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

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!

13 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 .

  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.

    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.

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