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

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15 thoughts on “Profiles in Coronary Artery Disease: Navigating the False Dichotomies of Dietary Ideologues”

  1. In my 30s I came across The China Study and gave the diet a try. I didn’t find it difficult to stick to and saw my LDL-c drop to 55(!)

    Awesome. I thought heart attack was something I’d never have to worry about.

    I’m in my 40s now and my LDL-c has crept up to about 125. I was worried about this and I mentioned my father had a heart attack at age 50 to my doctor. He had me do a CT calcium score which came back 75-90%ile for my age!

    News that I may have arterial plaque already is not what I wanted to hear, despite my efforts, but I went on a statin immediately.

    Another difficult bit of news is that I had a DXA scan done to look at BF% (surprise I look okay but I’m actually skinny-fat), but while I was there they did a bone mineral density check and it showed that I was lower
    density than 85% of people my age.

    Pretty tough to follow what you think is a great diet (and exercise!) and have lower bone density than 85% of people your age, which includes secretary people eating SAD diets. Was this a different unlucky thing, or was it caused by my unusual “heart attack proof” diet?

    Hmm!

    Reply
    • Michael,
      I asked Anna borek, a sensible vegan MD I follow on Twitter
      She indicates that vegans do have a higher fracture risk which may relate to failure to pay attention to nutrients of concern like Vitamin D, protein, B12 and calcium.
      Dr P

      Reply
  2. Thank you Dr P for this article. I went down a very similar path trying to navigate through the rocks and shoals of all this. I greatly appreciate all your time putting these articles together.

    Reply
  3. This has really been my frustration since having a heart attack, stent, and bypass 1.5 years ago at age 46. Nobody can tell me what is the proper way to eat. I have settled on a Mediterranean diet about 95% of the time. If I’m hungry for a good steak, I have one very infrequently at a great steakhouse. And I do drink a little bit of wine every month. Exercise daily and really focus on keeping stress down. I felt terrible initially on all the meds. But now I seem to have figured out a statin, beta blocker, and blood thinner combination that seems to work and I feel good. I’m not sure if this is the right way, but it is the best I have figured out from all the advice that is all over the place.

    Reply
  4. Daily supplementation of 400 mg Co Q-10 may relieve the statin-related muscle spasms. I take 5 mg Rosuvastatin 3tx/week with no issues if w/ the 400 mg Co Q-10. My cardiologist in Phoenix was specific about the 400 mg or otherwise not likely to be useful. A 2020 systemic review and meta-analysis reported supplemental Co Q-10 was not effective in reducing muscle pain, but authors noted the dosage was 100-300 mg, small study samples, and lots of heterogeneity in the studies. Kennedy et al., https://www.sciencedirect.com/science/article/pii/S0021915020301386

    Reply
  5. Totally understood and I hold no grudge against his Dr’s at the time (over 20 years ago) as hindsight is always 20/20 🙂

    I think they believed they were saving his life at the time but it’s sure good to know there is a more conservative consensus. I now know that I personally need to start seeing a cardiologist at 47 years old and see what I can do with lifestyle and meds to mitigate what is probably oncoming. Currently on a Mediterranean diet and run a 5k 3-4 times per week but as we know, that doesn’t beat genetics.

    I am curious as to what point is it that you would refer a patient for a bypass and/or stenting? Is it typically after a heart attack or severe symptomatic angina? Maybe I need to re-read some of the old blogs….

    Thanks for your response, sir…

    Reply
  6. Many thanks for this post. I know several people in the Esselstyn cult and they are impossible. They don’t look that good, either, like Bill Clinton, dry and shriveled. Worse, I’ve seen cognitive decline. (Brain pathologies are my specialty. ) Esselstyn claims in his book that he guarantees that no one will get a heart attack if they follow his diet. That is an irresponsible claim along with being bad science. My father had almost no cholesterol (103) low LDL and had a heart attack and a stroke that killed him. I personally have obstructive hypertrophic cardiomyopathy with a previous heart attack. My LDL is rising like crazy, my Hdl is decreasing, my triglycerides rising. My ejection rates are normal because I was part of the Myocardia study and received the test drug, mavacampten which had excellent results for me. I tried two different statins which elevated my liver enzymes. Now I am taking Zetia with little results. I have no symptoms, can climb 4 sets of stairs with no problem, but I think I’m a walking time bomb. I have excellent cardiologists at UCSF. The Esselstyn people I know what me to drop my healthcare team and go to a nurse practitioner nearby who is part of their cult. They are true believers and medications and traditional healthcare show moral weakness.

    Reply
  7. I’m currently using 20mg of Crestor and 10mg of Ezetimibe daily along with other supplements, compounds and drugs

    Last blood test was on 7/8/2022 – my 68th birthday

    TC – 96
    TG – 52
    HDL – 51
    LDL (Calculated – 32
    ApoB – 43

    The plaque on my LM coronary artery has completely regressed. From a CAC score of 43.3 to a CAC score of 0

    The plaque on my LAD coronary artery, the Widowmaker, has stopped progressing and started to regress slightly. From a CAC score of 68.96 to a CAC score of 68.71

    The plaque progression on my RCA has slowed considerably. From a CAC score of 31.73 on 6/11/20 to a CAC score of 34.2 on 12/6/21

    Left Anterior Descending: Minimal coronary calcification (two small foci) with no significant soft plaque component. No hemodynamically significant stenosis at these two location, with 18% stenosis of the vessel at the level of the bifurcation and 27% stenosis of the vessel lumen located 1.7 cm from the bifurcation

    Right Coronary Artery: Minimal coronary calcification (one small foci) with no significant soft plaque component. No hemodynamically significant stenosis at this location, with 22% stenosis of the vessel lumen located 1.5 cm from the origin of the RCA.

    I will be getting another CTA sometime in June of this year to see if there is continued improvement

    I’m NOT on any special diet. Not vegan, keto, etc.

    I credit the regression to keeping my LDL and ApoB low and to certain supplements I’ using in addition to the statin and the Ezetimibe

    Reply
  8. Dr Pearson,

    Avid reader of your blog for years here and it’s a gold mine! I know you’ve mentioned statins as primary treatment for exertional angina and always wondered about something….

    My father had suffered from angina (he called it lung pain but we all knew better) when he went for walks, particularly on cold days, and this went on for a good few years into his late 60’s. Finally he went to the Dr and away they sent him to the catheter and a quad bypass days later. Said he had some high percentile blockage in all 4. Even then, I kind of questioned it all as he was relatively stable and I feel now, after reading your blog, that this should have been dealt with conservatively. The procedure really changed his personality somehow (for the worse) and he eventually died of a massive heart attack 14 years later.

    One strange factoid in all of this, he had the bypass at exactly the same age his father passed away of a massive heart attack at a barn dance in the late 1940’s after suffering from angina for at least a decade. Genetics are ridiculously hard to avoid….Anyway, what are your thoughts as to the rush to the cath lab and bypass in his situation (I realize you don’t have the full picture). He had smoked in early life and was on BP medication before all this.

    Thanks for all you do!

    Reply
    • King,
      I think I’ve written a lot on here (most recently in my Everyman post) about the rush to the cath lab and then the rush to surgery or stenting that existed for decades in cardiology.
      In centers that are up to date on the latest findings in CAD this should rarely happen in stable patients.
      I try not to second guess my fellow cardiologists , especially when I don’t have all the clinical information.
      Dr. P

      Reply
  9. Nice article to cover some of the issues around diet & CAD. I think ultimately a balanced diet with lots of fruit/Veg/Nuts and a little fish here and there and even a beef or chicken once a week could not hurt.

    Actually how we eat and a good routine is also important

    And lastly our attitude and state of mind is often ignore but is CRITICAL imo

    Reply
  10. I would take high dose, high quality omega-3 to get your AA/EPA ratio between 1 and 3. Also, check you homocysteine and lipoproteins (a) levels. If they are elevated, they can be lowered with targeted supplements. Both are less well known CV risk factors.

    Reply
  11. What a dietary journey! I had an elevated homocysteine and lipoprotein (a), and I was able to lower those with targeted supplements. At the age of 74, I don’t have any obvious vascular disease. I currently follow the Paced Protein Diet by Paul Arciero. Have you measured your homocysteine and lipoprotein (a)?

    Reply
  12. Thank you for posting this article from someone like me who has tried to negotiate the unbelievable amount of information and diets out there regarding heart disease. I am a 74-year-old woman, had a NSTEMI three years ago, which resulted in two stents. My main problem has been diagnosed as coronary spasm, currently on a statin, perindoprol, and low-dose aspirin. Would you have any other advice for managing coronary spasm?

    Reply
    • Angela,
      I have utilized predominantly long-acting nitrates and calcium channel blockers (diltiazem or amlodipine) for my patients with coronary spasm.
      A recent article notes (https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0239039) ” Calcium channel blockers are an established first-line pharmacotherapy for vasospastic angina because of their relaxation effects on coronary artery smooth muscles [4, 5]. In contrast, the usage of early generation beta-blockers is considered to be a contraindication in patients with vasospastic angina, as their use could aggravate a coronary artery spasm by leaving alpha-mediated vasoconstriction despite beta-mediated vasodilation [4].”

      I was also taught not to use pure beta-blocking agents in spasm.
      Perindopril I presume is what you are on . That is an ACEI-inhibitor not typically used for coronary spasm
      Dr P

      Reply

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