Cardiovascular Disease
as Food-Borne Illness
Caldwell B. Esselstyn, Jr., MD
Caldwell B. Esselstyn, Jr., MD, a distinguished Cleve-
land Clinic (Lyndhurst Ohio) surgeon for more than 30
years and an Olympic gold medalist in rowing, shifted
gears in his career to help people with cardiovascular
disease reduce and even reverse this disease through sig-
nificant dietary changes. While some people may view his
dietary recommendations as radical, Dr. Esselstyn argues
that the typical Western diet should be considered radical.
Highly recognized and awarded for his current work, Es-
selstyn talks in this column about his observations while
working with people with coronary artery disease and how
using food as medicine is helping people heal.
Q: Referring to cardiovascular disease as a food-borne
illness is a shift in thinking for many people. Would you say
more about this stance?
Caldwell B. Esselstyn, Jr. : I have always maintained that
coronary artery disease [CAD] is really nothing more than a
food-borne illness, because, when one thinks about it, it need
never exist, and if it does exist, it need never, ever progress.
There are people on this earth who will never have cardio-
vascular disease, nor will they ever have to worry or think
about it. Who are these people? Let us start with the Okinawans
or the Papua Highlanders in New Guinea, or people in rural
China or central Africa, or the Taraumara Indians in northern
Mexico. The common denominator of all these protected
cultures from cardiovascular disease is that, by culture, heri-
tage, and tradition, they all consume a whole-food and plant-
based diet.
It is an extremely provocative realization that the leading
killer of women and men in Western civilization, heart disease,
does not even exist in other cultures. We need to realize that we
are never going to “right the ship” with drugs and imaging and
procedures alone, which can have high costs, high morbidity,
high mortality, and absolutely nothing whatsoever to do with
the causation of the illness.
Q: In your writings, you state that so many Western
diseases, such as stroke, heart disease and type 2 diabetes,
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OCTOBER 2015
are diseases of “nutritional extravagance.” Would you
please share more about this?
Dr. Esselstyn: If we consider CAD as an example, wherein
all experts would agree that this disease has its inception when
we injure and compromise the capacity of the life jacket and
the guardian of our blood vessels, and that is the innermost
layer of the arteries, the endothelium. The endothelium is re-
sponsible for making an absolutely magic molecule of gas that
protects us all, and that molecule is nitric oxide. What are the
functions of nitric oxide? Number one, nitric oxide prevents all
of the cellular elements in the bloodstream from getting
“sticky.” It keeps the blood flowing like TeflonÒ acts rather
than like VelcroÒ acts. Number two, nitric oxide is the
strongest vasodilator in the body. That is to say, when a person
climbs stairs, the arteries to the heart and legs widen or dilate.
Number three, nitric oxide will prevent the walls of the arteries
from becoming thickened, stiff, or inflamed. It protects us from
having hypertension. Number four—and this is key—a safe
and adequate amount of nitric oxide will prevent a person from
developing vascular blockages or plaque.
So, literally, most people on the planet who have cardio-
vascular disease have this disease because they have suffi-
ciently trashed, injured and compromised the ability of their
endothelial cells to make nitric oxide and they simply do not
have enough to protect themselves from making plaque.
Early studies of our GIs [military personnel] at an average
age of 20, when they were autopsied in Korea, have shown that
* 80% of these people had gross evidence of CAD that was
visible without a microscope—not enough CAD for cardiac
events yet, but the disease was already established. Similar
studies were repeated 45 years later, this time looking at people
in the United States between the ages of 17 and 34 who have
died of accidents, homicides, and suicides. In these studies, it
was found that the disease was ubiquitous—again, there was
not enough disease for cardiac events yet. Sadly, when a
person graduates from high school in the United States, that
graduate gets a diploma and has a foundation for heart disease.
Q: Would you share with us how you became inter-
ested in your current work, which is focused on food as
medicine?
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Dr. Esselstyn: It was in my role as Chairman of the Breast
Cancer Task Force at the Cleveland Clinic in the late 1970s
that I became increasingly disillusioned with the fact that, no
matter how many women for whom I performed breast sur-
gery, I was doing absolutely nothing for the next unsuspecting
victim. This led to a bit of global research on my part, and it
was quite striking to see that breast cancer-rates in places such
as Kenya were 30 to 40 times less frequent than in the United
States. In rural Japan in the 1950s, breast cancer was identified
very infrequently. Yet, as soon as the Japanese women would
migrate to the United States, by the second and third genera-
tion—and were still completely Japanese Americans—they
now had the same rate of breast cancer as their Caucasian
counterparts.
What was perhaps even more powerful was the rate of cancer
of the prostate in the nation of Japan. How many autopsy-
proven deaths were there from cancer of the prostate in 1958 in
the entire nation of Japan? About 18 men died from prostate
cancer. By 1978, 20 years later, there were up to 137 deaths,
which still pale in comparison to the 28,000 men who will die
this year in the United States from prostate cancer.
At the same time, I began researching the link between
nutrition and cardiovascular disease, because here was a
disease that was the leading killer of women and men in
Western civilization and yet was literally nonexistent in many
of the other cultures that I have mentioned. It seemed that, if
we could persuade people to eat plant-based diets to save their
hearts, at the same time, these people might also be saving
themselves from other common diseases, including breast,
prostate, colon and pancreatic cancer. It was a matter of
saying, “look, if the reason that these other nations do not
have cardiovascular disease is because of what they are eat-
ing, then we should be able to make some modifications in the
Western diet for better health.” It would seem that would be a
legitimate way of seeing if we could halt and even reverse this
disease.
So, I began working with a small group of people initially
because I was still involved with obligations from my surgical
responsibilities. As sick as this small group of 22 original pa-
tients was, it was really quite striking that they all had severe
triple-vessel CAD, and the majority of them had also had either
stents, angioplasties, or bypasses. Five of the original 22 pa-
tients were told by their cardiologists that they would not live
out the year. However, under the direction of my nutritional
program, all 5 of those people have survived for close to 20
years now. It was really quite exciting to see how powerful,
how rapidly and, most importantly, how enduring the benefits
can be from dietary change.
Q: What are the main dietary principles that you rec-
ommend to people that you work with, such as what to leave
out and what to include in order to restore proper function
to the endothelium?
Dr. Esselstyn: My main goal in working with patients is that
I want to see them diminish or get rid of their chest pain or
angina literally within days, because, then, several things
ALTERNATIVE AND COMPLEMENTARY THERAPIES  OCTOBER 2015
happen. Not only are these patients getting better but also this
approach absolutely hooks them. They suddenly realize that
they have been stammering and staggering along for months
and years with pills and procedures, and now, suddenly, as
these patients concentrate on whole-food, plant-based nutri-
tion, they are getting relief from their pain.
One thing that hastens the healing process along is focusing
on greens. Here, I am a bit of a fussbudget, I confess, a
taskmaster, but not quite as mean as I look. If patients can
recognize and somehow get their heads inside their arteries,
these patients would see that plaque is an absolute caldron of
oxidative inflammation. Therefore, we need antioxidants
from food sources. If one wants to put raspberries, blueberries
and strawberries on one’s cereal, that is wonderful, but I
believe there is nothing that will trump the antioxidant benefit
of green leafy vegetables. Therefore, I want these patients to
include, six-times-a-day, green leafy vegetables that are the
serving size of a fist and have been cooked in boiling water for
5.5–6.0 minutes. That way, the vegetables are nice and ten-
der, and patients may anoint the vegetables with several drops
of delightful balsamic vinegar, because vinegar has been
shown to enhance the enzyme nitric oxide synthase, which is
within the endothelial cell and responsible for manufacturing
nitric oxide.
The antioxidant vegetables are those that are high in what we
call ORAC—oxygen radical absorptive capacity—value. I
want these patients to chew the green leafy vegetables along-
side their breakfast cereals. Then again, I want the patients to
consume the vegetables as midmorning snacks, with lunch, as
mid-afternoon snacks, at dinnertime, and then as even evening
snacks of kale. What is this accomplishing? All day long a
person is basking and bathing that oxidative caldron of in-
flammation with nature’s most powerful antioxidants.
What are the specific green leafy vegetables that I am talking
about? Specifically, bok choy, Swiss chard, kale, collard
greens, beet greens, mustard greens, turnip greens, Napa cab-
bage, Brussels sprouts, broccoli, cauliflower, cilantro, parsley,
spinach, arugula, and asparagus. Other core foods included in
the diet include whole grains, lentils, legumes, other vegeta-
bles, and fruit.
When working with patients with cardiovascular disease, my
plant-based dietary program also includes the elimination of all
added oils as well as any food that comes from animal sources,
such as meat, fish, chicken, fowl, turkey, and dairy foods—
milk, cream, butter, cheese, ice cream and yogurt. I am also
very fussy about having people watch their sugar intake, and I
also do not like my patients to consume caffeine and coffee.
When removing foods that injure the endothelial cells, we
often see these cells respond in some patients—literally, as
promptly as within 3 weeks. Positron-emission tomography
scans can show that an area of heart muscle that was previously
very poorly perfused with blood—within 3 weeks of a patient
being on the plant-based nutrition—can be restored. So that,
again, is why it is so important to include green leafy vegeta-
bles in addition to the avoidance of foods that injure the en-
dothelium. Obviously, it is a program that does not selectively
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treat only the arteries to the heart, but treats the arteries all over
the body as well.
Q: You have since worked with many patients with CAD
on the process of significant dietary change. Would you tell
us about that experience and the health outcomes that you
have observed?
Dr. Esselstyn: We have treated hundreds of patients with
CAD now, and, last July, we wrote about 198 of them and their
experiences.1 In our small original study, we had shown rather
dramatic evidence of CAD reversal, both from the standpoint of
the blockages that these patients had, and also from the stand-
point of the symptoms they had experienced, such as the disap-
pearance of chest pain and claudication.2 It was really exciting to
see these patients recognize that they were now being empow-
ered as the locus of control to halt and to reverse their disease.
The criticism of our initial study,2 however, was that it was
quite small and that it was not feasible to expect that a larger
group of patients would be able to follow the program or have
the same results. So, we studied a larger group of 198 patients
who were also receiving conventional cardiac care.1 Of these
participants, 177 (89.3%) were compliant with our nutritional
program—almost 90% compliance—and I think that is very
striking in terms of behavior modification. Among the compliant
patients, 104 of 112 participants who reported angina at baseline
experienced reduction or elimination of symptoms during the
follow-up period. Other results included imaging evidence of
disease reversal, a significantly lower rate of recurrent cardio-
vascular events, and weight loss (an average of 19 lbs).
It is quite apparent that one can stop
this disease in its tracks if one is able
to achieve compliance.
It is quite apparent that one can stop this disease in its tracks
if one is able to achieve compliance. That, in and of itself, I
think, is worthy of some comment, because when one is doing
behavior modification, next to religion and sex, there is probably
nothing as personal as food. Patients have to understand that
there are certain foods that—every time these foods pass these
patients’ lips—are absolutely going to decimate, trash, and in-
jure further and compromise the ability of the endothelial cells to
give these patients protection.
It’s important to point out that there is no question that, in the
middle of a heart attack, stents may be absolutely lifesaving
and save a lot of the heart from further injury. However,
thousands of patients in studies now have shown clearly that an
elective stent—simply because a person has cardiovascular
disease that is not an emergency—does not prolong life, and
does not protect a patient from a future heart attack. The ex-
citing thing is that, inasmuch as CAD is not a malignancy, it is
196 MARY ANN LIEBERT, INC.  VOL. 21 NO. 5
really quite amazing how rapidly the beaten-down, poor old
endothelial cells can begin to recover and respond through
nutritional change. Therefore, we find that, when counseling
these patients, it is absolutely key that they understand fully
that the reason they developed this disease in the first place is
that their endothelial cells are no longer functioning at a ca-
pacity that will allow them to protect themselves. Once these
patients get this concept in their heads and make the transition,
their bodies respond rapidly.
Q: How do you help patients make radical dietary
changes?
Dr. Esselstyn: Clinicians have to show respect to their pa-
tients in order for them to be compliant. The only way that I know
to show a patient respect is to give them my time. Given that
> 80%–85% of our patients come from outside the state of Ohio,
they can only stay for a few days at a time. Our teaching team felt
obligated to synthesize a teaching seminar of 1 single day of 5.5
hours. Participants would receive all of the information that we
thought was essential. They would learn what they had done that
created their disease and precisely how they each could be em-
powered as the locus of control to halt and to reverse the disease.
At the same time, we felt that every person should have a
very hefty notebook that had a copy of every one of my
PowerPoint slides, several of our scientific articles, a 44-page
handout with many recipes that add to the 220 that are in the
two books that we provide. Participants also learn about ac-
quiring and preparing plant-based foods and dealing with
reading ingredients and with travel and restaurants. All par-
ticipants also receive a DVD of an earlier seminar that we
filmed, so when that they go home and get a little rusty on some
aspect, they can view this and get themselves back up to speed.
Then, we always have 2 or 3 local or regional participants who
have had a previous successful experience share their stories.
This way, the people in attendance can say to themselves,
“listen, if he or she can do this, I can do this.” Then we answer
questions, have a delightful plant-based luncheon, and stay in
touch as necessary, either through e-mail or phone calls.
The other thing that is so important is that my secretary will
give me a list of all the participants, and about 2 weeks prior to
the seminar, I call every one of them, so that I can get totally
grasp their stories. At the same time, these patients have an
opportunity to ask me questions, so that, coming to the seminar,
we have a strong platform from which we can all move forward.
We usually hold these teaching sessions for no more than 10 or
12 patients in this seminar. We do insist, whenever possible, to
have the significant other or the spouse attend; and they come for
free, because both parties have to understand what is going on
and why we are asking patients to make certain changes.
Q: Do you think more clinicians are embracing the view
of the importance of a plant-based diet?
Dr. Esselstyn: Right now, many medical training programs
schools are still fixated on “pharmageddon,” learning all about
pills and medicines—and these are not the ultimate answer to the

To Contact Dr. Caldwell B. Esselstyn, Jr.
Caldwell B. Esselstyn, Jr., MD
Cardiovascular Disease Prevention and Reversal Program
Cleveland Clinic Wellness Institute
Cleveland Clinic
1950 Richmond Road
Lyndhurst, OH 44124
Phone: (216) 448-8556
Website: www.dresselstyn.com
chronic illnesses we see. It is lifestyle change that will make the
difference. The current conventional approach to cardiovascular
disease cannot cure patients and will never end the epidemic.
It is absolutely a mistaken belief that patients will not make
the transition to whole-food, plant-based nutrition. It is not that
the message is wrong. It is how the message is articulated. I
also think it may be a little bit unfair of me to ask our car-
diovascular colleagues to shoulder the burden of this transition.
They have busy schedules, may not have the passion for this
approach, and certainly many of these colleagues have no
training in nutrition or behavior modification. Rather, those
of us in lifestyle medicine welcome the opportunity to work
synergistically in the spirit of cooperative endeavor with our
cardiovascular colleagues to help their patients become em-
powered to halt this disease.
I think we are at a point now where it is totally, in my opinion,
unconscionable not to mention this option to patients, or to say
that significant dietary change is extreme. When a person says
that what we are doing is extreme, strict, or draconian, I think
that is absolutely false, because the truth is that the nutrition that
is most extreme, strict, draconian, and problematic is the one
that 97% of Americans are eating today. It is giving us this
epidemic of illness that does not exist in other places.
Fortunately, things are different now, compared with 30
years ago. There is no question that there are lot of young,
bright people who have really begun to embrace this approach
and others who recognize the frustration of what they have
been taught earlier, and it really changes the whole landscape
and the horizon.
Q: Do you have any final advice for clinicians regarding
treatment of CAD with a plant-based diet?
Dr. Esselstyn: When you have done this type of nutritional
work for years, you suddenly realize that the ultimate seismic
ALTERNATIVE AND COMPLEMENTARY THERAPIES  OCTOBER 2015
revolution in health, if you were to argue that we are on the
cusp of that, will come about not through the invention of
another pill, procedure, or operation. The seismic revolution in
health will come about in the United States when we in the
health profession begin to share with patients what is the
healthiest lifestyle. The primary message is to have them un-
derstand nutritional literacy, whereby they will be empowered
not only to halt cardiovascular disease and strokes and obesity
and hypertension and diabetes, but also other diseases, such as
diverticulitis, osteoporosis, asthma, and a host of other auto-
immune diseases. It is almost frightening to think that this
answer is so simplistic, safe, inexpensive, and enduring.
Following a typical Western diet is a great way to eat if a
person wants to live just until the “warranty period” or about 25
years of age. For people who want to go beyond 25, the way I
look at it is that one does not suddenly develop hypertension or
type 2 diabetes or obesity when they are 35 or 40 years of age.
What happens is that every time certain foods pass a person’s
lips, the person takes a hit and it causes injury. Now, the body is
remarkable. It will heal perhaps 80%–90% of that injury.
However, the person is left with that 10% deficit or injury,
which continues to accumulate in a painless fashion until we,
as physicians, now identify those accumulated hits or injuries,
and we give them names, such as hypertension or diabetes or
CAD.
It is very exciting for me to see that, as patients follow this
program, cardiovascular disease and other diseases that people
are struggling, with literally melt away. We are treating disease
with something that is so ridiculously simple. We are identi-
fying the impact of food in a way that can chronically injure us
or heal us. n
References
1. Esselstyn CB Jr, Gendy G, Doyle J, et al. A way to reverse CAD? J Fam
Pract 2014;63:356–364.
2. Esselstyn CB Jr, Ellis SG, Medendorp SV, et al. A strategy to arrest and
reverse coronary artery disease: A 5-year longitudinal study of a single
physician’s practice. J Fam Pract 1995;41:560–568.
Caldwell B. Esselstyn, Jr., MD, is the director of the Cardiovascular Disease
Prevention and Reversal Program at the Cleveland Clinic Wellness Institute of
the Cleveland Clinic in Lyndhurst, Ohio.
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