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26 Feb Caldwell B. Esselstyn, Jr., M.D.: Response to The New England Journal of Medicine article “Primary Prevention of Cardiovascular Disease with a Mediterranean Diet”

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Misleading Research

The New England Journal of Medicine article entitled Primary Prevention of Cardiovascular Disease with a Mediterranean Diet is misleading and inappropriately titled.  It should read Promotion of Cardiovascular Disease with a /Mediterranean and Control Diet.

All three dietary groups had almost equal facility promoting the growth and clinical appearance of cardiovascular disease in those who at study onset did not have this illness.   The single exception was the control group which had a significantly higher stroke rate; however at baseline, they also appeared to have a greater BMI, waist circumference, hypertension, anti hypertensive agents and diuretics suggesting a cohort at greater risk for strokes.

Earlier this month the British Medical Journal updated the randomized Sydney Heart Study, which confirms the findings of this present Spanish study that the addition of oils worsened the outlook for cardiovascular disease.

By way of contrast, our small plant based nutrition study (devoid of 10 food items contained in the Spanish Study Control diet group known to injure endothelial cells) took patients with established advanced cardiovascular disease and not only halted disease progression but was able to demonstrate disease reversal.  We will shortly publish an expanded version confirming our original findings.

The epidemiological ultimate confirmation of the power of plant based nutrition to prevent cardiovascular disease is best demonstrated in T. Colin Campbell’s China Study.  In a rural province in China over a three year period examination of over 250,000 death certificates, not one death was attributable to cardiovascular disease.

Caldwell B. Esselstyn, Jr., M.D.

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Caldwell B Esselstyn
Caldwell B Esselstyn

Caldwell B. Esselstyn, Jr., received his B.A. from Yale University and his M.D. from Western Reserve University. In 1956, pulling the No. 6 oar as a member of the victorious United States rowing team, he was awarded a gold medal at the Olympic Games. He was trained as a surgeon at the Cleveland Clinic and at St. George’s Hospital in London. In 1968, as an Army surgeon in Vietnam, he was awarded the Bronze Star. Dr. Esselstyn has been associated with the Cleveland Clinic since 1968. During that time, he has served as President of the Staff and as a member of the Board of Governors. He chaired the Clinic’s Breast Cancer Task Force and headed its Section of Thyroid and Parathyroid Surgery. In 1991, Dr. Esselstyn served as President of the American Association of Endocrine Surgeons, That same year he organized the first National Conference on the Elimination of Coronary Artery Disease, which was held in Tucson, Arizona. In 1997, he chaired a follow-up conference, the Summit on Cholesterol and Coronary Disease, which brought together more than 500 physicians and health-care workers in Lake Buena Vista, Florida. In April, 2005, Dr. Esselstyn became the first recipient of the Benjamin Spock Award for Compassion in Medicine. He received the Distinguished Alumnus Award from the Cleveland Clinic Alumni Association in 2009. In September 2010, he received the Greater Cleveland Sports Hall of Fame Award. His scientific publications number over 150, “The Best Doctors in America” 1994-1995 published by Woodward and White cites Dr. Esselstyn’s surgical expertise in the categories of endocrine and breast disease. In 1995 he published his bench mark long-term nutritional research arresting and reversing coronary artery disease in severely ill patients. That same study was updated at 12 years and reviewed beyond twenty years in his book, Prevent and Reverse Heart Disease, making it one of the longest longitudinal studies of its type. It is most compelling, as no compliant patients have sustained disease progression. Today, beyond 20 years compliant patients continue to thrive. Dr. Esselstyn and his wife, Ann Crile Esselstyn, have followed a plant-based diet for more than 26 years. Dr. Esselstyn presently directs the cardiovascular prevention and reversal program at The Cleveland Clinic Wellness Institute. The Esselstyns have four children and eight grandchildren.

  • JenO

    Thanks for commenting on this. I saw the report on the news last night and wondered why they didn’t say “…and if you follow a plant-based diet your odds for decreasing cardio vascular disease decrease even further”. The media has a long way to go…

  • http://www.facebook.com/davidstillson David Stillson

    I’ve given up on letting the news media tell me anything. I think I’ll stick to common sense instead.

  • Rissa

    I’m sorry but…wait circumference? Come on I can’t share if someone can’t make sure everything is correct. I get so much flack already I don’t need people going off on that they can’t even get the spelling correct.

  • Pingback: Caldwell B. Esselstyn, Jr., M.D.: Response to The New England Journal of Medicine article “Primary Prevention of Cardiovascular Disease with a Mediterranean Diet” | The Engine 2 Diet | plantcentric()

  • Tina

    I really wanted to share this article, as I deeply respect Dr. Esselstyn. However, the basic editing errors render this article elementary and undermine the information presented. So disappointed.

  • Pingback: Spanish Mediterranean Diet Study Shows Promise | Plant-Based Odyssey()

  • Mark

    I couldn’t believe it when I saw a doctor on a TV News show yesterday showing the audience how much olive oil “we should be consuming” each day–it totaled out to something on the order of 1.5 litres per month! Unbelievable.

  • Maria

    Could you list the ten foods specifically in the Spanish Study Control that you eliminated in your program? Thank you.

    • http://www.facebook.com/peter.rowe.104 Peter Rowe

      Maria, I don’t know the specifics of the Spanish study, but Dr. Esselstyn’s diet is pretty simple to describe. Strictly Vegan. No food, including no ingredient, can come from any animal source, with the possible exception (in moderation) of honey, as it contains neither fats nor animal proteins. That’s the primary directive. Secondly, no added oils. Not in cooking, nor as any ingredient. Not a drop. If an ingredients list describes any oils at all, you don’t eat it. You don’t add oils, nor cook with them. Between this, and the vegan directive, you’ve covered most of Dr. Esselstyn’s plan. Add to this a directive of whole grain/whole food, instead of processed. Whole wheat instead of white bread, for example, is much more nutritious, and much lower in glycemic index, which works to lower triglycerides and has other benefits. You also would perhaps use things like soy products, which are also often highly processed, with caution (a good idea anyway, given some of the other aspects to soy in terms of GMO foods, and possible effects on endocrine systems, but this is not specifically part of Dr. Esselstyn’s diet plan). Finally, among the few plant based foods high in fats, if you have existing heart disease, you’d avoid nuts and avocado. If you don’t have existing heart disease, you’d use these foods only in moderation, simply so that your overall intake of fats accounts to only around 10 percent of total calories. I’ll bet that if you examine the diet described in that Spanish study, and compare to what I’ve described of Esselstyn’s diet, you can work out for yourself what is eliminated… Hope this helps.

      • mwlovin

        PETA NAZI..(just a joke, don’t go off on me) But you know, this doc and his book are pretty self serving, and other doctors say this man assumes too much to be viable…he is not all wrong and he is smart too…but he seems to have a stubborn bias in all research and data he approves….not really objective in his assessments, he seems to find ways to blame it on meat and anything not vegan.

      • Richard Breault

        Much of the diet is theory and has no evidence to support it….several examples are eggs, non-contaminated fish or fish oil, and avocados. There is no proof that a diet that includes these in moderation will not reverse heart disease.

        • Peter Rowe

          As I’ve noted before, actual total proof is rather elusive in science. What you get is ever increasing amounts of data, which point more and more strongly towards a certain conclusion. In the case of the animal based foods you list, while there may not be such absolute proof (or I’m not aware of it, which is likely, since I’m not a medical professional, merely an involved patient who tries to stay informed), there IS a lot of data that points to that conclusion. For one thing, it’s easily shown via the BART test, what the effect of various foods have on the effectiveness of the endothelial cells in the arteries. Virtually all fats, eaten in sufficient quantity (which doesn’t usually need much), can be shown to impair that action, being the release of Nitric oxide to control vasodilation and blood supply. I don’t know whether this means actual damage, but believe that over time, that’s part of the result. If nothing else, lower levels of NO are known to promote plaque deposits, or more accurately, higher levels of NO help prevent it. Also, the ratio of various amino acids among animal based foods is not that different. They all are higher in the amino acids containing sulfur, possibly resulting in higher homocysteine levels. from Wikipedia: “A high level of homocysteine makes a person more prone to endothelial injury, which leads to vascular inflammation, which in turn may lead to atherogenesis, which can result in ischemic injury.” So while I don’t know of any study that specifically says fish promotes heart disease, you can show that increased oils (any), which includes fish oils, have an effect which may contribute to it. And you can show that the animal based proteins are more likely to promote it. And you can conclusively show that a diet without any of these (Essesltyns diet, or Ornish’s diet, among several authors who’ve demonstrated similar results with similar vegan low oil diets) does indeed arrest and to selective degrees, reverse heart disease. Is this absolutely proof of anything? Perhaps not. But I love, or loved, the taste of fish and a number of other animal based foods. The data was enough to cause me to drop all of them from my diet, and the results I’ve experienced so far, seem to support that decision. You, of course, are free to make your own decisions regarding your own diet. And if you can show me conclusive proof, or even really well done study evidence that shows Esselstyn and Ornish are wrong, then you’ll have my (and I’ll bet, theirs too) attention. So far, I’ve not seen any such studies or even suggestions of such.

  • Disappointed

    It is difficult to know what to believe, there are always so many contrasting ‘beliefs’. We have been on the the engine 2 Diet for 28 days. While my husband has lost 11 pounds and we are looking forward to getting his blood work re-done, I have had no change in weight, no relief from GERD and have hit walls trying to get any help. We’ve bought the book, been following on f/b and online but it appears the only way to get specific questions answered or get any assistance requires ‘buying’ more. Pay for a membership where there is more information and questions answered. Spend close to $600 for an immersion weekend. I have to say that sadly, while the Esselstyn community has ‘credentials’, so do other fad diet experts. I see nothing here that seems much different than another ‘doctor’ on the television ‘news’ reporting some other ‘research’.

    • mskatonic

      I had the same issue when I tried the Engine 2 diet. No weight loss, no change in my blood work, lots of crankiness, overall disappointed. I’ve since gone back to eating whole foods, cut back on sugar, eliminated most grains, and I feel great.

      And this article really doesn’t explain what problems Dr. Esselstyn has with the study. “All three dietary groups had almost equal facility promoting the growth and clinical appearance of cardiovascular disease in those who at study onset did not have this illness.” Well, can you explain what those are? Can you cite something, anything? What are your benchmarks? What do you consider to be “bad”? It sounds off the cuff and reactionary, which is surprising coming from a medical man who must know in this day and age that to make a point, you need to be ready to come in with facts, not vague references to a “small plant based nutrition study”.

      I don’t disagree that industrial oils are largely responsible for inflammation and atherosclerosis in many people eating modern diets, but it seems wrong to conflate them with natural oils like coconut, nut, macadamia, and so on. Cottonseed and soybean oils are almost certainly bad for you. “Good” fats, on the other hand, are almost certainly not, and a lack of it in the diet could even be considered a detriment.

      • Alyssa

        I am also disappointed and feel like the Engine 2 team has let me down. They seem to always talk about how they are there for you as a support system, etc. But, when I asked for help and even offered to pay someone for advice I reached a dead end. I did everything that Natalia told me to, and even sent her a detailed food journal for a week just to get no response or help in the end. Even with repeated follow up emails.

    • Jill Honer

      It can be very frustrating, especially when many of us don’t have medical or nutrition degrees. One month feels like a long time, but you will see improvements. I like what Dr. Doug Graham says, “you’re as strong as your weekest link.” exercise, sleep, and positive thinking are as important as diet. My son tried being vegan years ago, and didn’t do well at all. He wasn’t plant based vegan. Eating real food instead of packaged vegan food is also important. You may have been completely plant based, but I know that’s where some people make mistakes. Plant based vegan should help gerd, too. The diet is naturally alkalining. It takes time, and it’s hard to be patient when we’re waiting to feel good. There are lots of free video blogs on YouTube. I watch how studies are financed and I research the researchers before I make health decisions. ‘fully raw’ and ‘rawfully organic’ are both good sites with videos, recipes, and diet tips. Good luck! It is a journey, but it can be interesting and fun.

      • Jill Honer

        sorry – weakest link!

    • Franco45

      I had a heart attack and stent placement in September . The unadjusted bill from the hospital was $98,000. So $600. For an immersion weekend Doesn’t sound so bad.

    • shelley stanfield

      Disappointed, we found by reading both Dr esselstyns book and the engine 2 offered up some differences and we found Dr He’s approach is geared more towards reversing disease, its more strick than Rips, he recommends little to no oil even plant sources, no processed soy products, and even tofu only occasionally, because its 40% fat. I suggest that approach. My Midwest mom of 75, who started the diet about 3 months after my husband and I did ( plant strong 14 no now) and she came off of her simvastatin for cholesterol and her metformin for diabetes , the cholesterol med was something shed been using since she was in her 50s. Or some form of the med. She also lost 25 pounds with diet alone! Shes never been athletic and now she feels good enough to work out at the gym!She was a huge cheese lover, lots of cold pressed olive oil, meats and also processed sweet snacks. Not any more! If she can do it, you can, just hang in there and remember it took years to damage our bodies, give it time to heal! If you have Facebook check out Engine 2s for networking with people in the same boat, sharing tips and recipes, and success stories! All free! And if you haven’t watched forks over knives, its free on Netflix as is Rips Engine 2 kitchen rescue! Don’t give up, you can do it. And once you start feeling and seeing the results , you’ll never want to go back! :-)

    • http://www.facebook.com/peter.rowe.104 Peter Rowe

      Dear Disappointed, First, you should understand that both Rip Essestyn’s engine 2 diet, and his father, Dr. Calwell Esselstyn’s diet, upon which Engine 2 is based, are designed for health, especially the prevention of cardiovascular disease. Weight loss is not the primary goal of these diets, and while common, is not guaranteed. Among other things, it’s quite possible to follow these plant based diets and still consume more than enough calories to retain your current weight. If you concentrate your diet on the green leafy veggies, with less in grains, starches, beans, rice, etc, you’ll cut calories. And, the high nutritional value of these foods will give you an equal sense of having eaten enough. With that, you can start to loose weight. But again, these are not fad, weight loss diets. These diets are designed literally, to save your life. You will find interesting information if you look at other diets that espouse essentially the same ideas, ie Dr. John McDougall, Dr. Joel Furhman, Dr. Dean Ornish, Dr. Neal Barnard, Dr. T. Colin Campbell, and a number of others. All these people start with a diet that is strictly vegan. Not vegetarian, but vegan. Then they reduce fats and oils, and highly refined grains/processed foods. While these authors may discuss different aspects, and stress different points, in essence all these people are describing what is for all intents and purposes, the exact same way of eating. If you compare diet plans and fads in general, it’s like a herd of cats going in all directions, with in common that they start with weight loss, and generally a book or product with which the authors intend to make money (sometimes, lots of it.). They start from that point, and diverge in all directions. Incomprehensible. Then look at the people I mention above. All highly trained scientists and doctors, they started from a wide range of places and interests, generally looking not at weight loss, but health, cardiovascular disease, cancers, and the like. Instead of the herd of cats, when they looked, they all seem to have come to the exact same conclusions about diet, with only minor differences in emphasis or interest or style. This is a powerful insight, and should give you confidence in following Engine 2, or any of the suggestions from these others. What you’re fixing is your health first. When you do that, with good nutrition, all sorts of things start to happen. But you should understand that 28 days to make a judgment is an impatient unrealistic expectation. It takes, for one thing, at least six weeks or more just to start to reset your brain chemistry to no longer crave the fats, the dairy, and more. Till then, your body is still trying it’s best to remain as it was. Give this time. Understand that these diets are not temporary quick weight loss, then back to your old ways, ideas. You may benefit from reading Dr. Caldwell Esselstyn’s “Prevent and Reverse Heart Disease”. It gives much more of the medical information about what and why these diets work. Joel Furhman’s books give more detailed information on the various nutritional values of these foods, and how to maximize the benefits. Dr. T. Colin Campbell’s “China Study” has been called the gold standard in Epidemiological studies on diet and health. Reading it will give you a much greater understanding of what you’re trying to do, and why it’s worth doing. And as I said, please give yourself a little time for you, and your body, to adjust to a whole new way of eating. Instant gratification is not what any of these diets are about, though you may find you start to feel better quickly. Actual weight loss, like actual reversal of heart disease, is more gradual. But it does indeed happen. Since I switched to Esselstyn’s diet a bit over 2 years ago, I’ve lost over 50 lbs, and now weigh what I did in high school (168). This did not happen immediately, or quickly, but was gradual, almost unnoticed, even though I actually was often eating more calories than before when I was gaining weight no matter what I did. I didn’t do this for weight, but it’s a welcome bonus. My cardiovascular health is noticeably improved, and my diabetes control is much better. Those, for me, were the real aims, and so far, I’ve not been disappointed.

      • http://www.philippeorlando.com Philippe Orlando

        Peter, what do you think of Denise Mingler. I’m not one of her followers, but I’d like to know your opinion.

    • jeremy

      granny smith apples will do amazin work for gerd give it a try trust me

    • HorseLover

      As I imperfectly follow Dr. Fuhrman since March 1st, I dropped Nexium in July. At that time my weight had gone from an all time high of 230 to around 188. Just work the program and you will get there! I am told it might take a year or more for OA to resolve. Good Luck!

    • Sylvia Boecker

      For Gerd, google “Sherry Brescia”. she is the Esselstyn of GERD.

  • http://www.facebook.com/bill.gere Bill Gere

    Since we constantly get bombarded by sales pitches for the “diet of the week”, It would be quite helpful if Engine2 or Dr. Esselstyn would devote an area of the website with a few paragraphs on each of the top diet fads, and explain why these highly advertised diets and books both help and fail our health. – Thanks for all your good information!

    • http://www.dachia.com Dachia

      PCRM has a spot for this, I think. I don’t think they do all the stupid little diets that come down the pike, but they do cover the biggest ones.

  • http://www.facebook.com/cindiequilts Cindie White-Weiss

    I told my husband last night, “Let’s wait and see what Dr. Esselstyn says.” I knew you would debunk this. Thanks.

  • Ekonokat

    To disappointed and mskatonic, I respectfully disagree and think you must be doing something wrong. I have been plant strong and following Dr. E’s advice since I saw the Clinton/Gupta program. I was able to get off of steroids, non-steroidals and daily pain pills almost immediately and had a complete remission of my severe PMR/arthritis. I feel better than ever. I try my best to avoid sweets and breads, both my downfalls, but do avoid as completely as possible sugar, oils and white flour or anything that is not whole grain. Try to re-evaluate what you are eating and see if you are really compliant. It does work!

    • Franco45

      I agree. We have been on the Dr’s diet since my HA in September. At the same time i kicked up my exercising. After 6 weeks my total cholestrol went from 177 to 152 and i was not taking any statins. I lost 16 pounds. Looking back, my biggest fault was cheese and olive oil. I had thought that olive oil was the “perfect” oil. Two salids a day. At least a liter a month. The question remains: is it the diet or the exercise???

    • mskatonic

      It does work. For you. The assertion that it works for EVERYONE? Not the case with me.

      I tried to be vegan for a year. And not a junk food vegan: a whole foods, whole grain, low-fat vegan who ate her beans and her veggies and her salads and was constantly starving and sick and gaining weight. Physical recovery from exercise? Forget about it. When I went back to meat and healthy fats, I saw my cholesterol levels improve, my overall energy (and muscle recovery) go up, and my life get back in line.

      I don’t deny that “plant strong” works for some people. I think, however, that many people come in many different configurations, and it’s reckless to propose that everyone will thrive on a 100% plant-based diet.

      Implying that I “just didn’t try hard enough” is also reckless. If something isn’t working, you stop doing that thing. Then you find something that does work. Which, thankfully, I did.

      Again, though: the main reason for my initial critique was that I would really like for the doctor to cite reasons for why he doesn’t agree with this study. Holding up the China Study doesn’t help; there’re numerous rebuttals to it. Vegans need to move away from it: it’s a flawed study and it isn’t helping their case.

      In short, he has debunked nothing. He has simply waved his hands at the issue and hoped it’ll go away. That’s not doing the hard work of citing WHY the study is wrong — that’s comforting the choir. And your movement deserves better.

      • Tim Korat (Science Teacher)

        Nice post, The only problems I see (after over 20 years of personal study on nutrition) with this/these diets is the utter lack of fat soluble vitamins (A,D,K). The diets work for most people because your liver has an amazing capacity for storing and reusing these vitamins to prevent deficiencies but you’ll never have an abundance of them without dietary consumption. You need these in your diet because in your small intestine they are needed to bond with the alkaline minerals so the minerals are assimilated properly in high amounts. This is necessary to conteract and neutralize the daily acidic waste created and the excess acidic waste stored in between your fat cells and fatty tissues. Without neutralizing and eliminating these acids your body will refuse to let go of the fat cells as doing so would cause acidosis and damge the body. These acids are the underlying cause of all problems in the human body. (See Dr. Paovo Airola, Dr. William A. Lane, Dr. George Crile (also from Cleveland) and Dr. William Howard Hay (whos book was written on the shores of Lake Erie 3 hours east of Cleveland). Dr. Weston A. Price discovered activater X which was later Identified as Fat Soluble Vitamin K and his book “Nutrition and Physical Degeneration” gives much info on fat soluble vitamins
        and their role in preventing cavities as well as helping in the uptake of A,D and K.

        • RDCDEx30

          Umm – here’s the thing Mr Science teacher – apparently you need to study nutrition a little bit more. Greens are chock-full of Vitamin K. Most of our foods contain very little Vitamin D ( that is what sunshine is for?) and Vitamin A is synthesized in the human body from plants ( which contain beta-carotene). So your idea does not hold water. On top of that since fat- soluble vitamins are stored in the body fat ( and in the liver )-so they do not have to be constantly replenished.

          • James Kling

            Perhaps you should heed your own advice. Vitamin K is not a single vitamin, but K1 and K2, of which K2 has some interesting sub-types.

            “Greens are chock-full of Vitamin K.”

            Greens contain K1, which is only converted to K2 at about the rate of 10:1. Numerous studies show that K2 has a strong inverse correlation to chronic heart disease, reduction in arterial calcifications, prostate cancers, rheumatoid arthritis, and all-cause mortality. Those same associations are largely absent with K1, so it would appear that the food sources of K2 (eggs, liver, cheese, butter, meats, and natto) are superior to vitamin K in greens unless consumed in sufficient quantity to convert to like levels of K2.

            “On top of that since fat- soluble vitamins are stored in the body fat ( and in the liver )-so they do not have to be constantly replenished.”

            That is just bad science. Vitamin D is metabolized in the liver to calcidiol, and converted to calcitriol in the kidneys. It is then used by the body as steroid precursors, and works synergistically with vitamin K and calcium to shuttle calcium away from soft tissue and into bones. These fat-soluble vitamins don’t just sit around in our fat cells, inactive: they are constantly being used in numerous metabolic functions, and often (as noted) synergistically, meaning a deficiency in one can have side-effects: if one is low in vitamin K or D, calcium may deposit in arterial walls, rather than bones. In short, fat-soluble vitamins need to be replenished to the extent that they are used, and they are being used constantly.

            “Most of our foods contain very little Vitamin D ( that is what sunshine is for?)…”

            Most people do not receive adequate sunlight to synthesize vitamin D, due to seasonal limitations, insufficient time spent outdoors, sunblocking agents, etc. Food sources of D3 include fish, liver, and eggs.

            “Vitamin A is synthesized in the human body from plants ( which contain beta-carotene)…”
            Well, you’ve gotten that correct. But the body requires dietary fat to be able to absorb fat-soluble vitamins, so eating a raw carrot will not provide as much beta-carotene as carrots cooked with butter.

  • jinx watson

    What no one is talking about is who funded the “Mediterranean Diet Study?” [olive oil association, nut association, the Mediterranean diet association. . . look and see!] I don’t pay any attention to medical research unless it’s funded by NIH or medical schools. I have followed Esselstyn’s eating plan for two years since my heart attack (after a lifetime of eating “Mediterranean style”) and my cholesterol is way down, weight way down and I have never felt deprived of any kind of food. As someone who loves to cook and invent dishes, I’m having fun!

    • SenatorCletusSoffpossum

      Ahh yes, who funded the study. The often overlooked aspect of research. From what it looks like the Mediterranean diet study was funded mostly by the Spanish government. Spain produces 45% of the worlds olive oil and doesn’t exactly have a thriving economy right now. Doesn’t necessarily make it invalid but does raise an eyebrow. Very interesting.

  • http://www.facebook.com/profile.php?id=1675060873 Shabih Alqamar

    Thank You !

  • Optimist

    Too all disappointed, disgruntled and in dismay. Plant based is the way too go. Its the only diet that truly boots your cardiovascular system. Remarkable how something so simple can be so powerful. I spent endless hours in the gym trying to strengthen my cario but never dreamed I could be this much improvement. I struggled for years to get the vegan thing right. Only when I went low fat did it relly work. I believe the key is whole foods and portion size. You can’t eat the same portions you did when your not plant based. For example 2 slices of toast and an apple doesn’t cut it for breakfast. Now I eat 1 cup of oats with a table spoon of flax seed and 3 or 4 fruits. People still believe in the low calorie nonsense while eating plant based and that’s a recipe for failure. You have to double or triple the volume of food you eat especially with fruits nd vegetables. The plant based diet is nutrient dense not calorie dense so you need eat a lot more. Most likely your not eating enough. The food you eat may be healthy but your still starving. Your body will never let go of fat if its starving. Another tip that may be helpful is cut out caffeine. I found huge results from eliminating caffeine especially in my waistline. The other thing is I went from doing intense exercise to moderate and got better results. It’s like doctor Caldwell says “Diet trumps everything”. Also check out the hr + lectures from Dr. Allan Goldhammer. Very informative and motivational.

    • Guest

      Micronutrient dense, yes. But severely lacking in B12, choline, and other important nutrients that you can’t get no matter how high you pile your plate.

      And I know Engine 2 dismisses the need for protein, but I find those claims dubious.

      Again, great if it works for you, but it doesn’t work for everyone, and people should recognize that.

      • Why are you commenting?

        No one says it works for everyone. And you are wrong about protein, B12 and other nutrients. Beans, soy, broccoli, and even spinach have protein.

        If you have diabetes and heart disease and other autoimmune diseases, then you are better off trying this first than taking the poison the chemical companies want you to buy.

  • http://www.facebook.com/teresa.berger.5 Teresa Berger

    Can we please get this article published?

  • Shelley Stangler

    The New York Times had an article in today’s (march 3, 2013) paper slathering praise on the Meditteranean diet while dismissing Drs. Esselstyn, Barnard and McDougal’s work as a “book” which indicates that a vegan diet prevents heart disease, although that remains “unproven,” and to drive home that point, has a picture of a man who is a vegan with a tag line that the diet “has never been rigorously tested.” I hope the writer does not consider herself an unbiased journalist. My husband not only lost tremendous weight (which admittedly one could do with weight watchers or eating grapefruits all day as well), but his diabetic retinopathy went into remission, his cholesteral is way below “normal” levels without medication, and his diabetes is so well-controlled that his glucose readings are normal. The only thing I do agree with is that Esselstyn is too strict for most people to follow. I also note that it is not “marriage friendly.” However, there is no question that the plant based diet is the way to go. It is a disservice to the public to suggest that it is OK to pour 1000s of calories of oil and nuts all over your food.

    • Penny

      Well said! It amazes me that 18 years of data collected Dr E’s patients, 20 years from the China Study are “flawed”. Lets ask how unbiased the USDA was when they invented four major food groups, the Food Pyramid, the recommendation of meat and dairy in a “healthy diet. Oh wait, that was done in an effort to promote the cattle and dairy industry wants it? Yes, it was. If we’re going to debunk, let’s look at all the players.

      • Jo Ann Ivey

        Well said Penny! I was watching a Dr. Gregor video which included emails he had from the USDA to someone advertising eggs (thanks to the Freedom of Information Act). The emails were up on the screen for all to see! The USDA said because of truth in advertising laws, those selling eggs COULD NOT use the words ‘safe’ or ‘healthy’. The USDA actually recommended using the words ‘satisfying’ or ‘fresh’. The number of cases of salmonella poisoning from eggs per year is too much for safe, and the cholesterol content to remain within guidelines per serving is not healthy.

    • http://www.facebook.com/peter.rowe.104 Peter Rowe

      Agreed that the NYT’s article is junk journalism. Calling the lifes work of these three scientists, and a bunch of others, just a “book” which is unproven suggests that journalist hasn’t bothered to read the book(s). Nor does he/she understand science. In science, there is seldom any total proof of anything. But there are ideas, theories, conjectures, which are then tested and demonstrated The amount of data amassed by Esselstyn, Ornish, and others, on diet and heart disease is far more than just a little, or open to much doubt. Esselstyn took a relatively small sample of people, true, but all had been expected to live between six months and two years, max. All but one were just fine, and healthy, many many years after starting Esselstyn’s program. Ornish finds the same. Over 20 or more years, these two and others have found what amounts to virtually 100% success. Not just some improvement in some percentage of cases. It’s literally, all of the people who do this, which indeed can be rigorous, get those positive results. How much evidence do you need? It’s likely that people who don’t get the results they expect, may be looking for the wrong results or expectations, rather than what these diets can actually do. Even more likely is that they neither fully understand what they are trying to do or how to follow these plans, nor are they actually following the plans correctly. These are precise diet plans, and for the best results, they must be understood and followed. Not “almost” followed…

      And to the commenter who suggests that the China Study is flawed, you can find almost anything you look for on the internet, including lots of people who’ll manage to cook up some opinion on just about anything. It is true that one can criticize the book itself. Campbell is a scientist, not a professional writer. And the book attempts to distill a massive amount of study data into a consumer friendly book. The critics make the mistake of confusing the published consumer book with the science itself, or the published scientific papers, that go into far more detail. If critics talk about some aspect of the China Study not fully demonstrating something, they should go back to the actual, real data, not call the book wrong. People who actually understand the amount of quality of the data collected by the study, don’t come up trying to refute it. This wasn’t just Dr. Campbell and a couple people cooking up some study. This was hundreds, maybe more, researchers working on a massive study, collecting massive amounts of data. And the correlations it shows are so numerous, and so strong, that for those who claim it’s correlation not causation, well, they’re technically right, but it’s a pretty weak point given the strength and quantities of those corrolations, to then discount the links found.

  • Kneyda Sommer

    The E2 diet worked for me. I went on it along with my family 1 1/2 years ago. We all are doing great and feel great.

  • Penny

    Sadly, the plant based path is not something that the five or so major food production corporations, the evil GMO companies, lobbyists, etc want us to know about. They will promote their bottom line and people will follow and eat. Our food system is in peril and so is our nations health. Thank you Dr Esselstyn for taking the path less traveled and continuing to heal, inform and educate.

  • TheUltimatePessimist

    Last night I had a beautiful piece of cod, with a bit of cajun spices and broiled with moderate olive oil, and then some pan seared escarole (using about 1 tbls of olive oil) with chic peas, some lemon juice and cracked pepper and a touch of romano cheese, and a glass of red wine and a glass of water, after having ran 3 miles at moderate pace after stretching earlier in the day. If you maintain that kind of diet and lifestyle you’ll be fine, notwithstanding the well-intentioned claims of the Vegan/No Oil arguments and, if you truly enjoy food, it will be enhance your quality of life and reduce your stress. Don’t worry about the village in China; I don’t aspire to eat like them and would rather eat the way my ancestors ate, not the way an American with corporate-food eats. I think the problem with the discussion is that it is absolutist. That said, if you are happy to eat the Vegan/No Oil diet, I have no problem with that, but be careful not to turn your nose at my choices which I think are fine.
    Thank you.

    • http://www.philippeorlando.com Philippe Orlando

      I don’t understand; if you intend to eat fish and oils, why do you read this site?

    • alleycat5703

      I think your screen name TheUltimatePessimist says it all

    • Richard Breault

      So you think your choices are fine, so do millions of people with heart disease that say everything in moderation is fine…

    • JoAnn Downey

      We all make our own choices, but Dr. Esselstyn’s regimen is backed up by peer-reviewed scientific studies. Remember the Ornish diet beat all other diets including the Mediterranean in CVD prevention and reversal.

  • Xandersun

    Esselstyn has made a great contribution to our understanding of diet and heart disease. But he takes his own findings to an unhelpful extreme. Within his findings, ironically, are the seeds to destruction of his own rigidly prescribed diet.

    1) His diet is so amazing that it can actually reverse heart disease! Well, it then easily follows that you do NOT have to keep to the diet ALL THE TIME. I’m sure a study can be done to show that eating a moderate amount of meats or dairy or oils for one month (say the Thanksgiving to Christmas time frame), can be reversed by going on his diet for the remaining 11 (or whatever amount of time required to revers the effects of the one month). Maybe you can have one day a month where you eat oils and meat. Or even if not, the main principle to be got from this is that there must be some ratio of staying on a meat/oil permissible diet and then reversing whatever bad effects by going on Esselstyn’s diet.

    2) Studies have shown that there is a genetic component to heart disease. Thus, I would assert that some people may be able to withstand a moderate amount of meats or oils better than others, and that time on the Esselstyn diet to repair “damage” will vary widely across individuals.

    3) Enjoyment of food varies as widely across people as their attitudes towards excitement and adventure in life. For some people,”Foodies,” the opportunity to have a rich and varied diet and try various different types of food is a major component of their happiness. Contrast this to people who are quite satisfied with the familiar and comforting, i.e., who always order the same dish at a restaurant and have a small repertoire of dishes that make them happy. Going on a strict Esselstyn diet will be much harder for the former than the latter (if the latter find an oil-free vegan option that they like and can latch onto).

    4) If you get somebody genetically predisposed to NOT having heart disease who is a “Foodie”, there has to be a cost benefit analysis to heart disease avoidance. If all you may gain is 5 extra years of life (say you die at 92 instead of 97) by sticking to a strict Esselstyn diet instead of a modified one, it may not be worth it to forego something that gives you so much pleasure all your life to gain a mere 5 years of life. If it could be shown that living an ascetic lifestyle away from electricity could add another 5 years to your life, could it possibly be practical or good public policy to advocate everyone give up electricity and meditate?

    I really feel Esselstyn has decided to take it upon himself to make all the value judgments upon what is practical and pleasurable in life, by infusing his own wants and abilities into his diet program. A strict oil free vegan diet may be easy for him, but if they discovered that thinking and speaking in Chinese would extend your lifespan an extra 10 years, or learning just some Chinese would only extend your life span an extra 5 years do you really think he would stop all he was doing to learn fluent Chinese, or would he just say, “you know what, 5 extra years just isn’t just worth the disenjoyment I would get having to give up ever thinking in English again and trying to master Chinese.”

    Dogmatic “so-spaketh-he” instructions are never a practical or winning proposition in either diets or religion.

    • How much prove do you need?

      If you don’t want to do it, don’t.

      What is your purpose in complaining about it? Are you trying to tell the rest of us who succeeded in improving our health from staying on it?

      Do you work for the cattle industry or some other group that will be hurt by this?

      Shame on you!

      • Xandersun

        Sigh. This is the problem with Esselstyn and his followers, so dogmatic and defensive they can’t even properly read and analyze constructive criticism.
        I am saying nothing of the sort. For the people that the diet has really helped, they should stay on it. The only true way to ensure that your health will improve is to stay on it all the time. BUT, it is not necessarily true that staying on the diet 100% of the time is either necessary nor attractive to many or even most people (especially the attractiveness part). He should be spreading the gospel not with dogmatism, but more flexibility. The very foundation of his own principle is that HEART DISEASE IS REVERSIBLE, if you start on the right diet. A priori, that means if you “slip” off the diet, you can always get back on it again and reverse whatever damage you caused by the slip.
        So why not also tell people “if you think it is too hard, then start with a modified diet and slowly work your way up to the full Esselstyn diet”? Or, “try a modified diet and then check with your physician (and get tests) after a year to see if you are genetically predisposed to get the benefits without having to do the full Esselstyn diet”? At least you will get many, many more people considering starting down the right path, even if they can’t go all the way at the very start.
        Can you imagine how small and irrelevant Christianity would be as a religion today if the first Christians acted like Esselstyn and demanded people believe and act exactly like the Aramaic speaking Jews who were the originally Christians? In fact, why do you think there are so many Christian sects today? Everyone has there own twist but they all are striving toward the same goal. Christmas is essentially a pagan ritual that was adopted to disguise celebration of Christ’s birthday. Can you imagine if the Pope stated that from now on, you absolutely cannot celebrate Christmas anymore, being of pagan origin, and that you will go to hell if you do? How would this help spread the gospel?

        • Gilbert

          From my understanding, in some people, even though the disease is stopped from progressing, they do not attain a lot of reversal. They just have the end of progression, and some existing damage is encased and will not interfere, . In those cases, the existing underlying damage, being still there, will resume, when animal products are reintroduced. In these cases, the resumption of animal products could cause a heart attack in short time frame.

        • Jo Ann Ivey

          Most people won’t change without motivation, and some even not then. I was motivated by plaque in my aorta, which after a few years ‘magically’ disappeared. My motivation kept up because I felt SO much better eating this way and feeling younger every year. Some, like Bill Clinton, need a couple of stents and a heart attack, and even after that I wonder if he adheres to the diet as much as he could. An example I heard about half measures was in reference to a patient who had surgery for lung cancer, and post op his doctor said he’d have to give up cigarettes. The patient in all seriousness asked the doc if he thought one or two cigarettes would be ok.

    • JoAnn Downey

      You will be amazed at how your taste buds change and how much you actually like eating this way because it makes you feel healthier and younger. Moderation kills in many cases – cigarettes, alcohol – so if you are so addicted to one or more foods that you can’t conceive giving them up for your health, remember lots of folks have successfully given up an addictive substance and were much happier for it.
      Oils, meat, eggs – they all cause arterial inflammation. Eating the Esselstyn way is our best shot at preventing heart attacks as well as a host of other diseases.

  • pat sayre

    Dr Esselstyn, I am writing you in behalf of my husband, John Sayre. He rowed with Rusty Wailes in 1960. We had dinner together at Rusty’s memorial. John has been extremely healthy all of his 77 years but has been fatigued for the last few months and sought help with our family doctor. He learned that he had A – Fib and a leaky valve in his heart. Now he is on a cocktail of Warfarin, LiIsinopril and Metoprolol. For a man who has never taken anything stronger than Advil, this has been horrendous. He has diarrhea, can’t sleep, doesn’t want to eat, has lost 12 pounds in a month and has no energy. I wonder if a change of diet could have the same effect as the prescribed medicines. He has always had low blood pressure and has been extremely vital. What would you recommend he try in place of these medicines. I would gratefully appreciate any thoughts you might have. Thank you very much. Pat Sayre – dish@wavecable.com – 360-588-1995.

  • HorseLover

    thanks Dr. E. I will print print this out and mail to my cardio in Wilmington, DE and my FP. I see a cardio because I had an MI in 2000. At a check up in December I told him about your work and others with plant based diets. His reaction, “Nutrition has no effect on lipids.”

    In early March I had blood work. The results: my sugar was normal, from a previous pre-diabetic level, cholesterol, HDL were normal. LDL was 100 which he would like lower before taking me off Zetia and Welchol. BTW I had begun the Fuhrman program “full throttle” on March 1st.

    My cardio was delighted and surprised. He said the results at Duke did not show great results. Again, no faith I could get my LDL further down.

    I am writing in early August down 35 lbs, around 185. Now I feel like kicking in the exercise to high gear. To date I,have mostly relied on dog walks and hikes and activity associated with caring for and riding my horse.

    My 28 year old healthy ovo veg son just came home for a visit and he looked crazy great after 2 months with Cross Fit…down 15 lbs and way up on muscle! I am psyched.

    Forks over Knives and your book has been a tremendous help to me. I am glad to find your posts here and look forward to reading them all.

  • Gilbert

    To – Xandersun
    – If you have a severe case of heart disease, it is very good that you think this way. We need people who would like to test those theories. There is a bit of shortage of willing volunteers on that.

  • Sharon Sigman

    Jeff Okun just finished showing me your wonderful video Forks Over Knives. I was very impressed and hoping to start following the diet.

  • Linda Morris Caughman

    As of Christmas Day of 2013 I will have been on the plant-based diet for one year. My mother got me the book for Christmas last year. It has been a wild year but I made it. It took 7 months to start enjoying my new way of eating and stop fighting with the cravings and missing eating out. My doctors still don’t agree but the test results don’t lie and they are great. I must confess the results are amazing. I went off all my meds within the first week and my cholesterol went from over 200 to 127. I go for my 3rd carotid artery ultrasound next month and am hoping for improvement of some kind. It was 70% blocked last October 2012, it has stopped and is holding its own as of June 2013, with another one scheduled for Jan 2014. My blood work was perfect last month which included everything from protein, cal, iron, and vitamins. All on the high end of normal. I have NEVER felt better and work circles around my younger co-workers. I also have not been sick when others around me are all sick. I am 53 and hope to avoid any further advancement of heart disease. I can use all the positive information that others have to share on the results of revering heart disease. I know one person in NW Arkansas that was 100% blocked and is actually 0 blocked today. It took him over 2 years. Thanks for reading. Look forward to your encouragement and stories.

    • Val

      I, too, fare well with this lifestyle…3 years ago at age 53, my carotid ultrasound said “zero plaque burden.” My internist who pretty much insists on carotid scans for patients of all ages was so pleased. We had a health screening at work last week: BMI=20…Total Cholesterol=150, HDL=89. Technician said she “rarely ever” sees numbers this good. I feel well every day and have tremendous energy–haven’t had a sick day from work in over 10 years. It WORKS folks! Plant-strong for the win!

  • YitzI

    I have been on Dr. Esselstyn’s diet for nearly two months now. Except for Triglycerides all of my cholesterol numbers improved a bit, with LDL down 25 points, Total Cholesterol down about 15 points, Triglycerides up from 177 to 248 ??? I’m confused by that!

    My fasting glucose went from 100 to 103, also not what I expected. The other thing is my CRP has ranged between 24 (not 2.4) and 34 the last few months, I hoped it would go down but it remains at 24.

    At this point I’m disappointed, I expected more for my hard work and dedication to the All plants, and no oils regime. I have lost about 20 pounds in the last month, 40 pounds lost prior to that and I have about 60 pounds to go. I am pleased with the rate of weight loss, my energy level is good, but I’m not happy with the rate of change in my blood chemistry. I have exercised every day 30 to 45 minutes except for the last 2 1/2 weeks due to a bad cold. What should I do, or what should be my expectations?

    • http://www.potatostrong.com/ Will Kriski

      2 months isn’t that long, you’re body clears out fats (tris) so they could be in the blood. But the common problem is too much sugar, either hidden in various packaged foods, even sauces, etc as well as dried fruits, refined flours/sugars. Fructose is processed in the liver where is creates tris if the glycogen stores are full.

  • Elizabeth Rice

    This is not a diet, rather a way of eating. And, it seems to work!

  • gwn

    Can someone explain
    1) why are skim milk and egg white not acceptable for protein and vit D
    2) what do you use in place of oil or butter in pan cooking, or stir fry
    3) what do you use for salad dressing besides vinaigrette?
    Thx

    • http://www.potatostrong.com/ Will Kriski

      1) eggs and milk are not only cruel, but contain saturated fat and cholesterol which clogs arteries, and casein from dairy has been shown to promote cancer.
      2) Just fry with water or vegetable broth in a non-stick skillet
      3) I use balsamic vinegar, some people add mustard and agave/maple syrup (3-2-1 ratio), or there are raw dressings using tomatoes, mango, etc.

  • JoAnn Downey

    I dropped my fat intake to 10% of calories (22 grams of fat/2000 calories) and my cholesterol and LDL dropped 40 points. LDL-P dropped 350 points!

  • mirjack

    HOW DO WE ENSURE WE ARE GETTING ENOUGH PROTEIN ON THE STRICT ESSELSTYN EATING PLAN WE’VE BEEN ON IT FOR THREE MONTHS AND MY HUSBAND FEELS BETTER, HAS MORE ENERGY, AND DOESN’T HAVE ANY CRAVINGS. HOWEVER, HE FEELS HE IS LOSING MUSCLE MASS. I ALWAYS INCLUDE COMPLEMENTARY FOODS (OR QUINOA) IN TWO MEALS A DAY BUT HAVE NO WAY OF KNOWING WHAT’S CORRECT.
    HELP!

  • Unavieja

    After being on this diet for 6 months, I took a trip to Mexico and was compelled to eat some foods that contained a small amount of chicken and oil. Generally, I was able to adhere to the diet most of my 10 days there but at least on 3 or 4 occasions, I know I ate oil and several bites of chicken. Surprisingly, I felt healthier after that. I had lost too much weight and had been experiencing some mental confusion and was told by my Dr. that my blood readings showed that I had hyponutramia (spelling?) or below normal sodium levels. Something is not right. I’m going to have to consult with a nutritionist or dietician or something. Is this a common problem with this diet?

    • http://www.potatostrong.com/ Will Kriski

      You’re probably not eating enough, I find starch-based is best, potatoes, rice, beans, oatmeal, etc.

  • Jennie Jane

    Serious weight gain with this diet: I follow the diet scrupulously, and I love it. It is easy for me, and I feel better. But, I have to be honest: I have gained one pound a week on the diet. And I am taking in approximately 1200 to 1500 calories per day, maximum. I write down everything I eat, and I do not cheat. I am meticulous. I find this utterly astonishing (even had my thyroid tested), and I can only think that it is too many carbs. I eat grains only for breakfast. Lunch is mainly fruits and dinner is all vegetables–zero salt, zero sugar, all cooked fresh in plain water, or eaten raw. I have a doctorate degree, and I’m not stupid: I know how to do the diet exactly, and I know I have not cheated once. So I am terribly sad about this, and if I keep gaining, I’m afraid I will have to abandon the diet. Eating fewer calories than I am will render proper nutrition impossible. So if your body is as uncooperative as mine, be careful, as this diet can plump you up depressingly fast. :(

  • Chris Oppy

    I note that Dr. Esselstyn bases his “no oil” position on Colin Campbell’s work in China Study and cites Campbell as responding in 1997 that the Mediterranean diet and the rural Chinese diet are practically the same but that “the absence of oil in the rural Chinese diet is the reason for their (the Chinese) superior success.” (p 84, of Esselstyn’s book titled: Prevent and Reverse Heart Disease). Dr. Ellelstyn cites this as the logic for no oil, and I agree with Ellelstyn that oil appears the culprit and I will eliminate it from consumption….HOWEVER, if Dr. Ellelstyn intends to stand by the Campbell position as cited, he needs to adhere to the rest of Colin Campbell’s statement that the successful health results of the Mediterranean diet matches with the rest of the Chinese diet. Therefore, I plan to continue with my Mediterranean-Chinese diet (which also matches the Nathan Pritikin diet Ellelstyn raves about in his same book on p. 88) which includes nuts and limited (high quality) fish, poultry, and red meat. I note this appears to also be what Dr. Roizen, Chief wellness officer at the Cleveland Clinic, recommends if I’m not mistaken. Thank you.

  • m237b

    Would have to agree with some folks here – this diet causes significant weight gain. I have a daily log on consumed foods and must admit that even being within a range of 1000-1500 calories still causing the weigh gain. Find it it puzzling how anyone could loose any weight with this amount of carbs…

  • b665s

    I have gained weight on a plant strong diet, but I am insulin resistant and my small LDL-P has gone up on it. I am a little discourage and can’t take satins and won’t take Actos because I broke my right arm this year. I am keeping a food journal and checking to find out what foods to eat or not eat so I can lose weight. Maybe if you watch the starchy carbs you might lose some weight.

  • Great

    can you give one month Idea of what to eat for breakfast, lunch, dinner and snack on this plan