#148: Dr. Caldwell B. Esselstyn, Jr. - How to Build an Endothelial Fortress and More!
Rip and “Essy” want you to build an endothelial fortress and remain heart attack-proof
In honor of Father’s Day, we're thrilled to welcome Dr. Caldwell B. Esselstyn Jr. back on the podcast to answer YOUR questions.
Dr. Esselstyn provides his thoughts and advice on questions related to cholesterol, exercise, sodium, fat, atrial fibrillation, the best diagnostic tests for your heart, and – of course – how to build an ENDOTHELIUM FORTRESS.
About Dr. Caldwell B. Esselstyn, Jr.
Caldwell B. Esselstyn, Jr., received his B.A. from Yale University and his M.D. from Western Reserve University. In 1956, pulling the No. 6 oar as a member of the victorious United States rowing team, he was awarded a gold medal at the Olympic Games. He was trained as a surgeon at the Cleveland Clinic and at St. George’s Hospital in London. In 1968, as an Army surgeon in Vietnam, he was awarded the Bronze Star.
Dr. Esselstyn has been associated with the Cleveland Clinic since 1968. During that time, he has served as President of the Staff and as a member of the Board of Governors. He chaired the Clinic’s Breast Cancer Task Force and headed its Section of Thyroid and Parathyroid Surgery. He is a Fellow of the American College of Cardiology.
In 1991, Dr. Esselstyn served as President of the American Association of Endocrine Surgeons, That same year he organized the first National Conference on the Elimination of Coronary Artery Disease, which was held in Tucson, Arizona. In 1997, he chaired a follow-up conference, the Summit on Cholesterol and Coronary Disease, which brought together more than 500 physicians and health-care workers in Lake Buena Vista, Florida. In April, 2005, Dr. Esselstyn became the first recipient of the Benjamin Spock Award for Compassion in Medicine. He received the Distinguished Alumnus Award from the Cleveland Clinic Alumni Association in 2009. In September 2010, he received the Greater Cleveland Sports Hall of Fame Award. Dr. Esselstyn received the 2013 Deerfield Academy Alumni Association Heritage Award In Recognition of Outstanding Achievement & Service, and the 2013 Yale University George H.W. Bush ’48 Lifetime of Leadership Award. Dr. Esselstyn has also received the 2015 Plantrician Project Luminary Award, the Case Western Reserve University School of Medicine 2016 Distinguished Alumni Award, and the American College of Lifestyle Medicine 2016 Lifetime Achievement Award.
His scientific publications number over 150, “The Best Doctors in America” 1994-1995 published by Woodward and White cites Dr. Esselstyn’s surgical expertise in the categories of endocrine and breast disease. In 1995 he published his bench mark long-term nutritional research arresting and reversing coronary artery disease in severely ill patients. That same study was updated at 12 years and reviewed beyond twenty years in his book, Prevent and Reverse Heart Disease, making it one of the longest longitudinal studies of its type. In July of 2014 he reported the experience of 198 participants seriously ill with cardiovascular disease. During 3.7 years of follow up of the 89% adherent to the program, 99.4% avoided further major cardiac events.
Dr. Esselstyn and his wife, Ann Crile Esselstyn, have followed a plant-based diet since 1984. Dr. Esselstyn presently directs the cardiovascular prevention and reversal program at The Cleveland Clinic Wellness Institute.
The Esselstyns have four children and ten grandchildren.
Episode Timestamps
4:50 It’s Showtime!
5:55 I’m 100% plant-based, but have high cholesterol. Do I still need statins?
8:30 What is the best diagnostic test to see if my arteries are clogged?
9:52 Question about sodium consumption. The data is so confusing!
12:50 What are the best heart health tests I should take at 50?
14:15 LPa - What is it, and how can I improve it?
16:00 How do I build an endothelial fortress and lower my triglycerides?
18:15 Atrial fibrillation - Can it be reversed via diet?
21:45 Could I potentially have familial hypercholesterolemia?
26:39 Talk about the role of fats in a plant-based diet. Aren't some fats healthy?
31:30 What is your opinion on meds for clotting and atrial fibrillation?
33:30 Could I impact familial hypercholesterolemia with a whole foods plant-based diet?
34:14 Opinions on cardio exercise? Can too much be bad?
37:00 Can my HDL be too high?
44:05 How can I best treat mild atherosclerosis?
Episode Resources
Order Prevent and Reverse Heart Disease by Dr. Caldwell B. Esselstyn, Jr.
Dr. Esselstyn’s Prevent and Reverse Heart Disease Program Website
PLANTSTRONG Foods - shop our official unsalted broths- and our growing assortment of other delicious products made without oil, added sugar, or excessive sodium.
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Full YouTube Transcript
Rip Esselstyn:
When my father started his seminal research back in 1984... 38 years ago. Incredible. He had zero, zero idea how important his research would become and how he would become one of the leading authorities on how to fight heart disease with your fork. And if you haven't read his book, Prevent and Reverse Heart Disease by Dr. Caldwell B. Esselstyn, Jr., I highly recommend it. Essy, which is the nickname that he was given as a young adult, and as many of us like to call him is a real task master when it comes to counseling his patients and what goes into their mouth.
Rip Esselstyn:
And as he says, you should never sit down to a meal or go out to eat with the purpose of injuring your endothelium and your endothelial cells. And he means it. Well, as he is, and has been a huge inspiration for our PLANTSTRONG food line because we know how challenging it can be to always be prepared with a 100% whole food, plant-based, oil-free set of lunches and dinners.
Rip Esselstyn:
And that's why our ready to eat, heat and eat chilies and stews, for example, are the absolute perfect pantry staple to guarantee that you're never more than 90 seconds away from a delicious and nourishing meal. At PLANTSTRONG, we strive to meet and exceed my father's standards every day because his groundbreaking research is what started all of this. And for some, their life depends on following this lifestyle to fight back against heart disease, stroke, type two diabetes, and the constellation of chronic Western diseases that are afoot in this country. And we take that responsibility very, very seriously. You can learn more about all of this at plantstrongfoods.com.
Dr. Caldwell B. Esselstyn, Jr:
The seismic revolution in health that you see is really not going to come about from a drug or a pill, or a stent, or bypass surgery. But the seismic revolution in health that will come about will be when we in the profession have the will and the grit and the determination to share with the public, what is the lifestyle? And most specifically, what is the nutritional literacy that will empower them to absolutely annihilate chronic illness?
Rip Esselstyn:
I'm Rip Esselstyn and welcome to the PLANTSTRONG Podcast. The mission at PLANTSTRONG is to further the advancement of all things within the plant-based movement. We advocate for the scientifically proven benefits of plant-based living and envision a world that universally understands, promotes and prescribes plants as a solution to empowering your health, enhancing your performance, restoring the environment, and becoming better guardians to the animals we share this planet with. We welcome you wherever you are on your PLANTSTRONG journey and I hope that you enjoy this show.
Rip Esselstyn:
Hello, my PLANTSTRONG pals. My name is Rip Esselstyn. I am the host of the PLANTSTRONG Podcast, and we have a very special episode that we're going to be teeing up for you today. In honor of Father's Day, I am proud to welcome my father, Dr. Caldwell B. Esselstyn, Jr. to answer your questions, and boy howdy-diddy.
Rip Esselstyn:
We talk cholesterol, the good and the bad. We talk exercise, sodium atrial fibrillation, the best diagnostic tests, and of course all about building an endothelium fortress so all of you understand how you can become heart attack proof. The privilege to sit down with my father is not for one second lost on me and believe me when I say that the best Father's Day gift that I can have is sharing his knowledge with all of you. So let's go right into it, my Q&A with Essy, with a few special appearances from my mother, Ann.
Rip Esselstyn:
Hey, we're live. It's showtime. Hey, I am back in Cleveland. I'm doing an event in Pittsburgh and so I thought I'd take a little detour and spend the night in Cleveland to be with Ann and Essy for a night. I also thought this would be a great opportunity to get this guy on the PLANTSTRONG Podcast. It's been a while and a lot of you have written in some questions that you'd love for him to answer. And so this was the perfect time. Before we hit it off though, Ann, say hello.
Ann Crile Esselstyn:
I have to say hi to everybody. You're so lucky to have what you're going to get.
Rip Esselstyn:
All right. And this is really a tribute to Father's Day. And what better way of showing my appreciation to this man than by sharing him with all of you. So let's hit it off. Okay?
Dr. Caldwell B. Esselstyn, Jr:
Yeah, let's do it.
Rip Esselstyn:
All right. We got a couple here. So this first, this is from Deborah's World Change. Thank you for the question. "I am whole food plant-based and have been vegan for 11 years, but I have a 250 cholesterol level. I was 285 before quitting oil. My weight is fine and blood pressure always is very low and I work out daily. Doc wants me on statins. Help me, Dr. Esselstyn."
Dr. Caldwell B. Esselstyn, Jr:
Well, it's interesting. When you look from a global perspective, you ask yourself about those countries where cardiovascular disease is virtually non-existent and you say, for instance, how many statins do they take in rural China, Central Africa, the Papua Highlands in New Guinea, the Tarahumara Indians in Northern Mexico. No heart disease, no statins. So the key here, I think, actually takes us to a very interesting problem that many people's experience, that is to say they find that they're cholesterol, no matter what they do remains, say elevated. Maybe it's going to be 190, 200.
Dr. Caldwell B. Esselstyn, Jr:
For example, if I have a thousand patients who perfectly follow our program, there might be some with a cholesterol of 102, 140, 160, 180, 200, 220. Now, does that mean that all those people who have a cholesterol of 200 or 220 are going to perish from heart disease? No. Because if you are eating a hundred percent without any injury to your endothelial cells, you have more or less built an endothelial fortress. So even if you have a few extra molecules of cholesterol, coursing through your bloodstream, if you know that your inflammatory tests, your tests of blood vessel inflammation, if those are all normal, you're going to be fine.
Rip Esselstyn:
So what are some of those tests?
Dr. Caldwell B. Esselstyn, Jr:
Well, the test of the inflammatory profile would be something like the F2-isoprostanes, oxidized LDL, asymmetric dimethylarginine, and myeloperoxidase.
Rip Esselstyn:
What about TMAO? Is that something you can mention?
Dr. Caldwell B. Esselstyn, Jr:
Absolutely, you can. TMAO, I'll add that, yes.
Rip Esselstyn:
Okay. Well, good. Let's let's move on. Okay?
Dr. Caldwell B. Esselstyn, Jr:
All right.
Rip Esselstyn:
So this next question is from Karen Brenda. And her question is, "What is the best diagnostic test to check to see if your arteries are clogged?"
Dr. Caldwell B. Esselstyn, Jr:
There's been a sort of a toss up between getting a calcium score or was getting a CT angiogram. And I think that probably the weighted evidence is just tilting a little bit more toward a CT angiogram. CT angiogram. You just put a little contrast in a vein in your arm, then they time it so that when that contrast is going through the arteries to your heart, that's when they take the X-ray. And then they can see whether you've got blockages or not. It's really very safe and very, very effective for giving you some insight as to what the status of your coronary arteries is.
Rip Esselstyn:
Is there a reason why you prefer that to the calcium score?
Dr. Caldwell B. Esselstyn, Jr:
I just think it shows more the vessels directly, whereas the calcium score just shows you bits and pieces of calcium that are in the various plaques that you've got.
Rip Esselstyn:
Well, I think there may be a question later on too that addresses-
Dr. Caldwell B. Esselstyn, Jr:
Good.
Rip Esselstyn:
Yeah. All right. So this is a question from Stephan Jedward, and it's about sodium. "I'm interested in the role of high sodium. A particular cardiovascular doctor popular on Instagram is promoting 3,500 milligrams of salt with water before exercise." He says, "Sugar, not salt is the enemy. Also promoting a grass-fed meat based whole foods diet. The data is somewhat confusing or not seeming to be conclusive on salt. So I would appreciate this being cleared up. I understand that everyone must have salt and it's naturally occurring at least 1,200 to 1,500 milligrams per day would be my understanding. Salt is not the ultimate enemy. Super high salt in processed foods with no exercise would be dangerous. We need sodium and electrolytes. And the research is mixed regarding the exact safe amount with the other contributing factors. So that's why I asked." It's almost like he tried to answer his own question there. So any thoughts on salt?
Dr. Caldwell B. Esselstyn, Jr:
Sure. I think there's pretty well a consensus from a very, I think, educated physicians that there are numerous studies clearly to showing that excess salt will contribute to hypertension. And so if somebody does have cardiovascular disease, you want to try to keep your daily consumption somewhere close to 1,500 milligrams. Now, there's the other question was about meat.
Rip Esselstyn:
Yeah, grass-fed.
Dr. Caldwell B. Esselstyn, Jr:
Yeah. Let me comment on that because there was an interesting gentleman, a physician by the name of George Mann. And George Mann was a great disciple of the fact that if you wanted to eat meat that was grass-fed, you would not be getting into trouble with cardiovascular disease. So to his credit, he marshaled his resources and went to Africa and they looked at the Maasai.
Dr. Caldwell B. Esselstyn, Jr:
Now as you know, the Maasai herdsman in Africa, and they thrive on milk ,and meat, and blood. George Mann was able to get something like 50 autopsies of the Maasai who had died. Lo and behold, they're loaded with cardiovascular disease. So, so much for the grass-fed approach.
Rip Esselstyn:
Right.
Dr. Caldwell B. Esselstyn, Jr:
But there's so many other things in meat that are troublesome, the TMAO, the saturated fat. I mean, all those things are perilous.
Rip Esselstyn:
Yeah.
Dr. Caldwell B. Esselstyn, Jr:
Yeah. The cholesterol.
Rip Esselstyn:
The protein itself.
Dr. Caldwell B. Esselstyn, Jr:
There you go.
Rip Esselstyn:
Right?
Rip Esselstyn:
Absolutely.
Dr. Caldwell B. Esselstyn, Jr:
Yeah. It's a long list. All right. Let's move on. Okay. This question is from Diana Redkurt. These are kind of funny names that people put together. It's their handles. What are the heart health tests someone should have at 50? And are the tests the same if I've been eating a strict Esselstyn style diet since 2017.
Dr. Caldwell B. Esselstyn, Jr:
So how many years have they had...
Rip Esselstyn:
It's now been five years.
Dr. Caldwell B. Esselstyn, Jr:
Yeah. I think you have to be a little bit cautious about any test in that situation that carries any degree of risk. So if you wanted to do something like a stress echo stress test, all right, there's no radiation. There's no contrast to injure your blood vessels. Right? And yet, if you have a... Let's say that this is a situation where I often find that when I first encounter somebody and they have had a stressed test that they have failed, we find that if they repeat that a year after being on the program, it's either markedly improved or it's back to normal.
Rip Esselstyn:
We like that.
Dr. Caldwell B. Esselstyn, Jr:
We do.
Rip Esselstyn:
That's exciting. All right. This next question is from Heidi Cook's Plants. And we've heard a lot about this Lp(a) number, right? So her question is, "Is there a way to improve one's Lp(a) number? What dietary changes would you suggest if you're already eating a whole food plant-based diet?"
Dr. Caldwell B. Esselstyn, Jr:
Yeah. I-
Rip Esselstyn:
First, could you back up and tell people what is Lp(a)?
Dr. Caldwell B. Esselstyn, Jr:
Yeah. Well LP small A is a form of cholesterol. And when you think about it, it's estimated that roughly 20% of Americans will have an elevated LP small A but that same figure applies to rural China, Central Africa, the Papua Highlands, Okinawa, the Tarahumara Indians, whereas their epidemic of heart disease. All right? So if they're eating whole food plant based diet and you're making what we call an endothelial fortress. Remember, the endothelial cells are those that line the inside of the artery. If you have an endothelial fortress from eating without any injury to it, then even if you have an extra molecule of LP small A coercing through your bloodstream, that should not be deleterious or injure you.
Rip Esselstyn:
So the LP little A is that a form of LDL or is this-
Dr. Caldwell B. Esselstyn, Jr:
It's a form of cholesterol, yeah.
Rip Esselstyn:
Okay. So again, we want to have an endothelial fortress.
Dr. Caldwell B. Esselstyn, Jr:
That's it.
Rip Esselstyn:
Okay. A lot of people that jump in eating a whole food plant-based diet, it seems like a lot of times their triglycerides go up a little bit. So here's somebody Seleshula that wants to know the best way to lower triglycerides.
Dr. Caldwell B. Esselstyn, Jr:
Yeah. You want to be careful of simple carbohydrates. By that, I mean, for instance, you want to avoid dried fruit. All right? You wanted to think about avoiding smoothies, especially which may have... You may have put in the smoothie an apple, an orange or banana. And when you do that, you separate the fructose and the fruit from the fibers. Whereas ordinarily, when you're just eating the fruit, the absorption would be rather measured and slow and safe. When you put it in a smoothie and now you separate the fructose from the fiber. It's like a rocket going off in your stomach and suddenly there's a potential injury to your liver and to your endothelium as well.
Dr. Caldwell B. Esselstyn, Jr:
But you want to also avoid the process foods which may have hidden sugar or white flour. Those are the things you want to try to avoid. Alcohol. Alcohol is notorious. I mean, I will frequently hear a patient say, "Dr. Esselstyn, my triglycerides are having trouble." And I said, "Well, do you ever drink alcohol?" They said, "Yeah, but I only have three glasses of wine a night just to relax."
Rip Esselstyn:
Well, just one glass will do. I know when I was doing my pilot study for the first book, Engine 2 Diet in 2007, 2008, I had my pilot study participants, 62 of them. And I had three, their triglycerides when they first started were fine. And then as a celebration, the last night when they were done, some had a glass of wine, some had one or two beers and their triglycerides were like 200, 250. And it was that one glass of wine.
Dr. Caldwell B. Esselstyn, Jr:
Yeah.
Rip Esselstyn:
Incredible. Okay. This is from Zero Waste Middle. And the question is, "My husband has a fibrillating heart and may get an ablation soon. Can food choices do anything for this? He used to be very fit and athletic, but now his ability to do sports is much lower."
Dr. Caldwell B. Esselstyn, Jr:
Yeah. Atrial fibrillation is probably the most common arrhythmia that is seen in the public. We want to talk a little bit about how that evolves. Remember that in the right upper atrium, there is a SA node, the sino-auricular node. That is the master spark plug when we all have a contraction of the heart. The SA node fires. Then there's this beautiful rhythmic contraction of the upper chambers to the lower chambers of the heart.
Dr. Caldwell B. Esselstyn, Jr:
Now ,what happens in atrial fibrillation is that there seems to develop several of these smaller spark plugs that want to get in on the act. So as soon as your essay node fires its usual normal contraction, one of these smaller spark plug will fire. Instead of getting a nice "lub-dub, "lub-dub" it'll be "lub-dub-whoop-lub-lub." It's a very inefficient contraction.
Dr. Caldwell B. Esselstyn, Jr:
Now, there's several ways that this is managed. One is they do what we call a conversion where you may be asleep for two or three seconds. Then they zap you and your rhythm, your normal sinus rhythm will cover back. But sometimes that doesn't last for more than half an hour or it may last a day or two.
Dr. Caldwell B. Esselstyn, Jr:
So they often will use medication, but that's really just sort of slows the rate of your heartbeat and tries to make it more efficient. So ablation is increasingly I think picking up speed as those physicians who do ablation become more and more skillful at doing this because there's no question that if you follow a thousand people who are fibrillating and a thousand who have normal sinus rhythm, there'll be a higher mortality in those who have the irregular rhythm.
Dr. Caldwell B. Esselstyn, Jr:
So I would really encourage those who've had a stubborn atrial fibrillation that hasn't rapidly converted back to normal with medication or drugs to seriously think about an ablation in the hands of somebody who has great expertise with this, because it can be very effective in resolving the issue.
Rip Esselstyn:
No, it's surprising. I feel like I swim with a bunch of masters. People have for 25 years and it seems like a handful of them are now having this.
Dr. Caldwell B. Esselstyn, Jr:
Atrial fibrillation?
Rip Esselstyn:
Yeah.
Dr. Caldwell B. Esselstyn, Jr:
Yeah. And the other group that seems to be developing it are, believe it or not, some very, very fit people who are long distance runners. There's a higher incidence of atrial fibrillation that develops in those people.
Rip Esselstyn:
Yeah. Was there an article that was in the New York Times about that? Could have been?
Dr. Caldwell B. Esselstyn, Jr:
Could have been.
Rip Esselstyn:
All right. This is from Herring Family Travel. "My total cholesterol and LDL went up after eating plant-based for three years. I follow the no oil, no nuts, coconut, et cetera. Does this mean that I potentially have familial hypercholesterolemia? And am I doomed to take a cholesterol-lowering medication?
Dr. Caldwell B. Esselstyn, Jr:
What is his cholesterol?
Rip Esselstyn:
You know what, this was not given.
Dr. Caldwell B. Esselstyn, Jr:
That was not included?
Rip Esselstyn:
It was not included. But let's say his cholesterol was 270, would you say there's familial hypercholesterolemia?
Dr. Caldwell B. Esselstyn, Jr:
Was his LDL that went up or was it his total cholesterol that went up?
Rip Esselstyn:
It says both.
Dr. Caldwell B. Esselstyn, Jr:
It says both went up.
Rip Esselstyn:
They say both went up. But we don't know what exactly they were eating. I mean, we know that-
Dr. Caldwell B. Esselstyn, Jr:
Yeah. It's so hard to really answer that with any degree of insight unless you have some sort of a diet diary and you really can follow that along. Otherwise, we're just really sort of treading water.
Rip Esselstyn:
In your opinion, when you have a total cholesterol and/or an LDL that's above a certain number, is that now an indication that you have familial hypercholesterolemia?
Dr. Caldwell B. Esselstyn, Jr:
Actually, where you're going to have the breakover point for hypercholesterolemia is really not... In my estimation, that is not yet really clearly defined. I think the important thing is if somebody does want to clarify whether they're in a safe range or not, and let's say they're doing the very best they can from a nutritional standpoint, and they're not eating anything with cholesterol. They don't seem to be eating anything that would stimulate their hepatic production of cholesterol. And yet they don't want to commit to getting onboard with a lot of statins and that perhaps the side effects that come with statins.
Dr. Caldwell B. Esselstyn, Jr:
They have to know that they can get some reassurance about how their blood vessels doing if they get an inflammatory panel. We've talked about that a little earlier today, the inflammatory panel will help them to define whether there's any inflammation. And if all those inflammatory indices are normal then you don't have any inflammation in your blood vessels. You should be feeling pretty confident.
Rip Esselstyn:
Yeah. I know we've had some-
Dr. Caldwell B. Esselstyn, Jr:
I mean, I have lived with somebody and actually many people since I started this back about 34 years ago, they've never been able to get their cholesterol much below 200. They're perfectly fine.
Rip Esselstyn:
Well, I know that we had a family that came to one of our immersion retreats and their before cholesterols, the whole family was in the 300s. One was in the 400s.
Dr. Caldwell B. Esselstyn, Jr:
Oh, then that is familial hypercholesterolemia. But they can even help.
Rip Esselstyn:
And then they were able to bring it down into the high 200s.
Dr. Caldwell B. Esselstyn, Jr:
Right.
Rip Esselstyn:
But which is higher than most.
Dr. Caldwell B. Esselstyn, Jr:
Yeah. But they should also check their inflammatory indices.
Rip Esselstyn:
Yeah. Now keep in mind, if any of these questions you don't know, we can pass on them and we'll just go to the next one. This is from Terry Williams regarding vascular Parkinsonism, which I'm not familiar with. You?
Dr. Caldwell B. Esselstyn, Jr:
No. That suggests that there must be some degree of vascular blood vessel problem in the head and I'm not quite sure about that, but I can say this. We have had multiple occasions where people, for instance, with a carotid artery going to their brain, and even once the artery that is blocked is inside the brain, we have seen remarkable examples of disease halting and reversing. Yeah.
Rip Esselstyn:
Hmm.
Dr. Caldwell B. Esselstyn, Jr:
So if that is due to vascular Parkinson's, is due to disease of the blood vessels that this can certainly have a very positive effect.
Rip Esselstyn:
Yeah. Well, that's good to know because they go on to say that I get the stroke effects that are current and may not be reversed, but wondering if it would stop the progression. So it sounds like anything that's kind of going on in the brain like that, there's a potential for a lot of help?
Dr. Caldwell B. Esselstyn, Jr:
Yes.
Rip Esselstyn:
Yeah. Anne Paddock wants to know, "Will you talk, Dr. Esselstyn about the role of fats, particularly avocados, nuts and coconut, parentheses, which is full of saturated fat in a whole food plant-based, no oil and minimal salt diet. I ask because my total and LDL numbers go up if I don't keep my consumption of these items low." Which makes sense, right?
Dr. Caldwell B. Esselstyn, Jr:
Yeah. Saturated fat will stimulate the liver and crank more cholesterol.
Rip Esselstyn:
Yeah. But she also would love to know if you could expand on it, the role of avocados, nuts. And obviously, we know coconut is 92% saturated, right?
Dr. Caldwell B. Esselstyn, Jr:
Right.
Rip Esselstyn:
But what about avocados and nuts? And why are you such a task master on that?
Dr. Caldwell B. Esselstyn, Jr:
Well, I guess it's because I hate to see failure in my patients. I guess when you compare the results that we've been able to achieve, and then we compare them with other results, I have nothing but great admiration and respect for anybody who's trying to be a physician, who's committing to this. I think I find that our program is about as stringent as anybody's.
Dr. Caldwell B. Esselstyn, Jr:
So I guess the reason that we succeed perhaps where others fail is that nobody else is as mean as I am. And so this gets back to the question you asked about the avocado and the nuts. Let's take the nuts first. Now, if I happen to say that it's okay for somebody to have three walnuts on their cereal in the morning, that's not what people will hear. They'll hear that they say, "Dr. Esselstyn said that nuts were okay." And they'll be in the glove compartment. They'll be in the bathroom, the kitchen, the bedroom, the hallway, the living room.
Dr. Caldwell B. Esselstyn, Jr:
Nuts are highly addicting and they have a lot of saturated fat. Saturated fat is a real rascal for contributing to heart disease. And so this is why I took away the avocado and the nuts. In other words, we're completely eliminating any of the building blocks of this disease and I'm not going to apologize for success.
Rip Esselstyn:
What do you think about some of your-
Dr. Caldwell B. Esselstyn, Jr:
No, that's one other thing. But you asked besides nuts that was something else.
Rip Esselstyn:
What it coconuts?
Dr. Caldwell B. Esselstyn, Jr:
Well, more saturated fat.
Rip Esselstyn:
Yeah. But some of your colleagues think that it's very important for people to consume some nuts and seeds, and they're advocating for one ounce. One ounce a day. Do you even feel like one ounce is too much?
Dr. Caldwell B. Esselstyn, Jr:
I feel that's what my colleagues want. That's not what I want. I want my patients to succeed.
Rip Esselstyn:
So there's no ambiguity around this?
Dr. Caldwell B. Esselstyn, Jr:
Well, what we wanted to do is I want to see the others studies, had a similar result. Then I'll be more open minded about it.
Rip Esselstyn:
So even the wonderful, beautiful walnut, you're not a fan. We understand the almonds and the cashews.
Dr. Caldwell B. Esselstyn, Jr:
For instance, I'll say it, but nobody should hear me say it.
Rip Esselstyn:
Okay. This is just between us right now.
Dr. Caldwell B. Esselstyn, Jr:
It's probably having a few walnuts on your cereals. I mean that's so safe because it's so much lower in the mischief makers, lower in saturated fat. But I don't do that because people will immediately transfer that to saying it's okay to have nuts. Then we'll be in trouble. Where are all the studies of patients seriously with heart disease who have ever halted and reversed their disease with nuts?
Rip Esselstyn:
Yeah.
Dr. Caldwell B. Esselstyn, Jr:
So many of the peer-reviewed scientific articles, who do you suppose does the funding for those articles? The nut companies, right. So when there's that conflict-
Rip Esselstyn:
Blue diamond.
Dr. Caldwell B. Esselstyn, Jr:
When there's that conflict, that raises a red flag.
Rip Esselstyn:
What's up, Ann?
Ann Crile Esselstyn:
I can't believe you got him to say that.
Rip Esselstyn:
Well, you need to talk here.
Ann Crile Esselstyn:
Unbelievable.
Dr. Caldwell B. Esselstyn, Jr:
Having a bad day.
Rip Esselstyn:
Okay. So this is from somebody, Return to Jehovah. "I have several questions for Dr. Esselstyn but let's start with this one. I've been eating whole food plant based since November of 2021. Is there any reason to think that my blood would need to be artificially thin by a drug?" My doctor says I've had a few instances of AFib and put me on Eliquis. I think it gives me headaches and I don't want to take it. I'm not eating any animal products and have eliminated oils as much as possible. Thank you."
Dr. Caldwell B. Esselstyn, Jr:
The key thing here is that the patient has said that they were having atrial fibrillation and you cannot be cavalier about atrial fibrillation because remember, what is atrial fibrillation? There's that irregular beating of the heart. And what happens in the left atrium? The left atrium has a small extension on it called the the atrial appendix. The left atrial appendix that because of this irregular heartbeat, often the blood just sits in that appendix. And when the blood is sitting in that appendix in your left atrium, it clots.
Dr. Caldwell B. Esselstyn, Jr:
And then what happens from time to time when there is a full contraction of the heart, the clot that is in that left atrial appendix now goes out into the left ventricle and then it goes out into your circulation. And that is the cause of the clots that are notorious and people who are having atrial fibrillation. So if that patient is having regular episodes of atrial fibrillation, it is quite reasonable to ask that patient to be anticoagulated, to have their blood thin so that they will not form a clot in that appendix if they're fibrillating.
Rip Esselstyn:
Right. So it's probably a good idea for this person to be on this.
Dr. Caldwell B. Esselstyn, Jr:
Right.
Rip Esselstyn:
Yep. Okay. Read you loud and clear there. This question is from Terry Eats Plants. "Dr. Esselstyn, would you please let me know whether a whole food plant-based diet can impact..." Again, here, here it is again, so familial hypercholesterolemia.
Dr. Caldwell B. Esselstyn, Jr:
Yeah. I think that there certainly can be some benefits in that because when you do that, you're going to be making yourself this endothelial fortress, which will really work in your behalf and protect you.
Rip Esselstyn:
Third time we've talked about that fortress. Have you ever heard of something called citrus bergamot to get LDL cholesterol levels down?
Dr. Caldwell B. Esselstyn, Jr:
I've never heard of it.
Rip Esselstyn:
Never heard of it. Okay. All right. Well, there you go. Terry Eats Plants, keep eating whole food plant-based. This is from TI42106. Doesn't sound very human, does it?
Dr. Caldwell B. Esselstyn, Jr:
Sounds like a neighbor.
Rip Esselstyn:
"What are your opinions on different types of cardio exercise? Sprinting is very popular right now, but I have my doubts that it's ideal for longevity. Related, seriously are marathons healthy or harmful to the old ticker?" What are your thoughts on exercise?
Dr. Caldwell B. Esselstyn, Jr:
Yeah, I think exercise is no question, it's a bonus. And as a bonus, you want to have it be something that you look forward to on a regular basis. So if I doubt that there're going to be many people who are going to do the extreme exercise to exhaustion, but you get just as much benefit whether you're regularly walking at a certain distance. You may be jogging. You may be biking. You can be swimming. It just seems to be important that you do it on a regular basis and maybe get your heart rate up a little bit.
Dr. Caldwell B. Esselstyn, Jr:
But that type of regular exercise plus whole food plant-based nutrition, then you're likely to have your vessels be as eternal as someone from Central Africa. Or the Papua Highlands. Yeah.
Rip Esselstyn:
So speaking of exercise, have you exercised yet today? You doing anything?
Dr. Caldwell B. Esselstyn, Jr:
I have. Today, it was kind of walking. Excuse me. Today, it was raining mildly. Now, when it's raining mildly, I can't do what I almost regularly do, which is biking because when you bike in the rain, you don't see well. So I went ahead and I did some walking today.
Rip Esselstyn:
Right. Well, also riding in the rain can be slippery and that's not a good combination.
Dr. Caldwell B. Esselstyn, Jr:
I'm familiar with that.
Rip Esselstyn:
Yeah. But typically, are you biking every day?
Dr. Caldwell B. Esselstyn, Jr:
Every day.
Rip Esselstyn:
For how long?
Dr. Caldwell B. Esselstyn, Jr:
Usually it's about 40 minutes. There's a nice driveway into a private school over here where they don't seem to object to my writing where there's several hills in it. I get usually about three laps there. I've gotten into the red zone a little bit. Pulse rate is up. I'm sweating. It hits the bonus part.
Rip Esselstyn:
No, I know that and do you come up that one hill at all?
Dr. Caldwell B. Esselstyn, Jr:
Yeah, always.
Rip Esselstyn:
That's good. Three loops of that.
Dr. Caldwell B. Esselstyn, Jr:
Absolutely. Whew.
Rip Esselstyn:
Okay. Let's move on. This is Miss Derma Path 1. She wants to know, "Can your HDL be too high? My HDL started off very low." Let's see, "Started off very low 32 about 10 years ago. But of my..." Let's hold on a sec. Let me read this and we'll... Can your HDL be too high?
Dr. Caldwell B. Esselstyn, Jr:
Why don't we talk about HDL?
Rip Esselstyn:
Yeah. Hold on. Okay. All right. This is from Miss Derma Path and she wants to know, "Can your HDL be too high?" Hers used to be 32. It's now 70, which that's quite a jump. And her total cholesterol is 162, and she has a family history of cardiovascular disease. So she's concerned.
Dr. Caldwell B. Esselstyn, Jr:
I think we ought to kind of review, the HDL cholesterol. Now, back in the 1970s, '80s, maybe even in early '90s and some people who were not informed even today, it was felt that a high HDL cholesterol was protective.
Dr. Caldwell B. Esselstyn, Jr:
This all began to change for me about 34 years ago when the very first group of patients that I was studying, these were largely men... Nothing against women, but these were men and the accepted low normal level of HDL cholesterol for men is 40 milligrams per deciliter. Within about two or three months of starting that study every single one of those men had dropped their HDL cholesterol into the low 30s. But at the same time, they were losing weight. At the same time, they were losing symptoms of heart disease. And when we carefully studied them, they were reversing their disease all where they lowered the normal level of HDL cholesterol.
Dr. Caldwell B. Esselstyn, Jr:
Ornish was noticing the same thing. So the next great study that happened was when Pfizer invented a drug that was going to end all heart disease. It was called Torcetrapib. Half of the pill was Lipitor, which would drop your bad LDL cholesterol. The other half was Torcetrapib, which would take your HDL cholesterol over a hundred through the roof. It was interesting that just about the time that Pfizer was going to bring this drug out under the public because it was going to end all heart disease, the chairman of Pfizer got a phone call from the chairman of the independent monitoring committee.
Dr. Caldwell B. Esselstyn, Jr:
"Mr. Pfizer chairman, we have a problem." "Okay. What's that?" "Well, in the group that was the control group, there had been 51 deaths. However, in the Torcetrapib group, there were 81 deaths. It was killing people." So fortunately it never came out. Then the next thing that came out about HDL was from Dan Rader and his team from the University of Pennsylvania.
Dr. Caldwell B. Esselstyn, Jr:
They drew blood on 2,000 patients. They measured the HDL cholesterol. Some were high, some were medium, some were low. Then they did a fascinating thing. They took each of those cholesterols and they measured its capacity to do its job of reverse cholesterol transport. And what they found was there was absolutely no relationship whatsoever to the measured blood level of HDL cholesterol and its ability to do its job of reverse cholesterol transport.
Dr. Caldwell B. Esselstyn, Jr:
Then the next and the final thing that was interesting, the very next month, as a matter of fact that study that I mentioned about Dan Rader and his team from the University of Pennsylvania that was in the New England Journal of Medicine in January of 2011. It was the on the 13th of January. It was the very next month in the journal of-
Rip Esselstyn:
Hey, Ann, please be quiet.
Dr. Caldwell B. Esselstyn, Jr:
... of cardiovascular review. The team from UCLA had particularly looked at the APOL A1, which is the protein portion, the protein moiety of the HDL molecule. And they found that when you were eating the Western diet, you injured that APOL A1 and you converted your HDL molecule from normally a strong, positive anti-inflammatory molecule. When you injured the APOL A1, it becomes a proinflammatory molecule. So now your HDL is joining with your LDL to injure you.
Rip Esselstyn:
So it almost becomes like a rogue HDL.
Dr. Caldwell B. Esselstyn, Jr:
Yeah.
Rip Esselstyn:
You know what's interesting because I've now looked at probably 2,000 different cholesterol levels, HDL, LDL. Women typically seem to always have those high HDLs get in the 70s, 80s, 90s.
Dr. Caldwell B. Esselstyn, Jr:
Well, I had a patient who she still is doing beautifully, but when she came to see me she had just had a heart attack and her cholesterol HDL was 120.
Rip Esselstyn:
And her cardiologist probably told her it would be awesome.
Dr. Caldwell B. Esselstyn, Jr:
Oh, it was a protective wealth. That's been blown out of the water. Yeah. It's interesting because what is so important for patients to understand is that when you are eating whole food plant-based nutrition, which is so anti-inflammatory that as your body loses its inflammation, your liver says, "I'm going to make less HDL. You do not need as much anti-inflammatory molecule of HDL as I was giving you before."
Dr. Caldwell B. Esselstyn, Jr:
And this is so profound that when physicians are skeptical about these findings, tell them about what is the average HDL level of the Tarahumara Indians in Northern Mexico who never have heart disease. When Bill Connor studied them, the average HDL was 25, which would drive the unknowing cardiologist absolutely apoplectic.
Rip Esselstyn:
Right. Well, I have found that most people after they do our seven day immersion program or take the PLANTSTRONG challenge, their HDL if they're getting their numbers tested, typically comes down 10 to 15%.
Dr. Caldwell B. Esselstyn, Jr:
There you go. They have less inflammation in their body. They need less HDL.
Rip Esselstyn:
Right. So I think the moral of this story is if you're eating whole food plant-based and your HDL comes down below 40, it's okay.
Dr. Caldwell B. Esselstyn, Jr:
Absolutely.
Rip Esselstyn:
Right. The endothelial fortress. That's the most important thing. All right. Here we go. Last question. This is from Where You Wanna Go. "A recent scan revealed mild atherosclerosis. I'm vegan and have been for eight years." But we know that vegan doesn't mean whole foods plant-based. "Which foods should be avoided and is the buildup that I have reversible?"
Dr. Caldwell B. Esselstyn, Jr:
Yeah. One of the things that we found is that when you have an atherosclerotic plaque burden and it's in somebody who was young, it's interesting that the plaque is usually made up of inflammation fat and cholesterol, which is something the body can handle very well for reversing. On the other hand, on the other hand, when you have somebody who's more senior and they've had this plaque for decades. The plaque is more likely to be made up of actually scar fibrosis calcification. And it's less likely to go away when you're eating whole food plant-based nutrition, however.
Dr. Caldwell B. Esselstyn, Jr:
But what you've also found is, nevertheless, even those patients can get back to full activity of daily living without restriction. Why? Now this is a little bit complicated, so hold on.
Rip Esselstyn:
Okay. I'm going to focus.
Dr. Caldwell B. Esselstyn, Jr:
The arteries that get all the publicity are the right coronary artery, the left anterior descending and the circumflex. Those are the three main vessels. And then they branch. Well, where do they go when they branch. They all dive where they're supposed to go. They dive into the heart muscle and then they interdigitate and connect with each other. So that on a slide actually that you gave me, you can see these thousands and thousands of intramuscular vessels connecting and really joining.
Dr. Caldwell B. Esselstyn, Jr:
And it's really quite impressive how thorough the vascularity is of the heart. So there was a time when I did a study of what we call PET scans and a PET scan shows that the heart muscle is orange or yellow, it's getting a good blood supply. And then there's a patch on the side where it's green, it's poor blood supply.
Dr. Caldwell B. Esselstyn, Jr:
I counsel the patient the day he has the PET scan. He comes back three weeks later, we repeat the PET scan. The part that was green is now orange or yellow. It's re perfused. Now wait a minute. I said to myself because there's no way that you are going to reverse... In three weeks, you're not going to reverse this blockage. Why did this happen?
Dr. Caldwell B. Esselstyn, Jr:
So I talked to Rodriguez who is the chairman of the Cleveland Clinic Cardiovascular Pathology Section, who does 200 autopsies and looks at a heart through an autopsy perspective 200 times a year. I asked Rodriguez, I said, "How often, when you look at the vessels of this, these hearts, how often do you ever see atherosclerotic burden once the artery has dived into the heart muscle? His answer, "Never."
Dr. Caldwell B. Esselstyn, Jr:
Now I had the answer because why were we getting all this reperfusion of blood supply? Because when I first see these patients, their endothelial cells are so beaten down, they're barely making nitric oxide, which is that wonderful vessel dilator. And your endothelial cells have now become your enemy. They are making two molecules, endothelin and thromboxane, which are blood vessel constrictors.
Dr. Caldwell B. Esselstyn, Jr:
So literally all those intramuscular vessels, although they have no blockage inside them. They are all crimped and pinched and narrowed because of spasm from these endothelin and thromboxane. So what's beautiful to see is suddenly when the patients get it and they've been counseled and they stop eating anything that is going to further injure or impair their endothelial cells, the nitric oxide, the vessel dilator increases, and they totally stop making the endothelin and thromboxane. So all these intramuscular vessels suddenly open up.
Dr. Caldwell B. Esselstyn, Jr:
So when all those intramuscular vessels open up that reminds you of Poiseuille's law of flow through the hollow viscus. And remember, in your days in physics, translation, a tiny increase in diameter, an enormous increase in blood flow, which is why these patients often, especially the ones that have chest pain or angina within six, eight or 10 days, they'll say, "I don't know what's going on, but my pain is going away." And then you've got them hooked.
Rip Esselstyn:
Yeah. Well, it's incredible to me that it can happen that quickly in a matter of a week where you can actually notice the difference. And the dilation occurs and the... What were the two?
Dr. Caldwell B. Esselstyn, Jr:
Endothelin and thromboxane.
Rip Esselstyn:
Yeah, those guys. Those guys go away.
Dr. Caldwell B. Esselstyn, Jr:
That'll now be part of your vocabulary.
Rip Esselstyn:
Yeah. So I do have a question for you. Yesterday, I actually was talking to a firefighter from Southern California, 45 years old and he was concerned his total cholesterol was 243. He had a calcium score of 104, which at the age of 45, put him in the 90th percentile. And so he was very concerned.
Dr. Caldwell B. Esselstyn, Jr:
Sure.
Rip Esselstyn:
He's going to go back for another calcium score and it's probably going to-
Dr. Caldwell B. Esselstyn, Jr:
Go up.
Rip Esselstyn:
Going to go up.
Dr. Caldwell B. Esselstyn, Jr:
Let's talk about that.
Rip Esselstyn:
Can you talk about that?
Dr. Caldwell B. Esselstyn, Jr:
Oh yeah. I learned about calcium score in some deaths a number of years ago from William Castelli, Bill Castelli for 30 years, was a director of the world famous Framingham Heart Study outside of Boston. And Castelli said this, Castelli said, "If a physician orders a calcium score, it's going to give you two pieces of information. One is that you'll see the calcium and you'll know that the patient does have coronary artery disease where some of these smaller plaques on the side of the vessels have gotten calcified."
Dr. Caldwell B. Esselstyn, Jr:
He said, "It also tells you, but does not show you that that patient also has therefore a number of noncalcified inflamed plaque which are the ones that are more dangerous and subject to rupture. But he said, "Let's take the example of somebody who has a calcium score and it's 440, but they absolutely get it right. And the next year they're totally committed to whole food plant-based nutrition."
Dr. Caldwell B. Esselstyn, Jr:
Then they have another calcium score and it is now 550. But the patient he said is much better off. Because what has happened? During that year, that the patient has been consuming this highly anti-inflammatory diet, their inflammation is going down. And he said, "It is as though the body would like to get in on the act and it will deposit some calcium in those previously noncalcified inflamed plaque to help hasten along the quelling of that inflammation."
Dr. Caldwell B. Esselstyn, Jr:
And that leads us to the fact that so often in patients who are totally committed to improving their wellbeing with whole food plant-based nutrition, what happens is their calcium score will go up and they must not be told that they're getting worse because they're actually getting better. Why? Because when you have calcified those previously noncalcified inflame plaque and they've lost their inflammation, they're not going to rough you and hurt you.
Rip Esselstyn:
Yeah. And it sounds like too, if you have everything else that is showing that the inflammation is coming down. Your inflammation, markers, your cholesterol, your LDL, all those things, then this actually, it makes a lot of sense. But people have to be educated what is going on so they don't freak out because a lot of times, probably their cardiologist might say, "Hey, I'm concerned here." So they're not really aware of what Castelli told you.
Dr. Caldwell B. Esselstyn, Jr:
That's right.
Rip Esselstyn:
Do you know if Castelli is still alive?
Dr. Caldwell B. Esselstyn, Jr:
I'm assuming he is, but I don't know. I'm sure he must be he, but he's a few years older than I am.
Rip Esselstyn:
All right. Well, okay. So what you got going on this summer? You got anything exciting you're looking forward to?
Dr. Caldwell B. Esselstyn, Jr:
Well, I think the exciting thing this summer is to be up at the farm. It's always great to be at the farm. And there's a lot going on in terms of... I like to do some mowing to keep the farm up the trim and looking stylish. We may get a few projects involved. Whether we'll be able to get it this year or not, but there's a little red house on the hill that has-
Rip Esselstyn:
Where I got married.
Dr. Caldwell B. Esselstyn, Jr:
Yeah, exactly. And that's taken a few hits over the years and it really deserves to be restored.
Rip Esselstyn:
Right. Some nice projects at the farm. I look forward to being there for a couple weeks in July. Is there anything professionally that you're sinking your teeth in right now or you're excited about?
Dr. Caldwell B. Esselstyn, Jr:
Well, I think the thing that it really makes me so passionate about what I see as the seismic revolution in health is before us and the seismic revolution in health that you see is really not going to come about from a drug or a pill or a stent or bypass surgery. But the seismic revolution in health that will come about, will be when we in the profession have the will and the grit and the determination to share with the public, what is the lifestyle? And most specifically, what is the nutritional literacy that will empower them to absolutely annihilate chronic illness?
Rip Esselstyn:
Yeah. That is exciting. And it's amazing when you think about it, how far this movement has come since you initially dug your teeth into this in 1984. I can't imagine how pleased you are and the amount of people that are now following your slipstream like the Brian Asbills and others. It is impressive.
Dr. Caldwell B. Esselstyn, Jr:
If it works.
Rip Esselstyn:
Hey, Ann.
Ann Crile Esselstyn:
What?
Rip Esselstyn:
Can you come share with us what's for dinner tonight?
Ann Crile Esselstyn:
What did you say?
Rip Esselstyn:
What's for dinner tonight? Come on, mommy.
Ann Crile Esselstyn:
Dinner?
Rip Esselstyn:
Yeah. Hey, thank you. It's great.
Dr. Caldwell B. Esselstyn, Jr:
My pleasure.
Rip Esselstyn:
Yeah, come here. Let everybody know what's for dinner tonight, because I know you've been very excited about working on this. Will you you sit right here?
Ann Crile Esselstyn:
We are really excited about dinner tonight because somebody-
Rip Esselstyn:
You got a phone ringing.
Ann Crile Esselstyn:
Neighbors told us about these amazing Nori of sushi stacks. So we're having a sushi stack. Jane and I are going to do a YouTube on it soon. It is so fun. I've been waiting to have Rip try it. And then we're having asparagus.
Rip Esselstyn:
I can smell it.
Ann Crile Esselstyn:
Yeah. And we're having a fabulous dessert, my favorite dessert.
Rip Esselstyn:
What is it?
Ann Crile Esselstyn:
Which is blueberry cherry moose with all kinds of fruit. Wait. It doesn't matter. The phone is ringing and we just want to talk to you. Okay, bye/
Rip Esselstyn:
All right. It's probably Jane. All right. Over and out. Thanks, Everybody. Thanks. Thanks, daddy.
Dr. Caldwell B. Esselstyn, Jr:
Absolutely, Rip. My pleasure.
Rip Esselstyn:
Bye. I want you all to know how much I appreciate you listening to the PLANTSTRONG Podcast. I would love it if you would share this episode with anyone that you think will benefit from hearing the good news about plants. Remember, keep your loved ones near, build an endothelium fortress and always keep it PLANTSTRONG.
Rip Esselstyn:
The PLANTSTRONG Podcast team includes Carrie Barrett, Laurie Kortowich, Ami Mackey, Patrick Gavin, and Wade Clark. This season is dedicated to all of those courageous true seekers who weren't afraid to look through the lens with clear vision and hold firm to a higher truth. Most notably, my parents, Dr. Caldwell B. Esselstyn, Jr. and Ann Crile Esselstyn. Thanks for listening.
