Dispelling nutrition myths, ranting, and occasionally, raving

Revisiting Dr Esselstyn



A reader recently commented on a blog post from over a year ago: <a Something's Greasy About Dr Esselstyn's Diet. He suggested that I take a look at some recently published research supporting the diet (and, I think, revise my previously stated opinion).

One of the links was to a series of case studies presented by Dr Esselstyn. As we know, case studies can be interesting, especially in cases of rare conditions, but are not readily generalized. As coronary artery disease (CAD) is a fairly common condition, I feel that it’s more prudent to focus on larger research studies when developing recommendations for the public.

The other link was to a study conducted by, you guessed it, Dr Esselstyn. The study followed 198 CAD patients who were counselled in plant-based nutrition for approximately 44 months. Upon follow-up it was found that 21 were non-compliant (what ever that means… more on this to follow). The remaining participants all showed significant improvement, and only one experienced a related medical incident (i.e. stroke) during those 44 months.

The biggest issue with this study is that there was no control group. There is nothing to compare the participants with. It’s entirely possible that a group, provided with all the same medical treatments and advice, minus the nutritional counselling would have fared just as well. It does seem unlikely, but without the inclusion of such a group, there is no way to be certain that the nutrition counselling (and subsequent adherence) was the reason the participants fared so well. In addition, there was no control for any potential confounding factors. The authors didn’t control for anything. That means that the success could have been due to physical activity/exercise, sleep, stress reduction, socioeconomic status, etc.

There are a few other issues I have with this research. The article states that:

Initially the intervention avoided all added oils and processed
foods that contain oils, fish, meat, fowl, dairy
products, avocado, nuts, and excess salt. Patients were also asked to avoid sugary foods
(sucrose, fructose, and drinks containing
them, refined carbohydrates, fruit juices, syrups, and molasses). Subsequently, we also
excluded caffeine and fructose

However, “We considered participants adherent if they eliminated dairy, fish,
and meat, and added oil.”

My issue with the diet prescribed by Dr Esselstyn was the lack of healthy fats. I have no issue with a vegetarian diet (yes, I’m still not convinced that oil, fish, and dairy products are unhealthy, especially for those who do not suffer from CAD) which is what the adherent participants followed. This means that they could have added nuts, seeds, nut butters, sugar, coffee, avocado, and so on, to their diets and still been adherent. A far cry from the original Esselstyn diet. In turn, I also wonder what the non-adherent participants consumed. Did they eat some fish or meat? Drink some milk? Or were they chowing down on fast food and Hungry Man dinners on the regular? Without knowing these things we shouldn’t be too quick to jump to the conclusion that the Esselstyn diet is superior to all other diets when it comes to treating CAD.

Naturally, there’s also the issue that (despite stating that the authors had no known conflicts of interest) Dr Esselstyn is the author of a number of heart health and lifestyle books that would surely take a hit in sales were research contrary to his hypothesis to be published.

Sure, this study warrants further research into the benefits of plant-based diets (and Dr Esselstyn’s very low-fat plant-based diet) for CAD patients. I’d like to see some larger studies with control groups conducted. Until then, I’ll still be cooking with oils and enjoying my guacamole.



Author: Diana

I'm a registered dietitian from Nova Scotia, living and working in Ontario, Canada. My goal is to help people see food and nutrition from a different perspective and understand that nutrition and health are not necessarily a result of personal choice.

12 thoughts on “Revisiting Dr Esselstyn

  1. I read his book and have followed the diet for three years following my stent procedure. Esselstyn’s “studies” don’t need a “control group” because all the other diets act as the controls. No other diet has documented disease reversal other than Ornish and Esselstyn’s. When you can document comparable or better results eating something else, then a controlled study would be reasonable to pin down the true mechanism that reverses heart disease. Pritikin, Ornish and Esselstyn have been scoring unanswered points for decades. I wish you nay-sayers would put up or shut up. If you can do as good or better with three times as much fat in your bloodstreams–prove it, show me the arteries!


    • His diet may well work, but if he wants the medical community to adopt it then he needs to have good research (with a control group… drop-outs from the study do not count as controls) to back it up.


  2. Says you. According to the report:
    “The Cleveland Clinic Institutional Review Board determined that these were acceptable outcome measurements to evaluate the nutrition program.”
    If it’s good enough for the Cleveland Clinic, it ought to be good enough for you.


  3. I wonder if the control “victims” in “your” study would agree after two out of three of them died or had another cardiovascular event while the 10% fat dieters stopped the disease in its tracks, just like in the previous smaller study predicted would happen. You can have the last word. Bye.


  4. I just posted a comment on your unrevised article.
    Anyway here it is again as it may be interesting for you to research some of the points I make:

    Hello Diana,
    Allow me to disagree even more respectfully. The statement “Fat is an essential nutrient” is, apart from being bullshit, irresponsible for you to make and, if actually someone trusts your diet advices, even dangerous. Let me explain:
    1. Essential nutrients are the ones that cannot be synthesized in our bodies. That being said you cannot say fat is essential, as fat is not a single nutrient, analogically to carbohydrates and proteins.
    2. You are, obviously for lack of education, mistaking fat for fatty acids. There are only two fatty acids, that the human body cannot synthesize on its own, but needs for very fundamental processes. The first essential fatty acid is LINOLEIC ACID, which happens to be an omega-6 fatty acid, because it has its final carbon double bond in the n-6 position, which is the 6th position counting from the tail of the molecule if we consider the head of the molecule to be where the carboxyl group is. The other essential fatty acid is ALPHA-LINOLEIC ACID, which happens to be an omega-3 fatty acid, because its final carbon double bond is in the n-3 position.
    3. First any of these fatty acids may serve as a building block for any omega-3 and omega-6 fatty acid the body may require for its biological functions, as these two fatty acids provide the basic structure and easyly they can be enlongated, shortened or modified to all other omega-3 and omega 6 fatty acid. OMEGA-9 fatty acids are NOT ESSENTIAL and only can be used as source of ebergy, and its not an easy source, lets say it is a dirty fuel. (not as dirty as proteins btw)
    4. Now that I’ve made it clear what is essential and for what purposes let’s examine what happens next. Oversimplified the biological effects of the omega-3 and omega-6 fatty acids are mediated by their mutual interactions. That means: the effects of an omega 3 fatty acid for a specific biological function is defined by the amount of the corresponding omega 6 fatty acid for the same function. In that way you may get pro-inflammatory environment if you have a certain ratio of the needed omega 3 and omega 6 fatty acids and the opposite effect if you have a different ratio and if you are deficient in let say ALPHA-LINOLEIC ACID your body is unable to make its complicated stuff and a pro-inflamatory environment develops, which means that inflammations begin very fast, stop slowly and last a long time for very trivial reasons.
    5. Now lets talk how much of these TWO you NEED to function properly, to live, to thrive, to be healthy (it’s the same when we talk biochemistry). You need a certain minimum amount and a certain ratio. The minimum amount is a low single digit number of grams per day for ALPHA-LINOLEIC ACID depending on your weight. Say 3 grams or 5 grams if you’re bigger, or more active. The acceptable ratio of these two fatty acids omega-3:omega-6 is between 1:1 and 1:4. so the amount of LINOLEIC ACID needed is a few grams also, and a bit more is acceptable.
    6. What happens if you follow some non scientific dietary advices, as those given by dietitians or even worse doctors (both groups of people consider themselves some kind of scientist – idiots). If you consume bad ratio of the said fatty acids, like 1:10 and up you force your body do work very hard to keep your basics running, which i find very stupid. And if you consume much higher amounts than needed, say 5 times higher and up you force your body to burn fat as fuel which not the most elegant(efficient) energy production biochemical process your body is equipped to perform.

    Dear Dianna, please check your science! Your calculations are a complete bullshit. The body is extremely efficient when it needs to be and if it needs to be efficient a lot of times it becomes even more efficient. The DHA EPA thing is plainly stupid: if you consume regularly those fatty acids the body will down-regulate their synthesis and vice-versa. The 1.6 grams of ALPHA-LINOLEIC ACID found in flax seed meal is absolutely enough even on its own in any way science can look at it. 1.6 grams in flax seed meal is not rancid, damaged or malabsorbed don’t forget. Flax seed oil on the other hand has the rancid problem hugely. The fish oils have it too. Heating omega 3 fatty acids is not very clever you know…do you eat your fish raw most of the time? The japanese are onto something!
    As far as science is concerned Dr Esselstyn’s diet is completely acceptable and is capable of sustaining a healthy human being over very long periods. As a young scientists I see a lot of reason in such a diet and not many problems. This is the right way of medicine as fat as I am concerned and pseudo-dietary experts should keep the bold statements to themselves.
    If you’re interested in helping anyone I advise you to start learning from more reliable sources first. Women magazines are not such sources. Then bring your tone done when commenting on areas where you’re not sure you understand the complexities and interconnections between things.
    And before all-DO NOT MISLEAD PEOPLE

    Thank you!


  5. Oh brother. Just accept it and quit trying to find a flaw! The diet worked!


  6. Pingback: Thoughts on “The Myth of High-Protein Diets” | bite my words

  7. Diana-you are a voice of reason. These plant based evangelists are wound up so tightly, I wouldn’t dignify their comments with a response. This whole planet socially, economically, and traditionally is animal based. It never has been and never will be completely plant based except where animal products are unavailable or out of the range of affordability. Look now at the great success of the Ketogenic diet and how people are losing weight and reversing heart disease, diabetes, cholesterol problems and hypertension. How can this be with a diet that is the complete antithesis of anything plant based except for a few carbs from leafy green veggetables which many keto dieters avoid anyway. The fact is that both plant based and animal based diets can be perfectly healthy. What is destructive to our health and wellness are refined simple sugars and flours, fast foods, and food created in laboratories by the greedy, profit focused food industry – – – not animal products like milk, eggs and dairy or fresh wild caught fish and lean meats.

    Liked by 1 person

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