Foreword: Changing the Treatment Paradigm for Coronary Artery Disease (continued)
SHIFTING THE PARADIGM
Caldwell B. Esselstyn, Jr., MD
First national conference: Eleven years into my ca reer as a surgeon, I became disillusioned with the treatment paradigm of US medicine in cancer and heart disease. Little had changed in 100 years in the management of cancer, and in neither heart disease nor cancer was there a serious effort at prevention. I found the epidemiology of these diseases provocative, however: Three-quarters of the humans on this planet had no heart disease, a fact strongly associated with diet.
In 1985, I began a small research study focused on controlling coronary disease with diet. By 1991, the results of that study were encouraging enough to convene that first conference. There, I challenged a panel of experts to answer the question, “What do you tell the patient who says, ‘I’ll do anything, but I never want to have heart disease,’ or, ‘I’ve had a heart attack, and I never want another?”‘
One panelist replied, “Have him eat beans, beans, and more beans.” Another said that it was time for the public to embrace a plant-based diet. Those opinions contrasted starkly with the 1989 National Research Council guidelines in Diet and Health developed just 2 years before and led 10 of 13 faculty to agree on several concepts:
Present nutritional guidelines of government and national health organizations do not provide a maximal opportunity either to arrest or to prevent coronary artery disease.
The 1989 National Research Council guidelines recommended a diet in which no more than 30% of the calories would come from fat and that blood choles terol levels should be 200 mg/dL,1 although many scientists believed that greater health benefits would derive from a diet considerably lower in fat. These levels were unacceptable to the panel of experts that met in Tucson. Because we now know that 35% of heart attacks occur in people with total cholesterol levels of 150–200 mg/dL,2 and a target level of only 200 mg/dL guarantees that millions of US citizens will perish of coronary disease. Studies demonstrate that persons following present guidelines will have faster rates of disease progression than persons achieving lower serum lipid levels through diet and/or lipid- lowering drugs. Why is there a reticence to provide the public with guidelines that will spare them this disease or its progression?
Speculation about the degree of public compliance with a very low-fat diet must not alter the accuracy of the recommendations.
The National Research Council position was that a dietary fat recommendation lower than 30% would be too frustrating for those attempting to achieve a sig nificant reduction. Although it is uncertain to what extent people will adopt the advice because of habit, custom, and different tastes and textures of foods, it is nevertheless scientifically and ethically imperative to inform the public what constitutes an optimal diet. We must tell the public the truth about what is best for their health and let them decide their degree of compliance.
The optimal diet consists of grains, legumes, vegetables, and fruit, with 10% of its calories coming from fat.
A diet that would achieve superior results in de creasing atherosclerosis is a 10–15%-fat diet provided largely by a variety of grains, vegetables, fruits, and legumes. This diet minimizes the likelihood of stroke, obesity, hypertension, type-2 diabetes, and cancers of the breast, prostate, colon, rectum, uterus, and ovary.3 There are no known adverse effects of such a diet when mineral and vitamin contents are adequate.
These experts advocated a plant-based diet to achieve optimal lipid levels without requiring the ma jority of the population to consume cholesterol-reducng drugs. As long as Western society consumes but ter, eggs, cream, cheese, oils, ice cream, fish, poultry, and meat on a daily basis, the common Western dis eases will persist. No amount of technology or mediation will prevent these illnesses. That is why the faculty recommended the plant-based diet.
Children and adolescents require major attention to develop early habits of optimal nutrition. Schools should assume a significant leadership role in achiev ing this goal.
Because coronary disease begins in youth, primary prevention must begin there also. Changing nutrition patterns in children is much easier than trying to overhaul ingrained patterns in adults.
Second national conference: By 1997, the evidence had mounted from epidemiologic studies, pathophys iologic discoveries, lipid-lowering drug trials, and diet and lifestyle modification programs that noninvasive therapies could arrest or reverse heart disease.
Before the first conference, the United States– China Study,4 a major epidemiologic study of diet and disease, had demonstrated the link between dietary fat and heart disease, certain cancers, and other “Western” diseases. Its second phase, completed since the first conference and soon to be published, strengthens the evidence of that link. Data from the Framingham Heart Study clearly confirmed that atherosclerosis is not a concern when cholesterol levels are ~ 150 mg/ dL. In 1992, the Bogalusa Heart Study5 demonstrated that diet contributes to coronary artery disease risk starting in childhood.
Four major trials using 3-hydroxy-3-methylglu- taryl coenzyme A (HMG-CoA) reductase inhibitors, or “statins,” demonstrated the benefits of lipid-lower ing medical therapy. In 1994, the Scandinavian Sim vastatin Survival Study (4S)6 showed that such treat ment could decrease the relative risk of death and coronary events in patients with demonstrated heart disease without increasing the risk of death from other causes. In 1995, the West of Scotland Coronary Prevention Study (WOSCOPSY showed similar results in men with hypercholesterolemia and no history of in farction. In 1996,. the Cholesterol and Recurrent Events (CARE) Trial8 demonstrated reductions in the relative risk of infarction and death in patients with heart disease who had “average” total cholesterol 1evels (a mean of 209 mgldL). And in 1997, the Post Coronary Artery Bypass Graft (Post-CABG) Trial9 showed that aggressive lipid lowering with medical therapy decreases the progression of atherosclerosis in bypass grafts.
Basic research has revealed more about the patho physiology of coronary artery plaque, showing that the lesions susceptible to rupture and resulting in infarction are not the major stenotic ones we see on angiography but smaller, hemodynaniically insignifi cant plaques that can be affected by lipid-lowering therapy. Meanwhile, innovators had developed cre ative and safe nutrition programs for schools and had demonstrated that children and adults can accept and make major dietary and lifestyle changes that decrease their coronary disease risk.
So with the “modest” goal of shifting the treatment emphasis away from invasive interventions that treat symptoms toward noninvasive therapies that treat the cause, the second conference brought together the leaders of these studies–a rare nucleus of expertise– with physicians, nurses, nutritionists, and other health professionals. The goal is modest because we now know that we can manipulate the. critical factors that cause heart disease.
These expert clinicians, basic scientists, and epidemi ologists presented their findings in plenary sessions, dis cussed the significance of their findings in panel discus sions with the audience, and conducted seminars with the registrants on implementing therapeutic and dietary change. Even the meals served at the summit–which were 9.5–11% fat–demonstrated that a very-low-fat, plant-based diet can be tasteful, varied, and attractive. As an added reinforcement to the importance of lipid levels, registrants were given the opportunity to have a free lipid profile taken by Florida Hospitals.