Cardiovascular disease is a global epidemic.  In America, it has been the #1 leading cause of death for an astounding  93 consecutive years and counting!  Since 1901, it ranks in the top 3 leading causes of death. In most developed countries, the leading cause of death is cardiovascular disease.  The prevalence of heart disease is also increasing in developing countries. We have known for years, heart disease starts at a very early age as conclusively shown by the Korean Soldier study. In this landmark study, 300 American soldiers who died in the Korean war were autopsied. The average age was 22 and remarkably 77.3% of hearts showed evidence of atherosclerosis!  These men were young fit soldiers in the prime of their lives. The Korean men's hearts were examined and the investigators noted a lack of blockage and attributed it to dietary factors. The CDC reports that 26.6 million people in the United States have CAD. This number does not include the millions of children and young adults with early stages of heart disease. We know that heart disease is the leading cause of death in both men and women and kills more than 600,000 people annually in the U.S or about 1 in every 4 deaths.  Sadly, every year  735,000 Americans have a heart attack and it is preventable disease.  In February 2015, Dietary Guidelines Advisory Committee took a step in the right direction by recommending higher consumption of vegetables, fruits, whole grains, and a lower consumption of red and processed meat, and lower intakes of refined grains, and sugar-sweetened foods and beverages. The longest lived cultures in the world follow a predominantly plant-based dietary pattern.  In fact, heart disease is unheard of in adults and even the elderly in many traditional cultures.  Heart disease is virtually non-existent in cultures that eat a whole foods plant-based diet, maintain a healthy weight, and are physically active.(4-10)  Furthermore, elders from Okinawa, Sardinia, Loma Linda, Icaria, and Nicoya Peninsula have some of the highest rates of longevity in the world and as expected, their diet is predominantly plant-based.

The pathophysiology of CAD is complex and there is no unifying hypothesis in the medical community.  We do know the modifiable risk factors that contribute to CAD worldwide in both sexes include: hypertension, diabetes, dyslipidemia, smoking, abdominal obesity, psychosocial factors, consumption of fruits, vegetables, and alcohol, and regular physical activity as described in 52 countries in the INTERHEART study.  Also, endothelial dysfunction, inflammation, immunologic factors, and plaque rupture plays a role.  Prepubescent children, by the age of 10 years old, have numerous macrophage foam cells and fatty streaks seen on inner lining of the coronary arteries.  It is astonishing to note, that in America, a child by the age of 10 years old, has CAD with fatty streaks visible on the coronary arteries. It is a sad fact, that heart disease is so epidemic in America that we have risk calculators that help determine the likelihood of an advanced atherosclerotic lesion in a pediatric patients. Although heart disease has been the leading cause of death in America for almost 100 years, many experts and epidemiological studies support the claim that CAD is preventable.  Also, we know that through intensive lifestyle intervention, heart disease is reversible!

We have a preponderance of data that suggest that eating fruits and vegetables prevent or decrease risk of heart disease. (15-17) We also have a plethora of data that shows that a whole foods plant-based diet can reverse heart disease. (18-22) From the science, we know that we can prevent heart disease and we can also reverse it once it is established. One flawed argument that is prevalent is that heart disease is an inevitable part of the aging process. In many cultures, heart disease was rare until they adopted the unhealthy western diet. In the Kitava Study, Okinawa Study, Seventh Day Adventist Health Study and the China study, it was shown that populations who eat a predominantly plant-based diet and do not consume the highly processed Western diet had a very low incidence of heart disease.  

We have data that shows one can attain exceptional longevity without heart disease. One of the last indigenous cultures in the world to live a lifestyle and have a strictly native diet not influenced by western culture is the Kitava people. This indigenous people who live in Papua New Guinea only eat yam, sweet potato, taro, tapioca, banana, papaya, pineapple, mango, guava, water melon, pumpkin, vegetables, fish and coconuts.(4-7) In a study of 1,816 patients between the ages of 3 to 96, it was noted that there was no ischemic heart disease.(7) Most of this data was gathered by interviews, EKG, and physical exams of living people. It was reasonable to assume  that they were free of heart disease.  However, a conclusive determination can only be made on autopsy.

A landmark study on indigenous people from Uganda showed that heart disease was practically non-existent based on autopsy studies.(9,10) Even when the subjects were age matched with Missourians the rate of heart disease was non-existent in Ugandans and was astonishingly high in Americans.  An autopsy of the 632 Ugandan's found only 1 myocardial infarction and out of 632 Missourians same age and gender distribution showed 136 myocardial infarction.  In fact, out of 1,427 autopsies performed in this Ugandan study on subjects greater than 40 years of age only one small healed infarct was found and it was not even the cause of death.(10) These findings are quite astonishing considering how epidemic heart disease is in America.  What was the Ugandans secret to no heart disease?  Perhaps it was their diet.  Of Note, Ugandans in this study ate a whole foods plant-based diet.  The staple foods include green plantain, sweet potatoes, cassava, yams, maize, millet, pumpkins, beans, tomatoes, and green leafy vegetables.(9)   It is reassuring to see these studies with elderly humans that are not afflicted with heart disease.  What is the oldest documented case of no heart disease on autopsy?

An autopsy study of an Okinawan elder who was 100 years old and her coronary arteries did not show any evidence of atherosclerosis.(8) No heart disease in a 100 year old! The researchers state, “No arterial or ventricular dilatation or enlargement; no areas of infarction; no coronary artery calcification or atherosclerosis; no valvular calcification.”(8) As an aside, the study goes on to mention that her kidneys, esophagus, stomach, liver, pancreas, gallbladder, and bladder were essentially normal.(8)

There is sufficient evidence to prove that humans can live a long and healthy life and avoid heart disease.  This is very reassuring. It is refreshing that the Paleo gimmick and other fad diets have been effectively debunked by nutritional experts after reviewing nutritional literature. Just this Feb 2015, the Dietary Guidelines Advisory Committee recommends higher consumption of vegetables, fruits, whole grains, and a lower consumption of red and processed meat, and lower intakes of refined grains, and sugar-sweetened foods and beverages.  Of course, the meat and dairy industry and popular diet authors that are tell you that eating meat, dairy and eggs are healthy are upset about the latest scientific recommendation.  Indeed, if the USDA adopts these dietary recommendations, big industry will lose lots of money. Since most disease process have a multifactorial component, exercise should not be overlooked. Furthermore, the indigenous and rural populations with a low incidence of heart disease are extremely active burning lots of calories and virtually no one in those cultures are overweight let alone obese. Many studies have shown that exercise is an independent risk factor for heart disease. In other words, those who don't exercise regularly are at higher risk.(23-25)  One can dramatically lower the risk of heart disease by exercising regularly.(26)  Interestingly, there is a law of diminishing returns with exercising and a recent paper suggest that too much exercise can cause heart damage.(27)In sum, to live a long and healthy life, without heart disease, the following wellness plan should be followed: 1)Eat a whole foods plant-based diet.  2)Exercise every day for about 1 hour. 3)Maintain a healthy weight and avoid abdominal obesity 4)don’t smoke tobacco  5)keep blood sugar within normal limits. 6)Keep blood pressure within normal limits 7) control stress and 8)limit alcohol consumption.


1 Circulation. 1998;97:596-601

doi: 10.1161/01.CIR.97.6.596

(Circulation. 1998;97:596-601.)

2 .J Am Med Assoc. 1953 Jul 18;152(12):1090-3. Coronary disease among United States soldiers killed in action in Korea; preliminary report.



4    Lindeberg, S, Nilsson-Ehle, P, and Vessby, B. Lipoprotein composition and serum cholesterol ester fatty acids in nonwesternized Melanesians. Lipids, 1996;  31: 153-8

5    Lindeberg, S and Vessby, B. Fatty acid composition of cholesterol esters and serum tocopherols in Melanesians apparently free from cardiovascular disease - the Kitava study. Nutr Metab Cardiovasc Dis, 1995;  5: 45-53

6  Lindeberg, S, Nilsson-Ehle, P, Terént, A, Vessby, B, and Scherstén, B. Cardiovascular risk factors in a Melanesian population apparently free from stroke and ischaemic heart disease — the Kitava study. J Intern Med, 1994;  236: 331-340

7  J Intern Med. 1993 Mar;233(3):269-75.  Apparent absence of stroke and ischaemic heart disease in a traditional Melanesian island: a clinicalstudy in Kitava.

8.  J Gerontol A Biol Sci Med Sci. 2004 Nov;59(11):1195-9.First autopsy study of an Okinawan centenarian: absence of many age-related diseases.

Bernstein AM, Willcox BJ, Tamaki H, Kunishima N, Suzuki M, Willcox DC, Yoo JS, Perls TT.

9  Int J Epidemiol. 2012 Oct;41(5):1221-5. doi: 10.1093/ije/dys137. Serum-cholesterol, diet, and coronary heart-disease in Africans and Asians in Uganda: 1959.  Shaper AG, Jones KW.

10  Am J Cardiol. 1960 Jan;5:41-7.  Incidence of myocardial infarction correlated with venous and pulmonary thrombosis and embolism. A geographic study based on autopsies in Uganda. East Africa and St. Louis, U.S.A.


11 Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study.AUYusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F, McQueen M  Budaj A, Pais P, Varigos J, Lisheng L, INTERHEART Study Investigators, SO, Lancet. 2004;364(9438):937.

12J Atheroscler Res. 1969 May-Jun;9(3):251-65.  The pediatric aspects of atherosclerosis.

Strong JP, McGill HC Jr.

13  Arch Intern Med. 2005 Apr 25;165(8):883-90.  Risk scores predict atherosclerotic lesions in young people.

McMahan CA, Gidding SS, Fayad ZA, Zieske AW, Malcom GT, Tracy RE, Strong JP, McGill HC Jr.

14  Pediatrics. 2006 Oct;118(4):1447-55. Pathobiological determinants of atherosclerosis in youth risk scores are associated with early and advanced atherosclerosis.  McMahan CA, Gidding SS, Malcom GT, Tracy RE, Strong JP, McGill HC Jr; Pathobiological Determinants of Atherosclerosis in Youth Research Group.

15 Rimm EB, Ascherio A, Giovannucci E, et al. Vegetable, fruit, and cereal fiber intake and risk of coronary heart disease among men. JAMA 1996; 275:447.

16 Wolk A, Manson JE, Stampfer MJ, et al. Long-term intake of dietary fiber and decreased risk of coronary heart disease among women. JAMA 1999; 281:1998.

17 Law MR, Morris JK. By how much does fruit and vegetable consumption reduce the risk of ischaemic heart disease? Eur J Clin Nutr 1998; 52:549.

18  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).[21]

19 Gould KL, Ornish D, Scherwitz L, Stuart Y, Buchi M, Billings J, Armstrong W, Ports T, Scherwitz L. Changes in myocardial perfusion abnormalities by positron emission tomography after long-term, intense risk factor modification. JAMA. 1995;274:894-901.[22]

20 Ornish D, Scherwitz L, Billings J, Brown SE, Gould KL, Merritt TA, Sparler S, Armstrong WT, Ports TA, Kirkeeide RL, Hogeboom C, Brand RJ. Intensive lifestyle changes for reversal of coronary heart disease Five-year follow-up of the Lifestyle Heart Trial. JAMA. 1998;280:2001-2007.[23]

21 Ornish D. Avoiding Revascularization with Lifestyle Changes: The Multicenter Lifestyle Demonstration Project. American Journal of Cardiology. 1998;82:72T-76T.[24]

22 Prevent and Reverse Heart Disease, Caldwell B. Esselstyn, Jf, M.D.

23. Powell KE, Thompson PD, Caspersen CJ, Kendrick JS. Physical activity and the incidence of coronary heart disease. Annu Rev Public Health 1987; 8:253.

24. .Paffenbarger RS Jr, Hyde RT, Wing AL, et al. The association of changes in physical-activity level and other lifestyle characteristics with mortality among men. N Engl J Med 1993; 328:538.

25  Leon AS, Connett J, Jacobs DR Jr, Rauramaa R. Leisure-time physical activity levels and risk of coronary heart disease and death. The Multiple Risk Factor Intervention Trial. JAMA 1987; 258:2388.

26  Circulation. 1994 Jun;89(6):2540-4. Physical activity and 23-year incidence of coronary heart disease morbidity and mortality among middle-aged men. The Honolulu Heart Program. Rodriguez BL, Curb JD, Burchfiel CM, Abbott RD, Petrovitch H, Masaki K, Chiu D.

27 James O'Keefe Potential Adverse Cardiovascular Effects FromExcessive Endurance Exercise. Mayo Clin Proc. 2012 Jun; 87(6): 587–595