Profiles in Coronary Artery Disease: Navigating the False Dichotomies of Dietary Ideologues

I’m posting this reader’s story (with permission) which highlights many of the issues I have written about on my blog. My editorial comments are in blue.

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 coronary spasm after jogging.

(This strong family history of early heart attacks and/or death at under the age of 65 years of a parent should be a red flag for all individuals, no matter their lifestyle.)

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

That ideology says LDL and Cholesterol are meaningless (except for HDL and Triglycerides), so I didn’t worry about it.

(Sadly, this is correct. Many in the carnivore/Atkins/keto world promote the idea that the diet’s effects on metabolic factors and/or weight control are so beneficial they outweigh any abnormalities in lipids that may develop. Many of the gurus in this field dismiss LDL-C as a risk factor. It is also the norm that these gurus disparage medical treatment of abnormal lipids with statin drugs and emphasize perceived harms while minimizing the benefits.)

(A significant rise in LDL cholesterol with the traditional Atkins type keto-diet was found when healthy, young, normal-weight women were fed a ketogenic LCHF diet, rich in SFA and low in dietary fiber. Low carb, high fat diets which are predominantly olive oil or avocado oil may ameliorate the rise in LDL-C and apoliprotein B. Some individuals experience a dramatic rise of LDL to levels >190 mg/DL when on a LCHF diet, thus, most preventive cardiologist believe we have to monitor the response of LDL and apo B in all individuals and consider lipid-lowering therapy of diet change if it rises to levels implying high cardiovascular risk.)

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.

(There is a consensus in cardiology that stable CAD (exertional angina) as this man was experiencing should be managed with optimal medical therapy initially before proceeding to catheterization or stenting.)

The angiogram 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 the 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.

(I think he went on the optimal diet to prevent cardiovascular disease. The sodium intake, I’m pretty certain, was not too high with this diet.)

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.

(Muscle aches are common in everybody over the age of 40 years. They come and go, often without any clear-cut trigger. I always advise a 2 week trial off the statin to see if they go away, followed by a rechallenge if the pain does go away. Often, after this trial we discover the statins had nothing to do with the pain. If statins are reduced in this case, then it is imperative to closely follow lipids, LDL-C and apo B at the lower dosage. They will increase and further therapy with ezetimibe or PCSK9-i may become warranted. This is a very high risk patient and we would be targeting apo B <55 on treatment. Of course, lipoprotein (a) should be checked in such an individual.)

Back Pain on Exertion Returns

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.

(It’s very clear to me that at this point, a significant blockage in the coronaries had returned regardless of stress test outcomes. The optimal approach would be to check lipid parameters , optimize with the treatments I mentioned previously, and add a medication to help the angina (beta-blocker, nitrates, or calcium-channel blocker.)

A Switch to the Esselstyn Diet

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.

The False Dichotomy Promoted by Dietary Ideologues

In plant-based circles, there is this false dichotomy that’s put out – diet and lifestyle vs. medication and procedures/surgery. Either you “live correctly” or you have to resort to extraordinary measures that basically do 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 not NEED medication, right? So taking medication is just telling yourself you still have the 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.

More Stents Required

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.

(Subjective interpretation of the % blockage in coronary angiograms is remarkably inconsistent between readers. One cardiologist’s 50% is another’s 80%. The more eager the cardiologist is to stent, the higher the % blockage. )

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.

(Hooray!)

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.

(That is correct.)

Calling Out Esselstyn’s Claims

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.

(Exactly! The diets that work are the ones that people enjoy enough to stay on.)

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, Barnard, 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.

You can find my analysis of the science behind the Esselstyn diet, the Ornish diet, and the Pritikin diet on this website.

And I discuss misinformation regarding LDL-C and statin here and multiple other posts.

Skeptically Yours,

-ACP