A review of the popular netflix documentary, “What the Health.”
In June of this year, a popular documentary hit the e-shelves of Netflix called What the Health. The response has been far and wide with many claiming a conversion to veganism or citing its research to support their current lifestyle. This review will cover the overall climate of the film, fact check some of its claims and give my professional opinion as a food and nutrition expert in response to the film.
What the Health: Documentary Review & Fact Check
To be honest, when Facebook friends and acquaintances started raving about What the Health and restating some of its facts, my blood started to boil a little. I wanted to avoid watching the film because I assumed there was a lot of bias involved. Although there was bias, in all actuality the film was less shocking than I had presumed (though I did I brace myself for the worst).
That’s not to say that there aren’t incorrect facts and figures, outdated research, poorly-performed studies or research lacking strength (inadequate subjects, not duplicated, etc.) – because there are absolutely those weaknesses. I wasn’t shocked by the light music that played happily in the background while the now make-up-laden, smiling ladies and man presented as case studies exclaimed how great they felt after two weeks on a vegan diet because I expected that of the film. I wasn’t shocked by the staggering statistics on obesity, diabetes and cardiovascular disease because (they are accurate and) I was already aware of those. And lastly, I don’t disagree at all with emphasizing a plant-based diet. I think we should all be following a plant-based diet. That doesn’t necessarily mean I think everyone needs to eat a completely vegan diet (although it’s nutritionally adequate with the inclusion of a vitamin B-12 supplement), but yes I agree that a majority of your diet should consist of plant foods and we all need a whole lot more fiber in our diets.
What I would like to do in my approach of this review is calm fears by providing insight and context and fact-check some of the claims made by the producers or contributors to this film.What's up with What the Health? Insight, context and fact checking. #healthtalk #RDchat Click To Tweet
Overall Climate of the Film
As expected, the film is skewed towards a low-fat vegan diet. In the opening Kip Anderson, a film producer by trade, describes his qualifications as a “recovering hypochondriac.” The tone is dark and dramatic music plays during animal agriculture scenes and when the video spans over primarily overweight individuals walking along the street. Upbeat music accompanies any discussion of a vegan diet and its many benefits. The film advocates for a solely vegan diet and an expert on the panel states there is no room for “moderation.” The word “terrifying” is used when describing food. The film uses a scare-tactic approach to push its agenda of persuading viewers to a low-fat vegan diet.
Representatives Unable to Answer Questions via Phone
Kip, the main character of the film, repeatedly calls or shows up personally to major organizations like the American Diabetes Association and American Cancer Society only to feel defeated when the call center representative or secretary isn’t able to answer his questions. Understandably, these individuals would not be qualified representatives to answer his questions on diet and chronic disease risk or why certain foods are recommended on their websites. Although his drastic measures are understandably out of exasperation, the correct individual to have connected with in each case would likely have been their head of nutrition education (and probably media or public relations) for each organization.
At one point he does meet with Chief Medical Officer Dr. Robert Ratner of the American Diabetes Association (ADA) who refuses to discuss the role of diet and diabetes citing that there are too many different types of diets possible to recommend one specific diet. I don’t necessarily agree with his refusal to discuss the role of diet and diabetes; I think he could have commented more specifically. I do agree that there is significant data on numerous dietary patterns with beneficial effects on weight, HbA1c, cholesterol, triglycerides, and inflammatory markers.
Claim(s) #1. A lot of people have diabetes and heart disease and a lot of money is spent because of these diseases.
True. In the US, heart disease is the number one cause of death claiming 633,842 lives and costing Americans $207 billion dollars annually (1,2). An estimated 422 million adults – that’s 1 in 11 adults – worldwide have diabetes; one in three of these are overweight and one in ten has obesity (3). In the US alone, diabetes costs an estimated $245 billion in direct in indirect costs (4).
Claim #2. Diabetes is not caused by eating a high carbohydrate diet or sugar.
True, but insinuating that those with diabetes can eat all the carbohydrate they want is completely incorrect. Diabetes is caused by pancreatic insufficiency or insulin resistance, not by a high carbohydrate diet or sugar. In a normal healthy body, after eating carbohydrate, glucose (AKA carbohydrate AKA sugar) moves from the blood into the body’s muscles and cells and the body is able to use it for energy. In diabetes, either because of pancreatic insufficiency (beta cells unable to produce insulin or inadequate insulin production) or insulin resistance, glucose stays in the blood stream which damages the blood vessels. Blood sugar rises in all bodies with carbohydrate intake at least a small amount, and in normal healthy bodies blood sugar returns to normal within an appropriate time frame but in diabetes blood sugar does not return to normal quickly, causing micro- and macrovascular damage.
HIGH NET CARBOHYDRATE INTAKE (in diabetes) = HIGH BLOOD SUGAR RESPONSE = INCREASED RISK FOR MACROVASCULAR DAMAGE
Claim #3. Within minutes of eating dead meat bacteria toxins, the body gets a burst of inflammation, stiffening or paralyzing the arteries.
False or inadequate data. Atherosclerosis, or hardening of the arteries, is considered to be a chronic inflammatory disease. However, there is not data to suggest “within minutes dead meat bacteria toxins stiffen the arteries.”
Let’s look at the filmmakers’ references here and here for this statement. The first is basically a glorified YouTube video, which won’t be evaluated since it’s not a study and doesn’t meet any of the grades of evidence. The second is a study done in vitro, meaning it was not performed in humans, and it evaluated inflammatory reactions to different foods (cytokine secretion) and evaluation of the presence of TLR2, TLR4, and TLR5 stimulants in different foods. As a whole, inflammatory response and TLR2, TLR4, and TLR5 presence were increased in animal foods compared to plant foods. However, cytokine response to lamb, chicken nuggets, milk, eggs, beef and pork pie was the same as peppers, bananas and peas and a number of other plant foods, and lower than the cytokine response to bread. Research has generally supported fish as anti-inflammatory however fish was not included in the study. Despite research supporting dark chocolate as anti-inflammatory, the cytokine response to chocolate in the present study was higher than the response to any of the meats or yogurt, and comparable to the response to cheese. The study did not evaluate any effects on blood vessels; again it was performed in vitro only. In my opinion, more importantly than evaluating blood samples in a well plate in response to isolated foods would be to look at inflammatory response in humans in the context of an entire meal.
Claim #4. Eating 1 egg per day is just as bad as smoking 5 cigarettes per day for life expectancy.
False. Let’s review the references listed for this claim on the What the Health website here, here and here. The first is again a video which won’t be evaluated since it doesn’t meet any grades of evidence. The second is an observational study. What’s the strength of an observational study? Not much; it means they watched people, asked them questions and then drew between the lines. As my Stats 101 professor repeated over and over: correlation does not equal causation. The subjects weren’t asked for any other lifestyle factors except for egg yolk consumption and smoking, and all subjects were patients at a vascular clinic. Do we know if the people who ate the most amount of eggs also used high saturated fats in cooking? Or if they exercised less? Or ate out more regularly? Or used added sugars sugars regularly? Those lifestyle questions were not assessed. There were no subjects who did not have vascular damage (since they were all vascular clinic patients), so we have no control group without any vascular damage to compare their egg yolk consumption. And the last reference? It does not even address egg intake. Not even once. Hit control F and search “egg” or “eggs.” Nothing. Zip. There is absolutely inadequate data to suggest, by any means, that eating one egg per day is the equivalent of smoking 5 cigarettes daily.
Claim(s) #5. The leading source of sodium in the diet is chicken and it’s also the number one source of cholesterol in the diet.
Depends on the reference and age of consumer, and the second claim is false. According to NHANES 2003-2008 data cited here (which actually is valid data, but outdated) chicken and chicken dishes were the top contributor of sodium for adults ages 20-50 at 7.3% of sodium intake, with yeast breads right behind it at 7.2%. Chicken was not the number one contributor of sodium in children or in older adults. According to What We Eat in America 2009-2010 data, mixed dishes (e.g. sandwiches, burgers, pizza, pasta or rice mixed dishes, stir-fries, soups, and meat or poultry mixed dishes) are the number one contributor of sodium and saturated fat in the American diet, which both sodium and saturated fat are considered nutrients of concern for overconsumption and damaging to health (5).
The film reference listed here for chicken being the number one source of cholesterol in the diet actually does not state anywhere that chicken is the number one source of cholesterol, or review any intake data for Americans. The number one source of cholesterol in the diet is eggs and egg-mixed dishes (whole milk, butter, soups, quickbreads, pancakes/waffles/French toast) (6). Cholesterol is only found in animal foods. Our bodies produce cholesterol, so cholesterol is not a necessary nutrient to consume. Although an exact limit on cholesterol intake is not presently part of the Dietary Guidelines of Americans as of 2015, the authors continue to recommend limiting cholesterol intake. Further, saturated fat intake is recommended to be kept at ≤10% of total calories, which inherently limits total cholesterol intake (since most high saturated fat foods also contribute cholesterol) to between 100 mg and 300 mg depending on the calorie level of the diet (7). The American Heart Association recommends limiting saturated fat intake to 7% of total calories which would further limit the amount of total dietary cholesterol intake. The Institutes of Medicine (IOM) recommends limiting cholesterol as much as possible but does not outline an upper limit (8). Notably, the observation of dietary cholesterol increasing blood levels of cholesterol and on dietary cholesterol and increased risk of cardiovascular disease has been inconsistent in large population studies (8). Also important to note, is that fiber has a tendency to decrease LDL cholesterol (“bad” cholesterol) levels in the blood, which again supports the idea of all Americans increasing their intake of high fiber foods.
Is sugar really not that bad for you?
Simple sugars can have negative health impacts. Fructose in particular (which is found in added sugars like table sugar, brown sugar, molasses, honey, high-fructose corn syrup, agave nectar, etc. and also naturally occurring in smaller quantities in fruit) is particularly lipogenic, or converted to fat easily. Fructose also increases blood triglycerides, which is more pronounced in people with hyperlipidemia or insulin resistance, increasing the risk for atherosclerosis (hardening of the arteries) or other cardiovascular disease. High fructose consumption also tends to increase visceral adiposity (fat around the organs in the midsection) which increases chronic disease risk. Added sugars are not benign and should not be glorified as “totally harmless” as the film depicts to a degree. (This whole paragraph: Modern Nutrition in Health & Disease, 11th ed.)
Is it just the fact that vegans don’t eat animal foods that makes them healthier?
In graduate school I took a semester-long course on vegetarianism. Absolutely, there are fantastic benefits to a completely plant-based diet.
However, some confounding variables to consider on the research done in vegetarians is that on average, vegetarians are more likely to:
- Have a higher socioeconomic status
- Have higher education
- Be more health conscious overall
- Be non-smokers
- Be more physically active
- Participate in stress-reducing activities (like yoga, meditation, etc.)
Each of those are behaviors or factors which either reduce risk of chronic disease in and of themselves or are related to less incidence of chronic disease.
What about fat? They talked a lot about it in the film.
Notably, fat is frequently cited as the culprit for cardiovascular disease and diabetes in the film, however no trace mention of the essential nature for fat (i.e. fat-soluble vitamins A, D, E and K can only be absorbed when fat exists in the diet or discussion on essential fatty acids n-3 or n-6), or including mono- and polyunsaturated fats, is made. A healthy dietary pattern can certainly include ~25-35% of total calories from fat. As mentioned previously, limiting saturated fat intake to 7-10% of total calories and trans fats as close to zero as possible is recommended as we generally see an increase in LDL (“bad cholesterol”) levels with high saturated fat and trans fat intake. Fat is an essential nutrient, and preferably nutrient-rich sources of mono- and polyunsaturated fats should be used to meet the majority of fat needs.
Are Plant Foods Really That Much More Environmentally Friendly?
Yes and possibly no. A study published last year in Environment Systems & Decisions evaluated the environmental effects of Americans shifting their diets towards the 2010 Dietary Guidelines for Americans (since only 10-20% of American adults eat the recommended number of servings of vegetables daily and 15% meet fruit recommendations (5)) and found that reducing calorie intake to appropriate levels (since Americans are also overall eating too many calories) and shifting to the USDA recommendations would increase energy use by 38%, blue water footprint by 10%, and green house gas emissions by 6% (9). Although that may seem surprising, more resources would have to be used to produce equivalent calories overall to meet human energy needs since most plant foods are comparatively lower in calories than animal foods.
In no way do I disagree with the recommendation for everyone to increase the consumption of plant foods. Increasing plant intake increases overall fiber intake and a number of vitamins and minerals, phytonutrients and antioxidants. I do disagree with the fear-mongering approach of the filmmakers. Any film that makes you shudder or suggests cutting out entire food groups should be looked at with a critical eye. I do disagree with the filmmakers use of “alternative facts” to emphasize their agenda.
Certainly we would have a healthier population if more people followed a plant-based diet. However, in my opinion, I don’t necessarily think that including 2-4 oz of animal protein at meals makes it no longer “plant-based” when three-quarters of your meal is plants. A vegan diet doesn’t necessarily “work” for everyone. And quite frankly, you can have a really crummy vegan diet with significantly more highly-processed foods (like these “chik’n nuggets” from Morning Star Foods) with more ingredient names than words on the first page of an encyclopedia; I would much rather just include a few ounces of plain chicken. Animal foods also provide other important nutrients like vitamin B-12, zinc, iron, selenium, choline, n-3 fats in fish and more. Further, if you hate lentils and legumes, tofu, seitan and tempeh then you might have difficulty meeting baseline protein needs on a vegan diet. Any diet where you don’t eat or enjoy the food doesn’t do much good to provide your body the nourishment it needs. Veganism isn’t a fit for every one and every family, and I think that’s okay. In any case, I think we could all do a little better on striving to make a majority of each of our meals based on plant foods.
What are your thoughts on this What the Health review?
What other questions about What the Health did I not get to that you wish I would have covered?
Comment below and let me know.
Disclosures: None. This post was not created in partnership with any product or brand.