Vegetarian Diet – Will Going Vegan Reduce the Risk of Heart Disease?

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.

Will Heart Disease Be Eliminated if the World Goes Vegan?

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?

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Vegan Diet 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…”

Will Heart Disease be Eliminated if the World Goes Vegan?
Will we be seeing more heart surgeons having a good time on the golf course if the world goes vegan?

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 run out of business 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) …

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peter hawkins
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peter hawkins

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… Read more »

mike b
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mike b

Keep at it!!

Dave
Guest

I have to wonder if its the weight loss itself that’s a factor. Among other things weight loss will result in better blood sugar and lower blood pressure. I’ve also read that reduced abdominal fat results in better artery function. So again – maybe its the weight loss and it doesn’t matter how you achieve it. If you do it with a vegan diet, great. For others it might be a fish based diet or even “atkins”, but if you can lose the weight and keep it off that has to have a huge impact on your cardiovascular health.

Auggiedoggy
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Auggiedoggy

I started on pomegranate juice months ago for my bp. What I like about it is that unlike other fruit juices, this doesn’t cause a spike. I used to use beet root juice as it dilates the blood vessels but it is high in sugar and does spike your blood sugar.

Garry Lee
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Garry Lee

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.

Auggiedoggy
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Auggiedoggy

I wouldn’t trust that charlatan as far as I could throw him.

davewyman
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davewyman

Are you sure he isn’t a charlatan because you don’t trust him?

haplezz
Guest
haplezz

Gary Taubes is a salesman for the beef and dairy industry. Not to be trusted.

LDL Richard
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LDL Richard

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… Read more »

Dave
Guest

Several studies have shown that in fact, saturated fat is not associated with heart disease risk. There are likely other reasons the Ornish diet works, and a downside of Ornish is very few people can adhere to that kind of uptight lifestyle for a long period. Since the scientific evidence – aka real world data – indicate saturated fat is not associated with heart disease its a waste of time to continue focusing on it. For most people its going to be blood sugar/triglycerides/HDL problems.

https://www.sciencedaily.com/releases/2014/03/140305191429.htm

Auggiedoggy
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Auggiedoggy

I’ll go with the preponderance of research that indicates the association of saturated fat with heart disease rather than what “several” studies say.

haplezz
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haplezz

what do you mean very few people can adhere to the Ornish diet? The world used to contain a lot of rural societies where people, out of economic necessity, had to eat a low-fat whole-food diet! People were doing fine then for centuries. Then along came the modern world, and the refined carbs, and the cheap farmed beef, then… all of the sudden, you now say people can’t adhere to the rural diet??? Seems to me like people just are carnivores lacking discipline. In that case, fine, let them eat the new lavish diet of their modern world and wither… Read more »

Sigfús
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Sigfús

Thanks you Axel for yet another great post!

Mie
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Mie

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… Read more »

Doctor Vedic
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Doctor Vedic

Even with the absence of a raondomized controlled trial, this larger study is surely hypothesis generating? https://dresselstyn.com/JFP_06307_Article1.pdf

Mie
Guest
Mie

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.

LDL Richard
Guest
LDL Richard

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… Read more »

Doctor Vedic
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Doctor Vedic

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.

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

Richard LDL
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Richard LDL

@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… Read more »

Mie
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Mie

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… Read more »

Mie
Guest
Mie

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… Read more »

Richard LDL
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Richard LDL

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. https://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… Read more »

Mie
Guest
Mie

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. https://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,… Read more »

Doctor Vedic
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Doctor Vedic

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… Read more »

peter hawkins
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peter hawkins

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
Admin
Axel F Sigurdsson

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
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Peter Hawkins

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?

Doctor Vedic
Guest
Doctor Vedic

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

Axel F Sigurdsson
Admin
Axel F Sigurdsson

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.

RichardOrnishForLife
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RichardOrnishForLife

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… Read more »

RichardOrnishForLife
Guest
RichardOrnishForLife

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?

Mie
Guest
Mie

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… Read more »

RichardOrnishForLife
Guest
RichardOrnishForLife

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… Read more »

Mie
Guest
Mie

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.

https://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.

RichardOrnishForLife
Guest
RichardOrnishForLife

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… Read more »

RichardLDL
Guest
RichardLDL

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… Read more »

Axel F Sigurdsson
Admin
Axel F Sigurdsson

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.

RichardLDL
Guest
RichardLDL

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 🙂

JKart
Guest
JKart

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… Read more »

Mie
Guest
Mie

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.

Mie
Guest
Mie

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.

RichardOrnishForLife
Guest
RichardOrnishForLife

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. https://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… Read more »

Mie
Guest
Mie

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

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

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