More Incredibly Bad Science From Dr. Esselstyn's Plant-Based (Vegan) Diet Study

A while back the skeptical cardiologist exposed “The incredibly bad science behind Dr. Esselstyn’s plant-based diet.
The diet has the catchy slogan “eat nothing with a face or a mother” and Esselstyn was featured in the vegan propaganda film “Forks Over Knives.”
After detailing the lack of science I concluded:

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.

The post garned little attention initially but in the last few months several hundred visitors per day apparently read it and Essesltyn followers have started leaving me testimonials to the diet along with nasty comments.
Here’s are some typical ones (with my comments in red)

“If your (sic) not backed by some meat industry or cardiac bypass group I would be much surprised.”

I am completely free of bias. Nobody is paying me anything to do the research and writing I do. My only purpose is to find the truth about diet in order to educate my patients properly. I have  saved many more patients from bypass surgery than I have referred for the procedure.

“it is so arrogant to think the only science could come from clinical studies which may be funded by an interested party.”

Doctors like randomized (and preferably blinded) clinical studies because they minimize the bias introduced by interested parties like patients and zealous investigators (like Dr. E)  motivated to see positive outcomes. Small, non-randomized studies can only generate ideas and hypotheses which larger, randomized studies can prove with a greater degree of certainty.

“the entire nentire western medical system is skewed due to the big pharma influence…unfortunately western medicine believes the only science is the pen and the scalpel..whereas …history is the best teacher of all…”

By pen I assume you mean medications. If we examine history as  you suggest we see that life expectancy was 50 years in 1945  but today in developed countries it is around 80 years. This advance corresponds to (among other things) advances in vaccines, antibiotics, anti-cancer drugs, cardiac and blood pressure medications and surgery: the pen and the scalpel. It does not correspond to following a vegan diet.

“Your foolishness is the embarrassment.”

Thank you for this insightful comment! I’m considering it as my epitaph.
One man felt that changing to the Esselstyn diet dramatically improved his cardiac situation and commented:

“Nothing like bashing something that works just because you want to eat meat. .”

I do enjoy meat in moderation but I also really enjoy vegetables, nuts, fish, legumes, olive oil and avocados. I looked into Esselstyn’s diet in detail because it stands out as particularly misguided in banning nuts, avocados, fish and olive oil to heart patients.

..”.So sicking (sic) to see people talk trash about something that works so well… It saved my life…”

I’m happy you are doing well with your cardiac condition but it is impossible to know what would have happened to you on a more reasonable diet such as the Mediterranean diet (which actually has legitimate scientific studies supporting it). And again criticizing Esselstyn’s ideas and “study” can hardly be considered trash talk.

“I personally have followed dr. esselstyn’s program for what will be 5 years in 11/17 and have made tremendous gains in my cardio pulmonary function….my cardiologist looks at me in wonder…why are you here? and often says , if everyone did what you have…Id be out of business…so…isnt that telling and sad?”

I’m glad you’re doing well with the program, most patients can’t follow this kind of diet for more than a few months.  But perhaps we shouldn’t judge its effectiveness until  we make sure you don’t suffer a heart attack next week. Your cardiologist is wrong: see what I wrote about “dealing with the cardiovascular cards you’ve been dealt.” Some individuals inherit genes that guarantee progressive and accelerated atherosclerosis that will kill them at an early age despite the best lifestyle.

“…the phrase “follow the money” comes to mind…and since theres no big money to be made….science will attempt to dispell the results and thousands of years of history that proves this dietary system works…”

Using a scientific approach to analyze Esselstyn’s diet (which tries to claim a scientific basis) seemed appropriate to me but I wasn’t motivated by money. I’m looking for what is best for my patients, pure and simple.

The Plural of Anecdote Is Not Data

One man wrote:

“But since this is only anecdotal evidence – it must be junk science…”

Esseslstyn devotees like to post what their personal experience is with the diet but as skeptical medicine has pointed out “the plural of anecdote is not data.” 
One woman described in detail a good response her husband had after starting the diet following a heart attack:

I’m concerned about the skeptical cardiologist going after the person of dr. Esselstyn versus the science, such as quoting how you States dr. Esselstyn came up with the diet. So there may be a personal bias there. I’m sure there are more people out there on the esselstyn diet that are not noted in the study years ago. I hope there is another book coming out

I’ve reviewed in detail my comments about how Esselstyn came up with the diet but I am at a loss to find any ad hominem attack.
This woman went on to say

We will keep you posted, as my husband is willing to get another cardiac Cath and 12 months to visually see the difference after the diet.

I have to point out that if his cardiologist performs a cardiac cath (which carries risks of stroke, heart attack and death) for the sole purpose of checking the effect of the diet he is engaging in unethical medical behavior and likely insurance fraud. By the way, I hope that your husband is on a statin like most of Dr. Esselstyn’s are!:)
and a man wrote

Calling Essylstein ilk shows a little too much biased hatred on your part

Please note the definition of ilk “a type of people or things similar to those already referred to.” No pejorative there. And no ad hominem attack.  I wrote:

 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.

I should be able to criticize the methods and ideas of Dr. E without it being considered an attack on his person

Completely wrong. Esselstyn has saved my life. His book explains it all, how the endothelium cells get ruined, inflammation … heart attack proof (his words). One does not continue as head of the Cleveland Wellness Center if one is a quack.

Words are easy to come by on the interweb but Dr. E’s are not supported by science and as for the “Cleveland Wellness Center” it is probably not wise to get me started. Dr. E ‘s program is listed as being part of the Cleveland Clinic Wellness Center which is an attempt to capitalize on the market for pseudoscientific enterprises. He is not the director. The director recently came under intense criticism for promoting anti vaccine quackery. (See here).
The Wellness Center promotes so-called functional, integrative, complementary and alternative approaches. (Functional medicine is fake medicine!) These are approaches that have not been proven to work and could arguably be called quackery. (Let me be clear, however, I am not calling Dr. Esselstyn a quack but the fact that he is part of the Wellness Center does not add any scientific validity to his work.)

“I’m sure there are more people out there on the esselstyn diet that are not noted in the study years ago. I hope there is another book coming out”

Fake News, Fake Science

As a matter of fact, Dr. E has been hard at work over the last 30 years and has added a grand total of 176 patients who are considered “adherent” to the diet: about 6 per year. The “original research” was published in The Journal of Family Practice in 2014. Unfortunately the bad science present in the original publication has only been amplified.
In addition to any randomization or suitable control group for comparison, the data collection techniques are unacceptable:

“In 2011 and 2012 we contacted all participants by telephone to gather data. If a participant had died, we obtained follow-up medical and dietary information from the spouse, sibling, off-spring or responsible representative.”

In other words, there was no actual systematic review of medical records, autopsies or death certificates, just word of mouth from whomever answered the phone.

“Patients who avoided all meat, fish, dairy, and knowingly, any added oils throughout the program were considered adherent.”

Imagine, if you will, that your husband died 10 years ago and you received a call from Dr. E’s office or perhaps Dr. E himself and he asks you if your husband “avoided all meat, fish, dairy and added oils.”  For one thing, it would be very difficult for you to answer that question with any degree of accuracy: was your husband cheating on Dr. E’s diet when you weren’t looking, do you remember his entire diet from 10 years ago?
For another thing, you know that the caller has an agenda. If your husband died of a heart problem the caller is not going to be happy until he/she gets you to admit that your husband had some guacamole on Cinco de Mayo in 2002. If he’s alive and doing well, the caller is likely to be satisfied with a simple answer that , yes, he’s following the diet.
Yes, we have more data from Dr. E but it turns out to be even more incredibly bad than the first lot.
Let the anecdotes and ad hominem attacks begin!


42 thoughts on “More Incredibly Bad Science From Dr. Esselstyn's Plant-Based (Vegan) Diet Study”

  1. Dr Dean Ornish was the first person to show that you can reverse heart disease. His program is similiar to Dr. Esselstyn. Dr. Esselstyn’s program has saved so many people’s lives. Yes, it’s strict, but it works.

  2. Dr. Pearson,

    Thought you’d be interested in another case study. I have a lot of heart disease in my family on my father’s side. My father had two heart bypasses and passed away at 50 due to spasm after jogging. I was mildly overweight from childhood but didn’t have high cholesterol. Around Age 32 I became enamored with the low-carb movement and became a devotee to that diet “ideology” and despite losing about 20 lbs initially, my LDL shot up quite a bit and stayed pretty elevated. That ideology says LDL and Cholesterol are meaningless (except for HDL and Triglicerides), so I didn’t worry about it. I refused statins because of the bad press, in particular in the low-carb community. I continued eating this way through my mid 40’s and my weight fluctuated quite a bit. At my highest I was at a BMI of about 33.

    At the age of 45, I started having back pain whenever I walked. I could only walk for maybe 5-10 seconds before the pain made it difficult. I wasn’t doing any other exercise at the time, other than walking. After talking to primary care doc, they said I should get checked out by a cardiologist just in case due to my family history. I did, and this cardiologist recommended an angiogram because it was the gold standard to figure out if it was something heart-related. I relented because I wanted to know for sure. The angio revealed a bunch of blockages, 3 of which were 80% or higher. They could only stent one of these (the one that was 99% blocked, and that mitigated all the associated back pain. But there were a couple of other blockages of around 80% and some others in the 50% range.

    I went on meds and asked my doctor what diet to follow. The guy was not very interested in diet, but he said he thought Mediterranean had the most evidence behind it, so I began on what I thought of as a Mediterranean diet. Fairly plant-based, but lots of fish (mostly salmon) and a bit of chicken too – white meat without skin mostly. My thought was to try to do a Mediterranean diet that was as low-carb as I could make it. So I didn’t eat a lot of grains. I mostly ate veggies and fish, lots of olive oil, hummus, falafel, etc. I didn’t really pay attention to sodium, which I’m sure was well above the 1,500mg AHA recommendation.

    A little after a year after this, I decided some muscle aches I was having were statin-related and asked my doctor to get off of them. He said I could take 1 dose per week rather than per day, which I started doing.

    A little after 3 years post stent, I started having the same back pain when walking. It wasn’t nearly as severe, but it was definitely present and worrying. An echo stress test didn’t reveal anything, so my cardiologist didn’t advise I change anything or get any additional tests. However, this caused me such concern that I felt like I was going to be in the same boat as I’d been in before, would have to get another angiogram or worse. So I started researching angina relief and came across Dr. Esselstyn. I’d done many ‘crazy’ diets in my past and was always good at being 100% compliant for long periods if I wanted to, so I challenged myself to do his for a month to see if I could. Quite the 180 from a low-carb, meat-based diet! I figured if I could make it through that month and I felt better, than I might go for 3 and see how I felt, etc. So that’s what I did. I lost weight, and so of course I felt better, although the back pain didn’t really diminish. I had high hopes given Forks Over Knives, Esselstyn’s book and many anecdotes I found online. I read a lot with the intention, in a sense, to become “indoctrinated” so that I would be motivated to continue to do the diet. And that’s basically what happened.

    I became a huge adherent of Dr. Esselstyn and plant-based diets, I drank the Kool-Aid, so to speak. I did have success in that my LDL plummeted to the 60’s, at least after the first 6 weeks on the diet, and I had to get off my BP meds because I was getting light-headed due to lowered BP. I also lost so much weight that after 6 or 9 months on the diet I was lower than I ever actually remember myself weighing (only really weighed myself in college) and so probably was lowest since high school. BMI was around 21 or 22. My pain seemed to be getting better, but only very subtly, due to my heart not having to work as hard since I weighed less.

    In plant-based circles, there is this false dichotomy that’s but out – diet and lifestyle vs. medication and procedures/surgery. Either you “live correctly” or you have to resort to extraordinary measures that basically due a poor job of patching you up and don’t solve the underlying issues that lifestyle does, or so the thinking goes. As such, taking medication is seen more as a “failure” that you’re not doing lifestyle correctly. And if you are “reversing” your heart disease, then you should NEED medication, right? So taking medication is just telling yourself you still have disease and you’re supposed to be curing it with the diet. Thus, I felt it my responsibility to get off all my meds. I had already mostly gotten off the statin, and had totally gotten off my BP medication, so the main one left was a beta-blocker which was also serving as an anti-anginal (Metoprolol). He said I could try to wean off of it, and while my angina had gotten a little better, after cutting down the Metoprolol 1/4 dose, I found the angina came back and was at least as bad as it had been since it had restarted, perhaps worse. So I stayed at that 1/4 dose, convinced that eventually the angina would improve enough for me to finally get off of it.

    Fast forward 6 months or so. So this was about 1.5 years into the diet, and exactly 5 years after my initial stent, I awoke to back pain more extreme and different from anything I’d had. Went to ER and they determined I’d had an NSTEMI and they wanted to do another angio to stent if necessary/possible. Turned out that my previous stent (which was in the 2nd diagonal artery) had not been placed all the way in so was protruding a bit into the LAD and that was providing something for particles to latch onto in the LAD. That buildup was pegged at about a 90% blockage. They stented the LAD. Interestingly, they said the only other blockages they saw other than that one were at 40% or less, which seems a lot better than the info I had gotten 5 years earlier. I figured that this was still a ‘win’ for the diet, but I straightened up and took the full dose of meds now as prescribed.

    So, what do I take from the above? I think if I had remained on the statin, perhaps that buildup wouldn’t have happened or it would have taken a lot longer to happen.

    Ultimately, work of some other plant-based doctors who have been calling our Dr. Esselstyn’s claims (most notably Dr. Avi Bitterman) have convinced me that his claims are not evidence-based and his studies are quite flawed, as you’ve noted. I don’t think there’s anything necessarily harmful about doing his diet, but as you note it is very strict and so many people simply can’t follow it or follow it for very long. I followed it for almost 4 years without any problems, but in the last year have been adding nuts, avocados, tofu, and tempeh occasionally. When eating out, I will eat things that I know may have a very small amount of oil. Since it was sustainable for me to eat without all these things, it’s essentially icing to be able to eat these even occasionally. I still don’t eat animal products because I believe that with the exception of fish and at least some forms of dairy, we have decent evidence that they can actually increase risk, unless eaten in very small amounts. But I feel like even if I could eat those small amounts and get away with it, and certainly probably could get away with eating a small amount of fish, which has been shown to reduce risk in many studies, I prefer to opt out of doing so for both environmental and animal-welfare reasons. But at least I’m intellectually honest in that I don’t have to for health reasons. Some people do have problems in that they can lose TOO much weight due to how low-fat Dr. Esselstyn’s diet is, but as long as that isn’t the case, I believe one can eat a vegan diet, if that is your choice (a personal decisions) and get all the right nutrients from it save a few that can be supplemented.

    Unfortunately, I think the “vegan doctors” like Dr. Esselstyn, McDougal, Greger, Bardnard, et al, have decided that veganism itself is a more important line in the sand, and they will make claims to push that vegan line in the sand regardless of the evidence. Thus I’ve stopped listening to them. There are a select number of vegan doctors and nutritionists out there who don’t play this game, they give the evidence regardless if it “hurts the cause” because they believe that ultimately people should decide for themselves based on the truth and there are certainly other reasons to give up animal products (as I’ve noted). Unfortunately, the big personalities like Dr. Esselstyn have gained a somewhat cultish following. Dr. Esselstyn in particular is an extremely caring doctor, but he simply is biased. I believe he truly cares for people, but that doesn’t absolve his claims that can definitely cause harm (on his website and book he talks about being “heart attack proof” by eating his diet and simply getting your LDL under 80, plus dismisses the helpfulness of medication, and, in most cases, procedures).

    Anyway, sorry for this exceedingly long post, but I thought you’d like to hear from someone who went the full gamut – from low-carb ideolog, to vegan ideologue, to finally someone who is trying to seek the truth regardless of what “side” it favors.

    • Levi,
      Thanks for sharing your story and in such a wonderfully-detailed, thoughtful way.
      I’d love to post this a separate post on my blog if you are OK with that. Even without my input there are tremendous points on the vegan ideology and paths to the truth.
      I’m sure there are many who have followed this trajectory but are unwilling to share that they were deluded for so long.
      It could be totally anonymous or with any degree of identification of your preference.
      Dr P

  3. I am a male in my late 60’s, diagnosed by a cardiologist, after testing, (ecg. treadmiill stress, and angiogram) as having stable exercise induced angina as well as CAD, (40% blockage in 4 arteries). My father died of a heart attack at age 80. I am taking 40mg of rosvastatin and 5 mg of ramipril and have been following the Essetyn diet. for two months. ,
    M angina symptoms appear to be getting worse not better through so I am wondering if continuing with the diet is a good idea. What diet would recommend rather than the Esselsyn one?. I am motivated to follow whatever diet has the best chance of working.
    My problems with the Esseltyn diet are that it appears to be somewhat inconsistant, incomplete and is quite dated. It requires a lot of guesswork from the reader. Examples are: 1 wondering if hemp seeds would be an alternative to flax seeds for omega three considerations. There is no mention of that in the book. 2 the book has desert recipes using light tofu in a blender, rather than regular, but isn’t that just regular tofu with a higher water content. 3 Most name brand products mentioned are no longer available. 4 Does the book, copyright 2007, reflect current medical knowledge. or is it badly outdated. 5 The book mentions absolutely no oils, and then some recipes call for things like “spray with Pam”.
    I am also concerned that the book may be missing important aspects that are not discussed. For example rigorously following the diet means consuming a lot of legumes and flaxseeds, which are known to be very high in estrogen. Maintaining a testosterone/ estrogen balance is eseential for good health and people of my age face declining testosterone levels anyway, So maybe the Esselstyn diet may be increasing not reducing cardiac risk or at best breaking even..
    I’d b interested in you thoughts.

    • Andrew,
      Thanks for your thoughtful observations on the diet. As you say, it is “inconsistent, incomplete and is quite dated.”
      Given these issues plus the total absence of evidence supporting it I don’t recommend it to patients in your situation.
      I have a recent post on heart healthy diets which includes a link to a podcast where I expound on the diet I recommend, a variation of the Mediterranean.
      I had a conversation yesterday with a man age 45 who had an MI and stenting 2 years ago which I’d like to expound on in a post soon. I had to spend a lot of time convincing him not to worry about all saturated fats in his diet. He also was on high intensity statin therapy and I told him as long as you continue to take the statin, don’t smoke, exercise regularly, keep close to ideal body weight and we document your apo B <70 you will do fine with plaque regression and no further events.Beyond those factors I mentioned, radical low fat/vegan diets have no proven benefit.
      Dr P

  4. Dear Dr. A,
    I am confused as what to do. I am a 58-year-old male on 80 mg of atorvastatin and 10 mg of Zetia for cholesterol, as well as valsartan, amlodipine, and metoprolol for hypertension and heart beat. I had a CT angiogram with a total is calcium score of 1050. RCA 505, LAD 320, LCCA 173, and LCA 52. I get somewhat winded when I am walking. I get somewhat winded when I am walking fast and talking at the same time. Because of this my cardiologist recommended (If I am comfortable) and I am scheduled for cardiac Catheterization in a week. I am very anxious.
    I am a 58 year old male with family history of CAD. At 56, my dad had a Severe LAD blockage and coded for many minutes during a cath which was done through his groin. He was resuscitated stabilized, had emergency emergency bypass surgery. Needless to say, he ended up with massive brain damage. He lived another nine years but did not die of CAD. My older brother had chest pains at 56 despite clear stress test and bloodwork. He also had an 98% LAD blockage, was catheterized through the wrist and received a stent.
    I thought passing 56 without episode dodged a bullet, guess not!
    I have read and viewed about plant-based CAD reversal and would love to avoid catheterization if possible.
    Do you think I should/could avoid or delay this catheterization with my present medical therapies for cholesterol and hypertension and adding plant-based diet?

    • Peter,
      Clearly based on your calcium score you have advanced coronary atherosclerosis for your age.
      The test that you had, the CT angiogram (aka CCTA) is typically performed with IV contrast and gives information on the degree of blockage in the coronaries. Was that reported out to you?
      You are on an excellent combination of cholesterol lowering drugs which will substantially lower your long term risk. Consider getting tested for lipoprotein (a) if not already done. For such advanced plaque for age I usually set a goal of LDLC<60.
      Dr Peaerson

  5. funny if he is such a quack and his way of eating for heart patients or whomever does it is quackery, then why is he and his family so darned healthy? He’s in his 80s still hiking and being vital, his wife Jane, the same; his children( adults now) very fit, healthy and vital! Whose the quack here?

    • Suzanne,
      I discourage judging a diet by how its leading advocates are doing. Take a look at my posts on the death of George Atkins to see why this makes no sense.

  6. I’m not a doctor (actuary, instead – and for the rabid – pensions. Please don’t blame me for your health claims issues or auto/homeowners/business insurance problems).
    I’m always surprised how people get married to an answer and become emotional as adults. Maybe surprised isn’t the right word, but disappointed. Unless our parents are mild and observing, and use their observations to improve, most of us are like that when we’re young. As I get older, I like to be right. Not in a way that becomes “I’m right and you’re wrong”, but I find the same satisfaction that others do in trying to get the right answer.
    And when I’m wrong, age has made it feel good to me to say it flatly. I’m wrong (of course, as an actuary, living a life where the world seems more like a group of odds or maybes, I more often say “it appears that I’m wrong, or I think I’m likely incorrect”). Real progress is made both when we’re right and when we listen and figure out that we’re not.
    I just watched the esselstyn documentary. It was pretty cleverly done compared to some others where the participants aren’t as mild and they come across as more militant, but someone like me (with no medical experience) will take other data points that we’ve collected and we can’t help but say “if it’s this simple, I should be able to find no criticism of this video, or no legitimate criticism, and lots of trials that back it up”.
    Years ago, a vegan told me that vegans don’t get cancer or heart disease. I told the person in this case that I thought that sounded odd, but I wouldn’t be surprised to see the rates were lower and would be curious about how much lower. I didn’t find the difference in rates to be big enough to warrant changing my diet to vegan for health reasons, but saw enough to figure I may be more selective with meat and eat a little bit less of it. I’m in a world of odds, and so is everyone else. What happens to each of us may be more definite, but it’s not as if we necessarily have the strings to pull to know how to manipulate the definites, so we deal in odds.
    Thanks for advocating for the group of folks who are trying to find better answers, and not just finding something that’s pleasing to hear or think and then hoping to find the answer that makes it so.

  7. Hi Dr A,
    In relation to my last post here, and now the Carona virus–
    I am aware that I fall into the high risk category because I have heart disease, though its stable, i am healthy, non smoker, exercise & symptom free for 12 years , Im known to have 2 x 70% lad blockages etc from 2013 angiogram.
    Do you see me still fitting into the
    High risk category in relation to the above?
    Can a good immune system help me lessen the category risk?
    Thanking you!

  8. Hi Dr A
    Thank you for your reply and consideration of my situation
    Its reassuring to have a professional view that concurs with mine.
    I will for now continue on a good plant based diet, fruits & mixed with a balance of fish, occasional meat, nuts and exercise and put the focus on good balanced health eating
    I do believe that a very good diet, medical therapy can keep my disease stable and without issues providing I now work hard on little stress and healthy lifestyle, and avoiding sugar
    Kind regards

  9. Interesting debate.
    Dr A, your thoughts on my experience
    I am 57, In 2008 I was diagnosed with Angina once, I changed lifestyle and never got symptoms again
    from 2008 I had 5 CT angiograms that all confirmed two 70% blockages in LAD
    Then in 2013 I had a Gold Standard Angiogram to investigate more accurately which confirmed the same two blockages in LAD as 80%. My cardio said that because I was symptom free and in relation to the big courage studies, I could chose medical therapy or stents. He recommended stent and i chose to continue medical therapy.
    So for 12 years I know I have had 2 blockages but never symptoms and live fine.
    However in March 17 after good living I had another Ct angiogram which said one 50% block LAD and nothing else. Then again in Feb 20 where it said one 70% LAD and same in the RCA ( I know these two years in between my diet took in much more sugar, cheese and bread and coke)
    In conclusion I have now gone back to strict diet of vegs, fruits and occasional meats once or twice a week and fish a little more often. But I am targeting the vegs and salads and fruits, nuts etc. I have lost 4 kgs in 3 weeks.
    Will I go for the stent for prevention? time will tell but it seems with being very aware of having an underlying condition, I can at least take good care avoid stress and bad foods and keep learning about health living.
    But it still annoys me that in my 30s I had a bad diet for 15 years, I remember and I think my arteries took the fallout, much to my regret.
    And it annoys me that I have this risk but Like I said Ive had it for 12 years and all I ever heard from various cardiologists was HAVE A STENT, never considerations to a wholistic way.

    • I don’t see any compelling indication for stent in patients with no symptoms. Even in patients with symptoms now the ISCHEMIA trial suggests medical therapy and stents have equivalent outcomes.
      For some lifestyle change is appropriate but statins are the most powerful tool to prevent progression of the CAD.

  10. LOVE this blog post! It so perfectly demonstrates the terrible quality of ‘how to think’ that has been taught in our education systems. I also love the line: “The Plural of Anecdote Is Not Data” because that is exactly what the un-thinkers use as “evidence” to make their points. What this post also demonstrates is how readily some people are inclined to believe the latest (or any) Guru. You can give them Anthony Storr’s “Feet of Clay” to read and they still won’t recognize it as applying to their special guru. And it is _always_ evil intent by “Big Pharma” that makes all criticisms of science valid.

  11. I had my first MI at 42 in 2015 and 2 stents in RCA all other arteries we normal. I then went on an esselstyn diet strict to 99% for about 3 years then I started adding a bit more fish and nuts even then everything was clean and whole. Last week during a routine treadmill stress test at high work load my readings showed a at depression at 144bpm and 12mins and the rest was stopped. An angio was conducted the other day and the diease has progressed to my left side LAD previous stents are clear.
    Now question is did the diet work? I wasn’t taking statins as TC was 4 , LDL 2 HDL 1.3 and trig 0.8 but now the drs want me on a statin . So confused

  12. Do you also criticize the studies by Dean Ornish who recommends a very comparable diet? As a physician having reviewed his results I would feel it is unethical no to present the Ornish program as an alternative to invasive procedures. I feel full unbiased explanation of both should be presented to patients. Those who think they are adequately motivated to make and maintain the lifestyle changes required should have the opportunity to make this choice. Invasive cardiac procedures have complications and are definitely unwarranted in asymptomatic patients.

    • I’ve discussed the limitations to Ornish’s study in response to comments and am close to expanding that to a full post.
      I would agree with your last statement and am close to another post discussing whether patients with very high risk calcium scores should get stress testing.

    • Jeanne, you’re creating a false dilemma or a straw argument here. I don’t see where the writer suggested nobody should be shown other options, just the reference that most patients adhere to a vegan diet for only a few months (even when it’s potentially terminal).
      There are two sides to this:
      1) the knife isn’t always the first fix or perhaps the best (you’re operating based on odds, right? As a physician you know that you’re doing that – there are few definites that you can tell when something isn’t absolute)
      2) in a situation where diet can be helpful, but adherence is low, then suggesting it as an alternative (and not replacement for) may be warranted.
      If we’re creating hypothetical situations, as you have, let’s assume that you have a patient that comes in with cardiovascular issues and a history of being non-compliant. Do you beat the drum about diet to them over and over indefinitely, or do you say at some point “a surgical solution may be better for you because you don’t follow directions”. Of course, people being soft forces you to say it differently.
      I’m sure patients are often dishonest with you, too, out of a desire to avoid conflict or for some other reason.
      I’m about 40 pounds overweight. It’s not a smart thing, but at this point, I don’t have hypertension of bloodwork issues. I’m just a bit fat. My physician is an advocate of 75 minutes of exercise per day. That’s great – I’ll never do it. He asked if I wanted to talk about how I became overweight, and I said “because I eat too much. It’s not that complicated. In fact, I’m surprised i’m not more overweight given how much I eat”.
      He said that he rarely gets that response from people. I told him that at some point, I’ll either be forced to lose weight (maybe I’ll even die, but the odds aren’t for that at this point), or I will choose to without being forced because I *want* to lose weight more than I *want* to overeat.
      How many of your patients are honest enough that you can really pretend to be as definitive as your assertion was? How do you know that a specific diet is really the driver here and it isn’t just losing weight (I’d bet the correlation to better health from weight loss without any specific diet being tied to it is much stronger than the additional contribution by diet type above weight loss or reduced food consumption). Why are you wedded to the diet that you just mentioned vs. anything else?

  13. Dr. Anthony, having just come across your website, I’m eager to know your thoughts on Heterozygous Familial Hypercholesterolemia? I have not been genetically tested, however, PCP believes this is what I have. My brother, also a M.D., was introduced to the Esselstyne theory/diet/protocol, whatever one chooses to call it. History, I’m post menopausal at 55, brother is 44. Father had AMI in early 60’s, ultimately leading to a 4vCABG. His father’s brothers, European descent, 4 of them, DIED of AMI in their early 50’s. Fast forward to now. Just had a Quest Lab Cardiac IQ done on myself. We eat a Mediterranean Diet for the record with the exception of no pork and no shellfish. Full fat dairy, olive oil, grass fed beef…..My total cholesterol is 291, LDL 199, Lipoprotein Subfractions high, CRP 3.0. I am non-diabetic or overweight, I do not have hypertension and have never take HRT. My brother’s lab is similar. Only he has had a significant increase in LDL’s in last 8 weeks.
    We both have started low dose Lipitor, ugh. Much to my concern. I have read your criticism of Esselstyne, but what do those who have a possible genetic anomoly do? I don’t believe I could stick with such a regimen, however, I don’t want to die either of a cardiac event that could have been reversed. Any suggestions?

    • So we humans have been doing it all wrong for the last several million years? Nature is the greatest laboratory and human history is the longest running “dietary study”. If humans are not designed to eat animals, there should be flourishing naturally occurring human vegan cultures. There are none, and the appearance of most long term vegans tells the whole story

  14. I’m grateful to continue to receive, via email, updates on this interesting thread. My persistent comment, over the past 25 years of doing Internet diet debates, is that choosing a personal diet plan is not like choosing treatment for sepsis or pancreatic cancer, wherein one has only a single opportunity to choose curative first line therapy.
    Let’s just take a step back and take a deep breath. Actually, let’s start with a self inventory.
    Body mass index. Serum metabolic indices. Blood pressure. Perhaps even a CT angio and calcium score. Look in the mirror. Are we happy with what we see?
    if everything is good, then … what’s the problem? Just keep doing it. If things are not going so great, and if one is worried about it, then try something different. Whatever makes sense and appeals to you. Try it for a couple of years. See where you are. If you are happy, then keep doing it. If you aren’t happy, then go on to plan B.
    I truly believe that health care practitioners would best serve their patients — from a weight and diabetes and heart disease and cancer prevention point of view — from following an individualized approach to life style management, considering what’s best for both health and happiness, on an individual basis, than trying to advance the point of view that there is one best diet and exercise plan which is optimum for everyone on the planet, against all logic, in the context of all knowledge.
    – Larry Weisenthal (Med Onc in Huntington Beach CA and recent year 2019 Boston Marathon qualifier)

  15. I appreciate your skepticism! Not all physicians have a lot of nutrition training (how people like me, who do have training keep our jobs!) and there are those who allow their personal bias to color how they view their “studies.” I agree that small studies are sometimes how we get to bigger studies, but lack of funding is not an excuse for publishing information that has not been well corroborated. I also like to point out to folks that because a person calls themselves, “Dr,” they could have a phd in history and still use the term, so you have to read carefully and understand who it is you are listening to. Keep up the darned fine work!

  16. I noticed you mentioned the increase in life expectancy since 1945. It brought to mind a figure I saw, a year or two ago, about the UK. Until about 1960, the modal age of death was 1.
    So a huge chunk of that increase in life expectancy came from reducing infant mortality.
    About the only useful thing that might have come out of Dr. Esselstyn may be the observation about eating a lot of meat. That does seem to be something typical of the USA. And then he goes to the opposite extreme.

  17. As a scholar and researcher–of course, primarily in the social sciences–I am very interested in the way that constructs develop over time. Generally, my interest is piqued due to the accepted (albeit understandable) limiting frameworks on which you base your arguments in this post. Specifically, I am interested in the point that you make that “The Wellness Center promotes so-called functional, integrative, complementary and alternative approaches. (Functional medicine is fake medicine!) These are approaches that have not been proven to work and could arguably be called quackery. (Let me be clear, however, I am not calling Dr. Esselstyn a quack but the fact that he is part of the Wellness Center does not add any scientific validity to his work.).”
    Some historians or rather more accurately some Foucauldian scholars might argue that the practice of the predecessors of modern medicine was considered to be nothing more than quackery for years. From a reading of Foucault’s (1963) “The Birth of the Clinic,” some could easily deduce that it was not until after continued work in establishing methods of scientific research and “scientistic bias” in addition to various paradigm shifts in cultural norms and beliefs that this negative perception of medicine changed.
    As a practitioner in a field and a scholar of the same, do you not find it problematic that all doctors should ignore clinical evidence and disregard experienced observations just because they say they are not “scientific”? Are there not various forms of viable empirical research that are not based on blinded studies? Are you discrediting ethnographic, phenomenological, and other qualitative and naturalistic methods simply because they don’t follow your definition of rigorous science? Do you discredit the peer-review process (I’ve noted that many if not most of these studies criticized are in refereed journals of medicine) and the reviewers that conduct the process, in my experience typically a double-blinded one? Are not new theoretical perspectives and conceptual frameworks as important to the advancement of medicine as any given field of science? Do you find no value in evidence-based medicine (Bernstein, 2004; Diederich & Salzmann, 2015; Eckermann & Coelli, 2013) which “integrates clinical experience and patient values with the best available research information” (Masic, Miokovic, & Muhamedagic, 2008)? (As a note, I realize there are specific criteria for evidence-based study, and I am aware of that criteria, but the quotes used in this comment get at the fundamental nature). Can we so confidently dismiss empirical “data” (i.e. experiential information or that which is verifiable by observation and experience) collected through ongoing practice, experience, and the development of expertise (e.g. a surgeon can learn surgery and even be able to perform it, but doesn’t experience and practice work to develop one’s expertise in performing surgery)?
    Additionally, should not medicine like all sciences value continued evaluation and refinement and therefore give due consideration to “alternative approaches”? Should not emergent and nascent ideas be valued as a motive to further test theories and hypotheses through various methodological approaches and not simply discredited? Should we likewise dismiss all institutions of higher education that have added colleges of osteopathic medicine to their programs as well because they do not follow the prescriptions of the degree of Doctor of Medicine — no pun intended (
    Ultimately, I see that these new alternative views have a value to the progress of new thoughts in medicine that are facing more or less the same criticisms and challenges that modern medicine did when it was emerging as a scientifically based practice. To assume that new findings in medicine historically did not occur after new theories and evidenced-based observations that “integrate individual clinical expertise with the best available external clinical evidence from systematic research” (Sackett, 1996) is disturbing. As with any new medicine that is first administered in human trials, the research for the effect in will have in humans is non-existent. For example, when new medical treatments are first tried on humans no one can truly say that the research is available for how well humans would respond to it. It can be inferred from the laboratory trials but whether humans will respond positively is a matter of study. Could it be possible that plant-based science as a nascent and emerging quest for improved health is no different? These questions are not intended to be antagonistic. My apologies if they come across as such. I am only establishing a line of inquiry as someone very interested in not only in this topic of plant-based health but also in the social and cultural constructs that define and legitimize research.

    • Sorry about my delayed response to this. I was on vacation in Europe and the enormity of the questions required a more thoughtful response than I could muster while traveling.
      You ask “should not medicine like all sciences value continued evaluation and refinement and therefore give due consideration to “alternative approaches”? Should not emergent and nascent ideas be valued as a motive to further test theories and hypotheses through various methodological approaches and not simply discredited?”
      I (and speaking for)/medical science definitely value continued evaluation and refinement. It is the essence of the scientific method and it is how we continue to refine medicine and understand what truly works. But emergent and nascent ideas before they are accepted as true must be tested in some way. Once they are tested and proven beneficial they are added to our medicinal or surgical armamentarium .
      “Should we likewise dismiss all institutions of higher education that have added colleges of osteopathic medicine to their programs as well because they do not follow the prescriptions of the degree of Doctor of Medicine — no pun intended”
      Doctors of osteopathy go through allopathic , scientific medicine training like MDs and often end up in similar post graduate training programs so they are not dismissed.
      On the other hand doctors of naturopathy and chiropractic are not practicing science-based medicine, most of them are quacks and charlatans and are dismissed.
      In the good clinician physician there is a combination of science-based treatment and decisions as well as experience-based decisions. We just don’t have evidence to apply to every situation that comes up and therefore we MDs have to make judgements based on our best estimate of the outcome and our experience in the past.
      However, time and time again, we have found that when certain treatments that we presumed were effective are actually tested scientifically they turn out to be no better than placebo or worse. Therefore, whenever we can, we rely on proven treatment modalities.

  18. Very interesting. One would think that the creators/proponents of these alternative approaches, be they diets or supplements would want to prove empirically that their wholistic approach/supplement or whatever is as good as or better than the “western medicine” approach that they so quickly dismiss. Why don’t they subject their approaches to clinical study just like “big pharma” has to? Why does the FDA allow the supplement manufacturers and people like Dr. Esselstyn to say their product is effective without having to prove it? I for one am open to using any approach that is safe and effective, but how do I know a diet or supplement is either? At least with conventional drugs there was a rigorous protocol that had to be followed before it could be marketed. ________________________________

    • Interesting point you made when you said diets should be subjected to the same rigorous tests as drugs. That would save us all from a lot of confusion as long as the testing for diets was not funded by Big Pharma. Thank you.

  19. I am a woman and had a heart attack at age 55 immediately following menopause. I had 5 bypasses
    10 years later I felt I was on the verge of another heart attack even though I passed a stress test and ok cholesterol scores
    Cath was done and discovered 4 of 5 bypasses no longer working and clogging in a volunteer artery.
    I was fine with dying but my family freaked so I went to Cleveland and got a stent.
    I also started on the Esselstyn diet 9 mo ago. I could not tell any difference in my energy etc but I lost about 18 pounds which was good for my self esteem.
    My father had his first heart attack at 36, died at 57. I’ve never smoked, always been active and not obese. I don’t think you can fight genes. I stay on the diet 98% because it makes my family feel better and I like being thinner. Otherwise I doubt Esselstyns science but figure it can’t hurt.

    • I’m just now sitting through a mandatory “Ed actionable” video for workers comp injury rehab program (don’t even get me started on the state of physical therapy therapy ractice). It features Dr. Esselstyn’s “remarkable” diet research and results. I smelled b.s. right from the start, when they mentioned the n=18 with no control group.

  20. Dr. P, I read your blog and find your opinions insightful and educational. I’m wondering about your opinion on Dr Dean Ornish’s Reversal Protocol and the the 30 years of research he’s done showing a vegetarian, ultra low fat diet can and does reverse blockages in your heart arteries.
    I’m not a radical animal rights activist or vegiitarian only person. I love meat. All kinds, cheeseburgers, pizza, fried fish and chips, sausage, bacon… it all and real butter too. Unfortunately at 33 years old I had my first 4xCABG. I followed the American Heart Associations protocol for my condition which in additional to diet included Stage 3 Cardiac Rehab for years. About 7 years later the ballon angioplasties started with restenosis after restenosis. 3 years later another emergency 4xCABG. After my recovery, I was having approx 7 angina episodes every day with no exertion and was eating Nitrostat like candy. This despite the efforts of some of the best cardios in the nation trying to help me. Luckily, I read an article in the Detroit newspapers about Dr’s Jodi and Felix Rodgers, cardiologists from Trenton, MI who had started a Orinish Reversal Ptrgram in their practice. Being out of options, I joined. After 6 weeks my angina episodes were down from 7 a day to 7 a month. After 6 months, my angina was gone. After a year I was walking 4 MPH most days, chasing the kids around, playing half court/full court basketball 4 days a week, moving heavy refrigerators and felt great. It wasn’t easy. Rarely ate out. My Top Doc’s from Beaumont Hospital In Royal Oak, MI were 100% supportive, eliminated some of my heart meds but cautioned the diet might be too restrictive for most people to stay on. I lasted 4 years. And another maybe 2 years partially following the diet.
    I’ve been completely off the Ornish Protocol for about 15 years now and after 4 stents, 2 AFIB ablutions, an Aflutter ablation and being told no more interventions are possible, I rue the day I fell off the Ornish wagon. I’m currently trying to jump back on but find it very difficult without the great support group I had in 1993. Is this scientific? No. But I am confident that Ornish’s research has held up and am praying it will help me again.

    • May be I am wrong what people consider meat in the US, to me cheeseburgers, pizza, fried fish and chips, sausage, bacon it is not meat at all it is crap junk food full of bad heavy processed flour, sugarS, bad oils etc, even the bacon it is cheap pork fed with crap flours and then processed with cheap salts, preservatives and sugar. To me meat it is a good trout, salmon, sardines (mainly fresh) a good steak etc and my good extra virgin olive oil (home made, we are in the season in my part of the world and just collecting the fresh olives), and with my 70 years I do not need a cardiologist or a doctor, 0 Coronary calcium score 2 years ago, perfect blood pressure and the only medication than I can think of in the last 40 years I antibiotics for an infection in my cut in my foot.
      Regarding Dr. E I have a good laugh about 2 or 3 years ago when I enjoy a YouTube video from this pseudo researcher, to me was like one of the classics videos from one of so many sect and churches exist in that country.
      It is true anyone than stops consuming cheeseburgers, pizza, fried fish and chips, sausage, bacon and going in a fast (no food) and having only water will improve from that rubbish, from there to extrapolate than Dr. it is a Saint it is along way.
      To be healthy you have feed the engine with the proper stuff and be prepared to spend the time in the kitchen (I dot see more than 1 hour or TV a week, I do not have the time) or be prepared to spend the time in hospitals, clinics, doctors and pharmacies, yes healthy food is not cheap but sickness it is a lot more expensive and more complicated.


Please leave your comments. The skeptical cardiologist loves feedback. He reads all and replies to all that warrant a reply.