Plant-Based Cooking spoke with Dr. Andrew M. Freeman, a.k.a. “The Vegan Cardiologist.” Freeman is director of cardiovascular prevention and wellness and director of clinical cardiology and operations at National Jewish Health in Denver, Colorado, and co-chair of the American College of Cardiology Nutrition and Lifestyle Workgroup. His whole food plant-based approach to reversing cardiovascular disease has received widespread attention including from Today, CBSNews, Yahoo!Lifestyle, Healthline, HealthDay and the ThoughtForFoodLifestyle podcast.
What was your medical school training like?
I wasn’t really exposed to nutrition or lifestyle medicine in any significant way. In medical training, you have to be a good conformist because if you stick out too much it can make it difficult to survive. The bottom line is I did my best to stay afloat and do what I had to do. Then I came out and for the first year or so I threw drugs and procedures at people exclusively because I really didn’t have a lot of practice doing anything else.
How and when did you personally go plant-based?
One family vacation we were up in Steamboat Springs, Colorado. We had eaten at a greasy burger place. I had just been starting to read about a variety of health-based topics and I literally finished The China Study that night, and from that point forward I was plant-based. I basically took the plunge. (Freeman is referring to “The China Study: The Most Comprehensive Study of Nutrition Ever Conducted and the Startling Implications for Diet, Weight Loss, And Long-term Health,” T. Colin Campbell, PhD and Thomas Campbell II, PhD, 2006)
How did you learn about The China Study?
I went to school as an undergrad at Cornell, so I had some idea of who Colin Campbell was although I didn’t really know much. And then one of my closest friends in medical school was vegan since he was a teenager because his dad had had a heart attack so early in life. So, I was exposed to this stuff, but I always thought it was crazy or weird. I never really thought it was something that I was going to do regularly.
As I went through my first couple years of training I started to wonder if there was something better – nobody ever really got fixed. I started doing some research, looked online and then I got exposed to a whole variety of books and papers and things that I never knew existed. And one of those was The China Study, which I was floored to read.
And then I literally consumed every book, documentary, and paper on the topic. I started to network with folks at national meetings and was just floored at the world that was opening up before my eyes.
How did a plant-based diet impact your own health?
Within six months of taking the plunge myself, I’d lost 35 pounds. I redid my life insurance physical and got a rebate check in the mail from them, believe it or not.
What happened to your clinical practice?
I started really pushing lifestyle changes hard on my patients. I had always paid it lip service, meaning, you know I said to my patients, “Hey, you should change your lifestyle,” and never really did more. Then I really started doing it with my patients. At the same time, I started doing a program called “Walk with a Doc,” where we would sort of use exercise as medicine with our patients.
I started that in Colorado, this will be our tenth year come May. That was an amazing program where I got to see how using exercise as medicine really made major effects. Of course, it didn’t make sense to do just exercise, you had to do exercise and diet and other lifestyle components.
I really revved up every category I could, all different aspects. That’s really what gave some amazing work for my patients and then also for me personally, it was probably the most rewarding time I’d experienced in medicine because you really could fix the root cause of a problem.
What kinds of changes did you start to see in your patients?
For the first time ever, when I got a patient to really bite onto this (no pun intended), I saw disease reversal. I saw diabetes go away, I saw blood pressure normalize, I saw people lose 25-30 pounds in a few months – pretty major things. If you had asked me during my training if there was such a thing as coronary disease reversal, I would have told you, “No.” I think it’s definitely possible now. There’s really good data, it’s just not really discussed often in medical school.
Why is this not discussed in medical school?
I think it’s a variety of factors. First, I think that eons ago it probably was, especially when there weren’t so many pharmaceuticals and procedures to use. Then I think these days in some ways the procedural device industry, the pharmaceutical device industry, they do a lot to underwrite the training that we partake of in school. I think that people get used to the idea that there’s a pill or a procedure for whatever ails you.
And of course, there’s a lot more money in putting in stents, or the latest valve, or using the latest injectable medicine then there is in day-to-day lifestyle changes. Which is sexier? Peas and carrots or the latest minimally invasive valve surgery?
Have you personally experienced any pushback from the medical industry?
No. I’m sure I’m on somebody’s hate list but by and large nobody’s really bothered me. I think to them, I’m small potatoes. I think that the movement is growing so rapidly that they’re starting to really feel it. When my colleagues and I started first doing this, I got sort of chided at work. They’d say funny things, for instance, if there was a meeting they’d say, “Well, Dr. Freeman has to approve this menu.”
But I think by and large they’ve realized, (A) It works. When you see asthma get better, or people who are so sick they need a heart transplant or a lung transplant get better, it’s really hard to argue with that. Then I also think that people have realized, especially administration, that people are seeking them out for this type of care, which to them means dollars, and I think they realized there’s something to it. Further, it’s helped me carve a professional niche which I never thought I’d have.
The Ornish Lifestyle Medicine Program, a 9-week program developed by Dr. Dean Ornish that you’ve implemented at two Denver hospitals, is not an entirely vegan program. How important is it to be vegan versus eating a plant-based but not entirely vegan Mediterranean diet?
There’s never been a head-to-head comparison of a Mediterranean diet versus the whole food plant-based diet. So, the exact answer to that is tricky to sort out. Further, the American Mediterranean diet is a little bit out of sorts – meaning the vast majority of people who follow the American Mediterranean diet are eating loads of feta cheese and lamb.
The real Mediterranean diet from the Mediterranean region is predominantly plant-based, so that’s an important distinction.
The Ornish program does have a very small amount of egg whites or non-fat cheese, but there is a completely vegan option. In fact, the people who run the program that I oversee are completely vegan and don’t recommend any of that. But the participants are free to choose from that, but it’s literally tiny, tiny amounts.
What I would say is that I try to get all of my patients to go all the way because I see some of those foods as “gateway drugs.” “Y’know oh, I only eat this once in awhile, I only eat that once in awhile,” and before long every day is the “once in awhile.” I try to get people to go all the way.
The analogy I make is that cyanide is still cyanide even if it’s only a pinch or a pound. But if somebody says to me, “Look, I can’t go all the way, I need to have the occasional egg white,” I say, “Fine, you do that, that’ll probably help you enormously compared to the standard American diet, but if you want to see maximum improvement, consider going all the way.”
What does science say about a vegan whole food plant-based diet?
If you look at the studies that were done for coronary disease reversal they were fully plant-based, so there’s plenty of evidence to suggest that. The question is if somebody incorporates a small amount of some sort of animal product, what is that effect? I don’t know the answer to that. But I would tell you that the evidence would suggest that avoiding it altogether from both cancer and cardiovascular disease risk is very strong.
There’s never been a head to head trial between Mediterranean and vegan wholefood plant-based. Remember that a Mediterranean diet followed the traditional way is a million times better than the standard American diet.
What is it about a plant-based diet that’s so powerful in reversing these so-called Western lifestyle diseases? Which conditions are most likely to be impacted?
I think there’s probably no limit. The way I see it is the common endpoint for virtually every disease is inflammation, be it asthma, coronary disease, even cancer many times starts with chronic inflammation. So, the question is what can you do to put your body into a fully anti-inflammatory environment?
The answer to that is multiple, but one of the key pillars of that is a whole food low-fat plant-based diet which by its very nature is highly anti-inflammatory.
Combining that with regular exercise, connection and support, and love with others – i.e., getting rid of mental inflammation – that seems to be where the best outcomes come from. I tell people to basically exercise more, eat mostly plants, stress less and love more. So, connection, support, love, stress relief, all of them sort of go together.
Are there key plant-based superfoods that are essential to eat?
In general, I tell people to be leery of superfoods. Every day there’s a new superfood – acai berries, kale, spinach. What I tell people to do is, “First, you don’t need to eat acai berries that are imported from remote mountainous regions.” Really, what you have to do is eat a variety of fruits and vegetables, eat the rainbow, eat what’s in season, freeze things when they’re in season and eat them as fresh frozen, but there’s no major superfood.
Eating greens of some sort in my mind is a superfood but it doesn’t have to be a fancy superfood, it could be spinach or kale or mustard greens, or whatever people are into.
Why are you telling people to be leery of superfoods?
A lot of the “superfoods” that are plant-based, they’re truly wonderfully good foods, but superfoods don’t change. It’s not like one year a superfood is acai and the next year it’s kale, right? Nature has provided for people to have “superfoods” very conveniently and easily that grow readily all over the place. Eating plant-based foods in the varieties that I recommend people do, that’s superfoods.
They don’t need to spend a thousand dollars on fresh acai berries, etc., there’s no need. If they’re in season and you happen to be where they grow, well, load up, sure. But I’m not sure you need to do much more than that.
If someone is eating very poorly and just starting to transition to a plant-based diet, which foods are most essential to eliminate first?
I tell people that most human beings really function much better with the all-or-nothing approach which is why diets like Atkins and keto and others are so successful. In short, what I try to get people to realize is it’s much easier to cut everything bad out at once than it is to cut out things piecemeal.
That “once in awhile” syndrome applies to a lot of things in life, and people do a lot better if they cut it all out because otherwise, they maintain their cravings and they end up never really kicking the bad habit.
That being said, are there particularly egregious foods? Processed red meats and red meats are probably those that are the worst. In general, dairy’s up there along with pretty much all of the animal products, to tell you the truth.
There are some people who say, “I can’t do that, I won’t do that.” Then I try to get them to go with a couple of options. One of them is “vegan before 6 p.m.,” there’s a famous chef who put out a book about that (Mark Bittman’s “VB6: Eat Vegan Before 6 to Lose Weight and Restore Your Health … For Good”). That way they don’t any animal products until dinner and they eat a small amount of sensible portions.
Or I get people to eat fish or chicken, ideally one meal per week at the most and see how they do. And then there’s people who say they can’t even do that, so we do something else. Look, I’ve got to meet people where they are. But if people want to see the most rapid success of all, they’ve got to challenge themselves to make these bigger changes.
How do you feel about oils?
I usually recommend low-fat eating which means using only those oils backed by evidence of potential benefit in small amounts such as olive, canola, and sunflower. It’s very easy to overdo it, so only a very small amount if any should be used. Sauteing and such should be done with broth whenever possible.
Have you had any patients that haven’t responded positively to a plant-based diet?
Yes, but typically they’re either not doing it all the way, they’re not really following a whole food plant-based diet, or, it’s not just diet, it’s also exercise, too. A lot of times if you eat really well most people lose weight pretty quickly, but there are people who don’t. If you’re sitting around on the couch all day eating mostly plants, that doesn’t always jive really well, either.
How do you feel about supplements?
I usually tell folks to avoid them unless they’re deficient or they’re not eating well. By and large, supplements make urine very expensive, most of the excess is not absorbed. Many of these supplements are extremely expensive and there’s really very little data. Vegan B12 needs to be supplemented or you need to consume nutritional yeast. Some people if they’re worried that they’re not getting enough ALAs or “fish oils” can consume an algal-based (vegan) fish oil.
In Colorado, it’s easy enough in the wintertime when you’re all bundled up to become vitamin D deficient, but by and large, I really don’t recommend supplements unless somebody is deficient.
Do you recommend testing for nutritional deficiencies?
I usually check B12 in most of my patients and vitamin D also. There’s not a great test for omegas (omega-3 and omega-6 essential fatty acids). I usually ask people to add ground flaxseed or walnuts or something like that, so they get those ALAs and so forth in their diet. If you eat oatmeal in the morning put a chopped-up walnut in there or some ground flaxseed and that usually covers it.
Do you have an underlying philosophy about nature and diet?
By and large, unless you live some place that doesn’t have plant-based food sources regularly like Siberia, unless you live in those places you really can eat a lot better than we do, provided people are willing to do that. You would be floored to see how poorly people eat when they have access to really healthful foods. I would say that yes, nature does provide.
The reason that fruits and vegetables are so vivid and brightly colored is that they’re loaded with antioxidants, and so that they’re attractive to us. That’s why the produce sections are there when you first walk into a grocery store rather than the meat section, which would make many people feel ill and leave probably.
What kinds of pressures are making it hard for folks to eat healthily?
The food industry, similar to the way some of the pharmaceutical industry operates, is aiming to create consumer confusion. Every day, every year, we see a study saying, “This is good for you, this is bad for you,” and what happens is that the public sees it and they throw up their hands and say, “You know what? I have no idea and I don’t care.” And that’s exactly the strategy, and a very effective one, that “Big Food” has taken on. And all I can say is that the effort that we can put in to reduce this confusion that’s generated, by having folks that are knowledgeable in nutrition make changes is really what we’re after.