Chocolate, Caffeine, Alcohol: What's OK on a Plant-Based Diet?
This spring, the documentary "Eating You Alive" played in select theaters for a special one-night showing. Like documentaries "Forks Over Knives," "What the Health" and "In Defense of Food," the film focuses on the benefits of a low-fat, plant-based diet, featuring folks who were able to radically improve their health by adopting certain eating habits.
So what does that kind of diet look like? It includes whole grains, fruits, vegetables and beans, and eschews all animal products, added oils (even olive oil!) and overly processed foods. The film includes interviews with well-known doctors in this field, including Neal Barnard, Caldwell Esselstyn and Joel Fuhrman (who advocates for a plant-based, but not low-fat, diet).
Is plant-based pointless?
But surprise, surprise: Not everyone, not even every medical expert, agrees on the benefits of a plant-based diet.
The oft-cited 2007 A-to-Z study published in the Journal of the American Medical Association, compared the Atkins, LEARN, Ornish and Zone diets to see how they aided in weight loss and improved other health markers. The study found those following the Atkins diet group actually showed greater weight loss than all other groups in the study, including the plant-based Ornish diet, and also had more favorable effects for dieters, like decreased blood pressure.
Still, a number of other studies back up the benefits of a plant-based diet: A study published in PLOS One in 2016 looked at patients with Type 2 diabetes following either a vegan diet or the conventional diet recommended by the Korean Diabetes Association.
After just three months, those following the vegan diet had better control of their blood sugar compared to the other group. The results support Barnard’s 2006 study in Diabetes Care on the same topic. And a 2017 review in the Journal of Geriatric Cardiology found evidence that plant-based diets are more effective than other diets for weight loss and management.
What to eat, what to avoid
But even if you've decided to try out a plant-based diet, you might be confused by some ingredients that have ever-changing reputations. Is caffeine okay? What about soybeans, which are high in fat? Is dark chocolate heart-healthy, or an unnecessary indulgence?
To help us figure out what's a healthy choice and what's not, we asked Esselstyn, Fuhrman and Barnard to weigh in on some of our favorite things. They don't agree on every item below, but it's good information to get you pointed in the right direction.
Esselstyn: “I don’t think caffeine is an essential ingredient for health, but if people like it in a cup of coffee or tea, that’s fine. I don’t really consider it a health food.”
Fuhrman: “Limit to two beverages a day.”
Barnard: “Yes, it is addicting, as coffee-drinkers are reminded every morning. But its health effects are negligible. What is more important is what goes into the coffee. Typical creamers are loaded with saturated fat. Soy-based creamers are healthier.”
Esselstyn: “Alcohol is a toxin—a toxin to the brain, a toxin to the heart and a toxin to the liver. For women, alcohol is a risk factor for breast cancer, and too much alcohol makes it very dangerous for people to drive. But, I don’t have a problem with somebody who wants to have a drink on the weekend, providing it’s under control.”
Fuhrman: “Limit to two to three servings per week.”
Barnard: “Some evidence suggests that alcohol, especially red wine, slightly reduces the risks of heart disease and Alzheimer’s disease. But the benefit may come from anthocyanins—the reddish pigments from the grape, rather than from the alcohol, meaning that you would be just as well off with grape juice. And even one drink per day—if it is every day—increases the risk of breast cancer and colon cancer."
Esselstyn: “Dark chocolate for patients with heart disease has too much saturated fat, but for people who don’t have heart disease and want to have dark chocolate, I don’t have a problem with that. Cocoa powder is probably okay, because there’s no saturated fat in that.”
Fuhrman: “Limit to 88 percent. Cocoa powder is okay if unsweetened and using a date as the sweetening agent.”
Esselstyn: “Maple syrup is perfect if used very sparingly for taste.”
Fuhrman: “Not recommended.”
Esselstyn: “I’m not a great fan of the artificial sweeteners, because one of the things we constantly do for patients with heart disease is to get them to down-regulate their fat and sugar receptor.”
Fuhrman: “Limit use.”
Nuts and seeds
Esselstyn: “That’s fine, for people who don’t have heart disease. For people who do have heart disease, nuts can be very addicting.”
Fuhrman: “Encouraged daily intake of 1.5 to 4 ounces daily depending on caloric needs.”
Esselstyn: “For patients with heart disease, I’m a little cautious. For patients who don’t, I think they’re fine, if (the patient is) not overweight.”
Fuhrman: “Limited to one per day or half per day if overweight.”
Esselstyn: “We would prefer in patients with heart disease not to cook with salt. When you go to restaurants there are foods that are just so loaded with salts. And salt is somewhat problematic with hypertension. If people cook without salt but the taste is requiring a little spark, they can use the amount of salt from a general use of a salt shaker.”
Fuhrman: “Limited to 1,000 to 1,200 milligrams per day.”
Esselstyn: “I think that’s fine. All soy products have about 40 percent fat, so it’s obviously for people who have weight issues want to be a bit more cautious.”
Barnard: “Soybeans and many other foods contain natural compounds called isoflavones. Because their chemical structure vaguely resembles sex hormones, some have suggested that soy products might cause breast cancer, or make breast cancer progress. It turns out that the opposite is true. ... Rather than encouraging cancer growth, soy milk, tofu and other soy products actually help prevent breast cancer and help women who have been treated for breast cancer to reduce the odds that cancer will come back.”
Esselstyn: “I think for people who have heart disease, a smoothie is probably okay if they don’t put a lot of sugar in it by putting in oranges and apples and so forth. A smoothie can be pretty tart without the sugar in it, so I would recommend that rather than use a smoothie, they eat the green leafy vegetables.”
Fuhrman: “Only permit one serving of fruit in a green smoothie."
Esselstyn: “Be a little careful with too much salt, but for many things they’re fine.”
Fuhrman: “It depends on the sweetening agent used.”
Esselstyn: “Dried fruit is just so concentrated with sugar. I’m not sure that’s a health food. Having a few raisins to add to your cereal is fine, but having a meal of dates can be problematic.”
Fuhrman: “In limited amounts such as one serving per day.”
Esselstyn: “They’re wonderful.”
Fuhrman: “In limited amounts, not more than one serving per day.”