Ticker: Don't die of heart disease
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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.
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.
Guidelines also leads to standards of care being random and heavily driven by politics & financial reasons disguised as medical best practice. South Korea and India are "parallel testing" places, which saves time, while the USA & others are serial testing places mostly because of their funding models.
Talk to any American doctor and they will give you a bunch of emotionally wrapped cope about why it's bad because the cognitive dissonance sucks and there are liability reasons to avoid admitting your wrong. I would argue that in many cases, parallel testing is cheaper because $300 of tests is cheaper than 4 chained $500 doctor visits. But whatever.
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!)
This strongly suggests that genetics definitely slips a thumb on the scale, but ultimately we are able to also impact our personal behavior.
More importantly, research such as https://pubmed.ncbi.nlm.nih.gov/31270766/ shows that there are techniques (such as mindfulness practices) that have been demonstrated to improve our abilities in practice. I have personally seen these have an impact.
Of course if you have a condition such as severe ADHD, you might not be able to reach the same level as is possible for someone with good genetics. But you still have the ability to move the needle. If you have a condition such as traumatic brain injury, even your ability to move the needle may be lacking.
But most of us should be able to make a positive change.
If it's 30-60% heritable, that leaves 70-40% to split between personal decisions and environment. It does not guarantee that personal decisions matter much at all...
And then further followed up with a link to research showing that it is, in fact, possible to change. With advice on how to change it.
You've communicated that by ignoring or dismissing the question of whether better outcomes are possible through other means than demanding that everyone follow doctors' orders and blaming them if they don't.
"Who cares if better outcomes are possible, so long as blame is in the right place"? Is that how we want to approach this?
She wanted to change, tried a many multiple of times and it failed. Fault, guilt, blame are useless concepts to use on the Other. And only in moderation should they be applied to the Self. There deep disconnects between what we think, know and do.
Bob the gambler wants to quit and wants to wager, sometimes sequentially and sometimes simultaneously.
The question isn't whether the whole Bob "means it", but which version of Bob we want to ally-with to war against the other, and what conditions or limitations we put on that assistance.
Statins, GLP-1 antagonists, etc isn’t magic, but it changes people’s behavior and bodies in such as way as to diminish the importance of willpower. Thus, it’s not that people are lacking instead our medicine is simply to primitive to help with a wide range of issues.
In 2015, https://pubmed.ncbi.nlm.nih.gov/26551272/ showed that medicating all of the way to normal works out better than medicating down to stage 1 hypertension, then insisting on diet and exercise. And yet my request in 2018 to be medicated down to normal blood pressure was refused, because the professional guidelines followed by the experts was to only medicate down to stage 1 hypertension, then get the patient to engage with diet and exercise. The expert standard of care was literally the opposite of what research had shown that they should do.
I agree that experts should not be accountable for my laziness. But can you agree that experts should be accountable for following standard of care guidelines that are in direct conflict with medical research? And (as in my case) refusing the patient's request to be treated in a way that is consistent with what medical research says is optimal?
My advice would be to "shop around" for doctors, establish a relationship where you demonstrate openness to what they say, try not to step on their toes unnecessarily, but also provide your own data and arguments. Some of the most "life-changing" interventions in terms of my own healthcare have been due to my own initiative and stubbornness, but I have doctors who humor me and respect my inputs. Credentials/vibes help here I think: in my case "the PhD student from the brand name school across the street who shows up with plots and regressions" is probably a soft signal that indicates that I mean business.
Thanks for posting this. While I would generally advise a healthy dose of skepticism for any individual study, this one was very large and seems to be both well designed and executed. While there was a (statistically) significant increase in side effects with more intensive treatments, only about 1% more patients had adverse effects versus the standard treatment group, which seems like a very reasonable risk given the improved outcomes.
I've been trying to get my blood pressure under control recently and was thinking getting down to 12x/8x was good enough, but this has me rethinking that.
not for me. My cholesterol was hovering in the high 200's, then finally hit 300 and I completely freaked out, radically changed my diet, and lost 22 pounds (from 180 to 158).
What did my high cholesterol do ? It did absolutely nothing. ticked down to like, 280.
So I'm on the statins. my total cholesterol went from high 200's to about 150 in a month and was impacting my liver function. so we reduced the statins to a very low dose (5mg three times a week, crazy low). My total cholesterol hovers around 200 now. My cardiologist tells me that the conventional wisdom of "diet and exercise" is almost entirely disproven to have any meaningful effect on lipids these days (though i havent researched deeply).
I would be immensely skeptical of this unless he was talking about something much more narrow, like how there's a fraction of people who have really unfortunate genetics and can only improve their blood lipids with medication.
We have mountains of data showing that diet can massively improve lipids, and the combination of diet and exercise are our largest levers for reducing the risk of heart disease for most people. (There are always some fraction of people who can do everything right but have outlier genetics that require medication anyway, just as some people have outlier genetics and can smoke a pack a day their whole lives and reach their 90s.)
I'd check out the Barbell Medicine podcast for anything related to the intersection of lifestyle and health. They're extremely evidence based with a preference for measurable improvements in outcomes over hypothetical mechanisms.
Relevant to this thread are their episodes on testing and screening, hypertension / high blood pressure, cholesterol, fiber, and the new PREVENT heart disease risk calculator.
I'd also check out the episodes on diabetes, Alzheimer's, fatty liver disease, and health priorities.
I am one of those unfortunate genetic people, sadly, and have had high cholesterol numbers since my early 20s. Most of my older grandparents passed from heart disease. Now in my 40s, have a decent diet, and my numbers are < 100 for LDL. Current (and previous) PCPs have indicated to me that diet will have little effect for me, and that I will likely be on statins for most of my life. Experiments with stopping the statins have shot my LDL numbers through the roof.
The good news is that it's a pretty low dose with decently high effect.
I'm familiar with the genetically high cholesterol thing and when you look at that you see parents/grandparents having heart attacks in their 40's. nothing like any of that in my family.
anyway yes im on the statins and probably need to boost my dose a little more to be below 200.
They are unlikely to get lipid levels down low enough to reach soft plaque regression levels. You need to get sustained levels below 50 to 70 depending on genetics, Lp(a), etc.
If you've lived a healthy life in general and don't have genetically bad Lp(a) this advice is probably enough for you staying that way. If you've spent a significant portion of it with bad lipids for whatever reason, you almost certainly need to go on a combo therapy to get to regression levels.
i don't know how to source that but I recall a few 20 points lower diets making the news over the years
These effects were first demonstrated in 1953. And has been confirmed over and over again since.
So don't discount the value of diet and exercise just because losing weight didn't fix your cholesterol.
still doesnt explain what my cardiologist was talking about, though. he's not the first dr. to tell me that "diet isn't really going to help you much". one dr. said, "if you went totally vegan, maybe it would have a slight effect". so no I didnt go totally vegan.
i think the idea is diet/exercise can make a 20 point dent in your total cholesterol but in practice, not much more than that, if you have total cholesterol over 250 kind of thing.
Accepted medical guidelines not long ago said to bring blood pressure from the dangerous range, to elevated, then encourage patients to engage in diet and exercise. Research such as https://pubmed.ncbi.nlm.nih.gov/26551272/ demonstrated that it is better to medicate all of the way to the normal range.
I personally had specialist in blood pressure follow the old advice around 2018. I asked for further medication, and he refused to give it. In so doing, he was following accepted practice, per professional guidelines. This left me with elevated blood pressure for several years. This despite the fact that when I was personally physically fit (when my blood pressure problems were discovered, I still had my crossfit bod), that did not help my blood pressure.
Guidelines are continuing to evolve. Even today, guidelines about how far down to take blood pressure are somewhat vague in the USA. Many countries stick to the older, higher, targets in who even gets medicated in the first place.
It wasn't until about 2 years ago that I encountered a doctor who was willing to medicate me all of the way into the normal range. Given the 2015 research, I'm very happy about this. But it is far from a guarantee that a random person on HN with high blood pressure will encounter a doctor who is willing to do the same.
That's why I believe that this is not a strawman position. I'd be curious to hear your case explaining why you wrongly assumed that it was.
Second, you are just giving your opinion about doctors. You are not providing evidence. In fact what you claim about doctors is just straight up wrong.
I already gave you a link to a 2015 study that demonstrates what the standard of care was at that point. Here is https://www.aafp.org/pubs/afp/issues/2018/0115/p72.html demonstrating that in 2018, the year I had my interaction, the standards were shifting. With not all major medical organizations endorsing bringing blood pressure down to what the 2015 study said they should.
In fact if you look at the actual AAFP guidance, see https://www.aafp.org/pubs/afp/issues/2018/0315/p413.pdf. Read to the last page and look for "Follow up". This matches my experience. I was brought to stage 1 hypertension, then "nonpharmological interventions" were recommended. Namely diet and exercise.
And now it is apparent that you were dead wrong. My doctor in 2018 was not some rogue jerk. My doctor was exactly following the recommended standard of care put forth in that year by a major medical association.
While the USA has evolved their standards further, that 2018 standard in the USA is still common in many other countries.
But look on the bright side. You just were given the opportunity to learn something.
It's more accurate to say that certain statins have significant side effects in certain patients. Atorvastatin made me dizzy. But I switched to Pravachol and that went away. I switched again to Rosuvastatin and it stayed away.
Not all statins are the same.
Some statins have significant side effect in some patients.
We have many "new" statins that the overwhelming majority of people have no side effects on. Exceedingly small amounts of people have issues with things like rosuvastatin and pitavastatin, and for people that do, repatha and other pcsk9 inhibitors often work fine.
> no downside to a better diet and frequent hard exercise (assuming proper technique). So it usually makes sense to at least try lifestyle modification as the initial therapy.
There is a downside to delaying treatment, and particularly so when they are far out of range, or have spent an extended amount of time out of range.
How many doctors recommend things like paleo diet, intermittent fasting and so on? Not many, I think - most simply focus on calories, combined with the advice that is either extremely generalized ("avoid sugar") or outright counterproductive ("eat 5 - 6 meals a day"). And then they wonder why people can't follow their diet.
Here I described my own experiences: https://ketoview.wordpress.com/2025/11/09/low-fodmap-keto-di...
No doctor wants their patient to have a stroke. But they also only get to meet patients where they are.
I think only recently have insurance companies started covering APoB testing in your annual exams (or that may just be my insurance…).
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.
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...
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.
Financed by who?
This is totally unsourced now but I did a deep dive quite a while ago now and it seemed to me that studies largely found that statins after a heart attack helped all cause mortality (though not by a ton), but if they were prescribed to someone before a heart attack it wasn’t nearly as clear. Considering how they often make people feel it seems like people should be a bit skeptical.
Not just throw a two-line comment disparaging the work of experienced specialists in the field.
For the curious, here are the author affiliations for this study:
Department of Public Health and Primary Care, University of Cambridge, Cambridge, England (Drs Ray, Seshasai, and Erqou); Department of Cardiology, Addenbrooke's Hospital, Cambridge (Dr Ray); Department of Clinical Pharmacology and Therapeutics, Imperial College, and National Heart and Lung Institute, London, England (Dr Sever); Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands (Dr Jukema); and Department of Statistics (Dr Ford) and BHF Glasgow Cardiovascular Research Centre, Faculty of Medicine (Dr Sattar), University of Glasgow, Glasgow, Scotland.
If you actually read the article, you would find the selection criteria and the explanation for the criteria.
First, a preface.
The article was published in 2009. At the time, AstraZeneca, the maker of the controversial statin Rosuvastatin, had been engaged in a yearslong intensive campaign to promote the drug. The editor of The Lancet wrote "AstraZeneca's tactics in marketing its cholesterol-lowering drug, rosuvastatin, raise disturbing questions about how drugs enter clinical practice and what measures exist to protect patients from inadequately investigated medicines"; CEO Tom McKillop [1] angrily fired back. Consumer rights group Public Citizen tried to get the medicine withdrawn for safety reasons; the FDA denied the request [2.]
AstraZeneca prevailed, and Rosuvastatin proceeded to make billions of dollars a year in sales. Today, 42 million Americans take it and in 2015 it was the most prescribed branded drug in America.
Now, back to the article. Most new drugs focus on studying the most diseased patients first and then, if possible, attempt to expand to the (far larger and more lucrative) prevention markets later. Statins are no different. The overwhelming majority of research on statins has been industry-funded, done on patients with CVD. Pharma companies want to expand to a larger market, of course. So there are efforts on many fronts. One was to broaden the definition of CVD or other criteria for starting statins. For example, in 2017 the definition of high blood pressure was successfully changed from 140/90 to 130/80. That bumped up the proportion of US adults with CVD from 36% in 2011-2014 [3] to 48% in 2013-2016 [4], or in other words, added 30 million US adults to the market. Similarly, in 2013 the 2013 ACC/AHA guidelines encouraged starting statins for anyone with LDL-C ≥190 mg/dl "even in the absence of other risk factors" which increased statin use from 31 million to 92 million Americans from 2008-09 to 2018-19 [5.]
Where did these changes come from, what motivated them? Studies, of course. Studies like the AstraZeneca-funded JUPITER trial, which claimed an improvement in the health of participants with even _low_ levels of LDL-C. A lot of this stuff was considered fairly strange, and it didn't seem to replicate. Thus the meta-analysis. Are statins truly useful for prevention?
So, in short: Most studies investigating statins in real depth are funded or influenced by industry. They usually focus on the sickest patients, presumably to get a larger effect size, yet the industry is constantly trying to prescribe to a wider audience - the healthier patients - often on grounds that mainstream health authorities find weak. This meta-analysis was only able to include 11 studies because industry SOP is to study the sickest patients yet prescribe to a wider audience. And as you might then expect: "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."
[1] If the name sounds familiar, it's because Tom McKillop was the CEO of RBS who "aggressively" pursued leveraged buyouts up until its collapse and bailout in 2008.
[2] Here's the 10-year followup on that: https://www.bmj.com/content/350/bmj.h1388
[3] https://www.ahajournals.org/doi/epub/10.1161/CIR.00000000000... "total CVD prevalence, age >20y, both sexes" from Table 12-1 is 36%/92.1M
[4] https://www.ahajournals.org/doi/epub/10.1161/CIR.00000000000... "total CVD prevalence, age >20y, both sexes" from Table 13-1 is 48%/121.5M
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.
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.
If a statin makes you feel miserable, I think any doctor would sympathize with a calculated decision to stop them. There are many types of statins to try though, so hopefully one would work without side effects.
Most with efficacy determined by the proxy variable of LDL-C levels, and with even more questionable results in actual lifetime improvement.
I too really wanted not to be that skeptical about medicinal research. But if I had high cholesterol and a doctor recommended newer statins to me, I don't think I would take them.
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.
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.
https://www.bmj.com/campaign/statins-open-data
So no settled science here.
Unless you consider the BMJ a trash journal of course.
I pointed to this BMJ reference because in the article there is the following: "To help drive down our ApoB, we have statins which do miracles for lipid management. Some people believe that everyone should be on a statin so long as they don’t have adverse side effects."
Most statins prescribed today are not for secondary prevention.
A lot of doctors prescribe a statin immediately on seeing just one measure of "high" LDL without looking at any other parameter or context.
Sorry, that's nonsense. It is a dangerous drug with plenty of side effects. If it had no side effects it would be sold over the counter. The brain needs cholesterol to function. If you artificially remove cholesterol this is what happens: https://www.health.harvard.edu/cholesterol/new-findings-on-s...
And considering serum cholesterol cannot pass the blood brain barrier and that it is all synthesized de novo in the brain makes it an even sillier claim. Your serum cholesterol level does not have impact on your brain's cholesterol levels.
Quite a few organs have the ability to synthesize cholesterol as needed and can do so just fine. Another area where we make use of cholesterol is for synthesizing hormones... but those organs can all synthesize it de novo just fine too.
The new pkcs9 inhibitors have gotten people down to extremely low levels of LDL (<30 and <10!) and found no impact to cognition, hormone production, etc. We have mendelian randomization studies looking at people that genetically do not produce pkcs9 and have basically nonexistent serum levels of LDL, no impact to cognition, hormone production, etc.
https://pubmed.ncbi.nlm.nih.gov/36779348/
https://www.ahajournals.org/doi/10.1161/ATV.0000000000000164
https://www.acc.org/Latest-in-Cardiology/Clinical-Trials/201...
https://www.acc.org/Latest-in-Cardiology/Clinical-Trials/201...
https://www.fda.gov/drugs/drug-safety-and-availability/fda-d...
FDA requires statins to have warnings about potential memory issues.
There are risks associated with extremely low cholesterol: https://www.webmd.com/cholesterol-management/cholesterol-too...
The human body creates cholesterol because it is essential for several vital biological functions. Cholesterol is a key structural component of cell membranes, providing rigidity and fluidity necessary for cellular function.
People reporting things doesn't mean much, because as your own original link mentions, people tend to overreport stuff when they are going to the doctor already for other things. What do actual studies that have controls show? We have human RCTs here that have looked at this very thing - and found no evidence of it.
A random article on webmd also says very little when it contradicts the data we have from human RCTs and provides no sources. The trials I linked specifically looked at the common concerns that people have raised as being possibly related to low cholesterol - and didn't find them.
No one is saying that cholesterol isn't essential - your brain literally won't work without it, among many other things. But there is a difference between serum cholesterol levels and its use in in your body. You do not need high serum LDL-C levels for your body to create cholesterol where it needs it.
Those studies I linked quite specifically check for these concerns on people with way lower LDL-C from PKCS9 inhibitors than even combo therapy of statins and ezetimibe will get most people.
If you want to trust individual anecdotes over RCTs while scare quoting the primary way we advance science in these fields, be my guest.
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.
I turned 50 fairly recently...
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.
Or you could take statins and prevent it from becoming an issue in the first place.
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.
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.
(I'll rant about one guy I know.. was any of this related to statin over perscribing? who can know)
Now that we have your LDL under management isn't it easier to just add metformin and gabapentin into the mix? I mean what are the chances you're not also put on a calcium blocker too?
Now you've got brain fog and sleepiness? weird! we have some modafinil for that but now that you're developing early-stage dementia know that it's progressive.
The PKCS9 inhibitor monoclonal antibodies are an option for most people if they show intolerance to multiple statins - insurance will usually relent at that point.
If your doctor isn't willing to work with you to find the medication that works best for you, then find a new doctor.
It sometimes seems like if you get one, you get the others. That's because all these diseases feed into each other.
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.
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...
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.
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.
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.
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).
Obviously life is more complicated than just one measure. I figure this is just another data point saying BMI is useful for population studies and not great for individual diagnosis.
https://professional.heart.org/en/guidelines-and-statements/...
Highly recommended to search their episodes for anything about health or fitness you've been curious about.
But yeah I agree with your message. Focus on the big impact macro level things. Hyper-optimizing it is a waste of energy
Notably risk goes up with the time spent with bad numbers, so the most leverage you have on affecting your lifetime risk is caring as early as possible.
It's an area under the curve situation. Waiting until you start experiencing symptoms is putting a band-aid on an open wound compared to avoiding injury at all by focusing on high impact habits related to diet and exercise.
Focus on adopting the following habits as early as possible: https://www.barbellmedicine.com/blog/where-should-my-priorit...
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.
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.
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.
Key Takeaway: Get a CT or CTA scan, and if you can afford it go for the CTA with Cleerly.
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.
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"
https://testdirectory.questdiagnostics.com/test/test-detail/...
https://www.labcorp.com/tests/120295/low-density-lipoprotein...
If you think a 100+ LDL-C is normal you're basing things off of significantly outdated information.
Expect the normal range to drop in the coming years as well - the AHA and NLA have both been talking about how this needs to go lower, and the science is robust. See my other comments for study links, the NLA's latest guidance, etc.
If your doctor is only getting concerned at 160+, find a new doctor.
If I die at 90 of a heart attack havjng maintained the ability to live independently up until then, I’d take that as a massive win compared to my relatives suffering through a decade of me with worsening dementia.
You're not sure of whether this is a good idea or not, so you ask various physicians, and the consensus is unanimous: the very suggestion is offensive, do you think doctors are unclean?
A clear conclusion has been achieved.
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.
For the people on the other side, "health at any cost" is pretty much the goal, usually limited by the "cost" side of things, especially in the parts of the world where they haven't yet figured out the whole "healthcare for the public" thing.
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
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.
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.
OP's LDL-C was 116 and this is on the very top end of what Forward Health's report says is OK, their report is wrong, this number is bad.
All the stuff about needing to measure ApoB, needing a high end concierge doctor, and the very long article about measuring 10-20 different numbers and doing more exercise than the guidelines and being at risk of heart attack if you don't do amounts of exercise that the author consider unreasonable etc., some of this may have value, but this all seems to be a lot of very lengthy personal opinion by the techbro author of the post. The key insight is simply that your LDL-C becomes a cause for concern over 100, perhaps even over 70, and he was not as healthy as some tech company told him he was. No surprise there, I will talk to actual doctors instead of using services from "tech forward" startups any day of the week.
ApoB is still a reasonable thing to check though, at least once - Lp(a) is the primary cause of atherogenic particle counts being high when LDL-C isn't the culprit, and it's usually a genetic factor. Having a high Lp(a) will bounce your ApoB up and give you a better understanding of the total atherogenic particle load. You could have fine LDL-C or Lp(a) on their own but the total amount could be enough to be worrisome.
Lp(a) being problematic is definitely less common than it being more or less fine, but it's certainly not incredibly rare, either.
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.
It's crazy that we haven't optimised MRI scans so that they can be routine.
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.
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.
I live in the UK and emulsifiers seem to be added to everything: sauces, yogurt, bread.
However I can definitely listen to a podcast when using a static bike... As long as your heart rate is 75‰
You are confusing two different things.
But on the flip side, even if it isn't ideal, if that tip makes at least one person actually do any kind of cardio at all, even if it's the worst one on the planet, it's still better than nothing.
In fact, I'd probably consider your statement of preemptively shooting someone down like that (imagine being a 3rd reader of the original comment + your response), is massively more harmful to others than parent who at best tried to trick someone into doing bad cardio, which again would be better than nothing.
I do have a hard time with mind muscle connection during weight training if I'm listening to something other than music, though.
Nonsense. Elite distance runners are doing 80% of their miles at essentially a conversational jog with a starkly lower HR than the 20% of intense miles. Cardio exercise under all levels of intensity is optimal, not just easy or just hard.
The majority of your cardio should be LISS unless you have extreme time constraints, but most people can find 30-60 minutes per day to get the recommended time in. This is an intensity at which you can hold a conversation.
If you have time for TV, you have time for watching it from a treadmill.
Peak HN right here. The epitome of confidently incorrect
Could you recommendation some good alcohol-free beers, please?!
[https://brewdog.com/collections/alcohol-free]
[https://www.majestic.co.uk/beer/peroni-0-0-4x330ml-bottles-7...]
Note that not all "zero %" beers are actually zero %... some have 0.5% alcohol.
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.
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.
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!
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.
Humans have eaten complex carbs only for the last 10k years since agricultural revolution. Before that, outside of a small part of Africa, there physically wasn't enough carbs available to say that they made any substantial amount of our diet.
Most ancenstral carbs were uber high in fiber, and very low in glucose (starch) and fructose.
Also lots of roots are edible with cooking, and it looks like we've been cooking for about a million years. Then there's wild rice, cattails, beans, berries, all sorts of stuff.
I agree that most wild plants are high in fiber and low in sugar, but there are are a lot of complex carbs to be had, if you have fire.
Also how much must you eat of these to get enough in order to get enough digestable carbs due to the high fiber content?
> Pontzer, an evolutionary anthropologist who studies modern-day hunter-gatherers, says traditional diets vary widely, and the vast majority of them include a high percentage of carbohydrates.
> For instance, the Hadza, a hunter-gatherer group in northeast Tanzania that Pontzer has studied for the past ten years, spend their days walking eight to 12 kilometers, climbing trees and digging for root vegetables. Their diet consists of various meats, vegetables and fruits, as well as a significant amount of honey. In fact, they get 15 to 20 percent of their calories from honey, a simple carbohydrate.
> The Hadza tend to maintain the same healthy weight, body mass index and walking speed throughout their entire adult lives. They commonly live into their 60s or 70s, and sometimes 80s, with very little to no cardiovascular diseases, high blood pressure or diabetes—conditions that are rapidly growing in prevalence in nearly every corner of the world.
https://globalhealth.duke.edu/news/what-can-hunter-gatherers...
And from another source:
> Because humans initially evolved in Africa, where wild animals generally lack appreciable fat stores (2), it seems clear that they consumed a mixed diet of animal and plant foods, given the apparent limitations of human digestive physiology to secure adequate daily energy from protein sources alone (4).
> Hunter-gatherer societies in other environments were doubtless eating very different diets, depending on the season and types of resources available. Hayden (3) stated that hunter-gatherers such as the !Kung might live in conditions close to the “ideal” hunting and gathering environment. What do the !Kung eat? Animal foods are estimated to contribute 33% and plant foods 67% of their daily energy intakes (1). Fifty percent (by wt) of their plant-based diet comes from the mongongo nut, which is available throughout the year in massive quantities (1). Similarly, the hunter-gatherer Hazda of Tanzania consume “the bulk of their diet” as wild plants, although they live in an area with an exceptional abundance of game animals and refer to themselves as hunters (18). In the average collecting area of an Aka Pygmy group in the African rain forest, the permanent wild tuber biomass is >4545 kg (>5 tons) (19).
> Australian aborigines in some locales are known to have relied seasonally on seeds of native millet (2) or a few wild fruit and seed species (20) to satisfy daily energy demands. Some hunter-gatherer societies in Papua New Guinea relied heavily on starch from wild sago palms as an important source of energy (21), whereas most hunter-gatherer societies in California depended heavily on acorn foods from wild oaks (22).
> In nature, any dependable source of digestible energy is generally rare and when discovered is likely to assume great importance in the diet. Animal foods typically are hard to capture but food such as tree fruits and grass seeds are relatively reliable, predictable dietary elements.
https://ajcn.nutrition.org/article/S0002-9165(23)07053-3/ful...
Evolved to eats omnivorous diets yes no doubts, but to thrive on omnivorous diets, perhaps no. Most people I know thrive on meats and do worse otherwise.
is that why we have flat molars? for eating meat?
(spoilers: no, the flat molars are not for eating meat)
My genes gave me pretty big ones.
>They are optimized by millions of years of evolution to process and run on meat.
We are omnivores, we are optimized to eat everything
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.
The direct impact of those extra ingredients alone or in combination is not entirely clear at this point, aside from building evidence that people whose diets include more of that seem to be less healthy.
Some stuff is BIO, cream or coconut milk are lower fat version, or carrots are are without residual pesticides. Less salt since we use less salt, and taste buds quickly adjust so its still adequately salty, a better mix of herbs and spices so taste is.. simply better, more refined. We use with much less sugar, the same as for salt above (if you eat sweet stuff sparingly then even mildly sweet stuff tastes amazingly, just don't go from one extreme to another).
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.
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”.
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?
Feels like the whole thing could be shortened to just say "here's the tests you run, the drugs you might take, the lifestyle changes you should consider".
I’m located in Europe, so I may have a slightly different view, but my doctors clearly care and discuss with me about prevention, risks, tradeoffs, …
They praise the methods of the „good“ doctors and stamps the others as driven by financial gain. Who says the expensive ones are any better in this regard? Who says they are more or less exaggerating the importance of test results to make you come back?
The worst will basically laugh me out of their office for daring to belong to a marginalized identity or failing to already have the health knowledge I'm there trying to gain from them.
Maybe I have awful luck... but I have very little faith at this point. The most effective relationship I had was with a hack who was willing to just prescribe whatever I asked him for and order whatever tests I asked him for (I think most of his patient base were college students seeking amphetamine salts).
> If you smoke, don’t. It’s going to kill you.
And then this about alcohol:
> I think it’s unreasonable to tell people not to drink alcohol if they like it.
Why is it unreasonable to tell people not to drink alcohol, but reasonable to tell people to stop smoking? Shouldn't the smoking section also get a "at least make sure it’s really good tobacco that you enjoy and don’t smoke too much of it"?
It seems like the personal preferences (don't like smoking, but does like alcohol) is getting in the way of their medical-but-not-medical advice, instead of being able to apply their recommendations equally regardless of what they personally like.
I looked at Germany, according to Wikipedia the average consumption of pure ethanol per person per year in Germany as of 2019 was 12.2 liters. This was the 5th highest in the world, and equivalent to 686 standard 5% beers per year.
According to the WHO “moderate drinking” is 1 drink per day for women and 2 drinks per day for men, so the average German is already consuming above WHO guidelines.
It gets worse when you consider that about 1/4 of Germans don’t consume alcohol at all, and another 1/4 barely consume any, suggesting that the “average” isn’t really telling us much and the 70th, 80th, and 90th percentiles have very concerning consumption numbers. I assume most of those people consider themselves “social drinkers” but statistically they cannot be.
sure if you want to risk it fine, but don't try to claim there is no risk when there is.
As for the other countries: 56% of French either "don't drink" or "only on special occasions", 43.5% of Spaniards never drink or less than 2x per week, and 35% of Italians do not drink compared to 12% who drink daily.
Like it or not the median data point in these population sets are those of people who drink very little.
I hear this kind of phrasing frequently in the discourse nowadays, but it doesn't seem like a useful framing to me. Is there a safe amount of chocolate? A safe amount of sex? Are we supposed to stop enjoying every pleasure of life as soon as someone does a large study with high enough statistical power to show some negative effect on health, no matter how small?
The question is whether the enjoyment we derive from these things is worth the risk, not whether there is a "safe level", whatever that means.
Chocolate is beneficial in moderation as far as we know so not sure why you brought it up. So is consexual sex with repeat partner.
Ironic, since alcohol is classified as a Group 1 level carcinogen by IARC, just like tobacco.
1. https://www.who.int/europe/news/item/04-01-2023-no-level-of-...
It is very difficult to have any level of confidence with the medical industry so my current approach has been to eat as healthy as possible while staying as fit as I can without undue extreme stress.
For fitness I’m obsessed with biking so I do like 90 minutes of endurance/tempo pace 5 days a week and usually a race once a week. Zwift is great with a Tacx when weather is bad (often).
That isn’t a time option for everyone but it is also likely well beyond what is necessary for most people.
I also don’t drink or smoke or vape which I think is important.
Not going to say I’m an expert or an exemplar of health but I am really trying everything I know to do at this stage.
My family has a history of cardiovascular disease despite us doing what we can w.r.t eating and exercise. I’d encourage you to get some tests at least.
My mother similarly was put on statins and is getting a cardiovascular work up (calcium scan) because she now has early atherosclerosis. She eats super healthy and is a former olympic sprinter..
Bonus anecdote: In my free time I do shifts as an EMT with my fire dept (911), that is a big wake up call to wanting to be as healthy as can be. The number of patients I see who are 50+, nearly all are on 5-10+ meds, few are just one 0, 1, or 2. At that age I see type 2 diabetes, hypertension, high cholesterol, and more.
But I would be very happy to do any elective non invasive tests. On the fence about going beyond that until/unless the Dr. flags it as needed.
Elevated LDL-cholesterol levels among lean mass hyper-responders on low-carbohydrate ketogenic diets deserve urgent clinical attention and further research
https://pubmed.ncbi.nlm.nih.gov/36351849/
A few other more recent papers:
https://pubmed.ncbi.nlm.nih.gov/35498420/
https://www.jacc.org/doi/10.1016/j.jacadv.2024.101109
Note: I'm not a doctor.
My father-in-law is more like you. Athletic, skinny, been that way all his life. Heart attack and quad bypass in his 40s.
There are two known harms from scans:
- Radiation. This is why people shouldn't get these scans several times a year, but 1-2 are very unlikely to move the needle. The average radiation from a full chest CT is just under the average dose for ~2 years of normal background radiation. (I don't know if a CTA uses less than average.)
- Acting on something you would otherwise have ignored, where ignoring it might have been the right answer. The main problem here is that it's hard to get a medical opinion saying "you should ignore this" because of perverse incentives: there's an aversion to recommending doing nothing because that could lead to a lawsuit, whereas "overtreatment" will not get a doctor sued. However, you can make a deliberate decision to do this anyway even after getting the scan; seek second and third opinions, consider alternatives, weigh risk versus reward, make a considered decision.
Any decent doctor should be at least following those, and you can pretty easily find them from the major disease-focused organizations.
Importantly, there are also recommendations for how often you see a doctor based on things like age and known disease risk. You might discover you have risk factors that are genetically resistant to lifestyle factors, and the earlier you find out, the more leverage you have to decrease your lifetime risk with appropriate medication.
I'd check out the Barbell Medicine podcast episode on the health priorities they recommend patients focus on: https://www.barbellmedicine.com/blog/where-should-my-priorit...
- Get a regular physical, or at least a blood test. (Don't wait 5 or 10 years)
- If it shows cholesterol issues, get an advanced lipids blood test, which can indicate whether it's caused by genetics (LipoA/ApoB?)
- If eating and exercise alone aren't helping, consider taking statins for cardiovascular health
- Consider a CT scan to check for calcium build-up, which is not reversible (afaik)
fwiw, I think the advice is much more than just "eat well and exercise".
A CAC will show calcified build-up, not reversible (or at least not in any appreciable way)
A CTA will show soft plaque buildup, which IS reversible with a low enough atherogenic particle load. This generally means keeping your LDL-C below the 50-70 range, though if Lp(a) is the cause you'll likely need a PKCS9 inhibitor or an upcoming CETP inhibitor to drive it down.
Also for those who do take blood pressure medication: never quickly change the dosage, and especially never quit taking it w/o supervision!
I've seen several untimely deaths b/c someone ran out of their BP medication and could not get to a pharmacist quickly enough. Alternatively the person became irritated with the medication and simply stopped taking it.
Maybe part of starting BP medication should be the doctor giving you a "safety package" that includes a full month's worth of the drug and is to be put on a shelf somewhere where you can get to it should your usual prescription run out.
It makes zero sense to prioritize one over the other, any more than it makes sense to ignore diet and exercise.
This can happen when we choose to treat otherwise benign issues that would have had few negative consequences for our health or longevities. Those treatments can have negative effects that are worse than the ailment we’re trying to treat.
I know it’s a natural tech-guy impulse to quantify everything and get access to as much data as you can, but that myopic focus can actually lead us to optimize for the wrong thing.
Telling people what to do rarely fixes anything. People need dozens of impressions for those changes to sink in. Friends, family, social outings, commercials, movies, songs all promoting overindulgence won’t be overcome with a helpful pamphlet or nagging.
One person may run an intense soup kitchen 15 hours a day and feel little stress, and another can sit at a computer for 9 hours sending pointless emails and feel tremendous stress.
But being difficult to put into action doesn’t mean the advice is wrong. Sleep deprivation measurably increases cortisol and inflammatory markers. Exercise measurably reduces them. These actions have quantifiable sometimes immediate effects regardless of how we define stress.
How exactly stress corresponds to biomarkers doesn’t matter if your desire is to lower it.
The issue is that many of us don’t pay attention to how we keep our body & mind throughout the day, or do so on a very superficial level. So strain on the body can accumulate for a long time.
“Stress management” is a lifetime skill. It doesn’t come in bulletpoints, it’s as broad as “living happily”.
Edit: That said, this can make the advice “be less stressed” a bit vacuous.
But people do get scared when random health issues flare up and become more conscious of how they deal with stress in life.
So it’s not bad to keep reminding people either :)
“Try not to stress” or “reduce stress” – but how to do that? Stress itself is nebulous, and the countermeasures are inconclusive.
Think of the last time you were angry or frustrated. Did your spouse telling you to “calm down” fix the problem?
More specifically, it’s “change your diet and eat/drink less”, which is the hardest part. Diet’s impact eclipses regular activity, and it’s consequences build up and compound over decades.
People don’t need more facts and information – those are in surplus. In fact, for most people when they receive too many facts, they just glaze over.
The changes needed are trivial
My sister is a hospital doctor and was remotely checking in with my dad’s care team every shift when he got sepsis after TWO different ERs missed pneumonia even with chest Xrays. Mistakes she corrected included getting him off the ventilator after the need had passed and also preventing him from being discharged directly home — instead he went to a rehab facility for 2 weeks. When I arrived after a few days in rehab he would barely stay awake long enough to eat. He went on to make a full recovery.
A leaner cut like tenderloin is fine.
Ultimately you just want to keep the calories you get from saturated fats from animal sources to less than 10% of your daily calories. You can still enjoy a nice steak or burger every once in a while, but they shouldn't be a daily staple if health is a priority.
Try eating the usual health-promoting diet high in fiber and low in saturated fats from animal sources, mostly whole foods, lots of fruits and veggies and legumes and whole grains, lean meats, etc.
After a few months, check your blood work.
Then reintroduce fattier cuts of meat into your diet and see what your numbers do after a few months.
Processed meats are so bad, they should be eliminated entirely from everyone's diet. The World Health Organization has classified processed meat as a Group 1 carcinogen. No amount of it is considered safe.
Unprocessed read meat is still a problem and WHO advises less than 350g a week. Which is 12–18 ounces of cooked meat. 12g is about one adult serving of steak. So you really are looking at 1.5 servings per week of unprocessed red meat to be safe. At most! You probably should try for less or closer to 12g.
And really if you're at a healthy weight, then I'm not sure how helpful this is. Obesity is a bigger risk factor. This is a bit of the elephant in the room for heart health. Not only should we not be eating things associated with heart disease but also we need to keep ourselves at a healthy weight.
yes obesity is bad, as the source enemy of most diseases that kill and are not cancer is inflammation. find a diet that makes you not obese and have low inflammation, that is vastly superior to "Mediterranean diet" or "plant diet" for everyone.
Nitpick: he mentions LDL-C but the test results don't mention that at all. Only later do I see that is "LDL Cholesterol".
https://www.nhs.uk/conditions/coronary-heart-disease/treatme...
EDIT - I misread the comment. It’s never too late to start, just be careful for injuries as that will block your ability to exercise.
The resulting science is then reported as “When you cross 35, your chances of being pregnant immediately drop” or “The brain stops developing at 18” and so on.
Almost nothing in the body is really like this, though. You can quit smoking later in life and it will help. You can eat better later and it will help. You can exercise and it will help. Very few things are “the damage is done”.
The only constraints are that the later you start the more risks you face. E.g. if you first deadlift in your 50s and you decide to follow Starting Strength you’re going to have trouble.
In a real sense, you've spent decades likely increasing your risk unnecessarily when taking action early would have given you the greatest leverage to lower your lifetime risk.
But you can't change the past. If you didn't plant a tree 20 years ago, plant it today and you'll still get some benefit, minimizing any future increase in risk and maybe even lowering it.
You could realistically have almost half your life left before you, and you can still end up being fitter and healthier than you've ever been in your life if you adopt healthy habits around diet, strength training, and endurance training.
However, many people suffer from heart failure which, despite the name, means partial heart failure. The permanent breathlessness gives them a terrible quality of life. They can live with this for decades sometimes but it's not much fun.
You say that as if stroke is orthogonal to heart disease. Much of what prevents one prevents the other.
Being worried about dementia but ignoring things like heart disease, diabetes, poor sleep, getting enough exercise, eating a health-promoting diet, etc. is like worrying about paying for retirement but refusing to save and invest.
There are a handful of high-impact habits that meaningfully lower your risk for the major killers people are worried about: https://www.barbellmedicine.com/blog/where-should-my-priorit...
He got up to make a sandwich for my mother in law, who was very sick, and don’t come back. Massive heart attack and aortic rupture - he was dead before he hit the ground.
My dad had a lot of stress over his career and his share of health issues but found a happy medium and improved his health greatly stating about in his late 40s. He was basically walk/running 2-5 miles a day for several years after retirement. He had a major stroke, recovered somewhat, and then ended up almost dying from a kidney stone and resulting infection. (He could not communicate pain as part of his aphasia.) long story short, he suffered in a lot of ways (pain, disability, loss of dignity) for 4 years before finally succumbing.
In online discussions, we tend to boil everything down to death. Reality is that longer you can put off complications, the better you will be when something more severe happens or you get sick. As you age, each time something happens, your recovery is a little less robust. Go to the doctor, take your statins and take care of yourself.
That's not totally off, but the thing about cardiovascular disease is it affects everything because it's how your body distributes oxygen. Stop distributing oxygen and you die.
That's not to say other organs aren't important, it's just that if you replace "cardiovascular" with "oxygen distribution" it becomes apparent that almost by necessity it's going to include a lot of deaths.
note that I said good life. There are lots of bedridden people, I don't want to be like that. I want to be like the old person still doing things in old age.
Monty Python, "The Meaning of Life", Part VII.
Dick Cheney (former USA Vice President) died a few days ago. Let's recap his publically known health:
- 1978 heart attack, age 37
- 1984 heart attack
- 1988 heart attack
- 1988 quadruple bypass surgery
- 2000 heart attack
- 2000 stent
- 2001 balloon angioplasty
- 2001 implantable defibrillator
- 2005 atery repair vascular surgery, stents behind the knees
- 2006 shortness of breath, hospitalized, blood clot
- 2006 travels everywhere with an ambulance standing by. Accidentally shoots friend. Friend has heart attack.
- 2007 deep vein thrombosis treatment, atrial fibrillation
- 2008 minor heartbeat irregularity
- 2010 January heart attack
- 2010 July Left-Ventricular Assist Device (LVAD) surgery for worsening congestive heart failure.
- 2012 heart transplant, cardiologist said "it would not be unreasonable for an otherwise healthy 71-year-old man to expect to live another 10 years".
- 2025 death, age 84, from complications of pneumonia and cardiac and vascular disease.
Or President Dwight Eisenhower:
- 1955 heart attack
- ? heart attack
- ? heart attack
- 1968 heart attack, heart attack, heart attack, heart attack
- 1968 cardiac arrest, cardiac arrest, cardiac arrest, cardiac arrest, cardiac arrest, cardiac arrest, cardiac arrest, cardiac arrest, cardiac arrest, cardiac arrest, cardiac arrest, cardiac arrest, cardiac arrest, cardiac arrest
- 1969 death from heart disease
Definitely not the best way to die. Heart disease is palpitations, fibrillation, chest pain, back pain, angina. It's leg swelling, breathlessness, dizziness, fatigue, slow wound healing. It's statins, beta blockers, stents, pacemakers, defibrillators, coronary bypasses, valve replacements, open heart maze scarring, angioplasty. It's not all widowmakers and sudden death. I would pick one of those "fell alseep and didn't wake up" things.
A frustrating thing about this suggestion -- if I tell my physician (I live in the US) that I want these unusual tests prescribed, s/he would scorn at me (as if I'm acting like a know-it-all and am questioning his/her wisdom attained through years of medicine school and practice).
I truly don't understand about US healthcare is why we allowed medical practitioners to put up barriers around medicine (sure, ban opioids,chemo drugs and maybe a handful of other toxic-with-low-dose meds) and testing by requiring everything doctor's prescription?!
For example, my wife had an swollen eyelid (through infection) recently. She is an oncologist in training (is a board-certified internal medicine doctor). She knows how to treat it -- by putting clean, warm cloth over her eyes to allow pores to expand and let secretions seep out (to treat the symptom); by adding anti-bacterial eye drop like Tobramycin ('mycin' means it's Penicillin-variant, which is usually used to treat bacterial infection) OR by taking antibacterial medicine like Azithromycin. If we were in our home country (in SE Asia), we'd just go to a nearby pharmacy and buy either the anti-bacterial eye drop or pill, and get it sorted. Since we live in the US (for now), my wife has to asked one of her coworkers to prescribe her the medicine (she wasn't sure if she can self-prescribe because we just moved to CA and don't want her to lose her license). Then she took the anti-bacterial pill three times (with the warm cloth treatment for symptom), and the infection was treated completely.
I strongly believe that this kind of infection treatment or self-prescribed blood tests should be allowed without any doctor prescription. Otherwise, it only adds more (unnecessary) patient volume to doctors, clinics and hospitals. I remember reading someone from India advocating for similar approach on HN or Reddit a year or so ago too. In India (just like my SE Asian country), they could just go buy medicines over the counter from a local pharmacy. No doctor's prescription needed (maybe the law is there, but it's not enforce strictly).
Younger guy. Keeps up with the research. Is interested in hearing about the research. He'd recommended statins to me when I first started seeing him, but I really wanted to see if lifestyle/diet modifications could help - I didn't succeed long term. He was supportive. I came back a few years after and mentioned statins again, but that I was particularly interested in pitavastatin because it looked to have the best side effect/positive effect ratio. I also said I'd like to try to target an even lower level moving forward, even if pitavastatin would likely get me in range, and he agreed that the research showed this should be a positive, so he added ezetimibe.
As noted in the other comment, in most of the US you can just walk in to labcorp or quest or another provider and get tests done without a doctor. NY is to the best of my knowledge the only exception here. The providers have them for order on their websites, and you can usually go through places like jasonhealth or privatemdlabs to get even lower pricing for the same labs at the same places.
This isnt even remotely correct. Penicillin is derived from a fungus, the -mycin antibiotics are derived from various Streptomyces bacteria.
Actually, V02 max is best improved through High Intensity Interval Training (HIIT) like doing 400m sprints 8x with a couple minutes rest inbetween. V02 max is famous for being one of the best predictors of longevity.
Zone 2 training (light jogging) is important in tandem (80% of exercise ideally), especially for overall cardiovascular health and lowering heart rate.
Best thing I ever did for my health was start running (mostly jogging) 4-5 times a week. It's amazing how much your health can be improved with 4x 45 minute jogs (just 3 hours/wk). I can consume practically any caloric food for needed energy and all my health metrics have been substantially linearly increasing since I started.
"the stuff that’s not good for you: pasta and pizza and bread."
Tell that to the paragons of fitness in marathon running or olympic swimming. There are none of them on low carb. The best cardio health requires cardio exercise and cardio exercise requires carbs as energy. Of course if you're not going to exercise and are okay with 50th percentile health, ya carbs will hurt you then because youre not using them.
My guess is the latter
- up to a 60% reduction in LDL cholesterol, with sustained reductions at 52 weeks;
- a 53% reduction in non-HDL, a combination of all types of cholesterol except for HDL (“good cholesterol”);
- a 50% reduction in ApoB, a protein that helps carry fat and various “bad” types of cholesterol throughout the body;
- a 28% reduction in Lp(a), a different type of lipoprotein that is structurally similar to LDL, determined by genetics and a risk factor for heart disease; and
- a similar rate of serious side effects (10% in enlicitide vs. 12% in placebo), a small proportion of participants left the study early because of side effects (3% vs.4%, respectively).
https://newsroom.heart.org/news/investigational-daily-pill-l...
Blocking PCSK9 isn't new, but thus far only available as an injectable:
https://my.clevelandclinic.org/health/drugs/22550-pcsk9-inhi...
"Ouabain /wɑːˈbɑːɪn/[1] or /ˈwɑːbeɪn, ˈwæ-/ (from Somali waabaayo, "arrow poison" through French ouabaïo) also known as g-strophanthin, is a plant derived toxic substance that was traditionally used as an arrow poison in eastern Africa for both hunting and warfare."
It was later found naturally occuring in the human body:
Key Paper: Gottlieb SS, et al. "Elevated concentrations of endogenous ouabain in patients with congestive heart failure." Circulation. 1992;86(3):846-849. Details: Researchers measured plasma EO in 21 patients with severe heart failure (NYHA class III-IV), finding mean levels of 1.59 nM—over 3x higher than in controls. EO correlated inversely with cardiac index (r = -0.62) and positively with mean arterial pressure, but not with atrial pressures, suggesting a compensatory role in cardiac output regulation rather than simple volume overload.
Most doctors recommend against these and against the full body MRI one can get because they believe you’ll always find things you don’t expect and that will make you indulge in interventions that have weak support, resulting in deleterious iatrogenic effects.
I found that I had no such impulse with the data I had. But a friend of mine, supplied with evidence of a little arrhythmia went through a battery of tests and experimentation. He was in line for getting a cardiac ablation when he finally quit his job and stopped having the problem. So I get why they say that. There’s people like that.
Anyway, if you’re curious what you can get for $800 email me and I’ll post here. I’d do it proactively but I’m traveling so it will take a little work.
Majority of calories on a Mediterranean diet come from carbohydrates. I think the author meant “light on processed sugars (unless warranted by a high endurance training volumes)”.
"High-sensitivity C-reactive protein (hsCRP) is an inexpensive and widely available blood test. While there has been debate within the medical community regarding the utility of hsCRP, this statement details the data confirming its value in clinical decision making in primary and secondary prevention."
https://www.acc.org/latest-in-cardiology/journal-scans/2025/...
Came back here and read all the cynical and critical comments, felt a lot better.
Thanks guys.
Don't know why his behavior wasn't noticed more in the comments but he's absolutely entitled.
Hospitals and everything have limited resources, by being the asshole who request things to go fast for him and only have the best of the best to practice on his daughter, he just deprived someone else daughter from good care.
This is selfishness, unless the nurses and doctors were napping, he shouldn't have that kind of behavior detrimental to everyone else. I couldn't read further what he got to say but, coming from this man, i don't see how it could be interesting or useful.
I don't have anything to prove it but the whole thing smell fishy, when he goes to these 'concierge doctors', of course they are going to find things that are not right and were 'missed' by his regular doctor. That's literally their business.
if you went there and you were told 'nop, everything is fine. Keep doing what you do', you would go back to your GP and forget about it. But if he frightens you with bloodwork that show 'not optimal' in big red, tells you how wrong your gp is and how you should listen to him, you're going to think this guy know so much more and deserve my money. It's business.
I trust the national health guidelines: eat healthy, do at least 30 min of activity per day and lift weights.
Everything else feel like nuisance, especially coming from folk like that.
Life or death procedures aren't a time for "you get what you get and don't have a fit."
I believe you have the right to say it when things are not right, but there is a fine line between that and the behavior he described.
And he wrote that he went to an expensive hospital, this isn't some low tier hospital filled with under qualified, under staffed personals.
I agree with most of what the author wrote, even a decent amount in the paragraph in question, but not wanting residents to get hands on experience while under the direct supervision of experts just because it is you or a loved one on the receiving end is not a reasonable ask. You have to do things to become an expert on doing them, and that means someone has to be on the receiving end of someone with little or no experience doing them. They get experience doing similar procedures in lower risk settings, etc., but eventually when it comes time for someone to do their first lumbar puncture on an infant, it's better if they're doing it under the watchful eye of someone who has done many.
If you've got a serious condition, you really do need to have a patient advocate, whether that's yourself or a family member or someone you're paying to fulfill the role or some combination thereof. The medical systems I've encountered for non-trivial care (US HMO, US PPO, Belgium, Norway) just aren't designed for holistic patient care. Each department does their own thing, and it's just luck if there's someone watching over the whole process from the individual patient's standpoint.
Perhaps you took exception to the comment about looking for an expert instead of a newbie (a resident, in the text) working on the author's 9-month-old. One could argue that that's a different issue than the general need for a patient advocate. Fair enough. But if I were watching out for my 9-month-old, I'd definitely want to ask about the track record of each of the doctors in the room. I mean, sure, new trainees need to practice somehow and all, and there's a tragedy of the commons there. But I certainly wouldn't brush someone off as "absolutely entitled" just because he wants the best care he can get for his 9-month-old.
I always thought that you got to choose wisely people that you need their expertise, especially in healthcare, but once you picked one hospital you got to commit and let them do their job.
I understand it's not easy when you are in charge of a 9 month old but you got to suffer through that.
If someone was to go so wrong that even an untrained eye could see, it's different.
Maybe I didn't have my fair share of bureaucracy. Maybe my standard are too low.
I sure did have my fair share of mistake when I went to emergencies, undiagnosed broken bones for instance. I never thought a second about requiring 'better' doctors, more competent nurses or more attention. I just accepted that it's thing that happens and nothing is perfect. Went back to the hospital 2 more times and eventually got everything back in order.
The reason the status quo doesn't work is that people don't actually follow the guidelines set
Barely anyone (like 10% last I saw) meets the recommended amounts of fruit and vegetable intake or exercise. We're all addicted to terrible foods, are sedentary, have high blood pressure and are overweight
Before you start micro optimizing everything just fix your diet, avoid saturated fat and sodium and get enough moderate intensity or better exercise every week
The 95/5 of it is just basic stuff everyone knows and yet barely anyone does
No, you should not be scared of this. Those are the wrong words to use for what this site is promoting. Conscious choices are much better than settling for fear.
So, if you hit the point where you already had a heart attack, you really want to prevent any further damage, but the "accumulated" risk is still there.
I think that's part of what makes LDL so tragic. You should care about it your whole life, but when you are young, you just don't.
Worse, high LDL is becoming a thing in children as well, that's an extra decade of accumulation which has historically not happened.
I don't think people should panic about these things, but I think it highlights the importance of developing good habits early, and the role parents and society has in making those habits easy for young people to adopt.
I like this list of experiments by Greg Muschen: https://x.com/gregmushen/status/1924676651268653474
When I started building an ECG Holter in my early 20s, I tried to get some friends to use it and kept hearing "yeah, but it’s not exactly sexy to wear that thing." That’s when it hit me how little people care about prevention until something goes wrong. We still have a huge awareness gap to close.
That was years ago. I have different doctors now but still no calcium scan. Time to ask again possibly.
I've now been on rosuvastatin and ezetimibe for several years with zero noticeable negative effects. I'm hoping that this with other behavior modification can help stave off further damage for a while.
(I think that's what the stats mean, right? I'm open to correction on this. I do believe the statin studies, I'm not a science denier. I think what I've said matches the science, as far as I understand.)
I think a pragmatic approach would be to try them if warranted by testing and be prepared to stop or change them if it has issues.
We're learning more and more about the mechanisms of cholesterol and there's a variety of medications out there: https://www.heart.org/en/health-topics/cholesterol/preventio...
And that doesn't address the role that fiber plays in managing it (and the virtues of fiber for health in general that are coming to light at a rapid clip)
I'm coming up on two years unemployed and feel like an idiot for not better preparing for ageism in our industry. I foolishly assumed that experience would make up for age.
Don't make the same mistake! Plan to have most of your income shrink drastically in your mid-40s.
If everyone did that, the whole system would grind to a halt. Doctors aren't in a rush because they enjoy so, they are because they're already overworked. 1 out of every 25 patients (their family) demanding extra attention is possible although still a burden. 21 out of every 25 is not possible.
My takeaway: if bloodwork were broader, covered more markers, there would be one less reason to have to advocate for your own health.
I find it odd that you would instead "advocate" for not being an advocate for your own health? Are we waiting for a friend to say, "Hey, you're looking a little rough."
If you are "looking rough", unless you are in imminent danger you should just go to the GP. Your GP is there to triage care. He'll recommend whether you need something prescribed from the pharmacy, a blood test or see a specialist.
If you get refered to a specialist, the hospital will try to ascertain if you need a really experienced specialist or if you have a relatively simple case that can be handled by one with, say, 11 years experience. If he decides the case is too complex, he can ask the more experienced specialist to preside.
If you short-circuit that and demand to be seen by the most experienced specialist, you are robbing a patient that might need that experienced hand of extremely valuable care, when you could have done with less. Like I said, egotistical.
> My takeaway: if bloodwork were broader, covered more markers, there would be one less reason to have to advocate for your own health.
Blood work needs lab workers who also have limited time. They could indeed do 10 tests but that means more labs and more lab workers which increases costs, which are already exploding. Better tests would be good.
ALL individuals (both youth and adults) should meet and/or exceed the following:
150 to 300 minutes per week of moderate-intensity aerobic physical activity, OR;
75 to 150 minutes per week of vigorous-intensity aerobic physical activity, AND;
Resistance training of moderate or greater intensity involving all major muscle groups on 2 or more days per week
</quote>
This boolean expression needs some parentheses...
Both granddads died in their 50s from heart attacks. I’m convinced I have an issue with my circulation but the blood tests I had done doesn’t seem to cover everything stated here.
Edema in the lower legs is a relatively common side effect of some types of blood pressure medication. If you are on BP medication, talk to the prescribing doctor about it.
If you aren't on medication, you should discuss starting something with your doctor. High blood pressure is a risk factor for many things you dont want to happen and is very treatable. (Of course, the standard health advice to improve your diet and exercise more very much applies here as well).
=> heart panel plus
https://en.minu.synlab.ee/heart-panel-plus/
I don't need doctors, I can get ChatGPT to analyse the results.
But a great article with really great suggestions. Too bad there's not better medical care by default but good to hear that we can take control.
Ordinary people don’t need to be obsessing to do better.
Can't help but feel this is a factor of the sleep deprivation that doctors seem to celebrate.
Clarification: Colchicine has been used by humans for over 3000 years. What's new is its use for cardiovascular disorders.
For reference, radiation levels:
Chest X-ray: ~0.1 mSv (millisieverts)
Head CT: ~2 mSv
Chest CT: ~7 mSv
Abdomen–pelvis CT: ~10 mSv
CTA (angiography): often 10–20 mSv
Are there non X-ray diagnostic imaging scans that can detect arterial plaque?
Interpretation: • < 2.0: Insulin sensitive • 2.0–3.9: Moderate insulin resistance risk • ≥ 4.0: High likelihood of insulin resistance
Your ratio = 5.0 → Suggests likely insulin resistance.
> In early 2023 during a routine skin check at my dermatologist [...]
Are routine skin checks a thing?
> [...] I’ve spoken with several of the world’s leading cardiologists and lipidologists [...]
How come?
If you have a dermatologist, I would imagine so.
Is having someone you can describe as "my dermatologist" a common thing? Probably not for most people who don't have a chronic skin condition of some kind, I would think.
"Yes, the article discusses hypertension, referring to it as "high blood pressure.""
I've forgotten that blood pressure is another word for it, as all medical papers use hypertension.
Thanks!
Why the f* not.
My in-laws are over 95. They refuse to go to an elderly home and as a result make everyone miserable, starting with themselves and inflicting infinite suffering on their children who each have a family of their own, and need to take care of them all of the time.
I don't want to do that to my own children. I don't want to not die. I don't esp. want to die but I'm not really afraid of it, it's just a normal part of life.
Preventing heart disease is probably a good thing, but if one prevents every ailment conceivable then how does this work eventually?
It might be easier to do this for someone else, but it seems narcissistic to assume I of all the patients is so special. If there’s nobody to advocate for me, clearly I’m not!
Let’s say I try it anyway. I tend to be a slow rational thinker in real-time situations, especially under pressure. If I try to advocate for myself and ask questions, I would need to have time to consider the responses (did I even get the information I requested, what are the implications) and maybe do some research in order to make an informed choice as to whether to proceed or not, or whether to ask further questions. However, if I actually request time and have people wait for me, I enter a high-pressure mode in which I can’t think well. The clock is ticking, the stakes are high.
Even if it’s a simple routine case, I am entrusting myself to people who have the power to kill me. If it’s anything beyond routine, killing or harming me may not even be consequential to them (mistakes happen). It is a very particular type of situation.
The natural thing for me to believe is that all of these people are professionals. If I have reasons to supervise them, it automatically implies I believe they are either unprofessional or malicious, in which case I really should not be there in the first place. The arrangement is that I am not supposed to know better than them. If I try to supervise them, that implies I think I do. At worst it would be disrespectful or offensive and would make them hostile on a personal level (which is always at play between humans, regardless of the protocol), at best it would make me look like a crackpot not to be taken seriously anyway. Besides, if I already assume they make mistakes or are unprofessional, their answers can be false anyway.
On the other hand, I am aware that many, many mistakes are made in hospitals daily, so I know they are not such infallible professionals.
As a result, this makes me very reluctant to go to a hospital or a clinic for any reason. It’s probably bad.
Anyone has advice for overcoming this? Maybe training to think quickly and finding ways out in high-stakes situations like this? Tricking yourself into a mode where you feel natural advocating for yourself and act in a way that makes people treat you seriously without being offensive to them (considering the power they have over you)? Learning to not care what people think in a healthy way? (Please don’t suggest LLMs.)
unfortunately, depression cripples my motivation to do physical activity
I still do some, but it's never enough
Reading it I couldn’t help but feel the author relied on ai research tools and is now passing that along to everyone reading as if it’s proven fact. When they link out to an ai search engine that’s not helpful when trying to cite sources.
Saying "LLM bad, human good" is both false and uninteresting.
I checked Jared Hecht (the author of this piece’s blog) at jared.xyz and the oldest piece is from March 2023. Why should we give someone who has no evidence of writing anything before the release of ChatGPT the benefit of the doubt that their work is all human written, when all signs point to otherwise?
It's like calling someone a witch in historical times. By the way, your comment looks to be AI generated, so please do us a favor and stop generating more slop.
And the second best time is now.
Like the article says this is only one of the many causes you could possibly work to prevent and if you die of something else then all that effort was for naught. Whereas if you put all your effort into living a worthwhile life then it doesn't matter what you die of or when.
I understand this man has kids he wants to live long for and that makes optimizing for living a long life worthwhile to him. But I don't think that a long life should be the goal in and of itself, it should be to live a worthwhile life.
Also, given the preferences you expressed in your comment, you especially should want to avoid strokes, or the many side effects of heart disease, which can make you less healthy for a long time.
But since I have a PhD in computer science in a relevant subdomain, I can certainly judge the part where he recommends the following:
> What should you do with your test results? Throw them into ChatGPT, of course!
Do not count on anything coming out of ChatGPT for medical advice. Period.
It feels like the guy had a... mediocre GP, got scared by skin cancer diagnosis and over-corrected to most expensive path possible and since stuff was found out we have this article, roughly correct but written in a sensationalist (or freaked out) style. Some claims are outright false (like GPs not knowing heart disease is the biggest killer... really).
Wife is a doctor with overreach between public and private healthcare, and those private services also have their own motivations which aren't often straightforward help-as-much-as-possible, rather milk-as-much-as-possible with tests, scans, long term treatments and so on. Especially CT scans pour non-trivial amount of radiation on the body that on itself can cause cancer down the line.
With public healthcare you at least know primary motivation isn't cash flow but helping patients, the issue is rather overwhelmed resources with limited time per patient. It always depends on individual, as with engineering there are better and worse, yet we all somehow expect every single doctor to be 100% stellar infallible expert with 150 years of experience across all branches of medicine (absolutely impossible for any human being). Look around at your work if you are an engineer and perceive the spread of quality/seniority of each colleague. Same happens in medicine, just stakes are (much) higher.
Back when 3.5 came out I gave it some information about me when I was a teenager on a condition that (multiple) doctors totally misdiagnosed. It immediately told me three tests I should have done, two of which would have diagnosed it right away. Instead, I had to deal with extreme fatigue for over a decade until I finally did research on my own and had those same tests done.
As far as test results go, right now we’re dealing with our dog having increased thirst. She’s been on prednisone for a year, and that’s not an uncommon side effect. We brought her in to the vet and they tested her and diagnosed in as stage one kidney disease, with no mention of the prednisone. I put those results and her details into ChatGPT and it told us it could absolutely be the prednisone, and told us we could use an inhaler for what we were using the prednisone for - chronic bronchitis. Our vet never offered than option. We’ll find out in a few months if she actually has kidney disease or not, but chances are it was just the prednisone.
As a bonus, the vet before this one diagnosed her bronchitis as heart failure. They didn’t run any tests, scans, etc. Just “sorry, your dog is going to die soon.” What a fun week that was.
ChatGPT is an amazing second opinion tool. Obviously you need to ask it neutral, well formed questions.
I have seen past comments here debating many relative basic concepts on medicine. Please don't take medical advice from engineers. Drink water, exercise, eat well. Otherwise seek medical advice from a doctor.
Thanks!
I love the idea of knowing biomarkers but have trouble with what I might do with them. Yes there are specific actions, but then what? A lifetime of SaaS to monitor?
Planning to ask my doctor for expanded tests in upcoming physical - definitely exploring everything I can.
But, doing basics too. Lot of exercise. Weights. Good diet. Get min 7 hours of sleep if possible. Try not to be a maniac filled with stress.
As far as heart disease goes, yes, it's the big killer and it's time people started waking up from the media haze, but to do that, you have to admit you were wrong, and for many, that is far too tall a hill to climb.
Giving out nicotine gum , would decimate the drugs industry, but likely resolve a lot of our chronic health and depression issues.
Is this not under-reported? I have known several people for whom smoking appears to be truly necessary. One said he was prescribed smoking to control his "shakes".
If you can get time off work and have a PPO, you can get the preventative care.
The big levers anyone can do (but most don't) are:
1. Exercise regularly (anything aerobic)
2. Minimize your saturated fat / cholesterol intake
That's a better tl;dr than the useless one presented in the article.
This was a good read until they recommended using ChatGPT instead of working with your doctor. Also they have some delusion about the actual cost of using ChatGPT.
> Pretty incredible. Also free.
Not free at all. Not a good idea to feed a private corporation your health data!
it’s honestly not as bad as y’all think
ChatGPT isn’t perfect but neither is your doctor (or your lawyer or accountant)
We are all going to die one day.
When I was younger, I would fret over this kind of article. Great, one more thing I have to worry about. Now I just mostly ignore it. It's impossible otherwise. If I dedicate hours and days and months to all the heart best practices, what about when the liver, esophagus, kidney, bladder, brain articles come out?
We all know the good practices. Don't be a dumbass. Don't drink too much, exercise and so on. Besides that, I'm very much going to be reactive, as the article cautions against. I just don't have time or mental energy to do otherwise.
In theory yes, but in practice we are all dumbasses to some extent.
I used to have your attitude until I saw a friend die of a heart attack at an early age - and it appeared to me that he would have survived if he had an indication. So, now I have changed my attitude to one of more data does not hurt.