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Monday, October 29, 2018

Serious Cardiac Disease and a Hopeful Path out of it

Life Threatening Information
It is NOT every day that you get significant information that can threaten and change your life. I recently experienced that remarkable event. I am writing about it for these reasons:
1.      Retention. I retain information much better if I process it, and I process information best when I write.
2.      Motivation. I want this information to change my behavior in a significant way. Writing it down gives me added incentive to make this change.
3.      Sharing. I found this information to be VERY important to my life and well being, and I am hopeful I can find a way to share it with those I love. Because of the nature of this information the sharing is not always accepted with an open mind – bear with me and you will see what I mean!
The challenge is to how share this in a way that will be persuasive for myself and anyone else. To that end, the information is here in two forms: a short summary, and a detailed account. Please read at least the first two pages. If you got this far and read no further, at least look at this short summary of the key book that documents how to reverse heart disease:

Short Summary

1.      I Have a Life Threatening Illness. On 7/9/2018, I discovered that I have a life threatening illness – heart disease – and I have had this illness for a couple of decades. I had 3 arteries with serious blockage: 80%, 95%, 99%, and two more with bad blockage – 40%. If I did nothing, this would kill me in fairly short order. To that point in life, I have never had a symptom of any problem with my heart. I think my exercise routine saved me from more serious problems.
2.      Surgical Intervention. On 8/15/2018 I had a surgical intervention. Three stents were placed in the worst arteries. That bought me some time. But those wondrous little metal gadgets are not a cure – they are temporary relief, at best. And they were not without serious cost – financial and risk related.
3.      Cure for This Illness. On 9/7/2018, I discovered that a cure exists for this illness. It is a cure, not a palliative, not a “it won’t get any worse.” It is a cure. I decided at that point to undertake this cure. Since 9/11/2018 I have been following that regime.
4.      The Cure is NOT Complicated. It is a simple plant based diet with a few rules.
a.      Eat no animal products – NONE. No meat, no fish, no eggs, no dairy, no cheese.
b.      Use no oil, no olive oil, no canola. NONE. This is the toughest rule.
c.      No coconut, no avocado.
d.      Eat only plant based food: fruits and vegetables, green leafy are best.
e.      Eat only whole grains – whole wheat, brown rice, oatmeal, flax, etc. No white flour, no refined sugar, not high glucose, etc.
f.       Eat soy products with caution, low fat, “light” tofu.
g.      Eat no nuts – another tough one that needs some explanation.
h.   Eat NO processed food - you can tell what they are by the labels. Whole Food.
i.       Eat as much as you want within these rules.
5.      The Cure is NOT Easy. This diet is simple, but difficult to follow. Our world has very little supportive framework for a plant based diet. The bias in marketing and food products is somewhat healthier than in the past, but meat, eggs, milk and processed foods are the norm. Eating out or eating with friends is the most problematic part.
6.      The Cure is Worth It. Some friends have shared that they wonder if life is worth living with all of these dietary restrictions. To me, life is worth living – and I would pay any price to continue it versus dying – especially if that price is not expensive in dollars, and promises to improve the quality of life in every other way, by eliminating some or all of these illnesses:
a.      Heart Disease. I have it, and I want to get rid of it.
b.      Cancer. I may or may not actually have it, but I want to prevent it as much as is possible.
c.      Alzheimer’s. Same comment – I may be on that path already, and although there does not seem to be a way to cure it, I think this diet will further defer the onset.
d.      Kidney Stones. I have them in spades, and I am hopeful this will help that problem. The evidence is weaker on this one, but I have hope, and it costs me very little added effort.
(Update 2021 - I stopped making kidney stones for 2 years on this diet - and then started cheating with peanut butter and some nuts - and the stones began to appear again.)
7.      This Diet Was Discovered in 1939. The first MD that seems to have discovered this was Dr. Walter Kempner, who came up with what he called "The Rice Diet," in 1939. He was curing life threatening illnesses back before we had any medications or procedures for them. It's a good tale which you can read here: https://www.drmcdougall.com/2013/12/31/walter-kempner-md-founder-of-the-rice-diet/.
8.      This diet is founded on solid scientific research. The very best information about this diet is in a couple of books. You can buy them at Amazon for about $10 each, used. I got digital copies from the library for free – and you can too. Think of the return on that investment!
b.      The China Study, 2005, by T. Colin Campbell, PhD.
c.    How Not To Die, 2015, by Michael Greger M.D. and Gene Stone. 

The China Study cited above is an extraordinary collection of population and diet research. If you find the book a bit much - click here to get a PDF summary of the whole study.
Or, try these videos. They are a tad long, but hey, adding 10 or 20 years to your life is worth a few minutes, right?
  1. How Not To Die, This is Dr. Greger giving, a synopsis of the book. At least watch a few minutes. He shows how this diet counters the major things that kill us.
    This one is similar but a lot more fun:
     https://nutritionfacts.org/video/uprooting-the-leading-causes-of-death/
  2. Dr. McDougal - Why Doctors do not recommend vegan diet. Scary - but gets your attention.
  3. Esselstyn Ted Talk. Short - but to the point.
The first author, Dr. Esselstyn, is a general surgeon, who has treated many patients who have successfully reduced and resolved late stages of heart disease by following a plant based diet. The second author, T. Colin Campbell, describes several of his studies about the impact of diet on many diseases, including heart disease. The second book also contains a great deal of information about similar studies. It also attempts to explain why the general public and most physicians and scientists appear to be opposed to this conclusion. The third book, by Dr. Michael Greger, is a remarkable collection of highly detailed research. It is amazing how much is known about diet and various plants and ingredients. If you want very detailed information, start with this one.
This article cited here is a more extensive evaluation, published in a medical journal. You might find that more persuasive. It is a PDF which will download when you click on it:  http://dresselstyn.com/JFP_06307_Article1.pdf.

9.      The research is bit complicated and is often contradicted and criticized in the media.
Dr. Campbell explains this at length, but the simple story is that between the food industry and big pharma, it is very difficult for scientific researchers to step outside of the prevailing view that meat and dairy are healthy foods. The food industry has also funded studies and publicity campaigns that obfuscates the basics of this research. The best research addresses the full human being and our complete diet, while studies focused on small groups and individual nutrients have many flaws. Another major factor is that most physicians seem to believe that no one will actually undertake a diet that is this difficult, so it is wiser to counsel a middle path of moderation.

Bottom Line
Get the books and read them. Or, read on here a bit for a personalized insight into this.
As an updated shortcut, please watch this video by Dr. Esselstyn. It will give you 90% of his, and the scientific basis for it. https://youtu.be/ZC3wRx4vV7g?si=IVv0oxpjbpavnLlG

For my personal bottom line, as of February 2022, my cardiac stress test results are NORMAL. YOU can do this too!

Long Details

I Have a Life Threatening Illness.
At this point in my life, I have done everything I can think of to avoid heart disease. My mother died at 51 of a heart attack, and my father died at 69 from the same problem. My paternal grandfather died young – I think from a heart attack. Cancer, kidney stones and old age accounted for the other three grandparents. Both of my brothers have had heart disease. 

In 1979 at the age of 40, I started a pretty decent exercise program. I have had back problems since 1972, so I had been lifting weights of some form every other day to try to strengthen my back. I had also played racquetball for a few years, but I had never done real aerobic exercise. So I started running – slowly! I remember that first day. I got up at 6:00 am – I always exercise at 6:00 am – laced up my sneakers and went out the door to run around the block. Our block was a circle about a quarter of a mile. I got less than 2 blocks away, and I could not breathe. I had to sit on the curb until I recovered. I walked the rest of the way around. The next time, I went half the distance around, etc. My running can only be described as a “slow jog.” One of my neighbors also ran, and he would always go by me like I was standing still.

I finally got up to 5K, about 3 miles, which I did in about 30 minutes. Not speedy, but not bad. I ran every other day, through the park, rain or snow, wind or hail, without fail. I ran when we were vacationing, on business trips – I always ran. On the off days, I would lift weights for about 20 minutes. After about 15 years, or age 55 or so, my left knee started bothering me, so I tried to switch to swimming. I found that a lot of work, and very boring. In the winter in MN, getting up at 6:00 am, driving to a pool and swimming for half an hour is tough to do. So I took up the bicycle – outdoors on nice days, and in the basement on a stationary bike for winter and inclement weather. I biked at least 30 minutes, every other day, or about 100 minutes per week, on average. I never actually enjoyed the indoor biking, but I would read a good novel, or listen to an interesting podcast. I think that exercise kept my weight, blood pressure, and cholesterol within normal bounds. I have never had a negative reading on any of those measures.

On 5/26/2018, over the Memorial Day weekend, we were at the lake with my son and family. I was laboring up the 5% grade from the lake carrying some stuff. I was panting when I got to the top – it’s called “labored breathing,” I had been having that problem for a few years walking up that grade, so I thought nothing of it. I am “getting old.” My son, a physician, happened to be walking with me, and he asked me if that happened often. I said, no – just coming up this hill. He suggested that I get a stress test. What’s a stress test?

About a week later, on 6/5/1028, at the end of my regular annual checkup, I mentioned to my physician that my son noticed my labored breathing while climbing the hill, and he suggested that I might get a stress test. My doctor thought that couldn’t hurt, and he scheduled the test.

The test was a simple walk on a treadmill on an incline, hooked up to an electrocardiogram, an injection of some dye or something, and a sonogram of the heart after all of this. I had no problem doing the stress test, and I figured I am home free. Later that evening, my physician called. I berated him for being in the office that late, and he apologized, and said he had a patient that required more than the normal time. He said he had the results of my stress test. They were “not terrible,” but “not great.” He had ordered two prescriptions which I should pick up and start taking immediately. One was a beta blocker, which would expand my blood vessels a bit, and the other was nitroglycerin. Nitroglycerin? What is that for? I said. He replied, that is for when you have a heart attack. WHEN? That got my attention.

Long and short of it, I visited with a cardiologist who scheduled a more complicated heart test: a CT coronary angiogram. Based on the results of that, he scheduled a stent procedure. On 8/15/2018, at the age of 79, I had three stents placed in my coronary arteries. The exam showed that I had arteries blocked at 99%, 95%, 80%, and two at 40%. The surgeon and my cardiologist consulted during the procedure, because normally, with that many blocks, a bypass procedure is preferred. They decided to go ahead with the stents, since I was not diabetic, and none of the serious blocks were at the sharp corners. Stent procedures have more risk for patients than bypass procedures because of the potential for knocking loose a bit of plaque, and causing a stroke or heart attack. Stents also tend to block up again, while bypasses stay open longer. I have thanked him many times for that decision.

I have serious heart disease, but I did not have a heart attack. I think my exercise routine created sufficient peripheral blood flow around those blocked arteries to keep me symptom free. I have been building up plaque in there for decades!

Future Prospects
My cardiologist put me on a blood thinner for the stents – that was to last about a year. He also put me on a beta blocker to increase the arterial size, and a statin – to reduce my cholesterol. My cholesterol has NEVER been a problem in the past, but lowering it further should not do any harm. It is my plan to stop all of these medications as soon as my doctors agree. 2022.06 - I am only on a low dose aspirin. 2024 I have stopped the aspirin - no need for it and it is somewhat risky.

I did a little research on how to prevent this from reoccurring. My cardiologist was very clear – adopt the Mediterranean diet. That study is quite well known: eat less red meat, more fruits and vegetables, good oils like olive oil and canola, and some red wine on occasion. It is interesting to me in retrospect that this famous diet is one that deals with the whole person, the whole diet, and a long term study of effects. It does not identify the mechanism that provides improved health outcomes. That is also a frequent criticism of the diet I finally adopted.

In the course of this research I interviewed two friends who had similar heart problems, and both had adopted a very different diet plan – a “plant based diet”. Both of them adopted a full vegan diet, but one opted for a more severe program, based on the studies documented in two books. As I looked at the data, it appeared to me that simply eating less red meat was not really going to improve things. People with my advanced state of heart disease tend to have another attack in a few years, since they have done very little to solve the problem. It appeared that a true, plant-based diet could actually remove the plaque from my arteries.

My most serious problem is my hereditary propensity for this disease. A few of us a blessed in that we can eat meat and other fatty foods and not experience any problem. That is clearly not the case for me, and for most of our population.

Diet Sources
Dr. DeanOrnish was one of the first modern MDs to indicate that diet may have an effect on reducing heart disease. In the early 90s he came up with a diet, based on fruits, vegetables and grains. This is a low fat, vegetarian diet. You can learn more about it here: https://www.everydayhealth.com/diet-and-nutrition/the-ornish-diet.aspx. The book is here: Dr. Dean Ornish's Program for Reversing Heart Disease (1990). 

This book is a fascinating insight into how the author came to understand the impact of diet on many diseases. I highly recommend it. The first part is a narrative of the author’s experiences in the Philippines with cancer and diet, and then how the China study came to be. In summary, this study of the Chinese diet accumulated thousands of data elements that clearly indicate that diseases such as cancer, heart disease and diabetes are very closely tied to diet. The book also cites many other studies, including those of Dr. Esselstyn – which see below. The latter half of the book is an examination of the food and drug industry, and some attempt to explain why these basic facts of the impact of what we eat on our health are so poorly regarded in our society.

This book sets out the detailed research of Dr. Esselstyn that persuaded him that a plant based diet can actually reverse heart disease. I have summarized the most important parts of the book here so that I do not forget what I learned from it. There is an excellent summary here as well:
http://www.dresselstyn.com/site/books/prevent-reverse/about-the-book/

Dr. Esselstyn is a general surgeon at the Cleveland Clinic. He was doing general research on the causes of breast cancer, and found some interesting information that seemed to point to diet as a critical factor. He found several countries where women have much lower rates of breast cancer than anywhere else. One country was Kenya. He began researching the effects of diet on cancer, and then heart disease. He also had a good friend, an MD, who was in the late stages of serious heart disease. He recommended this diet to him. The diet relieved his angina pain symptoms in a month, and in 3 years, all evidence of his heart disease had vanished. 

For the next step,  he asked other doctors the Cleveland clinic to refer to him their patients that had been treated for coronary artery disease, and were considered incurable. This article describes that: 
A Way to Reverse CAD? Journal of Family Medicine, July 2014, Vol. 63, #7.
This study is more recent and much larger than the one described in the book. 
This is my brief summary of that article.

From the Harvard Heart Letter October 2014:
In 2014 Dr. Esselstyn published a study in The Journal of Family Practice about his experience with a plant based diet with people with severe cardiovascular disease. The study, which included 198 people with documented cardiovascular disease, found that 177 were able to stick to the diet for an average of almost four years. During that time, only one person had an event (a stroke) that was deemed a recurrence of the disease. In contrast, 13 of the 21 people who didn't stick to the diet experienced a cardiovascular event.
All of these patients were referred by cardiologists at the Cleveland Clinic because they were not able to do any more for them. All of them were on medications to reduce their cholesterol. Some of the patients on the diet experienced relief of angina pain after just 3 weeks. The following is from the introduction to the book - it is a long quote so I would not forget - and so you might understand the message.
---------------------------
The following quote is the introduction to the 2007 book verbatim. It is a concise summary of the very first study. Remember, this was 1985!

THIS BOOK HAS ITS ORIGINS in the dramatic experiences of twenty-three men and one woman who came to me in despair and without hope some twenty years ago. At the time, I was a surgeon at the renowned Cleveland Clinic. Year in and year out, the clinic is widely recognized as the number one heart center in the world. And indeed, there is no way to exaggerate the remarkable innovations and feats of surgical wonder that my colleagues have been able to introduce into the world of medicine.
But a surgeon has only so many tools to use against a lethal disease, and in the case of the patients to whom this book is dedicated, the clinic’s physicians had found themselves in the position of having to say that there was nothing more they could do.
This is always the hardest moment both for the patient and the physician—the time when, in effect, a death sentence has been rendered. And that was the position the majority of these patients found themselves in back in 1985. They were, it must be acknowledged, a sorry lot by the time they arrived in my office—sorry in terms of both their physical health and their spirits.
Most demoralizing for those who had been the beneficiaries of the clinic’s surgical interventions was the recognition that so much that had been done to save them—repeated open heart surgery, angioplasties aplenty, stents, and a host of medications—seemed no longer to have any useful effect. Almost all the men had lost their sexual potency. Most had chest pains, the terrifying condition known as angina. For some, it was so agonizing that they couldn’t lie down and had to sleep sitting up. Only a few could take long walks, and some couldn’t even cross a room without excruciating pain. The fact is that some were walking dead men.
It was, no doubt, because they had completely run out of options that they agreed to the demanding conditions I set for entry into the trial cure that I had come to believe in.
What they had to give up, I explained, would not be easy for any American accustomed to a diet flush with deep-fried fast foods, thick steaks, and rich dairy products. But if they were prepared to join me in a diet not unlike the one followed by two-thirds of the world’s population, I held out the likelihood that we could overturn the death sentences that had been delivered to them by their physicians. In the process, we could demonstrate that the leading killer of Americans, heart disease, was a paper tiger that could be defeated—and without the use of a surgeon’s knife.
By now, most everyone is generally aware that what you eat has something to do with whether or not you will develop heart disease. Back when my study began, this wasn’t at all established. But also out of a personal sense of threat—everyone in my family had died early—I had begun looking for some alternative fate and had come up with the idea of low-fat, plant-based nutrition. On the West Coast, unbeknownst to me, Dean Cornish had started down the same path with several earlier published studies showing the benefits of lifestyle change. There we were, on opposite sides of the continent, not knowing nor having heard of each other at the time.
Almost all of those who came to me, who had been told there was little hope, today—twenty years later—are alive, their arterial diseases receded. They stand as living proof of what is possible for you and anyone else who chooses to do what is necessary to become heart-attack-proof. And they gave me the invaluable gift of confidence as I went on to counsel and treat hundreds of additional patients.
This book is dedicated to those original patients—to the adventure we had together, pioneering this experiment in the treatment of coronary heart disease, and to the way they picked up their lives and found, in the course of pursuing an alternative diet and lifestyle, a resumption of the joy of living. It offers a simple, basic hopeful way for you to navigate your way into a long and rewarding life. Let me tell you the story of my patients, of our research, and of what we have learned.
(Esselstyn Jr. M.D., Caldwell B.. Prevent and Reverse Heart Disease: The Revolutionary, Scientifically Proven, Nutrition-Based Cure . Penguin Publishing Group. Kindle Edition.)
------------------------

Criticisms of the Diet
The major criticism of the study is that it did not randomly assign individuals to the control group. The ones who completed the study were clearly very committed, and the ones who dropped out, clearly not.

Another criticism is that there is no way to identify the operative factors that actually work to reduce heart disease. Dr. Esselstyn says that it is better to study the whole diet and the whole human being, than trying to control for all of the components. He is convinced from other research that it is the reduction in fatty acids that provides the most benefit.

Mechanism
The fatty oil acids damage the endothelium, the lining of the arteries. It becomes inflamed, damaged, and plaque builds up around the damaged parts. Reducing the intake of the fatty acids to a very small amount allows the body’s repair mechanism to remove the plaque and restore the lining. If a “normal” amount of fatty acids continues to enter the bloodstream, or even a diminished amount, as with the Mediterranean diet, the body does not have sufficient resources to actually remove any plaque. But if the volume of fatty acids is small enough, it is able to remove plaque and prevent new plaque from forming.

From the Esselstyn Book: 
Brachial Artery Diameter and Fats – P 40
Dr. Robert Vogel, of the University of Maryland School of Medicine in Baltimore, has conducted some astonishing studies that demonstrate, among other things, what a toxic effect a single meal can have on the endothelium. Dr. Vogel used ultrasound to measure the diameters of the brachial arteries of a group of students. Then he inflated blood pressure cuffs on the students’ arms, stopping blood flow to their forearms for five minutes. After deflating the cuffs, he used the ultrasound to see how fast the arteries sprang back to their normal condition.
One group of students then ate a fast-food breakfast that contained 900 calories and 50 grams of fat. A second group ate 900-calorie breakfasts containing no fat at all. After they ate, Dr. Vogel again constricted their brachial arteries for five minutes and watched to see the result. It was dramatic. Among those who consumed no fat, there was simply no problem: their arteries bounced back to normal just as they had in the pre-breakfast test. But the arteries of those who had eaten the fat-laden fast food took far longer to respond.
Why? The answer lies in the effect of fat on the endothelium’s ability to produce nitric oxide. Dr. Vogel closely monitored endothelial function of subjects and found that two hours after eating a fatty meal there was a significant drop. It took nearly six hours for endothelial function to get back to normal.
If a single meal can have such an impact on vascular health, imagine the damage done by three meals a day, seven days a week, 365 days a year—for decades.

Nitric Oxide p 42
Nitric oxide is absolutely essential to vascular health—a finding that won the Nobel Prize for Medicine in 1998. It relaxes blood vessels, selectively boosting blood flow to the organs that need it. It prevents white blood cells and platelets from becoming sticky, and thus starting the buildup of vascular plaque. It keeps the smooth muscle cells of arteries from growing into plaques. It may even help to diminish vascular plaques once they are in place. To understand how plant-based nutrition facilitates nitric oxide production, you need to have a sense of the biochemistry at play. The essential building block for nitric oxide production is a substance called L-arginine, an amino acid that is in rich supply in a variety of plant foods, especially legumes, beans, soy, and nuts. Figure 6 shows, schematically, how L-arginine fits neatly into the enzymatic action of nitric oxide synthase, which then produces nitric oxide from the arginine and oxygen.
P. 42 However, as you can also see in Figure 6, there is a competitor for nitric oxide synthase: asymmetric dimethyl arginine, or ADMA, which is manufactured by our bodies in the course of normal protein metabolism. When we have too much ADMA, then L-arginine is edged out for a position in nitric oxide synthase, and the production of nitric oxide fails. There is another delicate enzyme with a formidable name—dimethyl arginine dimethyl amino hydrolase, or DDAH—that destroys ADMA, in order to favor production of nitric oxide. But the usual cardiovascular risk factors (high cholesterol, high triglycerides, high homocysteine, insulin resistance, hypertension, and tobacco use) all impair the ability of that delicate enzyme to destroy ADMA.



Esselstyn Jr. M.D., Caldwell B.. Prevent and Reverse Heart Disease: The Revolutionary, Scientifically Proven, Nutrition-Based Cure (p. 39). Penguin Publishing Group. Kindle Edition.

OIL and NUTS
ALL oils are excluded, because oils are simply highly concentrated fats.
ALL nuts are excluded for patients with actual heart disease, because they contain high levels of fats, and the diet works much better to remove plaque when the fatty acid level is lowest.
For more confirmation on the impact of nuts, watch this video below, and look at this research. IF you have a clean set of arteries, there is NO question but that nuts will reduce your arterial elasticity - it makes arteries worse. The studies done that show beneficial results from nuts were done on folks with lousy arteries and diet already. So . . . NO NUTS.  See: https://youtu.be/zkC0-sXruM8
This is a clear demonstration of the impact of a small bit of nuts on the health of your arteries, especially if you are already on a plant based diet - it uses the Pulse Wave Velocity (PWV) test.

Mediterranean Diet
The best evidence on how diet affects people with heart disease comes from the Lyon Diet Heart Study, which found that a Mediterranean-style diet cut heart attacks and deaths by 70% compared with a traditional American Heart Association diet. The Mediterranean-style diet emphasized fish, poultry, vegetables, beans, olive oil, and nuts and included only minimal amounts of meat, butter, and cream.
https://news.harvard.edu/gazette/story/2017/05/much-of-life-is-beyond-our-control-but-dining-smartly-can-help-us-live-healthier-longer/
This article is a very critical analysis of the Mediterranean Diet. Just read it and see what you think.
https://www.jeffnovick.com/single-post/2013/03/27/The-Mediterranean-Diet-A-Closer-Look-The-PREDIMED-Study
This one is even more critical of the methods and results:
https://www.healthline.com/nutrition/5-studies-on-the-mediterranean-diet#section2
Bottom line - for the modest improvements shown following this so called "diet", I will opt instead for a full plant-based version.

But That Can't Work
When I bring up this strict plant based diet, everyone, including my cardiologist say things like: that will never work; be more moderate - do the Mediterranean Diet - it’s been proven to work. Or NOT! Here is at least one critical evaluation of that diet as compared to this one:
There were some modest benefits to the Mediterranean diet - but not much. And there was certainly no reversal of the disease. Dr. Esselstyn's diet cannot be directly compared, but it is a much more successful path by the numbers, even if it is very difficult to maintain.

For some scary facts on how early this problem starts, watch the video on this page. Heart disease starts in childhood!

Bottom Line - Carl’s Conclusion

I have a serious heart condition. I have been accumulating plaque from fatty acid for decades. The Mediterranean diet seems to work to reduce heart disease for a healthy population over a long time. But there is no evidence that the diet will arrest the progress of the disease in anyone with a serious heart condition. And there is not even a claim that it can reverse the process to improve the disease.

I believe that my odds of dying from this disease in the near term are quite high, unless I undertake this type of diet.

The diet is difficult, but not impossible. It requires a considerable amount of attention and work, but the return of 5 or more years of healthy life is clearly worth any investment. Eating is fun. Eating fat food is particularly enjoyable, but it consumes a very small part of any given day, and a very small part of life. I am perfectly willing to forego that pleasure to prolong my life - especially a healthy life. I am also hopeful that I will be able to benefit from the many people who have already set out on this path, and have developed wonderful recipes that make eating quite enjoyable again. I have no illusion that I am ever going to enjoy a piece of apple pie again, or a chocolate sundae, but I am quite sure I can live with that. (There is actually a chocolate offering by the Nekter Juice Bar people, but don't overdo it!)

The larger problem is how to manage while eating out with friends, or traveling. Salads are good but you have to pay attention to avoid the dressing with oil and the cheese that is liberally sprinkled about on the greens. I have found some salad dressings with no oil, which I bring along in a small container to help flavor the greens. Fruit is generally available, and is always safe. Bread is also a problem, but most places now offer whole wheat options. There may be some egg in the bread, but one slice is a small exposure.

Cholesterol goals - Esselstyn's cholesterol goals are below 150. The normal standard is less than 199. At the start of this my cholesterol was 166 and had been as high as 197. On 2018.08.15 it was at 109, with statis and before the diet!  My diet started in earnest 9/11/2018. I plan to update this regularly.  2024 My latest reading is 129!  YAY.

STATINS are dangerous.
This is a recent addition. I just stumbled on this research on the actual way statins work, or do not work, and the potential side effects. It is pretty amazing that anyone prescribes them any more, especially if a non medical alternative such as diet has the same or better effect. The article is here:
https://articles.mercola.com/sites/articles/archive/2019/06/02/a-statin-nation.aspx
I don't think much of the rest of this website - keto is an dangerous as any other crazy diet.
I found the article a tad confusing, so I did a brief summary:
https://drive.google.com/file/d/1FQpkw7w9cDTh7kuEvMCxtklOfYZP5_U-/view?usp=sharing

Dairy - Milk, cheese, are killing you
Here's another one that you might find interesting.
https://youtu.be/TJvrlwnEqbs
John McDougall MD discusses what dairy products have going for them. They are not a great source of nutrition.

Other Diseases

There are other studies which indicate that this type of diet can delay or prevent many other diseases which can cause severe debilitation as one ages: cancer, Alzheimer’s, high blood pressure, diabetes, kidney stones, gout. The exact mechanisms for each of these are not yet firmly identified, but there are sufficient indications to think that this is the case. The following is a summary of a few of those.

Diabetes
This one seems to be pretty well researched and established. See this article in the Journal of Geriatric Cardiology.
A Plant Based Diet for the Prevention and Treatment of Diabetes

Cancer - the casein component of milk has been shown to feed existing cancers. In animals, removing all casein from the diet arrests cancer development. Other cancer causing agents have also been shown to be much less problematic in a population that follows this diet.
This is probably the most hopeful on cancer research, even if one already has the illness. https://www.forksoverknives.com/science-says-about-diet-and-cancer/#gs.b666k0
https://nutriciously.com/casein-cancer-connection/
Research Shows That a Healthy Diet Will Slow or Stop Most Cancers
Kick Cancer with a Plant-Based Diet
https://nutritionfacts.org/video/how-not-to-die-from-cancer/ - probably the best summary.

For a different tack, there is some research that ADDING fruits and vegetables can fight cancer. This TED talk by Dr. William Li explains the details of the effect of various foods on blood vessels. Angiogenesis is tied to 70 different diseases: alzheimer's, arthritis, MS, cancer, etc.: https://youtu.be/OjkzfeJz66o It's a good talk. The diet portion is focused on what we can ADD to our diet. See this list: https://caloriebee.com/diets/Anti-angiogenic-Foods-What-They-Are-and-Why-Theyre-Crucial-to-Include-in-Your-Diet
And that may be enough for cancer - but not heart disease. Let's hear it for tomato sauce!!

For more on the science see this survey study here:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3184418/

Kidney Stones
I happen to be a chronic stone maker, and I had ALL 30 of my stones removed in 2018 before the stent procedure. I will let you know if any new ones develop!
2020.12.15 Update - I get a CAT Scan once a year to count my kidney stones. Since the last removal in 2018 - shortly after my stent procedure - I have NO new stones, and the few in there have NOT GROWN. I have cured my chronic kidney stones. AMEN! That alone is a reason to stay on the diet.

https://nutritionfacts.org/video/how-to-prevent-kidney-stones-with-diet/
The theory is that some stones are caused by the excess protein from meat. But if you are a chronic stone maker you should also pay attention to oxalate levels. On this diet, the oxalate levels in my urine doubled - which might increase my stones. The problem is that many of the foods I have been emphasizing are high in oxalate. At a minimum, I plan to reduce those that are very high, which narrows my dietary choices somewhat. 

Recently, 6/2019, Dr. Michael Greger published a video summarizing a lot of research on kidney stones and oxalate. And the result is that the diet probably has very little to do with the genetic predisposition to form them. AND  . . . it is possible that the diet will in fact help.
https://nutritionfacts.org/video/oxalates-in-spinach-and-kidney-stones-should-we-be-concerned/
I will be back when I get my yearly scan for stones to let you know how this works out. 

MS - Multiple Sclerosis
This article explains why the McDougall research group is investing $750,000 in a study about multiple sclerosis. Worldwide, multiple sclerosis is common in Canada, the United States and northern Europe; and rare in Africa, Japan, and other Asian countries. Why?
https://www.forksoverknives.com/the-multiple-sclerosis-and-diet-saga/#gs.Bq4Esps
This is a description of an MD, Dr. Stancic, and her recovery from a very serious MS:
https://youtu.be/NM_YOiJ0Mks

Alzheimer's
Cited below is a lengthy article excerpted from the book: The Alzheimer's Solution. The authors are neurologists, and they believe that 90% of Alzheimer's victims can be greatly helped by means of a plant based diet. I have not read the book, but I did scan through some of the significant pages on Amazon. I think they are right, but they are a little bit cavalier about how strictly one must follow the diet to gain the benefits.
https://foodrevolution.org/blog/food-and-health/prevent-reverse-alzheimers/
This one talks about recent research on blood flow in the brain and Alzheimer's. That is a CLEAR connection to the dietary solution.
https://medicalxpress.com/news/2019-02-closer-alzheimer-therapy-brain-blood.html
https://www.nature.com/articles/s41593-018-0329-4 - the actual study.

This is from Forbes - basic research on how diet affects mental function:
Forbes: New Research Suggests That Food Really Does Affect How We Think

And one more: https://www.deseretnews.com/article/900047995/qanda-national-aging-expert-talks-about-how-to-avoid-developing-dementia-in-old-age.html

While you are on the Alzheimer's page, you may want to look at this article in the NIH database. It describes three case studies in Japan where patients with advanced Alzheimer's were cured with a regular daily teaspoon of turmeric.

Dr. Greger noted this in his latest book, How No To Age.  
This is a description of 3 anecdotal cases where individuals were CURED of dementia with nothing but turmeric. And as he said, what pharmaceutical company is going to spend the funds to do a formal study when the meds can be purchased in the local grocery store for almost nothing. In each of these cases, the subject was elderly, and each of them had quite advanced symptoms of dementia. 
The only medicine used was a teaspoon of turmeric per day - the spice from the grocery store. This is not circumin - that is an extract of turmeric and it appears to have no effect. Each showed almost immediate improvement, and were entirely recovered in a year.

Rheumatoid Arthritis and Autoimmune Diseases
This is not a formal medical study, but rather a description of 10 cases where this diet helped people with very serious rheumatoid arthritis. The theory is that every autoimmune disease can be helped in the same way. Read the summary here.
https://www.drmcdougall.com/2014/05/31/ten-cases-of-severe-mostly-rheumatoid-arthritis-cured-by-the-mcdougall-diet/
More detail on the study: https://www.drmcdougall.com/misc/2014nl/may/tencases.htm
This one is from the China Study team:
https://nutritionstudies.org/autoimmune-disease-genes-infection-environment-gut/

And a video with another study:
     https://nutritionfacts.org/video/why-do-plant-based-diets-help-rheumatoid-arthritis/

Fibromyalgia
I know this is starting to sound like a patent medicine universal cure all and panacea, but read this one to see the science behind this stuff.
https://nutritionfacts.org/2013/06/27/plant-based-diets-for-fibromyalgia/

Osteoporosis - calcium loss and bone fragility - cancer - leukemia - 
It appears that milk and dairy products are the primary sources of bone loss. It also gives you casein, the most powerful growth substance for cancer, etc. The industry says it is the other way around - but it is not. Here's a really scary video on milk
https://youtu.be/TJvrlwnEqbs

John McDougall MD discusses what dairy products have going for them. They are a great source of nutrition -- for getting fat and growing tumors! Dear lord - why do we give our children this stuff! It's worse than poison.

More Information
If this has gotten your attention, you should look at the primary website:

There are several other websites that are similar. Recipes are very helpful here. Two thirds of the Esselstyn book is actually recipes, and there is an accompanying book with even more.
A recipe source: https://www.plants-rule.com/.
For a simple example, you can make good pancakes, without milk and eggs! Use soy milk, a banana, and a bit of applesauce. They are great. And maple syrup, real maple syrup, is plant based. Amen! If the general public was ever really aware of this, we might actually see some decent restaurants that specialize in this diet - wouldn’t that be wonderful.

My Ethical Issue
My big concern here is that I know people who would benefit from this plant based diet enormously - friends and family with Alzheimer's, diabetes, a serious weight problem, MS, cancer, heart disease. I feel an ethical, personal responsibility to at least make them aware of this alternative "treatment" in some fashion. It is highly unlikely that their doctor will do it. I simply cannot just ignore that that this clear alternative exists, and not somehow try to make them aware of it. If you were faced with a disease which is clearly going to kill or incapacitate you - would you not like to be at least TOLD that there are alternative treatments that generally do work?!

These are not magical, mystical, crazy ideas - these are diet based treatments supported by myriads of medical professionals. They just happen to be contrary to the opinion of the vast majority of the food industry. So - what else is new?

People tell me - that diet is so difficult that no one will even consider it. That may be. It is one hell of a tough diet - but it is NOT impossible. Faced with death and disability, I opted for it - and you could to. Should you not at least have enough information to decide? My good friend Al made me aware of it years ago. I did not think it was crazy, but I did feel that I personally did not need to go THAT FAR. I was wrong. It took a serious coronary event for me to realize that. What will it take for you?
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Additional Information

As I read more about this diet, Google and the AI world in general keep offering me additional information. I started a supplemental page - but it's just easier and more available to put the additional information here. If you find something useful, compelling, interesting - and you have read this far - send it to me! My email is NOT impossible to figure out.
           Thanks.

Professional Research Journal Study
If you are an MD or a science type, you might find this research summary more satisfying.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4315380/
My only criticism of the article is that there is no indication how strictly the participants followed the diet in these studies. When people adhere to it strictly the results show much higher benefits - like 100%.

Kaiser Permanente Literature Survey 2013
This is an excellent 2013 summary of some of the research on diet based therapies, done by one of the largest medical provider in the U.S.: Kaiser Permanente.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3662288/#__sec4title
Dr. Esselstyn, Dr. Ornish and Dr. Campbell are mentioned, and the article cites at least 40 other studies.

The Abstract is worth reading:
The objective of this article is to present to physicians an update on plant-based diets. Concerns about the rising cost of health care are being voiced nationwide, even as unhealthy lifestyles are contributing to the spread of obesity, diabetes, and cardiovascular disease. For these reasons, physicians looking for cost-effective interventions to improve health outcomes are becoming more involved in helping their patients adopt healthier lifestyles. Healthy eating may be best achieved with a plant-based diet, which we define as a regimen that encourages whole, plant-based foods and discourages meats, dairy products, and eggs as well as all refined and processed foods. We present a case study as an example of the potential health benefits of such a diet. Research shows that plant-based diets are cost-effective, low-risk interventions that may lower body mass index, blood pressure, HbA1C, and cholesterol levels. They may also reduce the number of medications needed to treat chronic diseases and lower ischemic heart disease mortality rates. Physicians should consider recommending a plant-based diet to all their patients, especially those with high blood pressure, diabetes, cardiovascular disease, or obesity.
And here is a short summary of the key findings of the above study.
https://www.treehugger.com/health/5-remarkable-health-benefits-plant-based-diet.html

Forbes Magazine - How to Make the Transition
Here is a bit of advice on how to move to this kind of diet, from one of our most preeminent financial publishers.  https://www.forbes.com/sites/nomanazish/2018/11/30/how-to-smoothly-transition-to-a-plant-based-diet/#2fb42fb950dc
I was so persuaded that I jumped in feet first - you may need a more gentle transition - as long as you get there eventually!

Dr. Greg Feinsinger - How To Get Started
https://www.postindependent.com/news/local/doctors-tip-tips-for-converting-to-a-plant-based-diet-part-1/
He includes a discussion of the available videos and the impact of all of this on the planet. I think the planetary impact is positive, but the odds of getting a large number of people in the developed countries to eat this way are about zero. We have a better chance of banning all oil, gas and coal than changing our diet.

National Institute of Health Studies
This is a 2018 review of plant based diets and heart disease.  It mentions the practical need to reduce the impact of the diet - AND its effectiveness.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5971679/
“the diet design goals were to create patterns that would have the blood pressure lowering benefits of a vegetarian diet, yet contain enough animal products to make them palatable to non-vegetarians”.[  
This one is a review of the diet and its impact on cancer. It mentions The China Study.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3048091/
The magnitude of difference in cancer risk within China ranges by more than a factor of 10 across the 65 counties studied. Campbell and colleagues found that a group of diseases (notably cancers of the colon, lung, breast, brain, as well as leukemia, cardiovascular disease, diabetes) were all associated with a diet of nutritional extravagance – meaning a diet that was associated with higher levels of blood cholesterol and blood urea nitrogen. These risk markers were directly associated with the intake of milk, meat, eggs, dietary fat, and animal protein and inversely associated with dietary fiber and legumes.
Ornish Cardiac Rehabilitation Program
Dr. Ornish has developed a cardiac rehabilitation program based on the plant based diet. He has trained and developed a national network of providers who deliver this program, and he has persuaded several insurance providers to fully cover it as part of cardiac rehab. My personal cardiac rehab dietary session lasted 15 minutes, and consisted of "Follow the Mediterranean diet. Eat less red meat, more fruits and vegetables." Amen.
https://www.ornish.com/intensive-cardiac-rehab/

NYC City Hospitals and Bellevue Start Major Diet Related Therapy
Just to persuade you that this is not some crazy diet fad, here's another
Backed by this evidence, as well as advocacy from Brooklyn Borough President Eric Adams, NYC Health & Hospitals/Bellevue was motivated in November 2017 to develop the Plant-based Lifestyle Medicine Program, which offers patients with chronic diseases support services to transition to and stick with eating vegetarian. The public health system has invested $400,000 for the pilot program, which officially kicks off Jan. 16, 2019 with more than 300 patients.
You should note that they are only treating diabetes, obesity, high blood pressure, high cholesterol and heart disease. That is, of course, the primary focus of this dietary approach.
https://www.modernhealthcare.com/article/20190105/TRANSFORMATION03/190109969

Sugar as Toxin - Dr. Robert Lustig
I happened on this book, Fat Chance, by Dr. Robert Lustig, and found it very interesting from a "diet" perspective. Dr. Lustig is primarily concerned with obesity, and his book examines biology and research related to diet and obesity. I found it interesting for several reasons related to this diet.

The book is quite complex - full of science and research terms. I am sure most people will not finish reading it. It needs a brief summary. Fortunately, there are a couple of those available. For one, the author gave a TED talk that is pretty well done, and gets to the point much more quickly. You can find that here: https://youtu.be/gmC4Rm5cpOI. There is also a fine review of the book which briefly summarizes the major points, and also points out a few of the problems, which you can find here: https://thehealthsciencesacademy.org/book-reviews/fat-chance/.

What I found interesting was his research related to diet, and the real impact of sugar on our bodies.
  • Sugar is a toxin. You have to agree with him by the time you get to the end of the book. It is addictive, it manipulates all manner of biochemistry in us to get us to consume more and more.
  • Obesity is an illness in most people. It is not the lack of will power, or gluttony. Many of us have a genetic propensity to obesity, and the food industry has stacked the cards seriously so that we are all eating more and more sugar. He has a great empathy for people with this problem. It helped me have a bit more empathy for folk.
  • Glucose and sucrose are bad, but we handle them pretty well. Alcohol is really bad, but we manage to deal with it. Fructose is murder - ten times worse than alcohol in terms of the damage to the body. Watch the video above. 
  • Dieting is really hard work.  There are so many things in our food stream, in our air, in our environment, that maintaining any diet is extremely difficult for all of us. So . . . don't feel bad if you run at this more than once.
  • He pretty much discounts the Ornish diet because it does not control enough sugar and processed foods. He does not seem to be aware of the whole foods, plant based diet. Which I found kind of amazing since he has done so much research in the field. But  . . . 

A Book To Avoid
I was walking through Barnes and Noble and saw this book prominently displayed: The Plant Paradox, by By Dr. Steven Gundry. The title is interesting, and a quick scan seems to indicate that the author is privy to some detailed information about the dangers in some parts of the plant based diet. But a closer view shows that there is almost no foundation for the things he is espousing. A very critical review of the book was written by Dr. Campbell here: https://nutritionstudies.org/the-plant-paradox-by-steven-grundy-md-commentary/. Reading that makes one wonder why on earth Dr. Gundry published such a confusing and misleading book. This stuff is tough enough to learn about, without a mishmash of half truths thrown in.

AND another one to avoid
The book is The Big Fat Surprise: Why Butter, Meat and Cheese Belong in a Healthy Diet.
I really do not like throwing rocks at people who write books - it's a lot of work, and I have not managed to produce even one. But this book is extremely misleading in its claims. Fortunately, a couple of others have taken the book's author to task, so I can just refer you to them. The book's title is a pretty amazing claim, if you have read any of this research. See what you think.  The 1 star reviews at Amazon also have some pretty strong critiques.
This is a good critical review - it's a careful analysis of the first 5 chapters or so:
https://thescienceofnutrition.wordpress.com/2014/08/10/the-big-fat-surprise-a-critical-review-part-1/
Looks like it is pretty lousy science and fact checking. A few errors are understandable - this many looks to be intentional.

There is also an interesting exchange in Scientific American with this author. This might be a simpler read. The book author chose to criticize Dr. Dean Ornish's article in the magazine, and he responded. He was one of the first to really put this Plant Based diet on the map. Why she chose to attack in this way is not clear. Between this and the book, she put a lot of work into producing something that looks like it is intentionally misleading. Strange business!
https://www.scientificamerican.com/article/why-almost-everything-dean-ornish-says-about-nutrition-is-wrong/
The Wikipedia entry on her helps a bit. She is clearly being compensated for this stance by some portion of the meat and dairy industry. https://en.wikipedia.org/wiki/Nina_Teicholz Bit surprising that she hasn't figured out how to edit that entry.
AND, finally, Politico has the gory details. Her supporters are focused on changing the new dietary guidelines published by the US Government. Lobbyists all. Well, Thank you, Politico and the like.
https://www.politico.com/story/2015/10/the-money-behind-the-fight-over-healthy-eating-214517

OTHER DIETS
This is an excellent video by John McDougal, MD, about other types of diets: Adkins, low carb, etc.
https://youtu.be/kOfF_r2R8QM. You do NOT want to go the low carb route. Trust me on that.

ENOUGH. Way too long, way too much. I know that. But I really want you to think about this. Please! Thanks.

Education - an Investment in OUR Future

Our real estate taxes just rose precipitously - that's a big word for "a lot". We had three school board referendums that  passed at the last election. The third one passed by 16 votes. But, in my humble opinion, it is a good investment.

I also saw in the paper today that the governor of Tennessee has opted for tuition free schools for community colleges as a wise investment. And he is a conservative Republican. They have the first 2 years free for high school graduates, and 2 years for adults as well who want to continue their education. See: https://www.tennessean.com/story/news/education/2018/02/15/tennessee-reconnect-tuition-free-college/342665002/

"If we want to have jobs ready for Tennesseans, we have to make sure that Tennesseans are ready for jobs, and there is no smarter investment than increasing access to high-quality education," . . .
 http://money.cnn.com/2017/05/11/pf/college/tennessee-free-community-college/index.html

He's got that right. Fundamental economics 101 - the quality of the work force is key to attracting industries, creating opportunities, and growing our economy. New York state has adopted the same program - tuition free 2 year degrees.

I have been telling a story for years about my friend in Tanzania, Africa. We were visiting with him in 2000, sitting on his front porch. A young Maasai came up and started talking with him. My friend went inside and came out with some money, which he gave to the young man. I asked him what that was all about. He explained that this was the 2nd smartest kid in all of Tanzania. School is free, but he did not have enough money to get books and uniform, so my friend was helping him attend school. I have told that to people, and they say, "That was a nice thing to do". NICE THING TO DO! This is the 2nd smartest kid in this whole country. He comes from the second lowest status tribe, with the smallest opportunity to advance. Who knows what he can bring to the table for our future, who knows what he might discover, promote, create that would benefit all of us. How could we possibly not invest in his future.

We have the same thing every day in our world. We have immigrants who can hardly speak English. We have inner city kids whose parents may not be pushing them to get an education, who can probably never imagine even being able to afford the education. And some of these kids are the smartest ones among us. Our genetic progression is truly random - the genius ones, the creative ones, the ones with real grit, tend to show up randomly. It helps to have good parenting, it helps to grow up in a supportive community, to have good nutrition early on. But how can we possibly not search out the capable ones and make sure they can progress to their highest potential. That has to be the best investment we can all make in our future.

We figured this out decades ago with elementary, and then secondary education. That is not optional in our world - it is a basic requirement. That education gives you the basics to survive, and it helps us identify the potential in every one of us. If you have the potential beyond that point, then we should step up and make college free, if not mandatory!

I recently asked my friend what became of the second smartest kid. He replied:
"You are thinking of Lantang’amwaki Ndwati from an area some three hours north of us here. He went on to get straight A’s through secondary school and in Form five and Six. He expressed an interest in becoming a doctor so I contacted a doctor friend at Selian Lutheran Hospital in Arusha who was able to get him a scholarship to study medicine at KCMC Hospital in Moshi. To my embarrassment, he never showed up for the interview at KCMC and instead applied on his own to the University in Dar-es-Salaam in the school of Economics. He was accepted and got a masters from there and is now teaching Economics at Tumaini University in Arusha. I met him recently and found him happily married with children of his own."

My friend, a missionary priest, obviously figured that an MD would be the most useful thing in the world where he was at the time. The young man, however, decided that economics might present more opportunities and better fit his personal interests. I managed to get some advanced education through the good graces of many others, and at one point I would have also chosen economics over medicine. But that's a whole different story.

How can we not fund our own future by getting every potential PhD and MD that we have among us? These kids are like gold in the ground, waiting to be found and refined.

We had a friend who worked in China for many years. One of his friends was visiting here at the University of MN, a PhD geologist, doing research on the deep ocean vents in the Pacific Ocean. I don't see how the U of M is engaged in the Pacific, but I am glad they are. We befriended this professor, and brought him some used furniture as his student housing was sparsely furnished. We visited with him several times. His biggest concern was that his son would not be admitted to the graduate school of the prestigious university where he graduated, but would rather have to attend a lower rated school to obtain his PhD. In China, if you have the potential, they will fund your education to the highest level you can attain.

Here is an amazing tidbit, 6 European countries will give English speaking students free rides for tuition, no matter their country of origin: Norway, Finland, Sweden, Germany, Slovenia, France.
https://www.investopedia.com/articles/personal-finance/080616/6-countries-virtually-free-college-tuition.asp Let me clear on this - these countries will accept OUR brightest and best for free college education, and in English. (France only accepts EU citizens on this basis.) China will also let you pursue a degree in English, but it will cost you $3,000 a year. The best deals are reserved for those who study in Chinese.

Some schools charge registration fees, or nominal tuition. Here is the whole list: https://www.edvisors.com/plan-for-college/money-saving-tips/colleges-with-free-tuition/countries-with-free-tuition/
Those italicized are free to foreign students as well, usually in the local language:
Argentina, Austria, Brazil, Czech Republic, Denmark, Egypt, Finland, France, Germany, GreeceIceland, Kenya, Luxembourg, Malaysia, Mexico, Morocco, Norway, Panama, Poland, Scotland, Slovenia, Spain, Sweden, Turkey, Uruguay.

Other countries only offer free education to the very brightest, making it a competitive challenge to get an advanced degree: China, Russia,

WHY? Why do this free education thing? Here's one example:
"In the United States, the first free public institution of higher education, the Free Academy of the City of New York (today the City College of New York), was founded in 1847 with the aim of providing free education to the urban poor, immigrants and their children. Its graduates went on to receive 10 Nobel Prizes, more than at any other public university.[18]"
https://en.wikipedia.org/wiki/Free_education

https://www.insidehighered.com/news/2017/04/27/germany-sees-benefits-educating-international-students-free
The German population is rapidly aging, and these new graduates can remain for several years or longer on a work visa, and provide the country with a much needed boost to their workforce and younger population. Graduates who return home, bring with thema much a generally positive view of the country around the world. The largest percentage of foreign students in Germany come from China!

Are there negatives?  Yes - and it is worth paying attention to those. When public education is universal, the risk always is that the amount we spend on it will decline over time. Our current primary and secondary education systems are greatly stressed in some areas because people are not willing to pay enough to maintain good programs. Our universities could go the same way if the cost is totally a public burden, and people are resistant to paying more.

So - get out and vote! Look around - we really are all in this together.