Prevent Hypertension: Embrace Best Practices

Caldwell B. Esselstyn, Jr., MD

It’s a pleasure to be with you.

Laurie Marbas, MD, MBA

Well, it’s a phenomenal thing. You’re closing in on 90, and your experience with this goes back many decades. My first question would be, What is your overarching philosophy regarding the prevention and reversal of cardiovascular disease, including hypertension, with diet and lifestyle?

Caldwell B. Esselstyn, Jr., MD

Well, I think the thing that I always try to have patients understand is that truth be known, coronary artery heart disease is nothing more than a toothless paper tiger that needs to never, ever exist. If it does exist, that need has never, ever progressed. I think the thing that jumps out that anybody who is involved in prevention is a recognition of the fact that we have known for many decades that there are many cultures on the planet Earth where cardiovascular disease is virtually nonexistent. Why wouldn’t it be reasonable or sensible to take the information from those cultures and bring it to this country? But that is the dark side of American medicine and what we’re doing for cardiovascular disease today. We use drugs, we use stents, and we use bypass operations, none of which have anything whatsoever to do with the cause of the illness. It’s been very profound and exciting when you begin to take the information from these cultures where the disease is nonexistent, namely trying to have your patients understand a plant-based diet and then be willing to take the time to explain to them what the foods that every time they pass your lips you absolutely devastated and further injure the endothelium, which is manufacturing this magic molecule of nitric oxide, which is responsible for the salvation, preservation, and protection of all of our blood vessels. That’s the background.

Laurie Marbas, MD, MBA

Yes. It gets to going to the root cause, moving away from sick care to health care to prevention. Speaking of the whole plant-based diet, can you talk to us a little bit about how you discovered that a plant-based diet was helpful? What do you typically counsel patients to, or at least get started with? What are the main points there?

Caldwell B. Esselstyn, Jr., MD

Well, I started when I was in the late 1970s when I was Chairman of our Breast Cancer Society. I increasingly found myself disillusioned with the fact that, no matter how many women I was doing breast surgery on, I was doing absolutely nothing for the next unsuspecting victim. That led to a bit of global research, and it was quite apparent that multiple cultures were 30 and 40 times less frequent with breast cancer than in the United States. But if you look at rural Japan in the 1950s, it was very infrequently identified. But as soon as the Japanese women migrated to the United States by the second and third generations, they now had the same rate of breast cancer as their Caucasian counterparts. Even more compelling was cancer of the prostate. In 1958, the entire nation of Japan. How many autopsy-proven deaths were there from cancer of the prostate? 18. 

One of the most mind-boggling public health figures I know of was known in 1978. 20 years later, they were up to 137, which still pales in comparison with the 28,000 people who will die in this country from prostate cancer. It was somewhere along this journey that it became apparent to me that I was encountering many cultures where cardiovascular disease was virtually nonexistent. I said, Wait a minute. That’s the leading killer of women and men and women in Western civilization. Maybe if we could get everybody to eat to save their hearts, there’d be enormous savings also. Being protected from the common western cancers of breast, prostate, colon, and perhaps perhaps pancreatic. That was in the background. Then I had to go to you to do some research because you can’t just stand on the rooftop and yell, Go eat plant-based, and expect the entire population to make some transition. You’ve got to back it up with some science. That’s what got me started—first, a small study.

Laurie Marbas, MD, MBA

Wonderful. And can you tell us a little bit about the results that you had with this study?

Caldwell B. Esselstyn, Jr., MD

It was quite exciting. The thing that I was most concerned about was a lack of patient compliance. I used them for these 24 patients, 18 of whom stayed with us for the full 12 years. I used the same mantra that I use for my cancer patients that I learned from a wonderful West Coast surgeon by the name of Bert Dunphy, Bert used to say that patients with cancer are not afraid to suffer. Patients with cancer are not afraid to die, but patients with cancer are afraid of being abandoned by their physician or by their family. For the first five years, I was seeing them every two weeks in the office. We would draw and check their cholesterol, blood pressure and their weight. I would go over every morning at eight. After five years, I got courageous and stretched it out to once a month, and then after ten years, they were pretty well on autopilot. We were seeing them quarterly. 

Then, at 12 years old, we said, Wait a minute, this is as long a study as there is out there for this arrangement. It was time we reported it. It was very exciting because these patients—all 18 who stuck with us for 12 years—had 49 coronary events, among them in the hands of expert cardiologists during the eight years before coming into the study. But once they came into the study, all but one patient, who, let’s just say, was a little sheep who wandered from the flock, everybody else stopped their disease. We often had striking examples of disease reversal. Now, the reason that I think that my program has been successful, or perhaps others may fail, is that nobody else was as mean as I am.

Laurie Marbas, MD, MBA

But I just don’t believe that.

Caldwell B. Esselstyn, Jr., MD

That I mean, attention to detail. I very clearly spelled out the foods that I wanted them to eliminate. We mentioned the foods that you can have. In the last decade, we’ve modified it further to take advantage of the newer research that shows that mankind has an alternate pathway for making nitric oxide besides the endothelial cells, which are green leafy vegetables that can be chewed after they have been anointed either with balsamic or rice vinegar and when those have been chewed up and they produce nitrate, which can then further be reduced to nitrite, then when your gastric acid reduces the nitrite to more nitric oxide, which can enter your nitric oxide. When I have these people do this six times a day, all day long. They are almost like you’re turning them into a nitric oxide factory.

Laurie Marbas, MD, MBA

It’s fantastic. I love it when you just rattle off your list of your favorite dark green, leafy veggies.

Caldwell B. Esselstyn, Jr., MD

Oh, you mean? Well, the first of the top six are Kale, Swiss chard, spinach, arugula, beet greens, and beets. But you’ve got to want the whole list. It goes like this. Bok Choy, Swiss Chard, Kale, Collards, Collard Greens, Beet Greens, Mustard Greens, Turnip Greens, Napa Cabbage, Brussel Sprouts, Broccoli, Cauliflower, Cilantro, Parsley, Spinach, Arugula, Asparagus. The reason I go through that list is because I want the patients to understand how beneficial that can be for their memory.

Laurie Marbas, MD, MBA

Well, if anyone can highlight the beautiful living into our older years, older years in which you’re doing everything right like the eating, the exercise, the socialization, everything your purpose. It seems you’ve got everything figured out and are moving in the right direction. I aspire to be you when I grow up.

Caldwell B. Esselstyn, Jr., MD

That’s all due to Ann.

Laurie Marbas, MD, MBA

That’s all due to Ann? You are a smart man, you see. You give credit to the wife. Can we speak a little bit about other things besides the dark green leafy vegetables in the context of hypertension or cardiovascular disease that you people should focus on as well as other things? And what should we be removing?

Caldwell B. Esselstyn, Jr., MD

Well, the ones that we want to remove. I wrote a paper about the dangers of oil that was in the International Journal of Disease Reversal Prevention. The title of the paper I wrote was Is Oil Healthy? In that paper, I review the animal studies and the human studies that show how oil injures the endothelial cells. We want to have people stop oil, all oil, whether it’s olive oil, corn oil, soybean oil, sunflower oil, coconut oil, palm oil, oil, cracker oil on a chip, oil on a piece of bread, oil, and a salad dressing, to eliminate oil as well as animal protein, meat, fish, chicken fowl, turkey, and eggs. We also eliminate dairy milk, cream, butter, cheese, ice cream, and yogurt. Why? Because those foods injure endothelial cells and take away your nitric oxide. Also, we want to eliminate sugary drinks, Diet Cola, Pepsi, and Coke, and sugary foods like cakes, pies, cookies, stevia, agaves, the excesses of maple syrup, and molasses. 

I’m a little bit of an outlier here, but I don’t like nuts. I don’t like peanuts, peanut butter nut butter, cashew sauce, or avocados; they contain too much saturated fat. Lastly, coffee with caffeine. Decaf, yes. Black tea and green tea. Yes, but coffee with caffeine? No. Now, the key here, I think, is to educate patients. This is so important. If patients can understand that the reason they have their heart disease is because they had sufficiently trashed, injured, and compromised the endothelial capacity to make nitric oxide when they realized they were short on nitric oxide, they’ve lost their protection, and that it wasn’t done by their genes or by their stress. It was done by their food. How exciting it can be for them to transition from one pile of delicious food that is destroying them to another pile of delicious food that enhances them. Until we got to the question.

Laurie Marbas, MD, MBA

We have these dark green leaves. We’re moving the processed foods, the oils, the fats, and those things. What other foods would you say, especially in the context of high blood pressure, would be super beneficial? Where would you encourage people to go?

Caldwell B. Esselstyn, Jr., MD

Just the vegetables—you can’t do better than the phytonutrients that are enclosed in them. The reason I started this is probably the work of Nathan Bryan out of the University of Texas. I like patients to chew not smoothies or juicing, but chew green leafy vegetables six times a day, roughly the size of one 3 to 1 half cup after it has first been steamed or boiled for five and a half to six minutes so it’s nice and tender. Then you must anoint it with several drops of a delightful balsamic or rice vinegar. Why? Research has shown us that the acetic acid in those vinegar can restore the nitric oxide synthase enzyme contained within the endothelial cells. That’s responsible for making nitric oxide, and therefore I want them to chew this alongside their breakfast cereal again as a mid-morning snack. Again with their lunch and sandwich. That’s three. Mid-afternoon for dinnertime, five. Of course, I adore it when they have that evening snack of arugula or kale. The second benefit that comes from ensuring the green leafy vegetable is that it restores the capacity of your bone marrow to once again make the endothelial progenitor cell, which will replace our senescent, injured, worn-out endothelial cells. 

Now, the third benefit is that when you’re choosing green leafy vegetables, you are chewing green nitrate. As you chew the green nitrate, it is going to mix with the facultative anaerobic bacteria that reside in the crypts and grooves of your tongue. Those bacteria are going to reduce the nitrates that you’ve been chewing to a nitrate. When you swallow the nitrate, it is now your gastric acid, which is going to further reduce the nitrate to more nitric oxide, which can enter your nitric oxide pools. Now there’s a caveat. Well, first of all, think of it: what you’re doing for minimal expense, no side effects, what you’re doing all day long, dawn to dusk, morning tonight, you’re restoring nitric oxide, the very molecule, the deficiency of which is giving you this disease in the first place. Now that there’s a caveat, and that is that toothpaste with fluoride, public drinking water with fluoride, and mouthwash will injure the beneficial bacteria in your mouth, and I don’t mean acids because antacids will reduce your gastric acidity and you will be unable to reduce the nitrate and more nitric oxide.

Laurie Marbas, MD, MBA

If we have these antacid medications over the counter and so many people live in so many places, they’re not even sure about the fluoride. What would you suggest to counter both of those?

Caldwell B. Esselstyn, Jr., MD

I’m sorry, I’d like to counter what?

Laurie Marbas, MD, MBA

Someone who doesn’t understand or know about fluoride. Do you ask? Do you have them filter the water or do anything special? 

Caldwell B. Esselstyn, Jr., MD

They have to get a filter. If they’ve got public drinking water that has fluoride,.

Laurie Marbas, MD, MBA

Yes, I encourage all the patients, regardless of where they live, to filter their water. It’s just that I don’t trust it. But also, when it comes to, let’s say, someone who does have medications—let’s say they have Barrett’s esophagus or something—they do require some type of antacid medication. Is there anything else they can do to help increase their nitric oxide besides everything you’ve just mentioned?

Caldwell B. Esselstyn, Jr., MD

You mean besides the green leafy vegetables and the. Well, you want to have an anti-inflammatory diet. That, of course, is the one that we always push. There would be whole-food plant-based nutrition.

Laurie Marbas, MD, MBA

Absolutely. Okay. Then, as far as we can, can we ask a little bit about the nuts? Are there any nuts that you find that might be helpful, or where do you find them?

Caldwell B. Esselstyn, Jr., MD

Yes, you could probably say the one that would escape would be a walnut because it has omega-three and it doesn’t seem to have as much saturated fat. But I don’t include that because I’m pushing a flaxseed meal and chia seeds and green leafy vegetables. I think we’ve got that pretty well covered. But if I start mentioning walnuts, that’s not what people will remember. Those say Esselstyn is letting you have nuts now. That is going to be a differentiation.

Laurie Marbas, MD, MBA

You give him an inch; they take a mile-type thing.

Caldwell B. Esselstyn, Jr., MD

Yes. It was quite an interesting study. The ultimate business spot, I think, was Vasily Ivanovich in the 1970s with rhesus monkeys; some groups got corn oil and others got peanut oil. Sadly, after a year, they sacrificed animals. However, there was a stunning amount of atherosclerosis in the peanut oil group.

Laurie Marbas, MD, MBA

As far as others are concerned, you have accountability. You were meeting with patients regularly for your studies and different things. I know you still call people that I meet just randomly. It’s Dr. Esselstyn calling and talking to me; that is what Dr. Esselstyn does. That’s amazing. But for someone who doesn’t have a Dr. Esselstyn in their life, how can they overcome the challenges? What have you found that is challenging for your patients? Then they were able to work through it and stay consistent on this healthy diet.

Caldwell B. Esselstyn, Jr., MD

Yes, I think there are two things that we do presently. My practice, as I’ve mentioned, is to treat patients who come from overseas, in Canada, or the United States. We do this all virtually now. We used to do it, believe it or not, in person. People would fly to Cleveland and spend money at a hotel. Fortunately, now with virtual, we’re reaching so many more people. I want to hear your question again.

Laurie Marbas, MD, MBA

What are some of the challenges that people have in staying consistent on the diet if they don’t have someone like you that they’re meeting with regularly? Any ideas or suggestions that you’ve seen?

Caldwell B. Esselstyn, Jr., MD

To get them to be adherent.

Laurie Marbas, MD, MBA

Yes.

Caldwell B. Esselstyn, Jr., MD

We have a seminar that I conduct with maybe 20 or 30 people online, which is going to take five and a half to six hours. They’re going to learn all about how they created the disease, and they’re going to learn all about plant food acquisition and preparation from Ann. Then we have several sessions of testimonials. Then my son-in-law, Brian, who is the Director of the National Science Foundation, gave a wonderful presentation on food architecture. They get 3 hours of science from me. The thing that we want to do is lock them in with an understanding. I have a rule that everybody who is going to be attending should receive their cell phone number two weeks before the seminar starts. I insist on calling every one of them so that I can get my arms around their story and, at the same time, they can ask questions of me.They’re coming to the seminar. We have a strong platform from which we can all move forward, so it’s going to be very hard for anybody who has a brain in their head and has gotten exposure to us. 

I am quite proud of it because most cardiologists say, Dr. Esselstyn, that it doesn’t work. For how long? They can’t get their patients to follow it. How much time did you give them? Well, I’m very busy, Dr. Esselstyn. 15 minutes. If you think you’re going to change your lifestyle in 15 minutes, you’re dreaming. People get 6 hours at the seminar and another 45 minutes with me with a phone call beforehand. I’ve got them. locked in with an understanding advice, destroying their endothelium through the production of nitric oxide. They’ve lost their protection, and they are going to be responsible for getting it back. Now, how does anybody with a brain in their head look me in the eye after they’ve gone through that and say When I had my first heart attack, that was exciting? I think I’ll destroy some more endothelial cells and have another one. What?

Laurie Marbas, MD, MBA

Well, I’m curious because you mentioned the black sheep or the sheep that strayed from your flock there during your study. When he came back, what was his reasoning, or what happened?

Caldwell B. Esselstyn, Jr., MD

They just got well, mostly what happens because this does happen that surrounds, suppose somebody, for instance, after the five years out from our program, their angina has left them. Their exercise tolerance is wherever they want it. Then they made this, and that program was so strong, it cured me. I’m going back to what I used to like to eat. That’s the fatal mistake.

Laurie Marbas, MD, MBA

Yes. They just reignite the fire, and off they go again.

Caldwell B. Esselstyn, Jr., MD

Yes, yes. It takes a while. They don’t, they don’t leave the programs and begin doing it. It takes, they get what they get when they begin to just feel that everything is returning to normal, they’re going to say yes.

Laurie Marbas, MD, MBA

Let our guard down. Well, I agree with you. I think my most successful patients are the ones with whom I have the most frequent ongoing contact and who are available to answer questions 100% of the time. Hundred percent. Well, I think this is a great place just to pause, but thank you so much for joining us today, everyone. I hope you found our conversation very insightful and engaging. If you’re a summit purchaser, stay here because we’re about to dive a little bit deeper with Dr. Esselstyn for a few more questions.  If you’re not, click on the button below on the site, wherever that is, and access the rest of the conversation. If you’re watching this, thank you for being a valuable member of our community. Dr. Esselstyn; maybe just ask a few more questions. How do you feel this is more of a personal question? This has changed your life. You started eating a whole-foods-plants-based diet in your 50s, if I recall, from maybe nine different conversations. Tell me about doing this work versus the work that you did before. I would just love to see you give us an update on how you feel. Everything has gone through all these many decades of practicing this way.

Caldwell B. Esselstyn, Jr., MD

Well, it’s in my 30 years at the clinic as a general surgeon. And I was chairman of our breast cancer task force and head of the section on thyroid and parathyroid surgery. That was early, very engaging, and very rewarding to try to help these patients. But that got replaced by a bigger mission because, other than just helping the individual patient with surgery, hopefully, you will be able to spread the word about probably what is undoubtedly the most powerful tool in our toolbox that we have ever had. Just when it began to dawn on me that the leading killer of women and men in Western civilization was, as I said at the outset, a toothless paper tiger. It needed to never, ever exist. When you think of the amount of misery and suffering that you can get away from, simply by getting people to accept this whole food plant-based nutrition. 

Because not only what we’ve found profoundly and not only helps people with cardiovascular disease, but it absolutely can destroy diabetes, hypertension, vascular dementia, dementia itself is also important, also Crohn’s disease, ulcerative colitis, rheumatoid arthritis, lupus, multiple sclerosis, allergies, and asthma. The list goes on. Think about how incredibly powerful, whole food plant-based nutrition is for chronic disease. I always say that what I see before us, quite honestly, is a seismic revolution in health in this country, which is going to come about not from the invention of another pill or another stent or another bypass, but the seismic revolution will come about when we in the profession have the will, grit, and determination to share with the public what a lifestyle is, and more specifically, what a nutritional literacy that will empower them to destroy chronic illness.

Laurie Marbas, MD, MBA

I think that’s correct. We have to step out of our shells and get in front of the patients and explain very simple things they can do. It has profound effects. So I think you’re exactly there. Well, any other final advice you might have for someone who’s watching this and saying, I have heard all this stuff, how can I get started at home? Is there any advice or closing words you’d like to share with the audience?

Caldwell B. Esselstyn, Jr., MD

I think what can help is that they can begin to familiarize themselves with the written word or the film. There’s a Fungus Over Knives, which is a nice way to get your toe in the water. There are several of us who have written books there that you can go to YouTube with, looking up some of these familiar characters, and they’ve got some wonderful presentations to help that will help you. I guess what I’ve just previously said, this would be my summary of what this will get us because, when you think about it, it’s so I made it to this phase in my career. What is so exciting is the belief that I can have that is founded in rock-solid science about how people can eliminate chronic illness.

Laurie Marbas, MD, MBA

Yes, absolutely. I think it just feeds itself. If you’re a provider, health care provider, or physician and you see patients get better. It’s that you just want more of that and just share more of it. So it just feeds itself. The patients share. The ripple effects are profound. Thank you, Dr. Esselstyn, for your time today. I appreciate it.

Caldwell B. Esselstyn, Jr., MD

Laurie, it’s an absolute pleasure. Thank you.