Is Oil giving you Heart Disease? | Dr. Caldwell Esselstyn

Summary

In this insightful conversation, Dr. Caldwell Esselstyn, a renowned physician and author, challenges the Mediterranean diet's health claims, advocating for a plant-based, very low-fat diet to prevent and reverse heart disease. He emphasizes the importance of avoiding dietary fats, oils, animal proteins, and sugars, while promoting a diet rich in whole grains, legumes, and vegetables. Dr. Esselstyn also discusses the role of nitric oxide in cardiovascular health and the potential benefits of green leafy vegetables in restoring endothelial function.

Takeaways

• 🍽 Dr. Caldwell Esselstyn, a physician and author, advocates for a plant-based, very low-fat diet to prevent and reverse heart disease.
• 🚫 He strongly advises against consuming any form of dietary oil, including olive oil, due to their potential to harm endothelial cells.
• 🥜 Nuts, while often considered healthy, are considered addictive and should be avoided in his diet plan.
• 🥦 Esselstyn emphasizes the importance of consuming green leafy vegetables, which can help stimulate the production of nitric oxide and improve endothelial health.
• 🌾 He promotes a diet rich in whole grains, legumes, a variety of vegetables, and some fruits, excluding animal proteins and dairy.
• ☕ Esselstyn discourages the intake of caffeinated coffee, fluoride toothpaste, and antacids, as they may negatively affect the beneficial bacteria in the mouth and reduce gastric acidity.
• 🧂 The use of vinegar, particularly balsamic or rice vinegar, is recommended as it contains acetic acid that can help restore nitric oxide synthase enzyme in endothelial cells.
• 💊 He criticizes the Predimed study, arguing that despite a Mediterranean diet showing some benefits, it did not eliminate cardiovascular events and may have been misrepresented in media.
• 🔍 Esselstyn's stance on oils, including olive oil, is based on research showing their negative impact on endothelial cells, despite some studies suggesting potential benefits.
• 🥑 He does not recommend avocados or nut butters due to their high fat content, which he believes could be detrimental to heart health.
• 📚 His book 'Prevent and Reverse Heart Disease' outlines his diet program in detail and has been a New York Times bestseller.

Q & A

What is the main argument against the consumption of olive oil according to Dr. Caldwell Esselstyn?

Dr. Esselstyn argues that olive oil, along with other forms of oil, injures endothelial cells, which are crucial for heart health.

What dietary changes does Dr. Esselstyn recommend for patients with heart disease?

He recommends a plant-based, very low-fat diet, which includes eliminating all forms of oil, animal protein, dairy, sugary drinks and foods, and caffeine, while focusing on whole grains, legumes, vegetables, and some fruits.

What is the significance of the endothelial production of nitric oxide in the context of heart health?

Nitric oxide is important for maintaining the health of blood vessels. Its production decreases with age, which can contribute to cardiovascular issues. Dr. Esselstyn suggests certain dietary practices to stimulate its production.

How does Dr. Esselstyn suggest incorporating green leafy vegetables into one's diet to improve heart health?

He advises consuming approximately one third of a cup of green leafy vegetables, steamed or boiled, six times a day, anointed with balsamic or rice vinegar to enhance nitric oxide production.

What is the role of acetic acid from vinegars in the context of Dr. Esselstyn's dietary recommendations?

Acetic acid from vinegars can restore the nitric oxide synthase enzyme within endothelial cells, which is responsible for making nitric oxide, thus supporting heart health.

What are some of the top vegetables recommended by Dr. Esselstyn for their heart health benefits?

The top recommended vegetables include kale, Swiss chard, spinach, arugula, beet greens, and beets.

What is the Predimed study and what were its findings in relation to the Mediterranean diet and heart disease?

The Predimed study was a large Spanish study that compared the effects of a Mediterranean diet supplemented with olive oil or nuts versus a control diet on cardiovascular events. It found a reduction in events in the Mediterranean diet groups but did not eliminate the risk entirely.

What was Dr. Esselstyn's critique of the Predimed study's findings?

Dr. Esselstyn critiqued the study for having participants with no documented heart disease at the start but still experiencing significant cardiac events during the study, suggesting that the Mediterranean diet did not halt the progression of heart disease as claimed.

What is the significance of flow-mediated dilation (FMD) in the context of the discussion on dietary fats and heart health?

FMD is an indicator of endothelial function and cardiovascular health. Some studies suggest that certain fats, like olive oil, may temporarily inhibit FMD post-meal, but long-term effects can vary and are not entirely conclusive.

Why does Dr. Esselstyn maintain a strong stance against the consumption of any form of oil, including olive oil?

Despite some studies suggesting potential benefits of olive oil, Dr. Esselstyn maintains his stance due to consistent evidence from other studies showing that oil, including olive oil, injures endothelial cells, which he believes is detrimental to heart health.

What is the importance of the nitrate to nitrite conversion process in the context of Dr. Esselstyn's dietary recommendations?

The conversion of nitrate to nitrite by oral bacteria and subsequent conversion to nitric oxide in the stomach is a natural process that Dr. Esselstyn suggests can help restore nitric oxide levels, which are important for heart health.

Outlines

00:00

🍽 Controversy Over Mediterranean Diet's Impact on Heart Health

The first paragraph introduces a debate on the healthfulness of the Mediterranean diet, particularly focusing on its high-fat components like olive oil and nuts. It mentions Dr. Caldwell Esselstyn, a physician advocating for a plant-based, very low-fat diet to combat heart disease. Esselstyn's program at the Cleveland Clinic and his book, 'Prevent and Reverse Heart Disease,' are highlighted. The paragraph sets the stage for a discussion on dietary fat, oil, and heart disease, suggesting that even small amounts of oil can be harmful and advocating for the elimination of oils, animal proteins, dairy, and sugary substances from one's diet. It also introduces Esselstyn's adjusted program to enhance nitric oxide production in the endothelium, recommending the consumption of green leafy vegetables with vinegar to support this process.

05:00

🌿 The Role of Green Leafy Vegetables in Nitric Oxide Production

This paragraph delves into the specifics of how green leafy vegetables and vinegar can boost nitric oxide production in the body, which is crucial for cardiovascular health. It explains the process by which chewing these vegetables leads to the conversion of nitrate to nitrite and then to nitric oxide, facilitated by the body's own gastric acid. The paragraph also warns against the use of fluoride toothpaste, public drinking water with fluoride, and antacids, as they can inhibit the beneficial bacteria and reduce gastric acidity necessary for this conversion. A list of top vegetables for this purpose is provided, emphasizing the importance of whole food plant-based nutrition in restoring memory and overall health.

10:07

🛑 Critique of Olive Oil and the Predimed Study

The third paragraph presents Dr. Esselstyn's critique of olive oil and the Predimed study, which suggested health benefits from a Mediterranean diet high in olive oil. Esselstyn challenges the study's findings, arguing that the diet did not prevent heart disease but rather contributed to the creation of cardiovascular issues. He points out that the study's participants, despite being free of heart disease at the start, experienced numerous cardiac events during the trial. Esselstyn also discusses the variability in the effects of different fats on flow-mediated dilation (FMD), suggesting that the impact on FMD is not consistent across all fats and can even be beneficial in the long term for some, like olive oil.

15:07

🚫 Unwavering Stance on Eliminating Oil and Nuts from the Diet

In the final paragraph, Dr. Esselstyn maintains his stance on the complete avoidance of oil and nuts, despite some studies suggesting potential benefits. He explains his reasoning behind this strict dietary approach, emphasizing the effectiveness of his program and the potential risks of deviating from it, especially for very sick patients. Esselstyn also addresses a misunderstanding regarding his position on olive oil due to a review article in which he was a co-author. He clarifies that despite the article's recommendations, he still believes that all oils, including olive oil, are harmful and should be avoided. The paragraph concludes with a brief note on the Predimed study's participant criteria and the observed reduction in heart attack events among those on Mediterranean diets, while also highlighting that this reduction does not equate to the elimination of risk.

Keywords

💡Olive oil

Olive oil is a liquid fat obtained from olives, commonly used in cooking for its flavor and health benefits. In the video, it is debated whether olive oil is healthy or not, with Dr. Caldwell Esselstyn arguing against its consumption due to its potential to injure endothelial cells, despite it being a staple in the Mediterranean diet.

💡Nuts

Nuts are a group of edible seeds that are often consumed for their nutritional value and are considered part of a healthy diet by many. However, Dr. Esselstyn describes them as 'highly addicting' and suggests that once started, consumption is hard to stop, indicating a concern about overconsumption and its health implications.

💡Mediterranean diet

The Mediterranean diet is a dietary pattern characterized by high consumption of fruits, vegetables, olive oil, and fish, with moderate amounts of dairy, poultry, wine, and nuts. The video discusses the potential downsides of this diet, particularly the use of oil, which Dr. Esselstyn advises against.

💡Cardiovascular disease

Cardiovascular disease refers to a class of diseases that involve the heart or blood vessels. Dr. Esselstyn's program at the Cleveland Clinic is focused on preventing and reversing heart disease through a plant-based, very low-fat diet, emphasizing the impact of dietary choices on heart health.

💡Endothelium

The endothelium is the thin layer of cells that line the interior surface of blood vessels and lymphatic vessels. In the video, it is mentioned that certain foods, including various oils, can injure the endothelium, which is a key point in Dr. Esselstyn's argument against dietary fats.

💡Nitric oxide

Nitric oxide is a molecule that is produced by the endothelium and plays a crucial role in vascular homeostasis, including the regulation of blood pressure. Dr. Esselstyn discusses the importance of maintaining nitric oxide levels and the role of green leafy vegetables in enhancing its production.

💡Plant-based diet

A plant-based diet consists predominantly or entirely of foods derived from plants, including vegetables, grains, nuts, and legumes. Dr. Esselstyn advocates for a plant-based, very low-fat diet as a means to prevent and reverse heart disease.

💡Flow-mediated dilation (FMD)

Flow-mediated dilation is a non-invasive measure of endothelial function, reflecting the ability of the arteries to dilate after increased blood flow. The video discusses how different types of fats can affect FMD, with olive oil being noted to inhibit it postprandially.

💡Acetic acid

Acetic acid is the main component of vinegar and is discussed in the video as a substance that can restore the nitric oxide synthase enzyme within endothelial cells, contributing to the production of nitric oxide and thus supporting vascular health.

💡Green leafy vegetables

Green leafy vegetables, such as kale, spinach, and arugula, are highlighted in the video as essential components of a heart-healthy diet. Dr. Esselstyn recommends consuming these vegetables with vinegar to enhance nitric oxide production and improve endothelial function.

💡Esselstyn heart disease program

The Esselstyn heart disease program is a plant-based, very low-fat diet regimen developed by Dr. Caldwell Esselstyn for patients with heart disease at the Cleveland Clinic. The program is featured in the video as an effective approach to preventing and reversing heart disease.

Highlights

Dr. Caldwell Esselstyn argues against the health benefits of olive oil and nuts, suggesting they contribute to the creation of cardiovascular disease.

Dr. Esselstyn is the director of the Esselstyn heart disease program at the Cleveland Clinic, advocating for a plant-based, very low-fat diet.

His book 'Prevent and Reverse Heart Disease' discusses the impact of dietary fat on heart health and has become a New York Times bestseller.

The interview delves into the effects of dietary fats, including oils, on endothelial cells and heart disease.

Dr. Esselstyn emphasizes the importance of avoiding all forms of oil, including olive oil, due to their harmful effects on the endothelium.

Animal proteins such as meat, fish, and dairy products are identified as contributors to heart disease and should be avoided.

Sugary drinks and foods, including diet colas and sweet treats, are highlighted as detrimental to heart health.

Dr. Esselstyn recommends a diet rich in whole grains, legumes, vegetables, and fruits as an alternative to harmful fats and proteins.

The significance of nitric oxide production by endothelial cells and its decline with age is discussed, with implications for heart disease.

A method to stimulate nitric oxide production involves consuming green leafy vegetables with vinegar to restore the enzyme nitric oxide synthase.

The interview addresses the potential of whole food plant-based nutrition to restore memory and cognitive function.

Dr. Esselstyn's research on the effects of oil consumption, including a paper published in the International Journal of Disease Reversal and Prevention, is mentioned.

The Predimed study, which suggests a Mediterranean diet with olive oil could reduce cardiovascular events, is critiqued by Dr. Esselstyn.

Flow-mediated dilation (FMD) as an indicator of endothelial health and its relation to diet, particularly the type of fat consumed, is discussed.

Dr. Esselstyn disputes the benefits of olive oil based on evidence showing it injures endothelial cells, despite some studies suggesting otherwise.

The interview concludes with a discussion on the limitations of the Predimed study and the importance of a strict diet to prevent heart disease.

Transcripts

And there's not much in olive oil that's healthy.  And nuts are highly addicting, once you start  

eating nuts you don't stop. And I think you've got  the title wrong, the title should be "The CREATION  

of cardiovascular disease with the Mediterranean  diet". Dr Caldwell Esselstyn is a physician,  

author and Olympic gold medalist. He's the  director of the Esselstyn heart disease program  

at the Cleveland Clinic where patients with heart  disease are advised to follow a plant-based very  

low fat diet. His book "Prevent and reverse  heart disease" is a New York Times bestseller. I  

recently spoke with Dr Esselstyn, we had different  views on a couple topics which made for a really  

interesting conversation, we're working really  hard on getting the full interview edited and  

packaged for release, in the meantime here's  the section where we talk about dietary fat, oil  

and heart disease. Enjoy. So what are the foods  that every time they pass our lips we injure the  

endothelium? They are: any drop of oil. Olive oil,  corn oil, soybean oil, sunflower oil, coconut oil,  

palm oil, oil in a cracker, oil in a chip oil, in  a piece of bread, oil in a salad dressing. Do you,  

Joe, ever eat oil? All right, we got that out of  the way. Next you got to get rid of your animal  

protein. Meat, fish, chicken, fowl, turkey  and eggs. How you doing on that? Okay. Also,  

we want to get rid of dairy: milk, cream, butter,  cheese, ice cream and yogurt. Okay. Also, we want  

to be careful about sugary drinks: Diet colas,  Pepsi and Coke and sugary Foods: cakes, pies,  

cookies, Stevia, Agave, excesses of maple syrup,  molasses, and honey. Also, I don't like peanuts,  

peanut butter, nut butters, cashew sauce or  avocado, and finally, coffee with caffeine. Decaf,  

yes. Coffee with caffeine, no. Injures endothelial  cells. Now, what are you going to eat? What are  

you going to eat? All these marvelous whole grains  for your cereal, bread, pasta, rolls and bagels,  

101 different types of legumes, lentils and  beans, all these marvelous red, yellow, green  

leafy vegetables, white potatoes, sweet potatoes  and some fruit. Now, I should share with you that  

about a decade ago I made a major change in the  program. That change came about from a recognition  

of the fact that the endothelial production of  nitric oxide is age dependent. So for example,  

you never heard of a boy or a girl at age  eight having a heart attack, right? No, they  

have nitric oxide coming out of their ears, but  by the time they're 50 and beautifully healthy,  

their endothelial production of nitric oxide is  now 50% of what it was when you were 25. Now,  

when you're 80 you've lost 70%, so the changes  I made were two: one, a greater stimulation of  

the endothelial production of nitric oxide and  number two, we embrace the newer research that  

shows us that mankind has an alternate pathway for  making additional nitric oxide. So, here we go:  

I need you to chew, six times a day, a green  leafy vegetable, approximately one third of a cup,  

after it has first been steamed or boiled, 5 and  a half to six minutes so it's nice and tender,  

and then you must anoint it with several drops  of a delightful balsamic or rice vinegar. Why?  

Because research has shown us that the acetic acid  from those vinegars can restore the nitric oxide  

synthase enzyme contained within the endothelial  cell and responsible for making nitric oxide. So,  

you're going to chew this alongside your  breakfast cereal, again as a mid-morning snack,  

again with your lunch and sandwich, that's  three, mid-afternoon, 4, dinner time, 5,  

and I adore it when you have that evening snack  of arugula or kale. Now, the second benefit,  

when you're chewing the green leafy vegetable  you are restoring the capacity of your bone  

marrow to replace our senescent, injured, worn out  endothelial cells. The third benefit, when you're  

chewing a green leafy vegetable you are chewing  a green nitrate. As you chew the green nitrate  

it is going to mix with the facultative anaerobic  bacteria that reside in the crypts and grooves of  

your tongue, those bacteria will reduce the  nitrate you've been chewing to a nitrite,  

when you swallow the nitrite it is your own  gastric acid which is now going to reduce the  

nitrite to more nitric oxide which can enter  your nitric oxide pool, so think about it,  

what you're doing for minimal expense and no  hideous side effects all day long, dawn to dusk,  

morning to night, you are absolutely replacing the  very molecule of nitric oxide the deficiency of  

which gave you this disease in the first place.  Now, there's a caveat to this: toothpaste with  

fluoride, public drinking water with fluoride and  mouthwash will injure the beneficial bacteria in  

your mouth and I do not like antacids because  antacids will reduce your gastric acidity and  

you will be unable to reduce the nitrite to  more nitric oxide. And I want to share with you,  

the top six vegetables would be: kale, Swiss  chard, spinach, arugula, beet greens and beets.  

If you want the whole list? Go for it. bok choy,  Swiss chard, kale, collards, collard greens,  

beet greens, mustard greens, turnip greens, napa  cabbage, Brussel sprouts, broccoli, cauliflower,  

cilantro, parsley, spinach, arugula and  asparagus. The reason I go through that  

like that for you is you have to know how whole  food plant-based nutrition can restore your  

memory. I don't think anybody doubts your memory  capacity. I'm sorry to be so long but that's,  

what I just told you is part and parcel of what I  do with the patient. So with oil, there's a lot of  

questions on oil but I just want to understand,  the recommendation to avoid all forms of oil,  

what is the pillar or pillars of data that led you  to this conclusion? I wrote a paper called "Is oil  

healthy?" that was published in the international  Journal of disease reversal and prevention in  

2019. Half of the paper was, I reviewed the  animal studies that injure endothelial cells  

and i reviewed the human studies I found and that  showed that oil would injure endothelial cells and  

I cited it with the appropriate references. So  this is one of the main arguments that I've heard,  

this idea that after eating for example olive  oil, flow mediated dilation is inhibited  

postprandially, this is one of the arguments,  that it then damages the endothelium and so  

we should avoid oil, this is the gist of the  argument. Well, there's a paper in there that  

very clearly shows how olive oil, palm oil injure  endothelial cells, that was one of the major  

findings. And there's a large Spanish study,  Predimed. Yeah. Yeah the Predimed study, and  

I can remember there was a reporter from The New  York Times, after the paper came out, that called  

me and said Dr Esselstyn this seems to disagree  with your philosophy, what do you think of it,  

of the paper? And I said well, I said I hadn't  seen it so she sent it to me and I said the title  

of the paper is the Mediterranean diet inhibits  formation of heart disease. They had three groups,  

an oil group, a nut group and then a low fat group  that was not low fat at all. Yeah. And over the  

course of five years in these 5,000, I think it  was 5,000 patients, they found that in the oil  

group, I forget but it was something like 80,  85 to 86 major events, something like 93 in  

the nut group and then of course in the low fat  Group which was not a low fat group it was like  

100 and something, so I said, now I want to be  sure I, because I talked to her on the phone,  

I said they're claiming that the Mediterranean  diet haults the progression of heart disease,  

but remember every single patient who entered  that study had to be checked and be sure that  

they did not have any heart disease, so in other  words they were documented as not having heart  

disease and what I found is in all three groups  there have been scores of major cardiac events,  

heart attack, stroke and death, and I think  you've got the title wrong, the title should  

be the creation of cardiovascular disease with the  Mediterranean diet. The events could be from from  

plaque that is already there from before, but  yeah, it's... but still, when you start and you  

make the premise or you declare that nobody has  symptomatic or cardiovascular disease they could  

identify to enter in the study and then suddenly  scores of patients in each category come down with  

major events, and that's why I objected to the  title. Yeah I understand what you're saying, I  

don't know if I would say that it's the diet they  were on during the trial that's causing that but  

it certainly seems to be a very partial effect,  I agree. I know what you're saying, it's just  

a partial reduction and they're still having all  these events that ideally we would want to avoid.  

Yeah I agree with that, so whether that's because  the compliance was not great or whether it's  

because of something else, yeah it's hard to say,  but it's an interesting point that you're making.  

With the FMD data I just wanted to bring up a  couple things that I found that I've never seen  

kind of discussed. I found that the effect on  flow-mediated dilation seems to depend on the  

type of fat, so with olive oil they see this  inhibition right after eating olive oil but for  

example with canola oil, no statistically  significant effect on FMD. Eating fish,  

no significant effect on FMD. Eggs also. So  basically as I was going through this kind of  

systematically, this post prandial effect seems to  depend a lot on the type of fat, it doesn't seem  

to be a a consistent effect of fat depressing  FMD. That was one thing that I noticed, and  

then another thing that I thought was even more  interesting was that it depends on the timing, so  

lots of things seem to affect FMD kind of acutely,  after exercise they see FMD be depressed but then  

longterm exercise improves artery function and  with olive oil the same pattern, after a meal we  

see FMD inhibited but long term in several trials  they see FMD improving on olive oil interventions,  

so it just seemed to me that the FMD argument  was not very compelling based on the evidence  

that I've seen. Well, isn't olive oil something  like 17% saturated fat? Yeah 14% I think. Yeah.  

These poor people who are vegans are thriving...  and maybe not all brands of olive oil are the  

same? Sure. There's probably differences  there. Maybe some have more than 14%? It's  

possible. And there's not much in olive oil  that's healthy. Well I don't know about that,  

there's studies comparing polyphenols and all  these other components that suggest that those  

have beneficial effects. Also, the unsaturated  fats, right? The ratio of unsaturated to saturated  

is huge for unsaturated fats, so it has 14%  saturated but the rest is all unsaturated,  

it's all monos and polys. Mostly monos. I´d  have to go back to look, my basic causation  

is it does injure endothelial cells. The other  thing that kind of threw me off, I thought you  

had changed your mind on olive oil because of that  review that came out in JACC in 2017. Whenever you  

are writing with a group you make compromises. I  felt so badly about this but I was so outvoted,  

or else they were gonna throw me off the paper  which I probably should have done. Got it,  

just to clarify why, yeah yeah, people at home  that might not know what I'm talking about, it's  

a review in JACC that recommends olive oil where  you're an author but yeah, that makes sense that  

there was a bit of uh, some negotiation and ended  up being a paper that recommends olive oil. That's  

a nice way of saying it. Yeah, a fight in the  background. Yeah. No and the reason that I read  

that paper and I thought you had changed your mind  is because honestly the way it phrases the data on  

olive oil agrees with the data that I've seen, so  one passage says "there is consistent evidence of  

beneficial effect of olive oil on cardiovascular  risk markers and morbidity and mortality. there's  

sufficient evidence to recommend its use". This  matches the data that I've seen with olive oil  

and the outcomes so that's why I surprised to  hear that you're still of the view that no oil,  

period. Oh yeah I'm still of that view yes. I  think the data are clear enough. Okay, I think  

we've clarified kind of our takes and the data  that we've seen. Other types of fat beyond oil,  

I know you said no avocados. Nuts, no nuts at all,  is that what you recommend? You said no peanut  

butter. Well if I say, if from my lips I say that  it's okay to have four or five walnuts that is not  

what people would hear. "Esselstyn now has said  that you can have nuts". I have never said that  

and I'm not going to say it publicly, no, it's  no nuts. See, what the bottom line is for me is  

that over the years we finally have crystallized  a a program which is astonishingly effective and  

so powerful, that to embark on something that is  devious from this that might threaten these very  

sick patients... I'm going to have to be wedded  to a program that works but very open-minded,  

hopefully, but I find it very hard for me to bring  in something like olive oil when paper after paper  

has shown me that it injures endothelial cells.  Just a quick final note, guys, on Predimed which  

we briefly touched on, just to give you a little  bit more information. I went over the details of  

Predimed again to refresh my memory and yes, they  did select participants that had no documented  

heart disease at baseline, so they couldn't  have any history of heart attacks or chest pain,  

angina, nothing like that, but these were patients  also that had to have very high cardiovascular  

risk, so they had to have either type two diabetes  or at least three other major risk factors,  

so things like smoking, hypertension, obesity,  dyslipidemia etc. So if they didn't have type  

2 diabetes they had to have at least three of  those. So those were the inclusion criteria,  

all participants were required to meet them,  then they took all the participants, they split  

them randomly into three groups, two were put on  Mediterranean diets, one with extra olive oil,  

one with extra nuts and the third group was a  control group that received the diet where they  

were supposed to reduce fat to some extent but  not a a sharp fat reduction by any means. And they  

observed less events like heart attacks on the  two Mediterranean diet groups but as Dr Esselstyn  

points out it wasn't an elimination of events by  any stretch, there were still plenty of events  

there, just less than on the control group. So  this is a good point, it's important to remember  

a 30% reduction in risk, that's about what they  saw, does not mean an elimination of risk, in fact  

if you're eliminating 30% of events by definition  most of the events are still there. So the trial  

points to the Mediterranean diet being superior  to the control diet for cardiovascular events,  

it does not show that the Mediterranean  diet eliminates all cardiovascular risk or  

that it handles any other risk factors that are  present, as in the case of these participants,  

or possibly pre-existing plaque from exposure  to risk factors over years before the trial  

started. So hopefully that gives you a bit more  context for our conversation, we'll try to have  

the full interview out as soon as possible,  thanks for watching, I'll see you soon.