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A New Cardiovascular Approach: Eating for Life

Caldwell B. Esselstyn Jr., MD | 11/06/05

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Plummeting cholesterol numbers and reversals of coronary cartery disease come down to one thing: There's no cheating on this diet developed by Caldwell B. Esselstyn Jr., MD.

When it comes to heart disease, Caldwell B. Esselstyn Jr., MD, says moderation kills. So he plays diet hardball. There's no ice cream, peanut butter or meat. No oil, cheese or doughnuts. Not even a dollop of whipped cream or mashed potatoes and gravy on Thanksgiving.

No compromises, no exceptions. Giving in, even just a little, is like pouring gasoline on a brushfire.

"Oil, dairy and meat are atherosclerotic linchpins," says the 67-year-old Cleveland Clinic surgeon, who has committed the past 17 years to preventing and reversing heart disease. "We must eliminate the lethal phrase, 'this little bit won't hurt.' "

No one is immune to Dr. Esselstyn's mantra. Not even Dick Cheney, vice president-elect. Following Cheney's recent heart attack -- his fourth -- Dr. Esselstyn felt compelled to write to him: "We are dumbfounded by your 40-pound weight gain since the Gulf War, smoking up to two years ago, and your reference to getting home to a Thanksgiving dinner and all the trimmings upon your hospital discharge. ... You are still eating the very building blocks of heart disease.

But even as Dr. Esselstyn plays hardball, he does so with a soft edge. "I am an uncompromising but caring presence," he says. He eats the way his patients eat. He calls them, carefully monitoring progress. He insists that spouses participate. He has them over for dinner, sharing recipes and encouragement with those who choose to live by the rules. And when they fall off the wagon, he's there to pick them up. Perhaps that's the secret to his 15-year patient success rate.

"The thing about Esse," says Abraham Brickner, PhD, former director of the Office of Health Services Research and Program Development at the Cleveland Clinic and an Esselstyn diet follower, "he is single-mindedly focused. He is not deterred from his position, and his patients are ready to jump out the window for him."

Dr. Esselstyn says compliance has been the key to success. "When they see their [cholesterol] numbers going down and feel their angina disappear, they are able to stick with it," he says. For Dr. Brickner this is true. His cholesterol dropped from 235 to 123. But he moved grudgingly toward this diet. It took Dr. Esselstyn's hand-holding to get him past the cravings and ready to maintain the diet on his own.

The way Dr. Esselstyn's patients tell it, they succeed because he gives them a chance at life -- a chance that far outweighs previous predictions.

Take Evelyn Oswick, a communications professor at John Carroll University near Cleveland. After her second heart attack, her cardiologist gave her little hope. "He told me to go home and wait to die. But he did tell me about a doctor starting a research program," says Oswick, referring to Dr. Esselstyn.

"Esse came to talk to me and at first I thought, I'll never do this. I love my chocolate and desserts. But I thought about it for a couple weeks, and I really didn't want to die. When I showed up, Esse laughed and said, 'You're the last person I expected.' "

Oswick was one of the first to join Dr. Esselstyn's ongoing study and has been faithfully following the program for 15 years. "I know without this program, I would not be here today. But you have to want to do it; you have to want to live."

So how did a world-renowned surgeon and head of the section of thyroid and parathyroid surgery at the Cleveland Clinic get so wrapped up in broccoli, rice and grains?

Simply put, he was frustrated. "That was the rub," Dr. Esselstyn says. "I was successfully performing mastectomies and partial mastectomies, but what was I doing for people getting disease?"

Dr. Esselstyn started looking for ways to keep patients out of surgery. After working long days in the operating room, he scoured the literature looking for answers -- for ways to help people prevent disease.

"In places like Kenya and rural Japan, breast cancer, prostate cancer and coronary artery disease were almost nonexistent," he says. Why? Dr. Esselstyn points to dietary patterns and plant-based diets. He decided to focus his research on coronary artery disease, something he believed he could change in his lifetime.

Patterning the nutritional elements of his study after that of Asian rural diets, he has conducted the longest ongoing longitudinal study of its kind. The Asian diet is made up of complex carbohydrates that come from rice, whole grains and noodles. There is little or no red meat or dairy, and the fat content is about 20%. In Dr. Esselstyn's diet there is no meat or dairy and 10% fat.

Stopping the progression

Severely ill patients -- some with heart disease so advanced that standard intervention techniques such as bypass and angioplasty were no longer an option -- have had the progression of their disease stopped or reversed after adopting the strict regimen. "Sadly for patients, doctors practice palliative cardiology. That is totally unacceptable," he says. "Angio stents ... are temporary fixes. There's the drama of the angio, but there's not much drama in talking about broccoli. Diet is not very sexy."

Like most in the study, Joseph Crowe, MD, a surgical oncologist and director of the breast center at the Cleveland Clinic, credits Dr. Esselstyn with saving his life.

"I walked out of the OR and had a crushing chest pain, severe headache. It was pretty dramatic," he says. "My cholesterol was low, I was relatively active, I didn't know what I could do to change things," Dr. Crowe says.

Dr. Esselstyn called him; the diet was something Dr. Crowe could do. "I have three little kids. I wanted to live." Four years later, Dr. Crowe had a cardiac cath with totally normal results. "[Dr. Esselstyn] is one unusual guy; the work he has done is out of his devotion to helping people," says Dr. Crowe. "Many times he's going against the grain. Here's this world-renowned surgeon who's spent weeks, months, years devoted to coronary artery disease prevention out of the goodness of his heart."

Dr. Esselstyn likens his diet to patterns uncovered by the China Project, one of the world's largest ongoing culturally related nutritional studies.

In 1983 researchers from Cornell University in New York, the Chinese Academy of Preventive Medicine in Beijing, and Oxford University in England began gathering data on how people lived and died in 65 rural Chinese counties. "We found that their nutritional habits are very different from Americans," says Banoo Parpia, PhD, a Cornell University Division of Nutritional Sciences senior research associate.

The study's main hypothesis: The greater the proportion of a variety of good-quality plant-based foods, the lower the rate of chronic degenerative diseases. Researchers charted weights, blood pressures, disease and reproductive histories. While analysis and study continues, one of its major findings to date asserts that risk of coronary artery disease decreases with increased consumption of plant-based foods and decreased consumption of animal foods. To fully prevent coronary artery disease, plasma cholesterol must be maintained at well under 150.

In addition to following the links between these dietary patterns and diseases, the researchers also charted the migration patterns of Asians coming to America as they conformed to Western diets. Men in China have a 1-in-100,000 rate of prostate cancer. Chinese-American men living in San Francisco had a 19-times-greater rate of the disease.

Anthony Yen moved to the United States from China when he was 17, and quickly developed a love of all things American: greasy hamburgers, deep-fried foods, prime rib and ice cream by the quart. By the time he was 58 he couldn't breathe. "When I would walk into the wind my chest would tighten," he says. "This was my wake-up call."

Twelve years ago this international businessman, now 70, had a quintuple bypass. "I wanted to know why I had this problem and how to stop it. My cardiologists could not help me. I tried biofeedback, but I still wanted to know how to stop the disease. I wanted to be around to see my children grow up," Yen says. "Someone said, there's this guy named Esselstyn."

Allowing no cracks in the door

Dr. Esselstyn is the kind of man who makes you feel immediately comfortable. He laughs easily. He's impassioned about most things he takes on. And he's reluctant to shine a light on his own accomplishments. It's always those around him who helped him succeed. He credits his wife, Ann, whom he met while a medical student at Cleveland's Western Reserve University (now known as Case Western Reserve), with the success of his 17-year research study. "I couldn't have done it without her," he says.

Dr. Esselstyn wasn't always dairy-, meat- and oil-free. He grew up on a cattle farm in upstate New York. The hardest foods for him to give up were peanut butter and cheese. But after 16 years, he doesn't crave the foods he now calls hideous.

"These people had to know I was asking them to make a significant change," he says, referring to those participating in his research. "They also had to know that Ann and I were willing to eat the way they eat."

Perhaps life in rural New York gave him the winning edge. He went to the local public school; four boys and six girls were in his elementary school class. After eighth grade, he went to Deerfield Academy in Massachusetts and then Yale. But summers he worked construction back home. "I worked on the New York State Thruway and the Taconic Parkway," he says.

And even though he's been awarded a host of degrees, medical honors and the Bronze Star while an Army surgeon in Vietnam, the pinnacle of his career occurred in 1956. Pulling the No. 6 oar as a member of the U.S. Olympic rowing team, he won the Olympic gold medal in Melbourne, Australia. "There's nothing quite like it," he says of winning the medal. "It's one of the most spectacular moments you can have as a human being."

In June 2000 Dr. Esselstyn gave up his surgical post at the Cleveland Clinic. But he's not retired. He just has more time to devote to what has been his avocation, arresting heart disease through dietary changes.

He recently returned from a 16-day, 27-stop presentation tour in India, which was funded by the Physicians Committee for Responsible Medicine. He believes that getting the word out will begin a process of change.

"In India there are 30 million people with heart disease," he says. "Even though there is a broad base of vegetarians, they eat a lot of clarified butter, ghee. They worship dairy and cheeses, and they now even have a Kentucky Fried Chicken."

In addition to the dietary campaign, the Esselstyns enjoy their 400-acre farm in New York's Hudson Valley. They spend time with their four children and five grandchildren.

But even when Dr. Esselstyn speaks of his personal life, the conversation always winds back to food and changing eating habits. He's impassioned about food labels and adamant against pushing moderation.

"It's increasingly apparent that not one single morsel can pass through their lips," he says. "Moderation kills. Once you let them have a crack in the door, their rehabilitation is finished. It's gasoline on the fire."



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