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Plant-based diet to save the heart

Print edition : Jan 06, 2001 T+T-
Interview with Dr. Caldwell B. Esselstyn.

"Food, and not merely meditation or exercise, is the key to avoiding coronary artery diseases," says Dr. Caldwell B. Esselstyn of the Cleveland Clinic Foundation, United States. "A low-fat vegetarian diet, free of meat, eggs, dairy products and oi ls," he says, "can make you virtually heart-attack-proof. This also saves your colon, prostate and breast, apart from eliminating diabetes, hypertension, obesity and stroke." He cites certain communities such as North Mexican Indians and Papua Highlander s in New Guinea that have not known heart diseases - not because of meditation or exercise but because of their plant-based vegetarian diet.

The World Health Organisation (WHO) estimates that by 2015 deaths due to heart diseases will double in India, and by 2025 India will have 57 million diabetes patients - the highest number for any country. It also estimates that the risk of coronary arter y disease for Indians is three to four times higher than that for Americans, six times higher than that for the Chinese and 20 times higher than that for the Japanese. Dr. Esselstyn's message, which comes after a 12-year scientific study, published in th e American Journal of Cardiology in 1997, the longest study of its kind, is that low-fat vegetarian diet and cholesterol-lowering medication are the most effective ways of stopping the progress of coronary artery diseases.

Trained in the U.S. and the United Kingdom, Dr. Esselstyn now heads the Department of Thyroid and Parathyroid Surgery. He was a captain in the U.S. Medical Corps and served as an army surgeon in Vietnam. He was the president of the Cleveland Clinic Found ation's medical staff (1977-78) and the chairman of the Breast Cancer Task Force of the foundation. He was also on the foundation's Board of Trustees and Governors (1979-1984).

The important posts he held in the U.S. include the chairmanship of the Society of Surgical Oncology (1989-90) and the presidentship of the American Association of Endocrine Surgeons (1990-91). He chaired and organised the first two major national confer ences in the U.S. - one in Tucson, Arizona, on the elimination of coronary artery disease (1991), and the other in Orlando, Florida, on lipids in the elimination and prevention of coronary artery disease (1997). He has published over 150 scientific artic les and was in 1994-95 on the list of Woodward-White Publishers' "The Best Doctors in America".

In 1985, frustrated that preventive medicine was not effective enough in the case of coronary artery diseases, a major killer worldwide, he initiated the study on ART (arrest and reversal treatment) therapy. He published his findings - now his message ac ross the world - in 1990, and updated them in 1997, after 12 years. According to experts, his findings are most compelling as not one of the patients under study had a coronary event during the study period.

Dr. Esselstyn was recently in India as part of a lecture tour across Asia, where heart diseases are on the rise. In Chennai, he spoke to Asha Krishnakumar on coronary artery diseases and the associated risks explained in his research findings. Exc erpts from the interview:

What is the significance of your 12-year research work, which is said to be one of the longest such studies in medical literature?

The theory on which our research was based was that there are many races and people from obscure lands - such as the people of rural China, the Papua Highlanders in New Guinea, Central Africans, the villagers of Okinawa and North Mexican Indians - who ha ve not heard of coronary heart diseases. This was primarily related to their lives, culture and tradition, which revolved around their food habits - of relying on plant-based diet. This is surely the healthiest diet on earth, and this is what I used on s ome of my patients who were severely affected by coronary heart disease. I also used some modest amounts of cholesterol medication on them. The idea was to reduce their cholesterol levels to that of the people in those places where the disease is non-exi stent. (In India the ideal cholesterol level, that of low-density lipoprotein, or LDL, could be 130.)

I started with 24 patients (23 of them men), all very ill; many of them had been told to go home to wait for death. I studied them and summarised the results first for five years, and then for 12 years which, I believe, makes it the longest such study in medical literature. They started with an average cholesterol level of 227, after five years the average was 137, and after 12 years 145. This again, makes it the lowest cholesterol level attained in any such study.

Did all the 24 patients remain with you till the end?

I knew within 12-15 months of the start of the study that six of them were not cooperative as they did not understand the consequences and, hence, I asked them to withdraw but the understanding was that they would return to their cardiologists for standa rd cardiac care. But their health deteriorated in the 12 years - four had a new bypass, one had another angioplasty, and the sixth died.

But the 18, who had 49 coronary events in the eight years before the study, stayed with me and met the goals of the study. After 12 years, 17 of the 18 had no coronary event. One sheep, which wandered away from the study after six years, suffered more of the disease and is now back with the flock after a by-pass.

So, the message from the study, more for the U.S. than for India, is that there is no need to go in for the expensive bypass surgeries if only we took care of our diet - no oil, no dairy and animal products. It may not be difficult to follow this diet if you have the support of people who would creatively show you how to avoid these food products and still come out with some marvellous dishes just with plant-based products.

What are the risks associated with coronary heart diseases?

Apart from the bad diet I spoke about, which is the main culprit, high blood pressure, over-weight, family history, diabetes and so on are the risk factors of coronary heart disease. But, if your cholesterol is between 125 and 130, I don't care how much you smoke, what your blood pressure is, what your family history is and whether you are fat or not. So long as you do not build on the building blocks, that is, bad diet, the other risk factors would not hasten the process of the disease or make it inten se. It always falls back on the key issue - the diet. That is the story in a nutshell.

Why is the number of people with heart diseases on the rise?

There is a surge in the numbers. Globally, it was 1.1 million in 1990, but now it is over 1.5 million. Change in dietary habits is the key issue. But without doing something about it we look to expensive bypass, artificial heart and so on for solutions. Ten years ago the U.S. media played up the news of artificial heart transplant - there were big, attractive pictures of the man with the artificial heart with wires and the machine. The television and the print media flashed a lot of stories. But all tha t is a worthless piece of junk if you realise how easily it could have been avoided.Bypass surgery or angioplasty merely treats the symptoms and not the disease. Interventional processes are like what a plumber does to set your tap right for the moment.

What motivated you to do this study?

In the 1970s, I was chairman of the Breast Cancer Task Force in the Cleveland Clinic Foundation. I was getting disillusioned with what I was doing for breast cancer. Whatever I was doing - mastectomy, partial mastectomy - I was doing nothing to protect t he next unsuspecting victim from this disease. And, at that point, I began looking at the world literature for epidemiological study of this disease.

I found that in Kenya it was 20 times less frequent than it was in the U.S. and even in the 1950s it was practically unheard of in rural Japan (but for those who migrated to the U.S., their second generation has the same incidence of breast cancer as the ir Caucasian counterparts). In 1958, in the whole of Japan there were only 18 breast cancer deaths. In the U.S. 180,000 cases were diagnosed this year. I know that in my lifetime there is no way I can save these patients with cancer.

But coronary heart disease is different - it can be arrested and even stopped. My feeling was that by resorting to proper dietary habits people would not only be saving their hearts, but also their colon, prostate and breast. They also eliminate diabetes , hypertension, obesity, stroke and many such things. It is important to understand that every time we take in ghee or oil, we sustain an irreversible injury that would accumulate and lead to a point when you land with grievous diseases and end up with h eart attack or cancer. Thus, I conducted this study and took up propagating this as my life's mission.

How is your prescription different from that of Dr. Dean Ornish?

He and I are good friends. Both of us agree that there are different ways of dealing with the problem. Dean propagated meditation and structured exercise. I think these are somewhat helpful. But my contention (which is where we differ) from all my resear ch of the nations that did not have the disease is that the disease was not there in these nations not because they were involved in deep meditation every day or because they all have training in some personal exercise regimen. It was not there because b y culture, heritage and tradition these people did not put into their mouths anything that is a building block for this disease. And my concern was if I asked my patients to be committed to meditation twice a day, structured exercise and the significant nutritional changes, people would not be able to comply with. This was simply because each one of us has only a limited number of behavioural modification units within us.

Dean published after five years and stopped. His 20 patients had 25 new coronary events. This is because he did not use cholesterol-reducing drugs and also had them doing too many things. It is not as if people who cannot exercise (as in the case of thos e with a stroke) or are not inclined to meditate cannot arrest or reverse the coronary disease. My study shows that the single most important factor to stop the disease's progress is to avoid totally oil, dairy and meat products.

What is the primary goal of your treatment?

Our main aim is to stop the disease from progressing. With our diet prescription and medication, our cholesterol patients showed remarkable progress as shown by the follow-up angiograms (done by trained technicians in our laboratory), taken in triplicate s with a gap of six months so that there would be no bias of recall. For instance, in a 67-year-old pediatrician there was a 10 per cent improvement within a six-month period; for a 58-year-old factory worker, there was a 20 per cent improvement in the s ame period; and in a 54-year-old security guard there was a 30 per cent improvement in the same period.

What is the mechanism? How do you get these results?

Cholesterol and triglycerides are the types of fats that lead to atherosclerosis (fat deposition) in the cells lining the inner blood vessel wall to form a plaque. This causes the narrowing of the cavity of the blood vessel. Atherosclerosis does not happ en suddenly, but progressively and blocks the blood vessel.

Of those who get heart attacks, the disease blocks off the functioning of the heart progressively only in 15 per cent of the cases. This is because when the disease progresses slowly, you tend to build up tiny collaterals around it. Not enough to ward of f the disease but enough protection to slow down the process of complete blocks. You may not have a heart attack but you may still have angina.

Most heart attacks occur suddenly as symptoms do not occur with 20-50 per cent blockage. Only when the blockage is 70 per cent do symptoms start showing up. The bad cholesterol accumulated in the cells which have blocks begin to manufacture enzymes that thin the cap over the plaque. Thinning mostly occurs at the upper end where the shoulder of the plaque meets the wall of the artery. The enzyme then erodes the plaque, ruptures it and blood flows through it. This activates platelets. And, in a matter of minutes you get a little crack, which leads to a severe heart attack in no time. Thus, as the disease has not grown slowly there is no collateral to prevent heart attacks.

What we do in our treatment is to thicken the cap and shrink the plaque. So long as the cap is thick you cannot rupture the plaque, no matter what happens. That is why our prescription is very successful.