A 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.
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.
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.
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.
- Kannel WB, Castelli WP, Gordon T. Cholesterol in the prediction of atherosclerotic disease. Annals of Internal Medicine. 1979;90:85-91.
- 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.
- Masterjohn C. Cholesterol and Stroke. Wise Traditions.2007; 8(3):28-38.
- Masterjohn C. How Essential Are the Essential Fatty Acids? The PUFA Report Part I: A Critical Review of the Requirement for Polyunsaturated Fatty Acids. Cholesterol-And-Health.com Special Reports. 2008; 1(2):1-25.
- 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.
- 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.
- 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.