Intended for healthcare professionals

Observations From the Heart

Saturated fat is not the major issue

BMJ 2013; 347 doi: (Published 22 October 2013) Cite this as: BMJ 2013;347:f6340

Re: Saturated fat is not the major issue

What happens if you eliminate all sources of saturated fat from the diet rather than just reduce their intake? The results obtained by two US researchers are impressive, showing the way to a safer and better standard of care in ischaemic heart disease.

A plant-rich Mediterranean diet is already recognised to be effective in the prevention of heart disease. Going a step further, evidence is mounting that a plant-based diet, consisting of unprocessed grains, legumes (beans, lentils and peas), vegetables and fruits, can prevent, arrest and even reverse coronary artery disease.

A leading advocate of this approach is Esselstyn, a US-based cardiac surgeon. In 1985 he recruited 24 patients with triple-vessel coronary artery disease for a research study, originally designed to last five years (1).

His goal was to achieve, through plant-based nutrition and cholesterol-lowering drugs, a serum cholesterol level less than 150 mg/dL (3.9 mmol/L), as is seen in cultures - for example Okinawa or rural areas of China - where coronary artery disease is rarely seen. Participants were asked to avoid oil, meat, fish, poultry and most dairy products; eat mostly unprocessed grains, legumes, vegetables and fruit; and consume alcohol and caffeine only in moderation. Patients were also given cholesterol-lowering drugs, as appropriate.

According to an article in The American Journal of Cardiology (2), 18 of the participants were followed for 12 years. Although as a group the participants had a history of 49 coronary events – increasing angina (chest pain), heart attack or bypass surgery – during the eight years prior to the study, all but one had no events after the study began. The exception was a patient who was off the study for two years and experienced angina. He has since resumed the study’s diet and medications, following a bypass operation.

The six patients who did not adhere to the diet were released from the study within the first 15 months and returned to standard care. All had further coronary events, 13 during the 12 years of follow-up. One patient who adhered to the program died shortly after the five-year mark from a cardiac arrhythmia. According to Esselstyn, this probably resulted from damage to the heart caused by the patient's original massive myocardial infarction prior to the start of the study. Angiograms taken just two months before this patient’s death had shown reversal of coronary lesions.

Prior to the study, Dr. Esselstyn’s group had average total cholesterol levels of 237 mg/dL (6.13 mmol/L). The group now averages 145 mg/dL (3.75 mmol/L). Low-density lipoprotein (LDL) cholesterol levels are around 82 mg/dL (2.12 mmol/L). About 70% of the participants have experienced regression of their disease, meaning that the plaques appeared smaller and smaller on successive angiograms.

Esselstyn feels that these results are particularly important because they show that this therapy arrests, rather than just slows, atherosclerosis. Patients become empowered and feel in control of the disease that previously dominated their lives.

Because adherence to the program was key, Esselstyn used methods to aid patients’ compliance. He conducted a 60-90 minute interview with each patient and the patient’s spouse at the start of the study. He monitored patient cholesterol and overall progress with office visits every two weeks for the first five years. Patients learned the results of their blood work by a personal phone call from Esselstyn the night of their office visit. And several times a year, participants and Esselstyn gathered at one of their homes to review treatment objectives, exchange menus and socialise.

This and other studies convincingly show that coronary artery disease can be reversed by aggressively lowering cholesterol through a very low fat vegetarian diet and, if needed to achieve the target cholesterol level, lipid-lowering drugs.

Esselstyn has expressed his view that it is “scientifically and ethically imperative to inform the public what constitutes an optimal diet. He follows the same diet as his patients. In 1985, his total cholesterol was around 185 mg/dL. It now hovers around 110. Esselstyn's website is at

Ornish has also shown that coronary artery disease is reversible using intensive lifestyle modifications (3).

Diet is of crucial importance not only in disease prevention but also because of the size of its associated environmental impact. The number of farm animals in the USA now equals the number of Americans multiplied by 32. On a global scale the environmental damage from livestock alone is truly gargantuan. Robert Goodland, who served as the World Bank's environmental advisor for over 20 years, has recalculated the contribution of livestock to global warming and found that it far exceeds previous estimates of around 18% (4). His most recent published estimate is 51%, a figure mentioned in a recent interview:

Oppenlander has also examined food choices and their huge, multi-faceted impacts on the global environment in his book Comfortably Unaware (5). A lecture in which he effectively communicates the scale of the damage to our eco-systems is available online:

Goodland strongly urges everyone who is concerned to improve our chances of preserving a liveable environment to get behind the twin goals of reforestation and widespread adoption of a sustainable plant-based diet.


1. Esselstyn C. A strategy to arrest and reverse coronary artery disease: a 5-year longitudinal study of a single physician's practice. J Fam Pract.1995 Dec;41(6):560-8.

2. Esselstyn C. The Am J of Cardiology 1999 August 1; 84:339-341

3. Ornish. Intensive lifestyle changes for reversal of coronary artery disesase. JAMA 1998 Dec 16;280(23):2001-7.

4. Worldwatch Institute: Livestock emissions - still grossly underestimated?

5. Oppenlander, Comfortably Unaware – global depletion and food responsibility (published 2011).

Competing interests: No competing interests

06 December 2013
Colin J Walsh
retired GP
Cardiff, Wales