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.
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.
REFERENCES
- 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.
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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).
Esselstyn off base
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.
I take it the writing on the wall concerning the typical American diet is not clear to you nor the impact on health costs or the environment.
Correct me if I am mistaken but having read significantly about diets that have a proven record of reversing heart disease I believe they all concluded that whole plant-based food had to be the primary focus with elimination of most processed foods and a reduction in the consumption of animal products. Esselystn does take this approach further than any long-living culture in history however, reversing a disease does take more than having lived an entire life on a good diet.
James, you should live your life the way you wish but it is likely going to take another hundred years before we really know what is going on with heart disease. Industry and government, along with the medical field, have been an obstacle in the quest and I doubt it will soon change.
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.
Director of Research – Wellness Formulations, LLC
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.
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”.
Seems like many are ignoring the fact that there is a control group. There are millions just in the US consuming the Standard American Diet (SAD) and we know what the disease record of those people are…There are also many that have underdone the typical medical procedures more than once and we know what the results were there also…
We can look at the diets of a great percentage of segments of a population in countries like China and Okinawa or the end of the spectrum and see the impacts on disease.
I really do not understand the diversion about a control group or the misguided comments about Joe Crowe’s 156 while ignoring the fact that his LDL at the start was 98. Esselstyn never said it is only the 150 that is important…BTW, the change in diet did knock the LDL well below the required level.
Elimination of seed oils and all processed food, meat is not the culprit people have been eating meat, lard , butter for centuries- heart disease was essentially non existent before the introduction of industrial seed oils into the American diet.
I wonder if the Dr had done a comparison study with vegetarian eaters vs people who eat pure food -meat( grass fed grass finished)fruit, some vegetables, raw milk,
pure water.what the results would have he seen.
I ate pretty much all vegetarian diet for 10 years- I was never fully satiated on this diet, always felt hungry, and had many bouts of intestinal intolerance while eating mostly plants-
Since you promote the idea of eating vegetarian- where do you get the essential amino acids and vitamin b-12 that is missing in eating all plants- not to mention the saturated fat humans need to maintain health.
I now eat mostly meat , little if any processed foods, fruit, very little vegetables and get my sweets from fruit and honey , drink raw milk- and feel satisfied, satisfied and healthy- my recent blood tests have proved that as well. An ancestral diet is the the true human diet in my opinion.
The patients were on statins.
Not sure where you source your info James Masters
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.
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/
Right on my man
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 CNN.com 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.
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 225..it went down to 155.My ldl is 90. MY A1C was 7.2..it’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…
Low-energy allusions
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.
Completely false, yours is a fake comment. I saw this exact same comment posted about 8 times on reddit, and twice on you-tube.
Are your comments false or fake? I too am doing much better following Esselstyn’s recommendations. This diet gives me hope of a future with less pain, more energy, and lower cholesterol!
I am on the Plant based no oils diet and have been for 2 years following a HA in Sept 13. I am happy with this diet and aside from a small statin dose med free. Possibly giving up the statin now. I do exercise by running 3.5 miles 4-5 days per week. I stay pretty active and I stopped smoking the day I had the HA. I know there are more variables to cover, but I like the diet and have gotten creative with the food. I do cheat occasionally. But no more than less than 10% of the time.
Sorry you had your HA, but you surely are completely on the wrong course of recovery. I now know 23 vegans who’ve had heart attacks within 5 years of starting the diet. Plant foods contain no K2, and K2 is what removes the calcium from the arteries, while it also directs the calcium in your body to where it needs to go (bones, teeth, and cells).
The amount of exercise you’re doing is also running the risk of arterial inflammation.
You have to remember something, the human body is made up of 3 things: Fat, Protein, and Water. It’s not made up of vegetables, fruits, grains, or beans. People need to understand this when choosing their diet.
You can’t build, repair, recycle, or replace any tissues in your body if you’re not using “like” nutrition. A few carrots, some celery, an apple, or a bowl of beans, isn’t going to help rebuild any tissue when it’s not made up of said things. Just as cells and your brain are primarily fat.
A second study was released by Esselstyn in 2014. 198 patients, 180 or so stayed on the diet, the other 20 did not. The test ran an average of 3.7 years. The ones who stayed had 0.5 percent occurrence of heart attack, stroke, or death (hard endpoints). The ones who did not stay on it, had 66 percent of the same. I was not able to find hard endpoint results as good as these anywhere else.
Why this study is null and void: It didn’t take into consideration the biggest health factor, sleep. No participants were quarantined for the entire duration of the study to account for their sleeping patterns. Bogus mixes of chow were used in the study that do not constitute a normal human diet.
Heart Disease is based on the relationship between Vitamin D, Calicum, and K2. Heart disease is calcification in the arteries.
Vitamin D pulls calcium in the blood to get ready for transport. It’s “supposed” to go to areas in need like bones, teeth, and cells (yes cells use calcium). Sometimes calcium ends up where it shouldn’t (Arteries, Kidney Stones, Gallstones). K2, plays the traffic cop, it directs calcium where it needs to go, but also removes it from areas it shouldn’t be.
Heart Disease is calcium ending up in the arteries and causing inflammation, this is the fault of lack of K2 in the diet, simple as that. So now the question is, where is K2 found?
Well this is what Vegans don’t like to hear, K2 is primarily found in: Saturated fatty red meats, fatty fish, egg yolks, cheese, and full fat dairy. This is what Vegans really really don’t like to hear: Vitamin K in plants has not been shown to convert in the liver to it’s usable for K2. There have been no studies supporting this, because anytime it’s been tested, it falls short, it doesn’t convert.
Now even if Vitamin K were to be used, the half-life of it in the human body is 30 min, while K2 is 12 hours. Vitamin K is useless with a 30 min half-life.
So low and behold, your heart disease reversing diet, is an all meat diet, fatty red meat primarily.
People also need to stop listening to this Vegan propaganda garbage and understand this one simple fact: If someone unfortunately ends up in the hospital with cardiac event such as a heart attack, the doctors will mega-dose the patient with Vitamin K2. Yes that’s right people K2, not Vitamin K, K2. They mega-dose people with the very vitamin that is found in saturated fatty red meats, fatty fish, egg yolks, cheese, and full fat milk. So why not just do yourself a favor and eat as nature intended you to, eat meat. Humans aren’t Ruminants, they cannot break down plants for energy like Ruminants can.
Going Vegan you’re asking for heart disease, this is simple common sense, that even for the most hard headed can figure out due to the process of elimination. Start right at the hospital, what do the docs give cardiac patiens?? K2, and where is K2 found, in a nutshell, high cholesterol food.
I’ll introduce the possibility that any diet comparison may be null and void unless they factor in the relative impact of “iron fortification” and magnesium intake.
Anyone switching away from flour-based products will ingest much less fortified iron.
I recommend everyone investigate the survey of the research done by Morley Robbins (search his name). I think he’s found some of the top key biochemical “levers” to promote wellness. One of those keys is retinol status.