In Cholesterol Lowering, Moderation Kills
By Caldwell B. Esselstyn, Jr, MD
Department of General Surgery, Cleveland Clinic Foundation
Amercian diet is responsible for an epidemic of coronary artery
disease. A plant-based diet with less than 10% fat will prevent
coronary disease from developing, halt the progress of existing
disease, and even reverse the disease in many patients. Given proper
support and education, motivated patients with a history of coronary
disease can follow this diet and prevent future cardiac events.
Even if all Americans kept their total cholesterol below
200 mg/dL, as recommended by the American Heart Association, millions
would develop coronary artery disease.
Strong evidence from a wide variety of sources shows
that total serum cholesterol levels must be kept below 150 mg/dL to stem
America's epidemic of coronary artery disease. My own experience with
heart disease patients shows that cholesterol levels can be kept below
this threshold with a diet low in lipids and cholesterol-lowering
medications as needed. This low-lipid therapy stops coronary disease from
progressing and even reverses it.
Unfortunately, our national health and medical
organizations continue to recommend a cholesterol threshold of 200 mg/dL
and a diet containing up to 30% fat, despite clear evidence that this
threshold is too high to prevent or cure heart disease. It is true that
these recommendations have the potential to reduce the incidence of heart
disease, but only by a moderate amount. Unfortunately, when it comes to
lowering cholesterol, moderation kills. With lower lipid levels, coronary
artery disease need never exist. When it does exist, it need never
A Plant-based Diet for Advanced Disease
In 1985, I embarked on a program to help a group of
patients with severe coronary artery disease. Most were debilitated by
angina and other symptoms, and their angiograms showed severe stenoses. In
some cases, disease was so advanced that standard interventional
techniques such as bypass grafts or angioplasty could no longer be
These patients (1 woman and 23 men) agreed to adopt a
plant-based diet with fats making up less than 10% of calories. They ate
no oils, fish, meat or dairy products (except skim milk and non-fat cheese
and yogurt). The patients also took cholesterol-lowering medication as
necessary to maintain their total serum cholesterol below 150 mg/dL.
Social and personal support was crucial for this group
to learn about and follow the program, which was called
arrest-and-reversal therapy. At enrollment, we discussed the treatment
objectives in depth with both the patient and his or her spouse. For the
first 5 years, the patients came to the clinick twice each month; visits
were once a month during the second 5 years, and quarterly after that. On
the evening of each clinic visit during the first year, the patient was
telephoned to discuss his or her lipid results, diet, and medications.
The patients also met several times a year as a group to
discuss the program, share recipes, and socialize. I committed myself to
the same diet, and patients reported that this was an additional source of
No relaxation or structured exercise regimens were
included in the program. In my opinion, people have a limited number of
lifestyle modification "credits"; if they spend all their credits by
trying to change too many aspects of their lifestyle simultaneously, they
may "go broke" and fail to change any of them.
At 5 Years, Heart Disease was Halted
Eighteen patients adhered to the diet and medications,
bringing their mean cholesterol level from 237 mg/dL at baseline to 137
mg/dL at 5 years. None experienced any coronary events; in contrast, these
18 had had 29 events in the 8 years before the study. None underwent any
interventions. All 11 of those who underwent angiography at 5 years had no
additional stenosis, and 8 had regression.
One patient died of ventricular arrhythmia just after
his 5-year angiogram, but the angiogram showed that the disease had
regressed and autopsy found no evidence of myocardial infarction.
Six nonadherent patients were released from the study
within the first 18 months to return to standard care. Although their
baseline levels of disease were similar to those of the adherent patients,
these 6 patients suffered 13 new cardiac events after leaving the study.
At 12 Years, the Benefits Continue
Today, the remaining 17 patients continue to follow the
prescribed diet and medication schedules. At 12 years, their mean
cholesterol level was 145 mg/dL. They experienced no disease progress or
interventions. One left the study briefly but suffered a recurrence of
severe angina and returned to the diet and medication after undergoing an
elective bypass operation. The rest experienced no coronary events. 2.
These results are important because they show that sharply reducing
cholesterol levels is safe and that it stops coronary atherosclerosis
rather than merely slowing it.
Support from Other Research
When our arriest-and-reversal study began, strong
observational evidence already supported the benefits of low cholesterol
levels. For example, 35% of the cases of ischemic heart disease found
among the Framingham Heart Study cohort occurred among those with total
serum cholesterol levels between 150 and 200 mg/dL. In contrast, few of
those with levels below 150 mg/dL developed the disease, and none died of
it. 3. Atherosclerosis was already known to develop silently over many
years of high-fat diets; autopsy studies of young, healthy men killed in
the Korean and Vietnam conflicts found that many already had advanced
atherosclerotic lesions. 4,5
More supporting data continued to pour in. For example,
coronary artery disease is virtually unknown in populations that subsist
primarily on grains, legumes, vegetables, and fruits, such as those in
rual China. 6,7 Normal adult cholesterol levels in these populations range
from 90 to 150 mg/dL.
More than 10 years ago, Blankenhorn and colleagues
showed that coronary artery disease can be halted or reversed by lowering
lipid levels with medication. 8 More recently, Dean Ornish and other
investigators confirmed the benefits of a low-cholesterol diet. Their
results showed that patients derived the most benefit if lipids are
lowered by diet combined with medical therapy, rather than by diet alone
or by modest diet changes combined with medication. 9-11
The AVERT study provides similar supporting evidence.
The study showed that aggressive lipid-lowering medication is at least as
effective as angioplasty plus standard care. However, the AVERT patients
continued to eat a fairly standard diet, and 13% of them continued to
experience cardiac events. This suggests that medication alone cannot
confer the full benefit of lipid lowering. 12 A recent review of
cholesterol-lowering studies showed that the degree of benefit is related
directly to how much cholesterol is reduced. 13
Low Cholesterol Addresses the Cause of the Disease
artery bypass grafting, angioplasty, and other coronary interventions are
directed at severe coronary stenoses. However, 85% of heart attacks are
now known to be cause by rupture of smaller, unstable plaques, many of
which are not even visible on angiiography. Thus, costly "heroic"
interventions do not reduce the risks of new heart attacks, slow disease
progression, or even prolong survival for most patients. 14
In contrast, lowering levels of total cholesterold and
low-density lipoprotein (LDL) prevents coronary disease from starting or
progressing. Lowering lipid levels also lowers concentrations of harmful
foam cells within plaques and reduces the quantity of proteolytic enzymes.
As a result, plaques may shrink, their caps stabilize, and they become
much less likely to rupture.
America Resists Lowering Fat
Despite the strong evidence in favor of reducing both
dietary fat and serum cholesterol, Americans continue to increase their
consumption of fat. Television and print advertisements aggressively push
delicious, colorful, habituating, high-fat food. At our most memorable and
emotional events - birthdays, weddings, funerals, and banquets - the food
is even richer and more harmful than our everyday fare. Fad diets even
promise weight loss and better healthy by increasing our consumption of
fats and protein. It is clear that we live in a toxic food environment.
Unfortunately, the American Heart Association has failed
to show strong leadership on this issue. If the coronary artery disease
epidemic is seen as a raging fire, and cholesterol and fats are the fuels,
the AHA has merely recommended cutting the flow of fuel. The only tenable
solution is to cut off the fuel supply altogether - by reducing
cholesterol levels to those proven to prevent and reverse coronary
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