Tag Archives: Esselstyn diet

One Question On A Borderline Stress Test and One Comment About Me , Gundry And BIG PHARMA

A reader asks me the following question:

I’m 35 years old male and was positive for myocardial ischemia during stress test. The cardiologist said that my result was borderline. I’m not sure what does he meant by “borderline”. Also does it help if I do CAC score since my stress test already came out with positive MI?

Good questions.

First off, to understand what any stress test means we have to know the pre-test probability of disease. For example, in 35 year old males without chest pain the likelihood of any significantly blocked coronary artery is very low. This means that the vast majority of positive or borderline tests in this group are false positives, meaning the test is abnormal but there is no disease.

Even if we add exertional chest pain into the mix the probability of a tightly blocked coronary in a 35 year year old is incredibly low (but there are some congenital coronary anomalies that occur.)

The accuracy of stress tests varies depending on the type. The standard treadmill stress test with ECG monitoring is about 70% sensitive  and 70% specific. Adding on a nuclear imaging component improves the sensitivity (it makes it more likely we will pick up a blockage if it is present) to about 85% however, in the real world, the specificity (chance of a false positive) is still quite high. Accuracy varies a lot depending on how good the study is and how good the reader is.

Borderline for either the stress ECG the stress nuclear (or stress echo) means that the test wasn’t clearly abnormal but it wasn’t clearly normal. It is in a grey zone of uncertainty.

Given your low pre-test probability of disease it is highly likely your “borderline” test result is a false positive. Whether anything else needs to be done at this point depends on many factors (some from the stress test)  but most importantly, the nature of the symptoms that prompted the investigation in the first place.

If there are no symptoms and  you went for more than 9 minutes on the treadmill likely nothing needs to be done.

Would a coronary calcium scan add anything?

A very high score (>let’s say 100 for age 35) would raise substantial concerns that you have a coronary blockage.

A zero score would be expected in your age group and probably wouldn’t change recommendations .

A score of 1 up to let’s say 100  means you have a built up a lot more plaque than normal and should look at aggressive modification of risk factors but likely wouldn’t change other recommendations.

So the CAC might be helpful but most likely it would be a zero and not helpful.

A Nasty Comment.

The skeptical cardiologist gets lots of nasty comments about his post on the bad science behind Dr. Esselstyn’s diet and another post on the totally bogus Plant Paradox book/diet by Stephen Gundry. I don’t think Esselstyn is a quack but he pretends that there is scientific support for his wacky diet when all he has is anecdotes.

With Gundry, on the other hand, there is a strong smell of quackery.

With this new book he’s developed a line of ridiculous foods that he’s approved.

Gundry will sell you a 75$  piece of chocolate with resveratrol added to it. Despite the multiple health claims for this antioxidant (found in red wine) there are no proven health benefits.

 

Snake oil and supplements abound in all of his presentations and there is much promotion of useless expensive skincare products and  foods that only he sells.

I’m thinking of  adding promotion of special, super-charged olive oil to the red flags of quackery.

There’s no health  reason to get extra-virgin olive oil adulterated with anything. Just make sure you are actually getting EVOO.


Here’s one of Gundry’s supporters comments.

Thank you for your opinion and that’s exactly what it is YOUR OPINION. I suggest you try the Plant Paradox. You sound like someone from a pharmaceutical company. Why don’t you write about how BIG PHARMA is deceiving the public along with how they are keeping people sick.

People who leave nasty comments on my blog typically don’t identify themselves. I can’t tell if this is an authentic comment or someone paid by Gundry’s vast snake oil empire.

They really like using ALL CAPs.

And they like to accuse me of being from BIG PHARMA or in the pay of BIG PHARMA.

BIG PHARMA and I, apparently, have the goal of misleading the populace about the benefits of Gundry’s BS diet and useless supplements so that they will remain sick and require drugs that  gain us huge profits.

I’m still waiting for the checks from BIG PHARMA to roll in. In the meantime I am scrupulously avoiding lunch with pharmaceutical reps and drug/device sponsored boondoggles.

Pharmalargically Yours,

-ACP

N.B. If you’d like to see how much money BIG PHARMA is paying me (or any doctor) you can go to the Dollars for Docs website run by Pro Publica here.

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!

-ACP