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Prevent and Reverse Heart Disease by Caldwell B. Esselstyn PDF Print E-mail
Written by Chris Masterjohn   
Friday, 27 March 2009 19:23

book-thumbdownA Thumbs Down Book Review

Prevent and Reverse Heart Disease: The Revolutionary, Scientifically Proven, Nutritionally Based Cure By Caldwell B. Esselstyn, Jr., MD Penguin Group, 2008 Reviewed by Chris Masterjohn

Caldwell Esselstyn Jr.’s new book, Prevent and Reverse Heart Disease, promises a “revolutionary, scientifically proven, nutrition-based cure” for heart disease. The “cure,” however, is neither revolutionary nor scientifically proven. While it may be based on nutrition, little in the book is based on reality.

The Diet

Esselstyn’s dietary rules are straightforward: no animal products, no fats or oils of any kind, no nuts or avocados and no refined grains. The diet allows unlimited amounts of vegetables, legumes and whole grains, and permits three servings of whole fruit per day. If you do not have heart disease, you can eat walnuts and avocados in moderation.

Esselstyn recommends a number of supplements: a multivitamin, calcium, vitamin B12, vitamin D, flax seed. . . and statins. Yes, he really calls the cholesterol-lowering statin drugs “supplements.” Most of these are intended to make up for the nutrients one misses out on by avoiding animal products. The statins, of course, are meant to lower your cholesterol—that is, if you cannot lower your total cholesterol below 150 mg/dl with diet alone.

The Science

Esselstyn repeatedly claims that you will never, ever get heart disease so long as you bring your cholesterol level low enough. “We can go directly to the bottom line,” he writes. “This is it: if you follow a plant-based nutrition program to reduce your total cholesterol level to below 150 mg/dL and the LDL level to less than 80 mg/dL, All Thumbs Book Reviews you cannot deposit fat and cholesterol into your coronary arteries. Period.”

This is a remarkable claim since he begins the book by describing the case of a patient of his named Joe Crowe who had a heart attack with a cholesterol level of only 156 mg/dL. The entire lower third of his left anterior descending coronary artery was diseased. Are we to believe that a measly 6 mg/dL makes the difference between zero atherosclerosis, on the one hand, and enough atherosclerosis to cause a heart attack, on the other?

It is true that one publication of the famous Framingham Heart Study found a total absence of heart disease among the small handful of people whose cholesterol levels were this low,1 but plenty of such people died of heart disease in the much larger MR FIT trial.2

Esselstyn claims that a lowfat, plant-based diet will prevent stroke just as effectively as it prevents heart disease, but all he offers for “evidence” is data showing that atherosclerosis is a major cause of stroke. The ugly facts that slay his beautiful hypothesis, however, are that low cholesterol levels make one much more likely to die of stroke and that the risk of stroke gets lower and lower the more fat and animal protein one eats.3

Esselstyn discusses the role of oxidized LDL in heart disease, but twists his information about oxidative stress to suit his dietary recommendations. For example, he writes that fats and oils increase oxidative stress whereas plants and grains contain antioxidants. Nowhere does he point out, however, that only polyunsaturated fatty acids (PUFAs) contribute to oxidative stress4 and that coenzyme Q10, found mostly in animal products, is the master antioxidant of the LDL particle.5

In a chapter entitled “Moderation Kills,” Esselstyn cites evidence that lowfat diets do nothing to prevent heart disease and that one out of four patients who lower their cholesterol to 150 mg/dL with statins sustains a heart attack or dies within 2.5 years of starting treatment. His conclusion? That lowfat diets are not nearly low enough in fat, and that cholesterol-lowering treatment only works if you lower your cholesterol at least in part with a plant-based diet. Of course, an alternative explanation would be that lowfat diets do not work and that cholesterol-lowering cannot guarantee anyone freedom from heart disease.

The Esselstyn Diet on Trial

Esselstyn does, however, offer one study purported to show that his extremely lowfat diet does, in fact, reverse heart disease. In his book’s foreword, T. Colin Campbell, author of The China Study, claims that this study ranks “among the most carefully conducted and relevant medical investigations undertaken during the past century.” In reality, the study is nothing of the sort.

Esselstyn ran a five-year trial in which he put heart disease patients on his diet, treating them with cholesterol-lowering drugs if necessary to bring their cholesterol down to 150 mg/ dL.6 There was no control group. Twenty-two percent of those who began the intervention dropped out of the study within the first two years; thirty-five percent of those who completed it did not submit to the follow-up analysis of their cardiovascular health; of the twenty-two patients who began the trial, only eleven remained in the final analysis. Of these eleven, occlusion of the blood vessels became better in five, stayed the same in one, and became worse in four.

Despite the inconsistent results, the average change in the width of the blood vessels was an increase in 0.08 millimeters. This represents an apparent reversal of atherosclerosis—on average. Likewise, on average, the degree to which blood vessels were constricted decreased by seven percentage points. Six of the eleven dropped out of the study after the first five years; in the following five years, there were ten heart attacks among the six that dropped out while there were none among the five who remained on the program.

Since there was no control group and there was such a high drop-out rate, it is difficult to make much sense of the study. Did the people drop out because their health was not important to them? Or did they drop out because the vegetarian diet made them feel fatigued, unsatisfied, and even less healthy than their original diet full of meat and junk food? Were the people who completed the study but did not submit to the final measurements of their blood vessels reluctant for no reason, or were they reluctant because they were afraid of the results they would obtain based on how the diet made them feel?

It is possible that an extremely lowfat diet would provide some benefits simply because it is extremely low in PUFA. Since the plants are so low in fat, the body will produce its own fat from carbohydrates. The primary product of this biochemical pathway is palmitate, which is a saturated fatty acid. Because it is saturated, it is not vulnerable to oxidation. Ironically, one of the benefits of eating a diet so low in fat is that a much greater portion of the total fat obtained is saturated.

The question is whether we can eat a diet that protects our blood vessels from the ravages of oxidized lipoproteins while also eating enough fat and protein to maintain robust physical and mental efficiency and ensuring adequate intake of nutrients like zinc, vitamin B12, vitamin B6, vitamin D, DHA, taurine and others that are primarily found in animal products. Evidence indicates that there is indeed a way to accomplish this.

A Better Way

In 2004, researchers from Tufts University, Harvard School of Public Health and several other institutions published a report in the American Journal of Clinical Nutrition that the editors of the journal called “The American Paradox.”7 The study measured the change in atherosclerosis over the course of three years among postmenopausal women who participated in the Estrogen Replacement and Atherosclerosis trial. Like Esselstyn, the authors measured atherosclerosis directly by coronary angiography.

The results certainly surprised the authors. The progression of atherosclerosis was worse with higher intakes of PUFA, and to a lesser extent, with higher intakes of carbohydrate. The higher the intake of saturated fat, by contrast, the slower the progression of atherosclerosis. In the highest quartile of saturated fat, atherosclerosis was reversed!

In this study, the group with the highest intake of saturated fat only achieved a 0.01-millimeter increase in mean coronary artery diameter, which is much smaller than the average improvement in Esselstyn’s patients. The effect changed from a slowing of progression to a reversal at about thirteen percent of calories from saturated fat, however, and if we extrapolate from these figures, a further increase to eighteen percent of calories from saturated fat would have produced a reversal of atherosclerosis twice the magnitude produced in Esselstyn’s study. Although extrapolation is by its nature somewhat speculative and inherently inconclusive, the same can be said of intervention trials with no control groups.

Traditional Diets

The most flagrantly biased assertion in Esselstyn’s book is his claim that traditional diets are all lowfat and plant-based. His list of native populations among whom “heart disease is virtually unknown” includes the Tarahumara Indians of Northern Mexico, the Highlanders of Papua New Guinea, and “many native Africans.” He fails to point out that the Highlanders of Papua New Guinea have traditionally been so protein-starved that they have resorted to cannibalism. He makes no mention of other groups in whom rates of heart disease are low or non-existent, such as the Maasai and the Inuit, who eat high-fat animal-based diets, the inhabitants of Crete, who eat highly saturated goat cheese as a daily staple, or the natives of Pukapuka and Tokelau in the Polynesian atolls, who live off fish and highly saturated coconut meat.

A Reality-Based Cure

Esselstyn cherry-picks the studies he presents and then stretches his interpretations of them as far as they can be stretched. The result is that the picture he paints of the relationship between diet and heart disease has little connection to reality. It is not revolutionary because advocates of vegetarianism, and opponents of dietary fat have been stretching science for ages. It is not scientifically proven because the “proof” is a single study with no control group and a high drop-out rate. While his plan is nutrition-based, a plan for reversing heart disease should be both nutrition- based and reality-based.

A reality-based plan for reversing heart disease would be low in PUFA, but not necessarily low in fat. It would be rich in fresh, traditionally raised and traditionally prepared foods, including animal products. It would include a component emphasizing exercise and happiness. And, luckily for those following it, it would taste good, too.


  1. Kannel WB, Castelli WP, Gordon T. Cholesterol in the prediction of atherosclerotic disease. Annals of Internal Medicine. 1979;90:85-91.
  2. Iso H, Jacobs DR, Wentworth D, Neaton JD, Cohen JD. Serum cholesterol levels and six-year mortality from stroke in 350,977 men screened for the multiple risk factor intervention trial. New England Journal of Medicine. 1989;320:904-10.
  3. Masterjohn C. Cholesterol and Stroke. Wise Traditions.2007; 8(3):28-38.
  4. Masterjohn C. How Essential Are the Essential Fatty Acids? The PUFA Report Part I: A Critical Review of the Requirement for Polyunsaturated Fatty Acids. Special Reports. 2008; 1(2):1-25.
  5. Stocker R, Bowry VW, Frei B. Ubiquinol-10 protects human low density lipoprotein more efficiently against lipid peroxidation than does alpha-tocopherol. Proceedings of the National Academy of the Sciences USA. 1991;88(5):1646-50.
  6. Esselstyn CB Jr., Ellis SG, Medendorp SV, Crowe TD. A strategy to arrest and reverse coronary artery disease: a 5-year longitudinal study of a single physician’s practice. Journal of Family Practice. 1995; 41(6): 560-8.
  7. Mozaffarian D, Rimm EB, Herrington DM. Dietary fats, carbohydrates, and progression of coronary atherosclerosis in postmenopausal women,” American Journal of Clinical Nutrition. 2004; 80: 1175-84.

This article appeared in Wise Traditions in Food, Farming and the Healing Arts, the quarterly journal of the Weston A. Price Foundation, Fall 2008.

About the Reviewer


Comments (14)Add Comment
Esselstyn has no industry behind him!
written by Chester, Apr 07 2014
Tell me what is the industry behind Esselstyn; I believe there's no one. Besides, is it so hard to see the environmental issues related to a diet based on animal products? Are we so insensitive to the animal ethics issues that we cannot put their interests on the table? John McDougal is right: "most people like to hear good news about their bad habits". That's why the meat and dairy indrustry along with the media profit billions of dollars thanks to this kind of thinking.
written by 432olim, Jan 03 2014
Obviously Esselstyn's one study that he describes in his book is very lacking in thoroughness and size. It was just an initial proof of concept. However if you look at the results he got in the patients who followed through with his diet, they appear extremely promising, regardless of how much you may think he twists the results of the scientific studies he uses to explain why his diet works. Note that Esselstyn does not say other diets cannot result in optimal or near-optimal health and that his book is targeted to people with CAD hence the talk about statin drugs. It will be interesting to see what his new, recent study shows once its results are published (and if this author or website writes a big bad review of it too). If you look at the principles of his diet, it is basically keep saturated fat in the diet to a minimum, to avoid highly processed foods, refined carbohydrates, excessive sugar and salt - all standard dietary recommendations. Additionally he strongly encourages you to eat leafy green vegetables and lots of other fruits and vegetables containing fiber and antioxidants - another standard dietary recommendation.

Esselstyn was a champion olympic athlete. He has plenty of energy on his diet. So do his children who were notable college athletes and have eaten this diet their whole lives. He was a general surgeon, a very tiring, physically demanding job, and he ate this way.

It is possible to eat lots of tasty foods on Esselstyn's diet. It is pretty ridiculous to believe that any food that is considered tasty or any healthy meal has to include dairy or meat since the vast majority of the human population of the planet (75%) is lactose intolerant (basically everyone without European ancestry) and the amount of protein (the primary nutrient you are trying to get from your meat) necessary for the human body is pretty small. Most humans only need about 2 oz of protein per day, and it is possible to get all the protein you need from plants. The only thing a typical, healthy human needs that can only be gotten from animal products that cannot come from plants is vitamin B12. I would think that you could achieve a similar effect to that achieved by Esselstyn's diet if you were to add a few small portions of low/no fat animal meat to your diet each week to ensure sufficient B12 intake if you didn't want to take supplements.

If you read Roy Walford's books, you read that the only way scientifically proven to increase maximum life span for organisms is to reduce caloric intake while still eating a nutritionally adequate diet. If you try Esselstyn's diet, you will most likely find that your calorie intake drops drastically (unless you ate relatively little to begin with), and so Esselstyn's diet seems likely to lead to a longer lifespan. It certainly will be a longer life in those who don't die of heart disease but live to die of other things. There is a lot more that goes into long life than just diet - genetics, luck, good medical care, prevention of accidents, healthy mental attitude, etc.

If you read Harvard's Willet's book Eat, Drink, and Be Healthy, you will see data which may surprise you regarding calcium - calcium intake as low as around 400-500mg/day (
Four Notes Regarding The Esselstyn Diet
written by Tim Flake, Jan 02 2014
1) I suggest that those interested in this diet read "Why Most Published Research Findings Are False," by John Ioannidis, C. F. Rehnborg Professor in Disease Prevention in the School of Medicine and Professor of Health Research and Policy at Stanford University.

2) Esselstyn advises supplements of vitamin B12 and Calcium. Vitamin B12 is found only in animal sources; adequate calcium is very difficult to obtain from a diet based solely on vegetables. Our canine incisors indicate that our diet has not been strictly vegetarian, and it is reasonable to infer that meat has been a necessary source of nutrients. Milk is a very good source of both calcium and B12, with the caveat that some populations cannot easily digest lactose. Eating the grit included in corn meal ground in a limestone quern is one non-animal source of calcium. Some societies still use such production methods, but not many, and the characteristic diets of such populations are deficient in high quality protein. Broth made from animal bones simmered in water is a tasty way to get calcium, and better on the teeth.

3) Another good read is Biochemical Individuality: The Basis for the Genetotrophic Concept by Roger J. Williams. What is medicine to some folks is poison to others. Examples:

A. My wife's Mennonite grandmother ate an emphatically non-Esselstyn diet and only lived to be 105. When she was 103, she recited for us a very long poem in German that she had memorized that year.

B. Jeanne Calment lived to be 122. She loved olive oil and chocolate, which she consumed in very large amounts, and she smoked (sparingly) until she was 117. I read somewhere (but cannot find the source) that she stopped smoking only because she could not longer light her cigarettes herself. She was lucid until the end. (See both Wikipedia and Perfect Health Diet The latter source has many more examples.

4) We are not all Jeanne Calments. Clearly there is some wisdom in avoiding pleasures that will radically diminish the quality of life in old age, and because of the costs of health care, maintaining good health is to some extent a matter of social responsibility. Nevertheless, even if a life devoid of pleasure could be prolonged indefinitely, who would want it? No diet, except one, conveys eternal life, and few choose to follow it. In that diet neither vegetarianism nor meat-eating avail anything. For this present time, then, consider this wisdom:

"Behold that which I have seen: it is good and comely for one to eat and to drink, and to enjoy the good of all his labour that he taketh under the sun all the days of his life, which God giveth him: for it is his portion." (Ecclesiastes 5:1smilies/cool.gif

So then--An aperitif followed by a nice first course of pasta with a little olive oil and butter; a perfectly roasted leg of lamb with a glass or two of well chosen and properly aged Bordeaux; a salad with vinaigrette followed by cheese, a chocolate dessert, and brandy and cigars--surely the pleasures of dining are worth a few years of vegetable casseroles accompanied by cups of tea.

But consider also this wisdom: "It is good neither to eat flesh, nor to drink wine, nor any thing whereby your brother stumbles, or is offended, or is made weak." (Romans 14:21) There are many who do not even get adequate calories or have clean, safe water to drink. Let us help them while we indulge ourselves in matters of diet which for us, because of our affluence, are matters of choice.
written by c i denton, Nov 11 2013
I am trying this plant based diet. When you state "do not anything with a mother or a face", what are you talking about that doesn't have a face?

Thank You
Low-energy allusions
written by Chad Sichello, May 16 2013
I suggest the author of this article try Dr. Esselstyn's diet for six months and then revisit this article. The continued allusions to low-energy or fatigue are blatant assumptions and discredit a large part of the basis for his argument. I am a highly active individual, I run at least two marathons a year, two Olympic length triathlons, I play soccer almost every weekend when I'm not traveling worldwide for my work. I also have two children under the age of seven who have boundless energy that they feel obliged to spend on their father when I get home each night. I switched to a plant based diet one year ago and the results counter every assumption made by this author. My jet lag is less severe after Middle East or Asia trips, I have bested my personal best for marathons twice since I began this diet, my recovery time after my distance races has improved significantly and I have more energy and far far less fatigue than when I was a carnivore. For the record, I am 37 years old and previously, my marathon and triathlon times were slowly getting worse. I have not changed my training regime, I simply don't have the time to add to my current regime. All I've done is change my diet. At my annual physical my doctor was amazed at my improved health over the past year.

Please try this diet, do moderate exercise and then six months later, revisit this article, I think you will surprise yourself.
written by Richard Hughes, Feb 22 2013
You are wrong...simply put..whose payroll are you on?? .It's that simple. If we can get through the money and power we will live longer. What is his purpose?. To sell his book?? All of his seminars are free. I was lbs now 195. My T.C was also went down to 155.My ldl is 90. MY A1C was's 6.2 now. All because i went to a plant base eating style...You are similar to our lawmakers. Most are whores to the pimps,the pimps being special interests...
written by John R. White, Jan 12 2013
Dr. Esselstyn has not discovered anything new in diet. Dr. Pritikin "Pritikin Diet" had the exact same theory. yes you could loose a lot of weight if you could suffer enough with the Diet. Dr. Pritikin contracted Leukemia and committed suicide in his bath tub by slitting his wrist.
Dr.Esselstyn recommends Statins as a suppliment, a Liver damaging substance. Why because his Pritikin diet will not achieve his claims without them. So that is not good health.
Watch DR. Esselstyn's documentry on and take a good look at his skin color and texture, the brittle hair and if you could examine his nails they will be brittle as glass. A well balanced diet without sugars, very limited Wheat products and small portion sizes, exercise, balanced fluid intake , no smoking or tobacco products and very light drinking is the only way to survive to death which by the way is 10 out of 10 for all. There are much worse health conditions or ways to die than heart desease. We must remember it is "life that we are trying to achieve.
written by Josh Barton, Jun 04 2012
Peter, do you understand nutritional science? What was the diet like of the meat eaters in the control group? Did they consume refined and processed foods? Soda? Polyunsaturated vegetable oils? Fast food? Did they smoke? In short, was it a Standard American Diet or was it an omnivorous diet without the known disease triggers?

This article is relevant: http://behealthynow.wordpress....m-disease/
Not sure where you source your info James Masters
written by Bananas, Mar 12 2012
Disease was clinically arrested in all 11 participants, and none had new infarctions. Among the 11 remaining patients after 10 years, six continued the diet and had no further coronary events, whereas the five dropouts who resumed their pre-study diet reported 10 coronary events.

Sounds pretty good to me.
written by Dale Holmes, Feb 16 2011
Instead of nitpicking Esselstyn's generalizations/methods & twisting the facts, Masterjohn needs to focus on the critical results of Esselstyn's 12 (not 5) year study.

Here's Esselstyn's main result: "Among the fully compliant patients, during the 12 year study, there was not one clinical episode of worsening coronary artery disease...", whereas, in the 8 years prior to the study, these patients had collectively experienced 49 such episodes (heart attack, stroke, bypass, stent, etc.) [I suggest that not one of these patients saw a need for a control group.] This is a mindblowingly positive clinical outcome and I would challenge Masterjohn to prove that it is not "reality". Instead of trying to discredit Esselstyn over nonessentials, there should be a call for larger and more rigorous studies to confirm or refute the the results.

By the way, the Before & After cardiac PET scan data is also very very positive in showing profound flow restoration. Show me that that's not "reality".
Director of Research - Wellness Formulations, LLC
written by Nicholas Pokoluk, Feb 11 2011
As a biochemist I have been doing research on various factors affecting CVD now for over four decades. I STRONGLY support Dr Esselstyn's position of diet and CVD. The evidence is overwhelming for a diet that supports healthy endothelial layer and this approach will do that. For those without CVD markers or diagnosis I would support some inclusion of nuts and some canola or EVOO.
written by Gene Perri, Jul 03 2010
After a first CAD event & angioplasty in 1988 I followed a strict, very low fat, almost 100% vegetarian diet for 14 years without any problems.
In 2002 I had to have angioplasty again. I continued with the same diet except I became stricter and didn't allow any exceptions.
Then, in May 2009, I began to have severe chest pain. I decided the diet really wasn't the solution and I didn't want the standard medical solution (angioplasty or bypass surgery). My wife & I began to research how to correct the problem. Through the Internet, we discovered Dr. Linus Pauling and his wonderful book "How to Live Longer and Feel Better".
I began to follow Dr. Pauling's guidelines in the book and, in less than a week, my chest pain went away. It is now July 2010 and I am still following the Dr. Pauling's guidelines and am completely free of CAD problems.
One final note - I scrapped the fat free diet.
Esselstyn off base
written by James Masters, Mar 25 2010
So let me get this straight, Esselstyn only had 11 people in the final analysis. Of that, about HALF got worse? Half got worse? This is unbelievable that someone would have the nerve to parade this nonsense around as a 'study' when it is completely non-scientific. No control group? Half got worse? And he wants to extrapolate this to billions of people. Unbelievable.
written by PETER CIESLAR, Jan 17 2010
Findings from the Oxford Vegetarian Study, a 12 year study of 6000 vegetarians and 5000 meat-eater found that the incidence of coronary heart disease mortality was 28% lower in vegetarians compared with matched omnivores, after all non dietary factors had been taken into consideration (Thorogood, 1994).

Burr & Butland (1988) found vegetarians to suffer significantly lower mortality from heart disease than health conscious non-vegetarians. Mortality from ischaemic heart disease was 57% lower in vegetarians than the general population, and 18% lower than in non-vegetarians following a healthy lifestyle. Deaths due to cerebrovascular disease was 43% lower in the vegetarians compared with the general population.

A study of nearly 28 000 Seventh Day Adventists in California noted a clear trend of increasing incidence of heart disease with rising frequency of meat consumption (Snowdon, 1988).

The Coronary Artery Risk Development in Young Adults (CARDIA) Study examined diet in relation to health in over 5000 young adults aged 18 to 30. Vegetarians were found to have greatly improved cardiovascular fitness and a lower risk of heart disease (Slattery, 1991). A low level of meat consumption was linked to improved general health.

An eleven-year study of 1900 German vegetarians has found mortality from cardiovascular disease to be 61% lower in male vegetarians and 44% lower in female vegetarians than the general population. For ischaemic heart disease, mortality was reduced still further, to only one-third of that expected (Claude-Chang, 1992).

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Last Updated on Monday, 04 June 2012 13:06