Caldwell B. Esselstyn, Jr, MD; Stephen G. Ellis, MD;
Sharon V. Medendorp, MPH; and Timothy D. Crowe
Background. Animal experiments and epidemiological studies have suggested that coronary disease could be prevented, arrested, or even reversed by maintaining total serum cholesterol levels below 150 mg/dL (3.88 mmol/ L). In 1985, we began to study how effective one physician could be in helping patients achieve this cholesterol level and what the associated effect of achieving and maintaining this cholesterol level has on coronary disease.
Methods. The study included 22 patients with angiographically documented, severe coronary artery disease that was not immediately life threatening. These patients took cholesterol-lowering drugs and followed a diet that derived no more than 10% of its calories from fat. Disease progression was measured by coronary angiography and quantified with the percent diameter stenosis and minimal lumen diameter methods. Serum cholesterol was measured biweekly for 5 years and monthly thereafter.
Results. Of the 22 participants, 5 dropped out within 2 years, and 17 maintained the diet, 11 of whom completed a mean of 5.5 years of follow-up. All 11 of these participants reduced their cholesterol level from a mean baseline of 246 mg/dL (6.36 mmol/L) to below 150mg/dL (3.88 mmol/L). Lesion analysis by percent stenosis showed that of 25 lesions, 11 regressed and 14 remained stable. Mean arterial stenosis decreased from 53.4% to 46.2% (estimated decrease=7%; 95% confidence interval [CI], 3.3 to 10.7, P<.05). Analysis by minimal lumen diameter of 25 lesions fotind that 6 regressed, 14 remained stable, and 5 progressed. Mean lumen diameter increased from 1.3 mm to 1.4 mm (estimated in crease=0.08 mm; 95% CI, --0.06 to 0.22, P=NS). Disease was clinically arrested in all 11 participants, and none had new infarctions. Among the 11 remaining patients after 10 years, six continued the diet and had no further coronary events, whereas the five dropouts who resumed their pre-study diet reported 10 coronary events.
Conclusions. A physician can influence patients in the decision to adopt a very low-fat diet that, combined with lipid-lowering drugs, can reduce cholesterol levels to below150 mg/dL and uniformly result in the arrest or reversal of coronary artery disease.
Key words. Coronary disease; cholesterol; nutrition; atherosclerosis; preventive medicine. (J Earn Pract 1995; 41:560-568)
By the mid-1980s, experimental studies on animals and epidemiological studies had indicated that total serum cholesterol levels below 150 mg/dL (3.88 mmol/L)were associated with the absence of atherosclerotic heart disease and with possible arrest and even reversal of the effects of heart disease."2 It was also evident that very low-fat diets, with and without drugs, could reduce progression and achieve partial regression of coronary artery disease in humans.3-'5
These studies caused one of the authors (C.B.E) to rethink the treatment of heart disease, as well as his own lifestyle. Aware that medical, angiographic, and surgical interventions were treating only the symptoms of heart disease and believing that a fundamentally different approach to treatment was necessary, he identified through referrals a number of heart patients willing to adopt a program of major dietary change and to be followed for several years so that the effects of the regimen could be documented.
This article describes the medical changes that occurred in these participants after maintaining a very low-fat diet over several years. It presents the results of an exploratory study on what a single physician can accomplish with his or her patients, without additional funding, expensive interventions, or a large medical infrastructure. .
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