I am not a statin skeptic--or rather, I don't want to be a statin skeptic. I've done the research and it makes sense to me, but I still feel some social and psychological pressures to reject statins.
When I see that it is widely accepted that ApoB is better to measure than LDL-C, but the industry continues to measure LDL-C, but not ApoB, I wonder why. It makes me skeptical.
When I see that the purpose of statins is to reduce plaque buildup in the arteries, and that we have the ability to measure these plaque buildups with scans, but the scans are rarely done, I wonder why. Like, we will see a high LDL-C number (which, again, we should be looking at ApoB instead), and so we get worried about arterial plaque, and we have the ability to directly measure arterial plaque, but we don't, and instead just prescribe a statin. We're worried about X, and have the ability to measure X, but we don't measure X, and instead just prescribe a pill based on proxy indicator Y. It makes me skeptical.
In the end statins reduce the chance of heart attack by like 30% I think. Not bad, but if you have a heart attack without statins, you probably (70%) would have had a heart attack with statins too. That's what a 30% risk reduction means, right?
As you can see, I'm worried about cholesterol and statins.
If you fix it without statins through better lifestyle and diet, that is the preferrable route.
As to why medicine is like this, it's because it's conservative, usually about 17 years behind university research[0], and doctors are shackled to guidelines in most health systems or risk losing their licenses. It isn't a coincidence that the article author had his out-of-pocket concierge doctor tell him the more up-to-date stuff.
I have an objection to the "better lifestyle and diet" approach.
Sure, it is absolutely true that better lifestyle and diet has a huge effect. However it is absolutely certain that the vast majority of people who are told to improve their lifestyle and diet, won't.
The result is doctors giving advice that they know won't be followed. And thereby transferring potential fault from the doctor to the patient, with no improvement in actual outcomes. "I told the patient to lose weight and maintain that with a controlled diet." And yet, most people when told to diet, won't. Most people who start a diet won't complete it. And most people who lose weight on a diet, have the weight back within 5 years. Where each "most" actually is "the overwhelming majority". And the likelihood of the advice resulting in sustained weight loss probably being somewhere around a fraction of a percent.
What, then, is the value of the doctor giving this lecture?
(Disclaimer. I have lost 20 of the pounds I gained during COVID, and am making zero progress on the remaining 30. A few months ago I successfully started a good exercise routine. Given my history, I would expect to only follow it for a few years before falling off the wagon. I believe that this poor compliance puts me well above average. But do you know what I do reliably? Take my prescribed medicine!)
To expand, one of the coverage pillars of malpractice insurance (in the US) is the "standard of care". This is basically what most doctors and their associations consider acceptable, which by definition excludes new, better techniques.
This is both a bug and a feature. A move fast and break things philosophy would cause more harm than good, but it also prevents rapid adoption of incremental improvements.
There is virtually zero chance that a doctor will lose their medical license for diverging from the from the usual clinical practice guidelines around statins. Check the state medical board disciplinary records.
But if they're employed by a health system and fail to follow company policy then yes, they could be fired.
No, actually, you should improve your lifestyle and diet and also take statins.
Ever cardiologist ever will tell you that statins work best when you make diet and lifestyle changes. They tell you that, to your face. It's not a secret. This actually goes for A LOT of medications. Usually, medication + diet and exercise is better than medication alone. They also test medications like this.
You can only do things to reduce your risk. And whatever intervention would be based on overall population statistics, since it's difficult to know your own personal risk. Heart disease kills marathon runners. You can't just "fix it". Someone who has naturally high cholesterol won't magically be okay by changing their lifestyle and diet.
> When I see that it is widely accepted that ApoB is better to measure than LDL-C, but the industry continues to measure LDL-C, but not ApoB, I wonder why. It makes me skeptical.
ApoB is shaping up to be an incremental improvement in measurements, but health and fitness influencers have taken the marginal improvement and turned it into a hot topic to talk about.
This happens with everything in fitness: To remain topical and relevant, you always need to be taking about the newest, most cutting edge advances. If it’s contrarian or it makes you feel more informed than your doctor, it’s a perfect topic to adopt for podcasts and social media content.
ApoB is good, but it’s not necessarily the night and day difference or some radical medical advancement that obsoletes LDL-C. For practical purposes, measuring LDL-C is good enough for most people to get a general idea of the direction of their CVD risk. The influencers like to talk about edge cases where LDL-C is low but then ApoB comes along and reveals a hidden risk, but as even this article shows there isn’t even consensus about where the risk levels are for ApoB right now. A lot of the influencers are using alternative thresholds for ApoB that come from different sources.
> In the end statins reduce the chance of heart attack by like 30% I think. Not bad, but if you have a heart attack without statins, you probably (70%) would have had a heart attack with statins too. That's what a 30% risk reduction means, right?
30% reduction in a life threatening issue is huge. I don’t see why you would want to diminish that.
If you were given the choice of two different dangerous roads where one road had a 30% lower chance of getting into a life-threatening car crash, you would probably think that the choice was obvious, not that the two roads were basically the same.
numbers often quoted in favor of statins use relative instead of absolute risk. when seen in absolute terms there is little case for statins except in some possible particular cases. they also do little, if anything, when it comes to life extension — the expected lifespan of a statin user is often estimated to be four days longer than that of those who do not use them. not only is this essentially statistical noise, it discounts the lowered quality-of-life side effects experienced by many who have been put on statins.
>If you were given the choice of two different dangerous roads where one road had a 30% lower chance of getting into a life-threatening car crash, you would probably think that the choice was obvious, not that the two roads were basically the same.
You could absolutely think that they were basically the same, depending on the base rate. The differece between a one-in-a-million and 0.7-in-a-million is 30%, but it wouldn't be humanly perceivable. We're all likely faced with situations like that regularly. Differing airlines probably have much greater variances in their crash statistics, but it just doesn't matter in 99.99999% of flights.
Meta-analysis conclusion: This literature-based meta-analysis did not find evidence for the benefit of statin therapy on all-cause mortality in a high-risk primary prevention set-up.
Guidance from the National Lipid Association, based on a review of the current understanding of the science across quite a few different meta-studies, analysis, etc. Many of the referenced studies are meta-studies significantly larger than the one here.
We have mountains of studies showing the negative impact of LDL-C (and inflammation! Which statins also reduce) on health. We have mountains of studies showing positive impact from statins. We have specific mechanistic understanding of how LDL-C and other atherogenic particles cause heart disease. We have mountains of studies show that statins directly lower the amount of atherogenic particles you have.
This has been studied enough and sliced enough ways that yeah, there is evidence on both sides. But one side is effectively a mountain range, and the other is a small hill. I know which way I'm going to land on it.
Concentration of ApoB-carrying lipoproteins in the bloodstream as the driver of heart disease is one of the most strongly proven facts in medicine. Statins are proven to lower LDL (a close-enough substitute for ApoB in most situations) by about 30%. I can't look at the study now, but most likely it's a situation where patients' cholesterol has not been lowered enough by medication to make a meaningful difference. If you have an LDL of 160, statins aren't going to be sufficient. The issue is doctors/patients not targeting a sufficiently low cholesterol level.
> When I see that it is widely accepted that ApoB is better to measure than LDL-C, but the industry continues to measure LDL-C, but not ApoB, I wonder why. It makes me skeptical
Because this is a recent understanding and healthcare tends to be a conservative industry that moves slowly. Sometimes too slowly.
And also because LDL remains an excellent measure. The risk with LDL isn’t false positives. If someone has high LDL they likely have an elevated risk of heart disease. The problem with LDL testing is that someone with low LDL may still have a high risk of heart disease which may be captured in APoB testing.
> When I see that it is widely accepted that ApoB is better to measure than LDL-C, but the industry continues to measure LDL-C, but not ApoB, I wonder why. It makes me skeptical.
Part of this is just that insurance coverage lags science. We've known that ApoB is more accurate than LDL since the 1990's or 2000's, but to be covered by insurance, several more steps have to happen.
First, the major professional societies (like the American College of Cardiology or National Lipid Associations) have to issue formal guidelines.
Then, the USPSTF (US Preventive Services Task Force) needs to review all of the evidence. They tend to do reviews only every 5 or 10 years. (Countries aside from the US have different organizations that perform a similar role.)
If the USPSTF issues an "A" or "B" rating, then insurance companies are legally obligated to cover ApoB testing. But that also introduces a year or two lag since medical policies are revised and apply to the next plan year.
The net effect is that the entire system is 17 years, on average, behind research.
ApoB blood tests are relatively cheap. You can pay out of pocket about $70 if you really want one and insurance won't cover it.
Most commercial health plans will cover an ApoB test for members with certain cardiac risk factors or medical conditions. But they generally won't cover it as a preventive screening for all members. I don't think we have enough evidence to justify broad screening yet, although that may be coming.
> When I see that the purpose of statins is to reduce plaque buildup in the arteries, and that we have the ability to measure these plaque buildups with scans, but the scans are rarely done, I wonder why.
I'd love to know where to get the right advice on this topic.
I have high LDL-C, had a heart CT in hospital last week, yet the hospital's cardiologist phoned me yesterday to cancel a scheduled appointment to discuss the results(!), because she said I have zero arterial plaques and there's simply no need for us to meet.
How old are you? I was told that they're not considered diagnostic until somewhat later in life (>50) because the plaque may not have calcified yet, which could cause a false negative.
I was found to have high cholesterol in my late 20s. At the time the doctors (my cardiologist, then a second one brought in for advice) determined that the source was hereditary, but the effects would be the same. So they put me on statins. It's been 40 years now. I changed the statins three times since, when the actual one, at a specific time was no longer able to keep the values within acceptable limits. Approximately 8-9 years ago (I think) I ended up on Rosuvastatin 20mg, which I'm still taking every day. I do not maintain any diet (it'd be very hard, as I'm a heavy meat eater) and cholesterol levels are still staying within acceptable limits. Of course YMMV
No heart attacks or strokes? I'm in the same boat (hereditary issue), and altering my diet has never had any substantial effect on my numbers. I'm not overweight and rarely eat red meat, but have had trouble keeping onto a primary care physician long term (the people I keep picking seem to move between clinics constantly) in order to retain consistent access to a statin prescription, but as I continue to age I've been getting increasingly anxious that my time is coming.
I haven't had to touch statins to get my lipids profile much better. I used zepbound to lose about 50lbs and then weaned myself off that. I was a little afraid my “completely normal after 8 months of weight loss” blood panel status at the end of my zepbound journey would go back to the “bad” region, but I have maintained going on a year with a much better whole foods/lean meats based diet and moderate exercise (I do let myself have some red meat on Saturdays, otherwise I would explode from hamburger desires). So it was done through a combination of lifestyle changes and zepbound to help me bury the hunger monster long enough to learn new habits and get to a new normal. Him suggesting that “probably” most people should be on statins whether they need them or not seems like covering up the source of the problem. I do know that some people just naturally have lipid issues even when doing “all the healthy things” though. My mom is one of them.
I ALSO want to not be a statin-skeptic but, like you, these things look very weird to me. The most prescribed drugs in the country and we don't even try to check if they are addressing the actual problem?
We have checked to see if they are addressing the problem more than probably any drug in history. The idea that we haven't is the result of skeptics cherry picking results that back up their point while ignoring the huge quantities of evidence supporting the efficacy of statins and other LDL lowering medications like ezetimibe, pcks9 inhibitors, etc.
Statins are so good at what they do they even reduce the risk in people who are already at low risk for heart disease.
That prior discussion gives no good reasons. The linked medium posts are, to be frank, trash.
Statins are well-tolerated drugs with little to no noticeable side effects. You might have to try a few. You may need to combine ezetimibe to maintain a moderate statin dosage level, and that's it. (Like the author of this article)
Source: Leading cardiologists worldwide, and doctors of the rich and famous.
I'm a big statin sceptic so just putting that up front.
I think things haven't changed because most people underestimate how slow institutional scale change is. There is a reason why HR departments and consultants have Change Management experts. The inertia is huge. Young people don't appreciate this because they thrive on new ideas. Old folks don't and will subconsciously push back, like a form of institutional homeostasis.
Also, while I believe your heart attack stats are correct, I'm more interested in all cause mortality. I believe there statins are a net negative.
A single study showed a single statin reducing GLP-1 levels and ascribed it to gut microbiome changes that could be totally resolved with UDCA supplementation.
If this even ends up being reproduced it at most says there is an easy fix for people taking atorvostatin and that it might be a concern with other statins, but this should be treated with the same health skepticism of any other single study finding.
Not all statins raise blood sugar either - pitavastatin usually shows an improvement in insulin sensitivity.
one better simple indicator than large panels, if you can't get access to them or don't have them is simply your triglycerides/hdl ratio. aim to be under 2 if using mg/dl and under 0.87 if using mmol/L. it's one of the strongest correlated indicators of cardiovascular disease. way better than any classic cholesterol ratios.
Statins can be effective for many patients (and there are multiple different statins with varying effects) but there are also alternative or additional drugs such as Leqvio (inclisiran) and Repatha (evolocumab). Patients should do their research and talk to their doctors. It might take some trial and error to figure out what works best.
The general advice is that the scans are only useful sometimes. That is, they can show a problem. But a clear scan doesn’t mean you’re fine. So don’t base anything on a clean scan, be proactive with all the rest of it. My two cents, by the way: Repatha is pretty amazing.
There is no reason take statins, ever. They will destroy your muscles, then cause diabetes and thus indirectly kill you. They will prevent a heart attack by... four days.
If biomarkers are elevated, the question must always be, "why is this elevated", and "is there a natural change in habit and diet that can reverse this elevation".
Artifically lowering the marker with a drug is like pasting duct tape on a leaking pipe - the leak is still there and it will likely quietly get worse over time and then eventually kill you anyways.
I find it unbelievable that our society swallows any drug without second thought. You body produces cholesterol on purpose. There must be reason why it produces it. "Ah well, who cares, let's just throw in a wrench and make it stop producing the cholesterol" and hope for the best...
Arguing against nonsense like this gets so exhausting.
Statins do not destroy your muscles. Newer statins make this already exceedingly rare side effect even rarer, but let's look at them as a general class:
Blinded RCT/Meta-analysis shows about 11 complaints per 1k patient years, with 90% of them not actually being due to the statin. But because people act like they're common, they mistakenly believe it was the statin, which just reinforces this idea. And that's for muscle pain.
For actual significant muscle injury? Even lower. 1 or less per 10,000 patient years.
Effectively, you might get one muscle ache per year per 100 people and at most a 1 in 10,000 chance of serious myotoxicity.
As for diabetes, rosuvstatin usually has a neutral to positive impact on insulin sensitivity, and pitvastatin almost always has a positive impact. Some statins do have negative impact, but it's not universal.
It's not like duct tape on a leaking pipe - it's like removing items in a pipe that damage the pipe walls. Yeah, ideally they're not in the pipe to begin with, but removing them is better than letting them stay, and diet and exercise only do so much to remove said items.
Your body can synthesize LDL de novo in the organs that use it, and one of the heaviest users, the brain, can't get cholesterol out of your diet/serum levels at all - LDL cannot pass the blood brain barrier.
There are people with genetic mutations that mean they don't produce LDL, or at least not at high levels - their increased longevity and incredibly rare incidents of ASCVD is what drove the creation of PKCS9 inhibitors.
Statins also lower LDL-C levels - they don't make your body stop producing cholesterol in general, or even LDL-C. Even if your body couldn't make it on-demand where needed, statins aren't going to drop your serum levels to 0.
> When I see that it is widely accepted that ApoB is better to measure than LDL-C, but the industry continues to measure LDL-C, but not ApoB, I wonder why.
That's pretty simple to explain. No conspiracy.
LDL-C is much much cheaper to measure. ApoB costs 36x times as much, so Insurance Companies don't like to pay for it
My wife had high cholesterol numbers, so her doctor wanted to give her statins. She asked about a scan, he begrudgingly said well, I guess you could do that. Her scan showed 0 plaque.
It was almost certainly the former, and the former is is basically an indicator that the damage is already done.
Soft plaque takes a long time to calcify. But soft plaque is the stuff that ruptures, and will clog up your arteries just as much.
Statins are best used as a preventative measure - once the plaque is there it's difficult to regress it even while soft, and as far as we know effectively impossible once it is calcified.
I’m sensing a potentially significant misallocation of resources. My mental model is that there’s a hypothetical quantification of not just your time and money, but your anxiety, attention bandwidth, mental energy, etc.
I think, in some ways, the trick is being able to short circuit the entire journey represented by this website in favour of some form of, “I’m 40. I should be more mindful of heart disease. I should add a 30 min walk to my mornings.” And then move on with your life.
I think many cultures, but especially American healthcare culture, foment a growing background noise of constant anxieties and stressors. Life is sufficiently complex but there’s always a peddler eager to throw you a new ball to juggle (and pay for).
I think the article makes a valid point: stop worrying about 90% of the other stuff and focus on the thing that will almost certainly kill you - heart disease - for which there are easy diagnostic and preventative measures. I think they're arguing for a better allocation of resources, if anything.
I think people should be mindful of it since they were 18 - it's something that progresses over decades. You can have a lot bigger impact making changes when you're young rather than at 40
But yeah I agree with your message. Focus on the big impact macro level things. Hyper-optimizing it is a waste of energy
If I'm not wrong, it takes 20 years to revert the damage of smoking.
I don't think you need to care at 18, but the effects will be seen over the course of 20 years
Seriously there is too much shit to worry about to micro manage each facet, unless your like a Bryan Johnson billionaire with a staff.
Beyond just heart disease & cancer taking you out entirely its: my eyesight is going, my hearing, every joint in my body could fail, my brain is slowing, etc.
There is just way too much shit to do anything other than be like: sleep, exercise, eat better and don't drink too much.
And even him doesn’t know what’s working and what’s making things worse. He claims to have really good biomarkers but that’s when cherry-picking numbers from studies made in a range of more than two years (!!).
You’ll never see a published set of tests from him. What you’ll see is ads to buy his supplements.
There are roughly 5 areas of which combined cover 80+% of things you can control.
1. Exercise (aerobic and strength, doesn’t have to be much but more is better).
2. Diet (mostly whole foods, mostly plants, low saturated fat).
3. Prevention (regular check ups and following doctor’s advice).
4. Meaning / purpose (either being passionate about your job or having such hobbies outside of it).
5. Friends and community.
This isn’t too much. By many that’s the bare minimum for having a satisfactory life.
> Beyond just heart disease & cancer taking you out entirely its: my eyesight is going, my hearing, every joint in my body could fail, my brain is slowing, etc.
Absolutely right. You can’t fix everything. But if you can only dedicate time, money, and attention to one thing, cardio health is probably highest impact for most people. This article makes that case. Also it makes the case that there are a few things that will have an outsized positive effect on cardio health and we’d be wise to focus on them.
Key Takeaway: Get a CT or CTA scan, and if you can afford it go for the CTA with Cleerly.
There is a reason that we don't recommend getting imaging for everyone, and that reason is uncertainty about the benefit vs the risks (cost, incidentalomas, radiation, etc, all generally minor). Most guidance recommends calcium scoring for people with intermediate risk who prefer to avoid taking statins. This is not a normative statement that is meant to last the test of time: it may well be the case that these tests are valuable for a broader population, but the data haven't really caught up to this viewpoint yet.
The central point of his article is that he went to a doctor who followed the guidelines, tested him and found he wasn't at risk for heart disease.
But then he went to another, very expensive concierge doctor, who did special extra tests, and discovered that he was likely to develop heart disease and have a heart attack.
Therefore he is arguing that THE STANDARD GUIDELINES ARE WRONG AND EVEN IF YOU DO EVERYTHING RIGHT AND YOUR DOCTOR CONFIRMS IT YOU MAY BE LIKELY TO DIE OF HEART DISEASE ANYWAY, SO ONLY THE SPECIAL EXTRA TESTS CAN REVEAL THE TRUTH.
I want a second opinion from a doctor. Is this true? Is this for real? Because it smells funny.
I strongly suspect the truth is both are "right", but they're both optimized answers to slightly different problems.
Mainstream medicine is hyper optimized for the most common 80% of cases. At a glance it makes sense: optimize for the common case. Theres some flaws in this logic though - the most common 80% also conveniently overlaps heavily with the easiest 80%. If most of the problems in that 80% solve themselves, then what actual value is provided by a medical system hyper focused on solving non-problems? The real value from the medical system isnt telling people "it's probably just a flu, let's just give it a few days and see" it's providing a diagnosis for a difficult to identify condition.
So if your question is "how do we maximize value and profit in aggregate for providing medical care to large groups of people", mainstream medicine is maybe a good answer.
But if your question is "how do we provide the best care to individual patients" then mainstream medicine has significant problems.
Research science in this area has been in agreement for a long time now that ApoB is a more informative indicator than just LDL-C, because there are a variety of different atherogenic particles, not all LDL particles are created the same, etc.
His ApoB numbers are quite readily and apparently out of range. Hell, even his LDL is out of range for the two largest lab providers in the US - Labcorp and Quest both have <100 for their reference range. But the science shows that plaque progression is still generally occurring at levels above 70 LDL-C even with low Lp(a) and other atherogenic particles - the reference ranges are likely to get moved lower and lower as practice catches up with research.
His numbers are well within the range of concern based on pretty universal consensus across the research in this area over the past couple of decades. Preventative cardiologists and lipidologists would almost certainly agree with this concierge doctor.
The claim on an individual level is not objectionable to me. The question is that if we extrapolate it out to the population and actually take this action for everyone, do we make people better off? This is what clinical trials (or at least large observational studies) try to achieve. Right now, it is not clear.
His evidence is also kinda weak. And appeal to authority largely about someone who he's paying to tell him he has health problems. The incentives aren't aligned.
I also disagree that the 50the percentile is the breakpoint between healthy and unhealthy. There's a lot more to deciding those ranges beside "well half of the population has better numbers"
Maybe he got missed--let's concede that. What about the other 10 or 100 or 1000 or subjected themselves to tests and didn't find anything? Where are their stories?
If you have enough people, the tests, themselves are eventually going to harm somebody.
For example, certain scans require contrasts like gadolinium that bioaccumulates. That's not a big deal if we only pump it into people 2 or 3 times in their lives when something in their body is about to explode. It's a lot bigger deal if we're doing that to them every year.
The bottom line is these tests aren't some sort of one-size-fits-all panacea, and nor can they perfectly predict the future. In fact Oprah herself backtracked on it, via an article by Dr. Oz in her magazine in 2011: https://www.oprah.com/health/are-x-rays-and-ct-scans-safe-ra...
A good rule of thumb is don't take medical advice from Oprah or Dr. Oz. But in the case of the latter article, he wasn't wrong.
> But then he went to another, very expensive concierge doctor, who did special extra tests, and discovered that he was likely to develop heart disease and have a heart attack.
It’s scarily common in medicine for doctors to start specializing in diagnosing certain conditions with non-traditional testing, which leads them to abnormally high diagnosis rates.
It happens in every hot topic diagnosis:
When sleep apnea was trending, a doctor in my area opened her own sleep lab that would diagnose nearly everyone who attended with apnea. Patients who were apnea negative at standard labs would go there and be diagnosed as having apnea every time. Some patients liked this because they became convinced they had apnea and frustrated that their traditional labs kept coming back negative, so they could go here and get a positive diagnosis. Every time.
In the world of Internet Lyme disease there’s a belief that a lot of people have hidden Lyme infections that don’t appear on the gold standard lab tests. Several labs have introduced “alternate” tests which come back positive for most people. You can look up doctors on the internet who will use these labs (cash pay, of course) and you’re almost guaranteed to get a positive result. If you don’t get a positive result the first time, the advice is to do it again because it might come back positive the second time. Anyone who goes to these doctors or uses this lab company is basically guaranteed a positive result.
MCAS is a hot topic on TikTok where influencers will tell you it explains everything wrong with you. You can find a self-described MCAS physician (not an actual specialist) in online directories who will use non-standard tests on you that always come back positive. Actual MCAS specialists won’t even take your referral from these doctors because they’re overwhelmed with false cases coming from the few doctors capitalizing on a TikTok trend.
The same thing is starting to happen with CVD risks. It’s trendy to specialize in concierge medicine where the doctor will run dozens of obscure biomarkers and then “discover” that one of them is high (potentially according to their own definition of too high). Now this doctor has saved your life in a way that normal doctors failed you, so you recommend the doctor to all of your friends and family. Instant flywheel for new clients.
I don’t know where this author’s doctor fits into this, but it’s good to be skeptical of doctors who claim to be able to find conditions that other doctors are unable to see. If the only result is someone eating healthier and exercising more then the consequences aren’t so bad, but some of these cases can turn obsessive where the patient starts self-medicating in ways that might be net negative because they think they need to treat this hard to diagnose condition that only they and their chosen doctor understand.
It's important to note that there's geographic variability in guidelines. Also, the article doesn't give enough information about the author's other risk factors. For a similar patient (based on the initial lab results), treated by a doctor adhering to the European guidelines, at least the following items would have been considered:
- Lipid lowering drugs
- ApoB testing
- Coronary CT (if the pre-test likelihood of obstructive coronary artery disease was estimated to be > 5%)
Not sure I follow or maybe you skipped typing a word.
You listed the risks and concluded “all generally minor.” The benefit is absolutely nonzero. So, what’s the hold up?
And how have the data not caught up? People outside the US are getting the CT scans, while US doctors prefer to lick their finger to guess the weather.
My wife’s last interaction with a doctor: patient presents with back and chest pain accompanied by occasional shortness of breath at the age of 39, doctor reluctantly asks for a EKG - which takes 5-10 minutes and is done in the next room, right away and covered by insurance with a small copay - and has the gall to be surprised when EKG showed subtle abnormalities. If she hadn’t advocated for herself, as the OP argues, doctor would just skip the EKG.
This experience left me thinking maybe doctors are discouraged from asking for imaging and guidelines are there to protect their criminally negligent behavior. I have no proof or even proxy data for the claim about doctors being discouraged from asking for imaging. But it is objectively criminally negligent to not ask for imaging in a case like this.
"Smaht" people continuously parrot things they read elsewhere, usually in a contrarian way, to assert themselves in a futile and shallow way.
There is absolutely nothing wrong with getting one CT at a specific point in your life to right a disease which, as TFA states, has a 25% incidence rate.
The smaht ones will now point me to that study of 1-5% of cancers being linked to CT scans. Yeah, sure, but those are not from people who got one-two in their lives.
There's something I deeply don't understand about this.
> I shared these results with a leading lipidologist who proclaimed: “Not sure if the lab or the primary care doc said an LDL-C of 116 mg/dL was fine but that concentration is the 50th percentile population cut point in the MESA study and should never ever be considered as normal.
> It’s also important to note that, according to a lipidologist friend, an ApoB of 96 is at a totally unacceptable 50th percentile population cutpoint from Framingham Offspring Study.
So... the exact median value is "totally unacceptable" and "should never ever be considered as normal"? I'm open to the possibility that the US population is so deeply unhealthy that this is true, but then that needs to be argued for or at least mentioned. Like, you can't say "you're exactly average in this respect" and expect your and that's terrible to be taken seriously without any followup.
Or if I'm misunderstanding what's meant by "50th percentile population cut point" then again, I think this jargon should be explained, as it's plainly not the usual meaning of "50th percentile".
I had assumed "the MESA study population" was a particularly unhealthy bunch in terms of this measurement, meaning the 50th percentile puts one in the worst half of an already bad off group.
I don't know the exact details, but I thought the Framingham survey was just a cross-section of the population. So getting upset about a 50th percentile score makes no sense at a population level.
A quick Google says that the Mesa study was actually of people without cardiovascular disease at the beginning of the study. So again, these conclusions don't make any sense to me.
The other thing these number chasers don’t tell you is that extremely low LDL numbers are also associated with anger management issues. The stuff is used in your body to build things. You need some, and probably at least half of the number this doc is trying to say is scary. In fact in a different test he is advised to talk to his doctor about whether a 29 is safe.
Has the guidance changed that you want LDL less than 2.5x (or was it 2x?) your HDLs?
Every organ in your body that utilizes LDL can synthesize it de novo. Some of the heaviest users, like your brain, literally can't get it from your serum LDL levels - they do not pass the blood brain barrier. It is all synthesized locally.
PKCS9 inhibitors and mendelian randomization studies show that people function just fine with <10 LDL-C. (Other comments I have made in here have links to all the relevant studies)
Googling for statin and aggression links I find a fairly small set of studies with fairly disparate outcomes.
Going deep on biomarkers, blood tests, and debates about optimal levels is okay for some people who derive motivation from obsessing over topics, but I’m starting to notice a trend where people obsess about these things for a couple years before burning out and moving on to the next topic.
The best thing you can do for yourself is to establish healthy diet and lifestyle habits that are sustainable. A lot of people who jump from obsession to obsession do a great job at optimizing for something for a few years, but when their life changes they drop it completely and fall back to forgetting about it.
Fad diets are the original example of this: They work while the person is doing it, but they’re hard to maintain for years or decades. CrossFit and other exercise trends have the same problem where some people get extremely excited about fitness for a couple years before falling off completely because it’s unsustainable for them. Some people are able to continue these things for decades, but most people do it for a short while and then stop.
I’m now seeing the same pattern with biomarker obsessives: They go a few years obsessing over charts and trying things for a few months at time, but when the interest subsides or they get busy with life most of it disappears.
The most successful people over a lifetime are those who establish healthy habits that are easy to sustain: Eating well enough, reducing bad habits like frequent alcohol or fast food consumption, some light physical activity every day, and other common sense things.
The most important factor is making it something easy to comply with. The $300 biomarker panels are interesting, but most people don’t want to pay $300 every year or more to get snapshots that depend largely on what they did the past week. Some people even get into self-deceiving habits where they eat well for a week before their blood tests because the blood test itself has become the game.
Right on spot. Find a regime for body and mind that you can sustain without any significant mental effort, after some time lack of good behavior be it sports of healthy food makes one uneasy. Bonus points from getting happy from it / making it a passion, this helps a lot with coming back after some hiatus (ie injury, sickness, long travel etc.).
Personal story - I used to be super sporty, 4x gym training during work week - cardio & free weights, climbing over evenings after work, hiking/climbing/ski touring over weekends. Vacations were mostly more extreme variants of the same. Last year broke my both ankles with paragliding, one leg much worse, so took me some 8 months to be able to walk straight again, with some time in wheelchair, then crutches. All strength & stamina gone, flexibility 0, so had to rebuild from scratch and I mean deep bottom scratch from which you bounce very slowly, not some 1 month stop when things come back quicker. If all above weren't my proper passions I would have a hard time coming back to being again more active than most(sans that paragliding, took the lesson and have 2 small kids). That ankle won't ever be same but so far so good, ie managed some serious hike&via ferrata mix 2 days ago.
Getting happy from it is 100% the most effective way to change habits.
Unfortunately it’s also very subjective and hard to find out what makes you happy…
> starting to notice a trend where people obsess about these things for a couple years before burning out and moving on to the next topic.
Really spot on with one of my besties. He does all the tests. He has a concierge doctor. He reads extensively on the topics of fitness and nutrition. And yet he doesn't do any of it. It's just an intellectual exercise for him. And he has had two heart attacks in the last several years. It's so frustrating. I just wanna shake him.
I learnt a great trick about exercise: find a podcast or audio book that you really enjoy listening to. Here's the trick: you're only allowed to listen when you're exercising.
Also with food and drink: place friction between the treat and yourself. The easiest example is to not have biscuits / alcohol in the house.
Bonus tip: alcohol free beer is really good these days.
Alcohol free beer was a game changer for me. Also if I can’t avoid it alternating alcohol-containing and alcohol-free drinks.
For exercise your tip doesn’t help me at all. I hate audiobooks and podcasts so that would turn me off more from exercising. Also I want to concentrate on the exercise and not do it halfhearted.
What helped me was to realise how much better I feel after exercising - since then i kinda got addicted to it because I notice how much worse I feel after not doing it for a couple of days.
I agree on the friction. Just not having access to cigarettes is the best way for me to not smoke. I just don’t buy them and bumming one from someone else comes with a degree of personal shame for me that makes me avoid them (in almost all cases).
I naturally don’t like sweet stuff that much - however since I moved from EU to America (not US) it’s been really hard to avoid sugar.
Y’all put that stuff into everything it’s crazy; I gotta watch out like a hawk and go to special stores. In Europe it was so much easier, there are always cheap sugar free whole foods available in every supermarket.
I push hard enough during cardio that I can't really follow a podcast properly.
On the upside, it's only 30 minutes.
While lifting weight I do that since I rest for 90 seconds in between sets, which is actually very boring.
I started reading books during that time and that has been a big improvement.
If you're exercising for cardio, and you're able to follow your book or podcast, you're probably not doing good cardio. OTOH, it's not a bad way to do interval training while watching sports, go hard when they're yammering, slow down when the sports are happening (or, if you're watching soccer, you can go hard most of the time and then slow down for the replay if anything happens, which is unlikely)
> Sticking to a Mediterranean diet that is light on carbohydrates and saturated fats is almost always the safest bet. Almost every health diet is some permutation of this.
A permutation that's currently making the rounds in the press (even though the original research is from 20 years ago) is the "portfolio diet":
Lowering LDL cholesterol is arguably the most evidence-backed longevity intervention available today. Mendelian randomization studies suggest that each standard deviation of lifelong LDL reduction translates to roughly +1.2 years of additional lifespan, implying ~+2.4 to +3.6 years from sustained, meaningful lowering alone.
Pair this with tight blood-pressure control (aim systolic <130 mmHg) and a healthy BMI—every incremental improvement helps. Together, LDL, BP, and BMI form the most potent triad of interventions most people can implement now and expect to see substantial benefits 20–40 years down the line.
Everyone knows the recipe for healthy living, it's the same as for similar issues such as personal finance (spend less than you earn, save, etc.).
They seem simple on the surface but hard part is execution for most people, due to life circumstances and other factors. Unhealthy choices persist because society isn't built around healthy lifestyles.
So while the comment seems helpful on the surface, it misses the forest for the trees.
I think that there needs to be a bigger discussion here, regarding why have we engineered a society that inflicts suffering and illness on so many?
Not all things labeled "processed foods" are bad, it seems. There are enough scientists that say the distinction is often hypocritical (example from an article: a factory-made carrot cake is labeled UPF, but a home-baked one isn't, even though they're practically the same thing). Sugar, fats, and lack of fiber make factory-food unhealthy, they say. Others add that we can't feed the growing metropolitan areas without it.
Just expanding on a peer post, but industrial made food tends to have a large number of preservatives, stabilizers, coloring agents, and much more added for commercial reasons. An obvious example of this is in something as simple as bread. If you've ever made homemade bread. It goes stale in a day or two, and it's hard as a rock shortly thereafter.
But that loaf you buy at the store? It'll generally be covered in mold before it gets hard, and that's quite the achievement since it also tends to be more resistant to mold as well! Bread should get hard. This is where a ton of old recipes come from. The Ancient Greeks would dip it in wine for breakfast, Euroland has bread soup/puddings, and even stuff in the US like Thanksgiving stuffings or croutons.
>a factory-made carrot cake is labeled UPF, but a home-baked one isn't, even though they're practically the same thing).
Actually they are not. "Practically" is carrying a lot of weight there. The factory baked cake will have a lot more extraneous ingredients and usually has a larger quantity of sugar and fat. Similar to how restaurant food generally has a lot more salt and fat than home cooked food.
WRT the carrot cake, I will say that while there is only a minimal physical difference, there is a practical difference. Making a carrot cake at home is a commitment, and most people won't frequently go to the trouble except on special occasions... But one from the grocery store can be acquired casually and without effort, and it's easy to eat a lot more of something when it requires no effort.
You’re not wrong but it is not a fair TLDR. TFA has a TLDR which says
> If you only read one thing here, make it the “How to not die of heart disease” section.
Which itself is still quite long but it emphasizes:
> Every lipidologist I’ve spoken with has stressed the importance of measuring and managing ApoB above all else – it’s a far better predictor of cardiovascular disease than LDL-C (which is what physicians are most familiar with). Every standard deviation increase of ApoB raises the risk of myocardial infarction by 38%. Yet because guidelines regularly lag science, the AHA still recommends LDL-C over ApoB. Test for it regularly (ideally twice a year) and work to get it as low as possible (longevity doctor Peter Attia recommends 30-40mg per deciliter). Many lipidologists will say to focus on this above all else.
And:
> I asked several leading lipidologists to stack rank what they believe are the most important biomarkers for people to measure and manage. […], and will likely cost anywhere between $80-$120 out of pocket.
That’s a pretty interesting and relevant part of TFA. Omitting that is not a fair “long story short”, but rather just “different story”.
This is wrong. Our bodies evolved to eat a diverse omnivorous diet and complex carbs + the antioxidants present in vegetables and fruits are anti-oxidative.
Vegetables aren't "carb-heavy". And we don't need to recreate blindly the circumstances evolution had to adapt us to. E.g., our bodies evolved when the population was much smaller, but I don't think you want to argue for mass extinction.
Readit News
When I see that it is widely accepted that ApoB is better to measure than LDL-C, but the industry continues to measure LDL-C, but not ApoB, I wonder why. It makes me skeptical.
When I see that the purpose of statins is to reduce plaque buildup in the arteries, and that we have the ability to measure these plaque buildups with scans, but the scans are rarely done, I wonder why. Like, we will see a high LDL-C number (which, again, we should be looking at ApoB instead), and so we get worried about arterial plaque, and we have the ability to directly measure arterial plaque, but we don't, and instead just prescribe a statin. We're worried about X, and have the ability to measure X, but we don't measure X, and instead just prescribe a pill based on proxy indicator Y. It makes me skeptical.
In the end statins reduce the chance of heart attack by like 30% I think. Not bad, but if you have a heart attack without statins, you probably (70%) would have had a heart attack with statins too. That's what a 30% risk reduction means, right?
As you can see, I'm worried about cholesterol and statins.
As to why medicine is like this, it's because it's conservative, usually about 17 years behind university research[0], and doctors are shackled to guidelines in most health systems or risk losing their licenses. It isn't a coincidence that the article author had his out-of-pocket concierge doctor tell him the more up-to-date stuff.
[0] https://pmc.ncbi.nlm.nih.gov/articles/PMC3241518/
Sure, it is absolutely true that better lifestyle and diet has a huge effect. However it is absolutely certain that the vast majority of people who are told to improve their lifestyle and diet, won't.
The result is doctors giving advice that they know won't be followed. And thereby transferring potential fault from the doctor to the patient, with no improvement in actual outcomes. "I told the patient to lose weight and maintain that with a controlled diet." And yet, most people when told to diet, won't. Most people who start a diet won't complete it. And most people who lose weight on a diet, have the weight back within 5 years. Where each "most" actually is "the overwhelming majority". And the likelihood of the advice resulting in sustained weight loss probably being somewhere around a fraction of a percent.
What, then, is the value of the doctor giving this lecture?
(Disclaimer. I have lost 20 of the pounds I gained during COVID, and am making zero progress on the remaining 30. A few months ago I successfully started a good exercise routine. Given my history, I would expect to only follow it for a few years before falling off the wagon. I believe that this poor compliance puts me well above average. But do you know what I do reliably? Take my prescribed medicine!)
To expand, one of the coverage pillars of malpractice insurance (in the US) is the "standard of care". This is basically what most doctors and their associations consider acceptable, which by definition excludes new, better techniques.
This is both a bug and a feature. A move fast and break things philosophy would cause more harm than good, but it also prevents rapid adoption of incremental improvements.
But if they're employed by a health system and fail to follow company policy then yes, they could be fired.
Ever cardiologist ever will tell you that statins work best when you make diet and lifestyle changes. They tell you that, to your face. It's not a secret. This actually goes for A LOT of medications. Usually, medication + diet and exercise is better than medication alone. They also test medications like this.
I think only recently have insurance companies started covering APoB testing in your annual exams (or that may just be my insurance…).
ApoB is shaping up to be an incremental improvement in measurements, but health and fitness influencers have taken the marginal improvement and turned it into a hot topic to talk about.
This happens with everything in fitness: To remain topical and relevant, you always need to be taking about the newest, most cutting edge advances. If it’s contrarian or it makes you feel more informed than your doctor, it’s a perfect topic to adopt for podcasts and social media content.
ApoB is good, but it’s not necessarily the night and day difference or some radical medical advancement that obsoletes LDL-C. For practical purposes, measuring LDL-C is good enough for most people to get a general idea of the direction of their CVD risk. The influencers like to talk about edge cases where LDL-C is low but then ApoB comes along and reveals a hidden risk, but as even this article shows there isn’t even consensus about where the risk levels are for ApoB right now. A lot of the influencers are using alternative thresholds for ApoB that come from different sources.
> In the end statins reduce the chance of heart attack by like 30% I think. Not bad, but if you have a heart attack without statins, you probably (70%) would have had a heart attack with statins too. That's what a 30% risk reduction means, right?
30% reduction in a life threatening issue is huge. I don’t see why you would want to diminish that.
If you were given the choice of two different dangerous roads where one road had a 30% lower chance of getting into a life-threatening car crash, you would probably think that the choice was obvious, not that the two roads were basically the same.
You could absolutely think that they were basically the same, depending on the base rate. The differece between a one-in-a-million and 0.7-in-a-million is 30%, but it wouldn't be humanly perceivable. We're all likely faced with situations like that regularly. Differing airlines probably have much greater variances in their crash statistics, but it just doesn't matter in 99.99999% of flights.
Meta-analysis conclusion: This literature-based meta-analysis did not find evidence for the benefit of statin therapy on all-cause mortality in a high-risk primary prevention set-up.
There have been a lot of studies on statins. If a meta-analysis comes along and only cherry picks a couple of them, something is up.
Guidance from the National Lipid Association, based on a review of the current understanding of the science across quite a few different meta-studies, analysis, etc. Many of the referenced studies are meta-studies significantly larger than the one here.
We have mountains of studies showing the negative impact of LDL-C (and inflammation! Which statins also reduce) on health. We have mountains of studies showing positive impact from statins. We have specific mechanistic understanding of how LDL-C and other atherogenic particles cause heart disease. We have mountains of studies show that statins directly lower the amount of atherogenic particles you have.
This has been studied enough and sliced enough ways that yeah, there is evidence on both sides. But one side is effectively a mountain range, and the other is a small hill. I know which way I'm going to land on it.
Because this is a recent understanding and healthcare tends to be a conservative industry that moves slowly. Sometimes too slowly.
And also because LDL remains an excellent measure. The risk with LDL isn’t false positives. If someone has high LDL they likely have an elevated risk of heart disease. The problem with LDL testing is that someone with low LDL may still have a high risk of heart disease which may be captured in APoB testing.
Part of this is just that insurance coverage lags science. We've known that ApoB is more accurate than LDL since the 1990's or 2000's, but to be covered by insurance, several more steps have to happen.
First, the major professional societies (like the American College of Cardiology or National Lipid Associations) have to issue formal guidelines.
Then, the USPSTF (US Preventive Services Task Force) needs to review all of the evidence. They tend to do reviews only every 5 or 10 years. (Countries aside from the US have different organizations that perform a similar role.)
If the USPSTF issues an "A" or "B" rating, then insurance companies are legally obligated to cover ApoB testing. But that also introduces a year or two lag since medical policies are revised and apply to the next plan year.
The net effect is that the entire system is 17 years, on average, behind research.
Most commercial health plans will cover an ApoB test for members with certain cardiac risk factors or medical conditions. But they generally won't cover it as a preventive screening for all members. I don't think we have enough evidence to justify broad screening yet, although that may be coming.
I'd love to know where to get the right advice on this topic.
I have high LDL-C, had a heart CT in hospital last week, yet the hospital's cardiologist phoned me yesterday to cancel a scheduled appointment to discuss the results(!), because she said I have zero arterial plaques and there's simply no need for us to meet.
I feel really quite lost with this stuff :/
A zero is still a zero though, and is associated with low risk of heart disease in the near future.
Statins are so good at what they do they even reduce the risk in people who are already at low risk for heart disease.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6...
That prior discussion gives no good reasons. The linked medium posts are, to be frank, trash.
Statins are well-tolerated drugs with little to no noticeable side effects. You might have to try a few. You may need to combine ezetimibe to maintain a moderate statin dosage level, and that's it. (Like the author of this article)
Source: Leading cardiologists worldwide, and doctors of the rich and famous.
I think things haven't changed because most people underestimate how slow institutional scale change is. There is a reason why HR departments and consultants have Change Management experts. The inertia is huge. Young people don't appreciate this because they thrive on new ideas. Old folks don't and will subconsciously push back, like a form of institutional homeostasis.
Also, while I believe your heart attack stats are correct, I'm more interested in all cause mortality. I believe there statins are a net negative.
They also tend to be continued well into old age (off label) despite increasing fall risk, which is way more dangerous to an 80 year old.
If this even ends up being reproduced it at most says there is an easy fix for people taking atorvostatin and that it might be a concern with other statins, but this should be treated with the same health skepticism of any other single study finding.
Not all statins raise blood sugar either - pitavastatin usually shows an improvement in insulin sensitivity.
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If biomarkers are elevated, the question must always be, "why is this elevated", and "is there a natural change in habit and diet that can reverse this elevation".
Artifically lowering the marker with a drug is like pasting duct tape on a leaking pipe - the leak is still there and it will likely quietly get worse over time and then eventually kill you anyways.
I find it unbelievable that our society swallows any drug without second thought. You body produces cholesterol on purpose. There must be reason why it produces it. "Ah well, who cares, let's just throw in a wrench and make it stop producing the cholesterol" and hope for the best...
Statins do not destroy your muscles. Newer statins make this already exceedingly rare side effect even rarer, but let's look at them as a general class:
https://pubmed.ncbi.nlm.nih.gov/36049498/
Blinded RCT/Meta-analysis shows about 11 complaints per 1k patient years, with 90% of them not actually being due to the statin. But because people act like they're common, they mistakenly believe it was the statin, which just reinforces this idea. And that's for muscle pain.
https://www.ahajournals.org/doi/10.1161/atv.0000000000000073
https://academic.oup.com/eurjpc/article-abstract/26/5/512/59...
https://pubmed.ncbi.nlm.nih.gov/15572716/
For actual significant muscle injury? Even lower. 1 or less per 10,000 patient years.
Effectively, you might get one muscle ache per year per 100 people and at most a 1 in 10,000 chance of serious myotoxicity.
As for diabetes, rosuvstatin usually has a neutral to positive impact on insulin sensitivity, and pitvastatin almost always has a positive impact. Some statins do have negative impact, but it's not universal.
It's not like duct tape on a leaking pipe - it's like removing items in a pipe that damage the pipe walls. Yeah, ideally they're not in the pipe to begin with, but removing them is better than letting them stay, and diet and exercise only do so much to remove said items.
Your body can synthesize LDL de novo in the organs that use it, and one of the heaviest users, the brain, can't get cholesterol out of your diet/serum levels at all - LDL cannot pass the blood brain barrier.
There are people with genetic mutations that mean they don't produce LDL, or at least not at high levels - their increased longevity and incredibly rare incidents of ASCVD is what drove the creation of PKCS9 inhibitors.
Statins also lower LDL-C levels - they don't make your body stop producing cholesterol in general, or even LDL-C. Even if your body couldn't make it on-demand where needed, statins aren't going to drop your serum levels to 0.
That's pretty simple to explain. No conspiracy.
LDL-C is much much cheaper to measure. ApoB costs 36x times as much, so Insurance Companies don't like to pay for it
Unfortunately American retail prices might as well be generated by a PRNG, and do not mean much.
On Ulta, a basic lipid panel vs an ApoB test are $22 and $36 respectively. Looking at Indian lab prices, (approx. INR->USD), both are under $10 there.
https://www.ultalabtests.com/test/cholesterol-and-lipids-tes...https://www.ultalabtests.com/test/cardio-iq-apolipoprotein-b...
For anyone under 40, it's expected to have zero calcium. Even a measure of 1 or 2 when you're below 40 would be a bad sign.
It was almost certainly the former, and the former is is basically an indicator that the damage is already done.
Soft plaque takes a long time to calcify. But soft plaque is the stuff that ruptures, and will clog up your arteries just as much.
Statins are best used as a preventative measure - once the plaque is there it's difficult to regress it even while soft, and as far as we know effectively impossible once it is calcified.
I think, in some ways, the trick is being able to short circuit the entire journey represented by this website in favour of some form of, “I’m 40. I should be more mindful of heart disease. I should add a 30 min walk to my mornings.” And then move on with your life.
I think many cultures, but especially American healthcare culture, foment a growing background noise of constant anxieties and stressors. Life is sufficiently complex but there’s always a peddler eager to throw you a new ball to juggle (and pay for).
But yeah I agree with your message. Focus on the big impact macro level things. Hyper-optimizing it is a waste of energy
Beyond just heart disease & cancer taking you out entirely its: my eyesight is going, my hearing, every joint in my body could fail, my brain is slowing, etc.
There is just way too much shit to do anything other than be like: sleep, exercise, eat better and don't drink too much.
You’ll never see a published set of tests from him. What you’ll see is ads to buy his supplements.
1. Exercise (aerobic and strength, doesn’t have to be much but more is better). 2. Diet (mostly whole foods, mostly plants, low saturated fat). 3. Prevention (regular check ups and following doctor’s advice). 4. Meaning / purpose (either being passionate about your job or having such hobbies outside of it). 5. Friends and community.
This isn’t too much. By many that’s the bare minimum for having a satisfactory life.
Absolutely right. You can’t fix everything. But if you can only dedicate time, money, and attention to one thing, cardio health is probably highest impact for most people. This article makes that case. Also it makes the case that there are a few things that will have an outsized positive effect on cardio health and we’d be wise to focus on them.
Dead Comment
Hang on a second.
This guy is making a big big claim.
The central point of his article is that he went to a doctor who followed the guidelines, tested him and found he wasn't at risk for heart disease.
But then he went to another, very expensive concierge doctor, who did special extra tests, and discovered that he was likely to develop heart disease and have a heart attack.
Therefore he is arguing that THE STANDARD GUIDELINES ARE WRONG AND EVEN IF YOU DO EVERYTHING RIGHT AND YOUR DOCTOR CONFIRMS IT YOU MAY BE LIKELY TO DIE OF HEART DISEASE ANYWAY, SO ONLY THE SPECIAL EXTRA TESTS CAN REVEAL THE TRUTH.
I want a second opinion from a doctor. Is this true? Is this for real? Because it smells funny.
Mainstream medicine is hyper optimized for the most common 80% of cases. At a glance it makes sense: optimize for the common case. Theres some flaws in this logic though - the most common 80% also conveniently overlaps heavily with the easiest 80%. If most of the problems in that 80% solve themselves, then what actual value is provided by a medical system hyper focused on solving non-problems? The real value from the medical system isnt telling people "it's probably just a flu, let's just give it a few days and see" it's providing a diagnosis for a difficult to identify condition.
So if your question is "how do we maximize value and profit in aggregate for providing medical care to large groups of people", mainstream medicine is maybe a good answer.
But if your question is "how do we provide the best care to individual patients" then mainstream medicine has significant problems.
Research science in this area has been in agreement for a long time now that ApoB is a more informative indicator than just LDL-C, because there are a variety of different atherogenic particles, not all LDL particles are created the same, etc.
His ApoB numbers are quite readily and apparently out of range. Hell, even his LDL is out of range for the two largest lab providers in the US - Labcorp and Quest both have <100 for their reference range. But the science shows that plaque progression is still generally occurring at levels above 70 LDL-C even with low Lp(a) and other atherogenic particles - the reference ranges are likely to get moved lower and lower as practice catches up with research.
His numbers are well within the range of concern based on pretty universal consensus across the research in this area over the past couple of decades. Preventative cardiologists and lipidologists would almost certainly agree with this concierge doctor.
I also disagree that the 50the percentile is the breakpoint between healthy and unhealthy. There's a lot more to deciding those ranges beside "well half of the population has better numbers"
Maybe he got missed--let's concede that. What about the other 10 or 100 or 1000 or subjected themselves to tests and didn't find anything? Where are their stories?
If you have enough people, the tests, themselves are eventually going to harm somebody.
For example, certain scans require contrasts like gadolinium that bioaccumulates. That's not a big deal if we only pump it into people 2 or 3 times in their lives when something in their body is about to explode. It's a lot bigger deal if we're doing that to them every year.
Here's what the New York Times had to say about it the following year: https://www.nytimes.com/2008/06/29/business/29scan.html
The bottom line is these tests aren't some sort of one-size-fits-all panacea, and nor can they perfectly predict the future. In fact Oprah herself backtracked on it, via an article by Dr. Oz in her magazine in 2011: https://www.oprah.com/health/are-x-rays-and-ct-scans-safe-ra...
A good rule of thumb is don't take medical advice from Oprah or Dr. Oz. But in the case of the latter article, he wasn't wrong.
It’s scarily common in medicine for doctors to start specializing in diagnosing certain conditions with non-traditional testing, which leads them to abnormally high diagnosis rates.
It happens in every hot topic diagnosis:
When sleep apnea was trending, a doctor in my area opened her own sleep lab that would diagnose nearly everyone who attended with apnea. Patients who were apnea negative at standard labs would go there and be diagnosed as having apnea every time. Some patients liked this because they became convinced they had apnea and frustrated that their traditional labs kept coming back negative, so they could go here and get a positive diagnosis. Every time.
In the world of Internet Lyme disease there’s a belief that a lot of people have hidden Lyme infections that don’t appear on the gold standard lab tests. Several labs have introduced “alternate” tests which come back positive for most people. You can look up doctors on the internet who will use these labs (cash pay, of course) and you’re almost guaranteed to get a positive result. If you don’t get a positive result the first time, the advice is to do it again because it might come back positive the second time. Anyone who goes to these doctors or uses this lab company is basically guaranteed a positive result.
MCAS is a hot topic on TikTok where influencers will tell you it explains everything wrong with you. You can find a self-described MCAS physician (not an actual specialist) in online directories who will use non-standard tests on you that always come back positive. Actual MCAS specialists won’t even take your referral from these doctors because they’re overwhelmed with false cases coming from the few doctors capitalizing on a TikTok trend.
The same thing is starting to happen with CVD risks. It’s trendy to specialize in concierge medicine where the doctor will run dozens of obscure biomarkers and then “discover” that one of them is high (potentially according to their own definition of too high). Now this doctor has saved your life in a way that normal doctors failed you, so you recommend the doctor to all of your friends and family. Instant flywheel for new clients.
I don’t know where this author’s doctor fits into this, but it’s good to be skeptical of doctors who claim to be able to find conditions that other doctors are unable to see. If the only result is someone eating healthier and exercising more then the consequences aren’t so bad, but some of these cases can turn obsessive where the patient starts self-medicating in ways that might be net negative because they think they need to treat this hard to diagnose condition that only they and their chosen doctor understand.
- Lipid lowering drugs
- ApoB testing
- Coronary CT (if the pre-test likelihood of obstructive coronary artery disease was estimated to be > 5%)
- Diabetes tests
- Kidney tests
It's crazy that we haven't optimised MRI scans so that they can be routine.
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You listed the risks and concluded “all generally minor.” The benefit is absolutely nonzero. So, what’s the hold up?
And how have the data not caught up? People outside the US are getting the CT scans, while US doctors prefer to lick their finger to guess the weather.
My wife’s last interaction with a doctor: patient presents with back and chest pain accompanied by occasional shortness of breath at the age of 39, doctor reluctantly asks for a EKG - which takes 5-10 minutes and is done in the next room, right away and covered by insurance with a small copay - and has the gall to be surprised when EKG showed subtle abnormalities. If she hadn’t advocated for herself, as the OP argues, doctor would just skip the EKG.
This experience left me thinking maybe doctors are discouraged from asking for imaging and guidelines are there to protect their criminally negligent behavior. I have no proof or even proxy data for the claim about doctors being discouraged from asking for imaging. But it is objectively criminally negligent to not ask for imaging in a case like this.
There is absolutely nothing wrong with getting one CT at a specific point in your life to right a disease which, as TFA states, has a 25% incidence rate.
The smaht ones will now point me to that study of 1-5% of cancers being linked to CT scans. Yeah, sure, but those are not from people who got one-two in their lives.
> I shared these results with a leading lipidologist who proclaimed: “Not sure if the lab or the primary care doc said an LDL-C of 116 mg/dL was fine but that concentration is the 50th percentile population cut point in the MESA study and should never ever be considered as normal.
> It’s also important to note that, according to a lipidologist friend, an ApoB of 96 is at a totally unacceptable 50th percentile population cutpoint from Framingham Offspring Study.
So... the exact median value is "totally unacceptable" and "should never ever be considered as normal"? I'm open to the possibility that the US population is so deeply unhealthy that this is true, but then that needs to be argued for or at least mentioned. Like, you can't say "you're exactly average in this respect" and expect your and that's terrible to be taken seriously without any followup.
Or if I'm misunderstanding what's meant by "50th percentile population cut point" then again, I think this jargon should be explained, as it's plainly not the usual meaning of "50th percentile".
A quick Google says that the Mesa study was actually of people without cardiovascular disease at the beginning of the study. So again, these conclusions don't make any sense to me.
Has the guidance changed that you want LDL less than 2.5x (or was it 2x?) your HDLs?
PKCS9 inhibitors and mendelian randomization studies show that people function just fine with <10 LDL-C. (Other comments I have made in here have links to all the relevant studies)
Googling for statin and aggression links I find a fairly small set of studies with fairly disparate outcomes.
The best thing you can do for yourself is to establish healthy diet and lifestyle habits that are sustainable. A lot of people who jump from obsession to obsession do a great job at optimizing for something for a few years, but when their life changes they drop it completely and fall back to forgetting about it.
Fad diets are the original example of this: They work while the person is doing it, but they’re hard to maintain for years or decades. CrossFit and other exercise trends have the same problem where some people get extremely excited about fitness for a couple years before falling off completely because it’s unsustainable for them. Some people are able to continue these things for decades, but most people do it for a short while and then stop.
I’m now seeing the same pattern with biomarker obsessives: They go a few years obsessing over charts and trying things for a few months at time, but when the interest subsides or they get busy with life most of it disappears.
The most successful people over a lifetime are those who establish healthy habits that are easy to sustain: Eating well enough, reducing bad habits like frequent alcohol or fast food consumption, some light physical activity every day, and other common sense things.
The most important factor is making it something easy to comply with. The $300 biomarker panels are interesting, but most people don’t want to pay $300 every year or more to get snapshots that depend largely on what they did the past week. Some people even get into self-deceiving habits where they eat well for a week before their blood tests because the blood test itself has become the game.
Personal story - I used to be super sporty, 4x gym training during work week - cardio & free weights, climbing over evenings after work, hiking/climbing/ski touring over weekends. Vacations were mostly more extreme variants of the same. Last year broke my both ankles with paragliding, one leg much worse, so took me some 8 months to be able to walk straight again, with some time in wheelchair, then crutches. All strength & stamina gone, flexibility 0, so had to rebuild from scratch and I mean deep bottom scratch from which you bounce very slowly, not some 1 month stop when things come back quicker. If all above weren't my proper passions I would have a hard time coming back to being again more active than most(sans that paragliding, took the lesson and have 2 small kids). That ankle won't ever be same but so far so good, ie managed some serious hike&via ferrata mix 2 days ago.
Really spot on with one of my besties. He does all the tests. He has a concierge doctor. He reads extensively on the topics of fitness and nutrition. And yet he doesn't do any of it. It's just an intellectual exercise for him. And he has had two heart attacks in the last several years. It's so frustrating. I just wanna shake him.
Also with food and drink: place friction between the treat and yourself. The easiest example is to not have biscuits / alcohol in the house.
Bonus tip: alcohol free beer is really good these days.
For exercise your tip doesn’t help me at all. I hate audiobooks and podcasts so that would turn me off more from exercising. Also I want to concentrate on the exercise and not do it halfhearted.
What helped me was to realise how much better I feel after exercising - since then i kinda got addicted to it because I notice how much worse I feel after not doing it for a couple of days.
I agree on the friction. Just not having access to cigarettes is the best way for me to not smoke. I just don’t buy them and bumming one from someone else comes with a degree of personal shame for me that makes me avoid them (in almost all cases).
I naturally don’t like sweet stuff that much - however since I moved from EU to America (not US) it’s been really hard to avoid sugar. Y’all put that stuff into everything it’s crazy; I gotta watch out like a hawk and go to special stores. In Europe it was so much easier, there are always cheap sugar free whole foods available in every supermarket.
While lifting weight I do that since I rest for 90 seconds in between sets, which is actually very boring. I started reading books during that time and that has been a big improvement.
Could you recommendation some good alcohol-free beers, please?!
A permutation that's currently making the rounds in the press (even though the original research is from 20 years ago) is the "portfolio diet":
https://jamanetwork.com/journals/jama/fullarticle/196970
https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.123.0...
Some press mentions:
https://www.health.harvard.edu/heart-health/the-portfolio-di...
https://www.nytimes.com/2025/11/04/well/eat/health-benefits-...
https://www.cnbc.com/2025/11/05/the-portfolio-diet-what-it-i...
Pair this with tight blood-pressure control (aim systolic <130 mmHg) and a healthy BMI—every incremental improvement helps. Together, LDL, BP, and BMI form the most potent triad of interventions most people can implement now and expect to see substantial benefits 20–40 years down the line.
A few references: https://mylongevityjourney.blogspot.com/2022/08/a-short-summ...
What you put into your body: no processed food, cook yourself, lots of variety of veggies and fruits, little meat, little alcohol.
What you do with your body: regular exercise, low stress, enough sleep.
What you do with your mind: good social environment, good relationships.
And an apple a day keeps the doctor away!
They seem simple on the surface but hard part is execution for most people, due to life circumstances and other factors. Unhealthy choices persist because society isn't built around healthy lifestyles.
So while the comment seems helpful on the surface, it misses the forest for the trees.
I think that there needs to be a bigger discussion here, regarding why have we engineered a society that inflicts suffering and illness on so many?
But that loaf you buy at the store? It'll generally be covered in mold before it gets hard, and that's quite the achievement since it also tends to be more resistant to mold as well! Bread should get hard. This is where a ton of old recipes come from. The Ancient Greeks would dip it in wine for breakfast, Euroland has bread soup/puddings, and even stuff in the US like Thanksgiving stuffings or croutons.
Actually they are not. "Practically" is carrying a lot of weight there. The factory baked cake will have a lot more extraneous ingredients and usually has a larger quantity of sugar and fat. Similar to how restaurant food generally has a lot more salt and fat than home cooked food.
If you stepped inside a food factory you would see how false that statement is
> If you only read one thing here, make it the “How to not die of heart disease” section.
Which itself is still quite long but it emphasizes:
> Every lipidologist I’ve spoken with has stressed the importance of measuring and managing ApoB above all else – it’s a far better predictor of cardiovascular disease than LDL-C (which is what physicians are most familiar with). Every standard deviation increase of ApoB raises the risk of myocardial infarction by 38%. Yet because guidelines regularly lag science, the AHA still recommends LDL-C over ApoB. Test for it regularly (ideally twice a year) and work to get it as low as possible (longevity doctor Peter Attia recommends 30-40mg per deciliter). Many lipidologists will say to focus on this above all else.
And:
> I asked several leading lipidologists to stack rank what they believe are the most important biomarkers for people to measure and manage. […], and will likely cost anywhere between $80-$120 out of pocket.
That’s a pretty interesting and relevant part of TFA. Omitting that is not a fair “long story short”, but rather just “different story”.
This is wrong. Our bodies evolved to rend flesh and eat meat. They are optimized by millions of years of evolution to process and run on meat.
The biochemical pathways of carb-heavy diets put more oxidative stress on the body.
is that why we have flat molars? for eating meat?
(spoilers: no, the flat molars are not for eating meat)