Macrobiotics Detailed Scientific Review

Overview

Background

The word "macrobiotic" is derived from the Greek macros (large, long) and bios (life). Foods in this diet are believed to reflect the normal diet of the Japanese people before they became "westernized" and industrialized. The philosophy underlying the diet is that two antagonistic but complementary forces, yin and yang, are operative in the universe.

In general, yin energy (force or tendency) is upward reaching, hollow, expansive, cool and dark while yang energy is downward, contracting, more aggressive, dense, hotter and brighter1,2. When either of these forces reaches an extreme, it begins to grow in the opposite direction. Thus the traditional symbol of yin and yang always contains a piece of yin within yang and a piece of yang within yin. This concept can be illustrated by a seed which is extremely yang (dense, deep in the earth) but "wants" to grow up producing a shoot which is yin, in comparison to the seed and then leaves which are more yin eventually producing new seeds (with or without fruit), which are yang, and fall to the earth to begin the process anew.

Although the ideas of yin and yang have been around for more than 5,000 years, the food related concepts were first introduced into the United States in the 1960s by two Japanese philosophers and businessmen: George Ohsawa and Michio Kushi. Ohsawa based his concepts upon his understanding of the native Japanese food arts and his experience during his years in France when, low on money, he was forced to live off of food remainders from the marketplace. Both men subsequently lectured on the benefits that they had experienced with the diet, referring to it as an overall conception of life which would lead to longevity and vigor^3,4.

All of life, including food and disease, is seen as a play between these forces of yin and yang. As seen from a yin/yang perspective, foods range from the most dense animal meats such as beef to the less dense such as fish, and then in the center of this continuum can be found root vegetables, whole grains and cereals, followed by the stalks and leaves of vegetables. Continuing on toward more expansive foods, one finds fruits followed by refined sugars, alcohol and various drugs. Following the concept of extremes seeking their opposites, eating too much on one end of the scale (e.g., beef) will create a craving for food at the opposite end (e.g., pie or alcohol). Constantly being driven by unmanageable cravings from one extreme to another can be disruptive to one’s metabolism leaving one vulnerable to stress and disease. Centering one’s diet on whole grains and cereals is seen as a way to center one’s energies and life².

In addition to the type of food consumed, macrobiotic teachings encourage a variety of different methods of preparing and cooking food. Cooking with electricity and microwaves are generally avoided as are chemically treated or heavily processed foods, including vitamin and mineral supplements. The practice of chewing solid foods until they become liquid is encouraged to aid in their digestion. Food, in accordance with many religious teachings, is considered sacred, and both its preparation and eating are to be done in a calm and peaceful environment².

An older form of macrobiotics originally promoted by Ohsawa, consisted of a 10-stage diet with increasing stages of dietary restrictions. This restrictive diet is no longer advocated by macrobiotic counselors due to health problems (scurvy, malnutrition and death) that developed among some of the its followers^5,6.

Although Ohsawa died in 1966, Michio Kushi remains as an active leader. He is the author of several books on the subject including The Book of Macrobiotics, The Universal Way of Health and Happiness, The Macrobiotic Approach to Cancer, The Cancer-Prevention Diet, Diet for a Strong Heart and AIDS, Macrobiotics, and Natural Immunity. He founded the East West Foundation, a non-profit foundation with a subsidiary, the Kushi Institute, and Erewhon, a company that distributes natural and macrobiotic foods.

Today’s macrobiotic teachers recommend a less restrictive approach, with 50% to 60% of foods to be from whole cereals and grains, and the rest from vegetables, beans, fermented soy products, sea vegetables (i.e., seaweed such as kombu, wakame, hijiki, arame and mojaban), plus tea and soups made from appropriate ingredients. Small amounts of white-meat fish and fresh organic fruits can be included in the diet, while lightly roasted nuts and seeds are permitted as occasional snacks. The eating of eggs and dairy foods is discouraged (eggs because they are too dense, or yang, and milk because most animals do not consume milk after infancy). (Note that milk is not a part of the traditional Asian diet.) Macrobiotic teachers explain that no foods are actually prohibited, but they may be limited for periods of time in a therapeutic context⁴.

The book Recalled by Life by Anthony Sattilaro, a physician and president of Philadelphia Hospital, created widespread interest in the marcrobiotic diet during the 1980s⁷. In 1978, Sattilaro was diagnosed with prostate cancer that had metastasized throughout his skeleton at a young age (50s). Surgery to remove his testicles and months of pain followed. He was told that conventional medicine had nothing else to offer him. One day, feeling that danger was beside the point, he picked up two hitchhikers who were returning from a macrobiotic cooking school. Following their advice and, again, feeling that he had nothing to lose, he sought out a macrobiotic community and began to learn and practice the concepts. During the next year, the pain resolved and the metastatic lesions in his bones gradually disappeared. Although he did state that there was no way to know for sure whether it was the surgery or the diet that had brought about this recovery, he became one of the leading lecturers and proponents of this way of life. Dr. Sattilaro’s cancer eventually recurred over 10 years later⁶, but he lived many years later than his doctors had predicted. Dr. Sattilaro stated publicly that he had gone off the diet before the cancer recurred and had thus tested the value of the diet twice⁸.

Some articles have noted preventive effects against heart and circulatory diseases^9-11. Others have reported a possible protective effect against hormone related cancers due to a correlation between high intake of phytoestrogens and lower circulating levels of estradiol and testosterone¹².

A 1984 report from the Subcommittee on Health and Long Term Care of the Select Committee on Aging, House of Representatives, stated that the macrobiotic diet appears to be adequate if the mix of foods proposed is followed carefully and is consistent with the guidelines released by the National Academy of Sciences. (Of course, one also needs to follow these guidelines with the standard American diet to avoid obesity, high cholesterol and risk of strokes, heart disease and colon cancer.) The subcommittee did not, however, find any evidence of effectiveness as a cure for cancer¹³.

In 1993, an editorial in the Journal of the American College of Nutrition stated that perhaps the efficacy reported in some of the case reports and retrospective studies involving macrobiotic diets was a result of the diet being deficient in several nutrients, thus having the effect of controlling the growth of cancer as well. The editorial called for an expansion of nutritional concepts concerning cancer and other special needs¹⁴. A word of caution is appropriate here. . .ideas of somehow feeding the body while starving the tumor have been tried unsuccessfully in the past (not reviewed here) with the tumor simply continuing to derive its nutrients from the patient¹⁵.

Proposed Mechanism of Action

Body sites of tumors are classified as yin or yang according to macrobiotic and traditional Chinese/Japanese theory. Peripheral, upper or hollow organs are considered yin; lower, deeper or more compact organs are considered yang. Macrobiotic counselors attempt to match diets to tumor sites to restore the balance between yin and yang.

Prevention of cancer through various dietary factors has been demonstrated by long-term studies and endorsed by the American Institute for Cancer Research and the American Cancer Society (ACS) . The macrobiotic diet is a "lifestyle" approach to prevent various forms of cancer or other diseases¹⁶.

Adverse Effects

The ACS has stated that the macrobiotic diet provides inadequate nutrition for cancer patients, is unsafe and can cause malnutrition and death^6,17-19. One of these articles⁶ concerned a case of scurvy that occurred while practicing the older, more restrictive form of macrobiotics.

Several additional articles have reported deficiencies in various nutrients^5,20-26 - specifically vitamins D and cobalamin (B₁₂)^27,32, iron²⁸, calcium^29-31, protein-calorie malnutrition⁹ and linear growth retardation^33-35,43,44. Many of these articles concerned the specific needs of children and pregnant or lactating women.

Patients with cancer have unique nutritional requirements and need to exercise care with any diet^20,26. Particular care must be exercised for infants and children with cancer, since adequate nutrients must be supplied for growth as well as the metabolic requirements of the individual disease challenges³⁶.

Summary of Research

Amount and Type of Research

The literature search reviewed here is limited to those articles that specifically mention the consumption of a macrobiotic diet by cancer patients. There are, in addition, various components of this diet which could be separately reviewed such as shitake mushrooms (antitumor effect in mice), miso soup (reduction of stomach and breast cancer in Japan) and some forms of seaweed (antitumor effects in mice and rats).

In addition, there have been various studies which have confirmed different effects of vegetarian diets overall as compared to omnivore diets. Some of the outcomes of these studies have concerned measurements of enzymes or other components considered to be initiators or promotors of cancer. (See, for example, the differences in phytoestrogen intake between vegetarians and omnivores^12,37,38.) The following classification of articles refers only to those citations specifically concerning the macrobiotic diet as a treatment for cancer.

A search of the PubMed, Scopus, CINAHL and Alt HealthWatch databases from 3/1/2003 to 1/31/2006 revealed two new cases studies^45,46.  These case studies have been submitted to the National Cancer Institute Office of Cancer Complementary and Alternative Medicine (OCCAM) Best Cases Series and results will be reported when they are available.

Based on a previous review of the literature and other sources between 10/31/97 and 3/31/03, we identified 22 articles of which four were related to macrobiotics and cancer, and all four were retrieved. A prior review had identified 106 references, of which 51 (48%) were applicable to cancer and 41 (80%) were retrieved. Thus, a total of 55 applicable articles have been identified and 45 retrieved. We classified these references into the following types of information:

Note: The remaining three articles have been referenced in other agents concerning diet.

Of the three human related articles, studies were coded (5*) by the following study designs:

* One article contained three studies.

**These best cases are not National Cancer Institute certified "best cases"; rather they are defined as "best cases" because of their selection by the authors of the studies from among a larger group of cases. Subsequently published “best cases” will not be reviewed unless they have been validated by the National Cancer Institute. An additional set of best cases was described in a preliminary report to the American Public Health Association Meeting of November 1996⁴, but will not be reviewed until the final report is published in the peer-reviewed literature.

Summary of Human Research

One publication¹⁴ reported three retrospective cohort studies and included a set of case reports presumably abstracted from each of these studies. One study consisted of 23 respondents of 101 identified patients with pancreatic cancer who practiced a macrobiotic diet for at least three months. The survival of these patients was compared to 1,467 SEER patients with regional or distant stage pancreatic adenocarcinoma. Mean survival for the macrobiotic practitioners (cases) was 17 months compared to six months for the SEER controls. The cases also had a 52% one-year survival compared to 9.7% one-year survival for SEER controls (p<0.001; RR = 5.38)¹⁴. It should be noted, however, that the macrobiotic patients had to survive at least three months to be included in the study, but they were compared with all SEER patients including those who had died within the first three months.

The second retrospective study consisted of 18 Tulane Hospital patients with stage D2 prostate cancer who adopted macrobiotic diets as adjuvant therapy. These cases were compared with nine controls with the same stage of prostate cancer identified in the Tulane and another hospital registry. Mean survival was 177 months for the cases and 91 months for the controls. Although the controls had an elevated risk of death and lower cumulative survival rates, neither of these differences was significant (p=0.20) and the study suffered from the same design flaw of limiting the macrobiotic, but not the control patients, to a minimum three months survival for eligibility¹⁴.

The third study consisted a nationwide mailed survey to an unreported number of patients who had sought macrobiotic counseling. Analysis of questionnaires from the 182 respondents indicated that 1) most patients did not stay on a strict macrobiotic diet, 2) most used it because of intolerance to conventional therapy and 3) effects of the diet could not be distinguished from effects of conventional therapy. Data were also analyzed to determine survival length and quality of life, but the authors stated that they "could not distinguish clearly the effects of drug, surgery, radiation and change of diet interventions in patients who had ‘recovered’"¹⁴. (This survey followed two previous attempts to survey U. S. subjects with cancer who had sought macrobiotic counseling. As described by Kushi and colleagues, both attempts were limited by poor response rates and inability to obtain medical records⁴.)

A separate book included two best-case series of 28 and six patients, respectively^39,40. Both sets of cases were found and documented by a doctor whose spouse had inoperable cancer that improved following the adoption of a macrobiotic diet. Most patients in both sets also received conventional therapy. The U. S. Office of Technology Assessment (OTA) appointed an advisory panel of six physicians to independently review the set of six cases. Three physicians on the panel were "not impressed", two were "more positive" and one said that all but one case was "suggestive" of benefit⁴⁰.

Conclusions

Based upon five studies with limited ability to detect effects, it has not been demonstrated that the macrobiotic diet can prolong survival in patients with cancer. Nevertheless, some aspects of this diet could be helpful to some people, but this will require new studies with stronger designs.

Research concerning the macrobiotic diet in cancer has also been reviewed by the American Dietetics Association^36,41, Michael Lerner⁴² and Lawrence Kushi and colleagues⁴, who reached similar conclusions. The articles by Kushi⁴ and Lerner⁴² also contain indepth descriptions of the background of macrobiotics along with critiques of previous and current research issues.

Current Research

Macrobiotics is being compared with two other diets: flax seed supplementation and the American Heart Association diet in a clinical trial at the Rosenthal Center of Columbia University.

Brief notes about each of the studies reviewed are available in the Macrobiotics Summary of Human Studies Table.

Annotated Bibliography

¹⁴Carter J. Hypothesis: dietary management may improve survival from nutritionally linked cancers based on analysis of representative cases.

Ten noteworthy cases are presented.

³⁹Fawcett A, et al. East West Foundation. Cancer-free - 30 who triumphed over cancer naturally. (Part I)

⁴⁰Newbold, V. Remission of advanced malignant disease: A review of cases with a possible dietary factor. (No separate publication - part III of the article cited above with cases #1 - 28.)

Purpose: Survival and quality of life
Type of Study: Best  cases
Methods: (Various) The author and physician sought and found six patients diagnosed with advanced or otherwise untreatable cancers who recovered using macrobiotics. These six patients had pancreatic cancer with metastases to the liver, malignant melanoma, malignant astrocytoma, endometrial stromal sarcoma, adenocarcinoma of the colon and abdominal leimyosarcoma. (Four of these cases were also described in the series of 28 identified by Fawcett³⁹ above and two were new cases described below.) In addition to these cases, she also told of her husband who began eating macrobiotically after being diagnosed with incurable colon cancer for which he apparently received no conventional treatment.
Results:

Husband of author: Eight months after being described as hopeless, he was feeling "healthier than he had ever felt in his life. . .". A follow-up CT scan revealed that about 70% of the cancer was gone. No further information provided.

Six best cases: Review of CT scans and other medical tests revealed no evidence of tumors after adherence to the macrobiotic diet. All of the patients (except one whose cancer came back after she discontinued macrobiotics) were reported to be working full time, leading very active lives and feeling in excellent health. The cases were all reviewed independently and the diagnoses confirmed by the pathology and radiology departments of Holy Redeemer Hospital in Meadowbrook, Pennsylvania. At the OTA’s request³, six physician reviewers were mixed in their evaluations of the data, with three finding no compelling cases, two finding that at least five of the six cases had achieved a positive result with the macrobiotic diet, and one suggesting the need for a randomized trial before any conclusions could be drawn. Brief notes about these six cases follow:

Notes: Although these cases were reviewed by two different sets of physicians and noted in the OTA report³, they were not reported in the peer-reviewed literature. According to the author, Vivian Newbold, the American Cancer Society and the New England Journal of Medicine had turned down an article documenting these cases as being "of no interest".

Reference List

1. Beinfield H , Korngold E. Between heaven and earth: a guide to Chinese medicine. Paperback ed. New York and Toronto: The Ballantine Publishing Group, 1991.
2. Kushi M. The Macrobiotic Approach to Cancer: Towards Preventing and Controlling Cancer with Diet and Lifestyle. Garden City Park, NY: Avery Publishing Group Inc., 1991.
3. OTA. Macrobiotic diets. Unconventional Cancer Treatments: A Report of the Office of Technology Assessment to the United States Congress. Common Knowledge Press, 1990.
4. Kushi LH, Cunninghamn JE, Hebert JR, Lerman RH, Bandera EV, Teas J. The macrobiotic diet in cancer. J of Nutrition 2001 Nov;131(11 Suppl):3056S-64S.
5. Sherlock P, Rothschild EO. Scurvy produced by a Zen macrobiotic diet. JAMA 1967 Mar;199(11):794-8.
6. Anonymous. Questionable methods of cancer management: 'nutritional' therapies. [Review]. Ca: a Cancer Journal for Clinicians 1993 Sep-1993 Oct;43(5):312-3.
7. Sattilaro A. Recalled by Life. 1982.
8. Kushi L. Personal communication.
9. Wissel PS, Denke M, Inturrisi CE. A comparison of the effects of a macrobiotic diet and a Western diet on drug metabolism and plasma lipids in man. European Journal of Clinical Pharmacology 1987;33(4):403-7.
10. Washko P, Rotrosen D, Levine M. Ascorbic acid in human neutrophils. American Journal of Nutrition 1991;54:1221S-7S.
11. Pauling L. Effect of ascorbic acid on incidence of spontaneous mammary tumors and UV-light-induced skin tumors in mice. Americal Journal of Clinical Nutrition 1991;54(6 Suppl):1252S-5S.
12. Adlercreutz H, Hockerstedt K, Bannwart C, Bloigu S, Hamalainen E, Fotsis T, et al. Effect of dietary components, including lignans and phytoestrogens, on enterohepatic circulation and liver metabolism of estrogens and on sex hormone binding globulin (SHBG). [Review] . Journal of Steroid Biochemistry 1987;27(4-6):1135-44.
13. Woodman AM. Macrobiotic diet nutritionally adequate [letter]. Postgraduate Medicine 1986 Jun;79(8):38, 40.
14. Carter JP, Saxe GP, Newbold V, Peres CE, Campeau RJ, Bernal-Green L. Hypothesis: Dietary management may improve survival from nutritionally linked cancers based on analysis of representative cases. Journal of the American College of Nutrition 1993;12(3):209-26.
15. Steen RG. A Conspiracy of Cells: The Basic Science of Cancer. New York: Plenum Press, 1993.
16. Kushi M, et al. The Cancer Prevention Diet: Michio Kushi's Blueprint for the Relief and Prevention of Disease. New York: St. Martin's Press.
17. Anonymous. Unproven methods of cancer management. Zen macrobiotic diet. Ca: a Cancer Journal for Clinicians 1972 Nov-1972 Dec;22(6):372-5.
18. American Cancer Society. Unproven methods of cancer management--macrobiotic diets for the treatment of cancer. CA A Cancer Journal for Clinicians 1989;39(4):248-51.
19. Anonymous. Unproven methods of cancer managememt: macrobiotic diets. Ca: a Cancer Journal for Clinicians 1984 Jan-1984 Feb;34(1):60-3.
20. Arnold C. The macrobiotic diet: a question of nutrition. Oncology Nursing Forum 1984 May-1984 Jun;11(3):50-3.
21. Herbert V. Unproven (questionable) dietary and nutritional methods in cancer prevention and treatment. Cancer 1986;58:1930-41.
22. Anonymous. Zen macrobiotic diets. JAMA 1971 Oct;218(3):397.
23. Hanning RM, Zlotkin SH. Unconventional eating practices and their health implications. [Review] . Pediatric Clinics of North America 1985 Apr;32(2):429-45.
24. Herbert V, Yarbro CH. Nutrition quackery. Seminars in Oncology Nursing 1986;2(1):63-9.
25. Krey SH. Alternate dietary lifestyles. [Review] . Primary Care; Clinics in Office Practice 1982 Sep;9(3):595-603.
26. Bowman BB, Kushner RF, Dawson SC, Levin B. Macrobiotic diets for cancer treatment and prevention. [Review]. Journal of Clinical Oncology 1984 Jun;2(6):702-11.
27. Miller DR, Specker BL, Ho ML, Norman EJ. Vitamin B-12 status in a macrobiotic community. American Journal of Clinical Nutrition 1991 Feb;53(2):524-9.
28. Craig WJ. Iron status of vegetarians. [Review] . American Journal of Clinical Nutrition 1994 May;59(5 Suppl):1233S-7S.
29. Hauser SP. Unproven methods in cancer treatment. Current Opinion In Oncology 1993;5:646-54.
30. Salmon P, Rees JRP, Flanagan M, O'Moore R. Hypocalcaemia in a mother and rickets in an infant associated with a Zen macrobiotic diet. Irish Journal of Medical Science 1981;150(6):192.
31. Machiels F, De Maeseneer M, Van Snick A, Rayen I, Desprechins B, Osteaux M. A rare cause of rickets in a young child. Journal Belge De Radiologie 1995;78(5):276-7.
32. Schneede J, Dagnelie PC, Van Staveren WA, Vollset SE, Refsum H, Ueland PM. Methylmalonic acid and homocysteine in plasma as indicators of functional cobalamin deficiency in infants on macrobiotic diets. Pediatric Research 1994;36(2):194-201.
33. Dagnelie PC, Van Dusseldorp M, Van Staveren WA, Hautvast JGAJ. Effects of macrobiotic diets on linear growth in infants and children until 10 years of age. European Journal of Clinical Nutrition 1994;48(Suppl. 1):S103-12.
34. Dagnelie PC, Van Staveren WA. Macrobiotic nutrition and child health: Results of a population-based, mixed-longitudinal cohort study in The Netherlands. American Journal of Clinical Nutrition 1994;59(5 Suppl.):1187S-96S.
35. Dagnelie PC, Van Staveren WA, Hautvast JGJA. Stunting and nutrient deficiences in children on alternative diets. Acta Paediatrica Scandinavica - Supplement 1991;80(374):111-8.
36. Weitzman S. Alternative nutritional cancer therapies. Int J Cancer 1998; 11(Supplement):69-72.
37. Adlercreutz H, Fotsis T, Bannwart C, Wahala K, Makela T, Brunow G, et al. Determination of urinary lignans and phytoestrogen metabolites, potential antiestrogens and anticarcinogens, in urine of women on various habitual diets. Journal of Steroid Biochemistry 1986 Nov;25(5B):791-7.
38. Adlercreutz H, Goldin BR, Dwyer JT, Warram JH, Gorbach SL. Effect of diet on estrogen metabolism in women. Research on Steroids, Volume IX: Endocrinological Cancer Ovarian Function and Disease. Proceedings of the IX Meeting of the International Study Group for Steroid Hormones. Rome: December 5-7 1979.1981:5-10.
39. Fawcett A, Smith C. 30 who triumphed over cancer naturally. Cancer Free, Japan Publications Inc. 1995 Dec.
40. Newbold V. Remission of advanced malignant disease: A review of cases with a possible dietary factor. Cancer-Free: 30 Who Triumphed Over Cancer Naturally.Japan Publication, Inc., 1995:235-55.
41. McCallum PD & Polisena CG, eds. Clinical Guide to Oncology Nutrition; Chapter 16 by Molseed L. Alternative Therapies in Oncology; Chicago, Illinois: The American Dietetic Assn., 2000.
42. Lerner M. Choices in Healing: Integrating the Best of Conventional and Complementary Approaches to Cancer. Cambridge, MA: MIT Press, 1994.
43. Antony A. Vegetarianism and vitamin B-12 (cobalamin) deficiency. American Journal of Clinical Nutrition 2003;78:3-6.
44. Dhonukshe-Rutten R, Dusseldorp M, Schneede J, Groot L, van Staveren W. Low bone mineral density and bone mineral content are associated with low cobalamin status in adolescents. European Journal of Nutrition 2005;44:341-7.
45. Wolff M. Overcoming breast cancer through macrobiotics. Positive Health 2004 Nov;44.
46. Helmich P. A triumph over cancer. Alternative Medicine 2004 Sep;61-4.