COMMENTARY

Plant-Based Diets as Medicine: Food for Thought

Michelle L. O'Donoghue, MD, MPH; Kim A. Williams, MD; Caldwell B. Esselstyn, Jr, MD

Disclosures

April 30, 2018

Michelle L. O'Donoghue, MD: Hi. I am Dr Michelle O'Donoghue from Brigham and Women's Hospital in Boston. I'm thrilled to have joining me today two people I greatly admire for the work they have done in diet and better understanding the role that a plant-based diet may have for preventing and treating heart disease. First joining me is Dr Kim Williams, who is the former president of the American College of Cardiology. He is also the chief of cardiology at Rush University Medical Center. Welcome, Kim.

I would like to see it start from physicians. I would like to see that every patient who has a disease that can be helped by plant-based nutrition is afforded it.

Kim A. Williams, MD: Thanks for having me.

O'Donoghue: Also joining me is Dr Caldwell Esselstyn, whom people may recognize from the movie "Forks Over Knives" as well as other documentaries about plant-based diets. He is the director of the Cardiovascular Disease Prevention and Reversal Program at Cleveland Clinic Wellness Institute. Welcome, Dr Esselstyn.

Caldwell B. Esselstyn, MD: Thank you, Michelle.

Dr Esselstyn's Journey to a Plant-Based Diet

O'Donoghue: People would be very interested to know about our personal journeys. Dr Esselstyn, how did you find yourself embracing a plant-based diet?

Esselstyn: This is kind of a strange journey. I trained as a general surgeon, and after I finished my tour of duty in Vietnam as a combat surgeon, I was offered a position at the Cleveland Clinic in general surgery. Eventually, I became chairman of the Breast Cancer Task Force.

It was in the late 1970s and early 1980s when I became especially disillusioned with the fact that for the many women I was doing breast surgery, I was doing absolutely nothing for the next unsuspecting victim. That led to a bit of global research where I found it quite impressive that in such countries as Kenya, breast cancer was 30-40 times less frequent [than in the United States]. In rural Japan in the 1950s, breast cancer was very infrequently identified, and as soon as Japanese women migrated to the United States (and the second and third generations), they had the same rate of breast cancer as their Caucasian counterparts.

Perhaps even more powerful was cancer of the prostate. In the entire nation of Japan in 1958, how many autopsy-proven deaths were there from cancer of the prostate? Eighteen.[1] [Editor's Note: Two per 100,000 men died of prostate cancer in Japan in 1958].[2] This is perhaps the most mind-boggling public health figure that I've ever heard.

It was around then that I began to see that cardiovascular (CV) disease was virtually nonexistent in all these other nations and recognized that it was the number one killer of women and men in Western civilization. It seemed to me that there may be so much more bang for the buck if we could get people to eat to save their heart. They would also be saving themselves from the common Western cancers of breast, prostate, colon, and perhaps pancreas. Then in 1985, when I was still actively involved with surgery and didn't have time for a large study, we did a small study with about 18 patients who were seriously ill with CV disease.[3]

O'Donoghue: We want to circle back to that, because you did pave the path for demonstrating how a diet-based approach can actually reverse heart disease in some instances, which is quite compelling.

Dr Williams' Journey to a Plant-Based Diet

O'Donoghue: Dr Williams, how did you find yourself falling into a plant-based lifestyle?

Williams: Interestingly enough, as a young person, my mom had gone back to school and read the same kind of information. One day she came home from college and said that we were all going to be vegetarians. Of course, I followed it pretty much until I was out of the household. Then when I was married, there were all the misconceptions that you have to eat chicken and fish and protein. If I had just had the ability to do a search engine on salmon and chicken to find out exactly how much cholesterol they had, then I would have been prepared for what typically happens when people get a little older. In my case, my days as a professional tennis player were over and my days of intense coaching were over, and all of a sudden I was a nuclear cardiologist sitting in my lab most of the time. My low-density lipoprotein cholesterol (LDL-C) took off.

My quest was very personal. I had actually heard about Dean Ornish and heard about plant-based nutrition. I was just very fortunate that the month I found out about my cholesterol being elevated was when the "portfolio" diet[4] (nuts, plant sterols, avoidance of animal products) specifically addressing inflammation and LDL cholesterol was published. I went on it and 6 weeks later, my LDL-C had gone from 170 mg/dL down to 90 mg/dL.

O'Donoghue: Isn't that remarkable?

Williams: It really was.

Where Do Cows Get Protein?

O'Donoghue: I have followed a plant-based diet now for several years, and the questions I get most frequently are, where are you going to get your calcium if you don't have dairy? And where do you get your protein from? What is your usual response when people ask those questions?

Williams: The protein one comes up all the time. It is interesting that when you lead patients down a logical pathway, they come to the conclusion themselves. Whenever they say, "I can't do that, doctor; where would I get my protein?" I ask, "You're going to eat a cow for protein? Where did that cow get protein?" You get a quizzical look, and then the light bulbs go off. All large mammals on the planet—elephants, horses, even the largest dinosaurs—are plant-based animals, so there must be protein in vegetables.

Once that light bulb goes off, patients really open up to think differently about food. They realize that their training was wrong, their dietitian was wrong, and their physicians (who typically die of heart disease,[5] by the way) are not giving them information. So they come to the conclusion that they can actually do plant-based nutrition.

O'Donoghue: Your comment about what physicians are dying from is scary but true. Like many, I never really gave nutrition much thought in terms of its relationship to heart disease, and I'm a cardiologist. You think that you should eat healthier to maybe reduce cholesterol, but that medications will really move you forward. I've come full circle and really appreciate that diet should have the first-line role.

[W]e found that a number of them were truly reversing their disease...

Plant-Based Diets Reduce Heart Disease

O'Donoghue: Dr Esselstyn, you talked about your pilot study[3] where you carefully managed a handful of patients and helped them on their journey. These were patients who thought they had passed the point of no return with their heart disease.

Esselstyn: Right. These patients were asked to eat plant-based nutrition, meaning they would avoid foods we knew were going to injure their endothelium—that delicate innermost lining of the artery that produces the magic molecule of nitric oxide which is the great salvation and protector of all our vasculature. We asked the patients not to have a drop of any kind of oil, eat nothing with a mother or a face (meat, chicken, fowl, turkey, eggs), and avoid all dairy (cream, butter, cheese, ice cream, or yogurt). They were asked to be very easy on sugar.

It was really quite exciting to see. First they began to lose weight, and then they began to lose their symptoms. When we carefully studied them, we found that a number of them were truly reversing their disease and that was what was so powerful and so exciting. At the time, in 1991, I was so excited with what we were seeing that I asked Dean Ornish, Colin Campbell, William Castelli, Ernst Wynder, and a number of real other pioneers to have the first national conference on the elimination and reversal of heart disease. That is when I got to know Colin Campbell quite well.

It was very exciting to think that it was as simple as what somebody could eat. If you take almost anybody today with CV disease and spend enough time with them to get them to embrace the science, which you can put into a simplistic vocabulary, they realize that you are empowering them—it's not a drug, not a procedure, not an operation. You are empowering them as the locus of control to halt and reverse their disease. They can do it themselves.

O'Donoghue: It changes a patient from feeling like they are a victim of fate to giving them back that sense of power, which is very important. When I first have the conversation, a lot of patients say, "I could never give up meat. I could never give up dairy." The remarkable thing is, as you help them through their journey, their quality of life improves so much that they then could not be more thankful that they changed their course.

Esselstyn: The Western diet looks good, tastes good, and smells good, and yet it is injuring quietly. You do not feel pain when you eat those foods. On the other hand, the whole food plant-based diet looks good, smells good, and tastes good, and quietly heals you.

O'Donoghue: You feel better at the end of the day as well.

Esselstyn: And it does not wreck the planet.

We have a system that is based almost completely on sick care instead of healthcare.

Growing Interest in Plant-Based Nutrition

O'Donoghue: Recently, there seems to be a groundswell movement, and more people are talking about plant-based diets and lifestyles. Some high-profile athletes have been touting it as well. Dr Williams, what do you think it's going to take for clinicians to start prescribing it in everyday practice?

Williams: It's interesting that there has been a transition. I read an article the other day saying that there has been a 600% increase in vegans over the past 3 years in the United States.[6] That is encouraging, but it's happening for lots of reasons. We are going out and giving talks, and people are changing themselves and their families. There is some success, but I like your question.

I would like to see it start from physicians. I would like to see that every patient who has a disease that can be helped by plant-based nutrition is afforded it, and I would like to see it affecting the life of physicians and their families as well.

We have a lot of issues, particularly in cardiology. We talk about the quadruple aim[7]—switching over from just talking about patient access and quality and cost of care to talking about physician health and wellness. That includes the physician having a good basis of exercise, nutrition, and lifestyle, so that they can bring the message of health and healing to their patients.

We have a system that is based almost completely on sick care instead of healthcare. We call it "healthcare," but it really is sick care. What does it take? One of the most powerful things we can do to get rapid adoption of any kind of therapy is do large randomized studies that people cannot avoid. We have them in nutrition, like with the PREDIMED study on the Mediterranean diet.[8] People look at those Kaplan-Meier curves and say they want that for their patient, not realizing that a 30% decrease in heart attack, stroke, and death is a 70% persistence. We've got to do better than that.

The Institute of Medicine put out a guide for guidelines[9] and said there should be [at least] 50 people in each group, randomized and followed up. You can make guidelines from good observational longitudinal studies, but they will never get that level IA that changes people's minds. It will always be a question in their mind as they are dying. We have to double down and do this.

O'Donoghue: People look for a lot of excuses not to make a lifestyle change before they realize how much it's going to benefit them. I think you are exactly right. Studies need to be done, but they have been challenging. I hope we move in that direction.

Williams: I would challenge them myself. Dr Esselstyn, for example, did wonderful studies. The group that is noncompliant is used as a control group, and that is an excellent way to do it, except guideline committees are not going to take that as the gold standard. When you start getting P values like his that are so solid, how do you ethically randomize someone to a Mediterranean diet? It's not easy, but we have to do it somehow and assume that it is going to be at least 30% better than what they are eating now.

Parting Thoughts

O'Donoghue: Absolutely. One thing that often comes up is whether a partway approach is sufficient. People ask, "What if I embrace just a little bit more a plant-based diet into my lifestyle? Is that sufficient?"

When in our history of medicine have the heavens opened and given us this tool in our toolbox where we can eradicate illness, and all you have to do is eat delicious food.

Esselstyn: I'm asked the question, "How about if I just do it halfway?" My reply to that quite frankly is, "You can have a small heart attack, you can have a small stroke, you can have a modest amount of erectile dysfunction. But I think if you're really going to keep your vessels clean and protect yourself as you become more senior, especially from things like vascular dementia, [you need to follow a full plant-based diet]."

With total respect for the man I admire on my right, my parting message would be: What do we do in the meantime before the studies come? Do we just plod along in the good old American way, or do we say, "There are data that I cannot hurt my patient if I ask him or her to eat plant-based."

Being in this movement for 30 years and talking to kindred spirits, you begin to see that CV disease isn't the only illness that is positively affected by this. We know of people with multiple sclerosis who have reversed their disease. We know of people who have had hypertension, diabetes, or stroke, and it's gone. This includes ulcerative colitis, Crohn disease, lupus, rheumatoid arthritis, allergies, and asthma. When in our history of medicine have the heavens opened and given us this tool in our toolbox where we can eradicate illness, and all you have to do is eat delicious food with no side effects?

O'Donoghue: It makes such perfect sense. I think slowly people are getting there, but it has been taking some time. Thank you for discussing this. It's important to impart this message to as many people as we can.

I want to thank you both so much for joining me today. Signing off for Medscape, this is Dr Michelle O'Donoghue.

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