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A Way To Reverse CAD
A Way To Reverse CAD
A Way To Reverse CAD
FAMILY
PRACTICE
JFPONLINE.COM VOL 63, NO 7 | JULY 2014 | THE JOURNAL OF FAMILY PRACTICE 357
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based nutrition for disease treatment. These seling seminar (9 am-2 pm) with, at most,
self-selected participants requested consulta 11 other participants. Each participant was
tion after learning about the program through encouraged to invite a spouse or partner. The
the Internet, the media, prior scientific pub 5-hour program profiled plant-based cul
lications, the senior author's book (CBE Jr), tures that have virtually no cardiovascular
other authors’ supportive comments, or word illness, in contrast to non-plant-based cul
of mouth.213 A preliminary 25- to 30-minute tures where CAD is ubiquitous (confirmed
telephone conversation established disease by autopsy of young adults).14We referenced
presentation and severity by eliciting reports the plummeting death rates from strokes and
of symptoms, history of MI, stress test and heart attacks in Norway during World War
angiogram results, interventions undertaken, II when the German occupying forces confis
family history, lipid profile, and the presence cated their livestock, limiting Norwegians to
of comorbid chronic conditions. In these plant-based nutrition.15
calls, we outlined the program, established We emphasized the cellular compo
rapport, and documented the need for ad nents and mechanisms responsible for
ditional patient information. The Cleveland vascular health: the endothelial cell, endothe
Clinic Institutional Review Board determined lial progenitor cell, high-density lipoprotein
that these were acceptable outcome mea cholesterol (HDL-C), and inhibition of di-
> surements to evaluate the nutrition program. methylarginine dimethylaminohydrolase that
The impetus fo r causes vasoconstriction. These were discussed
this study was In te rv e n tio n in considerable detail, as were nutrition strat
an earlier small We explained to each participant that plant- egies to enhance endothelial health and to
trial in which based nutrition typically succeeded in arrest avoid endothelial dysfunction and injury. Par
17 patients w ith ing—and sometimes reversing—CAD in our ticipants viewed angiograms of CAD reversal
CAD had th eir earlier study. from prior intervention participants.
disease halted I The core d ie t. Whole grains, legumes, An associate with several decades of
afte r fo llo w in g lentils, other vegetables, and fruit comprised experience with plant-based nutrition dis
a plant-based the major portion of the diet. We reassured cussed plant food acquisition (including
nutritional patients that balanced and varied plant- food label reading) and preparation. Partici
intervention. based nutrition would cover their needs for pants learned how to alter common recipes
amino acids, and we encouraged them to to meet program standards. They received a
take a multivitamin and vitamin B12 supple 44-page plant-based recipe handout, 2 scien
ment. We also advised the use of flax seed tific articles confirming plant-based nutrition
meal, which served as an additional source effectiveness,416 and, after 2007, a copy of Pre
of omega-6 and omega-3 essential fatty acids. vent and Reverse Heart Disease.2The seminar
I Foods p ro h ib ited . Initially the inter concluded with a testimonial by a prior par
vention avoided all added oils and processed ticipant, a plant-based meal, and a question-
foods that contain oils, fish, meat, fowl, dairy and-answer session. We asked participants
products, avocado, nuts, and excess salt. Pa to complete and return a 3-week diet diary
tients were also asked to avoid sugary foods following the seminar. They were invited to
(sucrose, fructose, and drinks containing communicate concerns via e-mail or phone,
them, refined carbohydrates, fruit juices, syr and to forward copies of subsequent lipid
ups, and molasses). Subsequently, we also profiles, stress tests, cardiac events, angio
excluded caffeine and fructose. grams, and interventions.
Exercise was encouraged but not re
quired. The plan also did not require the prac S tu d y d a ta acquisition
tice of meditation, relaxation, yoga, or other In 2011 and 2012 we contacted all participants
psychosocial support approaches. Patients by telephone to gather data. If a participant had
continued to use cardiac medications as pre died, we obtained follow-up medical and di
scribed, monitored by their (other) physicians. etary information from the spouse, sibling, off
■ P re-in terven tio n train in g . Each par spring, or responsible representative. Patients
ticipant attended a single-day 5-hour coun who avoided all meat, fish, dairy, and, know-
TABLE 1
Stress test 74
M yocardial in fa rctio n 44
CAD, coronary artery disease; CT, com puted tom ography; SD, standard deviation.
* Three patients had documented peripheral artery disease or cerebral or carotid vascular stenosis, but no CAD.
t Many patients had more than one test done to establish the diagnosis o f CAD.
>
The core diet
included w hole
ingly, any added oils throughout the program ent with dietary intervention. Thirteen of grains, legumes,
were considered adherent. We inquired about these patients experienced at least 1 adverse lentils, other
weight change, lipid profiles, further stress tests event each—2 sudden cardiac deaths, 1 heart vegetables,
or angiograms, major cardiac events, interven transplant, 2 ischemic strokes, 4 PCIs with and fru it, and
tions, and any change in symptoms. stent placement, 3 coronary artery bypass avoidance o f all
graftings (CABGs), and 1 endarterectom y oils, fish, meats,
for peripheral arterial disease—for a patient dairy products,
RESULTS event rate of 62% (TABLE 2 ). avocado, nuts,
Characteristics of participants sugary foods,
Baseline characteristics of participants are Outcomes of adherent CVD participants and excess salt.
shown in TABLE 1. (Two patients from the In the group of 177 (89%) adherent p a
original group of 200 were lost to follow-up.) tients, 112 reported angina at baseline and
The rem aining 198 participants for whom 104 (93%) experienced improvement or res
data were available had CVD, were mostly olution of symptoms during the follow-up
m en (91%), averaged 62.9 years of age, and period. An additional patient with claudica
were followed for an average of 44.2 m onths tion also experienced symptom relief (TABLE
(3.7 years). 2). Of adherent patients with CAD, radio-
Three patients had noncoronary vas graphic or stress testing results were available
cular disease: 1 cerebral vascular disease, to docum ent disease reversal in 39 (22%).
1 carotid artery disease, and 1 peripheral arteri Twenty-seven CAD participants were able to
al disease. In the remaining 195 patients, angio avoid PCI or CABG that was previously rec
gram results confirmed the diagnosis of CAD om m ended. Adherent patients experienced
in 180 (92%). With the other 15 participants, worse outcom es significantly less frequently
electrocardiography, failed stress tests, or a his than nonadherent patients (Pc.OOl, Fisher’s
tory of enizyme-documented MI confirmed the exact test). In addition, for 135 patients for
diagnosis of CAD. Of the 195-patient cohort, w hom body weight was available, the average
44 (23%) had an MI prior to counseling. weight loss was 18.7 lbs.
Among the 177 patients who reported
Outcomes for nonadherent adherence to the dietary intervention, there
CVD participants were 5 noncardiac deaths (3 cancers, 1 pul
Twenty-one patients (11%) were nonadher m onary embolus, and 1 case of pneum onia).
CONTINUED
JFPONLINE.COM VOL 63, NO 7 | JULY 2014 | THE JOURNAL OF FAMILY PRACTICE 359
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Also, 9 CAD patients required vascular in has been validated with a high probability
tervention: 1 CABG for disease progression, by epidemiologic studies, including those of
1 CABG for malpositioned dissecting stents wartime deprivation, our previous noncon-
placed just prior to enrollment into the pro trolled study, and both randomized and
gram, 1 stenting procedure and 2 CABGs nonrandomized controlled studies where a
before valve repair, 2 stenting procedures to similar plant-based diet was a part of a com
correct grafted artery closing, and 2 CABGs prehensive lifestyle modification in conjunc
for asymptomatic patients persuaded of the tion with otherwise standard pharmaceutical
need by their primary caregivers. Two pa medical therapy.3,15’17,18'24'26
tients experienced a nonfatal stroke (one I Large cohort studies support nu
after refusing warfarin for atrial fibrillation, In addition, 2 large
tritio n a l in terv en tio n .
the second because of progression of CVD, prospective cohort studies have recently em
and one had stent thrombosis with acute MI phasized the importance of nutrition in de
after discontinuing clopidogrel as advised by creasing the risk of recurrent CVD events in
the primary care physician. One patient had people with CVD or diabetes and decreasing
3 stents placed before entering our study; the risk of developing CVD among healthy
1 occluded at 3 years into the study, necessi individuals. Dehghan and colleagues27 fol
tating restenting (TABLE 2). lowed 31,546 participants with CVD or dia
> Thus, only 1 major cardiovascular event betes over 4.5 years and divided them into
Only 1 m ajor (stroke) was related to disease progression quintiles of nutritional quality. Reduction in
cardiovascular in patients adherent with the dietary in CVD-related risk within the healthiest quin
event (stroke) tervention. This is a recurrent event rate of tile was 35% for death, 14% for MI, and 19%
was related 0.6%. Thus, 99.4% of adherent patients avoid for stroke. They found this protective associa
to disease ed major cardiac events. This result clearly tion was maintained whether or not patients
progression contrasts with that of other key peer-reviewed were receiving medications.
in patients studies of nutrition interventions for patients Crowe and colleagues28 followed
adherent w ith with CAD617'22 (TABLE W3 at www.jfponline. 44,561 men and women enrolled in the Eu
the dietary com), although the disease burden and the ropean Prospective Investigation into Cancer
intervention. presence of comorbid conditions may not be and Nutrition. Thirty-four percent (15,151)
comparable. Even if all events had been at were vegetarians, consuming neither meat
tributable to diet, the 10% (18/177) event rate nor fish. During an 11.6-year follow-up, they
("Worse" group in TABLE 2) over an average of found vegetarians had a lower mean body
3.7 years is much below that reported in the mass index, lower non-HDL-C level, lower
literature23 and the 62% of the nonadherent systolic blood pressure, and a 32% lower risk
group. of developing ischemic heart disease.28These
combined studies of 76,107 individuals sup
port an assertion of the power of nutrition for
DISCUSSION primary and secondary prevention of cardio
This program of treating the presumed cause vascular illness.
of CAD has yielded significant findings and By way of contrast are findings associ
raised practice implications. First, and quite ated with a typical western diet. Wilkins and
compelling, is that 89% of patients were will colleagues29 assessed lifetime risk and years
ing to make a substantial lifestyle transition lived free of total CVD by reviewing data from
to plant-based nutrition and sustain it for 905,115 person-years from 1964 to 2008. They
an average of 3.7 years (for some patients assessed risk factor presence and subse
up to 13 years). Most participants saw this quent CVD. While lifetime risk estimates for
as taking control of their disease (anecdotal total CVD for all individuals was >30%, the
reports). study found that even those men and women
Second, the results of this evaluation 55 years of age with optimal risk factors had a
provide further evidence that plant-based 40% and 30% likelihood of total CVD, respec
nutrition may prevent, halt, and reverse CAD. tively, by age 85. It would appear that even
This process of halting and reversing CAD optimal risk factors are no guarantee that the
TABLE 2
Outcomes
Reversal* 39 (22)
1 Patient w ith a tria l fib rilla tio n refused w a rfa rin and suffered a n o n fa ta l
stroke.
Disease progression 4 11
1 Stroke 2 Stroke
1 Restenting* 3 CABG
1 Endarterectom y fo r PAD
1 Heart transplant
Death 5 2
N oncardiac** 5 0
Cardiac 0 2
CABG, coronary artery bypass grafting; CAD, coronary artery disease; CVD, cardiovascular disease; LIMA, left internal mammary artery; Ml, myocardial infarction;
PAD, peripheral arterial disease; PCI, percutaneous coronary intervention; PCP, primary care physician; SD, standard deviation.
* Data missing fo r 5 adherent patients and 1 nonadherent patient.
t Percentage o f 112 patients w ho complained o f angina at the start o f intervention.
* One patient w ith atrial fib rilla tio n had documented angiographic reversal after 5 years in the study, then refused w arfarin 2 years after last angiogram and
suffered a nonfatal stroke.
§ Adherent patients experienced worse outcomes significantly less frequently than nonadherent patients (P<.001, by Fisher's exact test).
H One patient enrolled into the program w ith malpositioned dissecting stents th a t required CABG.
* Before study enrollment, the patient had 3 stents placed; one occluded at 3 years in th e study and was restented.
* * Includes 3 cancer-related deaths, 1 fatal pulmonary embolism, and 1 case o f pneumonia.
JFPONLINE.COM VOL 63, NO 7 | JULY 2014 | THE JOURNAL OF FAMILY PRACTICE 361
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typical western diet won't eventually result at most 10% ("Worse" group in table 2 ). An
in CVD. additional 27 counseled participants did not
I W h y are our results particularly fa require previously recommended interven
vorable? While nutritional modification is tions. These data on required interventions
beneficial, the question remains whether it and interventions recommended but found
has been optimized to its fullest potential in to be unnecessary (146/177; 82%), testify to
other studies. First, no other nutrition study the severity of illness in this cohort and il
has completely eliminated oils (including lustrate the remarkable comparative lack of
food products that may contain even small subsequent cardiovascular events in the 89%
quantities of added oil of any kind), and who complied with plant-based nutrition.
all animal, fish, and dairy products, which I Less need fo r stenting? The prompt
would avoid foods known to injure endo improvement (within 3 weeks) confirmed
thelial cells, as well as exogenous cholesterol by PET scan documentation of myocardial
and saturated fat. In avoiding exposure to reperfusion ( figure 1 ), resolution of angina,
lecithin and carnitine contained in eggs, milk and angiographic evidence of disease rever
and dairy products, liver, red meat, poultry, sal ( figure 2 ) demonstrated in our earlier
shellfish and fish, participants in our study studies involving plant-based nutritional in
were unlikely to have intestinal flora capable tervention argue against elective deployment
> of producing trimethylamine oxide (TMAO), of stents for reperfusion. Successful nutri
For adherent a recently identified atherogenic compound tional treatment of CVD, coupled with stan
participants, the produced by the intestinal flora unique to dard medical therapy, may extinguish major
adverse event omnivores that ingest animal products.30'32 cardiac event progression in the vast majority
rate was, at (Vegans do not possess the detrimental bac of patients.
most, 10% . terial flora.) I Enabling th e body to correct h arm
A second reason for our favorable results fu l processes. Future discoveries may help to
is the intensive, single-day, 5-hour counsel explain why plant-based nutrition is so effec
ing seminar that conveyed the message of tive, yet we can postulate likely mechanisms.
nutritional intervention with depth, clarity, When foods that injure or cause endothelium
power, and completeness through a Power dysfunction are avoided, the body readily
Point presentation, recipe handouts, books, restores the capacity of endothelial tissue to
video, strategies for plant food acquisition produce nitric oxide. Such change reduces
and preparation, and testimonials by prior production of vasoconstricting endothelin
participants. Thus informed, participants and thromboxane by injured endothelial
grasped in detail the importance of the endo cells.
thelial cell and its product, nitric oxide. They Our insistence on daily ingestion of gen
were educated to fully comprehend which erous portions of green leafy vegetables fa
foods injure endothelial cells and how tran vors an improved population of endothelial
sitioning to a whole-food, plant-based diet progenitor cells.33 Moreover, reductions in
empowers them as the locus of control to halt lipid, homocysteine, and triglyceride levels
and potentially reverse their disease. The pre and insulin resistance enhance dimethylar-
seminar phone consultation, the seminar ginine dimethylaminohydrolase to enzymati
itself, and follow-up psychological support cally reduce asymmetric dimethylarginine
resulted in an adherence of 89% during this and optimize nitric oxide synthase avail
3.7-year-long follow-up. ability in nitric oxide production. The blood
We believe food may be the most im level of HDL-C may decrease with this anti
portant lifestyle factor in establishing the inflammatory, plant-based nutrition. Never
presence or absence of disease.15,2426 The theless, the efflux capacity of HDL-C may be
adverse event rate among nonadherent par unrelated to blood concentration and could
ticipants was 62%. For adherent participants be significantly enhanced by the interven
(119 experienced intervention prior to coun tion to enable disease arrest or reversal.34,35
seling: 75 had PCI with stent placement, and Consumers of plant-based nutrition do not
44 suffered MI), the adverse event rate was harbor the intestinal flora unique to om-
nivores that enables production of proath- disease initiation and progression, these in
erogenic TMAO. The standard nutritional, terventions do not address disease causation.
pharmaceutical, and surgical interventions Not surprisingly, most patients experience
of present cardiovascular medicine may disease progression, more drugs, more im
not sufficiently address these protective aging, repeat interventions, progressive dis
mechanisms. ability, and, too often, death from a disease of
■ This study had several lim itatio n s. western malnutrition, the cause of which has
First, it included self-selected, very deter been largely left untreated. We have in press
mined patients. Without a control group, it several patient experiences that exemplify
is challenging to establish causality and as the repeated failure of present-day cardiac
sess how much of the observed changes are drugs and procedural interventions, and that
specifically due to the diet. Only some of confirm the capacity of whole-food plant-
the observed beneficial outcomes may have based nutrition to restore health in “there is
been due to the diet. This study was not pro nothing further we can do” situations.36
spectively randomized. Nevertheless, this In summary, the present cardiovascular
fact does not detract from proof of concept medicine approach tested beyond 40 years
that major cardiovascular events occurred can neither cure the disease nor end the epi
in probably <T% (and certainly <10%) of the demic and is financially unsustainable. The
entire adherent cohort, compared with 62% safety, diminished expense, and prompt, >
of the nonadherent cohort (TABLE 2). These powerful, and persistent results in treating The present
data convey a strong message of patients the cause of vascular disease by whole-food cardiovascular
accepting empowerment to be the locus of plant-based nutrition offer a paradigm shift medicine
control to arrest their disease and confirm from existing practice. We think the time is approach can
that patients will adopt a significant lifestyle right for a controlled trial. But in the m ean neither cure the
transition to plant-based nutrition to halt time, the data are sound and strong enough disease nor end
and regress what we believe is a largely food- that patients should be informed of this the epidemic
borne illness. option. DFP and is financially
The past several decades have witnessed unsustainable.
a substantial and sustained reduction in
CORRESPONDENCE
CAD. Nevertheless, CAD remains the number Caldwell B. Esselstyn Jr MD, The Wellness Institute, The
one killer of women and men in this country. Cleveland Clinic, 1950 Richmond Road, TR2-341, Lyndhurst,
OH 44124; aesselstyn@aol.com
Thousands of stable patients having stents
ACKNOWLEDGEMENTS
experience no reduction in major cardiac We are g ra te fu l to all participants in th e program ,
events.1234567While drugs have some effects on Jacqueline Frey, Ann Crile Esselstyn, and Jim Perko.
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N EW
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