Will Heart Disease Be Eliminated if the World Goes Vegan?

Will Heart Disease Be Eliminated if the World Goes Vegan?I became a bit puzzled the other day when I read a blog article written by Kim A Williams MD, a cardiologist at Rush University in Chicago and the next president of the American College of Cardiology.

Doctor Williams describes how one of his patient’s history inspired him to change his dietary habits and adopt a cholesterol free, plant-based diet.

He finds it interesting that the American Heart Association prevention guidelines do not specifically recommend a vegan diet.

Dr. Williams writes: “…Wouldn’t it be a laudable goal of the American College of Cardiology to put ourselves out of business with a generation or two“…

Obviously, he’s implying that heart disease may be eliminated if we all go vegan.

To make my case clear I have to emphasize that my puzzlement has nothing to do with whether I believe Dr. Williams is right or wrong. In fact, he might very well be right. However, the question is whether his implications are supported by scientific evidence.

Should doctors base their treatment decisions on anecdotal evidence?

We often warn our patients to adopt the experience of other people and make it their own, both when it comes to interpreting symptoms and advising treatment strategies.

However, to be fair to Dr. Williams I will mention that he believes that studies on vegan diets are “either very large and observational or small and randomized“…

But, then he’s also implying that the scientific data isn’t strong enough to recommend heart patients or the general public to become vegetarians. So where is he going then?

Vegan Diets and Heart Disease

The health of vegetarians has been addressed in a number of studies. The health effects of foods that are preferred or avoided by vegetarians has also been studied. Most of these studies are of observational nature. Suffice to say that there is strong evidence that vegetarians have lower rates of coronary heart disease, lower LDL-cholesterol and lower rates of hypertension, diabetes and obesity.

A combined analysis of the five biggest cohorts published in 1999 showed a 24% lower mortality from coronary heart disease among vegetarians compared with non-vegetarians. Recently published data from the EPIC-Oxford Study showed that vegetarians had a 32% lower risk coronary heart disease than did non-vegetarians. Vegetarians had lower BMI, non-HDL cholesterol and blood pressure

Randomized studies of vegetarian diets are few and small. Ornish’s Lifestyle Heart Trial showed a regression of coronary artery plaques among patients who adopted a program consisting of a low-fat vegetarian diet, stopping smoking, stress management and moderate exercise, compared with a “usual care” control group. These results were achieved without the use of cholesterol-lowering drugs. Although the study was randomized, only 48 individuals participated.

Another old and often cited study by Lester M. Morrison published 1960 tested 100 patients with proved coronary atherosclerosis. Fifty patients were treated with a low-fat, low-cholesterol diet. The other 50 patients were not given any specific treatment and acted as controls. By the end of 12 years, 19 of the 50 patients treated with the diet survived. Of the 50 control patients, all had died by the 12th year of observation.

Caldwin Esselstyn’s studies have also shown positive effects of a low-fat strategy in patients with coronary atherosclerosis. But again very few patients were studied. In his book, Prevent and Reverse Heart Disease, Esselstyn writes: … “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…”

It’s the Cholesterol Stupid

Obviously, there is a lot of evidence suggesting that plant based diets positively affect atherosclerosis and coronary artery disease compared with a traditional Western dietary pattern. But many questions remain. Do we have to avoid all animal products? How about dairy foods, eggs and fish? What are the advantages and risks of soy consumption? What about compliance? Are vegetarian diets more difficult to stick with than other diets. Well, clearly more research is needed before we can answer the question whether cardiologists will be out of business if the world goes vegan.

10853612_m

Will we be seeing more heart surgeons having a good time on the golf course if the world goes vegan?

Now let’s get back to Kim A Williams blog article. Williams apparently believes that cholesterol is what defines a healthy diet. He writes: … “I thought I had a healthy diet — no red meat, no fried foods, little dairy, just chicken breast and fish. But a simple Web search informed me that my chicken-breast meals had more cholesterol content (84 mg/100 g) than pork (62 mg/100 g). So I changed that day to a cholesterol-free diet, using “meat substitutes” commonly available in stores and restaurants for protein. Within 6 weeks my LDL cholesterol level was down to 90″...

In a paper published 2010 in the American Journal of Cardiology, William C. Roberts famously wrote: … “The lower the LDL cholesterol, the better, and this principle has been established repeatedly despite voices of the anticholesterol, antistatin fallacy mongers! It’s the cholesterol, stupid!“…

Dr. Roberts has been editor-in-chief of the American Journal of Cardiology for 32 years. Although not within the scope of my article, I can’t but wonder how many of the “anticholesterol, antistatin fallacy mongers” have managed to get their papers accepted for publication in the journal.

Mixing medicine with anal retentiveness is bad. You may remember that according to Freudian psychoanalysis “the term anal retentive (also anally retentive), commonly abbreviated to anal, is used to describe a person who pays such attention to detail that the obsession becomes an annoyance to others, potentially to the detriment of the anal-retentive person”. 

So, let’s open our minds a little bit. Is it possible that the positive health effects of eating fruits and vegetables have to do with something else than cholesterol? I can assure you that by admitting that’s possible, you’re not saying that cholesterol doesn’t matter, and hopefully you’ll not be classified as an “anticholesterol fallacy monger.”

Last week The BMJ published a meta-analysis of sixteen cohort studies analysing the relation between fruit and vegetable consumption and risk of all cause, cardiovascular, and cancer mortality. Higher consumption of fruit and vegetables was significantly associated with a lower risk of all cause mortality. However, there was a threshold around five servings of fruit and vegetables a day, after which the risk of all cause mortality did not reduce further. Mortality from cardiovascular causes, but not cancer, was significantly related to less consumption of fruits and vegetables.

The authors discuss the possible mechanisms underlying their findings. Antioxidant compounds and polyphenols in fruit and vegetables—such as vitamin C, carotenoids, and flavonoids may play a role. These have been shown to prevent the oxidation of cholesterol and other lipids in the arteries and to increase the formation of prostacyclin with positive effects on arteries and blood clotting.

Reduction in blood pressure may play a role. Fruit and vegetables are good sources of magnesium and potassium, which have been inversely associated with mortality in previous studies. Fruit and vegetable increase plasma concentrations of antioxidants, such as alpha and beta carotene and other compounds such as vitamin C, carotenoids, and other phytochemicals may be important as well.

So, after all, it’s not only the cholesterol (stupid) …

Comments

  1. peter hawkins says

    6 months ago i had a stent put in as a coronary artery was 90% clogged. another two didn’t look so good. i’m 63 and in otherwise great shape: no other heart/cholesterol issues, regular exercise. I went on a strict Vegan diet: no dairy, sugar, processed foods, bread or even fish. In 6 months I dropped 30+ pounds with no loss of muscle. I’m back to my 28 yr. old body when I was a thin, high-end athlete. Within 3 months, I also got off the statins and metoprolol – still on the clopidogrel and aspirin. I was also told that pomegranate juice was great for reducing plaque in the coronary arteries. I’ve taken the position that’s it’s my life/body. I basically feel really good, and swim everyday. Thoughts?

  2. Garry Lee says

    In the WHI trial (RCT) mentioned by Gary Taubes in Good Calories Bad Calories, the vegetables made no difference to heart disease, cancer or anything else.

  3. LDL Richard says

    Good article Doc, one of my favorites :),

    however, let me clarify few issues. When famous cardiologists such as William Castelli from Framingham are speaking about becoming immune to atherosclerotic CHD with a vegan diet, they are speaking about the Ornish/Esselstyn/McDougall variant of very-low-fat whole-food plant-based diet. By vegan diet they do not mean the high saturated fat diet of Western vegetarians. Vegetarian diet can be laden with animal fats, cheese, cream, butter, etc.

    Referenced as Oxford Vegetarian. Relative risk: 2.77 for dietary SFA (Mann, 1997).

    “A gradient of risk is apparent with increasing intake of total animal fat, saturated fat, and dietary cholesterol as well as some of the major food sources of these nutrients.”

    “The study differs from previous prospective studies of diet and IHD in that the volunteers were individuals whose self selected diet resembled, in nutrient content, current dietary recommendations rather than the relatively high saturated fat diet typical of most affluent societies.”

    Oxford study found that Western vegans ate a diet with 6% saturated fat on an average while South-Korean study showed that local lacto-ovo-vegeterians ate a diet with just 1% saturated fat. So we have vegetarian diets and vegetarian diets. This is easy for you to understand. For example, in all the studies that have studied the effects of low-carb diet, the low-carb arm has been adviced to avoid animal fats and instead choose vegetarian fat sources. It’s not the high animal fat low-carb variant we are dealing with these studies.

    Moreover, I’d like to clarify that whether the sample sizes are small in whole-food plant-based studies, it doesn’t matter anymore at this point. The fact that low-saturated fat whole-food vegan diets cures CHD is actually so overwhelming. The evidence comes from multiple lines of research, starch-based cultures around the world with cumulative exposure to very low cholesterol levels, the LDL receptor theory, etc. The effect seen in vegan studies is so strong that sample size becomes less meaningless, there’s so doubt about the effect of the diet. Michael Greger MD made some valuable point in regards to the pitfalls of evidence based medicine, excellent few minutes clip. Do not miss this.
    http://nutritionfacts.org/video/evidence-based-medicine-or-evidence-biased/

    Do not miss Ornish reply either; in Ornish study those with lowest LDL showed the largest regression of their disease: This is important point Doc, less reduction in LDL, less regression.
    http://www.medpagetoday.com/Cardiology/Prevention/47018

    Moreover, the whole context of William Roberts MD opens here:

    The Cause of Atherosclerosis
    http://ncp.sagepub.com/content/23/5/464.extract

  4. Mie says

    LDL-Richard,

    “The fact that low-saturated fat whole-food vegan diets cures CHD is actually so overwhelming.”

    Cures? No. As you know, there’s not a single high-quality randomized trial showing that vegetarian diets are superior in CVD management to other alternatives – and this kind of evidence is simply required to make any given treatment option the definitive option. The best evidence so far exists for Mediterranean diet (Lyon Diet Heart, PREDIMED) – not that the evidence for it as a WHOLE that clearly points out its superiority, period. So what about cohort data? Well, the meta-analysis of 5 prospective studies”, which Axel referenced, points to a plant-BASED diet in which adherence seems to be the key and. Is this a synonym for vegan diets? No. Strict vegans had HIGHER CHD mortality and/or all-cause mortality than e.g. lacto-ovo vegetarians and fish eaters. And what if there’d been an opportunity to adjust for further confounders, e.g. the quality of the meat eaten (processed vs unprocessed)?

    Of course, all this can be ignored and/or brushed away like Greger attempts in the video by ignoring issues like e.g. the patients’ right to evidence-based care, biases caused by small samples and lack of proper control & randomizing etc. etc. But that just makes crappy science.

    P.S. For all their advertising and hype, no low-fat vegan advocate such as Esselstyn, Ornish etc. etc. has produced either a convincing case for a vegan diets or a proper controlled trial. After all these decades and the money they make on their diet books and advice. In fact, whenever there’s been a controlled trial for e.g. weight loss in which a low fat vegan/vegetarian diet has been compared to a variety of other approaches, these diets have performed in remarkably … mediocre way. No wonder Ornish has a beef with longer randomized trials:

    http://www.sciencebasedmedicine.org/fighting-against-evidence/

  5. Mie says

    Yes. It was essentially observational. No control group, no other dietary interventions, no randomization –> no way of showing that this particular approach is the best.

  6. LDL Richard says

    Mie,

    1) great points. However, if you are willing to hang on, I will clarify. By comparing Ornish to Lyon you fail recognize the difference in study design. Lyon was about administering a Mediterranean diet a the top of a standard care. Cardiovascular drugs were in extensive use in both control and intervention arm. Ornish initially hypothesized whether intensive, drug-free lifestyle modifications could regress atherosclerosis as a process within the artery wall. Obviously, due to limited amount of patients, mortality benefits cannot be shown in this kind of a setting. However, I would like to point out it’s not just about mortality. Statins may not show mortality benefits among elderly people but they sure make their quality of life better, less cardiadic events.

    2) Greger MD concluded that evidence based medicine is fantastic as long as we do not assume that drug-study design is always optimal for tackling life-issues. This is easy for us to accept after watching his video. Moreover, I would like to point out that prior to this year (2014) there was not a single RCT showing mortality benefits of physical exercise, likewise, there’s not a single RCT showing that cigarette cessation is the key modifiable factor to influence lung cancer risk. There are actually 3 such trials that I am aware of the tested the hypothesis that smoking cessation would lower the risk of lung cancer mortality. All 3 trials failed to produce statistically significant findings despite reporting significant reductions in smoking prevalence in the group that received counselling on smoking cessation. These trials include the Whitehall Study, the Lung Health Study, and MRFIT, which included in total over 20,000 participants and up to 20 years of follow-up. The largest of these 3 trials found that the number of lung cancer deaths were actually 15% greater, albeit not statistically significant in the group that received counselling on smoking cessation.
    http://onlinelibrary.wiley.com/doi/10.1002/1097-0142(20001201)89:11+%3C2422::AID-CNCR16%3E3.0.CO;2-E/full

    3) If Ornish diet is able result in regression of CHD in short term we can fairly well assume it will do the same on the long-term. The argument that Ornish has a problem with long-term RCT’s does not hold water. Besides, evidence-based medicine is not in breach with Ornish. Patients can actually take statins and aspirin and eat the low-fat plant-based diet at the same time :).

    4) Not only are world-class cardiologists recommending plant-based diets, but actually the medical community at large are steering to that direction. I think the example set by Kaiser Permanente is telling.
    https://www.thepermanentejournal.org/issues/2013/spring/5117-nutrition.html

    Doc, your top-snocth, Harvard graduated colleague from New York shares some ideas:

    “For years after my training, I applied evidence-based medicine, recommended a “healthier” lifestyle, which typically included a Mediterranean-style diet, and watched as my patients’ diseases often progressed. I became frustrated. There had to be something more”
    http://www.forksoverknives.com/the-plant-based-lifestyle-is-the-best-medicine-i-ever-prescribed/

    5) The best argument for vegan diet I could ever make is the LDL receptor theory as elucidated by Brown & Goldstein. As B & G showed physiologically normal LDL cholesterol for human is in the same range (25 to 60mg/dl) as it for all free-ranging mammalians. They did this with the help of cell cultures. Population who eat plant-based, quasi-vegan diets have cumulative exposure to very low levels of serum cholesterol and hence virtually absence from heart disease and plethora of other chronic disease. Most adult people cannot even come close to normal cholesterol levels unless relatively stringent vegan diet is prescribed. If cholesterol is key modifiable risk factor to influence CHD risk (which it is) then it makes sense that we eat the most cholesterol lowering diet, and the earlier we start the better. Of course, one could always be more liberal and take statins and host of other cardiovascular drugs as a preemptive measure and opt the Mediterranean diet instead. I personally set the bar a bit higher.

  7. Doctor Vedic says

    Sure, which is why it wasn’t published in a better journal. I hope that they choose to at least look at age and disease matched controls for future papers (perhaps after median 5 year followup?). Regardless Esselystyn’s data showing intervention in only 1 treatment patient is still extremely impressive when looking at historical data.

    Check out table W3 in the paper (sorry for long link). Some studies with 2-3 years followup show upwards of 1 event per patient (though looking at PCI and CABG as an “event”), even in the treatment groups.

    http://www.jfponline.com/index.php?id=21643&tx_ttnews%5Btt_news%5D=264185&tx_ttnews%5BsViewPointer%5D=1&cHash=8f1b020bd127f9924e92463625a49eea

  8. Richard LDL says

    @Doctor Vedic,

    good point. The effect in Esselstyn’s study was so dramatic, rendering any requirement for drug-trial style RCT largely as unnecessary. There’s no doubt what the diet Esselstyn promotes can do anymore. There’s no excuse for doctors to not inform their patients about vegan diet therapy, even if they persist with their skepticism. Patient have the right to be informed about therapies that clearly work and are safe, especially when these therapies are espoused by some of the biggest echelons of medicine. Out of 200 patients with all diagnosed CHD only 1 patient had a cardiadic event during the survey. This patient continued with his habit of excessive salt intake and did comply with the recommendation Esselstyn set forth.

    Obviously, if Esselstyn had an RCT it wouldn’t hurt, but normal scientific reasoning always precedes any dogmatic requirement of evidence based medicine, double-blinded RCT, that is. Moreover, as concluded by Ornish, there’s not a single study which would show the effect of low-carb diet to coronary arteries (this applies to all other diets as well, besides the Ornish/Esselstyn/Pritikin approach). Not a single ethic board granting the permission for medical studies on humans would even allow such study to be conducted with the high-animal fat variant of low-carb.

  9. Mie says

    Richard,

    “Lyon was about administering a Mediterranean diet a the top of a standard care. Cardiovascular drugs were in extensive use in both control and intervention arm.”

    I know. However, the benefits in intervention arm took place ON TOP of the drug intervention. Now, of course, this was before statin-era so the results cannot be directly extrapolated. PREDIMED did, however, show benefits too on top of statin treatment.

    “2) Greger MD concluded that evidence based medicine is fantastic as long as we do not assume that drug-study design is always optimal for tackling life-issues.”

    I agree with that. However, he made other strong allegations concerning study quality and size which are ABSOLUTELY essential if we want the patients to have care based on best available evidence. To me this means Greger would let things slide because of … vegan bias?

    “3) If Ornish diet is able result in regression of CHD in short term we can fairly well assume it will do the same on the long-term.”

    No we cannot. CHD is a disease that never entirely goes away: atheroma formation starts again if one slips from the treatment. Long-term adherence and results are what matter.

    “The argument that Ornish has a problem with long-term RCT’s does not hold water.”

    Yes it does. Read the article, it links to Ornish’s own opinion piece.

    “Besides, evidence-based medicine is not in breach with Ornish. Patients can actually take statins and aspirin and eat the low-fat plant-based diet at the same time :).”

    Please. The issue is about your argument that low-fat vegan diet is the only/best way to go. This requires proof which cannot be given by stating the abovementioned.

    “4) Not only are world-class cardiologists recommending plant-based diets, but actually the medical community at large are steering to that direction. I think the example set by Kaiser Permanente is telling.
    https://www.thepermanentejournal.org/issues/2013/spring/5117-nutrition.html

    Not a systematic review nor a meta-analysis –> not acceptable if you want to argue for the superiority of any given diet. Once again, don’t compromise the scientific criteria.

    “5) The best argument for vegan diet I could ever make is the LDL receptor theory as elucidated by Brown & Goldstein.”

    Nope. A diet can include animal foods and still be low in fat and/or SAFA. And low fat isn’t even optimal in improving lipid values. As you should remember, both Mensink et al (2003) or Clarke et al (1997) (analyses of metabolic ward studies) should that replacement of carbs (even complex ones) with unsaturated fat is beneficial in terms of LDL, HDL, triglyserides and apoB (marker for LDL-P). On top of that, the results from Lyon Diet Heart and PREDIMED which demonstrate the benefits in hard end points.

  10. Mie says

    Richard,

    “Obviously, if Esselstyn had an RCT it wouldn’t hurt, but normal scientific reasoning always precedes any dogmatic requirement of evidence based medicine, double-blinded RCT, that is.”

    Denialism, plain and simple. No one’s arguing that RCT’s are the ONLY legitimate form of evidence. However, they are absolutely essential in clarifying whether treatment X (proposed as the standard form of treatment) can deliver or not. Of course, RCT’s can be poorly conducted too, but if there’s a dramatic difference between cohort data – which BY DEFINITION can never prove causality – and a high-quality RCT, then …

    You know this. You yourself (as the other vegan activist around here, whathisname?) have sited RCT’s such as metabolic ward studies when they’ve suited your purposes. Shame on you.

  11. Richard LDL says

    Mie,

    you refer to the work of Mensik et al to show that high carb apporoach is not optimal when it comes to lipid levels. I don’t get this argument. The biggest reduction in LDL cholesterol in a drug-free context that I am aware was shown by Ornish et al. A 40% reduction in LDL within a course of 12-weeks on an average patient. This is comparable to atorvastatin and has been verified in multiple hospital sites around the US.
    http://ornishspectrum.com/wp-content/uploads/effectiveness-efficacy-of-an-intensive-cardiac1.pdf

    The lowest cholesterol levels on living people have been consistently recorded in populations eating very low-fat, high carb plant-based diets; ethnic Javanese, rural Chinese, Central-Africans, Okinawa people, the Ushibuka cohort of the 7CS, etc.

    Both the intervention and control arm in Lyon study used statins. Lyon was a statin era study.

    Many people are probably biased against Ornish & co because they follow a very different dietary paradigm themselves. These folk refuse to accept some of the key tenants supporting plant-based, vegan approach, this includes the LDL receptor theory by Brown & Goldstein. If you can tolerate animal foods in abundance and show LDL <70 (1,8mmol/l), the upper treshold of the LDL levels in free-ranging apes, then good for you. People at the centre of the bell curve cannot tolerate animal products in order to have healthy lipid values apart from miniscule amounts.

    Many of leading authorities of prevantative medicine give a green light to the vegan therapy, as Doc already concluded, what does this tell about your interpretation of the science? William Castelli, the chief inspector of Framingham, shares his views on optimal diet in tackling chronic disease.

    “You know, we know that if I can get your total cholesterol down around let’s say 100 to 130 or so, and I have maybe not quite a billion people on the earth like that, and those people cannot get atherosclerosis. You know in the China Study, for example, when Chou En-lai was dying of cancer he started a study in China just like the Framingham Study. The only difference was it was in 880,000,000 people so it was a little larger than the Framingham Study. But you know they found these villages in China where you couldn’t get a heart attack or you couldn’t get diabetes and the women couldn’t get breast cancer and you know their total cholesterol were 127, but the chances we could ever get Americans down that low with diet and exercise are not good”.

    “KIRK HAMILTON: But what would the diet be if you didn’t have drugs and you could get everybody to do exactly what you wanted diet-wise in the United States? How would you reverse the heart disease?”

    “DR. WILLIAM CASTELLI: Well you’d have them on a pure vegetarian diet and not getting fat on the vegetarian diet.”

  12. Mie says

    Richard,

    “you refer to the work of Mensik et al to show that high carb apporoach is not optimal when it comes to lipid levels. I don’t get this argument. The biggest reduction in LDL cholesterol in a drug-free context that I am aware was shown by Ornish et al. A 40% reduction in LDL within a course of 12-weeks on an average patient. This is comparable to atorvastatin and has been verified in multiple hospital sites around the US.
    http://ornishspectrum.com/wp-content/uploads/effectiveness-efficacy-of-an-intensive-cardiac1.pdf

    That kind of comparison works ONLY when talking about a comparative study, NOT when comparing one study to another, different kind of study. Don’t muddy the waters.

    Concerning the point about low-fat plant based diet resulting in low LDL: yes, that’s the case. That doesn’t, however, mean that it would result in biggest reductions per se, should a diet richer in unsaturated fatty acids be compared to it. Or how would you explain the fact that rigorously controlled studies (metabolic ward environment) show precisely this? Nor does it mean that hard end point data (Med. diet) can be ignored. Nor cohort data indicating benefits from a bunch of other dietary regimes, too.

    “Both the intervention and control arm in Lyon study used statins. Lyon was a statin era study.”

    Nope. The original study started before the statin era, so aspirin and beta blockers were the medication of choice.

    “Many of leading authorities of prevantative medicine give a green light to the vegan therapy, as Doc already concluded, what does this tell about your interpretation of the science?”

    Science doesn’t care about authorities, only about arguments. And argumentation here should be based on evidence gotten from studies, not anecdotes from people who think the same way as you – unless you want to be every bit as pseudoscientific as a many low carb/paleo “gurus”.

    If there’d be proper evidence of the superiority of vegan diets, it’d should in medical literature and consequently in treatment protocols. But nope, what you’ve got is ecological data and cohorts, the latter showing nothing more than the fact that a variety of diets work better than the Western diet and that the difference between them are minuscule. The most meaningful – heck, if the diet is based on a few key principles, the ONLY meaningful criteria – is the patient’s ability to stick to it.

  13. Doctor Vedic says

    Few things to consider:

    1) Esselstyn’s “therapeutic” diet is much stricter than anything followed by most community vegans (ie, no added oils, refined carbs, etc). Much stricter also than the diet Dr. Kim Williams follows.
    2) Given the possibility of a Hawthorne effect seen in diet studies, it would be acceptable (from many people’s standpoint) to see a comparison to age and disease matched controls treated with standard of care medical therapy during the same time period at Cleveland Clinic. Given the volume of patients seen at that hospital, this shouldn’t be hard to do.
    3) If any cardiovascular drug (or cancer drug for that matter), even within an uncontrolled single arm trial, showed stable or improved disease in 98% of compliant patients (and without major side effects), think of the reaction that would occur within the respective medical communities. Many physicians would not hesitate to use said drug for “compassionate” purposes, off label.
    4) Is the data strong enough to dictate national policy? Of course not. But it is definitely strong enough to warrant replication studies at other institutions.
    5) Until then, given the dramatic findings and concomitant lack of side effects, it would be highly remiss for practicing cardiologists to not share this data with their patients as part of routine informed consent.

  14. peter hawkins says

    Question? Given the discussion(s) on the Vegan/Esselstyn diet, what test is given that actually shows the level of plaque build-up or decrease in the coronary arterties?

    • Axel F Sigurdsson says

      Peter

      The degree of stenosis/narrowing in the coronary arteries is usually assessed by coronary angiography. For those who don’t know, cornary angiography is a diagnostic procedure performed by injectiong contrast/dye into the arteries and then using x-ray technique to get images of the vessels.

      By using these images, plaque burden and degree of narrowing/stenosis can be calculated.

      • Peter Hawkins says

        Having had a coronary angiography (pre-stenting), my greater question is, given the risks associated with one, at what point is it worth it? 6 mo. later? 12 mo. later?

  15. Doctor Vedic says

    Axel, curious to learn your thoughts. Would you share Esselstyn’s data w/ your patients with existing disease?

    • Axel F Sigurdsson says

      Doctor Vedic.
      No I usually don’t go into Esselstyn’s or Ornish’s data with may patients. I think we need larger randomized trials in order to see if this approach improves clinical outcome.
      On the other hand, I consider a low-fat plant-based diet to be an option for patients with existing atherosclerotic heart disease. However, I believe there are other options as well.
      I try to educate my patients about different approaches. What’s best in each case depends on many different factors as well as the patient’s preferences. You can’t force a specific dietary approach on any patient. It’s about shared decision making.

  16. RichardOrnishForLife says

    Mie,

    1) you are so much into your ideas’ that you start to spew very “funny” ideas and become inconsistent. Low-fat, high starch veg diet result in both reduction in LDL and HDL (9% reduction in Ornish trial). Thus, high starch-diet provides the biggest reduction in total cholesterol as well.

    In the very fist post I made I referred to a prospective cohort study showing that vegetarians eating most saturated fat had an excessive risk of 2.77 for developing a heart disease compared to vegetarians who less saturated fat. Vegetarian diet is not inherently healthy. High caste Indian vegetarians eat more animal fat than their rural, less affluent omnivorous peasants. Moreover, every epidemiologist knows that vegetarian diets harbor a huge sick-quitter effect similar from Tobacco studies, potentially diluting the effect of vegetarian diet. A dutch study found that 75% of the vegetarians in their cohort opted vegetarian diet because they underlining health problems at the baseline. This is less of an issues in cohort of 7th day adventists. Prospective cohorts also indicate that people who don’t drink at all have a higher mortality risk, yet when people with problems in their ethanol metabolism (and as a result do not drink at all) are studied a completely different picture emerges. You refer to diet cohort studies without even trying to understand what has happened.

    2) I don’t know how Lyon started but statin usage is clearly addressed in the study itself, as are the numbers of patients who were on them.

    3) “Science doesn’t care about authorities, only about arguments”.

    Exactly, and that’s why I try to constantly refer to expert opinion and argument. If you think that pop science debate on a blog should be about expressing your own, amateur ideas, I think we’ve come to a dead end. Obviously I cannot restrain from my own ideas, but I try to keep them in minimum and just refer to the opinion of the most appreciated experts in their respective fields and maybe try to explain the background of their reasoning. Obviously online cranks would say this appeal-to-authority, but I think this is the only way to go if you are into having some standards.

    The reason why vegan diets are becoming popular in medical community can also be partly explained against the background most stringent form of evidence-based-medicine. The new upcoming trials on PCSKY-9 antibodies will most likely show that reducing LDL to levels unheard before will carry significant benefits. The pendulum is back on the LDL as recently concluded by Frank Sacks. Evidence based medicine doesn’t give slightest support to the idea that CHD is having modifiable, causal risk factors, other than LDL cholesterol. At least if atherosclerosis is taken as a plaque formation process within the artery wall. Genetic evidence shows no matter what is the pathway that reduces LDL, having low LDL as early as possible will have tremendous effect on health. Already, from this perspective it makes to guide patients to plant-based, vegan diets. Kaiser Permanente has been doing some pioneering work. The medical community as large possible follows. We’ll see.

  17. RichardOrnishForLife says

    Doc,

    do you inform your local Icelandic patients about the data on low-fat, plant-based diets? If not, are you planning start doing so?

  18. Mie says

    Richard,

    “Thus, high starch-diet provides the biggest reduction in total cholesterol as well.”

    And, once again, this needs to be demonstrated in a COMPARATIVE study, in case you argue for vegan diets becoming the preferred treatment. Descriptive design just won’t do.

    “In the very fist post I made I referred to a prospective cohort study showing that vegetarians eating most saturated fat had an excessive risk of 2.77 for developing a heart disease compared to vegetarians who less saturated fat.”

    And this is irrelevant as no one’s arguing for increased SAFA intake per se.

    “You refer to diet cohort studies without even trying to understand what has happened.”

    … and suddenly the cohort studies become irrelevant if they don’t support you position. Please. Them goal posts don’t go any further. :-)

    “2) I don’t know how Lyon started but statin usage is clearly addressed in the study itself, as are the numbers of patients who were on them.”

    Not in the original 1994 paper, nope. The 1999 follow-up? Don’t know, since the paper states only “lipid-lowering drugs”.

    “Exactly, and that’s why I try to constantly refer to expert opinion and argument.”

    No, you’re referring to FRINGE opinions as these clearly aren’t reflected in treatment recommendations (see e.g. Nordic nutrition recommendations or ECS guidelines for dyslipidemias and/or CVD management and prevention) nor in clinical evidence. It’s one thing to state that low-fat vegan diets work better than the current default diet. It’s a WHOLE another thing to claim they should be the treatment of choice.

    “Evidence based medicine doesn’t give slightest support to the idea that CHD is having modifiable, causal risk factors, other than LDL cholesterol.”

    You’re confusing the pathophysiology of atheroma formation (in which LDL is both necessary and sufficient factor) and clinical manifestation of CHD in which e.g. the very IMPACT models you praise clearly show that a variety of major population-level risk factors come into play.

  19. RichardOrnishForLife says

    Mie,

    I don’t confuse anything, in fact this was the exact point that I made in the comment section of Doc’s last article (the one the preceded this one). Variety of population level risk factors come only in play in a population showing very high cholesterol levels to begin with (I even made a comparison to ionizing radiation, stochastic risk). These other factors become less relevant on people who have very low cholesterol levels early on. The Japanese showed higher blood pressure levels and smoked more than the Americans did in the late 1950s yet atherosclerotic CHD was virtually absent among them at the time. Most carriers of homozygot PCSK-9 knock-out mutation are obese and diabetic African-Americans with cumulative exposure to LDL levels of 50-60s since birth. Neither do they have cardiac events.

  20. Mie says

    Smoking, blood pressure etc. etc. are all modifiable and risk factors. The Japanese “paradox” is precisely another French “paradox”: boloney. The same ol’ risk factors apply to the Japanese too.

    http://circ.ahajournals.org/content/118/25/2725.full

    As for obese & diabetic people: cardiac mortality in diabetics is the leading cause of death among them. Modify the key risk factor (LDL) and mortality goes down. Surprise? No. Does it mean that e.g. treating high blood pressure is insignificant? Nope.

  21. RichardOrnishForLife says

    Mie,

    there’s no Japanese paradox, I referred to baseline stats from the 7CS. 70% of Japanese men smoked and 40% smoked more than 20 cigarette per day, no heart disease. Obviously the cholesterol levels have increased among Japanese as they’ve shifter away from their rice based diets and we see the “other risk” factors having more bigger impact.

    Daniel Steinberg sharing the “fringe view”:

    “One important line of evidence comes from a consideration of the Japanese experience. In 1952, mortality from CHD among Japanese men 55 to 64 years of age was <10% of what it was in the United States.15,16 Their total cholesterol levels at the time averaged ≈160 mg/dL (estimated LDL, ≈80 mg/dL). It is noteworthy that the Japanese enjoyed this relative immunity to CHD despite the fact that the prevalence of one of the major risk factors—cigarette smoking—was much higher in Japan than in Western countries,17 and another—-hypertension—was just as high.18 Even the diabetic population in Japan fares better than the diabetic population in Western countries. In 1985, almost 30% of British male diabetics but only ≈15% of the Japanese male diabetics had CHD.19 The implication is that if blood cholesterol levels are sufficiently low, the other dominant risk factors, including cigarette smoking, hypertension, and diabetes mellitus, constitute much less of a threat”.

    A crucially important point needs to be noted here: For whatever reasons, the Japanese have their lower cholesterol levels for their entire lifetimes.

    http://circ.ahajournals.org/content/118/6/672.full

  22. RichardLDL says

    BTW,

    Doc. You wrote that patients in the Ornish et al study showed a trend towards regression of heart disease. Weren’t the findings statistically significant thus makint the term “trend” technically misleading and incorrect? I like to hear your comments. Moreover, I think you ought to have mentioned that the study by Ornish was a drug-free, and unlike in many other studies the coronary arteries themselves were looked. The study also and the 5-year follow-up also looked at clinical end-point, angina, death, cardiadic events, revascularization, etc.

    I couldn’t notice the overall tinge of skepticism while reporting the findings from plant-based interventions. This is ok, but it’s bit puzzling to me that you embrace low-carb approach yourself. Sure we have low-carb studies that show improvement in HDL/triglyceride ratio, but do we have drug-free low-carb studies showing the effect on coronary arteries in people with severe atherosclerosis, heck we do not even low-carb studies that would have looked at the coronary arteries of the patients at the top of drug therapy.

    • Axel F Sigurdsson says

      Thanks Richard. I agree with you. It’s not fair to use the word “trend”. I’ll change that. To tell you the truth I don’t embrace low carb any more than plant-based interventions. However, I’ve written more articles on low carb, mainly highlighting its usefulness in metabolic syndrome and obesity. I would be very happy if more of my patients adopted a low-fat plant-based approach.

  23. RichardLDL says

    Ok,

    thanks for the clarification. Good to hear and observe that you’ve broadened your scope. A much welcomed review of plant-based diets.

    -Thanks :)

  24. JKart says

    Based on the research studies mentioned in the article, it appears abundantly clear that confounding factors that would lead to better vegan CVD/CHD outcomes have not been accounted for. It is obvious for those who choose the vegan/vegetarian diet approach they also often choose other lifestyle choices that produce better cardio-health.

    Good for them! But their associating cardio-health exclusively to a plant-based diet and lower LDL is another example of blatant confirmation bias. A compulsive bias, almost obsessive in a way that makes one wonder.

    Per my own observational experience, I have found that a lot of vegan/vegetarians to possess unhappy, obsessed and intolerant personality behaviors, who make for miserable, always angry companion relationships. Their constant compulsion to frown upon others dietary choices and promote their superiority on their sleeves definitely makes for very negative-vibe dinner conversations.

    The worst, in my opinion, are those who openly want to dictate their diet choices on others, 24/7 – just really awful, unpleasant people to be around. I just don’t see that type of behavior from people who love their meat; they just seem to be non-pushy, happier and a lot more pleasant.

    Personally, I’ve wondered at times if these witnessed vegan/vegetarian ugly personality disorders are somehow tied to diet/nutrition (lack of LDL?). Are there any studies linking low LDL with aberrant mental conditions? With unhappiness? With irrational health fears?

    If there are such studies, I would not be surprised in the least.

  25. Mie says

    Richard,

    “there’s no Japanese paradox”

    Indeed. As the article I linked shows, the same “classic” risk factors predict CVD mortality in Japan, too.

    “Daniel Steinberg sharing the “fringe view”:”

    You’ve got to learn to read. By “fringe” I referred to those who claim that low-fat vegan diet is the only way to go, despite the lack of evidence. Not to Steinberg who wrote about Japan.

    As for vegan diets, Reijo already linked you a study in which low-carb vegan diet outperformed the low-fat one. As predicted, given the LDL-lowering effect of unsaturated fatty acids.

  26. Mie says

    JKart,

    “Personally, I’ve wondered at times if these witnessed vegan/vegetarian ugly personality disorders are somehow tied to diet/nutrition (lack of LDL?).”

    Personally, I wonder why you consider your anecdotes to be interesting and/or relevant to the topic at hand.

  27. RichardOrnishForLife says

    Mie,

    the studies by Jenkins et al are interesting. But, they haven’t outperformed Ornish et al. Ornish treatment still results in highest LDL reduction to my knowledge ever recorded in a randomized setting. And the low-fat variant probably result in greater weight loss since caloric dense foods are banned. I am saying this only to address the possible weight-loss confounder related to low-fat vegan diets and their effect on serum cholesterol levels.
    http://nutritionfacts.org/video/solving-the-mystery-of-the-missing-calories/

    However, thanks Jenkins & Co I will start to add more soy products to my diet. I already get plenty of gluten which has to my knowledge also has cholesterol lowering properties.
    http://www.medicalnewstoday.com/articles/277306.php

  28. Mie says

    Richard,

    “But, they haven’t outperformed Ornish et al.”

    Once again: comparing different studies with different study designs etc. etc. makes no sense, period. You need a comparative trial. Furthermore, Ornish is rather a multi-faceted lifestyle intervention including stress management, exercise etc. etc.

    “I already get plenty of gluten which has to my knowledge also has cholesterol lowering properties.”

    I haven’t heard of that and the study by Jenkins et al. doesn’t offer any detailed insight into the matter. There’s, however, evidence to the contrary: see e.g. this

    http://www.ncbi.nlm.nih.gov/pubmed/18348715

Let me know what you think!