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Mad Cowboy Interview 05: Dr. Caldwell Esselstyn, Jr.
(Part 01 of 03)




M:  "Would you please give us a summary of your background?"

C:  "I grew up on an Aberdeen Angus Beef Farm in upstate New York, and received my undergraduate degree from Yale University.  I went to medical school at Western Reserve University in Cleveland Ohio, and my internship and most of my residency at the Cleveland Clinic, a portion of that at St. George's Hospital in London, England.  After I finished my training, I had two years in the Army, the first year at Fort Bragg, North Carolina, and the second year trying to help clean up the carnage in Vietnam.  Then I came back to Cleveland and was asked to join the staff of the Clinic in the Department of Surgery."

M:  "Your father died of heart disease in 1975.  Did this have any impact on your research?"

C:  "My father had his first heart attack when he was 43 and went on to develop atrial fibrillation through the years, came down with diabetes in his sixties.  Then he developed a cancer of the prostrate, and it was while he was dying of cancer that he had his last heart attack.  Although he was a great big strong fellow who played football at Yale, he really was sort of a badly living fossil from the ravages of of Western nutrition.  Between the combination of a heart attack in his early forties, prostrate cancer and diabetes, it doesn't get much worse than that.  Whether that influenced me or not, I don't really know.  I did general surgery and at some level, maybe subliminally, maybe there was this desire to get to the "roots" of this family illness."

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CURRENT SITUATION IN THE U.S.

M: 
"It's kind of ironic that this is "National Heart Month," and I think that you're probably the person best qualified to summarize the current situation in the U.S. regarding Heart Disease right now."

C:  "My own feeling is that if you were to summarize where we stand on this epidemic, we have a great many brilliant minds that are focussed on mechanisms, drugs, and procedures, and we've have sort of abandoned the capacity of the public to take care of this epidemic on their own.  I would like to say right now that perhaps there can be no greater condemnation of 21st Century medicine then its refusal to share with the public the causation and cure of its most frightening chronic illnesses.  How in the world can we have someone who's had two or three heart attacks and a couple of bypasses, and not say to them --- look them in the eye and say "Look.  I'm tired of doing these bypasses for you.  Why don't you cure yourself?  I mean, it's not that these people can't do it, it's just that they don't have the information available.  It's extremely difficult to in any way applaud what medicine is doing in this arena because the public just isn't being told what they can do to cure themselves.  To paraphrase John Kennedy: "Ask not what you country can do for your health, ask what YOU can do for your health."

M:  "This more or less begs the question: is this calculated?"

C:  "Oh, I don't think that this is the case.  It's that the mentality of medicine is such that if there's a blockage we can bypass it, if there's a blockage, we can open it up.  But what there's not, is any sound appreciation that the metabolic derangement of the human organism is so grave from eating this Western diet, that it ends up creating all these metabolic disturbances.  And somehow the mentality of medicine is that they cannot really accept the idea that someone's own metabolism is much wiser, much more brilliant, safer, and less expensive in resolving this epidemic than we with our tools and our drugs.  The truth of the matter is that nothing is a strong and as capable as the anatomy and metabolism of the patient's ability to restore themselves, and it's a very very hard sell, as somewhere in there, we see this ugly equation of finances."

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AN EPIDEMIC

M: 
"When you call heart disease an epidemic, you're not mincing words.  What are the numbers?"

C:  "Well, right now we're having close to a million people die of cardiovascular disease every year, and 500,000 dying of heart attacks.  For many people [1 out of 4] the first manifestation of the disease is that they suddenly find themselves dead. When you think about the attempt to treat this with, let's say, stents --- stents have a mortality that is accepted at 1%, but 1% of a million stents, which is the number that are done per year in this country, adds up to about 10,000 people that are dying.  Now if you had 10,000 U.S. soldiers dying in Iraq this year, that would really be called carnage.  It's very difficult, because this has been going on so very long --- we sort of accept this epidemic.  It's a huge tragedy --- yet back at the turn of the century in 1895, 1900, Sir William Osler said in one of his writings that he'd "never seen a case of angina pectoris."

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TYPICAL HEART DISEASE TREATMENTS

M:
  "How is heart disease typically treated?"

C:  "What typically happens is that the patient develops symptoms of heart disease, usually chest pain or a shortness of breath, and in the course of being investigated one of the things they'll have is a stress test, and if they fail the stress test, then that's sort of an automatic entry into the catheterization laboratory, where you will find the blockage.  Now literally, practically all Americans over the age of 55 are going to have some blockage, because if 80% of us have this disease as 20-year olds, certainly most will in their 50's and 60's.  As a matter of fact, Dr. Lewis Kuller, who is a Professor of Medicine at the University of Pittsburgh School of Medicine has said the following [from conclusions of a 10-yr. study]:  "All males 65 years of age and older who have been exposed to the traditional Western diet, have cardiovascular disease and should be treated as such."  How powerful is that?  What kind of statements is that about the kinds of food that we're eating?  Fortunately, as hideous as it is that we have this disease which is epidemic throughout the population in this country, we also have this wonderful information that there are many cultures that are plant-based, where this disease is virtually non-existent.  And if we really get our act together, we can change our basic nutritional formulae to be plant-based, avoiding the oils, the dairy, and the meat that are causing this disease.  Cardiovascular disease is just one of the tragedies, I didn't mention diabetes, hypertension, strokes, and obesity... gallstones, diverticulitis, and on it goes."

M:  "The typical bypass procedure and angioplasty, could you summarize what they're like?

C:  "Once the patient has a blockage identified on the angiogram they will usually follow that up with a fine balloon that is inserted and deflated into the area of narrowing of the artery.  Let's say an artery is 90% blocked, they'll then inflate the balloon, and it does actually what we call a "fracture." It doesn't just push the plaque up against the wall of the artery, it fractures the tissue layers of the artery.  After the angioplasty, they found that just after six months, the healing process was so over-done trying to heal that fracture, for over 50% of the people who have their blockage, it was now closed again."

M:  "Aw, no..."

C:  "...so that wasn't such a great track record.  Then they said, let's put in sort of a "wire bracket" that is, after we dilate it, we'll hold it open with this sort of metal scaffolding.  That was better, because only about 15 to 25% of those would close down after six months.  But that still wasn't good enough.  So then the idea was to put a coating of drug on the wire stent, and the drug would be gradually eluting, that is to say it would gradually dissolve off the wire cage and it was extremely inhibitory to the natural healing response of the artery."

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DRUGS & BYPASS ISSUES

M:
  "It just gets worse and worse..."

C:  "And that was actually quite exciting, because now only about 5 or 10% would be narrowing.  But recently, there's been a very worrisome finding, and that is when you stop the anti-clotting drug, which is necessary after all these stents, when you stop that after six months to a year in these drug-eluting stents, there's a disturbing number of persons who will suddenly have a clot in that area of the stent and you have a heart attack or die.  One of the reasons that has been put forth as to why that happens is that in all patients who have the angioplasty, it seems to wipe away the delicate single layer of cells called the endothelial cells that actually line the inside of the artery.  When those cells are present your blood is flowing through the artery like it's with teflon, but when those cells are wiped away it's like velcro.  The blood would clot there unless they were taking this anti-clotting drug. 

So now the situation is a bit of a bind, because anybody who now with the drug-eluting stents is going to take the anti-clotting drug for an indefinite period, maybe for the rest of their lives.  But this a a problem, not only because it's expensive ($1600 a year), it leads to bruising, gastral-intestinal hemorrhaging in some situations, and less frequently even cerebral hemorrhaging.  And let's suppose a patient who has had a successful stent is taking this anti-clotting drug now has to have hip surgery, or oral surgery, or colonoscopy... they have to stop taking the anti-clotting drug, with a great concern and a great fear that if they stop, they may clot their stent and have a heart attack or die, and that has happened.  So... the approach, as you can see with all this manipulation, is not great. 

If you have a bypass operation there is a higher mortality rate then with a stent.  It's an bigger procedure as they have to saw the chest in half and then widen it so you can take veins from your leg and place them on the heart to bypass the blockage.  Now the problem here is that the veins that are used were absolutely never intended to be in the arterial system.  So literally with every beat of the heart, there's a much higher pressure that these veins are now subjected to and there's injury, and that repeated injury leads to scarring and fibrosis, so that the veins lock again and obstruct blood flow.  That was one of the great problems with bypass surgery, that the stents often would go down, and they either had to have a repeat surgery, or something else.  They did try bypasses with arteries, and that seems to be better.  But not everybody has the right anatomy to have that kind of bypass, and in addition, there are often not enough arteries to go around, so they end up using veins anyway.

One of the bigger problems that is rarely discussed, with bypass surgery, is that there's a vein that goes to the brain when you clamp the aorta, when you're on the membrane-oxygenator and plastic, some minute debris from the equipment and even oxygen bubbles may sadly end up in the brain, so that it's well-recognized that the patients who have bypass surgery will often have temporary confusion, and maybe frank encephalopathy, it's harder for them to hold a job.  When it's carefully measured and recorded in a scientific study as reported in the New England Journal of February 2001, there really is about 50% of the people having permanently a loss of upwards of 22% of their cognition.  This, sadly, is not brought up or discussed often with the patient.  This is something that seems to "slide by."

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PARADIGM SHIFT

M:
  "You've clearly established that this is a serious epidemic and that so-called modern methods of dealing with it are horrendous and riskier than most people believe.  In the Forward to your book, Dr. T. Colin Campbell says that you are suggesting a paradigm shift in how we treat coronary artery disease.  Can you discuss how you came to these conclusions?"

C:  "What I was involved with is something that was ridiculously simple:  when one looks at the epidemiology of heart disease, and you see that it doesn't exist in cultures where they live primarily on plant-based nutrition, and they have a cholesterol of a range, let's say, of 90 to 150, as in the rural Chinese, it just begs the opportunity to take patients who are seriously ill with coronary disease and have them eat this plant-based nutrition and see if we can't absolutely halt the disease, or perhaps even reverse it."

M:  "Howard has suggested that this was a very audacious thing to believe you can do."

C:  "Well, you're absolutely correct.  It was audacious because back in 1985, when we started, and others started who actually accomplished it before I did, nobody had ever really reversed the disease, but on the other hand, nobody had ever tried it.  And the idea was to, at least as far as I was concerned, was to try and eliminate what we thought were the atheroma sclerotic foods, that is to say all the oils, the dairy, the meat, the fish, the poultry, and the white flour and the processed food.  This is exactly what happened with the research --- I went to cardiology and they were going to get me 24 patients who had advanced coronary artery disease."

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WALKING DEAD MEN

M:
  "I think you referred to them as the "walking dead men" in your book?"

C:  "Well, they either had failed their first or second bypass, or they failed their first or second angioplasty, or they were too sick for these procedures or they had refused them and there were a number of these people who literally could not take any more doses of the anti-angina medication --- they were very sick, and a number were told that they would not survive beyond a year.  So, the rock upon which this study was most likely to flounder was lack of patient compliance.  I think the way that I thought we could get an upper hand on that was to use the same mantra that I use with my cancer patients, which I learned  years ago from a West Coast surgeon, which is that was patients with cancer are not afraid to suffer, not afraid to die, but they are afraid to be abandoned by their physician and their family, and so for the first five years of the study I saw every patient myself every two weeks, went over every morsel they ate, checked their lipid profile plus their blood pressure and pulse.  Then for the next five years I saw them every four weeks, and in the last two years quarterly and by then, they were pretty well on their own --- on autopilot.  I also checked them all again at the time of the beginning of the writing of the book, 21 years later."

So, several things we did learn from this.  One is that patients WILL comply, when you explain to them exactly what the mechanisms of the disease are, and how we want to go about treating it --- when you give them the time, and the care and the support, they are more than delighted to do it.  What the cardiology community and most physicians will say is that the patients just won't follow the recommendations.  Well, they won't follow it if you just hang a piece of paper and say "these are the guidelines."  This has got to have the same degree of importance as a three-hour bypass operation.  Then I think you'll really get things done.  Another thing I think has to happen is that physician's have to be willing to say to a patient:  "look, this is absolutely the way to go.  This is going to cure you.  I'm tired of giving you these procedures.  You can do this."  The exciting thing, at least for my patients, is that they are the locus of control.  Not the cardiologist or the cardiac surgeon.  They themselves become the locus of control for this disease.  You just show them how to do it, and they can get it done."

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STUDY SAMPLE SIZE

M :
  "In your book you call your results and conclusions "irrefutable."  Hearing that from a scientist of your considerable reputation and experience, that's a very strong statement.  Do you think your sample size was a bit small, even considering that your study is the longest of it's kind yet accomplished?
"

C:  "I think that's an excellent question, as it's something that people will bring up --- it's sort of fashionable when you're questioning studies that one of the first things you might say, "the sample size is too small."  I think actually, believe it or not, that it's one of the strengths of study and I'll explain why.  When the study was started, in 1985, I first went to the head of our research division, who at that time, was Dr. Bernadine Healy.  She went on later to be head of the National Institutes of Health [and president/CEO of the American Red Cross].  Bernadine Healy told me at that time, "look, nobody has ever reversed this disease, but if you just have four patients with reversal on their angiogram, you have a New England Journal of Medicine article."  I had a total of 24 patients.

The other point about have a study this size is that despite the fact that I was still obligated to do my surgical duties, having a half day off every week for research allowed me to see these patients on a regular basis to give them the kind of support that was absolutely necessary in a behavior modification study that would achieve the kind of compliance that is essential to get these results.  If you try to do this one person with a thousand patients, it would be impossible.  The exciting thing is this:  we were able to show, as were four or five others of the same time frame, that indeed the disease could be arrested and reversed.  Let's suppose you have a disease that never before has been arrested or reversed.  Then you have several investigators throughout the country, within five or six years, finding the same thing.  Really, this disease is kind of a paper tiger.  Chronic heart disease is not inevitably progressive, like cancer, this is something that really can be changed, can be changed drastically when you make significant changes in the nutritional profile."

M:  "I think another advantage of the size was that you were able to quickly identify minute changes in cholesterol levels from people straying from the program."

C:  "Absolutely.  We were running a lipid profile every two weeks to get at cholesterol.  So suddenly we go "whoops!" we got to go over this, we have to tighten up and see what's going on here."

M:  "Sounds like the "red alert" on the Starship Enterprise.  You could tell immediately when there was a "cause and effect" thing going on."

C:  "Exactly."

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COMPARISONS TO ORNISH'S RESEARCH

M:
  "Your research reminds me Dr. Dean Ornish's efforts.  Was his work independent of yours, did you influence each other?"

C:  "We started totally independently.  As a matter of fact, one of my patients, in 1987, brought in a Discovery magazine with a picture of some of Dr. Ornish's patients in his program.  I called him, then went out and visited with him for a weekend.  I just wanted to see what somebody else was doing.  They were doing it differently in that he was very solidly attracted to the idea of using meditation and relaxation.  We did not have that in our program.  He had some very strong structured exercises as part of the program.  I encourage our patients to exercise, and I do not have it as a requirement.  I feel very strongly that each of us has within us just so many behavioral modification units.  If you ask patients to do too many things, something's gonna go.  I wanted them to understand that the most important thing, as far as I was concerned, is how they ate.  That was the key.  I did not feel from my epidemological review, that those nations where the disease was non-existent was because they were heavily involved with meditation or relaxation and structured exercise, but it was because, by culture, heritage, and tradition, they were just not eating any of the atheroma sclerotic foods. 

But, let me say by the way, that I think meditation and relaxation are wonderful... I think that exercise is fully appropriate and stupendous.  I had a couple of patients that had strokes, in addition to their severe heart disease, and here they are now, 21 years later, just kicking up their heels and doing fine.  They were not precluded from enjoying the benefits of this approach, despite the fact that they were not able to exercise nor did they meditate."

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