Additional Comments on more VegSource/Jeff Nelson anti- nut videos – April 2019
April 29, 2019 by Joel Fuhrman, MD
Jeff Nelson made 2 more anti-nut videos recently, forcing me to comment again. It is clear the misinformation, distortions and false accusations are reflective of his undisguised agenda.
I also would like to remind all that a Nutritarian diet has, at its core, the concept of maintaining low body fat with moderate caloric restriction, while consuming the excellent and complete spectrum of micronutrients, so I do not endorse overeating on any food, nuts included. It is clear, however, that fatty acid insufficiency can be a major factor causing disease, and this possibility is mostly ignored or denied by low-fat extremists.
For many years, scientific studies have documented a link between nut/seed exclusion and cardiovascular death, but now Mr. Nelson has taken the initiative to, as he says, “put the final nail in the coffin” of all those nut-promoting nutritional advocates like Dr. Greger and myself (Dr. Fuhrman) who have been hoodwinked into believing bad, falsified and otherwise meaningless studies that show that eating nuts is healthful and lifespan-promoting. He is out to prove nuts and seeds are dangerous.
And now, he claims he has “proof” that nuts are bad, from a person he interviewed who used a pulse wave velocity machine after eating nuts, that demonstrated a reduced pulse-wave velocity after eating nuts. He never even mentioned that a transient decrease in pulse-wave velocity occurs after every large meal, regardless of its macronutrient composition (a meal of carbohydrate would have this effect also), and that the instructions from the manufacturer for this equipment instructs it is only accurate in the post-absorptive or non-digestive stage. This finding means nothing. He is so jubilant about the negative finding here, which clearly shows his distorted bias, or he would have tempered his enthusiasm with the reality that a temporary decrease in arterial elasticity after a meal, when blood is shunted from peripheral vessels to the digestive tract, is not indicative of long-term vessel damage or loss of elasticity. In fact, studies with large numbers of people (not just one) show nuts benefit vessel elasticity. For example, Dr. Greger did review all the studies to date on nuts and artery function and concluded: “Therefore, eight studies to date have investigated the effect of nuts on brachial artery function; seven out of eight showed a significant improvement in arterial function, one showed a negligible effect, and none found nuts made things worse.” https://nutritionfacts.org/2015/08/13/how-walnuts-can-improve-artery-function/
It is important to address the other video attacking me and the value of utilizing nuts and seeds in the diet again, because as I said earlier—this is a life-and-death situation, and people can die from poor nutritional advice. At issue here is that quite a few studies (see table) corroborate each other and show a significantly greater risk of cardiovascular death and all-cause mortality in those excluding nuts and seeds. If these findings represent a true effect of nuts, it indicates that his low-fat, nut-avoiding gurus are offering very dangerous advice. Nelson denies the validity of all these studies and attempts to convince his followers that all this data, from every study, is either fabricated due to nut industry funding or just a meaningless association. He disrespectfully, and without any evidence, defames the reputation of some of our nation’s leading nutritional researchers at Harvard and Loma Linda, who he insinuates have been paid off by the nut industry to falsify this data. He also claims that since epidemiological studies do not prove causation, all this data can be simply ignored. Not only is it safe (according to him) to eat a diet with less than 10 percent of calories from fat, without nuts, but he is advocating that their inclusion is harmful.
Then Mr. Nelson repeats over and over again in his videos that it is likely why one of my severely ill patients died young—because she ate nuts, which he is lying about. It was explained in the article that this patient had bone marrow cancer and 3 heart attacks in a 3-month period, and 5 stents placed, with poor cardiac output and restenosis that could not be treated, and was over 100 pounds overweight and near death when she came to me in her early 60s. I consider her history a major success case, as she was enabled to walk again and live fully, and she lived well for another 15 years in spite of her heart issues and bone marrow cancer. Of course, Mr. Nelson left out the details of her history, so he could claim the nuts in the Fuhrman protocol must have killed her. I guess hundreds of success stories of disease-reversal and recovery on my website submitted by patients and readers must also be faked, and I have been fabricating the thousands of patients I have cared for and reversed their heart disease and high blood pressure (with nuts in their diet) over the last 30 years, and made up all those case histories presented in my books and television appearances.
As the only one of these physician “gurus” who actually has been caring for patients in a full-time, nutritionally-oriented primary practice for 30 years, attending to people damaged by radical low-fat advice, it is a subject I feel strongly about as I have seen too many people damaged. He is insinuating that I am also fabricating data for money, and my 30 years of caring for this community of “wounded “ and, in many cases, permanently damaged (low-fat) vegans who have become depressed and demented is also faked, because I make money promoting and selling supplements, including a vegan DHA.
Allow me to address some of his arguments and claims. I think it will become pretty clear that the veracity of anything he says has to be questioned.
First of all – Nut industry Funding
Nelson talks about industry funding corrupting research and Marion Nestle’s book on industry funding in scientific research and plays clips from an interview with her. Certainly, industry funding can shape the questions researchers try to answer, but we can’t dismiss a study purely because it is industry-funded. Let’s look at some of the major studies in question and where their funding came from. These are all of the studies on nut consumption and all-cause mortality that have been evaluated by the three most recent meta-analyses on the subject. As you can see, the results have been similar for those that had some nut industry funding and those that did not.
National Institutes of Health, International Tree Nut Council Nutrition Research and Education Foundation
15% lower risk of all-cause mortality for 5-6 servings/week; 20% reduction for 7 or more servings/week; 9% for cancer death, 24% for heart disease for 2+ servings/week[9]
Spanish Ministry of Health, Centre Català de la Nutrició de l’Institut d’Estudis Catalans; the research institution which employed some of the authors had previously received funding from the International Nut and Dried Fruit Foundation; one author was a nonpaid member of the Scientific Advisory Committee of the California Walnut Commission.
39% lower mortality risk for 3 or more servings of nuts/week[11]
National Cancer Institute, National Institutes of Health; one author declared a conflict of interest – had previously received a grant from the California Walnut Commission
24% reduction in all-cause mortality risk for 5+ servings/week[12]
Shanghai cohort: 17% reduction in risk in highest (>18.45 g/day) vs. lowest (<0.95 g/day) quintile of nut consumption; 38% reduction in risk of death from IHD[13]
Netherlands cohort: 23% risk reduction for 10+ g/d vs. 0 g/d.[14]
I gave an example of a recent non-industry-funded study that found a decrease in all-cause mortality risk associated with nuts. He countered by saying it doesn’t count because there wasn’t a dose response, and because of the possibility of confounding factors (any time a study suggests a benefit for nuts, he will bring up confounding factors). I have to reiterate that the three most recent meta-analyses did, in fact, report a dose response for all-cause mortality. Nelson leaves out any data that contradicts his agenda. Even a few weeks back a new NIH-funded, Harvard-based study published in Circulation research showed a 34% decreased death rate from cardiovascular disease in diabetics eating more tree nuts.[15] Good thing we have Jeff Nelson around to debunk all this fake news published by all these lying Harvard researchers.
He claimed I was citing “old, weak association” studies
I cited studies from the 1990s and early 2000s, such as the Adventist Health Study and Iowa Women’s Health Study. What he neglects to acknowledge is that these are the studies that suggested cardiovascular benefits for nuts before there was any funding from the nut industry. That’s part of the point in citing those. He sees that some of the early studies were done by Gary Fraser, and assumes they were funded by the nut industry, but that is incorrect. This was before the nut industry was funding any of his research.
The Adventist Health Study-1 started in 2004 and has concluded. The Adventist Health Study-2 recruited participants from 2001-2007 and is ongoing, and findings have been published as recently as October 2018.[16] Nelson refers to it as “old data,” which is not true.
There was no nut industry funding for this recent publication. AgroParisTech Foundation, ADEPRINA/AgroParisTech, (research institutions in France) and the National Institutes of Health funded this research. The Adventist Health Study-2 is the longest running and most threatening study to his point of view, because it divides the consumption into 5 different quintiles in an Adventist population, many of whom are vegetarians and vegans. The same study shows eating animal protein also increases cardiovascular death.
Confounding factors
For any study I cite that suggests a benefit for nuts, Mr. Nelson will dig into the discussion section, where the limitations of the study are discussed, and pull out the authors’ statements about the potential for additional confounding factors or existing factors they may not have been able to adequately control for. Every epidemiologic study on a dietary factor that finds a significant association will say something like that. Researchers need to do this, and it is true that the 39% increase risk of cardiovascular death may be off somewhat, maybe if all the potential cofounders were adequality taken into account the risk increased risk of death may have only been 35%, but that does not make the association and every epidemiologic study worthless.
When you are studying humans, there is always the possibility that there was another statistical adjustment that would have made the data more accurate, not worthless. Plus, some studies are drawing from more complete dietary and other background data than others.
Then he’ll say that it’s only an “association study” as opposed to a randomized controlled trial. The advantage of a prospective cohort study is that the sample sizes can be larger and the study can run much longer than most RCTs. Most RCTs won’t be able to run long enough to get enough data to evaluate mortality.
He mentions the Cochrane review of RCTs again and distorts the findings and purpose. The Cochrane analysis[17] attempted to find sufficient randomized controlled trials to support the long-term prospective studies and found a lack of such trials. The review looked for RCTs longer than 12 weeks that reported on death or cardiovascular events and as the authors stated, “none of the studies identified reported on deaths or cardiovascular events,” so they could not come to a conclusion. The fact that this investigation did not corroborate the Adventist and other long-term trial is meaningless. We still have to make a judgement based on the studies that presently exist.
Then he claims to have found a recent (2018) study that contradicts cardiovascular benefits of nuts. It didn’t.[18]
The researchers state “Nut consumption was inversely associated with risk of myocardial infarction, heart failure, atrial fibrillation and abdominal aortic aneurysm in the age-adjusted and sex-adjusted analysis. However, adjustment for multiple risk factors attenuated these associations and only a linear, dose-response association with atrial fibrillation (ptrend=0.004) and a non-linear association (pnon-linearity=0.003) with heart failure remained. Compared with no consumption of nuts, the multivariable HRs (95% CI) of atrial fibrillation across categories of nut consumption were 0.97 (0.93 to 1.02) for 1-3 times/month, 0.88 (0.79 to 0.99) for 1-2 times/week and 0.82 (0.68 to 0.99) for ≥3 times/week. For heart failure, the corresponding HRs (95% CI) were 0.87 (0.80 to 0.94), 0.80 (0.67 to 0.97) and 0.98 (0.76 to 1.27).”
This study did find linear dose-response for atrial fibrillation, and a significant association with heart failure. So it certainly did not suggest that nuts are worthless for cardiovascular health. However, the participants in this study were not eating many nuts, which likely accounts for some of the weaker associations. The highest level of nut consumption in this Swedish population was only 3 or more times/week and only 2% of the study population reported eating nuts that often. Several studies had 5 or more/week as the highest level, or even 1 or more per day. On this topic, the authors note: “…the effect of nut intake on cholesterol appears to be non-linear with an effect primarily seen at intakes of at least 60 g/day. As they explained, nut consumption in this study population was too low to have a meaningful impact on cholesterol levels.”
Mr. Nelson claims that because this study didn’t find associations for myocardial infarction (MI; heart attack) after multivariate adjustment, it is likely that previous studies did not control adequately for dietary factors. That is again not true. They used two different multivariate adjustments in addition to the age and sex-only adjustment. Multivariate 1 adjusted for education, family history of myocardial infarction before 60 years of age, smoking, walking/bicycling, exercise, aspirin use, alcohol, fruits, vegetables, and total energy. Multivariate 2 added adjustments for “potential intermediates of the nut-CVD relationship,” including BMI, history of diabetes, history of hypertension, history of hypercholesterolemia. The trends for total MI and nonfatal MI were significant in multivariate 1, but lost significance in multivariate 2. This reflected the small percentage of moderate and “high” (3x/week or more) nut consumers in this study: only 5% had moderate nut intake and less than 2% had high nut intake.
The authors also state in the discussion: “While results on nut consumption and incidence of myocardial infarction are inconclusive, the overall evidence indicates that nut consumption is inversely associated with mortality from CVD, in particular coronary heart disease. In a meta-analysis of 11 prospective studies, the HR of coronary heart disease was 0.76 (95% CI 0.69 to 0.84) for the highest versus lowest category of nut consumption.” Clearly, these scientists don’t think their data invalidates or contradicts the studies suggesting decreases in cardiovascular death associated with nut consumption.
Nelson’s claim that non-industry funded studies come to different conclusions is untrue.
Most of these large prospective studies (see table) were not industry-funded. I’ve highlighted the ones that were either industry-funded or had conflicts of interest related to the nut industry. Only one of these 14 studies did not find a significant association between nut consumption and all-cause mortality (Mann et al). If you can’t call this evidence “overwhelming” then you clearly have a biased agenda. If what Nelson is saying were true, we would expect all of the industry-funded studies to have positive results, and most or all of the non-industry-funded studies to have null results. That is not the case. Even the FDA, which sets a high bar for level of evidence and is extremely conservative about the health claims, permits a qualified health claim for using nuts and seeds to protect against cardiovascular disease.
Mr. Nelson also brings up Dean Ornish as someone also advocating this extremely radical fat-phobic advice, which he knows is untrue, too. As I stated in the earlier response and Mr. Nelson knew, Dr. Ornish has always recommended high-dose fish oils to accompany his low-fat diet, before he began to include nuts and seeds in his program. Using fish oils as a major source of fatty acids in place of the fat from dietary seeds and nuts has not been studied by this research and is not in question here. Nelson has been, and is, advocating and supporting the view that neither DHA supplementation nor nuts and seeds are necessary or healthful.
In my 2010 review article on vegan athletes, my affiliation with DrFuhrman.com and the sale of products and services were revealed when the article was submitted, contrary to what Mr. Nelson claims. The journal chose to acknowledge the affiliation “DrFuhrman.com” right at the top of the article, but then clarified in more detail after a complaint was submitted.
In conclusion, I take a more cautious approach to dietary and nutritional advice, even when data can be in debate. I make a thorough attempt to combine the preponderance of the evidence with clinical experience, while always erring on the side of caution, and moderating recommendations to meet the needs of each individual, which can be different. What is not discussed in depth here, but something I have addressed in my writings and lectures as well – is that telling people that an extremely low-fat vegan diet is safe and appropriate for all, and that nobody needs additional supplementation (with DHA) is irresponsible and dangerous. I will continue to fight against this contingency of radicals that has damaged the health of many with their radical agenda and philosophical rigidity.
Addendum to this post:
Jeff Nelson published another video attacking me, disparaging the above post as being fake news and empty of substance. He got very angry and lashed out. He tried as hard as he could to smear my name with false accusations. He also falsified the amount I charge for a 3-month stay at my retreat, to try to make me look bad. I have been the target of attacks by this contingency of low-fat extremists for years now—but I prefer not to mention names.
Accusations include that I had in some way changed the results of a weight loss study to make it look better. The researchers in that study who made that small error, acknowledged it in an addendum to the journal, correcting the calculations and made it clear that I was not involved in such calculations. The actual results of that study were still substantial, which should be the main point. My only part in this study was to open up my office charts so the researchers could review them and collect the data, I was not part of the calculations and statistical analysis.
As President of the Nutritional Research Foundation (NRF), I have done what I could to personally support the cost of, and raise money for, nutritional research that I deemed important. These studies are expensive. The sale of products at DrFuhrman.com has been supporting such nutritional research.
To be specific with one of the main issues here, I have reported that I have encountered some vegans, not supplementing with DHA, who have become demented, due to what I believe was from DHA deficiency. I also have encountered a few who developed Parkinson’s disease and some with low levels who have developed depression. Finding a limited number of these people does not demonstrate how rare or how prevalent this problem is. Nor does it mean for sure that the low DHA levels was the cause of their dementia or other problems. Therefore, I was instrumental in funding a study through the NRF of 166 un-supplemented vegans to ascertain the answer. That study, published in a peer reviewed journal, showed insufficiencies in about half and severe deficiencies in about a quarter. These severe deficiencies were consistent with other studies that demonstrate brain shrinkage with aging with this level of deficiency. Sure, more studies are always better, but we have to make a decision on the data we have and err on the side of caution.
I think this issue is critical for all vegans to be aware of. Even if it is one in a hundred or one in ten that gets harmed, it is still a needless event that could have easily been protected against.
I do sell an algae-derived vegan DHA, refrigerated and without additives (as well as lots of other products and services) and I feel it is important that I do so. I am doing what I think is best for my clients, patients, family and friends to best protect their health and longevity, and make it as easy as possible for them to do so. For those who don’t agree with my reasons for developing and supplying such a product, or think I am making up fake science and fake case histories in my writings, just to sell products and make money, they have the freedom to adhere to whatever dietary and nutritional program they choose.
I have a passion for doing what I am doing and feel blessed that I have the opportunity to help so many people recover their health and protect their future. I am always open to learning more and modifying recommendations, should advancements in science show a better way.
I am not paid anything from the nut or seed industry, (but maybe they should start sending me checks), but I think the research demonstrates with clarity that people with and without heart conditions are taking a significant increased risk if they cut all the nuts and seeds out of their diet. I have presented the evidence for this conclusion sufficiently. We have to go with whatever research is available at this time, plus my years of clinical experience in treating hundreds with heart disease over the years, supports the efficacy and safety of this method too. I have been in practice long enough to have followed these cases for decades and have watched these individuals grow old. I am confident and proud of giving people what I think is the best advice to protect their future.
Regardless if these attacks continue or not, this is all I am going to say on this matter.
References
[1] Fraser GE, Sumbureru D, Pribis P, et al. Association among health habits, risk factors, and all-cause mortality in a black California population. Epidemiology. 1997 Mar;8(2):168-74.
[2] Fraser GE, Shavlik DJ. Risk factors for all-cause and coronary heart disease mortality in the oldest-old. The Adventist Health Study. Arch Intern Med. 1997 Oct 27;157(19):2249-58.
[3] Mann JI, Appleby PN, Key TJ, Thorogood M. Dietary determinants of ischaemic heart disease in health conscious individuals. Heart. 1997 Nov;78(5):450-5.
[4] Ellsworth JL, Kushi LH, Folsom AR. Frequent nut intake and risk of death from coronary heart disease and all causes in postmenopausal women: the Iowa Women's Health Study. Nutr Metab Cardiovasc Dis. 2001 Dec;11(6):372-7.
[5] Fraser GE, Shavlik DJ. Ten years of life: Is it a matter of choice? Arch Intern Med 2001, 161:1645-1652.
[6] Blomhoff R, Carlsen MH, Andersen LF, Jacobs DR Jr. Health benefits of nuts:
potential role of antioxidants. Br J Nutr. 2006 Nov;96 Suppl 2:S52-60.
[7] van den Brandt PA. The impact of a Mediterranean diet and healthy lifestyle on premature mortality in men and women. Am J Clin Nutr. 2011 Sep;94(3):913-20.
[8] Baer HJ, Glynn RJ, Hu FB, et al. Risk factors for mortality in the nurses' health study: a competing risks analysis. Am J Epidemiol 2011, 173:319-329.
[9] Bao Y, Han J, Hu FB, et al. Association of nut consumption with total and cause-specific mortality. N Engl J Med 2013, 369:2001-2011.
[10] Levitan EB, Lewis CE, Tinker LF, et al. Mediterranean and DASH diet scores and mortality in women with heart failure: The Women's Health Initiative. Circ Heart Fail. 2013 Nov;6(6):1116-23.
[11] Guasch-Ferré M, Bulló M, Martínez-González MÁ, et al.; PREDIMED study group. Frequency of nut consumption and mortality risk in the PREDIMED nutrition intervention trial. BMC Med. 2013 Jul 16;11:164.
[12] Hshieh TT, Petrone AB, Gaziano JM, Djousse L. Nut consumption and risk of mortality in the Physicians' Health Study. Am J Clin Nutr 2015, 101:407-412.
[13] Luu HN, Blot WJ, Xiang YB, et al. Prospective Evaluation of the Association of Nut/Peanut Consumption With Total and Cause-Specific Mortality. JAMA Intern Med 2015.
[14] van den Brandt PA, Schouten LJ. Relationship of tree nut, peanut and peanut butter intake with total and cause-specific mortality: a cohort study and meta-analysis. Int J Epidemiol 2015.
[15] Liu G, Guasch-Ferré M, Hu Y, et al. Nut Consumption in Relation to Cardiovascular Disease Incidence and Mortality Among Patients With Diabetes Mellitus. Circ Res. 2019 Mar 15;124(6):920-929.
[16] Tharrey M, Mariotti F, Mashchak A, et al. Patterns of plant and animal protein intake are strongly associated with cardiovascular mortality: the Adventist Health Study-2 cohort. Int J Epidemiol.
2018 Oct 1;47(5):1603-1612.
[17] Martin N, Germanò R, Hartley L, et al. Nut consumption for the primary prevention of cardiovascular disease. Cochrane Database of Systematic Reviews 2015, Issue 9. Art. No.: CD011583.
[18] Larsson SC, Drca N, Björck M, et al. Nut consumption and incidence of seven cardiovascular diseases. Heart. 2018 Oct;104(19):1615-1620.
Joel Fuhrman, M.D. is a board-certified family physician, seven-time New York Times bestselling author and internationally recognized expert on nutrition and natural healing, who specializes in preventing and reversing disease through nutritional methods. Dr. Fuhrman coined the term “Nutritarian” to describe his longevity-promoting, nutrient dense, plant-rich eating style.
For over 30 years, Dr. Fuhrman has shown that it is possible to achieve sustainable weight loss and reverse heart disease, diabetes and many other illnesses using smart nutrition. In his medical practice, and through his books and PBS television specials, he continues to bring this life-saving message to hundreds of thousands of people around the world.
Additional Comments on more VegSource/Jeff Nelson anti- nut videos – April 2019
April 29, 2019 by Joel Fuhrman, MD
Jeff Nelson made 2 more anti-nut videos recently, forcing me to comment again. It is clear the misinformation, distortions and false accusations are reflective of his undisguised agenda.
I also would like to remind all that a Nutritarian diet has, at its core, the concept of maintaining low body fat with moderate caloric restriction, while consuming the excellent and complete spectrum of micronutrients, so I do not endorse overeating on any food, nuts included. It is clear, however, that fatty acid insufficiency can be a major factor causing disease, and this possibility is mostly ignored or denied by low-fat extremists.
For many years, scientific studies have documented a link between nut/seed exclusion and cardiovascular death, but now Mr. Nelson has taken the initiative to, as he says, “put the final nail in the coffin” of all those nut-promoting nutritional advocates like Dr. Greger and myself (Dr. Fuhrman) who have been hoodwinked into believing bad, falsified and otherwise meaningless studies that show that eating nuts is healthful and lifespan-promoting. He is out to prove nuts and seeds are dangerous.
And now, he claims he has “proof” that nuts are bad, from a person he interviewed who used a pulse wave velocity machine after eating nuts, that demonstrated a reduced pulse-wave velocity after eating nuts. He never even mentioned that a transient decrease in pulse-wave velocity occurs after every large meal, regardless of its macronutrient composition (a meal of carbohydrate would have this effect also), and that the instructions from the manufacturer for this equipment instructs it is only accurate in the post-absorptive or non-digestive stage. This finding means nothing. He is so jubilant about the negative finding here, which clearly shows his distorted bias, or he would have tempered his enthusiasm with the reality that a temporary decrease in arterial elasticity after a meal, when blood is shunted from peripheral vessels to the digestive tract, is not indicative of long-term vessel damage or loss of elasticity. In fact, studies with large numbers of people (not just one) show nuts benefit vessel elasticity. For example, Dr. Greger did review all the studies to date on nuts and artery function and concluded: “Therefore, eight studies to date have investigated the effect of nuts on brachial artery function; seven out of eight showed a significant improvement in arterial function, one showed a negligible effect, and none found nuts made things worse.” https://nutritionfacts.org/2015/08/13/how-walnuts-can-improve-artery-function/
It is important to address the other video attacking me and the value of utilizing nuts and seeds in the diet again, because as I said earlier—this is a life-and-death situation, and people can die from poor nutritional advice. At issue here is that quite a few studies (see table) corroborate each other and show a significantly greater risk of cardiovascular death and all-cause mortality in those excluding nuts and seeds. If these findings represent a true effect of nuts, it indicates that his low-fat, nut-avoiding gurus are offering very dangerous advice. Nelson denies the validity of all these studies and attempts to convince his followers that all this data, from every study, is either fabricated due to nut industry funding or just a meaningless association. He disrespectfully, and without any evidence, defames the reputation of some of our nation’s leading nutritional researchers at Harvard and Loma Linda, who he insinuates have been paid off by the nut industry to falsify this data. He also claims that since epidemiological studies do not prove causation, all this data can be simply ignored. Not only is it safe (according to him) to eat a diet with less than 10 percent of calories from fat, without nuts, but he is advocating that their inclusion is harmful.
Then Mr. Nelson repeats over and over again in his videos that it is likely why one of my severely ill patients died young—because she ate nuts, which he is lying about. It was explained in the article that this patient had bone marrow cancer and 3 heart attacks in a 3-month period, and 5 stents placed, with poor cardiac output and restenosis that could not be treated, and was over 100 pounds overweight and near death when she came to me in her early 60s. I consider her history a major success case, as she was enabled to walk again and live fully, and she lived well for another 15 years in spite of her heart issues and bone marrow cancer. Of course, Mr. Nelson left out the details of her history, so he could claim the nuts in the Fuhrman protocol must have killed her. I guess hundreds of success stories of disease-reversal and recovery on my website submitted by patients and readers must also be faked, and I have been fabricating the thousands of patients I have cared for and reversed their heart disease and high blood pressure (with nuts in their diet) over the last 30 years, and made up all those case histories presented in my books and television appearances.
As the only one of these physician “gurus” who actually has been caring for patients in a full-time, nutritionally-oriented primary practice for 30 years, attending to people damaged by radical low-fat advice, it is a subject I feel strongly about as I have seen too many people damaged. He is insinuating that I am also fabricating data for money, and my 30 years of caring for this community of “wounded “ and, in many cases, permanently damaged (low-fat) vegans who have become depressed and demented is also faked, because I make money promoting and selling supplements, including a vegan DHA.
Allow me to address some of his arguments and claims. I think it will become pretty clear that the veracity of anything he says has to be questioned.
First of all – Nut industry Funding
Nelson talks about industry funding corrupting research and Marion Nestle’s book on industry funding in scientific research and plays clips from an interview with her. Certainly, industry funding can shape the questions researchers try to answer, but we can’t dismiss a study purely because it is industry-funded. Let’s look at some of the major studies in question and where their funding came from. These are all of the studies on nut consumption and all-cause mortality that have been evaluated by the three most recent meta-analyses on the subject. As you can see, the results have been similar for those that had some nut industry funding and those that did not.
Publication
Funding sources
Findings
Fraser GE, Sumbureru D, Pribis P, et al. Association among health habits, risk factors, and all-cause mortality in a black California
population. Epidemiology. 1997 Mar;8(2):168-74.
National Institutes of Health
44% decrease in all-cause mortality for highest tertile of nut consumption[1]
Fraser GE, Shavlik DJ. Risk factors for all-cause and coronary heart disease mortality in the oldest-old. The Adventist Health Study. Arch Intern Med. 1997
Oct 27;157(19):2249-58.
National Institutes of Health
18% reduction in risk of all-cause mortality for nuts 5 times/week, 39% for death from CHD compared to less than once/week[2]
Mann JI, Appleby PN, Key TJ, Thorogood M. Dietary determinants of ischaemic heart disease in health conscious individuals. Heart. 1997 Nov;78(5):450-5.
Imperial Cancer Research Fund (UK)
Non-significant 23% reduction in risk for 5 ounces of nuts/week compared to less than one ounce/week[3]
Ellsworth JL, Kushi LH, Folsom AR. Frequent nut intake and risk of death from coronary heart disease and all causes in postmenopausal women: the Iowa Women's Health Study. Nutr Metab Cardiovasc Dis. 2001 Dec;11(6):372-7.
National Institutes of Health
12% decrease in risk of all-cause mortality in women consuming at least 2 servings of nuts/week compared to <1/month[4]
Fraser GE, Shavlik DJ. Ten years of life: Is it a matter of choice? Arch Intern Med 2001, 161:1645-1652.
National Institutes of Health
Nut consumption 5+ servings/week associated with 2.74 extra years of life in men, 1.87 years in women[5]
Blomhoff R, Carlsen MH, Andersen LF, Jacobs DR Jr. Health benefits of nuts:
potential role of antioxidants. Br J Nutr. 2006 Nov;96 Suppl 2:S52-60.
Research Council of Norway, Throne Holst Foundation, Norwegian Cancer Society
Nuts 5+ times/week associated with 11% reduction in risk of all-cause mortality compared to <1/week[6]
van den Brandt PA. The impact of a Mediterranean diet and healthy lifestyle on premature mortality in men and women. Am J Clin Nutr. 2011 Sep;94(3):913-20.
Dutch Cancer Society
8% for men and 5% for women lower risk in 75th percentile of nut intake compared to 25th percentile[7]
Baer HJ, Glynn RJ, Hu FB, et al. Risk factors for mortality in the nurses' health study: a competing risks analysis. Am J Epidemiol 2011, 173:319-329.
National Cancer Institute, National Institutes of Health, American Cancer Society
2+ servings of nuts per week associated with 14% lower all-cause mortality risk vs. little to none; also 14% decrease in CVD mortality[8]
Bao Y, Han J, Hu FB, et al. Association of nut consumption with total and cause-specific mortality. N Engl J Med 2013, 369:2001-2011.
National Institutes of Health, International Tree Nut Council Nutrition Research and Education Foundation
15% lower risk of all-cause mortality for 5-6 servings/week; 20% reduction for 7 or more servings/week; 9% for cancer death, 24% for heart disease for 2+ servings/week[9]
Levitan EB, Lewis CE, Tinker LF, et al.
Mediterranean and DASH diet scores
and mortality in women with heart failure: The Women's Health Initiative. Circ Heart Fail. 2013 Nov;6(6):1116-23.
National Institutes of Health
14% decrease risk of all-cause mortality in 4th quartile of nut consumption compared to 1st..[10]
Guasch-Ferré M, Bulló M, Martínez-González MÁ, et al.; PREDIMED
study group. Frequency of nut consumption and mortality risk in the PREDIMED nutrition intervention trial. BMC Med. 2013 Jul 16;11:164.
Spanish Ministry of Health, Centre Català de la Nutrició de l’Institut d’Estudis Catalans; the research institution which employed some of the authors had previously received funding from the International Nut and Dried Fruit Foundation; one author was a nonpaid member of the Scientific Advisory Committee of the California Walnut Commission.
39% lower mortality risk for 3 or more servings of nuts/week[11]
Hshieh TT, Petrone AB, Gaziano JM, Djousse L. Nut consumption and risk of mortality in the Physicians' Health Study. Am J Clin Nutr 2015, 101:407-412.
National Cancer Institute, National Institutes of Health; one author declared a conflict of interest – had previously received a grant from the California Walnut Commission
24% reduction in all-cause mortality risk for 5+ servings/week[12]
Luu HN, Blot WJ, Xiang YB, et al. Prospective Evaluation of the Association of Nut/Peanut Consumption With Total and Cause-Specific Mortality. JAMA Intern Med 2015.
National Cancer Institute
U.S. cohort: 21% reduction in risk
Shanghai cohort: 17% reduction in risk in highest (>18.45 g/day) vs. lowest (<0.95 g/day) quintile of nut consumption; 38% reduction in risk of death from IHD[13]
van den Brandt PA, Schouten LJ. Relationship of tree nut, peanut and peanut butter intake with total and cause-specific mortality: a cohort study and meta-analysis. Int J Epidemiol 2015.
No external funding
Netherlands cohort: 23% risk reduction for 10+ g/d vs. 0 g/d.[14]
I gave an example of a recent non-industry-funded study that found a decrease in all-cause mortality risk associated with nuts. He countered by saying it doesn’t count because there wasn’t a dose response, and because of the possibility of confounding factors (any time a study suggests a benefit for nuts, he will bring up confounding factors). I have to reiterate that the three most recent meta-analyses did, in fact, report a dose response for all-cause mortality. Nelson leaves out any data that contradicts his agenda. Even a few weeks back a new NIH-funded, Harvard-based study published in Circulation research showed a 34% decreased death rate from cardiovascular disease in diabetics eating more tree nuts.[15] Good thing we have Jeff Nelson around to debunk all this fake news published by all these lying Harvard researchers.
He claimed I was citing “old, weak association” studies
I cited studies from the 1990s and early 2000s, such as the Adventist Health Study and Iowa Women’s Health Study. What he neglects to acknowledge is that these are the studies that suggested cardiovascular benefits for nuts before there was any funding from the nut industry. That’s part of the point in citing those. He sees that some of the early studies were done by Gary Fraser, and assumes they were funded by the nut industry, but that is incorrect. This was before the nut industry was funding any of his research.
The Adventist Health Study-1 started in 2004 and has concluded. The Adventist Health Study-2 recruited participants from 2001-2007 and is ongoing, and findings have been published as recently as October 2018.[16] Nelson refers to it as “old data,” which is not true.
Tharrey M, Mariotti F, Mashchak A, et al. Patterns of plant and animal protein intake are strongly associated with cardiovascular mortality: the Adventist Health Study-2 cohort. Int J Epidemiol. 2018 Oct 1;47(5):1603-1612.
There was no nut industry funding for this recent publication. AgroParisTech Foundation, ADEPRINA/AgroParisTech, (research institutions in France) and the National Institutes of Health funded this research. The Adventist Health Study-2 is the longest running and most threatening study to his point of view, because it divides the consumption into 5 different quintiles in an Adventist population, many of whom are vegetarians and vegans. The same study shows eating animal protein also increases cardiovascular death.
Confounding factors
For any study I cite that suggests a benefit for nuts, Mr. Nelson will dig into the discussion section, where the limitations of the study are discussed, and pull out the authors’ statements about the potential for additional confounding factors or existing factors they may not have been able to adequately control for. Every epidemiologic study on a dietary factor that finds a significant association will say something like that. Researchers need to do this, and it is true that the 39% increase risk of cardiovascular death may be off somewhat, maybe if all the potential cofounders were adequality taken into account the risk increased risk of death may have only been 35%, but that does not make the association and every epidemiologic study worthless.
When you are studying humans, there is always the possibility that there was another statistical adjustment that would have made the data more accurate, not worthless. Plus, some studies are drawing from more complete dietary and other background data than others.
Then he’ll say that it’s only an “association study” as opposed to a randomized controlled trial. The advantage of a prospective cohort study is that the sample sizes can be larger and the study can run much longer than most RCTs. Most RCTs won’t be able to run long enough to get enough data to evaluate mortality.
He mentions the Cochrane review of RCTs again and distorts the findings and purpose. The Cochrane analysis[17] attempted to find sufficient randomized controlled trials to support the long-term prospective studies and found a lack of such trials. The review looked for RCTs longer than 12 weeks that reported on death or cardiovascular events and as the authors stated, “none of the studies identified reported on deaths or cardiovascular events,” so they could not come to a conclusion. The fact that this investigation did not corroborate the Adventist and other long-term trial is meaningless. We still have to make a judgement based on the studies that presently exist.
Then he claims to have found a recent (2018) study that contradicts cardiovascular benefits of nuts. It didn’t.[18]
Larsson SC, Drca N, Björck M, et al. Nut consumption and incidence of seven cardiovascular diseases. Heart. 2018;104(19):1615-1620.
The researchers state “Nut consumption was inversely associated with risk of myocardial infarction, heart failure, atrial fibrillation and abdominal aortic aneurysm in the age-adjusted and sex-adjusted analysis. However, adjustment for multiple risk factors attenuated these associations and only a linear, dose-response association with atrial fibrillation (ptrend=0.004) and a non-linear association (pnon-linearity=0.003) with heart failure remained. Compared with no consumption of nuts, the multivariable HRs (95% CI) of atrial fibrillation across categories of nut consumption were 0.97 (0.93 to 1.02) for 1-3 times/month, 0.88 (0.79 to 0.99) for 1-2 times/week and 0.82 (0.68 to 0.99) for ≥3 times/week. For heart failure, the corresponding HRs (95% CI) were 0.87 (0.80 to 0.94), 0.80 (0.67 to 0.97) and 0.98 (0.76 to 1.27).”
This study did find linear dose-response for atrial fibrillation, and a significant association with heart failure. So it certainly did not suggest that nuts are worthless for cardiovascular health. However, the participants in this study were not eating many nuts, which likely accounts for some of the weaker associations. The highest level of nut consumption in this Swedish population was only 3 or more times/week and only 2% of the study population reported eating nuts that often. Several studies had 5 or more/week as the highest level, or even 1 or more per day. On this topic, the authors note: “…the effect of nut intake on cholesterol appears to be non-linear with an effect primarily seen at intakes of at least 60 g/day. As they explained, nut consumption in this study population was too low to have a meaningful impact on cholesterol levels.”
Mr. Nelson claims that because this study didn’t find associations for myocardial infarction (MI; heart attack) after multivariate adjustment, it is likely that previous studies did not control adequately for dietary factors. That is again not true. They used two different multivariate adjustments in addition to the age and sex-only adjustment. Multivariate 1 adjusted for education, family history of myocardial infarction before 60 years of age, smoking, walking/bicycling, exercise, aspirin use, alcohol, fruits, vegetables, and total energy. Multivariate 2 added adjustments for “potential intermediates of the nut-CVD relationship,” including BMI, history of diabetes, history of hypertension, history of hypercholesterolemia. The trends for total MI and nonfatal MI were significant in multivariate 1, but lost significance in multivariate 2. This reflected the small percentage of moderate and “high” (3x/week or more) nut consumers in this study: only 5% had moderate nut intake and less than 2% had high nut intake.
The authors also state in the discussion: “While results on nut consumption and incidence of myocardial infarction are inconclusive, the overall evidence indicates that nut consumption is inversely associated with mortality from CVD, in particular coronary heart disease. In a meta-analysis of 11 prospective studies, the HR of coronary heart disease was 0.76 (95% CI 0.69 to 0.84) for the highest versus lowest category of nut consumption.” Clearly, these scientists don’t think their data invalidates or contradicts the studies suggesting decreases in cardiovascular death associated with nut consumption.
Nelson’s claim that non-industry funded studies come to different conclusions is untrue.
Most of these large prospective studies (see table) were not industry-funded. I’ve highlighted the ones that were either industry-funded or had conflicts of interest related to the nut industry. Only one of these 14 studies did not find a significant association between nut consumption and all-cause mortality (Mann et al). If you can’t call this evidence “overwhelming” then you clearly have a biased agenda. If what Nelson is saying were true, we would expect all of the industry-funded studies to have positive results, and most or all of the non-industry-funded studies to have null results. That is not the case. Even the FDA, which sets a high bar for level of evidence and is extremely conservative about the health claims, permits a qualified health claim for using nuts and seeds to protect against cardiovascular disease.
Mr. Nelson also brings up Dean Ornish as someone also advocating this extremely radical fat-phobic advice, which he knows is untrue, too. As I stated in the earlier response and Mr. Nelson knew, Dr. Ornish has always recommended high-dose fish oils to accompany his low-fat diet, before he began to include nuts and seeds in his program. Using fish oils as a major source of fatty acids in place of the fat from dietary seeds and nuts has not been studied by this research and is not in question here. Nelson has been, and is, advocating and supporting the view that neither DHA supplementation nor nuts and seeds are necessary or healthful.
In my 2010 review article on vegan athletes, my affiliation with DrFuhrman.com and the sale of products and services were revealed when the article was submitted, contrary to what Mr. Nelson claims. The journal chose to acknowledge the affiliation “DrFuhrman.com” right at the top of the article, but then clarified in more detail after a complaint was submitted.
In conclusion, I take a more cautious approach to dietary and nutritional advice, even when data can be in debate. I make a thorough attempt to combine the preponderance of the evidence with clinical experience, while always erring on the side of caution, and moderating recommendations to meet the needs of each individual, which can be different. What is not discussed in depth here, but something I have addressed in my writings and lectures as well – is that telling people that an extremely low-fat vegan diet is safe and appropriate for all, and that nobody needs additional supplementation (with DHA) is irresponsible and dangerous. I will continue to fight against this contingency of radicals that has damaged the health of many with their radical agenda and philosophical rigidity.
Addendum to this post:
Jeff Nelson published another video attacking me, disparaging the above post as being fake news and empty of substance. He got very angry and lashed out. He tried as hard as he could to smear my name with false accusations. He also falsified the amount I charge for a 3-month stay at my retreat, to try to make me look bad. I have been the target of attacks by this contingency of low-fat extremists for years now—but I prefer not to mention names.
Accusations include that I had in some way changed the results of a weight loss study to make it look better. The researchers in that study who made that small error, acknowledged it in an addendum to the journal, correcting the calculations and made it clear that I was not involved in such calculations. The actual results of that study were still substantial, which should be the main point. My only part in this study was to open up my office charts so the researchers could review them and collect the data, I was not part of the calculations and statistical analysis.
As President of the Nutritional Research Foundation (NRF), I have done what I could to personally support the cost of, and raise money for, nutritional research that I deemed important. These studies are expensive. The sale of products at DrFuhrman.com has been supporting such nutritional research.
To be specific with one of the main issues here, I have reported that I have encountered some vegans, not supplementing with DHA, who have become demented, due to what I believe was from DHA deficiency. I also have encountered a few who developed Parkinson’s disease and some with low levels who have developed depression. Finding a limited number of these people does not demonstrate how rare or how prevalent this problem is. Nor does it mean for sure that the low DHA levels was the cause of their dementia or other problems. Therefore, I was instrumental in funding a study through the NRF of 166 un-supplemented vegans to ascertain the answer. That study, published in a peer reviewed journal, showed insufficiencies in about half and severe deficiencies in about a quarter. These severe deficiencies were consistent with other studies that demonstrate brain shrinkage with aging with this level of deficiency. Sure, more studies are always better, but we have to make a decision on the data we have and err on the side of caution.
I think this issue is critical for all vegans to be aware of. Even if it is one in a hundred or one in ten that gets harmed, it is still a needless event that could have easily been protected against.
I do sell an algae-derived vegan DHA, refrigerated and without additives (as well as lots of other products and services) and I feel it is important that I do so. I am doing what I think is best for my clients, patients, family and friends to best protect their health and longevity, and make it as easy as possible for them to do so. For those who don’t agree with my reasons for developing and supplying such a product, or think I am making up fake science and fake case histories in my writings, just to sell products and make money, they have the freedom to adhere to whatever dietary and nutritional program they choose.
I have a passion for doing what I am doing and feel blessed that I have the opportunity to help so many people recover their health and protect their future. I am always open to learning more and modifying recommendations, should advancements in science show a better way.
I am not paid anything from the nut or seed industry, (but maybe they should start sending me checks), but I think the research demonstrates with clarity that people with and without heart conditions are taking a significant increased risk if they cut all the nuts and seeds out of their diet. I have presented the evidence for this conclusion sufficiently. We have to go with whatever research is available at this time, plus my years of clinical experience in treating hundreds with heart disease over the years, supports the efficacy and safety of this method too. I have been in practice long enough to have followed these cases for decades and have watched these individuals grow old. I am confident and proud of giving people what I think is the best advice to protect their future.
Regardless if these attacks continue or not, this is all I am going to say on this matter.
[1] Fraser GE, Sumbureru D, Pribis P, et al. Association among health habits, risk factors, and all-cause mortality in a black California population. Epidemiology. 1997 Mar;8(2):168-74.
[2] Fraser GE, Shavlik DJ. Risk factors for all-cause and coronary heart disease mortality in the oldest-old. The Adventist Health Study. Arch Intern Med. 1997 Oct 27;157(19):2249-58.
[3] Mann JI, Appleby PN, Key TJ, Thorogood M. Dietary determinants of ischaemic heart disease in health conscious individuals. Heart. 1997 Nov;78(5):450-5.
[4] Ellsworth JL, Kushi LH, Folsom AR. Frequent nut intake and risk of death from coronary heart disease and all causes in postmenopausal women: the Iowa Women's Health Study. Nutr Metab Cardiovasc Dis. 2001 Dec;11(6):372-7.
[5] Fraser GE, Shavlik DJ. Ten years of life: Is it a matter of choice? Arch Intern Med 2001, 161:1645-1652.
[6] Blomhoff R, Carlsen MH, Andersen LF, Jacobs DR Jr. Health benefits of nuts:
potential role of antioxidants. Br J Nutr. 2006 Nov;96 Suppl 2:S52-60.
[7] van den Brandt PA. The impact of a Mediterranean diet and healthy lifestyle on premature mortality in men and women. Am J Clin Nutr. 2011 Sep;94(3):913-20.
[8] Baer HJ, Glynn RJ, Hu FB, et al. Risk factors for mortality in the nurses' health study: a competing risks analysis. Am J Epidemiol 2011, 173:319-329.
[9] Bao Y, Han J, Hu FB, et al. Association of nut consumption with total and cause-specific mortality. N Engl J Med 2013, 369:2001-2011.
[10] Levitan EB, Lewis CE, Tinker LF, et al. Mediterranean and DASH diet scores and mortality in women with heart failure: The Women's Health Initiative. Circ Heart Fail. 2013 Nov;6(6):1116-23.
[11] Guasch-Ferré M, Bulló M, Martínez-González MÁ, et al.; PREDIMED study group. Frequency of nut consumption and mortality risk in the PREDIMED nutrition intervention trial. BMC Med. 2013 Jul 16;11:164.
[12] Hshieh TT, Petrone AB, Gaziano JM, Djousse L. Nut consumption and risk of mortality in the Physicians' Health Study. Am J Clin Nutr 2015, 101:407-412.
[13] Luu HN, Blot WJ, Xiang YB, et al. Prospective Evaluation of the Association of Nut/Peanut Consumption With Total and Cause-Specific Mortality. JAMA Intern Med 2015.
[14] van den Brandt PA, Schouten LJ. Relationship of tree nut, peanut and peanut butter intake with total and cause-specific mortality: a cohort study and meta-analysis. Int J Epidemiol 2015.
[15] Liu G, Guasch-Ferré M, Hu Y, et al. Nut Consumption in Relation to Cardiovascular Disease Incidence and Mortality Among Patients With Diabetes Mellitus. Circ Res. 2019 Mar 15;124(6):920-929.
[16] Tharrey M, Mariotti F, Mashchak A, et al. Patterns of plant and animal protein intake are strongly associated with cardiovascular mortality: the Adventist Health Study-2 cohort. Int J Epidemiol.
2018 Oct 1;47(5):1603-1612.
[17] Martin N, Germanò R, Hartley L, et al. Nut consumption for the primary prevention of cardiovascular disease. Cochrane Database of Systematic Reviews 2015, Issue 9. Art. No.: CD011583.
[18] Larsson SC, Drca N, Björck M, et al. Nut consumption and incidence of seven cardiovascular diseases. Heart. 2018 Oct;104(19):1615-1620.
Joel Fuhrman, M.D. is a board-certified family physician, seven-time New York Times bestselling author and internationally recognized expert on nutrition and natural healing, who specializes in preventing and reversing disease through nutritional methods. Dr. Fuhrman coined the term “Nutritarian” to describe his longevity-promoting, nutrient dense, plant-rich eating style.
For over 30 years, Dr. Fuhrman has shown that it is possible to achieve sustainable weight loss and reverse heart disease, diabetes and many other illnesses using smart nutrition. In his medical practice, and through his books and PBS television specials, he continues to bring this life-saving message to hundreds of thousands of people around the world.