Caldwell B. Esselstyn, Jr., MD
The Cleveland Clinic Foundation
9500 Euclid Avenue, Desk A80
Cleveland, Ohio 44195
2001; 4: 171-177
The world's advanced countries have easy access to plentiful high fat
food; ironically, it is this rich diet that produces atherosclerosis. In
the world's poorer nations, many people subsist on a primarily plant-based
diet, which is far healthier, especially in terms of heart disease. To
treat coronary heart disease, a century of scientific investigation has
produced a device-driven, risk factor-oriented strategy. Nevertheless,
many patients treated with this approach experience progressive disability
and death. This strategy is a rear-guard defensive. In contrast,
compelling data from nutritional studies, population surveys, and
interventional studies supports the effectiveness of a plant-based diet
and aggressive lipid-lowering to arrest, prevent, and selectively reverse
heart disease. In essence, this is an offensive strategy. The single
biggest step toward adopting this strategy would be to have United States
dietary guidelines support a plant-based diet. An expert committee purged
of industrial and political influence is required to assure that science
is the basis for dietary recommendations.
I have drawn two compelling observations from my service as the program
director of 2 national cholesterol conferences and my participation in 3
others over the past decade. First, a great deal is known about what
factors are responsible for causing coronary artery disease and what
populations are vulnerable. Second, the present emphasis of identifying
risk factors and those who are particularly vulnerable to atherosclerotic
disease will not resolve the cardiovascular epidemic, which presently
threatens 1 of 2 Americans and is predicted to become the number one
global disease burden by the year 2020.
Autopsy data from the conflicts in Korea
the Bogalusa study,4
and the PDAY5 study all testify to the ubiquitous nature of the disease in
young Americans. Recently, intra-arterial ultrasonography confirmed that
"normal" segments in patients with coronary artery disease also have
diffuse symmetrical atherosclerosis, which is not yet disfiguring the
intra-luminal diameter and thus is invisible to angiography.6
This work is further confirmation of the Roberts autopsy data, which
demonstrates that essentially all patients with ischemic heart disease
have triple vessel involvement.7
However, coronary artery disease is virtually absent in
cultures that eat plant-based diets, such as the Tarahumara Indians of
the Papua highlanders of New Guinea,9
and the inhabitants of rural China10
and central Africa.11
Hundreds of thousands of rural Chinese go for years without a single
documented myocardial infarction.10
Modern North America and Europe pride themselves on
having the world's most advanced medical care. What are these health-care
systems doing about coronary artery disease?
Present Heart Disease Management Strategies
-- Coronary angiograms of the distal left anterior descending artery
before (left) and after (right) 32 months of a plant-based diet
without cholesterol-lowering medication, showing profound improvement.
The present strategy focuses on interventional
procedures and risk-factor modification. This approach is strictly a
defensive strategy. It is pressing the limit of what society can afford.
Our present cardiology budget exceeds one-quarter of a trillion dollars
Millions of symptomatic patients - generally those with arterial stenosis
of more than 70% - have had interventions such as bypass, angioplasty,
stenting, or atherectomy.13
Unfortunately, these interventions are accompanied by significant
morbidity, mortality, and expense, provide only temporary benefit, and do
nothing for patients at greatest risk for myocardial infarction, those
with juvenile plaques of 30% to 50% stenosis, which are the ones most
prone to rupture.14
As Forrester states, "angiography does not identify and interventional
strategies don't treat those lesions most likely to cause a heart attack."15
Therapies involving diet and lipid-lowering medication
are not ignored by our health-care leaders, but sadly, their
recommendations are clearly inadequate. The American Heart Association and
the National Cholesterol Education Program (NCEP) recommend consumption of
not more than 30% dietary fat and cholesterol levels below 200 mg/dL;
numerous studies confirm that people who adhere to these recommendations
experience not arrest and reversal of their heart disease, but rather
continued disease progression.16
A question arises whether these recommendations expose millions to disease
development and progression. However, because of the general respect
commanded by these organizations, many doctors and patients perhaps are
misled, trusting that following their recommendations will protect against
-- Coronary angiograms of the circumflex artery before (left) and
showing 20% improvement (right) following approximately 60 months of a
plant-based diet with cholesterol-lowering medication.
The newer NCEP clinical guidelines, known as the Adult
Treatment Panel 111, suggest broadening the identification of those at
risk. This will mandate that millions of Americans take
cholesterol-reducing drugs as well as make some dietary and physical
activity adjustments. This is a rear-guard, after-the fact approach. It
tacitly acknowledges that our food environment is so toxic that millions
will become at risk and develop disease. As will be discussed, it is
preferable to advise the public too avoid the categories of food that
cause atherosclerotic disease.37
The National Research Council, in its 1989 report "Diet
recommended an upper limit of total cholesterol of 200 mg/dL and 30%
dietary fat, even though "a number of the scientists felt that a greater
reduction would confer additional health benefits."17
However, the committee felt that setting the cut-off too low would merely
frustrate the public. The council also surmised, incorrectly, that if the
upper level were set at 200 mg/dL, most Americans would achieve a total
cholesterol level of 150 mg/dL or less.17
That has not happened. Most Americans and their physicians feel "safe"
with a cholesterol total of up to 200 mg/dL. They are not. In the
Framingham study, 35% of ischemic heart disease occurred in patients with
total cholesterol levels between 150 and 200 mg/dL.18
In the CARE study, the average total cholesterol level in patients with a
history of heart attack was 209 mg/dL.19
In contrast, the American Cancer Society recommends no more than 20%
while the World Health Organization prefers no more than 15%.21
Coronary angiograms of the proximal left anterior descending artery
before (left) and showing 10% improvement (right) following
approximately 60 months of a plant-based diet with
Dr. Scott Grundy, chairman of the NCEP, proclaimed
approximately 14 years ago22
that 90% of heart attacks could be prevented if the population's
cholesterol was 150 mg/dL or less - a figure identical to that hoped for
by the National Research Council in 1989. However, neither the NRC, the
American Heart Association, or the NCEP is on record to show precisely
what diet will achieve the goal of cholesterol of 150 mg/dL. The basic
diet favored by these groups contains not only grains, legumes,
vegetables, and fruit, but also oil, low-fat milk and milk products,
butter, cheese, poultry, lean meat, and fish. I am unaware of any research
proving that by eating such a diet one can achieve a cholesterol level of
150 mg/dL or avoid coronary artery disease.
The Mediterranean diet and monounsaturated oils have
become unjustifiably popular because of the Lyon Diet Heart Study.23
This approach is difficult to accept. No studies of monounsaturated oils
have shown them to arrest and reverse coronary disease. The Lyon study did
show a slower rate of progression, but this is hardly an acceptable goal.
In a study of patients with coronary disease, Blankenhorn actually showed
the reverse, that disease progressed as rapidly in patients on a
monounsaturated diet as it did in those on a saturated fat diet.24
Rudel demonstrated a similar result in African green monkeys over a 5-year
Particularly compelling was his finding that disease in the two groups was
equivalent, even though the monounsaturated group had higher HDL, lower
LDL, and more favorable LDL-to-HDL ratio. He recently replicated the
results in rodents.26
The number of heart attacks continues to increase every
Although the age-adjusted death rate for heart disease has declined, the
decline may be artifactual.12
Stamler found deaths from cardiovascular disease approached 40% of those
dying in a group of 80,000 young men with follow-up ranging from 16-34
years. The data confirmed a continuous graded relationship of serum
cholesterol level to long term risk of coronary heart disease,
cardiovascular disease, and all cause mortality. They also demonstrated
substantial absolute risk and increased excess risk of coronary heart
disease and cardiovascular disease death for younger men with elevated
cholesterol levels and conversely a longer estimated life expectancy for
younger men with favorable lipids.35
Our stop-gap, device-driven, risk factor-oriented approach is not working.
Why? Because it fails to address our toxic food environment, which is
responsible for the disease. It is focused only on those who are already
ill or whose elevated lipids reflect an inability to detoxify their
American diet. What are the other alternatives?
Taking the Offensive
4--Coronary angiograms of right coronary artery before (left) and
showing 30% improvement (right) following approximately 60 months of a
plant-based diet and cholesterol-lowering medication.
As I have reported earlier,28,29
a plant-based diet in conjunction with cholesterol-reducing medication
eliminated progression of coronary artery disease over a 12-year period in
patients with triple-vessel disease. Most of the 18 patients had
experienced an earlier failed intervention of bypass surgery or
angioplasty. All patients who maintained the diet achieved the cholesterol
goal of less than 150 mg/dL and had no recurrent coronary events during
the 12 years. At 5 years, angiography was repeated in most cases. By
analysis of the stenosis percentage none had progression of disease, and
70% had selective regression.28
These data are compelling when one considers that the same group had
experienced more than 49 coronary events during the 8 years before this
The recent case of a colleague is particularly telling.
During September and October of 1996, a 44-year-old surgical colleague
experienced occasional chest discomfort, yet neither electrocardiogram,
stress echocardiography, or thallium scanning found evidence of disease.
While eating the typical American diet, he had a total cholesterol of 156
mg/dL and an LDL of 97 mg/dL. He was lean, non-diabetic, and normotensive,
did not smoke, and had no family history of coronary disease. His
lipoprotein (a) and homocysteine levels were normal. On November 18, 1996,
after his surgical duties, he became acutely ill with pain in the left
arm, jaw, and chest. Immediate coronary catheterization found all vessels
to be normal except for the left anterior descending artery, the distal
third of which was diseased. Enzymes confirmed a myocardial infarction.
However, no intervention was deemed appropriate.
This patient was aware of my ongoing study and was
curious for more information. He and his wife consulted me for an in-depth
review of the plant-based diet and techniques of this arrest and reversal
study. He became the personification of commitment to the plant-based
diet. Over the next 32 months, without cholesterol-lowering drugs, he
maintained a mean total cholesterol of 89 mg/dL and an LDL of 38 mg/dL.
The repeat angiogram 32 months after his infarction showed that the
disease was completely reversed.
Even though many people might find a plant-based diet
initially difficult to follow, every patient with the diagnosis of
coronary artery disease should at the least be offered the option of this
potentially curative arrest and reversal approach. As this young surgeon's
case illustrates, our plant-based diet approach can achieve total disease
arrest and selective regression even in advanced cases. This approach is
particularly compelling because patients can take control over the disease
that was destroying them. If traditional interventional cardiology is a
rear-guard action, our arrest and reversal therapy can be likened to a
military offensive against atherosclerosis.
Limitations of this study are its modest number of
participants and lack of comparable controls. Nevertheless, its size
permitted the caregiver an opportunity for frequent patient encounters.
These interactions enabled 75% of participants to achieve profound lipid
reduction, dietary goals, and relief of symptoms which continued to
improve throughout the study's 12-year duration. Patients essentially
served as their own controls often achieving profound angiographic
reversal of disease as reviewed in the angiographic core laboratory.
New recommendations for a healthy diet
The expert faculty at the First National Conference on
the Elimination and Prevention of Coronary Artery Disease have issued a
new set of recommendations:30
1) Present nutritional guidelines of government and
national health organizations do not provide a maximal opportunity
either to arrest or to prevent coronary artery disease.
2) The optimal diet consists of grains, legumes,
vegetables, and fruit, with <10%-15% of its calories coming from fat.
This diet minimizes the likelihood of stroke, obesity,
hypertension, type II diabetes, and cancers of the breast, prostate,
colon, rectum, uterus, and ovary. There are no known adverse effects of
such a diet when mineral and vitamin contents are adequate.
3) Children and adolescents require major attention
to develop early habits of optimal nutrition. Schools should assume a
significant leadership role in achieving this goal.
4) Speculation about the degree of public
compliance with a low-fat diet must not alter the accuracy of the
At the 1999 national cholesterol summit meeting, Dr.
William Castelli was asked what he would do to reverse the coronary artery
disease epidemic if he were omnipotent. His answer: "Have the public eat
the diet of the rural Chinese as described by Dr. T. Colin Campbell,"
author of the Cornell China study (personal communication, William
Castelli, Sept. 2-3, 1999). A recent prospective study of diet quality and
mortality in more than 40,000 women confirms the benefits of consuming a
diet high in fruits, vegetables, and grains.31
At a recent national meeting on hypertension, the
original DASH study32 was updated.33
It was found that a diet emphasizing grains, vegetables, and fruit (and
including low fat dairy and lean meat), with particular attention to
reducing sodium intake, resulted in blood pressure reductions equivalent
to those produced by hypertension drugs.
In addition, Dr. Dean Ornish has reported both 1- and
5-year data that support a plant-based approach to control coronary artery
Replace the "Food Pyramid"
An integral part of this offensive must be to eliminate
the toxic food environment. Look at the so-called Food Guide Pyramid, the
familiar geometric symbol used to promote the recommendations by the U.S.
Department of Agriculture and the Department of Health and Human Services.
It is laden with dairy products, animal products, and oils, which are the
essential building blocks for coronary artery disease. In addition, from a
design standpoint, the choice of a pyramid is potentially confusing and
misleading. Some viewers may be led to believe that the foods at the top
(meats, sweets, and fatty foods) are the most helpful, when in fact they
are the most harmful. To avoid such sources of confusion, we should
eliminate geometric figures and promote 3 simple food categories: safe,
condiments, and unsafe.
legumes, lentils, vegetables, and fruits
Condiments: nuts and seeds
Unsafe: oils, dairy foods, meat, poultry, and fish (not regulated
by inspection, and frequently contain unacceptable levels of PCB's,
dioxin, and mercury
In addition, we should recommend dietary supplementation
with a daily multivitamin, and, for those over 50 years old, an additional
1,000-1,200 mg calcium and 600 to 800 IU of Vitamin D. These
recommendations are in concert with those of the expert faculty from the
First National Conference on the Elimination of Coronary Artery Disease.30
Why are the current recommendations so weak?
When dietary recommendations are issued with the stamp
of approval of the U.S. government, the public should be able to trust
that these recommendations accurately guide them to foods that are
unlikely to cause disease and away from those that are known to cause
harm. Thus, any group promoting dietary guidelines for the public should
make its decisions based on science. However, the USDA has been subjected
to intensive industry lobbying, which compromises its capacity to be fair
At the least, neither the experts who testify before the committee nor the
committee members themselves should have relationships, financial or
otherwise, to the food industry. These same rules regarding conflict of
interest should apply to scientists who lead or are members of the
National Cholesterol Education Program and the Food and Nutrition Section
of the American Heart Association.
As recently as October, 2000, the Physicians Committee
for Responsible Medicine successfully litigated the USDA to ascertain the
compensation sources of the US Dietary Guidelines Committee. Six of the
eleven committee members, including the chairman, had relationships to the
meat, dairy, or egg industry.
Such conflict insures a perception that the American public and school
children will not receive an unbiased recommendation of what constitutes
the healthiest food choices. The USDA, by definition, a protector of the
agriculture industry should disqualify itself from this responsibility,
which more correctly may belong in the Centers for Disease Control.
The present device-driven, risk factor-identification,
rear-guard strategy diagnoses disease after the fact and offers no promise
of preventing disease or controlling its progression. We are fortunate to
possess the knowledge of how to prevent, arrest, and selectively reverse
this disease. However, we are not fortunate in the capacity of our
institutions to share this information with the public. The collective
conscience and will of our profession is being tested as never before.
Ties to industry and politics result in conflict within our private and
governmental health institutions, compromising the accuracy of their
public message. This is in total violation of the moral imperative of our
profession. The time is now for us to have the courage for legendary work.
Science and not the messenger must dictate the recommendations.
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Fig. 1. Coronary angiograms of distal left anterior
descending artery before (left) and showing profound improvement (right)
following 32 months of a plant-based diet without cholesterol-lowering
Fig. 2. Coronary angiograms of proximal left anterior
descending before (left) and showing 10% improvement (right) following
approximately 60 months of a plant-based diet with cholesterol-lowering
Fig. 3. Coronary angiograms of circumflex artery before
(left) and showing 20% improvement (right) following approximately 60
months of a plant-based diet with cholesterol-lowering medication.
Fig. 4. Coronary angiograms of right coronary artery
before (left) and showing 30% improvement (right) following approximately
60 months of a plant-based diet and cholesterol-lowering medication.