CardioBuzz: Vegan Diet, Healthy Heart?

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Actually, the data for a vegan diet really are NOT that compelling. Certainly a vegan diet is better than the Standard American Diet (“SAD”), but the overall benefits are surprisingly modest relative to the dramatic dietary changes required. By far the largest relevant single study is the American Adventist Health Study 2, with 73,308 participants of various vegetarian persuasions followed for about 6 years. See the important “Vegetarian Dietary Patterns and Mortality in Adventist Health Study 2,” JAMA Internal Medicine 173:13 (2013): 1230- 1238. Two important points: First, women hardly benefited at all as vegans compared to meat-eaters (although men benefited significantly). Second, pesco-vegetarians, i.e. vegetarians who regularly included seafood in their diets, had better mortality outcomes than strict vegans. Hazard ratios for All-Cause mortality, relative to Nonvegetarians=1.00, were 0.97 for vegan women, 0.88 for pesco-vegetarian women, 0.72 for vegan men, and 0.73 for vegan men. (For another analysis where fish-eating trumped a vegan diet, see also: “Mortality in vegetarians and nonvegetarians: detailed findings from a collaborative analysis of 5 prospective studies,” Am J Clin Nutr 1999;70(suppl):516S–24S.) Realistically, veganism, and even pesco-vegetarianism, is really tough for most people to do long- term and most Americans will fail to make it a lifetime practice. We’ll actually achieve much better net CVD outcomes by just telling patients to keep their meat--but to be sure to have 30 grams-per-day of extra virgin olive oil. And the CVD outcomes are actually better! See: “Primary Prevention of Cardiovascular Disease with a Mediterranean Diet,” N Engl J Med 2013;368:1279-90..


Show me one Vegan civilization that survived and thrived? I agree with promoting lifestyle interventions over drugs, but Vegan is not the way to achieve this. Why not start by not accepting Pharma money and stop with biased EBM guidelines? How bout supporting your members by distancing yourself from MOC that they overwhelmingly are against. To make your organization relevant, how bout supporting your members wishes and being transparent in your dealings with patients..


SRP makes good points, but their applicability seems to depend upon whether you define "patient" as "person with active CVD" or "person with a heart." What you say is true for the general public. However, for people who have already gotten sick on the SAD, the stringent diet and lifestyle program has proven, substantial disease- reversing effects that (as far as I know) have not been matched by olive oil supplementation alone. If you aren't going to actively encourage CVD patients to eat less meat, at least you shouldn't be discouraging them from that beneficial change by "telling them to keep their meat." I have seen a cardiologist tell a family member who was having a heart problem that he "could never get better" and "if you like steak, eat steak [daily, while taking warfarin forever]." I was appalled by this message. Fortunately, the patient didn't listen..


In response to SRP: You should review the literature more carefully. Rather than focus exclusively on one single study that you deem to be the largest single relevant study, why not consider the wealth of primary research, i.e., basic research (theoretical and applied), clinical research (experimental and observational), and epidemiological (experimental and observational), coupled with secondary research (meta analyses and reviews)? Evidence of the CV benefits of a vegan diet appear throughout and are much stronger than the one study you cited would indicate. Regarding the olive oil recommendation from the Mediterranean Diet study cited, know that you are sending people into the ER with that advice. The only outcome in which the Mediterranean Diet outperformed the control (i.e., the so-called low-fat diet) was in the number of strokes - not heart attacks, other CVD deaths, or all-cause mortality). The control, the so-called low-fat diet, had more fat than the Standard American Diet (the baseline was fat = 39% of calories for the control, and 37% at the end of trial, while the SAD fat = 35% of calories (for SAD, see: Last, Allen R.; Wilson, Stephen A. (2006). "Low-Carbohydrate Diets". American Family Physician 73 (11): 1942– 8.)). The rate of heart attacks, strokes, other CVD deaths, and all-cause mortality "was incredibly high" from both of the Mediterranean diet variations tested. Perhaps if and when the Mediterranean Diet can be conclusively shown to reverse heart disease, it will merit further consideration. But to date, all it seems to do is give it to people who previously did not have it. [Ed.: edited for length].

Greg MS RPh

Really, an MD who still believes in the cholesterol myth? Even Atkins beats Ornish Millions of ex vegans are laughing at you..


SRP, your comments are misguided. I have been meat and egg-free for 42 yrs and counting! I am American too and if I can do it, anyone can. I eat out at plenty of restaurants too. I am in Chicago, like this doc, and would be happy to share tips. 2nd, the studies you cited relied on short trial periods of eating as vegans, vegetarians. pescatarians, etc... A vegan or vegetarian diet will not work well as a temporary, stop-gap measure, but huge benefits do accrue across longer time frames..

A. Hominid

SRP: Thank you for the information..

joel kahn md

Awesome Dr W! If you are a heart doc you must teach disease reversal and if you study reversal you have Ornish, Esselstyn, and Pritikin to proudly stand on. I lead a 300+ patient support group for heart disease reversal in Detroit at and it is rocking it out!! A model for other cities. Good work!!.

martin ulmann

I am not an expert like SRP, but take care on your B12-levels..

joel kahn md

Greg, so bitter in your tone, did you create the human genome that when exposed to Dr.Ornish's plant based no added oil vegan diet responds by reducing genes associated with inflammation and increases gene transcription associated with vascular health as reported in Circulation in March? We know the blood type diet is fraudulent but to deny research by Nobel Prize winning scientists such as Elizabeth Blackburn PhD who co-authors Dr.Ornish's works lately, and that support the diet-heart hypothesis, is to is to express blatant ignorance of the literature. Big hugs to my Paleo friend but with over 3,000 Pubmed references for vegan nutrition and under 50 for Paleolithic nutrition that are largely 13 patients reported 3 times over and over, respect your plant eaters.


I am not a physician. I am a 62 year old female who did not have heart disease but had high cholesterol, high blood pressure, diabetes, and high triglycerides. I was high risk for stroke and heart disease. I was sick and tired of taking 20 meds a day to control these symptoms and doing nothing to address the cause. Not once was the Ornish Program mentioned to me by my physician and our hospital supports his program! At the end of a year, my numbers were in the normal range and the meds were gone except for the diabetes which is now controlled. My entire Ornish group has tremendous results. It is not hard to go meatless at all but any change towards a more plant-based diet is a great start. I'm appalled at the negativity of the doctor's responses to a plant- based diet. If I had depended on my physician's care, I would still be taking all of those meds. I have faith in my doctor who now sees the awesome benefits of the Ornish program!! Get on board!!.


Safe, simple, affordable, and delicious - I'm happy eating this way and sharing the vegan option with patients. It works especially well for diabetes and pressure control. A great patient/clinician resource to try out low-fat, plant-based is available at Register anytime for count-down emails. It starts fresh the first of every month, and provides 21 days of recipes, meal plans, grocery lists, videos, and other resources, all free. Multiple different languages, too..


wia & Langley - “the stringent diet and lifestyle program has proven, substantial disease- reversing effects...” and “You should review the literature more carefully. Rather than focus exclusively on one single study...why not consider the wealth of ...epidemiological [data], coupled with secondary research (meta analyses)? Evidence of the CV benefits of a vegan diet appear throughout”. --> Well, actually no. Please practice what you preach. How about citing some of those many randomized trials and meta-analyses of randomized trials on veganism that you claim? You cite none. And I didn’t cite just one study, just the best one on veganism. My other cite with evidence that pesco-vegetarianism trumps veganism combined 5 additional prospective studies. As for proven “stringent diet and lifestyle programs,” the largest and best randomized trial of intensive low-fat diet and exercise intervention was the recent multi-million-dollar, 10-year, 16-U.S.-study-center Look AHEAD trial. See: “Cardiovascular Effects of Intensive Lifestyle Intervention in Type 2 Diabetes,” N Engl J Med 2013; 369:145-54 for how that turned out. “Conclusions - An intensive lifestyle intervention focusing on weight loss did not reduce the rate of cardiovascular events in overweight or obese adults with type 2 diabetes.” All that intensive diet and lifestyle intervention and NO net cardiovascular gain. Unfortunately, we see this time and time again with regular patients--the vast majority just don’t comply with vegetarianism long-term. What is the definition of insanity, when you keep trying the same thing over and over and expect different results? Maybe it’s time to try the olive oil and nuts and fish thing instead?.


Langley - I agree that the PREDIMED “low-fat diet” was more similar to the Standard American Diet than to a truly low-fat diet. See the accompanying NEJM editorial or the detailed Supplemental Data. However, I disagree vehemently with your characterization of the “Results: The multivariable-adjusted hazard ratios were 0.70 and 0.72 for the group assigned to a Mediterranean diet with extra-virgin olive oil and the group assigned to a Mediterranean diet with nuts, respectively, versus the control group.” That is a 30% and a 28% decrease in “the rate of major cardiovascular events (myocardial infarction, stroke, or death from cardiovascular causes)” for those who just ate lots of olive oil or nuts along with their seafood and meats, a larger reduction than what is generally observed for vegetarians. Everyone should read the basic PREDIMED results cited earlier, as well as its progeny. For progeny, see "Changes in Ultrasound-Assessed Carotid Intima-Media Thickness and Plaque with a Mediterranean Diet: A Substudy of the PREDIMED Trial." Arterioscler Thromb Vasc Biol. 2014 Feb;34(2):439-45: “Conclusions - Compared with a control diet, consumption of a MedDiet supplemented with nuts is associated with delayed progression of ICA-IMT and plaque. The results contribute mechanistic evidence for the reduction of cardiovascular events observed in the PREDIMED trial.” And "Prevention of Diabetes With Mediterranean Diets," Ann Intern Med. 2014;160(1):1-10: “Multivariate-adjusted hazard ratios [for the development of diabetes] were 0.60 for the Mediterranean diet supplemented with extra virgin olive oil and 0.82 for the Mediterranean diet supplemented with nuts compared with the control diet.” And “Mediterranean Diet Improves Cognition: the PREDIMED-Navarra Randomised Trial,” J Neurol Neurosurg Psychiatry doi:10.1136/jnnp-2012-304792: “Conclusions - An intervention with MedDiets enhanced with either EVOO or nuts appears to improve cognition compared with a low-fat diet.” How about a cite for a big randomized vegan trial, guys?.


Look AHEAD proved only that a diet that includes liquid supplements does not lead to better cardiovascular outcomes..

Ashwani Garg MD

Great article Dr. Williams and I feel like a balanced view of the vegan diet. As you can see from the above comments, people get very emotional and defensive about their food, olive oil, fish and meat. This is because this concept is so foreign to them and only followed by less than 1% of the population. Sometimes in medicine, experimental treatments are given without the hard evidence. In most cases, there is possibility of reward but not without grave risks as well. In this case, there is absolutely no downside to trying this for a few months. However, I don't believe VEGAN equates with HEALTHY either. VEGAN is a good start and a good way to transition to a whole foods, plant based diet. The problem is that even though a diet may be vegan, it may contain a lot of processed foods, fat, refined grains, and too much vegan protein. The correct way to do it is as promoted by Dr. Caldwell Esselstyn, Dr. T. Colin Campbell, and Dr. John McDougall, basically, whole foods, plant based, incorporating real, recognizable food, in the following categories: fruits, vegetables, whole intact grains, and legumes. Small amounts of nuts and seeds can be added for their omega-3 content. The detractors are correct in that the evidence is not yet there, but sometimes you go with something based on observational studies or case reports, until there is hard data. At least this intervention has no harm! Unlike Niacin which was promoted so highly, and now look how many people have been suffering from flushing and were taking it to no avail. Until then, look at the data, and try it out yourself. The magical thing is that after a while it grows on you, and can have so much variety and flexibility that you have hundreds of choices at your disposal (maybe not when you eat out, but you can talk to the chef and be creative, and adapt quick-service foods to this diet). I applaud the president-elect of ACC for going this route, and encourage him in his efforts. We do need NIH to fund this research, but until then this breakthrough treatment need not be hidden from patients because of the prejudices of the majority of the medical community..


Just to be clear, I am not a fan of the Standard American Diet (“SAD”). But it does scare the heck out of me that the next president of the American College of Cardiology has gone vegan and is surprised that the ACC/AHA prevention guidelines do not specifically recommend a vegan or super-low-fat Ornish diet. What the cardiology community actually needs is an evidence-based admission that our two or three decades of preoccupation with low-fat advice has simply not borne fruit (no pun intended...). The actual epidemiological evidence on hard outcomes has simply not turned out to support our early guesses (and they were just guesses). We must confront the facts evidenced in, for example: “Meta-Analysis of Prospective Cohort Studies Evaluating the Association of Saturated Fat with Cardiovascular Disease,” Am J Clin Nutr 2010; 91:535–46. “Conclusions: A meta-analysis of prospective epidemiologic studies showed that there is no significant evidence for concluding that dietary saturated fat is associated with an increased risk of CHD or CVD.” If fat was so bad, then it should have become overwhelmingly obvious in the outcomes data that we have accumulated. But we haven’t actually seen that. What we actually see is that things like high consumption of olive oil (100% fat) or nuts (50% fat) significantly LOWERS diabetes, CVD, and mortality outcomes. Will the new president of the ACC lead the paradigm shift that is needed, or, as is common when paradigm shifts are called for, will we have to wait for the old guard to die off and the next generation, unencumbered by the group-think (and guilt?) of the past, to take over?.


Sorry, MichiganGetHealthy, but that is just wishful thinking, cognitive dissonance (look that up if you don’t know what it means). The Look AHEAD “Study Interventions: Eligible patients were randomly assigned to participate in an intensive lifestyle intervention (intervention group) or to receive diabetes support and education (control group) ... The [4-year] intensive lifestyle intervention was aimed at achieving and maintaining weight loss of at least 7% by focusing on reduced caloric intake and increased physical activity. The [intervention group] program included both group and individual counseling sessions, occurring weekly during the first 6 months [that’s 26 in-person sessions to start], with decreasing frequency over the course of the trial. Specific intervention strategies included a calorie goal of 1200 to 1800 kcal per day (with <30% of calories from fat and >15% from protein), the use of meal-replacement products, and at least 175 minutes of moderate-intensity physical activity per week. A toolbox of strategies was available for patients having difficulty achieving the weight-loss goals (see the Supplementary Appendix) ... Submaximal-exercise tests were performed in the full cohort at years 1 and 4 and in a subset of patients at year 2.” There were approximately 2,500 in the intensive intervention group and 2,500 in the control group. The study was stopped early after 9.6 years for futility, i.e. according to the actual outcomes data they were seeing, there was no way that were ever going to see a statistically-significant improvement in CVD outcomes. So the lesson is: even more drastic dietary intervention or more “recipes, meal plans, grocery lists, videos, and other resources”? Right... Dream on....


Not to beat what should be a dead horse, but low-fat proponents need to be able to explain the results of all of those studies in the 2010 Am J Clin Nutr meta-analysis mentioned earlier. For example, take the “Low-Fat Dietary Pattern and Risk of Cardiovascular Disease: The Women’s Health Initiative Randomized Controlled Dietary Modification Trial,” JAMA 2006; 295:655-666. “Design, Setting, and Participants--Randomized controlled trial of 48,835 post-menopausal women aged 50 to 79 years... Intervention--Intensive behavior modification in group and individual sessions designed to reduce total fat intake to 20% of calories and increase intakes of vegetables/fruits to 5 servings/d and grains to at least 6 servings/d [isn’t that pretty vegan?] ... Conclusions -- Over a mean of 8.1years, a dietary intervention that reduced total fat intake and increased intakes of vegetables, fruits, and grains did not significantly reduce the risk of CHD, stroke, or CVD in postmenopausal women...” Ooops. I mean, 20,000 in the very-low-fat/high-veggie cohort and no CVD improvement after 8 years? But like a zombie, the low-fat/veggie faithful keep rising from the dead... How many more studies like this do we need? Perhaps it’s religion: blind faith over evidence. Perhaps it’s financial bias: as Upton Sinclair once wrote “It is difficult to get a man to understand something when his job depends on not understanding it.” Perhaps it’s pride, one of the deadly (no pun intended) sins..


SRP - Yes, lifestyle change is difficult, and our society makes it harder. However, Dean Ornish and collaborators have publications - I presume you are familiar with PubMed; you can find them for yourself - that show that their program really can reverse coronary artery disease. Maybe they get better results than the study you cite because in a group of thousands of worried well [by classical definitions], many participants won't really adopt and stick to all the recommended lifestyle changes. Or maybe it's because the Ornish program better targets the drivers of CAD, whether by diet or otherwise, than the allegedly drastic interventions of Look AHEAD. (For all I know, the diet is unnecessary and it's only the meditation that matters - but I wouldn't assume that without seeing a supporting clinical trial.) Also, a dietary change that has no apparent benefit in the general population, as veganism does not, can still benefit people who suffer from specific diseases. Rigorously avoiding sugar and starch probably has no benefit for healthy people. For many people diagnosed with Type 2 diabetes, it could get or keep them off metformin. Consuming wine or beer regularly is correlated with increased life expectancy and health, but a person with severe liver disease is well advised to teetotal. Grain-fed red meat for the person with symptomatic CAD could be comparable..


wia - Since you won’t assume anything without seeing the clinical trial (none of which you can cite), how about actually looking at the 21 clinical trials in the Am J Clin Nutr 2010; 91:535–46. “Meta- Analysis of Prospective Cohort Studies Evaluating the Association of Saturated Fat with Cardiovascular Disease”? (You can find it using PubMed.) But I give up. You win. It’s the meditation. Let’s all just meditate our patients’ CVD away while crunching on vegan sprouts and granola... Yea, that’s the ticket... Dr. Williams - Not to be cynical, but if you were truly successful at putting the American College of Cardiology out of business, may I suggest that you won’t be doing any of the interventional cardiologists you represent any favors? Please calculate the NNT, the number-needed-to-treat, in the WHI RCT for me. What is it, infinity? How about the NNT from those 21 large-scale, long-term, hard- outcome studies in the 2010 Am J Clin Nutr meta-analysis? Infinity? So keep pushing those anecdote-based low-fat/fruit&veggie priorities. That is a much better strategy to keep your interventional cardiologists in their expensive cars and their kids in private schools?.


:-) Clever. Aside from the fact that people eat food, not molecules, let's assume healthy people gain no benefit, cardiovascular or otherwise, from avoiding saturated fat. That is hardly proof that there is no disease for which patients could benefit by avoiding saturated fat. You offer the straw man that I claim it's only the meditation. Indeed, there's evidence meditation has some benefit - sneer too much in front of an educated patient and it won't do much for your credibility - but I indicated that I doubted meditation alone explained Ornish's results. Therefore I assume the diet may have done some good. If you don't like one aspect of a proven multimodal intervention, the appropriate response is to seek - or conduct - a trial that compares the full intervention to one that is missing only that aspect..


Without challenging the benefits of a vegan diet, I am uneasy that Dr Williams is enthusiastic about the use of manufactured foods as replacements for meat, for example. We need to encourage the consumption of real food, most of which should have plant origins..

Dean Ornish MD

[Ed.: We are posting Dr. Ornish's submission in its entirety even though it is much longer than our 300-word limit because his work has been the subject of many comments on this topic.] I admire Dr. Williams for his courage and leadership. I also appreciate the lively discussion here. Given the limited space, a few comments: For the past 37 years, my colleagues and I at the non-profit Preventive Medicine Research Institute and UCSF, in collaboration with leading academic centers, have conducted a series of randomized controlled trial and demonstration projects showing that a whole foods plant-based diet (along with moderate exercise, stress management techniques, and social support) can reverse the progression of CHD and other chronic diseases. In 1979, we published a pilot study showing that these comprehensive lifestyle changes improved myocardial perfusion after only 30 days.(1) In 1983, we published the first randomized controlled trial showing that these comprehensive lifestyle changes could reverse heart disease as measured by exercise radionuclide ventriculography.(2) In 1990, we published the first randomized controlled trial showing that these lifestyle changes alone can reverse the progression of even severe coronary heart disease.(3) There was even more reversal after five years than after one year and 2.5 times fewer cardiac events.(4) We found a 40% reduction in LDL-cholesterol in the Lifestyle Heart Trial after one year, and none of these patients was taking cholesterol-lowering drugs.(4) Using cardiac PET scans to measure myocardial perfusion, 99% of the patients were able to stop or reverse the progression of their heart disease.(5) It is a common belief that the larger the number of patients, the more valid a study is. However, the number of patients is only one of many factors that determines the quality of a study. Judging a study by the number of patients is like judging a book by the number of pages. In our studies, we ask smaller groups of people to make much bigger changes in lifestyle and provide them enough support to enable them to do so. And because the degree of these lifestyle changes is much higher than a control group is likely to make on their own, it becomes easier to show statistically significant differences even though the number of patients is smaller. As Dr. Atillio Maseri, an internationally known and respected cardiologist, wrote: “Very large trials with broad inclusion criteria raise grounds for concern for practicing physicians and for the economics of health care. The first is the fact that the larger the number of patients that have to be included in a trial in order to prove a statistically significant benefit, the greater the uncertainty about the reason why the beneficial effects of the treatment cannot be detected in a smaller trial.” (6) A demonstration project of 333 patients eligible for revascularization found that almost 80% were able to avoid surgery by making these comprehensive lifestyle changes instead.(7) Another demonstration project of 2,974 patients found statistically significant and clinically significant improvement in all metrics, with 85-90% adherence to this lifestyle program after one year.(8) We also published the first RCT showing that these lifestyle changes can may slow, stop, or even reverse the progression of early-stage prostate cancer.(9) Changing lifestyle changes your genes—we found that these comprehensive lifestyle changes caused beneficial changes in gene expressions in 501 genes in just three months. (10) We also measured a 30% increase in telomerase in only three months in these patients. (11) After five years, we published the first study showing that these lifestyle changes lengthen telomeres, the ends of our chromosomes that control aging. (12) In evaluating studies of different diets, it’s important to look at actual measures of disease rather than only risk factors, which can be misleading. (13) After 16 years of review, CMS began providing Medicare coverage for “Dr. Ornish’s Program for Reversing Heart Disease” in a new benefit category, intensive cardiac rehabilitation. For more information, including PDF reprints of these studies, please go to The Mediterranean diet is better than the Standard American Diet, but the PREDIMED study did not show a reduction in cardiac events, only in stroke rates. (14) Thank you for the opportunity to participate in this important discussion. Dean Ornish, M.D. Founder and President, Preventive Medicine Research Institute Clinical Professor of Medicine, University of California, San Francisco REFERENCES: 1. Ornish DM, Gotto AM, Miller RR, et al. Effects of a vegetarian diet and selected yoga techniques in the treatment of coronary heart disease. Clinical Research. 1979;27:720A. 2. Ornish DM, Scherwitz LW, Doody RS, et al. Effects of stress management training and dietary changes in treating ischemic heart disease. JAMA. 1983;249:54-59. 3. Ornish DM, Brown SE, Scherwitz LW, et al. Can lifestyle changes reverse coronary atherosclerosis? The Lifestyle Heart Trial. The Lancet. 1990; 336:129-133. (Reprinted in Yearbook of Medicine and Yearbook of Cardiology (New York: C.V. Mosby, 1991). 4. Ornish D, Scherwitz L, Billings J, et al. Intensive lifestyle changes for reversal of coronary heart disease Five-year follow-up of the Lifestyle Heart Trial. JAMA. 1998;280:2001-2007. 5. Gould KL, Ornish D, Scherwitz L, et al. Changes in myocardial perfusion abnormalities by positron emission tomography after long-term, intense risk factor modification. JAMA. 1995;274:894-901. 6. Maseri A et al. The risk and cost-effective individual patient management: the challenge of a new generation of clinical trials. Cardiovascular Drugs &amp; Therapy. 10(6):751-8, 1997. 7. Ornish D. Avoiding Revascularization with Lifestyle Changes: The Multicenter Lifestyle Demonstration Project. American Journal of Cardiology. 1998;82:72T-76T. 8. Silberman A, Banthia R, Estay IS, Kemp C, Studley J, Hareras D, Ornish D. The effectiveness and efficacy of an intensive cardiac rehabilitation program in 24 sites. Am J Health Promot. 2010;24[4]:260– 266. 9. Ornish DM, Weidner G, Fair WR, et al. Intensive lifestyle changes may affect the progression of prostate cancer. Journal of Urology. 2005;174:1065-1070. 10. Ornish D, Magbanua MJM, Weidner G, Weinberg V, Kemp C, Green C, et al. Changes in prostate gene expression in men undergoing an intensive nutrition and lifestyle intervention. Proc Nat Acad Sci USA 2008; 105: 8369-8374. 11. Ornish D, Lin J, Daubenmier J, Weidner G, Epel E, Kemp C, Magbanua MJM, Marlin R, Yglecias L, Carroll P, Blackburn E. Increased telomerase activity and comprehensive lifestyle changes: a pilot study. Lancet Oncol. 2008; 9: 1048–57. 12. Ornish D, Lin J, Chan JM, Epel E, Kemp C, Weidner G, Marlin R, Frenda SJ, Magbanua MJM, Daubenmier J, Estay I, Hills NK, Chainani-Wu N, Caroll PR, Blackburn EH. Effect of comprehensive lifestyle changes on telomerase activity and telomere length in men with biopsy-proven low-risk prostate cancer: 5-year follow-up of a descriptive pilot study. Lancet Oncol. 2013 Oct;14(11):1112-20. 13. Smith SR. A look at the low carbohydrate diet. N Engl J Med. 2009 Dec 3;361(23):2286-8. 14. Ornish D. Letter to the editor. N Engl J Med 2013; 369:672-677.

mary davila

It is awesome that the next president of the American College of Cardiology is on a plant based diet. Maybe then some progress will be made getting America healthy. Anyone who has their doubts that the Standard American Diet is killing us needs to read "Prevent and Reverse Heart Disease" , "The China Study" , and watch the DVD "Forks over Knives". Many years of data and research. Plant based diet is not only sustainable it is HEALING!.


I have been a Nurse for 27 years and I have not known any person who consumed tons of meat that has been healthy. They have ended up Obese with Diabetes or High blood pressure or Coronary Heart Disease or Cancer and most of the time ALL of these..


I am thin (5'6", 125lb), physically-active, non-smoking 74 year old woman physician who had MI about 10 years ago. Although I had some mild coronary vessel narrowing in one vessel, the event was thought to be from small vessel disease or spasm. I was treated with aspirin. 15 year hx hypertension treated with amlodipine 5mg qd and carvedilol 6.25 mg bid. No diabetes. Although my cholesterol numbers are normal, I use simvastin 10mg qd to lower my LDL below 70. I follow a low fat Mediterranean-type diet with my only significant sources of fat being nuts, seeds, and seafood. I am interested in opinions regarding calcium supplementation for osteoporosis and its possible relationship to heart disease. I consume non-fat yogurt and other non-fat dairy products in order to avoid calcium supplements. Do most low-fat and/or vegan diets allow non-fat dairy products?.

william reichert

For MAD: I would have to agree/ Eating tons of meat is probably not good. However, a nice juicy steak now and then....... not so bad. Vegetables are good. Include them. By all means avoid tons of meat..

murry cohen

FINALLY cardiologists are catching up. I remember in the 1980s they ridiculed the entire vegan diet thing, and they were very suspect of Ornish. Now it is mainstream. The scientific innovation of one generation is the medical mainstream of the next. Everyone....ask your cardiologist about Williams' new position re diet, and then ask why he/she doesn't routinely advocate a plant-based diet for all their patients (the answer is probably that he/she hasn't committed to one him/herself). Keep after them. Threaten to change cardiologists to one whose treatment, of lack thereof, won't result in your needing open heart surgery..

dean wochner

Hang in there--you're absolutely right! Read the work of Caldwell Esselstyn, Neal Barnard, & others , in addition to Dean Ornish-- and another star patient is Bill Clinton, who was on the verge of repeat bypass surgery, started a plant based diet, & reversed the process. He now looks younger and healthier than he did 20 years ago. I'm another, vegetarian 20 years, vegan half that long. It's not easy to do & it's much harder yet to convince others to make the change- but it's a change well worth making. If you & the ACC can get even a small proportion of people to change through patient and doctor education, it will grow over time!.

Michael L. Loren, M.D.

What an amazing admission. The evidence is overwhelming regarding the benefits of a plant based diet. However patients love their junk food and meat. It will be hard getting them to make a meaningful change in their diet. The China Study by Campbell is a good reference on this topic. There is a lot of noisy misleading information out there. After all a lot of $$$ is at stake. Possibly the American public is ready to practice more healthy preventative care..

Justin Hamlin, DO

The vegan diet has absolutely no biological plausibility. Humans are mostly DESIGNED to be carnivorous. Besides, heart disease has already been shown by science to be an inflammatory disease, not a dietary disease..

Greg MS RPh

More than respect plant eaters, I love plant eaters. I particularly love them with garlic and grass feed butter..


Veganism is a diet designed around ideology, not health. Why cut out fish? Because you think eating fish is wrong or because you think eating fish is unhealthy? So if health is the MAIN reason for recommending a specific diet, why would a physician recommend a diet that refuses many heart healthy foods for ideological reasons?.

Leslie Nolen | The Radial Group

Two different issues at play here - Williams' decision criteria for selecting patient treatment protocols, and the actual data around the role of plant-based diets, etc., in CVD prevention and treatment. I'm deeply disturbed that Williams' rationale for recommending a treatment mostly seems, from his own description, to boil down to his own anecdotal experience and what appears to have been a very limited review and fairly simplistic understanding of available evidence in this area. Reading between the lines, it appears that his primary recommendation to pts for a healthy lifestyle involves switching to legume and grain products manufactured into meat analogs? I saw no mention of exercise, other than the obligatory hat-tip in the final paragraph (!) of his article. This is what happens when a physician starts assuming that what he believes works best for him will of course be best for everyone. I see this all the time at the wellness end of the spectrum, where new entrepreneurs emerge every day with &quot;businesses&quot; based on their own weight loss success methods. I don't expect to see this approach from physicians, however. I'd like to think that people who make truly data-driven decisions exist SOMEWHERE in our healthcare system..


First, I would like to thank MedPageToday for generating and hosting this discussion. Such real-time scientific give-and-take is how we can both hone-in on the best medical answers as well as accelerate the translation of research findings into actual clinical outcome improvements in patients. This is something that the technology of on-line discussions can excel at. Second, I would like to thank Dean Ornish for both putting his medical evidence in one place for those interested in actually critically reviewing it, as well as for being a tireless advocate for the extreme position on low-fat diets and, essentially, veganism. We need advocates, particularly at the extremes, in order to have a healthy debate. Third, I heartily agree with Dr. Ornish that “In evaluating studies of different diets, it’s important to look at actual measures of disease outcomes rather than only risk factors, which can be misleading. [Ref 13]” We are, indeed, frequently deceived when our dependent variables are intermediate or risk-factor measurements or elective and not hard-outcome event counts. We must save our recommendations for the hard-outcome results of large-scale, long-term, randomized studies, such as the WHI RCT and Look AHEAD. So while the results of the Ornish References 1, 2, 3, 5, 8, 9, 10, 11, & 12 may be of interest, they aren’t yet reasons for drastic dietary interventions. (And once a vulnerable plaque ruptures and a thrombosis begins to form, long telomeres aren’t going to save you...) Fourth, we need to explicitly distinguish our data and recommendations for primary prevention; secondary prevention; and for something in the middle, like for diabetics or those with high calcium scores. The costs-and-benefits, NNTs, and, so, policy recommendations, will differ..


A few additional comments on Dean Ornish’s points and references. First, does he really want to be noted for the argument that little studies are much better than big studies and that big studies are more suspect? Ummm, I don’t think that that position is ultimately going to garner a lot of respect. Apart from being mathematically and historically erroneous, it sounds a lot like sour grapes. The whole point of small-sample exploratory studies is to provide justification for expensive, large-scale studies, from which actual real-world experience can be predicted. With respect to his References 3 & 4, there were only 22/20 vegans with 1/no vegan women in the treatment sample (after half the potential sample were excluded based on unnamed criteria). After 5 years there were 4 myocardial infarctions [and strokes?] and deaths in the experimental group compared to 5 in the control group. Not a big difference. And the control group apparently had no statins. And if a finding does not scale up, then it should not become a medical recommendation. Isn’t the WHI Dietary Modification RCT about as close as we are going to come to a long-term hard-outcome test of the low-fat hypothesis? And the Look AHEAD RCT for quasi-secondary prevention? I, and the people who carried out such massive studies, truly wished for the results to indicate 30+% reductions in events and mortality--that would have made the way forward easy to discern. But if we are honest analysts, instead of simply creatures of dogma, then we have to admit that we failed. Low-fat hasn’t worked. New strategies are needed. In fact, there is a good argument to be made that our low-fat preoccupation is ultimately responsible for the current obesity epidemic..


Ref 7 was not a randomized trial. Moreover, its results were: “The number of cardiac events per patient-year of follow-up when comparing the experimental group with the control group was as follows: 0.012 versus 0.012 for myocardial infarction, 0.014 versus 0.006 for stroke, 0.006 versus 0.012 for noncardiac deaths, and 0.014 versus 0.012 for cardiac deaths.” Ummm, that’s higher CVD event rates with veganism, not lower, right? PREDIMED, with 5,000 supplementing with nuts or olive oil, was not powered to show reductions in individual event categories, so observing a statistically- significant difference in stroke rates alone is actually quite remarkable. The adjusted hazard ratios for strokes, MIs, CV deaths, and all-cause deaths were 0.54, 0.74, 1.01, and 0.97 respectively for nut supplementation, and 0.67, 0.80, 0.69, and 0.82 for EVOO supplementation, relative to the controls. Sorry, but that is impressive. (For additional progeny, see: “Association of Mediterranean Diet With Peripheral Artery Disease,” JAMA 2014, 311:415-416. “Results--After adjustment [the HRs for PAD were] 0.34 for participants in the Mediterranean diet plus EVOO group and 0.50 for the Mediterranean diet plus nuts group versus control group.”) So Dr. Ornish, agreeing with BK, why not lighten up a little and allow a little fish (or high-fat olive oil and high-fat nuts)? (1) Do you have any outcomes data indicating that that EVOO/nuts/fish consumption, added to a vegetarian diet, would not provide marginal benefits? (2) Do you have any explanation for why vegan women had no better all-cause mortality than meat-eating-women in the Adventist Health Study 2 or in the meta-analysis of 5 prospective vegetarianism studies cited in the first post? (3) Or for why pesco-vegetarians appear to have better outcomes than vegans? Thanks..


Leslie Nolen - You say: “I'm deeply disturbed [by] what appears to have been a very limited review and fairly simplistic understanding of available evidence in this area. ... I'd like to think that people who make truly data-driven decisions exist SOMEWHERE in our healthcare system.” I agree. But did you see the associated MedPageToday’s Current Survey, asking “Is there enough evidence to recommend that patients eat a vegan diet to prevent and reverse heart disease?” When I last saw the results, 47% of 1,582 presumably-medical respondents answered “Yes.” And has anyone been able to provide a single dataset indicating that female vegans actually have fewer hard CVD outcomes than fish-eaters--or even than carnivores? Don’t physicians know how to read anymore? Apparently it really is all just about insuring a steady stream of patients for cardiologists. I give up..

Matt S

There are multiple issues: 1) what to eat and 2) ideology and cultural aspects that are associated with each approach. Separate food from ideology. Focus on plant-based foods and daily physical activity that is realistic for you while pushing your limits incrementally. Eat food, not too much, mostly plants (Pollan). Review data by Campbell, Essylstyn, Pritikin and Ornish. See Loren's comment above RE the China Study. As hard as it is to accept, the data on dairy, meat and processed food consumption is never going to be positive in respect to cancer and metabolic associated lifestyle diseases. There will be few large studies of the rigor preferred in from industry funded studies and that's another loaded issue. Get used to it. There is junk science everywhere, especially in support of products from food and medical industries. Appoint a guideline panel that can stand the pressure. And, get up and take walk instead of reading these absurd blogs..

HeartDoc Andrew

The "huge unseen elephant" in the room is the amount of food that people are unwittingly overeating if they are not weighing their meals. We, who are weighing our meals, have discovered and continue to rediscover how much smarter it is for all of us to freely choose to hold to the right amount, which was empirically determined back in 1997 at Emory University to be 32 oz/day, than to be forced by bariatric surgery to stop the overeating. Not only have we avoided the upfront cost of peri-operative morbidity, we have all invariably experienced reversal/cure of markers of cardiometabolic syndrome. Simply Google "wonderfully hungry" to learn more about this non- dietary non-invasive approach to stop the overeating without harmful undernourishment..

john min

Thank you SRP! You really worked it, I appreciated your efforts. I must admit that I can't read statistical jargon well so much of what you wrote flew right over my head, but I do get that you were able to show that, again, the emperor is butt naked. Why does medicine always reach for the extremes and now think it's a great idea to promote veganism? For 40 years medicine has been wrong on fats and looks like they want to go another 40 years. My simple minded question is, how does a very low fat diet affect the absorption of fat soluble vitamins? We still need A, D, E and K, right? Do vegans suffer from low fat soluble vitamins? In any case, thanks for pointing out their after thought of mentioning exercise. Ultimately, for most folks, good health is simple: exercise, whole foods - organic and free range if possible (if nature made it, eat it, if man processed it, avoid it), sunshine, adequate sleep, stress control, and avoidance of toxins where possible. Those simple steps will keep the vast majority of people out of doctors offices and away from these ideological, medical industry, based health recommendations that for 40 years have been making millions of Americans ill, fat and dead. God help us if they start pushing a low fat vegan diet for kids, not that it would work for the kids or in practice! Just see FLOTUS's efforts backfire resulting in huge wastes of food and tax payer dollars. Kudo's to Justin Hamlin, Greg MS and BK!.


Rereading the comments, I need to make two clarifications. First, I should have been clearer that despite the seemingly long list, basically only 2 of all of Dean Ornish’s references had any results data on heart attacks, strokes, and CVD deaths. Just two: References 4 & 7. As Ornish himself stressed, intermediate values don’t necessarily translate to actual outcomes and it’s event rates that are ultimately important. His References 3 & 4 were the same tiny study, with fewer than 50 total CAD patients. (Note that the Reference 4 Table 6 events don’t add up and are dominated by elective PCIs, which we know today usually don’t lead to better outcomes--see N Engl J Med 2007;356:1503­16 and JAMA Intern Med. 2014;174(2):232-240.) His Reference 7 was non-randomized, comparing apples with oranges, lasted just 3 years, and was completed about 20 years ago. It had only 333 total CAD patients and the CVD event rates were actually higher for the vegans. So that is your SUM TOTAL of Ornish heart attack, stroke, and CVD-death hard-result data to compare to that in my cites. Second, note that the first study took place around 1990 and the second in the mid 1990s. Treatments--and outcomes--for the “controls” would be very different today, much better. In the first study, apparently none of the controls took statins and in the second, 54% of the vegan patients took lipid- lowering drugs, compared to only 32% of the “control” group. (Why become vegan today if you can just pop a pill instead?) Importantly, none of these old Ornish hard-outcome studies was on primary prevention; they were on patients with documented CAD. So with respect to the Current Survey question, there’s ZERO actual hard-event data on “preventing heart disease” here..


john min - It is not that a vegan diet is un-healthful. It is not. For men (but not women) the data indicate that it is significantly more healthful than a carnivore diet. It is just that: 1) a pesco-vegetarian diet appears better; 2) you don’t need to be low-fat, let alone super-low-fat; and 3) our record of getting lifetime patient compliance with strict diets, like a vegan diet, is poor and, from a practical point-of- view, we can get similar CVD outcomes results--and much better compliance and so, better net results-- with less drastic dietary advice (like avoid processed-meats and consume lots of EVOO and nuts). For a few good meat-consumption studies, search for: “Meat intake and mortality: a prospective study of over half a million people,” Arch Intern Med. 2009;169(6):562–571, “Meat consumption and mortality,” BMC Medicine 2013;11:63, and “Well-done Meat Intake, Heterocyclic Amine Exposure, and Cancer Risk,” Nutr Cancer. 2009;61(4):437–446..

Matt S

SRP - are you familiar with Pritikin, Essylstn and Campbell's data? Essylstyn's reversal and long-term survival data outcomes in particular are difficult to dismiss or avoid. Very large effect sizes don't need large RCT's to be detected and while it's tempting to academically attack non-randomized studies, it's just avoidance behavior. Consider how many patients are walking around with sub- clinical atherosclerotic disease, which is quite literally everyone. There is simply no downside to a plant-based, whole food way of eating with daily activity and over the long haul the approach does things medical therapies can't and will never do. It's the safest and most effective long term solution to chronic metabolic diseases. All of them. Every time..


Matt S - Familiar with Campbell and Esselstyn’s data (not Essylstn or Essylstyn)? Of course. Take a look at all of that data in the “Forks Over Knives: The Plant-Based Way to Health” book. With its “125 Recipes.” All of that hard data in there... Then print out all of my cites and compare the two. Go ahead. From one of the summary pages of the “Forks Over Knives” book: “olive oil can be problematic. The reason? Oil is 100% fat. ... ELIMINATE DAIRY. Casein, the primary protein in cow’s milk, may well be one of the most potent chemical carcinogens ever identified... DON”T WORRY ABOUT CARBOHYDRATES..” Ummm, where to start..? Look, I’m not against “Eat food. Not too much. Mostly plants,” as long as you include seafood and lots of healthy fats. But to say veganism is proven best and to recommend it to all of our patients is to just keep banging our heads against the wall. And to be philosophy-based instead of science-based..

michael van straten

All fascinating, but too focused on heart disease only. What about bone health and cognitive function? Spare a thought for pregnant and nursing mothers as well as child development. Having analysed thousands of diet diary's in my work I seldom found a patient without some deficiencies and virtually never a single one with adequate Vitamin D intake. Apart from iron and B12 problems, a vegan diet excludes the oily fish that provide essential omega three fatty acids. No matter what the vegans say, the lipid chemists maintain that plant derived omega 3 is not the same and many of us lack the enzyme needed for conversion. Even when the chemistry works it is very inefficient and declines with age. As the man who invented the word "Superfood" for a series of books of the same name, I endorse whole (and healthy) heartedly a huge increa.


michael - We are starting to go off-topic, but I agree heartily with your sentiments on vitamin D (or actually, hormone D...) The hard-outcomes data on vitamin D supplementation that have accumulated over just the last two years are pretty amazing. Here are a few meta-analyses that everybody should be aware of: (1) Duranton, Am J Nephrol 2013; 37(3): 239-248. “Results: ... In a random effects meta-analysis [of 14 studies with 194,000 CKD patients], receiving any vitamin D therapy significantly reduced the risk of all-cause mortality (relative risk 0.73).” Note that this was “active” vitamin D supplementation in mostly dialysis patients, but a 27% all-cause mortality benefit? Wow. (2) BMJ 2014;348:g1903 doi: 10.1136/bmj.g1903 Looking at 14 RCTs they concluded that “Supplementation with vitamin D3 significantly reduces overall mortality among older adults” with an all-cause mortality RR of 0.89. And this is with vitamin D3 dosages that many consider way too low. (3) PLoS One June 2013; DOI: 10.1371/journal.pone.0065835 on RCTs of vitamin D supplementation on Respiratory Tract Infections: “Findings: 11 placebo-controlled studies. Overall, vitamin D showed a protective effect against RTI (OR, 0.64) studies using once-daily dosing (OR = 0.51)”. (4) And even cancer survival with vitamin D: British Journal of Cancer, June 2014, doi:10.1038/bjc.2014.294 “Results: Over 2–7 years of duration...significantly reduced total cancer mortality” RR=0.88, from three RCTs at only 400–800 IU/day. I can see no downside to recommending 4000 IU/day of vitamin D3 supplementation to practically everybody. michael - you say that plant n-3 is not the same as fish- derived and many lack the conversion enzyme, which declines with age. Can you help with some cites for details? Thanks..


The half-million-person studies all compare carnivores mostly eating a meat-laden version of the Western diet to vegetarians mostly eating a starch-laden version of the Western diet. Just because someone is vegan does not mean that his diet is particularly healthful. A smaller study with a diet genuinely outside the disastrous Western norm is more informative. By the way, the study that proved it was beneficial to treat genuinely very high blood pressure had only a few dozen people in each arm, and yet nobody proclaimed it worthless, because the results were both statistically and clinically significant. So are Ornish's results. To reject his results out of hand because the studies aren't of blockbuster-prophylactic-drug size is to deny the scientific method. Indeed, veganism isn't really natural for humans, and I suspect that a slightly less extreme diet - say, adding fish and a little olive oil - along with the rest of the program would do just as well. Perhaps you would consider it wise for someone to conduct a trial of that? In the meantime, patients always have the right to consider such issues for themselves and act based on their own beliefs..

joan morris, NP

Dr Ornish's studies go back over 40 decades. As Dr Fuhrman writes we need to "Eat to Live" The evidence clearly supports a vegan diet yet supposedly expert cardiologists are telling patients who that a vegan diet will not help.

F Let MS

SRP - I'm not going to adress all your points but just a few things. You seem confident in your knowledge but I don't think that you have not reviewed the evidences seriously with the studies that you use to make your point and don't put all of this in a proper context. Michael Greger MD did a very good job of explaining the discrepencies between vegan and non-vegan in the papers that you cited. You say that the low-fat diet was a failure. Well, the thing is that the low-fat diet never was. No a single group of individual took there fat content sub 10% on a whole food plant based diet so that they could reap the benefits. Also, you still cited the 2010 meta regarding SFAs when it is a terrible paper. Jeremiah Stamler wrote a very good critric of it, and I urge you to listen to this youtube video regarding it. Most studies that were favorable to SFAs in this paper actually came to the conclusion that SFAs are detrimental. &lt;br/&gt;;br/&gt;;br/&gt; The evidence for a low to medium fat whole food plant based diet are consistent, strong, and coming from multiple lines of evidence. There's not a single reason to have daily meat. 2 serving per week is plently. Fish are HIGHLY contaminated with polluants and we are emptying our oceans with far reaching consequences. These are good reasons enough for me to avoid it..


Do you know what is the biggest predictor of mortality and morbidity in the elderly? Albumin. How many 75 year olds do you know cook daily, let alone can learn to put the proper combinations together to get there essential amono acids on a day to day basis, let alone know how to increase their protein in catabolic illiness like CHF, let alone post op? Becareful what you prescribe..


F Let MS - Follow the actual heart attacks and CAD deaths. See “Lipid levels in patients hospitalized with coronary artery disease: An analysis of 136,905 hospitalizations in Get With The Guidelines,” Am Heart J 2009 Jan;157(1):111-117. This compiles cholesterol data from over 130,000 actual American heart attacks, unstable angina hospitalizations, and admissions for by-pass or stent surgery at over 500 hospitals over 5 years--a good fraction of the nation’s total. Did they observe that people who actually have these bad CAD hard-outcomes have sky-high LDL cholesterol levels? Ummmm, no. They had to admit that “The present study demonstrates that among patients hospitalized with CAD, the admission lipid levels are below that of the general population.” That’s LDL cholesterol BELOW average, not above average. Ooooops! This explains the results of randomized trials like the Women’s Health Initiative Dietary Modification trial, where the 18,000 women on the low-fat diet lowered their total fat intake to 28.6% of energy, compared to 36.9% for the controls (at year 6), and yet they saw no statistically-significant CAD hard-outcome gain over 9 years. That is a dramatic fat- consumption difference, a 25-30% difference between nearly 40% and under 30%--and no benefit. In the Nurses’ Health Study, with nearly 80,000 women followed for 20 years, the highest-consumption quintile for saturated fat had no-worse outcomes than the lowest-consumption quintile (RR=0.97). Am J Epidemiol 2005;161:672–679. In fact, the highest quintiles in monosaturated fat and polysaturated fat consumption had actually LOWER event rates than the lowest-consumption quintiles (RR=0.82 and =0.75 respectively). How many more of these do we need? It’s time to admit that the king has no clothes..


Let’s just be clear about those American nurses results. The highest quintile in saturated-fat consumption, at 17.6% of energy from saturated fat, had the SAME CHD outcomes over 20 years as the lowest quintile, who had just 10.1% of their energy from saturated fat. No difference. Oooops. The lowest quintile in monosaturated fat, at 10.6% of energy, average, had 22% MORE bad heart outcomes (i.e. (1/0.82) ) than those with the highest monosaturated fat consumption, who averaged 18.0% of their energy in this kind of fat. Similarly, the lowest-polysaturated-fat consumers had 33% more events than the highest (1/0.75). Just makes you want to go out get into that low-fat stuff, huh? Sure, if you want to die... If you are educated enough, try and get through Gary Taubes’ Good Calories, Bad Calories book....


wla - Addressing your points: [A] I doubt there were many vegetarians in the half-million-person AARP study. Yes, in general it just mostly contrasted different degrees of meat consumption within the SAD framework. [B] Yes, not all vegan diets are equal, the biggest difference being their carbohydrate/fat ratios. One of the major points I’ve been trying to make from the get-go is that not all vegetarian diets are equal, (though people don’t appreciate this sufficiently). That is why I highlighted the interesting results of the Adventist Health Study 2. Given the sum of my cites, I would love to have “someone to conduct a randomized trial of that,” an Ornish vegan diet versus a vegan diet plus seafood and lots of EVOO and nuts and no real fat restrictions. That’s why I asked him if he had any data in that direction. I bet many more people would comply with something like that long-term. But such a trial would have to be designed to get hard-outcome results... [C] I don’t reject small studies out of hand, but I rarely make decisions based on them. They should be used as hypothesis- generating for larger, more-definitive studies. Take the original studies supporting niacin use. I and many others ran with it, partially out of wishful thinking. But the results of small-scale studies have to scale up--and show that there aren’t any small-scale-but-important unintended consequences. The recent large-scale, long-term AIM-HIGH and HPS2-THRIVE studies conclusively showed that the initial small-scale niacin studies weren’t correct. [D] Of course everybody is free to choose their diet. But these choices should be informed, based on hard-outcome evidence and reproducible facts, not dogma. Hopefully, we’ll eventually see a paradigm shift....


F Let MS - “Fish are HIGHLY contaminated with polluants [sic]”. Let’s not exaggerate and let’s not get irrational. While mercury really should be a major, major concern for pregnant women, the rest of us non-fetuses have little to fear. (This is something that I really happen to know about, hint, hint...) The data continue to indicate that seafood is an incredibly advantageous part of the human diet. See my first-post two cites on [Williams/Ornish] vegans versus pesco-vegetarians, as well as: Circulation. 2004;109:2705-2711; J Am Heart Assoc. 2013;2:e000506; JACC 2005;45:2015–21; Ann Intern Med. 2013;158(7):515–525 (or for Jeremiah Stamler, N Engl J Med 1997;336:1046-53). (But, importantly, it appears to be the WHOLE seafood itself, not just the n-3 fatty acids alone, that are key. Unlike with hormone-D, n-3 supplements--in the form of fish oil pills with EPA & DHA--have been recently proven to be worthless (like niacin). See the large randomized control trial at N Engl J Med 2013;368:1800-8 and meta-analyses at Arch Intern Med 2012;172(9):686-94 and JAMA. 2012;308(10):1024-1033, all pretty definitive, with scaled-up RCTs disproving suggestive earlier small-scale trials.) But the whole fish itself still appears to offer benefits...

Kim Allan Williams, Sr, MD, FACC, Rush University

“I’d like to be number 2!” Thanks to everyone who sent in comments, pro and con. It seems that diet strikes a raw nerve with many folks and at least it’s getting attention. All clinician scientists crave clinical data, preferably randomized controlled trials with hard outcomes. The area of CV disease and nutrition has far more observational data from free-living populations than randomized trials. We live in an epidemic of CV disease, and it has been the number one killer of Americans since 1918, the year it lost out to the Spanish Flu. Perhaps eliminating the need for cardiology is a bit too lofty to fathom, but we did rid ourselves of TB sanitaria, small pox vaccines and iron lungs for polio, all in my lifetime. But maybe we could have CV disease be number 2 before I retire? And no, I certainly don’t base practice on anecdotes. If I did, I’d go with a heart-warming one, like Venus Williams, who left the WTA tour in 2011 due to Sjögren's syndrome and returned to winning form last year after adopting a vegan diet, which has been proven to be anti-inflammatory (lowering CRP similar to a statin, JAMA 2003;290:502). A few data-driven points: 1. Plant based diets have flourished in many populations with remarkable health success (Marsh K, Am J Lifestyle Med. 2012;6:250- 267). Apparently, the only deficiency that has ever been documented was iodine deficiency in some British vegetarians. This isn’t likely in the US, where all of the table salt is iodized. But absence of proof is not proof of absence. Let’s keep looking at this. 2. “Competing Risks Analysis” from the Nurses’ Health Study reports that dietary cholesterol intake is associated with increased mortality, while fruit and vegetable intake is associated with lower mortality (Am J Epidemiol 2011;173:319) and less stroke (Stroke 2014;45:1613). All compelling, but observational, not randomized. 3. Some of the data is from the Adventists Health Studies: a. Vegans have less obesity, diabetes and hypertension than lactoovovegetarians, which have less than pescovegetarians, which have less than semivegetarians, which have less than nonvegetarians (Am J Clin Nutr 2009;89:1607S); but these disease states are surrogates for hard end-points (death or ischemic heart disease, for example). b. Vegetarian men had a 20% reduction in death and 30% reduction in ischemic heart disease in the Adventist Health Study 2 (JAMA Intern Med. 2013;:1-8), but the reduction in women was only 7% and 12%, respectively, and did not reach statistical significance. We clearly need more data here as well. 4. Eating meat increases carcinogenic and dysmetabolic IGF-1 levels (Cell Metab 2014;19:407), and atherogenic TMAO levels (N Engl J Med 2013;368:1575). It is associated with hip fractures, prostate disease, diverticular disease, gallstones, kidney stones, and constipation, and kills Swedes prematurely regardless of gender (Am J Clin Nutr September 2014 online ajcn.086249). Most vegetable- based protein replacements, particularly nuts, are associated with lower mortality (Arch Intern Med 2012;172:555). Again, observational. So instead of polls, opinions, syntheses of observational data, let’s get some large, well-designed randomized trials going? Lastly, the day that there is similar data on the dangers of processed soy as there is on processed meat, I will drop it like a hot potato – or perhaps just eat the potato..

howard keller

Good Italian sausage has sodium nitrate and mono sodium gluconate. Kim, no wonder it tasted good to you. Also if anecdotal data were valuable we would not need the Scientific Method and not have to go to me d school. I hate to say but it sounds like you found a religion. Be careful,.


There seems to be some confusion here. Plant based diets do allow nuts, and olive oil. Yet some posters are equating veganism as eliminating those from the diet. The other point is that vegans tend to have lower B12, and higher homocysteine levels than omnivores, and that likely contributes to an excess mortality. If people are going to go plant based, they need to ensure adequate B12 supplementation..


Dr. Williams - [2] “Competing Risks Analysis” from the Nurses’ Health Study reports that...fruit and vegetable intake is associated with lower mortality (Am J Epidemiol 2011;173:319)”. Dr. Williams, I am not sure that that is a fair representation of what that cite actually says. The only reference to fruits and vegetables that I can find in it says: “intakes of fruit and vegetables [was] eliminated from the final model because of nonsigniﬁcant associations with mortality”. While it does say that dietary cholesterol (per 105 mg/1,000 kcal) was associated with increased mortality (HR=1.07, 1.25, & 1.20 for cardiovascular, cancer (non-smoking), and other-cause mortalities respectively), it also says that higher polyunsaturated FAT consumption consumption was associated with LOWER mortality (HR=0.79, 0.86, & 0.79). (See my earlier reference to a fat-specific analysis of the Nurses data, Am J Epidemiol 2005;161:672–679.) And your cited study also says that higher glycemic load (per 41 units) was associated with higher mortality (HR=1.19, 1.14, and 1.35). Of course, vegan diets are typically much higher in carbohydrates, which has glycemic load, and lower in fats and protein, which have no glycemic load. So the Nurses data does not support a low-fat or vegan/vegetarian diet..


Dr. Williams - [3b] “in the Adventist Health Study 2 (JAMA Intern Med. 2013;1-8), the reduction in women [vegetarians in total mortality] was only 7% and 12% [in ischemic heart disease mortality] and did not reach statistical significance.” Dr. Williams, while technically true, I am not sure that that is a fair representation of what that study actually says about veganism. While there were substantial mortality reductions for vegan men, the hazard ratios for vegan women for ischemic heart disease and cardiovascular mortality were actually HIGHER than that of even carnivore women (HR=1 ref). The all- cause, IHD, and CVD mortality HRs for vegan women were actually 0.97, 1.39, and 1.18 respectively. Awfully disappointing, but--hey--the data are what the data are. Fortunately, the “vegetarian” subtotal also included pesco-vegetarian women and their HRs of 0.88, 0.51, and 0.90, which brought the “vegetarian” average HR down. So this study too does not support a vegan diet for women..


Dr. Williams - [5] “nuts, are associated with lower mortality (Arch Intern Med 2012;172:555). Again, observational. So instead of polls, opinions, syntheses of observational data, let’s get some large, well-designed randomized trials going?” Dr. Williams, please print out and read the basic PREDIMED citation, N Engl J Med 2013;368:1279-90, which arguably was the MOST IMPORTANT cardiology paper published last year. (Tied with Look AHEAD?) PREDIMED is, indeed, a large, well-designed RANDOMIZED trial for a reasonable period on (high-fat) nut supplementation with hard-outcome results. What more could you ask for? It produced a statistically-significant 28% reduction (!) in its primary outcome variable, “the rate of major cardiovascular events (myocardial infarction, stroke, or death from cardiovascular causes).” Sub-studies indicated plaque regression, a reduction in PAD (HR=0.60), diabetes (HR-0.82), and better cognitive scores. Wow. And all with just a couple handfuls of nuts every day. Please also print out and read my previously-mentioned PREDIMED “progeny” cites and the NEJM editorial and Supplemental Data associated with the original study. This randomized trial also looked at 100%-fat extra virgin olive oil supplementation and witnessed similar gains. (Too bad it didn’t also test a nuts+EVOO arm...) The control diet was not too dissimilar from a typical American diet (though with more baseline olive oil and less meat). What more do we need on nuts? Technically nothing--we should be running hard with just PREDIMED. Perhaps a secondary- prevention trial with nuts+EVOO? For the vegan crowd I also suggested earlier a hard-outcome RCT comparing a long-term Ornish vegan diet with a pesco-vegetarian diet with very high nuts, EVOO, and no fat restrictions? graham - the <10%-fat Ornish diet essentially doesn’t allow oils or nuts..

graham, MD

@SRP, the way I read it is that Dr Williams is recommending a plant based diet. Plant based diets do allow nuts, avocado, olive oil etc. Dr Ornish's <10% fat diet used in his trials was for the reversal of established symptomatic atherosclerotic coronary disease. However, in people who do not have such issues, his Spectrum diet does allow nuts (monosaturated fats) etc in Group 2 of his diet. Perhaps you could point to where Dr Williams is advising against the consumption of nuts..


graham - I never said that Dr Williams was against nuts. I implied that as President of the American College of Cardiology, with the new, randomized PREDIMED results, that he should lead an all-out publicity campaign for cardiologists, general practitioners, the general public, and the government to put nuts--and EVOO--at the very foundation of the food pyramid. If we are going to be evidence-based, as opposed to dogma- or anecdote-based, that's what the actual data tell us. The evidence on vegan diets and low-fat diets, on the other hand, is very, very problematical, as we have discussed here, and we don't need him championing a call in that direction. Leading plant-diet advocates (not just Ornish) are commonly against fats, and EVOO, and nuts, and fish. From page 5 of Esselstyn’s book Prevent and Reverse Heart Disease (2007): “Here are the rules of my program in their simplest form: [1] You cannot eat anything with a mother or a face [including] [3] You must not consume oil of any kind--not a drop. (Yes,...that includes olive oil...) [4] Generally, you cannot eat nuts or avocados.” That’s his plant-based program. Now look at all of the randomized PREDIMED hard-outcome (and Adventist 2) results, and the epidemiological results on fats. So how can you NOT conclude that any ACC advocacy effort pushing veganism--instead of EVOO/nuts/fish--is really just about maintaining a steady stream of CVD patients for cardiologists and interventionalists? What Dr Williams and the ACC do--or do not do--in the future on diet advocacy will tell us a lot about the true goals and legitimacy of this organization..


A note about Observational trials concerning vegan/vegetarianism. If someone is a vegan or vegetarian, it is reasonable to believe that they may be more overall-health-conscious than the average Joe, right? So in epidemiological studies on them, there is automatically a type of “selection bias” in the results. Compared to regular Joes (on the S.A.D.) they will--on average--be more likely to visit their GPs when they should; more likely to have colonoscopies and preventive tests; they will floss their teeth more and have less periodontal disease (if there is anything causal to that); importantly--they will more often seek and take all their medications, etc. They will engage in a broad spectrum of healthier behaviors--the hard-outcomes-effects of which, unfortunately, will be attributed in our statistical models to their vegetarianism, yet which the vegetarianism is not itself responsible for in any way. All of these associative- but-not-causal things create a “healthy user” confounder that we cannot adequately control for in our epidemiological models and that can have HUGE effects on the final results. (See, e.g. the excellent and important: BMJ 2006;333:15 and Circulation 2009 Apr 21;119(15):2051-7.) The important implications for observational trials are: (1) these models have to incorporate surrogate variables to try to control for, as much as possible, healthy-user confounders, and (2) any beneficial results we see for vegetarianism/veganism are likely (much?) smaller, in reality, than what the HRs appear to say. (When we accordingly quantitatively discount the women’s HRs in the Adventist 2 trial, we duplicate the troubling conclusion of the glycemic-load results in the Nurses trial that veganism may actually be harmful for women.) This is why Randomized trials are so much more definitive, as they inherently eliminate such confounders..

julie deardorff

Hi, I'm a Chicago Tribune reporter writing on this discussion. Would love to interview SRP --or others who want to weigh in. I'm at Thanks! Julie Deardorff Chicago Tribune 312-804-9782.

graham, MD

SRP, I think you're misrepresenting Ornish. He is not against nuts, and as I said before includes them in group 2 of his Spectrum diet, and in his article from the American Journal of Cardiology he discusses the role of a diet including nuts on lowering cholesterol. Esselystyn's work is driven on reversing heart disease, and in previous televised discussions Ornish has disagreed with Esselystyn on the elimination of fish and nuts. And Ornish's program has recommended the use of both fish oils and flax seed oil. As for the Predimed study, this was mediterranean vs a failed low fat diet. The controls failed to reduce their fat intake to low levels, and also increased their intake of poor quality carbs. The investigators admit this failing..

graham, MD

And as to whether vegans are more health conscious, I'd like to see some solid references before drawing such conclusions. Veganism describes an ethical approach to eating. In many countries, different types of vegetarianism are driven by religion and not for health purposes. And this is why ecological studies such as those carried out by Campbell are so important..

Ashwani Garg MD

The reason there is debate about Dr. Kim's suggestions to "go vegan" is that there are so many ways to be vegan, many of them unhealthy, and only some of them healthy. You can eat white bread and Oreos, a bunch of Boca Burgers, and a gallon of sweetened soy milk and be "vegan". However, if you don't make it a goal to be "vegan" and instead, go for whole foods, plant based diet, then you will commonly see an even greater reduction in blood cholesterol, and regression of atherosclerosis and diabetes. This research has been done. It's impossible to conduct a randomized, controlled, double- blind trial such as with drugs but the evidence is out there. Would you disagree that eating whole, unprocessed foods, including whole grains, beans, greens, vegetables, and fruits as well as a small quantity of nuts and seeds is good for your health? The debate seems to be the quantity of oils and fats, meat and dairy that one can include while still being "healthy". In my mind, we should strive for zero of the latter. Dr. Kim should be commended for his start, however make the goal of not promoting "vegan" but promoting "whole foods, plant based".


graham - (1) If Ornish is now supporting olive oil, nuts, and fish (and I means lots of each), then great! I am not sure if his newer Spectrum Diet is based on a re-evaluation of the overwhelming epidemiological evidence, or just a realization that few people can stomach his prior no-fat diet long-term. But Esselstyn continues to simply be 180-degrees wrong. (2) ecological studies (such as Campell’s) are by far the weakest form of evidence and while they may be hypothesis-raising, at this stage in the argument they have little weight. (3) With respect to “Ornish's program has recommended the use of fish oils...”: -- for regular people--it has recently been unequivocally established that fish oil supplementation (in contrast as to consumption of the whole fish) is useless. See: N Engl J Med 2013;368:1800-8 and meta-analyses at Arch Intern Med 2012;172(9):686-94 and JAMA 2012;308(10):1024-1033. For those on Ornish’s vegetarian and super-low-fat diets, however, fish oil pills may indeed be a helpful supplement. (4) In PREDIMED it isn’t a “failing” that the low-fat- counseled group increased their carbs! If they cut down on fats, they had to make it up somewhere. We should be thankful that the control group ended up with a diet similar to an American diet, for better comparative purposes. (For ethical reasons, they couldn’t have said that that was their original objective...).


Ashwani - If you say “large” quantity of nuts and “olive oil” and if you are male, than I can agree. See all the PREDIMED cites and the numbers in the Adventist 2 tables of JAMA Intern Med. 2013;1-8 (including for men vs women). But I don’t think that a little unprocessed meat and milk products occasionally hurts that much and it makes such a diet much more sustainable for more people. Note that extra virgin olive oil is dramatically different than other oils. It is really squeezed olive “juice,” not complexly-processed with solvents, contains polyphenols, and has a unique mono/poly fat profile, with little n-6 linoleic acid..


