IF YOU HAVE READ THIS FAR, you now know what you need to do. But if you’re like most of my patients, you still have some serious questions. In this chapter, I will address some of the most common concerns.

Can I change?

Many patients have told me how difficult it is to change. They mention how hard it is to maintain this nutrition plan when dining with friends and relatives, during work hours, while traveling, both in the United States and abroad. But you can do it. Many others have. The key is to remember that the rewards are greater than the frustration.

I have experienced this phenomenon myself and watched it in every patient with whom I’ve worked: after twelve weeks of eating no animal foods, dairy, or added oils, you lose your craving for fat.¹ You then begin to appreciate more than ever before the natural flavor of grains, vegetables, legumes, and fruit. You develop a series of menus that you especially enjoy. Occasionally, friends get interested in what you are doing, and daringly invite you to their homes for no-fat meals. You discover restaurants that actually will cater to your needs.

You can change. While switching to a strictly plant-based diet may seem challenging at the start, all you have to do is stick with it. The satisfaction of new tastes and, above all, the health rewards make it no contest.

Will I get enough fat and protein?

The answer, emphatically, is YES.

No fat deficiencies have been identified in people who eat a variety of plant-based foods. Overall, a diet made up of the foods on the “approved” list in Chapter 8 will contain approximately 10 percent fat. That level represents a significant departure from the 37 percent fat content of the typical Western diet, but it is ideal for good health. It provides all the fat you need without giving you the extra doses that wreak such havoc with your heart health.

And this diet will not cause a protein deficiency. Typically, the Western diet contains an excess of protein—especially animal protein. The nutrition plan I recommend provides a variety of healthy plant proteins, somewhere between 50 and 70 grams every day. That is entirely adequate for a healthy lifestyle.

Could a low cholesterol level be dangerous for my health?

Some years ago, there were reports that low blood cholesterol levels might be associated with lung, liver, or colon cancer and that they might also contribute to accidental deaths and suicide. For example, one trial from Helsinki, Finland, seemed to have identified more traumatic deaths in patients using cholesterol-lowering drugs.²

But subsequent reanalysis of the Helsinki study and all other trials of the effects of reducing cholesterol levels, with or without drugs, have shown no increased incidence of suicide, accidents, or cancer. The newer research makes it clear that otherwise healthy individuals who achieve low blood cholesterol through proper low-fat nutrition will enhance their health, not harm it. The West Coast Family Heart Study found a reduction in both depression and aggressive hostility among those on a low-fat, cholesterol-lowering program compared to the control group eating the standard high-fat diet.³ And in a large study from Scandinavia, patients with coronary artery disease were randomly chosen to receive either a cholesterol-lowering drug or a placebo, a harmless pill containing no medication. The members of the group that took the drug lowered their cholesterol by an average of 35 percent. After five and a half years of follow-up evaluation, they had experienced significantly fewer deaths, fewer new heart attacks, and fewer angioplasties and bypasses than those who took the placebo, and they showed no increase at all in deaths from accidents, suicide, or cancer.⁴

Will I have enough strength and energy?

If you believed all the advertisements that bombard us in print and on television, you’d think that people who didn’t consume dairy and animal products couldn’t possibly get the nutrients they need for strength and energy.

Nonsense. The truth is that excessive consumption of animal protein badly weakens our bodies. Among other things, it accelerates the loss of calcium through the kidneys, leading to the brittle, porous bone condition called osteoporosis. And take a look at the examples nature offers. The elephant has huge, strong bones to support its weight. Has anyone ever seen an adult elephant drinking whole milk for calcium? The muscles of an Aberdeen Angus bull are most impressive. But it is highly unlikely, to say the least, that any of those bulls have ever eaten steak.

There are plenty of examples of human athletes who achieved greatness nourished by plant-based diets. Art Still, a lean and muscular 270-pound defensive end, was convinced of the benefits of plant-based nutrition during his playing days in the National Football League. Carl Lewis, the champion sprinter, switched to a plant-based diet in the late 1980s. At the world championship track meet in Japan in 1991, at the age of thirty, he became the only man in history to broad jump farther than twenty-nine feet three times in one afternoon. At the same meet, he set a world record for the 100-meter dash and ran the anchor leg on the record-setting 4 × 100-meter relay team.

Or take the Esselstyn family. In 1984, the whole group joined Ann and me in moving toward eliminating dairy products, meats, and oils from our diet. Our eldest son, Rip, became an all-American swimmer at the University of Texas (and today is a firefighter in Austin, where his entire team at Firehouse 2 has adopted plant-based nutrition). Our second son, Ted, set a 200-yard backstroke record at Yale, and our daughter, Jane, won the Big Ten 200-yard backstroke championship while she was attending the University of Michigan. Our youngest son, Zeb, as an Ohio high school junior, was the state butterfly swimming champion. And Ann, now in her early seventies, runs between forty and seventy minutes almost every day.

You need not worry about strength and energy on my nutrition program.

What if my cholesterol won’t go below 150 mg/dL?

A tiny minority of the population, no more than 5 percent of all Americans, has an inherited cholesterol disorder that makes it impossible for them to reduce total cholesterol below 400 to 500 mg/dL, even with careful nutrition. Such patients need to be monitored by highly qualified cholesterol specialists, and in rare cases, may require liver transplants to help them regain the ability to reduce cholesterol.

But for the great majority of persons, that is not a problem. So the first thing I do when people tell me that they can’t reduce their cholesterol to 150 mg/dL or less is press them on precisely what they eat on Friday or Saturday nights, or what they might have consumed at that seemingly endless weekday meeting where there was “nothing else to eat.” Often, under my questioning, they reveal tiny deviations from the nutrition program—lapses so small that they didn’t even take them into account. One example: by the time you hold down the nozzle on a popular cooking spray long enough to coat a wok or pan, you’ll build up about a tablespoon of oil. Such transgressions can easily be enough to injure the endothelium’s capacity for producing nitric oxide, which in borderline cases can mean the difference between success and failure. It is that kind of attention to tiny details that makes my program work.

It is true that there are some people without heart disease who strictly adhere to a plant-based diet—no lapses at all—and even so, cannot reduce their cholesterol below 165-170 mg/dL. (Some researchers have suggested that years of eating fat and cholesterol may compromise the body’s natural capacity to reduce cholesterol levels.) For these people, a modest dose of a cholesterol-lowering medication under physician supervision should take care of the problem. It is worth noting, however, that anyone who achieves a cholesterol level of 165-170 mg/dL by eating a strictly no-fat, plant-based diet is already doing wonders for his or her health, even without reaching the optimal level. That person is, by definition, consuming large quantities of natural antioxidants, which prevents the body from oxidizing LDL cholesterol into its most dangerous, artery-clogging form.

Don’t my genes predetermine whether or not I’ll get heart disease?

I often hear some variation on the following theme: “My eighty-seven-year-old grandfather eats nothing but eggs, bacon, cheese, and pork, and seems fine. Since I have his genes, why should I change?”

That question brings to mind an analogy: depending strictly on your genes to keep you safe while living a high-fat lifestyle is much like getting through a busy four-way intersection that has no traffic signs or stoplights; a few people will make it across unscathed, but many more will be injured—or will perish. The grandfather living on fat is obviously someone with a good cholesterol clearance mechanism and strong artery linings that resist breakdown and deposits of fatty plaque. But it is important to remember that the male grandchild asking the question does not share his grandfather’s exact genetic profile. The questioner’s grandmother and two parents have added to his own genetic mix, and he has no guaranteed protection against coronary artery disease as the grandfather apparently does.

I also hear the converse of that question, which is rather more to the point: “Both my father and his brother died of heart attacks at age fifty-eight, and their father had the same fate at sixty-three. Is there really anything I can do to avoid their fate? Am I condemned by my genes to have heart disease?”

This time, the answer is an emphatic NO. If you maintain a cholesterol level under 150 mg/dL, or LDL under 80 mg/dL, you—and all the other relatives who inherited these genes—will be free of heart disease. Recall, once again, the house fire analogy I ask my patients to consider. If you do not throw any fuel at all on that fire, it cannot burn.

To paraphrase William Shakespeare, the fault is not in our genes, but in ourselves and the way we eat. And that brings me to a frequently asked question that gets a chapter all its own.