointed out.  

Moving on, let's consider Campbell's magical graphs.  I love this one:


My oh my, where to begin?  

Something has magically disappeared from this graph.  It is, alas, the first five weeks of the study.  Here's a depiction of the study design from the original paper, published in 1991:

Notice that big white area on the left beginning with week -5 and ending with week zero?  As you can see from the top of the chart, this is the "initiation" period.  Forks Over Knives only shows us the promotion period.  None of the animals were fed 5 percent casein during the initiation period:

As we can also see here, the rats weren't fed 5 percent or 20 percent protein, as claimed in the movie.  They were fed 5 or 20 percent casein, which is equivalent to 4.35 or 17.4 percent protein.  But that's small potatoes.

What's really a shame is that we never learn from Forks Over Knives what happens to the rats when they are fed 5 percent casein during those first five weeks of the study.  Here's a graph constructed from the data Campbell published eight years earlier, in 1983:

If we look at the two bars in the middle, we can see that rats fed 5 percent casein during the initiation period and 20 percent casein during the promotion period develop the most precancerous lesions, while rats fed 20 percent casein during the initiation period and 5 percent casein during the promotion period develop the least.  Whoa!  I guess those first five weeks really do matter!  And those are five weeks where the high-casein diet proves powerfully protective.

It would also have been nice if Forks Over Knives would have taught us something about the importance of the dose of aflatoxin used in these studies.  Consider the data from this
 1987 paper Campbell published with his graduate student George Dunaif:

All the rats were fed 20 percent casein during the initiation period.  The groups of rats represented by the upper curve stayed on 20 percent casein through the duration of the study.  The groups in the lower curve were switched to different diets for the promotion period ranging in casein content from 20 percent on the far left to 4 percent on the far right.  As we move from left to right the dose of aflatoxin increases.

We can see from the lower curve that the groups fed low-protein diets did not develop "no evidence of cancer whatsoever" as stated in the movie, but rather developed precancerous lesions of the exact same type as developed by the groups of the upper curve, only occupying in this particular case 0.3 percent of their livers instead of 0.3-1.1 percent.

We can also see clearly that if the dose of aflatoxin is low enough, the protein doesn't promote cancer at all.  It certainly would have been valuable for us to learn, then, how Campbell chose these doses, and just how high they were.  Campbell published a preliminary study in this very paper, testing a wider range of doses.  Here is the survival curve plotted together with the cancer curve in that preliminary study:

As we can see, the precancerous lesions begin developing at just under the dose required to begin killing the animals.  As I pointed out in The Curious Case of Campbell's Rats and in How T. Colin Campbell Helped Prove That Protein Protects Us, even the dose marked "150" on the graph, which produces, in Campbell's words, "a barely detectable, but significant, response," would be equivalent to eating over a million peanut butter sandwiches each containing 100 grams of peanut butter contaminated with the maximum concentration of aflatoxin allowed by the Federal Government.  

It would also have been nice if Campbell or the producers had shared with us some of the studies that gave animals smaller doses of aflatoxin every day instead of only showing these studies where the animals received large nearly lethal doses all in a short period of time.  Denise dug up a couple of these and I think they could be neatly summarized in a picture like this:

If you'd like more details explaining this figure or descriptions of other magic tricks Campbell had played with his graphs, you can find them in yesterday's post.

All in All...

Despite these flaws, I think Forks Over Knives is a great movie.  If I were to meet Dr. Campbell you can bet I'd want to shake his hand for all his staunch efforts to put food forks over medical knives.  There's a lot that he and I agree on.  Essestyn too, and the rest of them.  But the movie's not just about them.  It's also about the people who recovered their health.  They don't care how much protein Campbell's rats were fed or what happened to their bile ducts (hint: they proliferated).  They care about the weight they lost, about the morning time they have with their spouses now that they're waking up earlier, and about their greater strength and overall better quality of life.  

If you like success stories and can tolerate a few wayward graphs, I'd encourage you to pick up a copy of Forks Over Knives the next time you're in the meat section of Whole Foods.  If you don't shop at Whole Foods, or you don't eat meat, you can order it online at their web site.  Or on Netflix, as Ewa notes in the comments.

Read more about the author, Chris Masterjohn, PhD, here.


  1. Thanks for the great review. I just wanted to add that one can watch that movie streaming on Netflix.

  2. Hi- thanks for an informative post, sometimes people watch a movie and think it's the panacea to their problems, with that said, it's great when it inspires them to change and live healthier lives-- additionally, from a nutritionist blogger I follow I just read about a study on Plant-Based Diets Lead to High Homocysteine, Low Sulfur and Marginal B12 Status -- good read - thank you

  3. Re: Glutathione, Dairy, Panacea comment above this one

    (reached a character limit on my comment)
    Click here for full comment.

  4. Hi Ewa,

    You're welcome, and thanks for the tip!

    Thanks inspirehappy.

    Gwarm, that link is very difficult for me to read, it's full of other links and html, and I have no idea what the context is. That said, glutathione is not a major sulfhydryl in plasma, so increased plasma total thiols does not indicate increases glutathione. I'm assuming he's talking about plasma, but like I said I have no idea what the context is.

    Increase glutathione in plasma is most likely a good thing. But yes, you have to take it in context. Most toxic things will increase glutathione synthesis, but if they are actually having a toxic action they'll probably deplete glutathione even moreso.


  5. A fun and informative review. You are now officially my favorite health blogger. Keep up the great work!

  6. Great post buddy. I turned a def ear to the propaganda (not much of it) and generally liked it too. It's a step in the right direction to show people eating crap is no good. That said, people who are going to take it as the gospel will be well served to read reviews like your and Denise's.

  7. Good job Chrs! My plantains jump into my mouth ASAP too :-)

  8. Oh ok, the context was in the "" link shorteners.

    I had everything properly HTML formatted, and HTML hyperlinked proper, but I just couldn't post that comment because the blog software used here wouldn't allow the many characters.

    I was just asking about CAC & dairy, and responding to the panacea comment.

  9. Is glutathione what is in Kombucha when properly fermented? If so, does that make it a good drink when consuming something otherwise foreign to the body?

  10. Great post, Chris. Between you and C. Kresser, I often hear of two indicators of CVD that are apparently more important than serum cholesterol: 1. Oxidative damage 2. Inflammation. Can these be tested for? Where can I learn more about these factors? Keep up the great work.

  11. Responses to everyone but in detail to gwarm, Sarah, and Brian.

    Thanks for the props everyone!

    gwarm, I reread the link and it is still quite confusing. The initial link goes to something on Facebook. I don't see any link to Eades's initial comments. It's difficult to tell who is who, and there is no context given for what is actually being discussed. That said, I agree with most of the comments except plasma SH is not a measure of glutathione, and plasma glutathione is not a specific marker for mitochondrial glutathione, and glutathione is synthesized in the cytosol.

    MDA would more properly be called a marker of oxidative damage rather than oxidative stress, because it is an end product of lipid per oxidation. Oxidative stress just means that an increase in oxidants is burdening the system, or a lack of antioxidants, or some dysregulation of the communication networks involved, and does not necessarily mean that there is a measurable increase in lipid peroxidation. In principle, if glutathione synthesis is being increased in response to oxidative stress, you should also see an increase in SOD and other parts of this defense pathway, but if these measurements were in plasma I do not think you can infer the intracellular activity of these enzymes from whatever is in plasma. So I don't think this argument holds much weight.

    That said, given the data quoted, it does sound like a probable benefit. It's a bit silly to observe a bunch of presumably good things happen and say "well maybe this is just a reaction to the bad stuff." I think to argue that you should show some bad stuff happening.

    Sarah, I'm not sure if there is glutathione in it but usually it is glucuronate that people attribute to kombucha, which is also used for detoxification. Theoretically it could be of benefit during exposure to other stresses.

    Brian, there are plenty of inflammatory markers but none verified as solid and independent diagnostics of CVD risk-related inflammation. All are in their experimental stage. You can ask Chris K what he uses in practice. I will write more on the strengths and limitations of such markers in the future.


  12. First time reader. Great post. I'll be back.

  13. LOL @ the diagram of Whole Foods... and a very entertaining and informative post in general with an nice interspersal of visuals :-)

  14. Coronary artery disease is NOT- NOT - a disease of the lumen. It is a disease of the vesel WALL.

  15. Hi Anonymous (or Razwell, if that is you),

    I agree that the disease is one of the intima and not one of the lumen. As far as I know everyone agrees on this, and I did not say anything contradicting it.

    Thank you for your comments,

  16. Hi Razwell,

    I appreciate your comments about the importance of wisdom and the imperfections of the scientific method, but I'm not going to tolerate personal attacks here. Denise kicking your personal attacks out of her comment section does not authorize you to bring them over here. People behave overwhelmingly civil in the blog comments here, and I generally do not maintain it that way by deleting ad hominem attacks. But if incivility does find its way here, trust me it will not last long. As such, I am deleting both of your comments making ad hominem attacks against Colpo but keeping what I assume is your comment about the lumen.


  17. Hi Chris,

    I just came across your blog- tons of useful information here. I liked what I was reading until I came across the following:

    "Nevertheless, there are key differences between the ways males and females relate to these stimuli. I know what you're thinking. Male sharks want to feel competent, while female sharks want to feel cherished."

    What is your evidence for making this claim about difference between male and female sharks? Distressingly, it seems that you are drawing on stereotypes about men and women.

    Based on the credible information I have read elsewhere on your site, I would not have expected that. In the future, I hope that you will examine your own prejudices more thoroughly before injecting them into otherwise useful content.


  18. Hi Caroline,

    Thanks for writing. I'm glad you like the other material, and I appreciate your criticism here, but I imagine it must have at least occurred to you that this was a joke, no? Indeed, it was a joke.

    Even if it weren't a joke, and were taken literally, I attributed it to popular perception and reported Dr. Lisle to refute this "nonsense," and of course male and female sharks are not "men and women." But alas, it was indeed a joke.

    I hope that clears things up.



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