PART ONE The Heart of the Matter I Eating to Live "IT WAS A FRIDAY in November 1996. I had operated all day. I finished, said good-bye to my last patient, and got a very, very bad headache. It hit me in a flash. I had to sit down. A minute or two after that, the chest pain started. It radiated up my arm and shoulder and into my jaw." These are the words of Joe Crowe, the doctor who succeeded me as chairman of the breast cancer task force at the Cleveland Clinic. He was having a heart attack. He was only forty-four years old. He had no family history of heart disease, was not overweight or diabetic, and did not have high blood pressure or a bad cholesterol count. In short, he was not the usual candidate for a heart attack. Nonetheless, he had been struck--and struck hard. In this book, I tell Joe Crowe's story, along with those of many other patients I have treated over the past twenty years. My subject is coronary artery disease, its cause, and the revolutionary treatment, available to all, that can abolish it and that has saved Joe Crowe and many others. My message is clear and absolute: coronary artery disease need not exist, and if it does, it need not progress. It is my dream that one day we may entirely abolish heart disease, the scourge of the affluent, modern West, along with an impressive roster of other chronic illnesses. Here are the facts. Coronary artery disease is the leading killer of men and women in Western civilization. In the United States alone, more than half a million people die of it every single year. Three times that number suffer known heart attacks. And approximately three million more have "silent" heart attacks, experiencing minimal symptoms and having no idea, until well after the damage is done, that they are in mortal danger. In the course of a lifetime, one out of every two American men and one out of every three American women will have some form of the disease. The cost of this epidemic is enormous--greater, by far, than that of any other disease. The United States spends more than $250 billion a year on heart disease. That's about the same amount the nation spent on the first two and half years of its military venture in Iraq, and fully twice as much as the federal government allocates annually for all research and development--including R&D for defense and national security.1 But here is the truly shocking statistic: nearly all of that money is devoted to treating symptoms. It pays for cardiac drugs, for clot-dissolving medications, and for costly mechanical techniques that bypass clogged arteries or widen them with balloons, tiny rotating knives, lasers, and stents. All of these approaches carry significant risk of serious complications, including death. And even if they are successful, they provide only temporary relief from the symptoms. They do nothing at all to cure the underlying disease or to prevent its development in other potential victims. I believe that we in the medical profession have taken the wrong course. It is as if we were simply standing by, watching millions of people march over a cliff, and then intervening in a desperate, last-minute attempt to save them once they have fallen over the edge. Instead, we should be teaching them how to avoid the chasm entirely, how to walk parallel to the precipice so that they will never fall at all. I believe that coronary artery disease is preventable, and that even after it is under way, its progress can be stopped, its insidious effects reversed. I believe, and my work over the past twenty years has demonstrated, that all this can be accomplished without expensive mechanical intervention and with minimal use of drugs. The key lies in nutrition--specifically, in abandoning the toxic American diet and maintaining cholesterol levels well below those historically recommended by health policy experts. The bottom line of the nutritional program I recommend is that it contains not a single item of any food known to cause or promote the development of vascular disease. I often ask patients to compare their coronary artery disease to a house fire. Your house is on fire because eating the wrong foods has given you heart disease. You are spraying gasoline on the fire by continuing to eat the very same foods that caused the disease in the first place. I don't want my patients to pour a single thimbleful of gasoline on the fire. Stopping the gasoline puts out the fire. Reforming the way you eat will end the heart disease. Here are the rules of my program in their simplest form: You may not eat anything with a mother or a face (no meat, poultry, or fish). You cannot eat dairy products. You must not consume oil of any kind--not a drop. (Yes, you devotees of the Mediterranean Diet, that includes olive oil, as I'll explain in Chapter 10.) Generally, you cannot eat nuts or avocados. You can eat a wonderful variety of delicious, nutrient-dense foods: All vegetables except avocado. Leafy green vegetables, root vegetables, veggies that are red, green, purple, orange, and yellow and everything in between. All legumes--beans, peas, and lentils of all varieties. All whole grains and products, such as bread and pasta, that are made from them--as long as they do not contain added fats. All fruits. It works. In the first continuous twelve-year study of the effects of nutrition in severely ill patients, which I will describe in this book, those who complied with my program achieved total arrest of clinical progression and significant selective reversal of coronary artery disease. In fully compliant patients, we have seen angina disappear in a few weeks and abnormal stress test results return to normal. And consider the case of Joe Crowe. After his heart attack in 1996, tests showed that the entire lower third of his left anterior descending coronary artery--the vessel leading to the front of the heart and nicknamed, for obvious reasons, "the widowmaker"--was significantly diseased. His coronary artery anatomy excluded him as a candidate for surgical bypass, angioplasty, or stents, and at such a young age, with a wife and three small children, Dr. Crowe was understandably disconsolate and depressed. Since he already exercised, did not use tobacco, and had a relatively low cholesterol count of 156 milligrams per deciliter (mg/dL), there seemed to be nothing he could modify, no obvious reforms in lifestyle that might halt the disease. Joe was aware of my interest in coronary disease. About two weeks after his heart attack, he and his wife, Mary Lind, came to dinner at our house and I had a chance to share the full details of my research. Both Joe and Mary Lind immediately grasped the implications for Joe of a plant-based diet. All at once, instead of having no options, they were empowered. In Mary Lind's words, "It was our own personal disaster, and suddenly there was something small we could do." Immediately, Joe embarked on my nutrition program, refusing to take any cholesterol-lowering drugs, and he redefined the word commitment. He stuck to the plan rigorously, eventually reducing his total blood cholesterol count to just 89 mg/dL and cutting his LDL, or "bad" cholesterol, from 98 mg/dL to 38 mg/dL. About two and a half years after Joe adopted a strict plant-based diet, there came a point when he was exceptionally busy professionally, under considerable stress, and he noted a return of some discomfort in his chest. His cardiologists, worried about the recurrence of angina, asked for more tests to see what was going on. On the day of his follow-up angiogram, I went to Dr. Crowe's office after work. After we greeted each other, I thought I saw moisture in his eyes. "Is everything OK?" I asked. "You saved my life," he declared. "It's gone! It's not there anymore! Something lethal is gone! My follow-up angiogram was normal." Nearly ten years later, Mary Lind recalled that they had wondered, that first evening at our house, "how the Esselstyns did it"--how we had managed to completely change the way we eat. "Now it's part of our family," she says. "We've eaten the same things for a long time, and I'm on autopilot." Later, when I asked Joe what made him decide to change, he responded very simply. "We believed you," he said, and added, "since I had nothing else, the diet came first. If I had had bypass surgery, diet would not have been first. The diet set us on another path, empowered to do something we knew we could do." Joe Crowe's angiograms--both the original, taken after the heart attack, and the follow-up, two and a half years later--are shown in Figure 1 (see insert). It is the most complete resolution of coronary artery disease I have seen, graphic proof of the power of plant-based nutrition to enable the body to heal itself. The dietary changes that have helped my patients over the past twenty years can help you, too. They can actually make you immune to heart attacks. And there is considerable evidence that they have benefits far beyond coronary artery disease. If you eat to save your heart, you eat to save yourself from other diseases of nutritional extravagance: from strokes, hypertension, obesity, osteoporosis, adult-onset diabetes, and possibly senile mental impairment, as well. You gain protection from a host of other ailments that have been linked to dietary factors, including impotence and cancers of the breast, prostate, colon, rectum, uterus, and ovaries. And if you are eating for good health in this way, here's a side benefit you might not have expected: for the rest of your life, you will never again have to count calories or worry about your weight. An increasing number of doctors are aware that diet plays a crucial role in health, and that nutritional changes such as those I recommend can have dramatic effects on the development and progression of disease. But for a number of reasons, current medical practice places little emphasis on primary and secondary prevention. For most physicians, nutrition is not of significant interest. It is not an essential pillar of medical education; each generation of medical students learns about a different set of pills and procedures, but receives almost no training in disease prevention. And in practice, doctors are not rewarded for educating patients about the merits of truly healthy lifestyles. Over the past one hundred years, the mechanical treatment of disease has increasingly dominated the medical profession in the United States. Surgery is the prototype, and its dramatic progress--light-years removed from the cathartics, bloodletting, and amputations that dominated medicine in previous centuries--is nothing short of breathtaking. But surgery has serious flaws. It is expensive, painful, and frightening, often disabling and disfiguring, and too often merely a temporary stopgap against the disease it is intended to treat. It is a mechanical approach to a biological problem. Perhaps no area of medicine better illustrates the mechanical approach to disease than cardiology and cardiac surgery. Consider: the United States contains just 5 percent of the global population, but every year, physicians in American hospitals perform more than 50 percent of all the angioplasties and bypass procedures in the entire world. One reason is that mechanical medicine is romantic and dramatic, a natural magnet for media attention. Remember the drama several years ago surrounding implants of artificial hearts? Most of the recipients died within weeks of their surgery, and all lived their last days tethered to life-support machinery that, far from enhancing their quality of life, drastically reduced it. But no matter: the dramatic interventions engaged the national imagination for months on end. All told, there has been little incentive for physicians to study alternate ways to manage disease, so the mechanical/procedural approach continues to dominate the profession even though it offers little to the unsuspecting millions about to become the next victims of disease. Modern hospitals offer almost nothing to enhance public health. They are cathedrals of sickness. There are some signs of change. Physicians and researchers increasingly agree that lifestyle changes--controlling blood pressure, stopping smoking, reducing cholesterol, exercising, and modifying diets--are essential to overall health. It is hard to deny the evidence, mounting with every passing year, that people who have spent a lifetime consuming the typical American diet are in dire trouble. Dr. Lewis Kuller of the University of Pittsburgh recently reported the ten-year findings of the Cardiovascular Health Study, a project of the National Heart, Lung, and Blood Institute. His conclusion is startling: "All males over 65 years of age, exposed to a traditional Western lifestyle, have cardiovascular disease and should be treated as such."2 Even interventional cardiologists are beginning to question the rationale of their procedures. In 1999, cardiologist David Waters of the University of California performed a study that compared the results of angioplasty--in which a balloon is inserted into a coronary artery to widen the vessel and improve blood flow--with the use of drugs to aggressively reduce serum cholesterol levels. There was no disputing the outcome. The patients who had the drug treatment to lower cholesterol had fewer hospitalizations for chest pain and fewer heart attacks than those who underwent angioplasty and standard postoperative care.3 The larger lesson of that study is that systemic treatment of disease through aggressive reduction of cholesterol is clearly superior to selective intervention at a single site where an artery has been clogged and narrowed. And it caused considerable uproar among cardiologists. As Dr. Waters observes, "There is a tradition in cardiology that doesn't want to hear that." Why? Money! For many years, I resisted that conclusion, but the weight of the evidence is overwhelming. Interventional cardiologists earn hundreds of thousands of dollars annually, and particularly busy ones make millions. In addition, cardiology procedures generate huge revenues for hospitals. And the insurance industry supports the mechanical/procedural approach to vascular disease. It is far easier to document and quantify procedures for reimbursement than it is to document and quantify lifestyle changes that prevent the need for such procedures in the first place. As a physician, I am embarrassed by my profession's lack of interest in healthier lifestyles. We need to change the way we approach chronic disease. The work I will describe in the following chapters confirms that sustained nutrition changes and, when necessary, low doses of cholesterol-reducing medication will offer maximum protection from vascular disease. Anyone who follows the program faithfully will almost certainly see no further progression of disease, and will very likely find that it selectively regresses. And the corollary, overwhelmingly supported by global population studies, is that persons without the disease who adopt these same dietary changes will never develop heart disease. Cardiologists who have seen my peer-reviewed data often concede that coronary artery disease may be arrested and reversed through changes in diet and lifestyle, but then add that they don't believe their patients would follow such "radical" nutritional changes. But the truth is that there is nothing radical about my nutrition plan. It's about as mainstream as you can get. For 4 billion of the world's 5.5 billion people, the nutrition program I recommend is standard fare, and heart disease and many other chronic ailments are almost unknown. The word radical better describes the typical American diet, which guarantees that millions will perish from withering vascular systems. And in my experience, patients who realize that they have a clear choice--between invasive surgery that will do nothing to cure their underlying disease and nutritional changes that will arrest and reverse the disease and improve the quality of their lives--willingly adopt the dietary changes. Excerpted from Prevent and Reverse Heart Disease: The Revolutionary, Scientifically Proven, Nutrition-Based Cure by Caldwell B. Esselstyn All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.