Updated: Mar 11
If you have read part 1 "Reversing Heart Disease"you have come to understand that reversing heart disease is in fact a possibility. This possibility doesn’t rely on chance or mere faith.
What we see from the literature and interventional studies, is that if one follows the right protocol, one can take control of his or her own health. Symptoms of angina, or chest pain, can reduce within a matter of weeks. And if one persists over time, more significant changes can be realized, such as the opening up of major arteries that had been previously blocked or clogged. (1)
If you or your loved ones have ever experienced a heart attack or stroke, you have come to experience the reality of what your diet & lifestyle can do TO you.
Through this article, I hope you will also realize what diet & lifestyle can do FOR you as you will build up your physical health.
As you’ve learned, current guidelines have never proven to reverse heart disease like Dr. Esselstyn has. That may be because they are still quite lenient towards the addition and consumption of foods that may still negatively impact the progression of atherosclerosis, which underlies most cardiovascular disease.
Atherosclerosis is plaque (a combination of fat, cholesterol, calcium, and other substances found in the blood), that builds up in your arteries, resulting in clogged arteries or hardening of the arteries. The plaque reduces the amount of oxygen-rich blood getting to your heart, which can cause chest pain (also called angina).
Plaque can also lead to blood clots, which block blood flow and are the most common cause of a heart attack. (2)
The most successful nutritional intervention ever done on patients with cardiovascular disease, like heart disease, was performed by Dr. Caldwell Esselstyn.
We are going to see what this intervention is all about, look at what the science has to say and what else is beneficial based on current research.
Dr. Esselstyn's approach is quite different:
My nutrition program is quite different from most others. It is not about making moderate changes to slow the progression of heart disease. It is about embarking on a significant change in lifestyle that will actually arrest the disease‘s progression and selectively reverse its effects.
Dr. Esselstyn doesn’t beat around the bush. The reason you got to this place is because of your past diet and lifestyle decisions. Whether you follow these guidelines or not, is up to you, but do know that you have a choice and that you are in control of where you want your life to go.
Understanding key terms of the dietary protocol
To more fully understand the diet, a few terms need to be clarified first due to the importance placed on these by Dr. Esselstyn in his protocol.
Nitric oxide (NO)
The endothelium, a highly dynamic cell layer, covering the entire vascular system that is teeming with life and every bit as active as any other organ in the body.
In adults, approximately ten trillion cells form an almost 1 kg `organ'! (3)
The endothelium is involved in a multitude of massively important physiologic functions:
It controls the dilation and constriction, or widening and narrowing, of the arteries and other blood vessels.
It maintains blood fluidity and circulatory function.
It transports cells and nutrients.
It supports the growth of new blood vessels.
It maintains healthy walls of the blood vessels. (3)
Nitric oxide is a gas that flows through all your blood vessels, or the vascular system.
When nitric oxide is reduced, it leads to endothelial dysfunction, which sets you up for vascular damage and future coronary events, such as a heart attack or stroke. (6)
The Diet to Reverse Heart Disease
Esselstyn's diet has changed somewhat over the years.
He has adjusted it according to the scientific evidence of the effects certain foods can have on the endothelium.
There are quite a few rules in the dietary protocol of Dr. Esselstyn.
Let's go over them here.
They are accessible in a Facebook group called: ‘Esselstyn Plan Recipe Sharing and Conversation’
1) NO OIL
"Oils cause vasoconstriction and raise blood pressure as well as being damaging to the arterial endothelium (lining)."
Probably one of the most confusing rules, since most of us have learned we need healthy fats, from oils among others. However, there has been some evidence, as Dr. Esselstyn shows, where oils show to affect the endothelium negatively, even olive oil. (7)
He also acknowledges he has made substantial improvement with some patients, only after they finally excluded oil from their diets.
Since oils are the most energy dense food on the planet and offer little to no nutrition, Esselstyn's route is probably the safest way to go, especially if you need to reduce your LDL further. A pleasant side effect may likely come in the form of some weight loss as well.
Eat starches, non-starchy veggies and a max of 3 fruit servings. Starches are important for satiation so you do not get hungry. Being hungry is not sustainable. Starches are root veggies (potatoes, sweet potatoes), beans/peas/lentils, winter squash and 100% whole grains.
Exclusion of refined grains makes sense, because refined grains are linked to oxidative stress and endothelium dysfunction, (12), (13), (14) whereas whole grains reduce inflammation, that can worsen endothelial function, and are protective on their own. (15), (16), (17)
Dr. Esselstyn is mostly concerned that too much fruit causes an indirect rise in cholesterol, due to the rapid rise of blood sugar and secretion of insulin in response to the rapid rising blood sugar.
However, more current research suggests an association between fruit and LOWER cholesterol. (18)
In regard to blood sugar, fresh fruit consumption has shown it doesn't lead to higher blood sugar among diabetes patients, the people most sensitive to sugary foods. Fruit consumption actually showed that it lowers the risk of getting diabetes in the first place and it lowered the risk of dying from cardiovascular disease like heart disease among diabetics. (19)
Not all fruits are created equal though. There are certain types of fruit, like berries, that are significantly higher in antioxidants and can lower inflammation and LDL cholesterol, which are both risk factors for heart disease. (20)
Eat (chew) a fist-size (after cooking) serving of high nitrate veggies, with a few drops of balsamic vinegar or other vinegar, six times spaced throughout the day from breakfast to bedtime. This promotes the formation of nitric oxide (NO), the most powerful vasodilator we have, so arteries will dilate to their fullest. Esselstyn’s favorite 6 ‘greens’ for (NO) production are KALE, SPINACH, SWISS CHARD, ARUGULA, BEET GREENS, BEETS (yes, beets!) Dr. Esselstyn also has a ‘greens’ jingle which mentions bok choy, collard greens, mustard greens, turnip greens, napa cabbage, Brussels sprouts, broccoli, cauliflower, cilantro, parsley and asparagus.
This is probably one of the most important parts of the protocol.
Nitrate rich food contributes to the main extrinsic generation of nitric oxide through a series of steps; nitrate gets converted to nitrite, which in turn gets converted to nitric oxide. (21)
And it is this nitric oxide that does wonders for your endothelium, or the inside of your blood vessels.
Six times a day seems like a lot, but nitric oxide is a powerful guardian against plaque. Incorporating plenty of greens into your diet would be helpful regardless of having cardiovascular disease or not. You could always increase your portions over time, depending on the cardiovascular risks you have.
4) CHEW YOUR FOOD
Avoid all smoothies and juices. Chew your food.
The salivary glands play an important role in the production of nitric oxide. Hence Dr. Esselstyn says to chew your food, which is obviously the most optimal thing to do.
However, nitrates that pass our salivary glands eventually can be reabsorbed by them again, so your body is still able to produce nitric oxide. (21)
So, green smoothies can still be a nice addition to the diet.
A second note to make here is that some of these vegetables (spinach, beet greens and swiss chard) are extremely high in oxalic acid, which can cause problems especially to anyone with a history of kidney stones, or anyone who has used antibiotics. (22), (23)
Antibiotics can affect your microbiome to such an extent that it may affect the presence of some species that degrade oxalates in specific. (24)
This is especially important for those who juice or blend their greens, as oxalates appear to be absorbed more rapidly in liquid form than solid form. (23)
In my experience, if there are any underlying gut issues present (frequently after the use of antibiotics and/or long-term consumption of refined foods), the break down of oxalates may be impaired. This can then lead to an accumulation of oxalates, resulting in a myriad of health problems.
In short: Limit high oxalate greens like spinach, beet greens and (swiss) chard, even if you seem to have perfect digestion and kidney function.
5) HIGH FAT FOODS
Avoid all high fat foods like nuts, nut butters, coconut, olives, avocado, tofu, coconut, seeds (exception: 1-2 tablespoons of flax or chia seeds)
The no-oil rule makes sense in a way. After all, oils are refined and the source of oil, like nuts and seeds, has been stripped from the majority of its nutrients.
All these foods listed contain some amount of saturated fat, which is the fatty acid Dr. Esselstyn is on the lookout for the most.
He has 2 reasons for that:
Saturated fat clearly increases cholesterol as we know from 100's of metabolic ward studies, where you basically lock people up and control everything they consume. (25)
Dr. Esselstyn wants to minimize the risks and he has said before:
"With severe coronary disease, we don't always have the luxury of time. It is essential to start the healing of the endothelium, that vulnerable inner lining of the coronary arteries, as rapidly and completely as possible."
This could explain his die-hard approach towards fats and keep the diet as low in fat as possible. Healthy Omega-3 fats, in the form of flaxseeds, are encouraged on his plan, which provide a healthy dose of these essential fatty acids.
He is a little less strict when it comes to people who haven't had any coronary events and allows for some walnuts and avocado.
6) PROCESSED SUGARS
Avoid processed sugars like agave and maple syrup.
Refined sugars generally spike your blood glucose and your insulin and as a result harm the endothelium due to decreasing nitric oxide among others. (30)
Syrups, regardless of whether they are made from rice, or maple tree fluids, dates or the agave plant, have no notable nutrition, fiber and antioxidant content.
Empty calories are not recommended on this plan. A minimum intake of these kinds of calories is in my opinion justified.
Avoid caffeinated coffee.
Some studies have shown that FMD (flow-mediated dilation) - the ability of the artery to dilate - worsens after drinking caffeinated coffee. This is a clear sign of endothelial dysfunction. (31), (32), (33)
This is the reason Dr. Esselstyn recommends avoiding coffee.
Coffee is a complex substance and the way it affects the body depends on several factors, including your caffeine metabolism, how you brew your coffee, the antioxidant content (see here and here) of the coffee and whether you put something in your coffee like milk or sugar.
What would be a better alternative than coffee, is tea. In regards to endothelial health, tea, has not shown to worsen endothelial health. Quite the contrary, tea actually is strongly associated with improved endothelial function. (34)
On top of that, it also lowers cholesterol, including LDL, in people with and without cardiovascular risk. Although the lowering cholesterol properties were mainly found for green tea, not black. (35), (36), (37)
8) ANIMAL FOODS
Avoid all animal foods/meat/dairy/eggs
This may very well be the most strict rule for most people.
Animal food contains saturated fat. Since this plan is all about minimizing saturated fat, Dr. Esselstyn, in his first nutritional intervention, allowed for some low fat dairy, due to it being low in saturated fat. Perhaps to make it more acceptable for his patients.
Saturated fat clearly increases cholesterol as mentioned earlier. (25)
However, since then research has come forward that connected TMAO with a higher risk of dying from heart disease in both healthy people and people with already existing heart disease. TMAO is a pro-inflammatory metabolite produced by your intestinal microbiota, that feed on choline among others. (38), (39), (40)
Choline mainly resides in meat, dairy, fish and eggs, hence the elimination of these is advised.
Avoid salt in cooking and at the table, and be careful with condiments. The rule of thumb is no more milligrams of sodium in a serving as there are calories. Adding a SMALL amount of a higher sodium condiment to a whole low sodium meal is OK.
I know what you are thinking at this point. Dr. Esselstyn is a big meany, who just wants you to suffer unnecessarily. He's taking everything away you hold dear. Don't worry, we are not done yet. There is encouraging news coming up as well.
But first, why be careful with salt?
The last thing you want is for your arteries to become stiff. If you have ever held a raw spaghetti strain in between your fingers, you know how easily it breaks.
Once boiled it can curl and bend like a young gymnast, aspiring to become a yogi.
That's how you want your arteries to be.
In the general guidelines, optimal salt intake has not been clearly established. Complete restriction may be more harmful among heart patients. (45)
Although in these studies, nobody was on an Esselstyn type of diet.
Perhaps it's worth emphasizing this part then: "Adding a SMALL amount of a higher sodium condiment to a whole low sodium meal is OK."
I wouldn't use this as an excuse though to add your regular average amount of salt, because that is excessive and more likely to be harmful.
Dr. Esselstyn provides guidance on how to cook without oil.
Dr. Esselstyn recommends taking B12 and Vitamin D3
In Dr. Esselstyn's first intervention, he didn't use statins, the cholesterol lowering drug of choice. The reason why, is because statins were not yet available.
They were used during his second intervention.
Despite the fact that reversal of heart disease was clearly demonstrated in the first intervention, Dr. Esselstyn is of the opinion that you need to start avoiding harm and initiate the healing process as soon as possible, because time is a luxury you may not always have.
Statins can speed up the process and minimise more serious complications.
After all, the first symptom in 1 out of 4 patients is sudden death. (1)
The Good News
Dr. Esselstyn adds that it becomes easier over time, especially after 12 weeks, where every patient he has guided started to appreciate their newly developed taste palate:
"I have experienced this phenomenon myself and watched it in every patient with whom I've worked: after twelve weeks of eating no animal foods, dairy, or added oils, you lose your craving for fat. You then begin to appreciate more than ever before the natural flavor of grains, vegetables, legumes, and fruit. You develop a series of menus that you especially enjoy."
He adds that, as long as you stick with it, you will be able to adjust.
"The satisfaction of new tastes and, above all, the health rewards make it no contest."
It is well known that taste preferences can change over time. For sugary things it can even be within a few weeks, before you start adjusting to the absence of added sugar. (46)
Drastic times call for drastic measures
You have to decide for yourself where you stand right now and where you want to go. You have to decide yourself how you fill up your plate. Just know that, if you want the most change, your plate needs to be arranged very differently.
Whatever you do, I hope you are now already equipped with more knowledge to make a more informed decision for yourself.
With that in mind, here is one last quote from Dr. Esselstyn himself in regard to the addition of foods that can harm the endothelium:
If you do not throw any fuel at all on the fire, it cannot burn.
The science behind the diet
We've looked at the reasoning behind the individual dietary components and scientifically evaluated them. Nevertheless, certain elements still deserve a further explanation to create the most clear understanding possible.
A full and more in-depth scientific analysis on all key points will be covered soon.
This analysis will cover:
The role cholesterol plays in the progression of atherosclerosis;
A closer look at the importance of the endothelium;
Why Esselstyn's protocol is not the go-to treatment of choice;
Why federal guidelines are different;
The influence of multinational companies on dietary guidelines.
Be sure to check this out, to empower yourself fully so you can make the most informed decision for your health.