Dr. Esselstyn published the results of a five-year intervention with a low-fat vegetarian diet combined with the individualized use of cholesterol-lowering drugs to bring cholesterol down to 150 mg/dL.16 Since Esselstyn considered it unethical to allow patients under his supervision to eat a standard diet, there was no control group. Twenty-two percent of those who began the intervention dropped out of the study within the first two years; thirty-five percent of those who completed it did not submit to the follow-up analysis of their cardiovascular health; of the twenty-two patients who began the trial, only eleven remained in the final analysis. Of these eleven, occlusion of the blood vessels became better in five, stayed the same in one, and became worse in four.
Despite the inconsistent results, the average change in the width of the blood vessels was an increase in 0.08 millimeters. This represents a reversal of atherosclerosis - on average. Likewise, on average, the degree to which blood vessels were constricted decreased by seven percentage points. Six of the eleven dropped out of the study after the first five years; in the following five years, there were ten heart attacks among the six that dropped out while there were none among the five who remained on the program.
Since there was no control group and there was such a high drop-out rate, it is difficult to make much sense of the study. Did the people drop out because their health was not important to them? Or did they drop out because the vegetarian diet made them feel fatigued, unsatisfied, and even less healthy than their original diet full of meat and junk food? Were the people who completed the study but did not submit to the final measurements of their blood vessels reluctant for no reason, or were they reluctant because they were afraid of the results they would obtain based on how the diet made them feel?
Despite the lack of high-quality evidence, I have little doubt that many people would improve their health on Esselstyn's plan, and especially on Fuhrman's plan, which emphasizes nutrient density to a greater degree than does Esselstyn's. To the extent that the oxidation of lipoproteins such as LDL within the blood would accelerate the accumulation of atherosclerotic plaque, I would expect these plans to be beneficial in two respects: they are so low in added fats and oils that the subjects eat very little polyunsaturated fat, and the small amount of polyunsaturated fat that the patients do obtain from whole foods are accompanied by a rich array of antioxidants that protect them from oxidation.