Cardiovascular Disease as Food-Borne Illness

Caldwell B. Esselstyn, Jr., MD, a distinguished Cleveland 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 significant 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, Esselstyn 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 cardiovascular 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, heritage, 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, 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 responsible 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 Teflon® acts rather than like Velcro® 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 cardiovascular disease have this disease because they have sufficiently 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 interested in your current work, which is focused on food as medicine?

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 surgery, 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 generation—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 eating, 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 patients 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 patients 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 recommend 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 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 nutrition, 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 tender, 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 alongside 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 inflammation 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 cabbage, Brussels sprouts, broccoli, cauliflower, cilantro, parsley, spinach, arugula, and asparagus. Other core foods included in the diet include whole grains, lentils, legumes, other vegetables, 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 vegetables in addition to the avoidance of foods that injure the endothelium. Obviously, it is a program that does not selectively 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 standpoint of the symptoms they had experienced, such as the disappearance of chest pain and claudication. ² It was really exciting to see these patients recognize that they were now being empowered 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 cardiovascular 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 injure 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 exciting thing is that, inasmuch as CAD is not a malignancy, it is 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 capacity 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 patients 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 empowered 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 acquiring and preparing plant-based foods and dealing with reading ingredients and with travel and restaurants. All participants 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 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.

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

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 cardiovascular 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 empowered 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 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 understand 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 autoimmune 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 identifying the impact of food in a way that can chronically injure us or heal us.   ■