Changing to a whole foods plant based diet typically results in dramatic falls in blood cholesterol levels. The medical myth that diet has little effect on cholesterol stems from the fact that the current cholesterol lowering diet recommended in Australia is not effective. A diet rich in animal “protein” foods, with or without vegetable oil, will always raise cholesterol. In general, animal products raise blood cholesterol and whole plant foods lower blood cholesterol.

Cholesterol, fats and fibre

Dietary cholesterol raises blood cholesterol. However saturated fat has a much more powerful effect on raising blood cholesterol. Saturated fats stimulate the liver to synthesize more cholesterol which makes a big difference because most of the cholesterol in our bodies is made by the liver rather coming from the diet. This is why eggs, which are high in cholesterol but relatively low in saturated fat, don’t raise cholesterol as much as some other animal products. (Eating more eggs, however, is associated with more artery disease).

Only animals produce cholesterol. It is found in meat, chicken, fish, eggs and dairy foods. All plant foods are free of cholesterol. Most animal foods contain at least moderate amounts of saturated fats. Some commonly eaten foods such as cheese are alarmingly high in saturated fats. Chicken and lean red meat are promoted as low fat “protein” foods but both contain significant amounts of saturated fat (and to make matters worse, much of the red meat and chicken eaten by those on high protein diets are not the super lean cuts that are used for advertising these foods). Some plants do contain saturated fats: palm oil, coconut, and some nuts are actually quite high in these. But unsaturated fats are more common in the plants.

Only plants produce chemicals called phytosterols which prevent the intestine from reabsorbing the cholesterol that the liver has disposed of through bile. Oats are just one example of a whole plant food that contains sterols that lower cholesterol. Oats are also a nutritious mix of fibre, nutrients, protein and slow release carbohydrate. Cholesterol lowering sterol enriched margarine has no fibre, almost no nutrients, is very high in calories and contains considerable saturated fat. No contest.

Some types of fats produce favourable looking changes in blood cholesterol but do not reduce heart risk. Olive oil for example, improves the ratio of good and bad cholesterol but is still damaging to arteries. The solution to the health damaging effects of a fatty diet is to eat less fat not different fat.

For cholesterol lowering properties, whole plant foods win. They have no cholesterol, are generally extremely low in saturated fats, and they inhibit cholesterol reabsorption. The heart health benefits of whole plant foods go beyond just lowering fasting cholesterol. Plants are rich in phytochemicals that have antioxidant and anti-inflammatory qualities that reduce chemical damage to the endothelium and dampen down the inflammatory response in the artery wall. See Endothelium and atherosclerosis. Once again, the health damaging effects of the usual Australian diet are not just due to what people are eating but also what they are not eating.

The effectiveness of diet

The standard cholesterol lowering diet recommended by Australian health authorities has changed little over the past forty years. It includes generous quantities of meat, dairy foods and oils. The fat content of up to 30% of calories is still high by international standards and the meat and dairy, and even the margarine and olive oil contribute substantial amounts of saturated fats. The fibre content is low. The bottom line is that this type of diet has failed the field tests, lowering blood cholesterol by less than 10%. This has led the medical profession and the public to conclude that diet has very little effect on blood cholesterol and that high blood cholesterol must be caused by genes and other factors.

The main effect of genes is to influence the extent to which your cholesterol will become elevated when your body is exposed to a diet rich in animal products and low in dietary fibre. If you live on a low-fat plant based diet these “susceptibility” genes become irrelevant. The Apo E4 cholesterol gene mutation causes much anxiety in those that have it as it is associated with dementia and heart disease, but international studies suggest that these risks are negated by a heart friendly diet. There are some exceptions: one in every few hundred Australians carry a genetic mutation that causes high LDL cholesterol levels. Even these individuals can lower their cholesterol to moderate levels by diet alone.

All communities who consume low-fat plant-based diets have very low blood cholesterol levels. The China Study observed that in some regions average blood cholesterol levels were as low as 2.4. However some argue that these people were living a non-Western lifestyle and perhaps their low cholesterol was related to hard physical work, low stress or malnutrition. Previous theories attributing their low cholesterol levels to genetic or childhood epigenetic changes have been dispelled by the rapid rise in cholesterol and heart disease in newly Westernised Chinese city dwellers. This has occurred within one generation.

There are numerous studies showing that a low-fat mostly plant-based diet results in a dramatic reduction in blood cholesterol levels in those living an otherwise normal Western lifestyle. Nathan Pritikin became well known following the success of his live-in program which included a very low-fat predominantly plant-based diet and exercise program. Blood cholesterol levels fell by 25% in those that started with average cholesterol levels and by 36% in those who started with even higher levels. In the Lifestyle Heart Trial conducted by Dr Dean Ornish, average cholesterol levels also fell by about 25% (without cholesterol lowering drugs). Dr Caldwell Esselstyn virtually cured heart disease in a group of 18 subjects whom he treated for over 20 years with a no oil plant based diet. Average cholesterol levels fell from 6.3 to 3.5 (some subjects also used medication). Rip Esselstyn, author of Engine2, recorded average decreases in cholesterol of about 30% in those that followed his no oil plant based diet.

It seems that a whole foods plant based diet typically lowers blood cholesterol by 30%. The fact that falls in blood cholesterol are greater for those with higher initial levels makes sense because what is in effect happening here is that blood cholesterol levels are falling to levels that are normal for humans.

See also:

• Normal Cholesterol
• Endothelium
• Return to Heart Health main page

Resources

• Blocking the First Step of Heart Disease – In this short video, Dr Michael Gregor discusses how we can prevent atherosclerosis in our coronary arteries by increasing our intake of fiber-containing plant foods and decreasing our intake of trans fat, saturated fat, and cholesterol found in junk food and animal products.
• Cancer Reversal Through Diet? – This video starts off by discussing a landmark study by Dr Dean Ornish, way back in 1993, which showed that intensive lifestyle changes can reverse atherosclerosis, opening up narrowed arteries. The discussion then moves to cancer prevention: a welcome side effect for a heart disease treatment program.
• Lower Your Cholesterol Using Fiber! – Linda Carney, MD
• Cholesterol Prevention and Cholesterol Diet – PCRM, includes link to a 4-page PDF factsheet. See also Cholesterol and Heart Disease
• TEDxCambridge – Caldwell Esselstyn on making heart attacks history – Dr Caldwell Esselstyn discusses the results of his heart disease reversal diet.
• Vegans with High Cholesterol – Sarah Taylor

Page created 13th January 2013
Last updated 24th September 2018

There has been so much media coverage lately about saturated fat, with newspaper and magazine articles, and even peer reviewed journal articles claiming that saturated fat isn’t that bad after all. This news is well received by people who love to hear good news about their bad habits. It allows people to avoid the difficulty of change and to keep eating the foods that are making them sick.

Lurking in the background behind the saturated fat issue are powerful industries (in particular the dairy industry) whose products are relatively high in saturated fats. Most guides to healthy eating include the advice to eat less saturated fat, but they shy away from naming those foods we should eat less of for fear of offending the meat and dairy industries. So we end up with recommendations that mix food advice, e.g. eat more fruit and vegetables with nutrient advice e.g. eat less saturated fat. Why not just say “eat less cheese”?

The saturated fat/high cholesterol/atherosclerosis/heart disease link is well established. Nothing has changed to refute decades of research which link high fat animal products with heart disease, diabetes, cancer and other diseases. The only real challenge to the ‘saturated fat is bad’ paradigm is whether some of the adverse effects of foods high in saturated fat might be due to other features of these foods such as animal protein, carnitine, choline or haeme iron. For practical purposes it doesn’t really matter whether it’s the saturated fat or something else – it’s still meat and dairy foods that are contributing to chronic disease.

Many of the stories woven to refute the health hazards of saturated fat are based on several key scientific publications:

1. Chowdhury, R., Warnakula, S., Kunutsor, S., Crowe, F., Ward, H. A., Johnson, L., . . . Di Angelantonio, E. (2014). Association of Dietary, Circulating, and Supplement Fatty Acids With Coronary Risk: A Systematic Review and Meta-analysis. Annals of Internal Medicine, 160(6), 398-406.
2. Malhotra, A. (2013). Saturated fat is not the major issue. BMJ, 347, f6340. doi: 10.1136/bmj.f6340
3. Siri-Tarino, P. W., Sun, Q., Hu, F. B., & Krauss, R. M. (2010). Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease. American Journal of Clinical Nutrition, 91(3), 535-546. doi: 10.3945/ajcn.2009.27725 (NB This research was funded by the dairy industry)

It all sounds quite plausible until you actually look at the fine detail of the evidence given, which takes considerable time and skill… few health professionals do this, so what hope has the general public got? We are indebted to people like Plant Positive, Dr John McDougall, Dr Michael Greger, T Colin Campbell and others who invest the time and effort to cut through the smoke and mirrors. Below is an extensive list of resources that will help you understand what’s behind the sensational headlines.

Resources

These videos from Dr Michael Greger explain how industry works to confuse the public on the saturated fat issue. The second video presents powerful evidence that saturated fat does indeed raise blood cholesterol and the risk of heart disease:

• The Saturated Fat Studies: Buttering Up the Public – (4 min. video)
•  The Saturated Fat Studies: Set Up to Fail – (8 min. video)

An extensive analysis of this topic is provided by Plant Positive. His whole website (and YouTube channel) is designed “to correct specific falsehoods and flawed arguments that pervade the popular and academic discussion of nutrition”:

• PlantPositive: Making the Case for Plant-Based Nutrition (main website)
• How Time Magazine Sacrificed Its Standards to Promote Saturated Fat – This post addresses the June 2014 Time Magazine article ‘Eat Butter’
• Recent articles by Drs Chowdhury and DiNicolantonio – This post addresses the Chowdhury article
• Malhotra’s Major Issues, Part 1 – This post addresses the Malhotra article (see also part 2)
• Siri-Tarino’s Meta-Analysis, Part 1 (Saturated Fat and Heart Disease) – This post addresses the Siri-Tarino/Krauss article (see also part 2)
• Catalyst Corrected 1, The History of Diet-Heart, Part 1 – Plant Positive also addresses the irresponsible claims made on ABC’s Catalyst program in a 6-part series (see also parts 2-6)

Addressing the Siri-Tarino and Chowdhury Saturated fat articles:

• Saturated Fat and Heart Disease Meta-Analyses: Were Scientists Wrong? – Travis H L, 13 December 2014
• Dr. McDougall’s Comments on the National Headline About the March 18, 2014 Annals of Internal Medicine Article Suggesting Saturated Fat (Dairy, Meat, and Eggs) Is OK to Eat
• Saturated Fat: Still Unhealthy After All These Years, Pt 1 – Jeff Novick, RD also Part 2 which addresses saturated fat from the plant-based world: Saturated Fat: Still Unhealthy After All These Years, Pt 2
• Low Carb Hot Air—Again, again and again! – T Colin Campbell, October 2014
• Oversaturation of Fat in the Media – Susan Levin, August 2014
• Time Magazine says “Eat Butter” – Big Food’s Last Ditch Efforts – Dr John McDougall, 18 June 2014
• A Fallacious, Faulty and Foolish Discussion About Saturated Fat – by T Colin Campbell, April 2014
• Clearing Up The Confusion Surrounding Saturated Fat – by Travis H L, March 2014 “This analysis examines some of the serious omissions in several of the widely cited meta-analysis papers & focuses primarily on how saturated fat and low-carb diets influences fatal heart disease, an important end point that is largely ignored by the authors of these meta-analysis papers.”
• A Preliminary Evaluation of Chowdhury Meta-Analysis on the Association of Fatty Acids with Coronary Risk – extensive analysis of the meta-analysis by Fred Pollack, March 2014
• Ronald M. Krauss, MD—The Doctor Who Made Lard-eating Fashionable – Dr John McDougall, March 2014
• Food Poisoning: How Industry Is Killing Americans – Dr John McDougall, 27 March 2014
• Dr. McDougall’s “Is Saturated Fat OK to Eat” – Dr John McDougall, 19 March 2014
• Dietary fat and heart disease study is seriously misleading – Walter Willett et al., March 2014
• Diet-heart: a problematic revisit – Jeremiah Stamler (2010, AJCN)

Cholesterol **February 2015 update**

In Feburary 2015 it was reported that the new US dietary guidelines will withdraw their recommendation to limit dietary cholesterol. Below are some responses from plant-based practitioners:

• Dietary Guidelines, Cholesterol, Something Old & Something New – Jeff Novick, RD
• Cholesterol Confusion: Let’s Make Sense of It ; and Dietary Guidelines: Scientific Evidence for Nina Teicholz – Neal Barnard, MD
• What’s the Daily Required Intake for Cholesterol? – Linda Carney, MD
• Dr. Esselstyn On New Cholesterol Guidelines – Caldwell Esselstyn, Jr, MD

Saturated fat and cardiovascular disease **June 2017 update**

In June 2017 the American Heart Association published a ‘Presidential Advisory’ written by a team of highly experienced researchers who conducted a thorough review of the scientific literature into the effects of dietary saturated fat:

• Sacks, F. M., Lichtenstein, A. H., Wu, J. H. Y., Appel, L. J., Creager, M. A., Kris-Etherton, P. M., . . . American Heart Association. (2017). Dietary Fats and Cardiovascular Disease: A Presidential Advisory From the American Heart Association. Circulation, June 2017.

David Katz, MD wrote several articles trying to counter the pushback from low carb/high fat advocates in the days and weeks following publication of the AHA paper:

• Saturated Fat: Weighed, Measured, and Found Wanting – David Katz, MD
• Chewing, and Choking, on False (Nutritional) Equivalence – David Katz, MD
• 5 Ways Saturated Fat Defenders Deceive the Public – David Katz, MD

Ancel Keys’ research:

This white paper was commissioned by the True Health Initiative to explore the historical record and address the popular contentions with primary source material and related work, and in consultation with investigators directly involved. Popular criticisms directed at the study, and the lead investigator, Ancel Keys, turn out to be untrue when the primary source material is examined:

• Pett, K. D., Kahn, J., Willett, W. C., & Katz, D. L. (2017). Ancel Keys and the Seven Countries Study: An Evidence-based Response to Revisionist Histories. True Health Initiative.

Books:

• Campbell, T. C., & Jacobson, H. (2014). The low-carb fraud. Dallas, Texas: BenBella Books, Inc.

Related pages:

• Low carbohydrate diets
• Low fat diets for weight loss
• Why do we recommend a low-fat diet?

Page created 4 July 2014
Last updated 8 July 2017

Atherosclerosis is the thick cholesterol laden plaque that builds up on the inside of our arteries when we eat the typical Australian diet. Arteries do not simply gradually block up like a rusting water pipe. Heart attacks are most often the result of a sudden blockage in an artery that is only partially blocked with plaque. A whole foods plant based diet rapidly reduces the risk of heart attack.

The current paradigm of heart disease* views arteries as if they were water pipes. Factors such as high cholesterol, diabetes and smoking causes a gradual build-up of cholesterol on the inside of the artery like scale in a pipe. Eventually the pipe becomes blocked and blood supply is interrupted.

*There are many diseases that can affect the heart muscle and the heart valves. In this discussion we are using the term “heart disease” to refer to the diseases caused by narrowing or obstruction of the coronary arteries that supply the heart muscle. There are various terms that are used to label this type of heart disease: coronary artery disease (CAD), coronary heart disease (CHD), ischaemic heart disease (IHD), and myocardial ischemia. The processes which occur in the arteries of the heart can and do occur elsewhere in the body.

Atherosclerosis

Atherosclerosis is the end result of the complex process that leads to the accumulation of cholesterol and scar tissue within the artery wall. It is an insidious process that produces few if any symptoms until it is advanced enough to slow or block the flow of blood. In the early stages, fatty streaks develop inside the arteries as cholesterol builds up in the lining of the artery. The primary cause is the unnaturally high levels of LDL cholesterol associated with a diet rich in meat, dairy and processed foods and deficient in whole plant foods. The cholesterol deposited within the artery wall triggers an inflammatory response in which white blood cells invade the diseased artery wall, ingest the cholesterol and release further inflammatory chemicals. Eventually the interior of the artery becomes narrowed by a thick layer of cholesterol-laden scar tissue – this is atherosclerosis.

Arteries are not just water pipes and atherosclerosis has more consequences than just progressively reducing blood flow. The large arteries of the body are more like rubber tubes than hard pipes and they stretch with each heart beat and bounce back between beats, giving the smaller vessels a more steady blood flow. Atherosclerosis makes these arteries stiffer (“hardening of the arteries”) so that they no longer absorb the shock wave that each heartbeat produces. The smaller vessels further down the line then get pounded by the water hammer like shock wave of each heartbeat. These smaller vessels then become diseased more quickly resulting in damage the organs such as the brain and kidneys.

The paradigm of heart disease that views arteries as water pipes has an upgrade that describes how heart attacks occur.

Heart attacks

The gradual reduction in blood supply by atherosclerosis can cause the heart muscle to become weak and baggy so that it cannot pump effectively. The result is heart failure. Other organs in the body can also become progressively impaired. But heart attacks and most strokes happen when blood supply is suddenly cut off, resulting in death by asphyxiation to the cells downstream from the blockage. Atherosclerosis is an uneven process and forms localised lumps on the inside of arteries are called plaques. These plaques can burst open like a pimple on the inside of the artery. The material in the plaque causes the blood to clot immediately completely blocking the artery and obstructing blood flow to everything downstream. This can happen in arteries that are only partially blocked with plaque. Therefore an exercise ECG stress test can remain normal right up until the moment of the heart attack.

Cholesterol plaques that are actively growing are cauldrons of inflammation, and this inflammation causes the “cap” over the plaque to become thinner, increasing the risk of plaque rupture and heart attack – these are “unstable plaques”. It has been observed that rapidly reducing blood cholesterol stabilises plaques in just a few weeks, far quicker than the length of time it takes for a plaque to regress as demonstrated by angiograms. A plant based diet is much better than cholesterol tablets alone for stabilising plaques as it not only reduces fasting cholesterol, but also deals with the inflammatory storm that follows every fatty meat-based meal.

Heart disease in women may follow a slightly different course to men. It is the same disease process but plaque formation tends to be more diffuse. Diffuse plaque leads to relatively more diffuse heart damage (heart failure) than localised events (heart attacks).

Dr Michael Gregor describes the process of plaque formation and plaque rupture as analogous to pimples in his video Arterial Acne:

“Atherosclerotic plaques in coronary arteries may be more aptly described as pimples, initiated by the infiltration of cholesterol into the lining of our arteries. The ending, should blood flow to our heart muscle be cut off by a clot formed by the rupture of one of these inflamed pockets of pus in our arterial lining, is a heart attack”.

In this 8 minute video, Dr Esselstyn discusses how cholesterol accumulates in the coronary arteries, provoking an inflammatory reaction which can lead to plaque rupture. This is the main cause of heart attacks and mostly occurs in arteries that are not badly enough blocked to be treated with stents or bypasses. Fortunately plaques become more stable after only a few weeks on a whole foods plant based diet.

Caldwell Esselstyn, MD — “No More Heart Attacks — Ever”

Our current paradigm of artery disease, even with the ruptured plaque upgrade, is still too much of a water pipe analogy. Only by giving the endothelium centre stage can we understand how dietary factors cause atherosclerosis, high blood pressure and erectile dysfunction. See Endothelium, also Heart Health – Resources

By Dr Malcolm Mackay

Hypertension (high blood pressure) is a leading cause of death worldwide. It’s a major risk factor for heart disease and strokes and causes damage to kidneys and other organs. It is so common in older people in Australia and other developed countries that it has been considered a normal part of aging – but it need not be so. Blood pressure does not rise with age in communities who subsist on minimally processed plant-based diets. Even within developed countries, individuals who follow vegan diets have a quarter of the risk of hypertension as those who eat meat.

Nutrition research has established many specific links between diet and hypertension. Obesity, dietary salt and low vegetable intakes all increase the odds that individuals and communities will develop high blood pressure. Your doctor may know that the DASH diet is an evidence-based dietary approach to treating hypertension. It was designed to give patients many of the benefits of a vegetarian or vegan diet while still including some meat in the diet. The vegan group in The Adventist 2 Health Study had a quarter of the prevalence of hypertension compared to the ‘omnivores’.

It is important to control hypertension in the long term and we endorse the evidence-based use of medications to maintain blood pressure within safe limits. However, whole foods, plant-based nutrition has a powerful therapeutic effect on hypertension and most individuals will eventually be able to reduce and often stop their medications when there is a high level of adherence to this approach. We recommend that changes to medication only be made under medical supervision. It may sometimes be necessary to reduce medication within the first weeks of dietary transition to avoid excessively low blood pressure. A log of home blood pressure measurements may assist your doctor to ‘deprescribe’ medication as your health improves.

‘Essential hypertension’, elevated blood pressure with no apparent cause, is a lifestyle disease. Genes can make us more susceptible to the lifestyle factors that increase blood pressure but are rarely the cause hypertension on their own. The physiology of hypertension and the effects of lifestyle are complex but the simplicity of just eating whole plant foods addresses most of the underlying causes of this disease. Hypertension may be a smart physiological response by our bodies – increasing the pressure to push more blood through an impaired vascular system. Reducing the pressure with drugs does not treat the cause but it does reduce the risk of stroke and other complications.

A lifetime of exposure to a typical Australian diet can cause irreversible changes that contribute to a gradual increase in blood pressure with age and increasing rates of hypertension. Long term hypertension further accentuates some of these changes. The large arteries that form the trunk and major branches of our arterial tree stiffen such that they no longer stretch and recoil with every heartbeat to smooth out the pulse pressure – resulting in an elevated systolic (top number) blood pressure. The kidneys decline in function and become less efficient at excreting excess salt and fluid – the retained fluid causes blood pressure to increase. Smaller arteries can become narrowed by plaque, limiting flow, and stimulating a compensatory increase in blood pressure. Other changes to arteries and regulatory systems further accentuate the disease. The hypertension may pass a ‘tipping point’ (analogous to the climate change concept) and treating the cause, diet and lifestyle, may not bring it back to normal, but it will always help.

Arteries are living dynamic structures and what we eat at every meal enhances or inhibits their capacity to dilate when appropriate. The arteries all over our body must maintain some muscle tone to avoid the scenario where every artery relaxes at the same time, causing a catastrophic drop in blood pressure – known in medicine as ‘shock’. The muscular tone of arteries is controlled by the tile-like endothelial cells that line the arteries and produce a locally acting hormone, nitric oxide, that causes the artery muscle to relax a little. Anything that damages the endothelium – eg meat, oil, processed food, smoking – increases arterial tone throughout the body, raising the pressure needed to maintain blood flow. A healthy plant-based diet minimises things that damage endothelium – saturated fats, TMAO etc – while at the same time providing ingredients that protect the endothelial cells – eg antioxidants – resulting in a subtle relaxation of arteries all over the body leading to a reduction in blood pressure.

While a whole foods, plant-based diet is ideal for the prevention and treatment of hypertension, there are many small diet and lifestyle adjustments that will lead to even more effective blood pressure control. Non-dietary factors include: 

• Regular physical activity (150-300min per week)
• Adequate good quality sleep. (Sleep apnoea causes hypertension)
• Stress management and emotional well-being

Weight management is important. Excess body fat and the metabolic changes that are associated with abdominal fat and high dietary fat and calorie intake raise blood pressure through multiple mechanisms. Reducing the overall Energy Density of the diet and managing behavioural aspects of eating is the simplest, healthiest way to maintain a lean body in the long term.

Salt (sodium) has not been exonerated as a cause of elevated blood pressure, although some people may be more salt sensitive than others. The ratio of sodium to potassium is also important, as are some of the other minerals found in plants. Dietary fibre and other phytonutrients are probably also important. Eat a large amount of a variety of vegetables and other whole plant foods and you won’t have to worry about any of these nutrients. Sodium may need to be restricted to quite low levels to effectively reduce blood pressure eg. 1200mg per day or less. Whole plant foods contain way less sodium than this but many everyday foods like bread and sauces contain a lot more sodium.

Meals that are very high in fat can make our blood cloudy, sludgy and difficult to pump through the smallest blood vessels, the capillaries – this may result in a compensatory increase in blood pressure. Fat-laden blood is also damaging to the endothelium.

Back to endothelium: age and long-term exposure to damaging foods and lifestyles can leave us with a reduced number of endothelial cells, reduced capacity for nitric oxide production and greater sensitivity to anything that impairs endothelial cells. Even small amounts of animal products, fried foods and vegetable oils (even olive oil) may be enough to keep blood pressure elevated when the endothelium is already damaged. Clinicians who treat cardiovascular disease with whole plant foods are unanimous in their verdict – No Oil!

Endothelial function is maximised by high adherence to a low fat, phytonutrient rich WFPB diet. Dietary nitrates can give a further tweek to the blood pressure lowering effects of WFPB and may even improve athletic performance. Dietary nitrates are converted to nitrites with a little help from our mouth bacteria (so no antibacterial mouth washes) and these nitrites provide damaged endothelial cells with a substrate for nitric oxide production. Research has proven that dietary nitrates reduce blood pressure. However, the response takes 2-3hr and lasts less than 24hr, so you will need to eat nitrate rich foods several times a day to take full advantage of this effect. Beetroot juice was used in this study as it was easy to administer and could be compared with a nitrate-reduced placebo, but leafy green vegetables are an even richer source of nitrates and provide other phytonutrients. Dr Esselstyn is correct in recommending that his heart disease patients eat green leafy vegetables several times daily. We recommend incorporating leafy green vegetables into your breakfast as well as other meals. The therapeutic dose for blood pressure treatment and sports performance enhancement is approximately 8mmol of nitrates, which is the amount in half a cup of beetroot juice or 200g of spinach, a typical leafy green vegetable. These studies used single ‘doses’ and lesser quantities may be enough to top up blood nitrate levels when these foods are consumed frequently.

Normal blood pressure is 120/80 or less. Hypertension is defined a blood pressure of greater than 140/90 (on more than one occasion and measured at rest, following recommended protocols for accurate measurement). A lower blood pressure, 110/70 or less, is typical of healthy groups of people and is associated with even lower cardiovascular risk – it’s been suggested as a target for high risk patients. However, pushing blood pressure this low with pharmaceuticals increases the risk of drug side effects – whereas blood pressure reduction brought about by WFPB and lifestyle only has good side effects.

The bottom line is that a whole foods, plant-based diet – high in whole grains, tubers, legumes, vegetables and fruits – will optimise your blood pressure, and virtually all people with hypertension will improve and most will be able to reduce or cease their medication. Some individuals will need a high degree of dietary compliance to get full benefits – minimal salt, absolutely no oil and avoidance of fat-rich plants as well as coffee. Some specific plant foods such as leafy green vegetables, high in nitrates, actively reduce blood pressure. Regular exercise will further reduce blood pressure.

Do not stop your blood pressure medications without medical supervision.

Note: On Thursday 15th October 2020 we presented a webinar ‘Reverse heart disease with whole food plant-based nutrition’. You can purchase the replay for $20. Details:

Reverse Heart Disease WebinarReplay available for purchase

See also:

• Endothelium
• Should we be concerned about salt?

Resources

• Nitric Oxide & Dietary Nitrate: Another Reason to Eat Your Vegetables – Conor Kerley, PhD
• Oxygenating Blood with Nitrate-Rich Vegetables (video) – Dr Michael Greger, also this blog post: Which Vegetables Have the Most Nitrates?
• High Blood Pressure (Hypertension) – Dr John McDougall, and also this link which has a long essay on hypertension
• How I Treat Patients with Elevated Blood Pressure – Dr John McDougall (2009)
• High Blood Pressure: A Symptom, Not a Disease – Dr John McDougall (3 min. video)
• Dr. John McDougall Medical Message About: High Blood Pressure – (2 1/2 min. video – a slight variation from the previous video)
• High Blood Pressure – Alan Goldhamer
• Waking Up To The Effects of Caffeine – Jeff Novick (NB link broken)

Peer-reviewed articles:

• Appel, L. J., Brands, M. W., Daniels, S. R., Karanja, N., Elmer, P. J., & Sacks, F. M. (2006). Dietary approaches to prevent and treat hypertension: A scientific statement from the American Heart Association. Hypertension, 47(2), 296-308.
• Appleby, P. N., Davey, G. K., & Key, T. J. (2002). Hypertension and blood pressure among meat eaters, fish eaters, vegetarians and vegans in EPIC-Oxford. Public Health Nutrition, 5(5), 645-654.
• Borgi, L., Curhan, G. C., Willett, W. C., Hu, F. B., Satija, A., & Forman, J. P. (2015). Long-term intake of animal flesh and risk of developing hypertension in three prospective cohort studies. Journal of Hypertension, 33(11), 2231-2238.
• Goldhamer, A. C., Lisle, D. J., Sultana, P., Anderson, S. V., Parpia, B., Hughes, B., & Campbell, T. C. (2002). Medically supervised water-only fasting in the treatment of borderline hypertension. Journal of Alternative and Complementary Medicine, 8(5), 643-650.
• Kerley, C. P., Dolan, E., James, P. E., & Cormican, L. (2018). Dietary nitrate lowers ambulatory blood pressure in treated, uncontrolled hypertension: A 7-d, double-blind, randomised, placebo-controlled, cross-over trial. British Journal of Nutrition, 119(6), 658-663.
• Ma, L., Hu, L., Feng, X., & Wang, S. (2018). Nitrate and Nitrite in Health and Disease. Aging and Disease, 9(5), 938-945.
• Mattos, C. B., Viana, L. V., Paula, T. P., Sarmento, R. A., Almeida, J. C., Gross, J. L., & Azevedo, M. J. (2015). Increased protein intake is associated with uncontrolled blood pressure by 24-hour ambulatory blood pressure monitoring in patients with type 2 diabetes. Journal of the American College of Nutrition, 34(3), 232-239.
• McDougall, J., Litzau, K., Haver, E., Saunders, V., & Spiller, G. A. (1995). Rapid reduction of serum cholesterol and blood pressure by a twelve-day, very low fat, strictly vegetarian diet. Journal of the American College of Nutrition, 14(5), 491-496.
• McDougall, J., Thomas, L. E., McDougall, C., Moloney, G., Saul, B., Finnell, J. S., . . . Petersen, K. M. (2014). Effects of 7 days on an ad libitum low-fat vegan diet: the McDougall Program cohort. Nutrition Journal, 13(1), 99.
• Yokoyama, Y., Nishimura, K., Barnard, N. D., Takegami, M., Watanabe, M., Sekikawa, A., . . . Miyamoto, Y. (2014). Vegetarian diets and blood pressure: A meta-analysis. JAMA Internal Medicine, 174(4), 577-587.

Testimonials

• Charles Alexander: Listen to your body’s wake up calls – (written story)
• Howard Bartner: Coronary Heart Disease, Hypertension – (written story)

Page created 18 December 2014
Page last updated 13 December 2018 (substantially revised)

• Resources
• Success stories

“Some people think the ‘plant-based, whole foods diet’ is extreme. Half a million people a year will have their chests opened up and a vein taken from their leg and sewn onto their coronary artery. Some people would call that extreme”
– Dr. Caldwell B. Esselstyn, Jr.

“Normal” blood cholesterol levels in Australia are not normal or supportive of good health. These “normal” levels result in an enormous burden of heart disease and a population in which almost everyone has artery disease by age 65. The national goal of less than 5.5 is well up into the zone in which artery disease develops. The medical profession knows this and the official safe level for cholesterol following a heart attack is less than 3.8 approximately (the target being LDL<1.8). So, we have the situation where you can be reassured by your doctor that your cholesterol level of 5 is OK, suffer a heart attack later that day, and be told the next morning that your cholesterol needs to be less than 4 to prevent further heart attacks. A whole foods plant based diet can lower your cholesterol to a safe level without the inconvenience of having to have a heart attack first. More on Normal Cholesterol

 

Changing to a whole foods plant based diet results in dramatic falls in blood cholesterol levels. The medical myth that diet has little effect on cholesterol stems from the fact that the current cholesterol lowering diet recommended in Australia is not effective. A diet rich in animal “protein” foods, with or without vegetable oil, will always raise cholesterol. In general, animal products raise blood cholesterol and whole plant foods lower blood cholesterol. More on Diet and Cholesterol

 

Blood cholesterol is complex. Your blood test results will include measurements of some of the individual lipoproteins, HDL and LDL. But there are further levels of complexity that should make us wary dismissing the risks of elevated blood cholesterol on the basis of “good cholesterol” levels and ratios. More on HDL and LDL

 

Cholesterol lowering drugs and heart surgery are quick fixes for a complex diet related disease. The drugs only target fasting cholesterol, which although important, is only one part of the cholesterol-diet problem. Stents and surgery are seldom life saving and carry considerable risks. More on Drugs and Surgery

 

The endothelium is the lining of our arteries and consists of a single layer of tile-like cells. The endothelium is central to artery health and disease. Anything that compromises the health of the endothelium has an immediate effect on the flow of blood to every organ. Atherosclerosis, the obstruction of arteries by cholesterol, is merely the end result of repeated endothelial damage. Every fat and cholesterol laden meal causes an inflammatory storm within the arteries that lasts for many hours and has a measureable effect on endothelial function. More on Endothelium

 

Atherosclerosis is the thick cholesterol laden plaque that builds up on the inside of our arteries when we eat the typical Australian diet. Arteries do not simply gradually block up like a rusting water pipe. Heart attacks are most often the result of a sudden blockage in an artery that is only partially blocked with plaque. A whole foods plant based diet rapidly reduces the risk of heart attack. More on Atherosclerosis and Heart Attacks

 

Atherosclerosis is a whole body disease affecting every artery. Therefore any organ can potentially be compromised by impaired blood supply. A partially blocked artery may cause symptoms such leg muscle pain on exertion. A sudden complete blockage may result in a stroke. Diseased small vessels can cause dementia and kidney failure. Even in the absence of artery narrowing, an unhealthy artery may be unable dilate, resulting in erectile dysfunction. More on The Canary and Other Organs

Resources

Books

Esselstyn, C. B. (2007). Prevent and Reverse Heart Disease: The Revolutionary, Scientifically Proven, Nutrition-Based Cure. New York: Avery.
Dr Caldwell Esselstyn Jr. MD, author of Prevent and Reverse Heart Disease, carried out the longest and one of the most successful trials of curing heart disease with diet. He describes heart disease as a toothless paper tiger that need never exist. Have a look at a free Excerpt from Chapter One of Prevent and Reverse Heart Disease.

This is his website: Dr Esselstyn’s Prevent & Reverse Heart Disease Program – click on the Video tab to see a links to more videos that present his work, some of which are listed below.

Videos

• Prevent and Reverse Heart Disease with Caldwell B. Esselstyn, Jr., M.D. (1 hour 8 min video – 2018)
• Caldwell B. Esselstyn, Jr. MD, Treating the Cause to Prevent and Reverse Heart Disease – (47 min. video) This presentation by Dr Esselstyn provides an in-depth understanding of the science behind preventing and reversing heart disease with a low-fat whole food plant-based diet.
• TEDxCambridge – Caldwell Esselstyn on making heart attacks history – (14 min. video) This is a shorter version of Esselstyn’s presentation, explaining the diet and heart disease link in a 14 minute TEDx talk.
• Dr Esselstyn at Medina Ohio  – (1 hour 55 min. video) Dr Caldwell Esselstyn talks for more than an hour about how to prevent and reverse heart disease. In the last part of the presentation his wife Ann Esselstyn gives a quick lesson on how to prepare plant perfect meals.
• Caldwell B. Esselstyn, Jr., MD: How to Reverse Heart Disease, Part 1 – (5 min. video) and Caldwell B. Esselstyn, Jr., MD: How to Reverse Heart Disease, Part 2 (10 min. video)
• Dr. Robert Ostfeld – A Plant-Based Diet and Heart Failure: Case Report & Literature Review (55 min video interview)
• Dr Kim Williams – Fat, Sugar and Animal Protein – What’s the Harm? – (1hr 8 min video)
• Nutrition and Heart Disease: How to Prevent Against Heart Disease by Kim Williams, M.D., MACC, FAHA – (1hr 28 min video)
• Dr. John McDougall Interviews Dr. Kim Allan Williams, Webinar 05/02/19 – (1hr 15 min video)
• Dr Kim Williams: Exposes the True Cause of Heart Disease – (5 min. video)
• The Last Heart Attack – A Groundbreaking CNN Report by Dr. Sanjay Gupta (13 min video) NB Link no longer works to original full length CNN documentary so it has been removed.
• Dr. John McDougall Medical Message About Atherosclerosis  (3 min. video)
• Watch the film: Forks Over Knives

• Greens, Greens, Greens! How to eat them 6 times a day! – (15 min. video) Jane Esselstyn
• More Greens, More with Dr. Esselstyn, More Answers! – (29 min. video) Jane Esselstyn

Dr Michael Greger videos on heart disease:

Web resources

• Dr Esselstyn’s FAQ page – answers all those questions about nuts, seeds, leafy greens and warfarin, etc.
• Heart Disease & Atherosclerosis – John McDougall, MD, includes links to numerous newsletter articles
• Abolishing Heart Disease – Caldwell Esselstyn, Jr, MD

Podcasts

• How to Create a Successful Plant-Based, Diet-Driven, Heart Disease Reversal Program in a Cardiology Setting – An Interview with Kim Williams, MD, Past President, American College of Cardiology (50 min. audio)
• Dr. Caldwell Esselstyn on Ending the War Against Our Hearts – Howard Jacobson podcast (1 hr 33 min audio)
• Eradicating Lifestyle Disease with Cardiologist Robert Ostfeld, MD – Rich Roll podcast (2 hr audio)
• Is Butter Really Back? Heart to Heart with Cardiologist Joel Kahn – Rich Roll podcast (1 hr 40 min audio)

Peer-reviewed articles

• Esselstyn C. B., Gendy, G., Doyle, J., Golubic, M., & Roizen, M. F.
  (2014). A way to reverse CAD? Journal of Family Practice, 63(7), 356-364b.
• Esselstyn C. B., & Golubic, M. (2014). The nutritional reversal of cardiovascular disease: Fact or fiction? Three case reports. Experimental & Clinical Cardiology, 20(7), 1901-1908.
• Esselstyn, C. B. (2010). Is the present therapy for coronary artery disease the radical mastectomy of the twenty-first century? American Journal of Cardiology, 106(6), 902-904.
• Esselstyn, C. B. (1999). Updating a 12-year experience with arrest and reversal therapy for coronary heart disease (an overdue requiem for palliative cardiology). American Journal of Cardiology, 84(3), 339-341, A338.
• Ornish, D., Brown, S. E., Scherwitz, L. W., . . . Gould, K. L. (1990). Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial. Lancet, 336(8708), 129-133.
• Ornish, D., Scherwitz, L. W., Billings, J. H., . . . Brand, R. J. (1998). Intensive lifestyle changes for reversal of coronary heart disease. JAMA, 280(23), 2001-2007.
• Tuso, P. J., Stoll, S. R., & Li, W. W. (2014). A Plant-Based Diet, Atherogenesis, and Coronary Artery Disease Prevention. The Permanente Journal, 19(1).