Caldwell Esselstyn: Proponent of Plant Based Diet


Caldwell Esselstyn started his professional career as a surgeon at Cleveland Clinic and quickly became interested in prevention instead of surgery. Sadly, he fell into the traps of a person looking at population data to find the cure for a disease. If you have watched the movie “Forks over Knives “ you can hear him n detail – but if you don’t want to poke your eyes out we will give you a capsule summary of a surgeon who went from the operating room to the pseudoscience table.

Dr. Esselstyn noted the risk of heart disease in rural China was low in the 1970’s – and presumed that they didn’t have a “western diet.” Now there are two flaws in his population statistics: First in the 1970’s in rural China most individuals were starving to death – it was the end of the cultural revolution and any source of food that could be found and eaten was. The second issue is if you examine data from The China Study you will see that heart disease mortality was lowest in the rural communities that were able to eat more meat. In The China Study (again, I promise this will be a topic later) – they used mortality statistics from the time during the end of the Cultural Revolution. Rural China was starving then, all trees had been used for fuel, there were virtually no birds left (combination of deforestation and hungry humans) and rice was used for the army.

Dr. Esselstyn then talks about Norway during World War 2, when they were occupied by the Nazi Germany, and how that heart disease diminished as the Norske were forced to eat a plant based diet. That was a great assumption to make, but when examining the data from Norway there are a few interesting factoids – Meat consumption dropped 60% but fish increased 200 per cent. Vegetables and potatoes increased but sugar decreased by half. And when the data is put to a microscope in 1942 and 1943 when mortality declined, animal proteins were still higher than before the war. It appears that Norway suffered from increasing fish (great source of Omega 3 fatty acids) and foraged for foods such as wild greens, grew and ate a lot of potatoes, but had a low amount of sugars and almost no margarine (I don’t know a respectable Norwegian today who cooks with margarine). The sad part of the war was the increase of mortality from infectious diseases – especially pneumonia (my mother’s cousin who fought for the resistance died of this, as did many of his comrades).

Norway in WW2 ate a lot of fish- and this roe was popular

Esselstyn then did a study of patients with coronary artery disease patients who did not have diabetes, high blood pressure, or currently smoke. His goal was a plant based diet with less than 10 per cent of calories derived from fat. This severe diet eliminated oils, fish, fowl, and meat. They were allowed to eat a plant based diet including grains, vegetables, lentils, and fruits.

He followed these patients for up to 12 years – his numbers are confusing as he started with 24 patients and six dropped out (leaving 18). One of the 18 died from his heart disease (leaving 17). At ten years there were 11 patients. They did angiography and reported a regression of 11 lesions with 14 remaining stable.

Angiogram- xray – of a plaque. Not enough to do surgery on though

Analysis of this study is this: coronary angiography is unreliable, and subject to wide interpretation as to the percent narrowing of a vessel from plaque. Taken from a slightly different angle a lesion that is critical can look normal. Also, it is the platelets on these plaques that do the damage – and a small change in the amount of platelets sitting on a plaque will change it. None of the angiograms of these individuals rose to the level of requiring intervention (none needed bypass, or a stent, or balloon angioplasty).

This is not plaque along the heart vessel on the left, but clot. It resolves not because the patient magically ate vegetables, but because he was placed on aspirin, or other drugs.

When any study talks about a “cardiac event” it means to most of us a heart attack. If you have a small lesion in a coronary artery and then that lesion accumulates a blood clot that is what a heart attack is. The blood clot (from platelets – a sticky component of blood that helps you clot ) blocks the flow of blood to the heart muscle. If the clot blocks blood flow for a long time then the heart muscle dies and you have a myocardial infarction, if it opens up then all you have is a heart attack. This has little to do with the size of the lesion, and more to do with the complex chemistry of the coagulation system. Hence, taking aspirin a day or Plavix is more beneficial.

The other major problem with the study is that these individuals were on lipid lowering medications. Dietary reduction of lipid level (Cholesterol and lipoproteins such as VLDL, HDL) is about ten per cent on average, but never more than twenty per cent. However, lipid-lowering medications – such as Crestor – can remarkably lower levels of the lipids. In addition, lipid-lowering medications are best for reducing inflammation. They are anti-inflammatory to blood vessels, meaning in addition to lowering the lipids and cholesterol, their main effect is to reduce the chance of having a “coronary event.” The main reason for reduction in plaque with lipid lowering medicine is unknown – it is not the lipid, rather the transport vehicle – lipoproteins, that are the issue.

Crestor shown to be effective at decreasing the plaque in arteries

The final issue are my ancestors – Native Americans and Norwegians – who, when eating a diet high in fatty fish, have lower rates of heart disease. That is a population statistic, however, the science behind it is clear. Fish are high in omega-3 fatty acids, which Dr. Esselstyn wouldn’t like – but the omega 3 fatty acids are protective against heart attacks as well as raising the “good cholesterol” HDL, and have the same anti-inflammatory features that medications do.

One of my cousins, preventing heart disease and eating fat

Dr. Terry Simpson About Dr. Terry Simpson
Dr. Terry Simpson received his undergraduate and graduate degrees from the University of Chicago where he spent several years in the Kovler Viral Oncology laboratories doing genetic engineering. He found he liked people more than petri dishes, and went to medical school. Dr. Simpson, a weight loss surgeon is an advocate of culinary medicine. The first surgeon to become certified in Culinary Medicine, he believes teaching people to improve their health through their food and in their kitchen. On the other side of the world, he has been a leading advocate of changing health care to make it more "relationship based," and his efforts awarded his team the Malcolm Baldrige award for healthcare in 2011 for the NUKA system of care in Alaska and in 2013 Dr Simpson won the National Indian Health Board Area Impact Award. A frequent contributor to media outlets discussing health related topics and advances in medicine, he is also a proud dad, husband, author, cook, and surgeon “in that order.” For media inquiries, please visit www.terrysimpson.com.

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  1. thedoc says:

    What do you mean by reverse? So you have an atherosclerotic plaque- you want it to re-absorb? It never will after you are 18 years of age. You can stabilize a plaque, you can get some regression of the size, but unless you are totally starved you cannot reverse it. Its like reversing aging- can’t be done- we can hide aging, but old people are just old. With Ornish he saw – at best 3% reduction- but that is not significant – and is subject to error.
    Best way to reverse coronary artery disease– bypass the diseased artery

  2. Teresa says:

    So let me see if I understand correctly….it would be better to have surgery? And what of all the people I know that HAVE reversed these diseases that everyone is given pills for and made to believe that we are expected to get all these diseases and die sick with no quality of life? So easy to go to SURGERY before trying something as simple as diet change, and the reason is people would rather eat all this CRAP they are currently eating, take drugs and have surgery. Amazing and how sad.

    To Pete, please read the material he is so easily bashing, go some of these sites for Dr. Esselstyn, Dr. Neal Barnard, Dr. Joel Fuhrman, Dr. John McDougall, Dr. T. Colin Campbell and so many more!! Educate yourself! You dont have to believe anyone online, especially someone advocating surgery! Do you think its by chance that he provides these types of surgeries and is bashing other doctors? I know some of the people personally who have reversed diseases, including heart disease, Does it take work, yes it does…so if someone isnt willing to do the work to live well and have quality of life, then perhaps surgery is the better answer, but know that with all surgery, and medications, there are risks to your health, for the rest of your life!

    Here is hope that everyone educates themselves and is healed!

    Teresa

  3. Tim says:

    Sounds like sour grapes. Do you fear Dr. Esselstyn’s findings will cannibalize your Lap-Band business? I say, “Lead by example.” Dr. Esselstyn is the picture of health. I can’t say the same about you. You should adopt the plant-based lifestyle and your health will improve. You will look and feel a lot healthier, which will give your more crediability when you speak. Also, you will then make the choice to pursue a career of preventative medicine, rather than cutting-open people, unnecessarily. Much health Dr. Simpson.

  4. The Doc says:

    If I eat things that eat plants does that count? Preventive medicine is what we do- but sadly, some people need surgery – because not everyone can be perfect. My health is fine, thank you.

  5. The Doc says:

    The data for what you can and cannot do with food for disease is anecdotal at best. T. Colin Campbell’s data (he is not a MD but is a PhD) does not agree with his conclusions. When one is skeptical and critical of data it isn’t bashing doctors- in science and the science of medicine we do this. Surgery works well for some- but when it comes to surgery we have a simple saying- if they don’t change their lifestyle the surgery does little good.

  6. ZJ says:

    Dr. Simpson, you sure do seem to push buttons when you challenge conventional beliefs. I don’t make the connection on how sharing this information, in essence, trying to educate people, has anything to do with your (as Tim states) “Lap-Band business.” Because you’re a physician, and skeptic, I think you are able to offer unique or unconventional views that may challenge current cultural beliefs, which I see as a good thing. More accepted “practices” should be challenged and their validity tested, especially when it involves health. I do believe that an unhealthy diet has a negative effect on health – I also believe that over consumption of any kind is a bad idea. Information, moderation, and common sense seem like the keys to a healthier life.

  7. The Doc says:

    Thank you. Over consumption of anything is bad- agree- whether it is lean meat, soy beans, or baby seals. Humans are “flexible eaters” and can eat a wide range of things. To state that we can only eat non-animal proteins, or limit them flies in the face of the natural selection that allowed people to live from the Arctic to the equator.
    Still there are those that want food to be magic, food to cure disease- or change how one lives on some very narrow focus based on bad assumptions. That smacks of a pentacostal telling someone the only way to heaven is through their narrow religion. Most who practice extreme diets remind me of religious fundamentalists – with poor or no evidence – and lots of preaching. I hate preaching.

  8. Chris Young says:

    Terry:

    It is universally agreed by the majority of physicians & researchers that to the degree a diet is anti-inflammatory and antioxidative plays a major factors in whether someone develops arterial plaque. We also know that if inflammation is present, that a diet low fat, cholesterol & low in inflammatory substances is beneficial in limiting the amount of arterial plague forming agents found in the blood stream that can then attach to the cell lining of the vessel which then causes plaque buildup.

    As you should know the ingestion of fat causes the body to produce cholesterol to help in its assimilation & we do know that excessive cholesterol in the blood & inflammation are the main factors in developing arterial plaque.

    The authors/scientist that you attack are providing people with diets that are nutritious, anti-inflammatory & antioxidantive with foods that we have readily available. It is well known that salt, sugar, processed foods, & oils when cooked cause an inflammatory reaction in the blood vessels.

    – Please provide the foundation for your argument (scientific studies) that affirm your position that one can’t reverse arterial plaque through diet.

    Since you criticizing & attacking these researchers you should provide supporting scientific evidence to support your criticism. You provide nothing but hyperbolic statements that their research is flawed. You do so without any credentials in field of study/ research or practice that relate to coronary artery &/or vascular disease & or dietary solutions.

    Help me understand you why you are attacking these scientists? What is it you are trying to prove?

    Chris Young

  9. The Doc says:

    The logical fallacy of appeal to authority or popularity doesn’t fly here.

    Yes, anti-inflammatory nature of some diets are important, the question is which is truly anti-inflammatory. But anti-inflammatory does not decrease plaque formation, it does decrease the tendency of those plaques to rupture and cause acute occlusion. Omega-3 fatty acids are fats, and a diet rich in them is fatty diet, and my fellow Eskimos are quite heart healthy (until they smoke).

    The ingestion of fat does not produce cholesterol- the vast majority of cholesterol is from what the body makes, and the correlation of cholesterol and plaque formation has been long abandoned and not supported by the evidence.

    In terms of proving a negative – that is a common logical fallacy argument– prove this doesn’t happen. No one can prove a negative. You cannot prove reindeer don’t fly.

    I am not attacking any one of these individuals personally, I am however, providing a skeptical basis for science.

  10. Chris Young says:

    Terry :

    What is your skeptical basis for science???

    The Inuit ate a diet high in meat and fat, low in fruits and vegetables and still had low rates of heart disease and cancer (sadly only recently when more modernization came to them in the form of convenience stores, soda and other processed foods did you see the illnesses start to increase. Once sugar & processed foods came to them….things went sour).

    Their meat they ate was completely different from the meat you & I are eating. Theirs was wild, fresh, & mostly raw, seal and other animals that you are probably not going to eat. Not to mention they also ate the organ meats, which again….most people are not going to do. Because the animals were wild they were also not fed grains, contained good amounts of Omega 3s and low amounts of Omega 6s…the opposite of modern meats.

    Their meat was actually low in saturated fat and more mono-unsaturated…completely different from the meat profile of fattened cows on grains (very high in saturated fats and loaded with omega 6s…pro-inflammatory).

    Their meats were high in Omega 3s (anti-inflammatory) and overall diet was more a 1:1 ratio of omega 3s to 6s (unlike todays ratio of about 1:25(+) of omega 3s to 6s)

    So although we are not about to move to the great white north and eat raw seal or whale blubber, we can use the knowledge of the Inuit and take home the following lessons (and you will see many familiar things below)

    Eat a diet of moderate protein (make sure you are eating with fat and not going overboard, for most this is not an issue as even a high amount of 1g/lb of body weight is still usually 30% of total calories)

    We are not eating seals or their organ meats, so get your fruits and vegetables (as we need them for sources of vitamins that are not in our meats) duh!

    Have plenty of healthy fats including: some sat fats (but again look at how little sat fat the Inuit actually ate vs how much was mono-unstaturated), MUFA (Monounsaturated Fatty Acids like X-Virg Olive Oil). Even watch your sources of sat fat , as most is very high in pro-inflammatory Omega 6s from grains/vegetable oils & processed foods.

    Take some fish oil (Omega 3s) to help balance the Omega 3:6 ratios (most people probably need about 3g a day of EPA/DHA….about 2-3 teaspoons of fish oil). Some may need less, but that would mean their diet is already low in Omega 6s….which are everywhere nowadays!

    Lower dietary sources of Omega 6s including high fat grain fed beef/meats/eggs. Try for lean beef/meats (Omega 6s are in the fatty parts), Omega 3 eggs, or Grass Fed Beef (but be warned…even if it is says grass fed it doesn’t mean it is 100% grass fed…so read your labels carefully)

    Inflammation = increases in heart diseases and cancers….so get rid of the big evil inflammation messengers of Omega 6s/Veg Oils (excess PUFAs), Sugar, Trans Fats, & processed foods. Get rid of these evils and you will go along way to increasing your longevity and health.

    **** No processed sugars, oils, or “man made” foods are in the Eskimo/Inuit, Mediterranean, French paradox, portfolio diet, prudent die or diets proposed by Dr. Esselstyn, Dr. Neal Barnard, Dr. Joel Fuhrman, Dr. John McDougall, Dr. T. Colin Campbell. These diets are also are balanced in omega3 / omega6 fats & vitamins. Most of the these diets participants tend to not be overweight & tend to exercise. These types of diets/lifestyles can reduce or eliminate inflammation so that the body can manage the healing process.

    Are these diets/lifestyles all paradoxes or are they all onto something – low to no inflammation by eliminating “man made food” ?

    It is becoming increasingly clear that chronic inflammation is the root cause of many serious illnesses – including heart disease, many cancers, and Alzheimer’s disease. Stress, lack of exercise, obesity, genetic predisposition, and exposure to toxins (like tobacco smoke) can all contribute to such chronic inflammation, but dietary choices plays the largest role.

    I would tender that a therapeutic approach of diet, exercise, & stress reduction aka “lifestyle” as offered by Esselstyne, Fuhrmann, & others works to reduce or eliminate inflammation while providing substantial nutrients is the path to health & low to no inflammation. It is not to say that it is the only way but it appears to work if followed. ie, no cheating…. You can turn a good diet into a bad diet by if you too much of the one type of food on any diet. The simplicity of a plant based diet takes all the thinking out of the equation and force the right omega 3/6 balance as well is very low in inflammatory response

    These diets do not have added / processed sugar, Trans Fats, high omega-6 oils and low in omega 3, Milk pasteurized , processed dairy products, processed oils, Feedlot-Raised Meat, Processed Meat, Alcohol, Refined Grains, Artificial Food Additives & any other foods that may produce and allergic reaction to an individual.

    Simple whole foods in balance with the correct omega 3/6 balance!

    Here is what is known about FAT DIGESTION
    Dietary fats (lipids) during digestion, fats are broken down partially to free fatty acids and molecules with one, two, or three attached fatty acids–mono-, di-, and triglycerides.
    To digest fats, the gallbladder contracts and discharges bile salts, which are made in the liver and stored in the gallbladder. The bile salts emulsify the fatty acids, enabling fat to be “dissolved” in water to be absorbed. During fat absorption the bile salts are reabsorbed and recirculated by the liver about six times daily. The bile salt-coated fat is able to travel through the water in the intestine to the intestinal cells in the last portion of the small intestine, the ileum, where it dissolves in the membranes of intestinal cells.
    After absorption, lipids are repackaged with proteins as chylomicrons and sent to the liver. Here they are repackaged again in a coat of cholesterol and protein.( yes the body produces cholesterol as fats are ingested. To what degree is different in each person. This coating, which allows the fat to be dissolved in the blood, enables the fats to be transported to various parts of the body where fatty acids may be removed to provide energy for cellular components. The demands to make cholesterol by the liver for the coatings are greater for saturated fats than for polyunsaturated fats, which causes the former to contribute to higher blood cholesterol levels than the latter.

    Here is a bit on inflammation —

    Read the following http://circ.ahajournals.org/content/105/9/1135.full Circulation : Clinical Cardiology: New Frontiers Inflammation and Atherosclerosis Circulation. 2002
    “Substantial advances in basic and experimental science have illuminated the role of inflammation and the underlying cellular and molecular mechanisms that contribute to atherogenesis.”
    “Current evidence supports a central role for inflammation in all phases of the atherosclerotic process.”
    “ Substantial biological data implicate inflammatory pathways in early atherogenesis, in the progression of lesions, and finally in the thrombotic complications of this disease.”
    Clinical studies affirm correlation of circulating markers of inflammation with propensity to develop ischemic events and with prognosis after ACS. “
    “…the quest to identify proximal stimuli for inflammation, as one pathogenic process in atherogenesis or trigger to lesion complication, may yield novel therapeutic targets in years to come.

    http://circ.ahajournals.org/content/early/2012/03/02/CIRCULATIONAHA.111.046755.abstract Inflammation has been closely linked to auto-immunogenic processes in atherosclerosis.

    http://circres.ahajournals.org/content/96/9/939.full Adipose Tissue, Inflammation, and Cardiovascular Disease
    Mounting evidence highlights the role of adipose tissue in the development of a systemic inflammatory state that contributes to obesity-associated vasculopathy and cardiovascular risk. Circulating mediators of inflammation participate in the mechanisms of vascular insult and atheromatous change, and many of these inflammatory proteins are secreted directly from adipocytes and adipose tissue–derived macrophages.

    http://atvb.ahajournals.org/content/26/5/995.full?sid=ab7cb066-3880-486e-ae07-ea53e6d11420
    Dietary Factors That Promote or Retard Inflammation
    “A growing body of literature suggests that inflammation is pivotal in all phases of atherosclerosis, and biomarkers of inflammation (Table 1), especially high sensitivity C-reactive protein (CRP), have been shown in various studies to predict cardiovascular events.”
    http://circ.ahajournals.org/content/119/8/1093.full?sid=5cd2d0bd-edd1-4637-b850-f2cfce5916b0
    Epidemiology -Mediterranean Diet and Incidence of and Mortality From Coronary Heart Disease and Stroke in Women “The Mediterranean diet has been linked to beneficial effects on inflammatory markers, lipids, and blood pressure.”
    http://atvb.ahajournals.org/content/20/3/708.full?sid=5cd2d0bd-edd1-4637-b850-f2cfce5916b0 Atherosclerosis and Lipoproteins

    http://atvb.ahajournals.org/content/30/4/749.full?sid=ab7cb066-3880-486e-ae07-ea53e6d11420
    Integrative Physiology/Experimental Medicine
    Specific Dietary Polyphenols Attenuate Atherosclerosis in Apolipoprotein E–Knockout Mice by Alleviating Inflammation and Endothelial Dysfunction

    What is your skeptical basis for science???

  11. thedoc says:

    You have a partial answer – and inflammation is important to us. Without inflammation we could not rid ourselves of bacteria, we would not make it past our first year of life. Atherosclerosis is not an inflammatory process, it is the platelet action when a plaque ruptures that is inflammatory- or, in this case, causes a cascade of events leading to a clot. However, if you have an imbalance of the clotting mechanism you would bleed to death. Post operative myocardial infarctions, heart attacks, happen because after surgery the clotting mechanism is tilted toward clotting – thus unstable coronary plaques are at risk- however, without a clotting mechanism we could not do surgery.
    There is a far more molecular level to inflammation than diet. And population studies are often as wrong as they are right. Making broad sweeping statements based on population studies or what we think we know from them, is a common error.
    People always want to find the magic diet- it won’t ever be that simple.
    I am not skeptical of science- I am skeptical and science is the approach used to measure things.

  12. Lynn says:

    We look at Eskimos and their diets but are we also looking at their genetics? Most of them are probably pure-bred Eskimos, without other genetics at play. Maybe they are genetically more resistant to certain diseases. Possibly living in a cold climate makes them more hardy. Could people who live at higher altitudes have stronger hearts and lungs? Are they also a medically under-served population? Could that actually be beneficial to some people in that some medical intervention is unnecessary and harmful? Are they possibly calmer and have less stressful lives than city dwellers? My understanding though, of life in Alaska, is that they pay a lot for homes because they all have to be built high up off the ground. That could also make for a lot of healthy stair climbing!

  13. thedoc says:

    There does not appear to be a genetic predisposition to resist diseases, and in fact the opposite is true – when placed in cities they have more cancer and heart disease than white folks. No reason to think cold people are more hardy- or that it translates to disease resistance. Eskimos live at sea level, not at a higher altitude. The more medically served a population is the longer their lifespan and lower their infant mortality- no exceptions to this. Stress– try fighting polar bears for survival and having to hope you get heat when it is 50 below- no, their stress is more than yours will ever be. Homes are sometimes underground too

  14. Alice says:

    Dear Doctor,

    You must have science behind the obesity and now hypertension epidemic in our children? Forget about meat, what about processed and refined foods. That was my takeaway from the movie – whole foods. Refined foods are not containing the wholeness that our bodies need, e.g. juice without the fiber of eating the orange, isn’t good for you, but its better than refined sugar, no?

  15. Alice says:

    Oh, and also the processed meats with the salt. If you take out the salt, and other preservatives, perhaps the meat will be healthy?

  16. thedoc says:

    Salt was the first way we preserved meats and fish. Meat is just fine- and salt to season meat is just fine.

  17. Ellen B says:

    My husband had a major heart attack years ago, and had a stent implanted. The problem for him was high blood pressure his doctor had a hard time getting under control. On the day we met with his nutritionist, we asked, what do we do to prevent this from happening again. She told us plant based was the way to go. We made the transition, and today, we follow a plant based diet. I didn’t have a heart attack, but when my husband had his, my cholesterol was inching up and so was my BP. My mother died from compllication of diabetes and heart disease. I didn’t want to go that route, and seeing what my husband went through also, I wanted to do everything I could to prevent it. Today my husband is thriving, and his heart is regenerating. His cholesterol is 104 and tryglycerides 100. My levels are at a very healthy level. Both our BPs are excellent. We are at a healthy weight and have more energy than we ever had. When people at our jobs get sick with colds, a stomach virus or flu, we don’t catch it. You can say what you want to about Esselstyn, but what he promotes does work. We are living proof.

  18. thedoc says:

    Confirmation bias is hard to control. Clearly improving diet is always important- how you do it, be it going on a Mediterranean diet, Paleo diet, or whole foods is often much better than what people were on before. The vast majority >90% of cholesterol comes not from what you eat, but how your liver works – and is controlled best by statins. The stent did its job

  19. pete says:

    silly, course you can prove a negative. i.e. there are no married batchelors, square circles or muslims of the united states senate. as another poster mentioned, its just sour grapes with you and Ess. Sad.

  20. thedoc says:

    those are not negatives. But, that is ok – logic isn’t something many people are taught or understand. There are some rather complicated discussions regarding the proof of a negative, and quite insightful – but your comments are not at that level.

  21. Dr. Terry Simpson says:

    Not hundreds – and the quality of the work is still poor. Nothing wrong with trying- but lets not stretch the powers of plants to be more than the power of the angioplasty and medications the patients received.

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