BLOOD VESSEL DISEASE: THE TREE OF LIFE
My dad didn’t die from his life-threatening heart problems. He was one of the lucky ones. My mom, my sister, and I were lucky, too—we didn’t lose him.
For most Americans, the first indication they have heart disease may be the heart attack that kills them. Death, for these people, happens within an hour of the first symptom.1
Cardiovascular disease is the leading cause of human death on the planet. In the United States, one person dies every 40 seconds from cardiovascular disease. And it’s not just men. Heart disease is the top cause of death for women. Cardiovascular disease kills more people than all forms of cancer combined.2
These are almost entirely preventable deaths.
“You can identify heart disease years before the first chest pain,” Dr. Joel Kahn told Keegan and me, “the first heart attack, or God forbid, the first dropping dead. Very strong data from the past fifteen years shows that a certain lifestyle drops your risk of heart attack by about 85 percent.”
“Eighty-five percent?” I echoed. Like diabetes and cancer, my family’s heart disease has been heavy on my shoulders since I was a teenager.
“Yes,” said Dr. Kahn. “When I find individuals with silent early heart disease—no symptoms—who have no clue what they’re walking around with, I tell them about vitamin L: lifestyle. Not smoking; maintaining a healthy weight; exercising. And what comes out constantly from the scientific data is, ‘If you’re not getting five or six servings of fruits and vegetables every day, you’re denying yourself the greatest protection from cardiovascular disease.’”
I have been amazed, while speaking to these health professionals, by the human body and the complex, intuitive processes within us—especially the interface between our bodies and the food we eat. There are ingenious systems at work that most of us are oblivious to.
“Cardiovascular disease,” Dr. Esselstyn explained to Keegan and me, “has its inception when you injure the endothelium, that delicate single layer of cells that lines the innermost wall of our arteries.
“The endothelium makes nitric oxide. Nitric oxide is the strongest vasodilator—a substance that opens blood vessels—in the body. When you climb stairs, the arteries to your heart and your legs widen because of nitric oxide. Nitric oxide prevents our artery walls from becoming thickened, stiff and inflamed, and protects us from high blood pressure. And—this is key—a normal level of nitric oxide will protect you from ever developing arterial blockages. Every person with cardiovascular disease has thoroughly injured the capacity of their endothelial cells to make nitric oxide—they can no longer make enough to protect themselves.
“Now,” he went on, “if you stop consuming every last smidge of any nutrient that will further injure your endothelial cells, they recover. As they recover, they make more nitric oxide. As you make more nitric oxide, the disease is halted. We’ve often seen striking evidence of disease reversal.
“When endothelial cells are beaten down, not only are they not making enough of the vasodilator nitric oxide, they also begin to make vasoconstrictors, which narrow the blood vessels. Arteries, on plant-based nutrition, stop making the bad vasoconstrictors and start making the good vasodilator. With cardiovascular disease, all the blood vessels are diseased—not necessarily with plaque, but because the endothelial cells have been so injured they can’t make this wonderful vasodilator to revive their health.
“But suddenly,” he continued, “when these thousands of blood vessels once again start making nitric oxide, they all dilate. Even a tiny increase in diameter leads to a huge increase in blood flow. That happens throughout the entire vascular tree in the body. That’s what makes these people suddenly feel so much better.”
It sounded faintly miraculous. I loved Dr. Esselstyn’s image of the “vascular tree in the body.” The tree of life.
“People start to feel better, even within just a few weeks of eating a plant-based diet,” said Dr. McMacken. “Are those blockages dissolving right away? No, it’s because you’re removing the foods that cause inflammation, that promote cholesterol deposits in your blood vessels. You’re removing foods that interact with your gut bacteria to make more toxic substances, like TMAO. And you’re taking in antioxidants, phytonutrients, foods that further reduce your blood pressure and cholesterol, and help your blood vessels heal so they function properly.
“My own experience with patients,” she recalled, “and the studies also show, that when people adopt a fully plant-based diet, their cholesterol levels plummet within a few days. If you do blood tests after a couple weeks, there are dramatic improvements. By the same token, after several days of eating animal products, you can actually see inflammatory markers and cholesterol rising. Within just a few days.”
BEFORE WORLD WAR II, THE DEATH RATE IN NORWAY FROM circulatory diseases was steadily rising. Then, in 1940, the Nazis invaded. The Germans confiscated the country’s livestock, forcing Norwegians to live on grains, fruits, and vegetables. Almost instantly, the number of deaths from heart attack and stroke plunged. It was one of the most dramatic mass reversals of heart disease in history. But in 1945, with the end of the war, the Norwegians recovered their farm animals. They got their meat, milk, and eggs back. And they got their strokes and heart attacks back, too.3
Atherosclerosis, the medical term for plaque accumulation in artery walls, is ground zero for many heart attacks and strokes. Athera in Greek means “gruel.”4 Sclirosis in Medieval Latin is “a hardness, hard tumor.”5
This hardened gruel on artery walls is made up of many things, primarily cholesterol, fat, cellular waste, calcium, and clotting material.6 High blood-cholesterol levels can powerfully increase your risk of developing atherosclerosis and heart disease.7
And what causes high blood-cholesterol levels? According to the National Heart, Lung, and Blood Institute of the National Institutes of Health, eating foods containing cholesterol (like eggs, cheese, and meat), saturated fat (meat, dairy, fried and processed foods), and trans fat (fried and processed foods) will do the trick. Eating the saturated fat found predominantly in animal protein will raise your LDL (bad) cholesterol levels more than anything else in your diet.8
Now let’s go to North Karelia, Finland.
Early in the 1970s, Finland had the highest death rate on the planet from cardiovascular disease.9 In one distressingly ordinary example, 38-year-old Seppo Holttinen, a svelte, blond father of three who loved to dance, crumpled on the dance floor and died of his third heart attack. Holttinen’s father, one month earlier, was also killed by a heart attack.10
Seppo Holttinen lived and died in North Karelia, a Finnish region where 1,000 heart attacks occurred every year in a population of 180,000. The local diet was loaded with pork and dairy, especially butter,11 fatty milk, and cream.12 Over half the men also smoked.13 Fifty percent of the heart attacks struck men younger than 65, and 40 percent led to death, despite the fact that most men were getting plenty of physical labor as loggers and farmers.14
The situation became so severe that the Finnish government stepped in. In 1972 the North Karelia Project, a national pilot program aimed at halting cardiovascular disease—by reducing cholesterol, lowering blood pressure, and cutting smoking—was launched.15
Dr. Pekka Puska was director of the Project. He went on to become WHO’s director for Non-Communicable Disease Prevention.16 He and his small team must have felt like a crew in a rowboat charged with reversing an ocean liner, bearing down on them at full steam.
“The whole environment had to change,” Puska said. “The food industry, restaurants, cafeterias, supermarkets.”17
Puska and his staff doggedly spread their message—replace meat with vegetables, butter with vegetable oil, and cut back dramatically on smoking and salt—at churches, schools, community centers, supermarkets, and town meetings. The North Karelian community, thick with dairy farms, was not happy at first. The cold climate also meant that fruits and vegetables frequently had to be imported, a prospect that met with considerable resistance from people who had survived economically on milk from their cows and meat from their pigs.18
The North Karelia Project needed help. So they went in, as Puska described it, “boots deep in the mud.”19
The Project enlisted the powerful help of the Martha Organization, a women’s group. Together they hosted hundreds of “Parties of Long Life,” Sunday gatherings where families could hear the whys and hows of replacing meat with vegetables, and the importance of cutting back on salt and smoking. Recipes adding vegetables to traditional dishes were handed out, and the families were served the new, healthier versions. North Karelian stew, originally made with water, fatty pork, and salt, got a makeover, with rutabagas, potatoes, and carrots swapping out some of the pork. The results were delicious and popular—the new version was dubbed “Puska’s Stew.”20
The North Karelia Project was a true grassroots movement. Puska recruited 1,500 ambassadors from numerous villages, educating and urging them to speak to their neighbors.21
Things began to turn around. Dr. Puska persuaded bread companies to reduce salt and use vegetable oil instead of butter.22 He also convinced the local sausage maker to cut down on salt and use mushroom filler instead of pork fat.
“The sausage industry said in the beginning they couldn’t make the sausage with lower salt,” said Dr. Aulikki Nissinen, who worked with Puska. “Somehow they managed it when people started to demand it.”
Sausage sales went up.
To deal with the fruit shortage, the Project worked with cooperatives to gather and freeze the berries that grew for a short time in the region.
Puska and his team also swayed lawmakers and businesses to provide smoke-free workplaces.23
Cholesterol-lowering competitions sprang up between towns. Winning towns received cash and prizes like new bicycle paths. Cafeteria chefs collected unused salt and displayed it proudly in enormous glass jars. Puska and his team even appeared regularly on a proto–reality TV show that followed people as they changed their lifestyles. The country was riveted. The show ran for 13 years, and 25 to 50 percent of the country tuned in during any given season.24
After five years, the North Karelia Project expanded to all of Finland. Food labels were changed to make it easier for Finns to find low-fat, low-sodium foods. School cafeteria menus were overhauled. Dairy subsidies were dropped, though dairy farmers were encouraged to produce canola oil as a butter replacement.25
The North Karelia Project was a stunning success. Death from cardiovascular disease in North Karelia plummeted by 73 percent, and by 65 percent throughout Finland, over the 25 years of the Project.26
“The Finns have a very pragmatic, non-ideological approach to life,” said Dr. Derek Yach, director of the Rockefeller Foundation’s program on global health, who worked with Dr. Puska at WHO. “They see a problem and they don’t have a big long debate about what’s the philosophical reason or individual responsibility. They recognized that these lumberjacks were dropping dead and that it was because their food was not optimal.”
HEART DISEASE = AGING RUNS ANOTHER CULTURAL ASSUMPTION. IT’S comforting to put the blame on something none of us can control. Grandpa’s got a bad heart—the old ticker’s running down. No big deal. But actually . . .
“Heart disease need never occur,” Dr. Greger told us. “There are millions living in rural China, rural Africa, eating traditional plant-based diets where heart disease is almost nonexistent. When [Nathan Pritikin and doctors like] Dean Ornish and Caldwell Esselstyn put people with end-stage heart disease on the diet that these heart-disease-free populations were eating, hoping to slow the disease, something amazing happened. Arteries were opening up without drugs, without surgery. Our bodies can bring us back towards health if we stop damaging ourselves at every meal.
“If you whack your shin on a coffee table,” Dr. Greger continued, “it will get red and swollen. If you stand back and let your body’s healing properties work, you’ll be fine. But what if you whacked your shin three times a day, every day, at breakfast, lunch, and dinner? It would never heal. You’d say to your doctor, ‘My shin hurts,’ and your doctor would whip out his or her pad—‘No problem, I’m trained for this’—and write you a painkiller prescription. You’d resume whacking your shin three times a day, but boy, does it feel better with the pain pills. Thank god for modern medicine.”
NATHAN PRITIKIN, JUST MENTIONED BY DR. GREGER, WAS AN inventor, who used to eat three eggs every morning and a pint of ice cream after dinner. He loved butter and bowls of whipped cream. He was diagnosed with substantial coronary heart disease at the age of 41. His cardiologists gave him the textbook advice of the day: no exercise, no stress, no exertion. But Pritikin noticed in his own research that, as in Norway, heart disease dropped dramatically during World War II, despite the considerable stress. He also noticed that indigenous cultures eating mostly vegetarian diets had very little heart disease. Against the advice of his doctors, who told him flat out that he couldn’t control his cholesterol, he embarked on a low-fat, plant-based diet.
Within three years of his diagnosis, an electrocardiogram showed that his heart disease was gone. And for the next 25 years, he helped thousands of other people achieve the same results. When Pritikin died, his autopsy revealed arteries completely free of heart disease.27
Dr. Dean Ornish in 1990 published a landmark study, “The Lifestyle Heart Trial,” in The Lancet, the most prestigious medical journal in the world. Ornish and his research team put people with heart disease on a low-fat, plant-based diet, along with a program of moderate exercise, stress management, group support, and no smoking. They found that “comprehensive lifestyle changes may be able to bring about regression of even severe coronary atherosclerosis after only 1 year, without use of lipid-lowering drugs.”28 No drugs, no surgery.
“[There’s] a cartoon,” Dr. Ornish told the Washington Post, “of doctors busily mopping up the floor [around] a sink overflowing without also turning off the faucet. And it’s a great metaphor—that if you don’t turn off the faucet, if you don’t treat the underlying cause, even if you mop up the floor, even if you do a bypass graft or put a stent in, you’re not changing the underlying condition that led to it and so more often than not, those clog up as well . . . when people get put on cardiac drugs or cholesterol-lowering drugs . . . when the patient says, ‘How long do I have to take this?’ And what does the doctor say? ‘Forever,’ right? How long do I have to mop the floor? Forever. Well, why don’t I just turn off the faucet?”29
But that’s not how our medical system works.
“Preventive medicine as it exists today in America typically revolves around secondary prevention,” said Dr. Mills. “Mammograms, colonoscopies—we’re trying to detect diseases after they’ve developed. What we need is true primary prevention, in which we reduce the risk of developing disease in the first place.
“Take heart disease. We have a business of bringing people in after they’ve had a heart attack, doing the catheterization, putting in a stent to open up the blood vessels, the coronary artery bypass graft where we crack your chest open, take veins from various parts of your body and reroute the circulatory system to your heart. We also know that a plant-based diet significantly reduces or eliminates the risk of developing heart disease at all. Which is the better approach?”
Building on the work of Pritikin, Ornish, and his own pioneering efforts, our friend Dr. Caldwell Esselstyn published a startling study in July 2014.30
“We worked with 198 patients,” he told us. “To show you how sick they were, 119 had already had a bypass or a stent. Another 27 were told they’d have to get bypasses or stents. After they went through our program, they didn’t need them. Of the people with significant heart disease who adhered to our plant-based program over the next 3.75 years, 99.4 percent avoided any further cardiac event. Of the 21 patients who didn’t stick with our program, 62 percent had progressive cardiac events.”
“Wait,” I said. “Only 0.6 percent of the people who stayed with the plant-based diet had any more heart problems? But 62 percent of the people who didn’t follow the plant-based diet had more heart attacks and other issues?”
“That’s right,” said Dr. Esselstyn, nodding. “Heart disease is nothing more than a toothless paper tiger that need never exist. And if it does exist, it need never progress. Coronary artery heart disease is a completely benign, food-borne illness.”
The diet that Dr. Esselstyn used in his study was simple: whole grains, legumes, lentils, fruits, and vegetables, along with a multivitamin, a B12 supplement, and flaxseed meal for essential fatty acids. There were no added oils or processed foods with oils, nor was there meat, poultry, dairy, sugary foods/drinks, avocados, nuts, or excess salt. Unlike Dr. Ornish’s study, exercise, meditation, yoga, or psychosocial support were not required.31 It was all about the food.32
“Do people ever say your approach is too severe?” Keegan asked Dr. Esselstyn.
“A doctor in Texas told me that,” he laughs. “He said, ‘I think your approach is extreme, though I do think it works. I’m 38. I don’t have vascular disease. Why shouldn’t I eat what I want on the weekends?’
“I said, ‘You can eat whatever you want, but let’s look at the data. The autopsies of people who die of accidents, homicides, and suicides between the ages of 17 and 34 show they’re already loaded with cardiovascular disease. You’re 38, so you’re loaded with cardiovascular disease. Not yet enough for that first cardiac event. You want to continue destroying your endothelial cells for 104 days out of every 365. I don’t think that’s very smart. You may postpone your heart attack until you’re 65 instead of 55. You may delay your erectile dysfunction, you may delay your dementia, but you are still destroying your endothelial cells, and your disease is going to progress.’”
“What did he say to that?” I asked.
“Not much.”
“Erectile dysfunction is related to heart disease?”
“For males, the canary in the coal mine is often erectile dysfunction,” Dr. Esselstyn said. “The penile artery is tiny compared to the coronary artery going to the heart, so not infrequently, before somebody ever comes down with symptoms of heart disease, they’re going to find they can no longer raise the flag. Yet all is not lost. When I’ve counseled somebody for heart disease, perhaps ten or eleven months later, I’ll often get a phone call. ‘Dr. Esselstyn? This is Mr. So-and-So. I’m wondering if I don’t owe you another check, because recently something has . . . come up again.’”
Erectile dysfunction may be the thrust, pardon the pun, behind convincing a lot of guys to take cardiovascular disease seriously.
Heart attack? Whatever. Pass the wings.
Floppy penis? Wait, tell me again about plant-based . . .
“Before being a chief of cardiology, I was the director of a nuclear lab,” said Dr. Kim Williams. “We did a study that showed if a man checked ‘Yes’ on the erectile dysfunction box, the odds that he had blood vessel problems were much, much higher. Stroke, heart attack, erectile dysfunction—they’re manifestations of the same thing. Blood vessel disease. You need to improve blood flow to the organ itself. Any organ.”
“Erectile dysfunction can be a warning three or four years before a heart attack,” said Dr. Kahn. “If that’s happening to you and there’s no explanation, adopt a plant-strong diet right now. Do it years before you need to have your chest cracked open.”
I LOOKED UP THE AMERICAN HEART ASSOCIATION’S DIET RECOMMENDATIONS. I wasn’t surprised at what I found, after the websites of the American Diabetes Association and the American Cancer Society. Recipes for Grilled Chicken and Vegetables, Pork Tenderloin Stuffed With Spinach,33 and Steak Stroganoff;34 recommendations to eat low-fat dairy and skinless poultry and fish,35 and to buy cuts of beef labeled “choice” or “select” rather than “prime.”36
These suggestions made me think of a doctor who doesn’t tell his or her patients to stop smoking, “because I know how much you love it.” Maybe switch to e-cigs . . .
To the AHA’s credit, there’s a link in small font near the bottom of the “Making Healthy Choices” page: “Vegetarian Diets.” If you click on that, the AHA concedes, “Many studies have shown that vegetarians seem to have a lower risk of obesity, coronary heart disease (which causes heart attack), high blood pressure, diabetes mellitus and some forms of cancer.”37
They don’t make that information easy to find, though.
Another phenomenon I wanted to investigate was the Maasai. Like the Inuit Paradox, the Maasai Paradox belongs to the romantic, “Noble-Savage-Eats-Primitive-Meaty-Diet-and-Remains-Free-of-Corrupting-Disease” ideal that is so beloved by industrialized, privileged, and primarily white cultures.
The widely circulating rumor is that the Maasai, an East African seminomadic people in Kenya, traditionally consume only meat, milk, and blood, while retaining excellent heart health. A 1964 study, led by Dr. George Mann, reported no heart disease in Maasai men, who were also very slim, with low cholesterol. But the only methods to detect heart disease available to the scientists in the study were physical exams and EKGs.38
“As any physician can attest,” writes Dr. Thomas Campbell, “a patient can have a normal EKG and physical exam and still drop dead a week later of a heart attack related to atherosclerosis that has been progressing for decades.”39 Not only that, but the researchers were primarily examining young men. Roughly 60 percent of their 400 subjects were under the age of 44, and only three men were older than 55.40
That might be because Maasai men, even in 2015, have a life expectancy of 61.1 years, with a Healthy Life Expectancy—years of full health—of only 55.6 years.41 The average life expectancy of an American male is over 76 years old.42 (Imagine what it would be if the average American man ate a health-promoting diet . . .)
Nor were Mann and his researchers able to measure the diet of the Maasai. They wrote,
The accurate measurement of dietary intake of these people proved extraordinarily difficult . . . because of the erratic intake of food, there being no fixed meal patterns in the families, because there are no uniform units of measurement or utensil and because of the disruption of usual behavior in the presence of an observer.43
That makes it tough to accurately assess the link between diet and disease.
And then there’s the fact that the Maasai are so active (sedentary Americans would have to walk almost 12 miles more every day to be as active44) that the International Livestock Centre of Africa calculates the women and children were only taking in 50 percent to 70 percent of their estimated caloric requirements.45 That could account for the overall slimness of the tribe.
A few years after his initial study, Dr. Mann went back and performed autopsies on 50 Maasai men. He found “extensive atherosclerosis” comparable to older American men, busting the myth he himself had helped generate. Yet there were no heart attacks, and the Maasai men retained functional blood vessels. Mann and his researchers speculated that “the Maasai are protected from their atherosclerosis by physical fitness which causes their coronary vessels to be capacious”46—in other words, their extreme physical activity made their blood vessels a lot roomier, able to accommodate more “hardened gruel.”
So it’s not that the Maasai have no heart disease. They do. But there are radical factors that seem to keep the disease from striking the Maasai as it does Americans. Perhaps it’s simply that the Maasai, with their 55 years of healthy life expectancy, just don’t live long enough for their “capacious” blood vessels to get completely congested.
ALZHEIMER’S DISEASE IS ANOTHER BLOOD VESSEL DISORDER. IT’S THE sixth-leading cause of death in the United States, killing more people than breast and prostate cancers combined. Every 66 seconds, someone in the country develops Alzheimer’s.47
“We know a plant-based diet cleans out the blood vessels,” said Dr. Greger. “Guess what? We have blood vessels in our brain, our kidneys, our spine. One of the leading risk factors for dementia as we get older is the lack of oxygen and nutrients getting to the brain. The same artery-clogging fat and cholesterol buildup in arteries of the brain, just as in the heart. That’s why a plant-based diet can affect all organ systems at once, whether you’re trying to reverse erectile dysfunction, heart disease, or get blood to the most important organ of the body, the brain.”
“We’ve got over 5 million Americans with Alzheimer’s now—figures are going through the roof,” said Dr. Barnard. “There’s a lot of evidence that the fat in meat and dairy is a big contributor. The Chicago Health and Aging Project reported in 2003 that people who ate the most saturated fat had two to three times the risk of Alzheimer’s compared to other people.48 It’s not the only study to show that. A plant-based diet is key to preventing Alzheimer’s disease. Whether it could reverse it, that’s not known. If a person is in the early stages, there’s some evidence that lifestyle changes might help, but I do think there comes a point when the brain is too far assaulted by diet and lifestyle factors. There is a point where you’re not going to go back.”
AMY RESNIC IS FROM SWAMPSCOTT, MASSACHUSETTS, NORTH OF Boston. She’s 51 years old, a large woman with short dark hair.
“I recently went to my doctor for asthma,” she told Keegan and me. “While there, she did some blood work, and one of the tests was C-reactive protein. On a scale from 1 to 3—1 being low for a cardiac event, 3 being high—my number was 10.82.”
“What does that mean?” I asked, startled.
“That means I am on the road for a heart attack, probably within the next 30 days.”
“Did your doctor say what’s causing this?”
“She said maybe genetics. Doctors always say to lose weight, but that’s easier said than done. I know I need to do something. I’m tired when I wake up, tired during the day, I take a nap and still I’m tired. I can’t breathe. I’ve been using a CPAP machine to help me breathe at night, and sometimes during the day, for about five or six years.”
“Are you on any medications now?” Keegan asked.
She led us over to a table cluttered with pill bottles. She held up an inhaler. “This is a steroid that helps me breathe.” She held up another. “This is the rescue inhaler I use more than once a day. Both of these have an effect on my heart. I take diltiazem, for my heart. Ibuprofen, 800 milligrams three times a day for the pain in my neck and hands. Also cyclobenzaprine, a muscle relaxer. Oxycodone for pain. Lorazepam for anxiety. Topamax. Prozac. That’s it.”
She tidied up the bottles.
“I know I need to make a change for my health, or else I’m not going to be here very long.”