It's definitely an impressive result, but at the same time it's easy for me to come up with some counter arguments.
First, it looks like Esselstyn recommends a diet of about 10-15% calories from fat. This will taste like cardboard, and as a result people will eat far fewer calories which will activate intermittent fasting/low calorie genes that are thought to be very effective vs heart disease and cancer.
Second, the study is on very shaky methodological ground. The participants are self-selected, not randomized, which instantly completely invalidates it as a tool for average people with heart disease. For obvious reasons there is no control group, and aside from the placebo effect the comparison of the adherent vs non-adherent groups is very misleading. Considering the willpower required to eat cardboard all day, it would not surprise me at all if the causality ran the other way: the people where the diet was failing got depressed or disgusted and hit the ice cream aisle.
Third, the Standard American Diet is just so so so so so fucking bad. Literally not a single thing the average American eats (confinement animal products, soybean oil, soda, wheat) is healthy. For example, we don't know what fraction of the results are due to the massive increase in vegetable consumption which probably fixed numerous nutrient deficiencies, or the reduction in inflammatory omega-6 fatty acids, etc.
Anyway, I don't say this to detract from Dr. Esselstyn's work (he seems like quite a boss, by the way. Olympic gold in rowing, tour in Vietnam, hundreds of peer reviewed publications). I think there is no question that his diet is healthier than the SAD (not hard to do, of course). But at the same time, I hope you can see why I don't find this kind of thing super convincing as the holy grail.
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