The Incredibly Bad Science Behind Dr. Esselstyn’s Plant-based Diet

txorito pamplona
Txorizo Pamplona. This delightful sausage of Navarra in the basque region of Spain is right out in Esselsystn’s plant-based diets.

The skeptical cardiologist has heard a few cardiologist colleagues rave about the movie “Forks Over Knives” and promote the so-called “whole-foods, plant based diet.”

One of the two major physician figures in the movie is Dr. Caldwell Esselstyn, a former surgeon and now a vegan evangelist.

salad
You’ll be eating a lot of this on the Esselstyn diet but do not, under any circumstances add a salad dressing containing any oil of any kind to attempt to make it palatable or satiating.

Esselstyn, along with T. Colin Campbell (of the completely discredited “China Study” (see here for a summary of critical analyses of that data), Dean Ornish, and Nathan Pritikin, are the leading lights of a dying effort to indict any and all fat as promoting heart disease and all the chronic diseases of western civilization.

Esselstyn, in his book, “Preventing and Reversing Heart Disease” lists the following rules:

  • you may not eat anything with a mother or a face (no meat, poultry, or fish)
  • you cannot eat dairy products
  • you must not consume oil of any kind
  • generally you cannot eat nuts or avocados

What? No Fish or Olive Oil? You Cannot Be Serious!

oil
Whatever oil this might be (?sunflower) is right out even though it comes from a plant. According to Esselstyn, using his brilliant ‘logic and intuition” all fats, whether saturated or unsaturated are going to damage the lining of your arteries.

The best randomized controlled trials we have for diet to prevent coronary artery disease (CAD, the cause of heart attacks) have shown that supplementing diet with olive oil and nuts substantially lowers CAD.

Every observational study in nutrition has demonstrated that fish consumption is associated with lower cardiovascular disease.

Esselsstyn’s Really Bad Science

While working at the Cleveland Clinic, Esselstyn developed an interest in using a plant-based diet to treat patients with advanced CAD. He says he had an epiphany one rainy, depressing day when he was served a slab of bloody roast beef.

In his own words:

“my original intent was to have one group of patients eating a very-low fat diet and another receiving standard cardiac care and then compare how the two groups had fared after three years.”

If he had followed his original intent, and randomized patients entering the study, he could claim that he had performed a legitimate, important scientific study. Twelve of the 24 would be allocated by lottery to the Esselstyn diet and 12 to whatever was the standard recommended CAD diet at the time. Unfortunately this approach, due to a “lack of funding, was not practical.”

So instead, 24 patients were sent to him, “all suffering from advanced CAD” and began the horrifically strict dietary program he had developed based on his “logic and intuition.”

Interestingly, patients not only were put on Esselstyn’s incredibly low fat diet, but they were also given cholesterol lowering medications and were “switched to statin as soon as these became available in 1987.”

In addition, 9 of the 18 patients who stuck with the program had previously undergone coronary bypass surgery and two had undergone angioplasty of a coronary artery.

6 of the 24 original patients “could not comply with the program” and were sent back to their regular cardiologists. This gives you an idea of how difficult it was to follow this diet.

Esselsstyn’s “data” then consists of following 18 patients, 9 of whom had already undergone coronary bypass surgery, all of whom were taking statin drugs with his diet without any comparison group.

This group of 18 did well from a heart standpoint, of course. It is impossible to know if the diet had anything to with their outcome.  Most of them had already undergone the “knife” or had had angioplasties that took care of their most worrisome coronary blockages. They were all taking statin drugs . They were all nonsmokers and they were all highly motivated to take good care of themselves in all lifestyle choices.

Any patients who were not intensely motivated to radically change their diet would have avoided this crazy “study” like the plague.

This “study” is merely a collection of 18 anecdotes, none of which would be worthy of publication in any current legitimate medical journal.

Three of the 18 patients have died, one from pulmonary fibrosis, one presumably from a GI bleed, and one from depression. Could these deaths be related to the diet in some way? We can’t know because there is no comparison group.

Should Anyone Eat Ultra-low Fat Diets?

It is possible that the type of vegan/ultra-low fat diets espoused by Esselstyn and his ilk have some beneficial effects on preventing CAD, but there is nothing in the scientific literature which proves it.

Scientific reviews of the effect of diet on CAD in the last 5 years have concluded that the evidence is best for the Mediterranean diet, which emphasizes fish consumption, olive oil and nuts. These reviews dismiss ultra-low fat diets because of a lack of evidence supporting them, and an inability to get people to follow them.

If you have ethical or philosophic reasons for only eating things with no mother or face, then by all means follow your conscience.

Too often, however, I find that those who choose veganism for philosophic reasons want to find health reasons to support their diet and mix the bad science and philosophy into a bland evangelical stew they recommend for all.

I remain, therefore, in favor of cioppino, paella, butter and all the glories of the omnivore that make life so rich.

Omnivorously yours,

-ACP


I have updated this post with comments from readers and my response along with analysis of the latest “data” from Dr. Esseslstyn’s “study” at my post entitled:

more-incredibly-bad-science-from-dr-esselstyns-plant-based-vegan-diet-study


For an amazingly complete (and surprisingly entertaining) dissection of the scientific inaccuracies of “Forks Over Knives” with humorous overtones, I recommend Denise Minger’s post “Forks Over Knives: Is the Science Legit? (A Review and Critique). Be prepared for lots of graphs!

107 thoughts on “The Incredibly Bad Science Behind Dr. Esselstyn’s Plant-based Diet”

  1. Your dead wrong Doctor. Dr. Esselstyn’s diet saved my life.
    See: Search Results
    [PDF]A way to reverse CAD? – Dr. Esselstyn
    dresselstyn.com/JFP_06307_Article1.pdf
    THE JOURNAL OF FAMILY PRACTICE | JULY 2014 | VOL 63, NO 7. Caldwell B. Esselstyn Jr,. MD; Gina Gendy, MD;. Jonathan Doyle, MCS;. Mladen Golubic .

    1. The Massai tribe eat a diet of several pounds of meat per day, combined with milk, and do not have heart disease. The Inuit people ate a diet that was 75% saturated fat/ 25% protein most of the year and did not have heart disease. Now that they eat fruit, “veggies,” and grain-based products, they have soaring rates of breast cancer in addition to heart disease. These facts are being ignored by many in the medical establishment, and we have to ask them to explain them in light of the current debate.

      1. “Massai tribe eat a diet of several pounds of meat per day”
        Well said J.J. Harris.
        Imo veganism is part of an one world order and UN agenda.
        Much like climate change veganism is based on a decided science and
        official narratives. People parrot climate change but never bother to speak of the seven decades of weather & climate modification, this
        this plant based diet is no different.

          1. My brother died today in the or after being on the esseltine diet rigidly for 7 years. It doesn’t work. Don’t listen to this crap. A very grieving sister whose heart is broken.

        1. Massai are among the most impoverished of nations. HIV and other diseases kill them as they do most extremely poor populations. Maybe you can tell them what to eat to cure AIDS, malaria, dysentery, tuberculosis, etc. I didn’t think so.

        1. From your first reference ” The major modifiable CVD risk factors were smoking (84%), obesity (49%) (body mass index of greater than 30 kg/m2) and elevated blood pressure (130/85 mmHg or greater) (18%).
          84% of the Inuit are apparently smoking, by far the biggest risk factor for atherosclerotic disease.
          The second reference comes from T. Colin Campbell’s site. It references the 1964 GV Mann article which concludes
          A field survey of 400 Masai men and additional women and children in Tanganyika indicates little or no clinical or chemical evidence for atherosclerosis. Despite a long continued diet of exclusively meat and milk the men have low levels of serum cholesterol and no evidence for arteriosclerotic heart disease. The reasons for this disagreement with the popular hypothesis relating animal fat intake to coronary disease are examined. The authors concede that some overriding protective mechanism such as freedom from emotional stress or abundance of physical exercise may be present. They favor the conclusion that diet fat is not responsible for coronary disease.

          1. The low carbers love to quote outdated poor quality studies to support their view:

            “We’re left with a bit of a confusing picture, made murky by a lack of data. We don’t have mortality or illness statistics but have conflicting clinical and pathological reports. We don’t have good dietary data. Impressions of high animal food intake, primarily in the form of milk intake, have been supported, but blood and meat intake may have been misconstrued. Making things more complicated, these were people who may have been in relative calorie deficiency because of extreme daily physical activity. They may have been experiencing intermittent fasting.”

            https://nutritionstudies.org/masai-and-inuit-high-protein-diets-a-closer-look/

            The Masaai also have genetic adapations to a high fat diet:

            Lactase Persistence and Lipid Pathway Selection in the Maasai.
            http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0044751

            “Our analysis suggest that the identified regions harbor known and novel genetic polymorphisms responsible for the unusual lipid metabolism, cholesterol homeostasis, protection against cardiac diseases and adult lactase persistence in the Maasai.”

      2. Such a dishonest comment. The inuits eat fruits and vegetables and now have soaring rates of breast cancer. So your claim is fruits and vegetables causes cancer? The inuits abandoned their traditional diet of seal blubber and cold water fish for a western diet and that’s why their rates of cancer/disease are soaring. Not because they are eating fruits and vegetables. Keep eating the western diet and pointing to people’s like the inuits traditional diet as proof to what you’re doing is fine, even though your diet doesnt reflect their’s in the slightest. Heart disease is the number one killer for men and women in the US and the world. Enjoy your heart disease, diabetes, various cancers etc that are all associated with the type of diet you eat.

        1. The Inuit ate a hight fat diet w/o fruits,veggies, and grains and had lower disease rates than now, when their diet now includes those items. My statements stand.

          1. I think there is growing evidence that insulin is inflammatory to coronary arteries. Protein and fat tend to have a blunted insulin response, as to many plant foods; much of which changes when those plant foods are “juiced.” My triglycerides typically run between 34 and 45 when i’m low carb, and if i eat one hard boiled egg after each workout, i can maintain my HDL above 60. Some research suggests the T:HDL ratio above 2 is a better CVD risk measure than LDL. Time will tell. It always does

  2. Numerous PET scans in his book show plaque regression. You fail to mention Dr. Vogel’s demonstrations of endothelial tumult upon ingestion of fat. All those that stuck with his diet lived. Agenda, much?

    1. I wrote about PET scans in response to a similar query posted on my “It’s time to end the war on fat” post as follows “A PET scan is a type of nuclear imaging perfusion scan (under the general category of myocardial perfusion imaging or MPI). As such it is not directly looking at plaque but at coronary flow heterogeneity. Areas supplied by significantly narrowed coronary arteries (usually due to plaque) receive less of the radiotracer than area of muscle supplied by non-critically narrowed arteries. An improvement in a PET scan does not prove regression or elimination of plaque. I have dozens of patients who had critically narrowed coronry arteries with abnormal baseline MPI scans who improved to normal MPI scans over time. The most likely mechanism is recruitment of new arteries supplying blood to the heart muscle (collaterals).
      So , showing a PET scan or two on patients that improved proves nothing about the value of his diet. Also, many of his patients were on statins.”
      I pulled up the PDF referenced by Jack Runte in the previous comment and Dr. Esselstyn mentions a PET scan showing improvement after 21 days on the diet. Why on earth would you expose your patient to all the radiation from a nuclear PET scan after 21 days? No credible researcher would do this. It simply proves nothing, especially when the “study” is not randomized and the researcher running the study has a strong bias to find good results. The idea that plaque would regress this much in 21 days is absurd and this kind of anecdotal stretching to show improvement further weakens Esselstyn’s arguments.
      And even if patients were doing better on Esselstyn’s program, we don’t know what aspect was working. it is much more likely the statin drugs were the key to doing better.
      I think the experiment you refer to is after a Big mac equivalent and it is interesting but proves nothing about the long term effects of diet on atherosclerosis.
      Finally, you imply I have an agenda. My agenda is the truth. I’m not supported by any industry, company, food special interest group or philosophy other than utilizing science to find what is true about diet and cardiovascular disease.

        1. Truthfully the statin dose & duration are likely irrelevant as the diet achieves the ASCVD-regressing nonHDL cholesterol of much less than 90 + BP <120/70, & all other C-V risk are nullified by the diet alone (except tobacco). I did not say it was fun or easy, but what is the price freedom? HRS, MD, FACC

    2. Have you actually read Dr. Vogel’s study??

      http://sci-hub.bz/10.1016/S0002-9149(96)00760-6
      Effect of a Single High-Fat Meal on Endothelial Function in Healthy Subjects

      “Following this, subjects ate either a high or low-fat meal in varied order at least 1 week apart. The high-fat meal (900 calories, 50 g of fat, 14 g of saturated fat, and 255 mg of cholesterol) consisted of an Egg McMuffin, Sausage McMuffin, 2 hash brown patties, and a non-caffeinated beverage (McDonald’s Corporation). The isocaloric low-fat meal (0 g of fat, 13 mg of cholesterol) consisted of Frosted Flakes (Kellogg Company, Battle Creek, Michigan), skimmed milk, and orange juice. Lipoprotein and glucose determinations were repeated 2 and 4 hours after eating.”

      These meals are GARBAGE!!

      I don’t eat like this – I took an EndoPat test and my score was 3.56.

      http://www.itamar-medical.com/endopat-faq/

      “There are three basic categories for EndoScores:
      Red Zone: Score of 1.68 and lower. You do not have proper endothelial function and this could be an important signal of an imminent cardiac problem. This EndoScore may indicate the presence of disease and that an immediate evaluation and intervention may be needed, whether it is aggressive medical therapy or a medical procedure. It’s imperative that endothelial health be restored.
      Yellow Zone: Score between 1.69 and 2. Your endothelium is healthy and while you don’t have any additional risk, you are still not in the well-protected Green Zone. It’s vitally important that you now take charge of your own health and do everything you can to improve your EndoScore. Good health depends of certain lifestyle choice you make that include what you eat, how active you are, whether or not you smoke, the precautions you take to avoid injuries and accidents, and how you deal with tension and anxiety. The choice is yours. Choose health!
      Green Zone. Score between 2.1 and 3. Your endothelium is functioning optimally, and you have maximum protection. Keep up whatever it is that you are doing, because the foods that you have been eating and the physical activity you have been performing regularly have affected a number of risk factors implicated in vascular health and longevity, particularly blood cholesterol levels, hypertension, and obesity.”

      Just to be clear – I’n NOT a vegan/vegetarian. I eat full fat raw goat milk, full fat goat milk kefir, nuts, seeds, rice, legumes, fatty fish, fruits, veggies, etc.

  3. I appreciate your comment. But if statins alone could even only improve blood flow, surely wouldnt we be hearing more about this, since any positive statin news is typically highly touted everywhere? Re Vogel’s ‘ Big Mac test…if he produved endothelial dysfunction or inflammation with sat fat, even only for a few hours, repeatably, is it such a stretch to deduce likely long term damage from cascades of daily fat consumption? (Btw I’m not a vegetarian, though I’ve been leaning more toward Fuhrmans veggie n fruit recommendations, minimizing salt and tramsfat)

    1. Before I forget, let me say I am in total agreement with you about Bleak House. Love it. I have a “Nonesuch Dickens” volume of it that I treasure.
      About statins and endothelium, this 2007 review concluded “Statins have been shown to have pleiotropic effects apart from serum lipid-lowering effect in human. One of the major target organs for the effects of statins is the vascular endothelium, which plays an important role in the development of atherosclerosis and angiogenesis. Recent numerous studies have shown that the statins’ cholesterol-independent vascular effects appear to involve directly restoring or improving endothelial function by increasing NO production, promoting re-endothelialization after arterial injury, and inhibiting inflammatory responses within the vessel wall that are thought to contribute to atherosclerosis. This review provides an update of the unique effects of statins on endothelial cells including endothelial progenitor cells as well as highlighting the therapeutic potential of statins beyond their established lipid-lowering effects.”(http://www.ncbi.nlm.nih.gov/pubmed/16920035)
      How much of a stretch is it from an experiment in 10 volunteers which showed a drop in flow-mediate vasoactivity after 50 gram fat meal to a real effect on atherosclerosis of long term fat from real food? It is a HUGE step. let’s call it hypothesis-generating and let Jarndyce and Jarndyce settle it.

  4. If you cheat on the Esselstyn diet (may I assume the majority do cheat on their diet?) you end up on the Mediterranean. If you cheat on the Mediterranean you end up on … something not good.

    1. Funny that you bring up Dr. Esselstyn’s latest “study”. I happened to hear his presentation on this at the American College of Cardiology Meetings yesterday. This is his anecdotal report on 198 patients that have somehow gotten in touch with him over the last few decades. There is no science or objective data in this report. For example, the “paper” states “In the remaining 195 patients, angiogram results confirmed the diagnosis of CAD in 180 (92%).” We have no idea what the criteria for CAD is being used. There is no systematic follow up of imaging.
      The two figures that are in the 2014 paper (one patient’s angiograms and one patient’s nuclear studies) were trotted out at his ACC presentation.
      These prove nothing. The lack of blinding or randomization in his “study” discredits any findings.
      It was embarrassing to witness such poor science with a diet that has been discredited by recent studies.

      1. very interested, which recent studies discredit Esselstyn’s diet and what do you think of Grundy’s diet?

  5. Dr. Esselstyn’s very much promotes the intake of nuts and avocados…why lie? If your science is so great you don’t need to pad what you see as his down fall…the diet includes all nuts and avocados.

    1. On page 9 of my copy of Esselstyn’s 2007 book “Prevent and Reverse Heart Disease” he says
      “Here are the rules of my program in their simplest form:
       You may not eat anything with a mother or a face (no meat, poultry, or fish).
       You cannot eat dairy products.
       You must not consume oil of any kind—not a drop. (Yes, you devotees of the Mediterranean
      Diet, that includes olive oil, as I‘ll explain in Chapter 10.)
       Generally, you cannot eat nuts or avocados.”
      Later on in the book he says if you have heart disease no nuts but if you don’t have heart disease and your lipid levels are not elevated he will condone walnuts.
      “Those who have heart disease should avoid all nuts. Those without disease can consume
      walnuts in moderation because they can provide considerable omega-3 fatty acids, which are important for many essential bodily functions. But I am extremely wary of nuts. Although short-term studies funded by nut companies show that they may positively affect good and bad cholesterol, I know of no long-term studies indicating that they can arrest and reverse heart disease, and patients may easily overingest them, elevating their cholesterol levels.”

    2. I have read Dr Esselstyn’s book several times, and he bans nuts and avocados when on the heart disease reversal diet. I believe he and Drs Ornish, McDougall and Greger have the best method of preventing, or reversing, heart disease.

  6. Thank you for giving us good balanced information in your blog. It is incredibly interesting and, as someone whose doctor is adamant that I get on statins right away, i now need to educate myself. I look for expert opinions based on good science, without an agenda – or supported by drug companies or selling supplements or some other quick fast way to cure CAD. I am wading through past and current research and finding a ton of controversy on the subject. Who to trust, who to believe, how to make the best decision for my personal health outcomes. I keep going back to the science, to primary sources of research and I am shocked at what I am finding. Ok, lest this turn into a rant, I’ll finish by again thanking you for a most interesting blog.

    1. This is what I struggle with, there is almost too much information out there!! The more I read, the more I’m left wondering what the heck to eat!

  7. I have seen “Forks over Knives” and have read “The China Study” and I contest that this diet works!!!! I am a cancer survivor and gave up all animal protein and diary. Best thing I ever did. As one who works in the poultry industry I KNOW what is going into these animals. These animals are fed so many pharmaceuticals it’s beyond belief. Even so called grass fed, free range organic meat is garbage today. Don’t eat it!!!

    I would bet the people here are paid by one of the animal protein suppliers, diary or the government. They are EASY to spot!

    Genesis 1:29

    Then God said, “Behold, I have given you every plant yielding seed that is on the surface of all the earth, and every tree which has fruit yielding seed; it shall be food for you

    1. Russ D Hadick wrote:

      “I would bet the people here are paid by one of the animal protein suppliers, diary or the government. They are EASY to spot!”

      “Then God said…”

      hahahaha – Your tinfoil hat is showing!

      1. Russ,
        I’m the only one here. There are no other people other than me.
        I receive nothing from “animal protein suppliers” (whoever they are) or the government.
        Some day I hope to publish my diary and then perhaps all the work on the blog will pay off.:)
        Dr. Pearson

  8. Dr. Pearson. I’ve just completed reading your critiques of the Esselstyn work, and my opinion is that you are being much too dismissive.

    The Journal of Family Practice published two critical letters, an author’s response, and an editorial commentary. I believe that these are considerably more helpful and balanced. The Journal is open source, and I’d urge interested readers to read, in addition, the original paper for themselves, along with the comments, authors’ response, and editorial.

    Esselstyn’s data present a high class problem. He has a sizable group of patients, with a sizable degree of pre-existing coronary pathology. Folowing the dietary intervention, this group of patients did impressively well, by any standard. True, some did receive other interventions, including statins, and it’s impossible to conclude for certain that it was the diet which was the critical factor. But the strong suggestion is that the diet, in addition to usual care, produced unexpectedly favorable outcomes.

    Yes, the follow up methodology would not meet the standards of the NEJM or of a high impact specialty journal, but they clearly merited publication, as defended by the Journal’s editor.

    The results of this single study should not, of course, be viewed in a vacuum. The paper also contains a table reviewing the published results of other similar dietary interventions. I think a fair conclusion is that, in select groups of highly compliant subjects with coronary artery disease, the preponderance of evidence indicates objective benefit, with no suggestion of untoward effects.

    Now, I of course found your website because of a personal issue. I’m a 70 year old physician (medical oncologist) who has been a lifelong masters endurance athlete, and I was training to qualify for the Boston Marathon. I’ve been highly compliant with a Mediterranean style diet since the 1990s, after following the Pritiken Diet in the 1980s. On the Pritiken diet, I ran TCs of 135 – 147 with TC/HDLs of about 5. On the Mediterranean diet, my TCs ran in the 170s, with TC/HDLs in the low 3s.

    Because of my age, and a very strong maternal family history of premature death from CVD, and my strenuous athletic training, I felt it prudent to get tested for CAC and to receive a CT coronary angio. To my utter shock, these revealed both calcification and LAD plaque.

    Now, I know that I will have no difficulty at all being compliant with the rigorous plant based diet proposed by Esselstyn, Campbell, Ornish, et al. I have my baseline radiographic and lipid studies. I know the results of usual therapy alone (statins, anti-platelets), and I don’t find these to provide dependably acceptable benefit — where acceptable is plaque regression and calcium stabilization at non-toxic doses of statins.

    I believe that the preponderance of evidence indicates that I may well benefit from the Esselstyn diet, and I see no downside whatsoever in giving it a try, along with low dose statin and anti-platelet therapy, monitoring my lipids and CRP and perhaps eventually repeating the CAC and CT angio at some point. I also see no compelling reason to wait another 20 years before the definitive prospective randomized trial is carried out and published.

    Would I advocate this diet for the entire population of the USA? Obviously not, given the lack of definitive population evidence. But I’m not a “population;” I’m a specific individual with a specific problem, and I find Esselstyn’s findings to be highly relevant to my situation, and I am more than willing to take the informed “risk” in following his recommendations.

    1. @Larry Weisenthal MD PhD

      I’m in a similar situation – 63 years old with CAC of 47 on the LAD.

      Question – what do you consider a non-toxic statin dose to be? I currently take 5 mgs of Crestor ED.

      I switched from 20 mgs of Atorvastation ED on advice of my cardiologist.

      LAst blood work (on Atorvastatin) was

      Triglycerides – 44 mg/dL
      HDL- 67 mg/dL
      LDL Calculated – 70 mg/dL

      Total Cholesterol/HDL ratio is: 2.18
      HDL/LDL ratio is: 0.957
      triglycerides/HDL ratio is: 0.672

      1. Dear Mr. Grashow, I’m an oncologist and not a cardiologist. Your question is better addressed to Dr. Pearson. I wasn’t intending that my comment be generalized to anyone else. I was simply trying to explain the way I viewed this situation from my own unique individual perspective.

        I am grateful that Dr. Pearson cleared my comment to appear on his blog, which I think is quite excellent in its scientific rigor.

        I do wish to make one final comment. My avocations (since I’m no darn good at golf) are endurance athletics and arguing stuff on the Internet. I’ve been doing this since the early 1990s, beginning with the CompuServe Cancer forum. At one time, a search for my name on Google groups yielded more than 50,000 unique hits (they’ve cleaned out their attic somewhat, but if you google my name “Weisenthal” or “weisenthal/huntington,” you’ll still get a lot of stuff.

        I’ve argued cancer; I’ve argued sports; I’ve argued religion; I’ve argued politics (mostly politics); and I’ve argued diet and nutrition. As a result of 25 years of fighting Internet flame wars, I can say with complete confidence that nothing but nothing evokes more in the way of hot emotionalism than diet. Diet is intensely personal. You can disparage politics, religion, sports teams and people don’t take it personally. When you disparage diet, it is akin to disparaging the person him or herself and the reaction is immediate, visceral, and intense.

        I’m an evangelist for politics, sports, fitness, religion; and cancer. But I don’t do diet and nutrition evangelism any more. The only reason that I posted what I did is that — last week — I got the shock of my lifetime and I’m still in the Kubler-Ross stage of bargaining with it. I’m enough of a scientist to quickly move beyond denial, when faced with irrefutable evidence.

        Anyway, I’ll stop here, and I again want to thank Dr. Pearson for his intellectual integrity in allowing my comments to appear on his blog.

      1. Dr. Pearson, I’ve now taken more time to more extensively review the content herein. I don’t see where you’ve ever discussed the implications of the North Karelia (Finland) experience, which is, in my opinion, the most relevant and compelling real world intervention effort ever carried out and published.

        True, it was a global lifestyle intervention (smoking cessation, exercise, etc.) but a very prominent component was a massive reduction in whole fat dairy intake (where whole fat dairy is as integral to the traditional Finnish diet — as an aside, I’m half Finnish and was raised on a robust whole fat dairy diet).

        I would suggest that it would, perhaps, be appropriate to consider the North Karelia experience in a future blog post, in the context of your overall recommendations relating to consumption of whole fat dairy.

        1. I am saddened by this. In reviewing this propaganda booklet I note that they quote Michael Pollan extensively. Michael Pollan is not even close to a vegetarian. In his book Cooked he celebrates roasting a pig and I think he would be appalled at this diet,
          Clearly, a vegan is in control of the Kaiser “Lifestyle Program”

          1. I have nothing against veganism or vegetarianism. If an individual wants to pursue that as a diet on moral, religious, or philosophical grounds I am fine with it. However, veganism too often ends up like a cult or a religion in that its proponents feel compelled to convert the uninitiated to their diet. To accomplish conversion, frequently science is distorted. I am saddened when vegans make unscientific claims to support their diet in order to gain more adherents.
            Also, organizations like CSPI which are vegan for philosophical reasons should be more transparent about their dietary recommendations.

  9. Thanks for posting this. Very helpful. When Dr. Greger mentioned him, it sounded credible – until I read your post. THANKS!!!

  10. “I have nothing against veganism or vegetarianism.”

    “Txorizo Pamplona. This delightful sausage of Navarra in the basque region of Spain is right out in Esselsystn’s plant-based diets.”

    “You’ll be eating a lot of this on the Esselstyn diet but do not, under any circumstances add a salad dressing containing any oil of any kind to attempt to make it palatable or satiating.”

    it seems apparent from the above comments that you DO indeed have much against veganism by suggesting that vegan food is unsatisfying and that only the flesh, milk and eggs of exploited farmed animals makes eating enjoyable.

    that said, the health benefits are secondary to the environmental and ethical aspects-and this is from a 50 year old who has been vegan for over a decade and has not been to a doctor in 15+ years yet have perfect scores on my free annual blood test at work. focusing only on the health aspect excludes the non-human victims entirely from the equation and equates eating someone’s body with consuming an apple or an orange. the tremendously negative environmental damage driven by raising and killing farmed animals is undeniable. according to the World Watch Institute:

    “The human appetite for animal flesh is a driving force behind virtually every major category of environmental damage now threatening the human future – deforestation, erosion, fresh water scarcity, air and water pollution, climate change, biodiversity loss, social injustice, the destabilization of communities and the spread of disease.”

    if you wish to see why veganism is a moral imperative and an issue of social justice, i would very high;y recommend checking out the 2005 documentary “Earthlings” on youtube.

    “A man can live and be healthy without killing animals for food; therefore, if he eats meat, he participates in taking animal life merely for the sake of his appetite. And to act so is immoral.” -Leo Tolstoy

    “The real struggle in being vegan doesn’t involve food. The hardest part about being vegan is coming face-to-face with the darker side of humanity and trying to remain hopeful. It’s trying to understand why otherwise good and caring people continue to participate in needless violence against animals – just for the sake of their own pleasure or convenience.” -Jo Tyler

    “Livestock farmers, no matter what kind — from the largest, most cynical, and inhumane factory farm­ers to the smallest, seemingly most ethical pasture-based farmers — traffic in death. It is death that is our aim, our purpose. Death is the end. Life is the means. Money the reward.”- Bob Comis, former pig farmer

    1. Indeed, I agree that there are compelling ethical and environmental reasons to promote more vegetable and less animal consumption. I respect those who follow plant-based diets for these reasons. Too often, however, there is an attempt to claim health benefits to support the moral reasons which are not based in science.

  11. A family friend subscribed to this diet following an emergency angioplasty with stent placements and statins. He has a terrible family history. After several years he had another angioplasty with a 95 percent occlusion. This diet did nothing for him. He looks like a corpse and had no life. This is quackery, and it frightens me that people believe this stuff.

    1. Then he didn’t actually follow and eat right.. I’ve been 5 years am highly active and look and feel great… also… the amount of occlusion often has little to do with a cardiac event… eliminating chronic low grade inflammation… type of cholesterol and endothelial function means much more i feel

  12. Interesting points on all sides. All I know is that a follow-up angiogram in December 2015 rendered the diagnosis from the cardiologist: “I am sorry, there is nothing we can do for you medically.”, which I took to be doctor-speak for “start making your arrangements”. We started the Esselstyn regimen on December 27, and I saw my husband come back to life – within days breathing better, within weeks climbing stairs and walking at a normal pace. His heart meds have been reduced 3 times in 18 months. He has also lost about 30 lb almost effortlessly. Blood tests show that he needs minimal supplements (B12, iron), so he is getting enough in what he eats.

    It may not be for everyone, but I do not think we were ever meant to eat the meat and dairy in the amounts and levels of processing that so many do today. I do not have heart disease, and follow it about 80%, and have found my overall feeling of well-being has improved, and I too have lost weight with little exercise and effort. Eating oil-free plant based whole foods over time cleanses the palate and all foods taste amazingly wonderful.

    I would say try it for six weeks and see how you feel, then adjust for your own personal tastes/needs/desires.

  13. I think the problem is simple. Highly processed foods cause highly problematic health conditions. I hate when I see anyone start blaming macronutrients for our health problems, that macronutrient shamming is the foundation for all fad diets. The problem is crap foods plus a hypercaloric intake. Expanding on heart disease specifically, it’s a very complex disease. So complex that diet isn’t the only factor. We’ve proven that something so little as not enough sleep can increase heart disease risk. Also, what about the lack of collagen in our diets? Collagen keeps the arteries nice and flexible. Without collagen the arteries start to harden. It’s definitely not the macronutrients. The French have some of the lowest heart disease rates and they eat high fat diets. Likewise the Okinawa eat a high carb diet and have low heart disese as well. JUST EAT REAL FOOD!!! And possibly take collagen, personally I take one scoop of collagen peptides and two scoops of bone broth protein powder a day.

  14. It’s near impossible to know what’s right. As any adult knows, food, like everything else, follows fashion. I can’t help but wonder if different people thrive on different diets: Some do well as vegans or vegetarians while others need flesh to feel good. What we can all agree on, I think, is that excessive saturated fat, salt and sugar will make us sick and fat. The problem for many people is that it’s difficult to eat well for a variety of reasons: The food industry is very powerful and going toe to toe with it everyday is tough; good food costs a lot of money and lots of people don’t have lots of money; and, fast food is popular because it’s convenient. Real people need realistic solutions and none of the really radical diets are realistic for most of us.

  15. I am a 57 yo female with high cholesterol. I am 5′-2″ and in January of this year weighted 154 and had TC of 350. I started reducing fat intake and in June, at the urging of my son, began a plant based diet. I did not do it for ethical reasons, although I can am certainly aware of the environmental problems associated with meat and dairy production. I would say until last month, October, I was 97% plant based in my diet. My cholesterol dropped to 293 in October, not low enough. I realize now that although I have been eating vegan, I have been consuming high oil foods, such as olive oil (a lot of it), nuts (too many), avocado (a whole bunch because I live in Texas)!

    I read all of the above comments with interest and I believe we, as a culture, are on the cusp of understanding about what a healthy diet really is. IMHO all human bodies are generally the same but have intricate differences. That means to me that there is possibly an ideal human diet but within that, a variety of foods that can be eaten by individuals with different tastes and health requirements. I don’t think we know the ideal diet. It is one big melting pot of studies and opinions. But we will get there. Dr. Esselstyn is on to something. So are many others as they experiment and discover. That is a process. I think it best to be open minded about ANY method that has positive results. If it hasn’t been clinically and statistically validated, support that research instead of criticizing.

    With all due respect Dr., when you say things like, “I am saddened when vegans make unscientific claims…” your position is weakened and leads me to wonder about your motive. Your emotion about the vegan lifestyle is truly irrelevant if you are attempting to teach or lead with your critique. Unsubstantiated claims are simply…unsubstantiated. Does that mean there isn’t evidence out there, albeit some yet unknown, that can substantiate? Dr. Esselstyn and many others are working toward an understanding and hopefully scientific substantiation. It takes money and time. I am intrigued, yet not “all in” on ANY diet yet. However, I am open and supportive and willing to learn.

    1. I’m open to any and all diets that help my patients maintain ideal body weight and have healthier hearts. Esselstyn’s diet has clearly worked for some out there. . My personal philosophy is to eat lots of fresh vegetables. I think vegetarian diets can be healthy and contribute to weight loss.
      However, Esselstyn’s diet radically restricts all oils, even those shown to be beneficial for the heart (olive oil being the prime example). My post points out that although Esselstyn makes claims that his diet has scientifically proven to prevent heart disease, regress plaque and prevent heart attacks it has not.
      To promulgate such a radical diet one should have a solid scientific foundation.
      I’m not sure why my being saddened by vegans making unscientific claims weakens my position or makes my motive suspect. I’m saddened when any one makes unscientific claims to support their positions.
      The internet is full of wildly unscientific promotion of supplements, vitamins, nutraceuticals, superfoods and radical diets which only contribute to the confusion of the public when it comes to nutrition.
      I feel I can help with that confusion by focusing on what is scientifically supported (more olive oil, nuts, fish (not fish oil pills) for example) and what is not (not eating oils of any kind, taking the fat out of yogurt, veganism for example).

      1. Great blog. It would seem logical if bio-chemistry were fully understood the drug researchers would have found the universal solution. It is my understanding they are not even close. I would like to know if adding fairly small amounts of oils to Esselstyn’s diet neutralizes it? Negates it?

  16. I’m a 45y man, do a lot of sport and since I followed a 100% whole food plant based diet, no cheat or junk food, starting 1 year ago, I saw many improvements but after one year…iron went down, cholesterol increased (yes it did, I don’t know how, maybe too many grains?), some fatigue, my hands are always cold, bloating. One can argue it is some problem with phytates (I eat many legumes) or some grain (gluten?), I’m still trying to figure it out, point is that the idea veganism proposes is so zealot in some MD’s speeches that there is no space for doubt, which is a problem for the individuals who, as I, don’t respond very well after eliminating ALL animal foods. This can even challenge the adherence to this regimen, since an “all or nothing” mentality can only push you away from veganism if it does not work well.

  17. I make olive oil here in California. Olive oil is really a form of fruit juice without the fiber like orange juice or vegetable juice that is juice with no or little fiber. It’s the juice of olives which are naturally high in oil. Fresh organic raw unfiltered olive oil is not only delicious but very healthful. When you use my oil on a salad which is full of fiber and other nutrients you balance the oil and add even better fiber than what is removed when the olive oil is milled. I never heat my oil as in cooking. I cook in water and add the oil after the food is cooked. Better flavor and much better for you. Unfortunately oil like the kind I produce is hard to find and is nothing like commercial olive oil in the supermarkets. I know that Dr Esselstyn has no idea of the value of olive oil that is fresh and properly produced and prepared (no heating). And by the way I have been a vegan (with the exception of ethically produced honey) for 47 years and will be 70 in a few months. I feel almost too good.

    1. Tom,
      Thanks for your comments. Recently, after doing some reading about adulterated olive oil, I purchased some Bariani olive oil which comes from a family owned farm in California and seems to be closer to the oil that you produce.
      I’ve been very happy with the oil.
      It boggles my mind that some diets proclaim it not heart healthy
      Dr. Pearson

  18. You know now I hope that angiolpasties are nonsensical? No advantage mortality wise? They fail even with reduction of symptoms. Not better than placebo.
    Do I sense a worry about your salary? 😉

    1. No worries. I don’t do invasive coronary procedures. My goal with coronary patients is to avoid stents and bypasses as much as possible. See my 2017 year end wrap up discussion of the ORBITA stent study and my articles on subclinical atherosclerosis and preventing sudden death.

      1. I remain a big fan. We have some honest differences of opinion regarding conclusions to be reached, considering the totality of world data, but yours is an informed and welcome contribution to the conversation. Keep up the good (and too often unappreciated) work. 🙂

        – Larry Weisenthal/Huntington Beach

        >

  19. Reblogged this on Heart Matters and commented:
    I’m not one to be manipulated by the use of formalism, or authoritative professional opinion which are used to control philosophy, science, and medicine. I’m just a person who has been a macrobiotic vegan once for years. I simply know I can see social engineering and this as an agenda.
    The fact is veganism ( and little concern if that diet is based on genetically modified plants) is part of the new world’s order of UN’s Sustainable Development goals numbers 2 and 15.
    Veganism is part of the UN, FAO, and Codex Alimentarius
    I agree with this doctors take on this plant diet.

    1. This remark by “Mia” strikes me as very odd & unnecessarily accusatory: “formalism…control philosohy, science, and medicine… social engineering,,,new world order…” VERY strange remarks that cause me concern about Mia’s thinking. I stand by what I said which is largely factual and decent deductive reasoning.” HRS, MD, FACC

  20. Great article.

    Thanks for debunking this poor science.

    Another thing I find interesting is that both Esselstyn and I believe Ornish’s studies contained animal foods such as dairy(skim milk and no-fat yogurt) and in Ornish’s case egg whites also.

    So it is interesting to see vegans use these studies as reasoning to go strict vegan, when these diets appear to be more low-fat vegetarian plant-based diets.

    Esselstyn and co also claim that olive oil impairs endothelial function, which doesn’t appear to be an evidence-based claim. The latest systematic review/meta-analysis actually found the opposite, which is that olive oil improves FMD and may exert a beneficial effect on endothelial function.

    http://thenaturalhealthblogger.com/2017/05/15/does-olive-oil-cause-heart-disease/

        1. As just above, 90% will do just fine: that gets u an “A” in most endeavors, including this one to be disease free. HRS,MD, FACC

        2. The reason I come to this site and also read lots of comments here is because i want to read some opposing views to the vegan doctors, and then judge for myself if vegan diet really is a heart healthy diet. the vegan doctors sound sincere, whereas your emphasis of “Yes. Nothing with a face or a mother.” contains hints of disdains. You sounded more like a person with an anti-vegan agenda. If you really just want to critically analyst Dr. Esselstyns’s recommendation, do just that, don’t need to add things like:

          “I remain, therefore, in favor of cioppino, paella, butter and all the glories of the omnivore that make life so rich.

          Omnivorously yours,”

          as that reflected your not-purely-for-science sentiment..

          1. When I reiterate the phrase “nothing with a face or a mother” which is Esselstyn’s guiding principle I am emphasizing the lack of science in his program. Thus, any disdain that you are detecting is towards Esselstyn’s claims of being science-based. And obviously, the entire point of my post is to point out the incredibly bad science behind his diet.
            And if one realizes that there is no scientific support for the health benefits of eschewing butter and shellfish, for example, one can enjoy them in moderation and enjoy the rich diversity of food sources available during life.
            I will concede that my enjoyment of the complete palette of foods available is purely subjective but based on my observations through 30 years of discussing diet with patients , it seems to be the norm.

    1. Esselstyn is less the issue than his type of diet. He is correct at the 90% level which is far more than other approaches (excepting Ornish & “relaxed” unprocessed, ideally organic, whole foods 90 % veganism. HRS, MD, FACC.

  21. Has anyone checked out that vegetable plant seeds have pesticides. So my question is how healthy are they and where can we buy truly healthy veggies and by the way extra virgin olive is very healthy and Braggs Organic Apple Cider Vinegar and in the Bible it also has a list of meat, bird, fish and shell fish to eat and not to eat I believe diet should be balanced to much of anything is NO good

    1. Always do as best you can, Amimla protein concentrates the toxins in veg food they eat. Tru=y to be organic, BUT u will be better off & with a 50% lower carbon footprint being 90% vegan,. HRS, MD, FACC

  22. You write, “The best randomized controlled trials we have for diet to prevent coronary artery disease (CAD, the cause of heart attacks) have shown that supplementing diet with olive oil and nuts substantially lowers CAD.”

    Could you provide links to the studies you’re thinking of? Just beginning my journey into learning about this stuff — citations really help. — thanks

      1. PREDIMED results in ONLY a 30 % reduction in endpoints. Esseltyn, 90+% vegan,& Ornish -> 90+% reduction in Ischemic ASCVD events. Esselstyn,etc in my list above = FAR BETTER. HRS, MD, FACC

    1. predimed is a study funded by the spanish nut and olive oil industry…and further had more biased factors…oil and nuts (Other than a small amount of raw nuts occasionally) contribute to heart disease

      1. It is not accurate to dismiss PREDIMED as “funded by the spanish nut and olive oil industry”
        Here is the complete description of funding
        The Spanish Ministry of Health—Instituto de Salud Carlos III (ISCIII) funded the project for the period 2003–05 (RTIC G03/140). In 2006 a new funding modality was established by ISCIII through the CIBER (Centros de Investigación Biomédica En Red). Fisiopatología de la Obesidad y Nutrición (CIBERobn), which is providing funding for 7 of the original research groups, whereas the other 12 were funded by a new research network (RTIC RD 06/0045). Other official funds from Spanish government agencies have been obtained for subprojects related to intermediate outcomes (lipoproteins, inflammatory markers, vascular imaging, genomic and proteomic studies, etc.). Obviously, the donation by food companies of all the VOO and mixed nuts needed throughout the duration of the study is a substantial contribution. None of these companies (Patrimonio Comunal Olivarero, California Walnut Commission, Borges, La Morella Nuts and Hojiblanca) played or will play any role in the design, collection, analysis or interpretation of the data or in the decision to submit manuscripts for publication.
        And if you really want to read about the design and methods of the study go here (https://academic.oup.com/ije/article/41/2/377/690923)

    1. Actually there is. Many theorize that the dramatic increase in human brain size was related to increase fat consumption.
      And some papers show marked differences in lipids between primate species (https://www.scientificamerican.com/article/fats-in-the-brain-may-help-explain-how-human-intelligence-evolved/)
      “The results suggest that as human cognition evolved, the types and amounts of fat in key brain areas were rapidly shifting and mutating—and this growth was crucial to the development of our complex abilities.”

    2. The Brits couldn’t go to sea without developing scurvy unless they had lemons and limes for vitamin C. How, pray tell, did the Inuit, who never saw a citrus fruit and who did not eat the low-fat ape diet ever survive? What is it about the fat / animal protein diet that protected from scurvy, not only the Inuit, but the Arctic explorers who adopted their diet? It looks like there is plenty of reason to suspect humans have significantly different nutritional needs than other apes. Finally, gorillas have horrific gas and chronic diarrhea, suggesting a significant amount of what they consume is passed through their digestive tracts after being fermented into methane; which represents carbon not metabolically available to the consumer. Some have theorized that humans can survive as lower intestine fermenters, but none have demonstrated it.

      1. Sea mammals such as walrus, seal, and whale. Whale meat generally comes from the narwhal, beluga whale and the bowhead whale. The latter is able to feed an entire community for nearly a year from its meat, blubber, and skin. Inuit hunters most often hunt juvenile whales which, compared to adults, are safer to hunt and have tastier skin. Ringed seal and bearded seal are the most important aspect of an Inuit diet and is often the largest part of an Inuit hunter’s diet.[1]
        Land mammals such as caribou, polar bear, and muskox
        Birds and their eggs
        Saltwater and freshwater fish including sculpin, Arctic cod, Arctic char, capelin and lake trout.
        While it is not possible to cultivate native plants for food in the Arctic, Inuit have traditionally gathered those that are naturally available including:
        Berries including crowberry and cloudberry
        Herbaceous plants such as grasses and fireweed
        Tubers and stems including mouse food, roots of various tundra plants which are cached by voles in underground burrows.
        Roots such as tuberous spring beauty and sweet vetch
        Seaweed.

        Here’s a post from Dr. john McDougall, a top physician who has studied and practiced diet and health for about 50 years….FYI the Inuits suffer from a 20% +- lower life expectancy

        https://www.drmcdougall.com/misc/2015nl/apr/eskimos.htm

        1. Steve,
          It’s fun to look at cultures that live successfully on extreme diets but ultimately I don’t find these descriptions are useful to help we humans understand optimal current diet. Certainly, lots of hypotheses can be developed but nothing proven.
          Personally, I never cite the Inuits as support for fat consumption and I don’t cite the Hazda as support for honey consumption.

  23. You wrote: “The best randomized controlled trials we have for diet to prevent coronary artery disease (CAD, the cause of heart attacks) have shown that supplementing diet with olive oil and nuts substantially lowers CAD.

    Every observational study in nutrition has demonstrated that fish consumption is associated with lower cardiovascular disease.” This simply is not so: the studies by K L Gould &D Ornish are “the best” studies to date & clearly showed that what Esselstyn is implying is correct & all 3 of their works fits identically wi my 50 years & 225,000 patient visits of cardiology practice recommending a 90+% ideally organic unprocessed whole foods diet that not only prevents heart disease but is the ticket for the simultaneous prevention & often reversal of multiple diseases and conditions. Don’t get hung up on fake science, read the recent critiques by Ionnaidis re PREDIMED. Read the criticisms of so many studies by John Carlisle, Pocock & Stone, and A B Hill.

    1. A more precise summary of the data on fish consumption would use the phrase every meta-analysis of all observational data …..see the following
      2004 https://www.ahajournals.org/doi/abs/10.1161/01.cir.0000132503.19410.6b

      2015 Twelve prospective cohort studies with 672 389 participants and 57 641 deaths were included in this meta-analysis. Compared with the lowest category, the highest category of fish intake was associated with about a 6% significantly lower risk of all-cause mortality (RR=0.94, 95% confidence interval (CI): 0.90, 0.98; I2=39.1%, P=0.06). The dose–response analysis indicated a nonlinear relationship between fish consumption and all-cause mortality. Compared with never consumers, consumption of 60 g of fish per day was associated with a 12% reduction (RR=0.88, 95% CI: 0.83, 0.93) in risk of total death.

      2017https://www.tandfonline.com/doi/full/10.1080/10408398.2017.1392288

      Gould’s contribution to Ornish studies is nuclear imaging which I’ve discussed elsewhere. It proves nothing about underlying atherosclerosis. I’ve also discussed Ornish’s very weak study. I probably should put that as a separate post.
      I am never “hung up on fake science”

  24. My wif and I switched to a mostly WFPB diet about two and a half years ago. We have never felt better. We eat a little fish, and we aren’t militant about enforcing our choices. . .when we’re invited to dinner and our friends are so proud to share their “barbecue chicken wings” recipe, we eat it. We don’t make it for ourselves, but we understand that everyone is not going to follow our ideas. We are thankful for what we learned from FOK. I appreciate your POV…be careful not to be too militant or engage in personal attacks. You only hurt yourself.
    Thank you,
    Mark & Ramona

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