I am not a statin skeptic--or rather, I don't want to be a statin skeptic. I've done the research and it makes sense to me, but I still feel some social and psychological pressures to reject statins.
When I see that it is widely accepted that ApoB is better to measure than LDL-C, but the industry continues to measure LDL-C, but not ApoB, I wonder why. It makes me skeptical.
When I see that the purpose of statins is to reduce plaque buildup in the arteries, and that we have the ability to measure these plaque buildups with scans, but the scans are rarely done, I wonder why. Like, we will see a high LDL-C number (which, again, we should be looking at ApoB instead), and so we get worried about arterial plaque, and we have the ability to directly measure arterial plaque, but we don't, and instead just prescribe a statin. We're worried about X, and have the ability to measure X, but we don't measure X, and instead just prescribe a pill based on proxy indicator Y. It makes me skeptical.
In the end statins reduce the chance of heart attack by like 30% I think. Not bad, but if you have a heart attack without statins, you probably (70%) would have had a heart attack with statins too. That's what a 30% risk reduction means, right?
As you can see, I'm worried about cholesterol and statins.
If you fix it without statins through better lifestyle and diet, that is the preferrable route.
As to why medicine is like this, it's because it's conservative, usually about 17 years behind university research[0], and doctors are shackled to guidelines in most health systems or risk losing their licenses. It isn't a coincidence that the article author had his out-of-pocket concierge doctor tell him the more up-to-date stuff.
I have an objection to the "better lifestyle and diet" approach.
Sure, it is absolutely true that better lifestyle and diet has a huge effect. However it is absolutely certain that the vast majority of people who are told to improve their lifestyle and diet, won't.
The result is doctors giving advice that they know won't be followed. And thereby transferring potential fault from the doctor to the patient, with no improvement in actual outcomes. "I told the patient to lose weight and maintain that with a controlled diet." And yet, most people when told to diet, won't. Most people who start a diet won't complete it. And most people who lose weight on a diet, have the weight back within 5 years. Where each "most" actually is "the overwhelming majority". And the likelihood of the advice resulting in sustained weight loss probably being somewhere around a fraction of a percent.
What, then, is the value of the doctor giving this lecture?
(Disclaimer. I have lost 20 of the pounds I gained during COVID, and am making zero progress on the remaining 30. A few months ago I successfully started a good exercise routine. Given my history, I would expect to only follow it for a few years before falling off the wagon. I believe that this poor compliance puts me well above average. But do you know what I do reliably? Take my prescribed medicine!)
Your health is ultimately your own responsibility - it's your body. You have free will, and your appetite for risk is yours alone. You can choose to ignore expert advice and refuse to wear a seatbelt, skip your rehabilitation exercises, invest all-in on crypto, or smoke cigarettes. None of this responsibility should fall on the expert if they communicated the risks clearly.
What you're communicating here, perhaps unintentionally, is that what matters is not results, but blame. If the doctor said what to do but the patient didn't do it, all that matters is the patient is to blame.
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?
Struggling to change is different from not wanting to change. People seem to have trouble with basic distinctions like this when they're heavy into moralizing failure to change.
Profound point. My mother struggled with alcoholism and ultimately succumbed to that disease. In philosophy of mind they use “akrasia” and “akratic thinking” for acting against ones better judgement. It helped me somewhat getting to understand what my mother was going through at that time.
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.
I find it helps to explicitly abandon the expectation that each person has a unitary and consistent will.
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.
Reading this thread it seems like you're the only one moralizing and looking down on people. I don't see anyone here shaming people for their choices. But somehow you seem to have read the worst interpretation of every reply.
Drugs expand what helping yourself means to the point where people will actually do so.
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.
Or, as we're becoming aware with GLP-1 drugs, an injection. (For now!). It's better to help people behave better with drugs than moral condemnation. Almost infinitely better, as it turns out, regarding a lot of problematic behavior regarded as "untreatable" previously.
It may not be the case for statins specifically, but my main concern is side effects. If there was a panacea, I would support giving it to everyone, but lifestyle changes are usually more available, if not easier.
Yeah this prickles my hackles too. It took a fairly high dosage of zepbound and many months for me to get to a normal set of eating habits after a couple of decades of bad, but a prediabetes scare surprise on my labs pushed me into the program, but I would not have done it by "white knuckling". I needed some medication to help me along. All these people just saying "calories in and calories out" "just start exercising dude" are making a complex issue into a "simple solution" that almost never works because change takes time; a lot of time that many people don't feel on a deep level that they have to apply to it. So, they just give up after a couple of weeks of "grit" and "will-power". Isn't it like maybe 1-3% succeed over time, while the rest fail when trying to lose significant weight or other health issues that could be resolved with habit only?
To me the terms mix and it helps to separate the things that are externally manageable from the things that are not. The physical is complex but straightforward - the body biochemistry operates on material in, biochemistry mix, expenditure out. The brain is physical - neurons, pathways, etc. The mind, OTOH, is a virtual little candle isolated in a prison of meat and bone trying to understand how to interact with the world around it. External forces can alter the body and brain, but only the mind can change the mind. And does, in ways that are very difficult to control because the sole operator is part of the mechanism. People who try to change on their own and can't aren't failing or weak, it's just really f-ing hard.
If my health is my responsibility, then shouldn't the treatment that I receive be to the standard that I request?
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?
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.
Maybe 80-90% of people should take doctors at face value, but it is easy and only getting easier to at least access the knowledge to better advocate for your own healthcare (thanks to LLMs), with better outcomes. Of course, this requires doctors that respect your ability to provide useful inputs, which in your case did not happen.
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.
Open to evidence either way. I haven't seen people improve it even with what seems to be terrible negative consequences associated with poor temporal discounting ability, but I'd love to read differing perspectives.
Research on heritability have found that the amount of temporal discounting we do is moderately heritable. With twin studies ranging from 30-60% of our natural variability explained by genes.
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.
> This strongly suggests that genetics definitely slips a thumb on the scale, but ultimately we are able to also impact our personal behavior.
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...
> Sure, it is absolutely true that better lifestyle and diet has a huge effect.
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).
> 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 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.
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.
both of my parents have low cholesterol, my mom's cholesterol is naturally under 200, my dad is on statins but the highest he ever got was about 230. they are in their 80s. Nobody on any side of my family (for which I have about 25 first cousins) has ever had any heart disease of any kind, no bypass surgeries, no heart attacks, nothing.
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.
Diet and exercise are hugely important to health in general, and can make a significant impact on lipids.
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.
Your anecdotal report that diet and exercise did not have a huge effect on your cholesterol does not discount the mountain of evidence that we have showing that diet and exercise has a huge effect on health and lifespan.
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.
yeah I read all that and it's why i did "diet" (already exercised) first.
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.
I think people use it as cudgel to blame people and as a crutch to avoid action. And we ignore the psychological and other factors that make improving lifestyle and eating better difficult.
No doctor wants their patient to have a stroke. But they also only get to meet patients where they are.
You're arguing against a strawman. The reality is that most doctors will tell the patient their options and let them pick. While statins have some significant side effects in many patients, there is 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. And if that doesn't work for whatever reason then prescribe the drugs.
> While statins have some significant side effects in many patients
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.
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.
Yes, I'm sure you were arguing against a strawman. The majority of doctors will tell patients about the available options which are generally safe, and allow them to pick. And they don't usually blame patients. Your personal experience might have been different but it was atypical and just an anecdote.
First, if I'm basing it on things that actually happened, then by definition it cannot be a strawman argument. And your insisting otherwise is just plain rude.
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.
> While statins have some significant side effects in many patients
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.
That is because dietary advice they give is actually bad. It mostly boils down to "limit calories while eating standard western diet" but that is impossible to follow long-term as SWD and similar (e.g. food pyramid) diets are nutrient-deficient.
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.
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.
You are conflating two different things. The standard of care in a malpractice lawsuit is not necessarily the same as clinical practice guidelines. In reality doctors are free to rapidly adopt incremental improvements, especially when they are evidence based.
17 years is far from rapid or move fast and break things. ApoB has been known about for quite a long time, since the 90s its effects have been obvious, and showed up in research in the 70s-80s!!! It's still not part of standard testing!!!
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.
There is virtually zero chance that a doctor will lose their medical license for diverging from the from the usual clinical practice guidelines around statins. Check the state medical board disciplinary records.
But if they're employed by a health system and fail to follow company policy then yes, they could be fired.
Different countries are different, some are far more trigger happy about it like Canada. What you suggest as an alternative other than 'git gud' diet & exercise also changes it.
You can only do things to reduce your risk. And whatever intervention would be based on overall population statistics, since it's difficult to know your own personal risk. Heart disease kills marathon runners. You can't just "fix it". Someone who has naturally high cholesterol won't magically be okay by changing their lifestyle and diet.
Many commercial health plans will only cover an ApoB blood test for patients with certain conditions or risk factors. But if you want it you can pay out of pocket for like $70.
> When I see that it is widely accepted that ApoB is better to measure than LDL-C, but the industry continues to measure LDL-C, but not ApoB, I wonder why. It makes me skeptical.
ApoB is shaping up to be an incremental improvement in measurements, but health and fitness influencers have taken the marginal improvement and turned it into a hot topic to talk about.
This happens with everything in fitness: To remain topical and relevant, you always need to be taking about the newest, most cutting edge advances. If it’s contrarian or it makes you feel more informed than your doctor, it’s a perfect topic to adopt for podcasts and social media content.
ApoB is good, but it’s not necessarily the night and day difference or some radical medical advancement that obsoletes LDL-C. For practical purposes, measuring LDL-C is good enough for most people to get a general idea of the direction of their CVD risk. The influencers like to talk about edge cases where LDL-C is low but then ApoB comes along and reveals a hidden risk, but as even this article shows there isn’t even consensus about where the risk levels are for ApoB right now. A lot of the influencers are using alternative thresholds for ApoB that come from different sources.
> In the end statins reduce the chance of heart attack by like 30% I think. Not bad, but if you have a heart attack without statins, you probably (70%) would have had a heart attack with statins too. That's what a 30% risk reduction means, right?
30% reduction in a life threatening issue is huge. I don’t see why you would want to diminish that.
If you were given the choice of two different dangerous roads where one road had a 30% lower chance of getting into a life-threatening car crash, you would probably think that the choice was obvious, not that the two roads were basically the same.
numbers often quoted in favor of statins use relative instead of absolute risk. when seen in absolute terms there is little case for statins except in some possible particular cases. they also do little, if anything, when it comes to life extension — the expected lifespan of a statin user is often estimated to be four days longer than that of those who do not use them. not only is this essentially statistical noise, it discounts the lowered quality-of-life side effects experienced by many who have been put on statins.
This is all true. If you take a statin and it causes no issues, you're... maybe (30%, yay!) better off for it.
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.
>If you were given the choice of two different dangerous roads where one road had a 30% lower chance of getting into a life-threatening car crash, you would probably think that the choice was obvious, not that the two roads were basically the same.
You could absolutely think that they were basically the same, depending on the base rate. The differece between a one-in-a-million and 0.7-in-a-million is 30%, but it wouldn't be humanly perceivable. We're all likely faced with situations like that regularly. Differing airlines probably have much greater variances in their crash statistics, but it just doesn't matter in 99.99999% of flights.
Meta-analysis conclusion: This literature-based meta-analysis did not find evidence for the benefit of statin therapy on all-cause mortality in a high-risk primary prevention set-up.
Have you read their methodology and understood how they did their selection? You could critique their actual methodology. Maybe their selection is backed by strong arguments, right? And if you think their methodology is weak, then please explain why.
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.
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.
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.
Lots of people. Statins are fairly cheap and a lot of people are on them. Cholesterol is also cheap to measure. As a result the two are commonly studied. Even if your goal isn't the above it is probably in the study data.
Guidance from the National Lipid Association, based on a review of the current understanding of the science across quite a few different meta-studies, analysis, etc. Many of the referenced studies are meta-studies significantly larger than the one here.
We have mountains of studies showing the negative impact of LDL-C (and inflammation! Which statins also reduce) on health. We have mountains of studies showing positive impact from statins. We have specific mechanistic understanding of how LDL-C and other atherogenic particles cause heart disease. We have mountains of studies show that statins directly lower the amount of atherogenic particles you have.
This has been studied enough and sliced enough ways that yeah, there is evidence on both sides. But one side is effectively a mountain range, and the other is a small hill. I know which way I'm going to land on it.
Concentration of ApoB-carrying lipoproteins in the bloodstream as the driver of heart disease is one of the most strongly proven facts in medicine. Statins are proven to lower LDL (a close-enough substitute for ApoB in most situations) by about 30%. I can't look at the study now, but most likely it's a situation where patients' cholesterol has not been lowered enough by medication to make a meaningful difference. If you have an LDL of 160, statins aren't going to be sufficient. The issue is doctors/patients not targeting a sufficiently low cholesterol level.
> When I see that it is widely accepted that ApoB is better to measure than LDL-C, but the industry continues to measure LDL-C, but not ApoB, I wonder why. It makes me skeptical
Because this is a recent understanding and healthcare tends to be a conservative industry that moves slowly. Sometimes too slowly.
And also because LDL remains an excellent measure. The risk with LDL isn’t false positives. If someone has high LDL they likely have an elevated risk of heart disease. The problem with LDL testing is that someone with low LDL may still have a high risk of heart disease which may be captured in APoB testing.
> When I see that it is widely accepted that ApoB is better to measure than LDL-C, but the industry continues to measure LDL-C, but not ApoB, I wonder why. It makes me skeptical.
Part of this is just that insurance coverage lags science. We've known that ApoB is more accurate than LDL since the 1990's or 2000's, but to be covered by insurance, several more steps have to happen.
First, the major professional societies (like the American College of Cardiology or National Lipid Associations) have to issue formal guidelines.
Then, the USPSTF (US Preventive Services Task Force) needs to review all of the evidence. They tend to do reviews only every 5 or 10 years. (Countries aside from the US have different organizations that perform a similar role.)
If the USPSTF issues an "A" or "B" rating, then insurance companies are legally obligated to cover ApoB testing. But that also introduces a year or two lag since medical policies are revised and apply to the next plan year.
The net effect is that the entire system is 17 years, on average, behind research.
ApoB blood tests are relatively cheap. You can pay out of pocket about $70 if you really want one and insurance won't cover it.
Most commercial health plans will cover an ApoB test for members with certain cardiac risk factors or medical conditions. But they generally won't cover it as a preventive screening for all members. I don't think we have enough evidence to justify broad screening yet, although that may be coming.
> When I see that the purpose of statins is to reduce plaque buildup in the arteries, and that we have the ability to measure these plaque buildups with scans, but the scans are rarely done, I wonder why.
I'd love to know where to get the right advice on this topic.
I have high LDL-C, had a heart CT in hospital last week, yet the hospital's cardiologist phoned me yesterday to cancel a scheduled appointment to discuss the results(!), because she said I have zero arterial plaques and there's simply no need for us to meet.
How old are you? I was told that they're not considered diagnostic until somewhat later in life (>50) because the plaque may not have calcified yet, which could cause a false negative.
I was found to have high cholesterol in my late 20s. At the time the doctors (my cardiologist, then a second one brought in for advice) determined that the source was hereditary, but the effects would be the same. So they put me on statins. It's been 40 years now. I changed the statins three times since, when the actual one, at a specific time was no longer able to keep the values within acceptable limits. Approximately 8-9 years ago (I think) I ended up on Rosuvastatin 20mg, which I'm still taking every day. I do not maintain any diet (it'd be very hard, as I'm a heavy meat eater) and cholesterol levels are still staying within acceptable limits. Of course YMMV
No heart attacks or strokes? I'm in the same boat (hereditary issue), and altering my diet has never had any substantial effect on my numbers. I'm not overweight and rarely eat red meat, but have had trouble keeping onto a primary care physician long term (the people I keep picking seem to move between clinics constantly) in order to retain consistent access to a statin prescription, but as I continue to age I've been getting increasingly anxious that my time is coming.
So far everything is good. I only had more of a logistic issue, once, when moving to France from the US, a few years back (retirement) and when my new doctor told me that the French do not recommend statins for people at my age and overall good shape (active, fit, etc. ), even if the numbers are high. I asked her to give me a referral to a cardiologist, to whom I mentioned my 35 years of statins in the US, and who was of the opinion that after such a long time and with no apparent side effects, he would recommend continuing on this type of médication. And that was it, so I'm now getting the prescription renewals almost "automatically", even as my cholesterol is staying within limits (under the assumption that it may increase, should I stop, especially considering the amazing cuisine and products to which I now have access :) )
I haven't had to touch statins to get my lipids profile much better. I used zepbound to lose about 50lbs and then weaned myself off that. I was a little afraid my “completely normal after 8 months of weight loss” blood panel status at the end of my zepbound journey would go back to the “bad” region, but I have maintained going on a year with a much better whole foods/lean meats based diet and moderate exercise (I do let myself have some red meat on Saturdays, otherwise I would explode from hamburger desires). So it was done through a combination of lifestyle changes and zepbound to help me bury the hunger monster long enough to learn new habits and get to a new normal. Him suggesting that “probably” most people should be on statins whether they need them or not seems like covering up the source of the problem. I do know that some people just naturally have lipid issues even when doing “all the healthy things” though. My mom is one of them.
I ALSO want to not be a statin-skeptic but, like you, these things look very weird to me. The most prescribed drugs in the country and we don't even try to check if they are addressing the actual problem?
We have checked to see if they are addressing the problem more than probably any drug in history. The idea that we haven't is the result of skeptics cherry picking results that back up their point while ignoring the huge quantities of evidence supporting the efficacy of statins and other LDL lowering medications like ezetimibe, pcks9 inhibitors, etc.
Statins are so good at what they do they even reduce the risk in people who are already at low risk for heart disease.
That's fair. I know a lot of generic drugs are imported too, so maybe there isn't much pressure within the USA there. Unless the big domestic pharmaceutical companies are still making a lot of money on it even if generic options exist? I don't know.
That prior discussion gives no good reasons. The linked medium posts are, to be frank, trash.
Statins are well-tolerated drugs with little to no noticeable side effects. You might have to try a few. You may need to combine ezetimibe to maintain a moderate statin dosage level, and that's it. (Like the author of this article)
Source: Leading cardiologists worldwide, and doctors of the rich and famous.
I 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.
Yeah, for each level of cardiovascular risk (in America, probably calculated with PREVENT) there is a target LDL which should guide whether you should start or not a statin.
I recently went on a statin (atorvastatin) and found I have the WILDEST dreams of my life if I don't take them in the morning, and my doctor said my liver readings were elevated after use but not enough he wants to switch it yet. Which alternative statins should I be looking at, or do they have even harder side effects to deal with?
I have intense anxiety attacks on atorvastatin. Rosuvastatin at the low dose (5mg) doesn’t do much, but at 10mg and 20mg it caused the same effects. It took years and multiple cycles of going on and off the drugs to become confident this was the problem. I switched to Repatha which doesn’t have this problem (it does make me a bit hungry though) but it’s expensive and it took a while for my insurance to approve it.
> Statins are well-tolerated drugs with little to no noticeable side effects.
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...
No, your post is nonsense. You link a random article that doesn't even make the argument that you're making - that it's low cholesterol causing the memory loss - or that statins are causing the memory loss at all.
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.
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.
> Memory loss and confusion have been reported with statin use.
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.
You can do a "study" to prove anything you want. And study outcomes often do vary depending on who is paying for it. The FDA is a neutral party. I recommend prioritizing the FDA warnings over "studies".
The FDA errs on the side of placing more warnings rather than fewer. They'd rather have false positives than false negatives. The warning is also clear that there is not a definitive causal link.
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'm a big statin sceptic so just putting that up front.
I think things haven't changed because most people underestimate how slow institutional scale change is. There is a reason why HR departments and consultants have Change Management experts. The inertia is huge. Young people don't appreciate this because they thrive on new ideas. Old folks don't and will subconsciously push back, like a form of institutional homeostasis.
Also, while I believe your heart attack stats are correct, I'm more interested in all cause mortality. I believe there statins are a net negative.
A single study showed a single statin reducing GLP-1 levels and ascribed it to gut microbiome changes that could be totally resolved with UDCA supplementation.
If this even ends up being reproduced it at most says there is an easy fix for people taking atorvostatin and that it might be a concern with other statins, but this should be treated with the same health skepticism of any other single study finding.
Not all statins raise blood sugar either - pitavastatin usually shows an improvement in insulin sensitivity.
How many doctors are cycling through all the statin classes to find the least-bad option for each patient?
(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.
If you go and tell your doctor you're having trouble with a statin, they should have you try a new one, yeah. Some might need to get clued in on pitavastatin, as it only recently went generic and insurance companies really didn't want to approve it before this due to the cost and wide field of generic statins, but it tends to have one of the best profiles when it comes to side effects.
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.
Statins can be effective for many patients (and there are multiple different statins with varying effects) but there are also alternative or additional drugs such as Leqvio (inclisiran) and Repatha (evolocumab). Patients should do their research and talk to their doctors. It might take some trial and error to figure out what works best.
one better simple indicator than large panels, if you can't get access to them or don't have them is simply your triglycerides/hdl ratio. aim to be under 2 if using mg/dl and under 0.87 if using mmol/L. it's one of the strongest correlated indicators of cardiovascular disease. way better than any classic cholesterol ratios.
The general advice is that the scans are only useful sometimes. That is, they can show a problem. But a clear scan doesn’t mean you’re fine. So don’t base anything on a clean scan, be proactive with all the rest of it. My two cents, by the way: Repatha is pretty amazing.
There is no reason take statins, ever. They will destroy your muscles, then cause diabetes and thus indirectly kill you. They will prevent a heart attack by... four days.
If biomarkers are elevated, the question must always be, "why is this elevated", and "is there a natural change in habit and diet that can reverse this elevation".
Artifically lowering the marker with a drug is like pasting duct tape on a leaking pipe - the leak is still there and it will likely quietly get worse over time and then eventually kill you anyways.
I find it unbelievable that our society swallows any drug without second thought. You body produces cholesterol on purpose. There must be reason why it produces it. "Ah well, who cares, let's just throw in a wrench and make it stop producing the cholesterol" and hope for the best...
Arguing against nonsense like this gets so exhausting.
Statins do not destroy your muscles. Newer statins make this already exceedingly rare side effect even rarer, but let's look at them as a general class:
Blinded RCT/Meta-analysis shows about 11 complaints per 1k patient years, with 90% of them not actually being due to the statin. But because people act like they're common, they mistakenly believe it was the statin, which just reinforces this idea. And that's for muscle pain.
For actual significant muscle injury? Even lower. 1 or less per 10,000 patient years.
Effectively, you might get one muscle ache per year per 100 people and at most a 1 in 10,000 chance of serious myotoxicity.
As for diabetes, rosuvstatin usually has a neutral to positive impact on insulin sensitivity, and pitvastatin almost always has a positive impact. Some statins do have negative impact, but it's not universal.
It's not like duct tape on a leaking pipe - it's like removing items in a pipe that damage the pipe walls. Yeah, ideally they're not in the pipe to begin with, but removing them is better than letting them stay, and diet and exercise only do so much to remove said items.
Your body can synthesize LDL de novo in the organs that use it, and one of the heaviest users, the brain, can't get cholesterol out of your diet/serum levels at all - LDL cannot pass the blood brain barrier.
There are people with genetic mutations that mean they don't produce LDL, or at least not at high levels - their increased longevity and incredibly rare incidents of ASCVD is what drove the creation of PKCS9 inhibitors.
Statins also lower LDL-C levels - they don't make your body stop producing cholesterol in general, or even LDL-C. Even if your body couldn't make it on-demand where needed, statins aren't going to drop your serum levels to 0.
I feel like statins are harder to accept than vaccines. With vaccines we can say it is just training our existing immune system to recognize and fight something. So how would you straightforwardly explain statins to a scientifically literate adult so they can make an informed decision. But part of that means honestly acknowledging whatever scientific unknowns and uncertainties there are in this area of human biology.
> When I see that it is widely accepted that ApoB is better to measure than LDL-C, but the industry continues to measure LDL-C, but not ApoB, I wonder why.
That's pretty simple to explain. No conspiracy.
LDL-C is much much cheaper to measure. ApoB costs 36x times as much, so Insurance Companies don't like to pay for it
My wife had high cholesterol numbers, so her doctor wanted to give her statins. She asked about a scan, he begrudgingly said well, I guess you could do that. Her scan showed 0 plaque.
It was almost certainly the former, and the former is is basically an indicator that the damage is already done.
Soft plaque takes a long time to calcify. But soft plaque is the stuff that ruptures, and will clog up your arteries just as much.
Statins are best used as a preventative measure - once the plaque is there it's difficult to regress it even while soft, and as far as we know effectively impossible once it is calcified.
I’m sensing a potentially significant misallocation of resources. My mental model is that there’s a hypothetical quantification of not just your time and money, but your anxiety, attention bandwidth, mental energy, etc.
I think, in some ways, the trick is being able to short circuit the entire journey represented by this website in favour of some form of, “I’m 40. I should be more mindful of heart disease. I should add a 30 min walk to my mornings.” And then move on with your life.
I think many cultures, but especially American healthcare culture, foment a growing background noise of constant anxieties and stressors. Life is sufficiently complex but there’s always a peddler eager to throw you a new ball to juggle (and pay for).
I think the article makes a valid point: stop worrying about 90% of the other stuff and focus on the thing that will almost certainly kill you - heart disease - for which there are easy diagnostic and preventative measures. I think they're arguing for a better allocation of resources, if anything.
Thanks for posting this. I was able to plug in all the required values from my last checkup and blood work. Even EGFR was there, I've never paid attention to that before.
It depends. Overall, lowest all-cause death indexed on BMI seems to be around 27 plus or minus [0]. Interestingly, for all subjects (not just healthy non-smokers), BMI 30-32 isn't really associated with a dramatic increase in all cause mortality.
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.
I'm not sure that's true? Insurance is hesitant to cover their expense for less extreme cases, and they're very expensive. But I haven't heard of prescribing being a real bottleneck. They're not controlled substances and the side effect profile is pretty mild (other than price).
I think people should be mindful of it since they were 18 - it's something that progresses over decades. You can have a lot bigger impact making changes when you're young rather than at 40
But yeah I agree with your message. Focus on the big impact macro level things. Hyper-optimizing it is a waste of energy
If I'm not wrong, it takes 20 years to revert the damage of smoking.
I don't think you need to care at 18, but the effects will be seen over the course of 20 years
Lots of the damage done can't be undone when it comes to heart diseaese.
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.
Seriously there is too much shit to worry about to micro manage each facet, unless your like a Bryan Johnson billionaire with a staff.
Beyond just heart disease & cancer taking you out entirely its: my eyesight is going, my hearing, every joint in my body could fail, my brain is slowing, etc.
There is just way too much shit to do anything other than be like: sleep, exercise, eat better and don't drink too much.
And even him doesn’t know what’s working and what’s making things worse. He claims to have really good biomarkers but that’s when cherry-picking numbers from studies made in a range of more than two years (!!).
You’ll never see a published set of tests from him. What you’ll see is ads to buy his supplements.
> Beyond just heart disease & cancer taking you out entirely its: my eyesight is going, my hearing, every joint in my body could fail, my brain is slowing, etc.
Absolutely right. You can’t fix everything. But if you can only dedicate time, money, and attention to one thing, cardio health is probably highest impact for most people. This article makes that case. Also it makes the case that there are a few things that will have an outsized positive effect on cardio health and we’d be wise to focus on them.
Key Takeaway: Get a CT or CTA scan, and if you can afford it go for the CTA with Cleerly.
There is a reason that we don't recommend getting imaging for everyone, and that reason is uncertainty about the benefit vs the risks (cost, incidentalomas, radiation, etc, all generally minor). Most guidance recommends calcium scoring for people with intermediate risk who prefer to avoid taking statins. This is not a normative statement that is meant to last the test of time: it may well be the case that these tests are valuable for a broader population, but the data haven't really caught up to this viewpoint yet.
The central point of his article is that he went to a doctor who followed the guidelines, tested him and found he wasn't at risk for heart disease.
But then he went to another, very expensive concierge doctor, who did special extra tests, and discovered that he was likely to develop heart disease and have a heart attack.
Therefore he is arguing that THE STANDARD GUIDELINES ARE WRONG AND EVEN IF YOU DO EVERYTHING RIGHT AND YOUR DOCTOR CONFIRMS IT YOU MAY BE LIKELY TO DIE OF HEART DISEASE ANYWAY, SO ONLY THE SPECIAL EXTRA TESTS CAN REVEAL THE TRUTH.
I want a second opinion from a doctor. Is this true? Is this for real? Because it smells funny.
I strongly suspect the truth is both are "right", but they're both optimized answers to slightly different problems.
Mainstream medicine is hyper optimized for the most common 80% of cases. At a glance it makes sense: optimize for the common case. Theres some flaws in this logic though - the most common 80% also conveniently overlaps heavily with the easiest 80%. If most of the problems in that 80% solve themselves, then what actual value is provided by a medical system hyper focused on solving non-problems? The real value from the medical system isnt telling people "it's probably just a flu, let's just give it a few days and see" it's providing a diagnosis for a difficult to identify condition.
So if your question is "how do we maximize value and profit in aggregate for providing medical care to large groups of people", mainstream medicine is maybe a good answer.
But if your question is "how do we provide the best care to individual patients" then mainstream medicine has significant problems.
Part of providing good care is not burdening the patient with tests or treatments that are very unlikely to yield benefit. Put another way, the mission of healthcare is not "health at any cost."
The mission of healthcare in the eyes of those who provide it, isn't "health at any cost".
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.
Cost here doesn't just include financial cost, but also time. As an extreme example, you could surely catch diseases earlier by visiting a doctor for an hour or two every day - getting tests for all sorts of things you might have conceivably developed. But that would make your life worse, and so most people wouldn't do that even if it was free.
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.
Thanks for the astute and informed comment. So re-reading that portion of the article, it seems to me the answer to my question is not that any general or consensus guidelines are wrong, but that a company called Forward Health is doing lipid panels and providing an incorrect interpretation of the results.
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.
I would agree that this article overstates a lot of things.
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.
The claim on an individual level is not objectionable to me. The question is that if we extrapolate it out to the population and actually take this action for everyone, do we make people better off? This is what clinical trials (or at least large observational studies) try to achieve. Right now, it is not clear.
His evidence is also kinda weak. And appeal to authority largely about someone who he's paying to tell him he has health problems. The incentives aren't aligned.
I also disagree that the 50the percentile is the breakpoint between healthy and unhealthy. There's a lot more to deciding those ranges beside "well half of the population has better numbers"
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.
Cardiovascular diseases are huge risk factors for dementia, so if your goal is to avoid dementia you should try to have a healthy cardiovascular system.
If health science was as simple as health outcomes are proportional to one or two measurement percentiles, sure. But that's hardly true. Health is a lot more complex than that and the disease risk cannot be quantified by a small number of parameters
Maybe he got missed--let's concede that. What about the other 10 or 100 or 1000 or subjected themselves to tests and didn't find anything? Where are their stories?
If you have enough people, the tests, themselves are eventually going to harm somebody.
For example, certain scans require contrasts like gadolinium that bioaccumulates. That's not a big deal if we only pump it into people 2 or 3 times in their lives when something in their body is about to explode. It's a lot bigger deal if we're doing that to them every year.
The bottom line is these tests aren't some sort of one-size-fits-all panacea, and nor can they perfectly predict the future. In fact Oprah herself backtracked on it, via an article by Dr. Oz in her magazine in 2011: https://www.oprah.com/health/are-x-rays-and-ct-scans-safe-ra...
A good rule of thumb is don't take medical advice from Oprah or Dr. Oz. But in the case of the latter article, he wasn't wrong.
> But then he went to another, very expensive concierge doctor, who did special extra tests, and discovered that he was likely to develop heart disease and have a heart attack.
It’s scarily common in medicine for doctors to start specializing in diagnosing certain conditions with non-traditional testing, which leads them to abnormally high diagnosis rates.
It happens in every hot topic diagnosis:
When sleep apnea was trending, a doctor in my area opened her own sleep lab that would diagnose nearly everyone who attended with apnea. Patients who were apnea negative at standard labs would go there and be diagnosed as having apnea every time. Some patients liked this because they became convinced they had apnea and frustrated that their traditional labs kept coming back negative, so they could go here and get a positive diagnosis. Every time.
In the world of Internet Lyme disease there’s a belief that a lot of people have hidden Lyme infections that don’t appear on the gold standard lab tests. Several labs have introduced “alternate” tests which come back positive for most people. You can look up doctors on the internet who will use these labs (cash pay, of course) and you’re almost guaranteed to get a positive result. If you don’t get a positive result the first time, the advice is to do it again because it might come back positive the second time. Anyone who goes to these doctors or uses this lab company is basically guaranteed a positive result.
MCAS is a hot topic on TikTok where influencers will tell you it explains everything wrong with you. You can find a self-described MCAS physician (not an actual specialist) in online directories who will use non-standard tests on you that always come back positive. Actual MCAS specialists won’t even take your referral from these doctors because they’re overwhelmed with false cases coming from the few doctors capitalizing on a TikTok trend.
The same thing is starting to happen with CVD risks. It’s trendy to specialize in concierge medicine where the doctor will run dozens of obscure biomarkers and then “discover” that one of them is high (potentially according to their own definition of too high). Now this doctor has saved your life in a way that normal doctors failed you, so you recommend the doctor to all of your friends and family. Instant flywheel for new clients.
I don’t know where this author’s doctor fits into this, but it’s good to be skeptical of doctors who claim to be able to find conditions that other doctors are unable to see. If the only result is someone eating healthier and exercising more then the consequences aren’t so bad, but some of these cases can turn obsessive where the patient starts self-medicating in ways that might be net negative because they think they need to treat this hard to diagnose condition that only they and their chosen doctor understand.
It's important to note that there's geographic variability in guidelines. Also, the article doesn't give enough information about the author's other risk factors. For a similar patient (based on the initial lab results), treated by a doctor adhering to the European guidelines, at least the following items would have been considered:
- Lipid lowering drugs
- ApoB testing
- Coronary CT (if the pre-test likelihood of obstructive coronary artery disease was estimated to be > 5%)
The year is 1846, and a doctor has a radical new idea: doctors should wash their hands between performing autopsies and delivering babies!
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?
Not sure I follow or maybe you skipped typing a word.
You listed the risks and concluded “all generally minor.” The benefit is absolutely nonzero. So, what’s the hold up?
And how have the data not caught up? People outside the US are getting the CT scans, while US doctors prefer to lick their finger to guess the weather.
My wife’s last interaction with a doctor: patient presents with back and chest pain accompanied by occasional shortness of breath at the age of 39, doctor reluctantly asks for a EKG - which takes 5-10 minutes and is done in the next room, right away and covered by insurance with a small copay - and has the gall to be surprised when EKG showed subtle abnormalities. If she hadn’t advocated for herself, as the OP argues, doctor would just skip the EKG.
This experience left me thinking maybe doctors are discouraged from asking for imaging and guidelines are there to protect their criminally negligent behavior. I have no proof or even proxy data for the claim about doctors being discouraged from asking for imaging. But it is objectively criminally negligent to not ask for imaging in a case like this.
"Smaht" people continuously parrot things they read elsewhere, usually in a contrarian way, to assert themselves in a futile and shallow way.
There is absolutely nothing wrong with getting one CT at a specific point in your life to right a disease which, as TFA states, has a 25% incidence rate.
The smaht ones will now point me to that study of 1-5% of cancers being linked to CT scans. Yeah, sure, but those are not from people who got one-two in their lives.
There's something I deeply don't understand about this.
> I shared these results with a leading lipidologist who proclaimed: “Not sure if the lab or the primary care doc said an LDL-C of 116 mg/dL was fine but that concentration is the 50th percentile population cut point in the MESA study and should never ever be considered as normal.
> It’s also important to note that, according to a lipidologist friend, an ApoB of 96 is at a totally unacceptable 50th percentile population cutpoint from Framingham Offspring Study.
So... the exact median value is "totally unacceptable" and "should never ever be considered as normal"? I'm open to the possibility that the US population is so deeply unhealthy that this is true, but then that needs to be argued for or at least mentioned. Like, you can't say "you're exactly average in this respect" and expect your and that's terrible to be taken seriously without any followup.
Or if I'm misunderstanding what's meant by "50th percentile population cut point" then again, I think this jargon should be explained, as it's plainly not the usual meaning of "50th percentile".
I had assumed "the MESA study population" was a particularly unhealthy bunch in terms of this measurement, meaning the 50th percentile puts one in the worst half of an already bad off group.
I don't know the exact details, but I thought the Framingham survey was just a cross-section of the population. So getting upset about a 50th percentile score makes no sense at a population level.
A quick Google says that the Mesa study was actually of people without cardiovascular disease at the beginning of the study. So again, these conclusions don't make any sense to me.
Of course it makes sense. 30% of this population will die of heart disease. You don’t want to be at the median of that population if you can avoid it. And as a society we need to move the median, not just accept it. Which means giving people better advice based on better data.
The other thing these number chasers don’t tell you is that extremely low LDL numbers are also associated with anger management issues. The stuff is used in your body to build things. You need some, and probably at least half of the number this doc is trying to say is scary. In fact in a different test he is advised to talk to his doctor about whether a 29 is safe.
Has the guidance changed that you want LDL less than 2.5x (or was it 2x?) your HDLs?
Every organ in your body that utilizes LDL can synthesize it de novo. Some of the heaviest users, like your brain, literally can't get it from your serum LDL levels - they do not pass the blood brain barrier. It is all synthesized locally.
PKCS9 inhibitors and mendelian randomization studies show that people function just fine with <10 LDL-C. (Other comments I have made in here have links to all the relevant studies)
Googling for statin and aggression links I find a fairly small set of studies with fairly disparate outcomes.
I believe there was a time they thought statins were causing mood disturbances, but I was talking about unmedicated individuals with naturally low serum levels.
Going deep on biomarkers, blood tests, and debates about optimal levels is okay for some people who derive motivation from obsessing over topics, but I’m starting to notice a trend where people obsess about these things for a couple years before burning out and moving on to the next topic.
The best thing you can do for yourself is to establish healthy diet and lifestyle habits that are sustainable. A lot of people who jump from obsession to obsession do a great job at optimizing for something for a few years, but when their life changes they drop it completely and fall back to forgetting about it.
Fad diets are the original example of this: They work while the person is doing it, but they’re hard to maintain for years or decades. CrossFit and other exercise trends have the same problem where some people get extremely excited about fitness for a couple years before falling off completely because it’s unsustainable for them. Some people are able to continue these things for decades, but most people do it for a short while and then stop.
I’m now seeing the same pattern with biomarker obsessives: They go a few years obsessing over charts and trying things for a few months at time, but when the interest subsides or they get busy with life most of it disappears.
The most successful people over a lifetime are those who establish healthy habits that are easy to sustain: Eating well enough, reducing bad habits like frequent alcohol or fast food consumption, some light physical activity every day, and other common sense things.
The most important factor is making it something easy to comply with. The $300 biomarker panels are interesting, but most people don’t want to pay $300 every year or more to get snapshots that depend largely on what they did the past week. Some people even get into self-deceiving habits where they eat well for a week before their blood tests because the blood test itself has become the game.
Right on spot. Find a regime for body and mind that you can sustain without any significant mental effort, after some time lack of good behavior be it sports of healthy food makes one uneasy. Bonus points from getting happy from it / making it a passion, this helps a lot with coming back after some hiatus (ie injury, sickness, long travel etc.).
Personal story - I used to be super sporty, 4x gym training during work week - cardio & free weights, climbing over evenings after work, hiking/climbing/ski touring over weekends. Vacations were mostly more extreme variants of the same. Last year broke my both ankles with paragliding, one leg much worse, so took me some 8 months to be able to walk straight again, with some time in wheelchair, then crutches. All strength & stamina gone, flexibility 0, so had to rebuild from scratch and I mean deep bottom scratch from which you bounce very slowly, not some 1 month stop when things come back quicker. If all above weren't my proper passions I would have a hard time coming back to being again more active than most(sans that paragliding, took the lesson and have 2 small kids). That ankle won't ever be same but so far so good, ie managed some serious hike&via ferrata mix 2 days ago.
Getting happy from it is 100% the most effective way to change habits.
Unfortunately it’s also very subjective and hard to find out what makes you happy…
> starting to notice a trend where people obsess about these things for a couple years before burning out and moving on to the next topic.
Really spot on with one of my besties. He does all the tests. He has a concierge doctor. He reads extensively on the topics of fitness and nutrition. And yet he doesn't do any of it. It's just an intellectual exercise for him. And he has had two heart attacks in the last several years. It's so frustrating. I just wanna shake him.
I learnt a great trick about exercise: find a podcast or audio book that you really enjoy listening to. Here's the trick: you're only allowed to listen when you're exercising.
Also with food and drink: place friction between the treat and yourself. The easiest example is to not have biscuits / alcohol in the house.
Bonus tip: alcohol free beer is really good these days.
Alcohol free beer was a game changer for me. Also if I can’t avoid it alternating alcohol-containing and alcohol-free drinks.
For exercise your tip doesn’t help me at all. I hate audiobooks and podcasts so that would turn me off more from exercising. Also I want to concentrate on the exercise and not do it halfhearted.
What helped me was to realise how much better I feel after exercising - since then i kinda got addicted to it because I notice how much worse I feel after not doing it for a couple of days.
I agree on the friction. Just not having access to cigarettes is the best way for me to not smoke. I just don’t buy them and bumming one from someone else comes with a degree of personal shame for me that makes me avoid them (in almost all cases).
I naturally don’t like sweet stuff that much - however since I moved from EU to America (not US) it’s been really hard to avoid sugar.
Y’all put that stuff into everything it’s crazy; I gotta watch out like a hawk and go to special stores. In Europe it was so much easier, there are always cheap sugar free whole foods available in every supermarket.
I push hard enough during cardio that I can't really follow a podcast properly.
On the upside, it's only 30 minutes.
While lifting weight I do that since I rest for 90 seconds in between sets, which is actually very boring.
I started reading books during that time and that has been a big improvement.
If you're exercising for cardio, and you're able to follow your book or podcast, you're probably not doing good cardio. OTOH, it's not a bad way to do interval training while watching sports, go hard when they're yammering, slow down when the sports are happening (or, if you're watching soccer, you can go hard most of the time and then slow down for the replay if anything happens, which is unlikely)
> If you're exercising for cardio, and you're able to follow your book or podcast, you're probably not doing good cardio
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.
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.
Maybe our brains work differently, but I have absolutely no problem following a podcast while running, and my race times indicate that I'm doing good cardio.
I do have a hard time with mind muscle connection during weight training if I'm listening to something other than music, though.
> If you're exercising for cardio, and you're able to follow your book or podcast, you're probably not doing good cardio.
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.
> Sticking to a Mediterranean diet that is light on carbohydrates and saturated fats is almost always the safest bet. Almost every health diet is some permutation of this.
A permutation that's currently making the rounds in the press (even though the original research is from 20 years ago) is the "portfolio diet":
Lowering LDL cholesterol is arguably the most evidence-backed longevity intervention available today. Mendelian randomization studies suggest that each standard deviation of lifelong LDL reduction translates to roughly +1.2 years of additional lifespan, implying ~+2.4 to +3.6 years from sustained, meaningful lowering alone.
Pair this with tight blood-pressure control (aim systolic <130 mmHg) and a healthy BMI—every incremental improvement helps. Together, LDL, BP, and BMI form the most potent triad of interventions most people can implement now and expect to see substantial benefits 20–40 years down the line.
Everyone knows the recipe for healthy living, it's the same as for similar issues such as personal finance (spend less than you earn, save, etc.).
They seem simple on the surface but hard part is execution for most people, due to life circumstances and other factors. Unhealthy choices persist because society isn't built around healthy lifestyles.
So while the comment seems helpful on the surface, it misses the forest for the trees.
I think that there needs to be a bigger discussion here, regarding why have we engineered a society that inflicts suffering and illness on so many?
Not all things labeled "processed foods" are bad, it seems. There are enough scientists that say the distinction is often hypocritical (example from an article: a factory-made carrot cake is labeled UPF, but a home-baked one isn't, even though they're practically the same thing). Sugar, fats, and lack of fiber make factory-food unhealthy, they say. Others add that we can't feed the growing metropolitan areas without it.
Just expanding on a peer post, but industrial made food tends to have a large number of preservatives, stabilizers, coloring agents, and much more added for commercial reasons. An obvious example of this is in something as simple as bread. If you've ever made homemade bread. It goes stale in a day or two, and it's hard as a rock shortly thereafter.
But that loaf you buy at the store? It'll generally be covered in mold before it gets hard, and that's quite the achievement since it also tends to be more resistant to mold as well! Bread should get hard. This is where a ton of old recipes come from. The Ancient Greeks would dip it in wine for breakfast, Euroland has bread soup/puddings, and even stuff in the US like Thanksgiving stuffings or croutons.
>a factory-made carrot cake is labeled UPF, but a home-baked one isn't, even though they're practically the same thing).
Actually they are not. "Practically" is carrying a lot of weight there. The factory baked cake will have a lot more extraneous ingredients and usually has a larger quantity of sugar and fat. Similar to how restaurant food generally has a lot more salt and fat than home cooked food.
Yes, right off the bat a factory made carrot cake will very likely contain dough conditioners, colors, and preservatives that no home cook would put in their scratch made version.
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.
Yep just a glance at the ingredients shows obvious differences. Other issues I've seen studies about include contaminants from conveyor belts, and for many snack foods, processing into smaller particles, effectively making them partially pre-digested.
WRT the carrot cake, I will say that while there is only a minimal physical difference, there is a practical difference. Making a carrot cake at home is a commitment, and most people won't frequently go to the trouble except on special occasions... But one from the grocery store can be acquired casually and without effort, and it's easy to eat a lot more of something when it requires no effort.
Every time I cook (and thats quite often) I put a bit different ingredients that some factory would put in since they are the cheapest variant.
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).
You’re not wrong but it is not a fair TLDR. TFA has a TLDR which says
> If you only read one thing here, make it the “How to not die of heart disease” section.
Which itself is still quite long but it emphasizes:
> Every lipidologist I’ve spoken with has stressed the importance of measuring and managing ApoB above all else – it’s a far better predictor of cardiovascular disease than LDL-C (which is what physicians are most familiar with). Every standard deviation increase of ApoB raises the risk of myocardial infarction by 38%. Yet because guidelines regularly lag science, the AHA still recommends LDL-C over ApoB. Test for it regularly (ideally twice a year) and work to get it as low as possible (longevity doctor Peter Attia recommends 30-40mg per deciliter). Many lipidologists will say to focus on this above all else.
And:
> I asked several leading lipidologists to stack rank what they believe are the most important biomarkers for people to measure and manage. […], and will likely cost anywhere between $80-$120 out of pocket.
That’s a pretty interesting and relevant part of TFA. Omitting that is not a fair “long story short”, but rather just “different story”.
This is wrong. Our bodies evolved to eat a diverse omnivorous diet and complex carbs + the antioxidants present in vegetables and fruits are anti-oxidative.
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.
I've taken courses in primitive wilderness survival, and one of the staple foods was grass seed.
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.
What's possible depends on where you are. But for example:
> 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.
> 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.
>Our bodies evolved to eat a diverse omnivorous diet and complex carbs
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.
Vegetables aren't "carb-heavy". And we don't need to recreate blindly the circumstances evolution had to adapt us to. E.g., our bodies evolved when the population was much smaller, but I don't think you want to argue for mass extinction.
I might just be tired, but this seems highly repetitive. The author mentions friends in the field and concierge doctors multiple times in as much as I read.
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".
It’s also demonizing doctors and the healthcare system a bit too much for my liking.
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?
In the US my best doctors produce out of date advice about obvious things, have a very distinct gap between "everyday" (stuff they actually see) and "incredibly rare" (stuff unique enough to be a case study they heard about) in their knowledge/understanding and rarely advise things that require me to be a proactive and rational person (because they don't serve these often), so they'll spend two seconds being like "diet and exercise" without a discussion on how that'd work or what adjustments I'd actually make (leaving me to do this research myself) and then suggest a prescription (because even their least proactive patient will probably take a pill). They'll wait until things become a disorder before addressing them (or discussing with me how to address them).
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).
I'm in the US, and my experience has been similar. My doctor is good, and while we're usually limited to 30 minutes at my appointment, we have good conversations and rarely is his answer "here is another pill" or "go take this random test."
Somewhat related, one of my thoughts was “what if these concierge doctors just keep running tests until they find something, anything, to justify their fees”?
> 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.
The inconvenient truth that the vast majority of adults refuse to acknowledge is that there is no safe level of alcohol. Any drink is going to damage you, marginal though it may be. Unfortunately the healthiest thing you can do is simply never drink alcohol.
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.
For alcohol, the default is social drinking which is why you don't have widespread alcoholism in most countries where people consume plenty of alcohol. For smoking the default is constant nicotine top up(the nicotine delivery is instant, lasts seconds to minutes and the withdrawal symptoms starts in an hour). Both harmful of course but the alcohol has much less harmful defaults.
“Alcoholism” is outdated and has been widely replaced by AUD (Alcohol Use Disorder).
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.
Average German lifespan is about 80 years. What if it was 70 years for an 80th percentile drinker and 90 years for a 20th percentile drinker, I assume that changes your conclusion? These are of course entirely made up numbers, and the data doesn't even exist as far as I'm aware, but goes to show how useless averages may be.
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.
You really should push for an ApoB test in general - most people are bit by LDL-C and not other atherogenic particles like Lp(a), but it's still common enough to find out. The good news is Lp(a) is largely genetic so if you know you have low levels you likely don't need to test again anytime soon.
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.
A regular lipid panel won't test for Lp(a) which is genetic. So you need to test specifically for Lp(a) once in your lifetime because you need to know your risk factors. The test was $35.20 when I had it done by LabCorp last year. 20-30% of the population (including me) have high Lp(a). Statins don't reduce Lp(a).
I was planning to start getting scans ordered for specific risks like aneurysm or heart attack but what holds me back is the idea the scans will harm me worse than those things.
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.
A relevant anecdote. I’m very athletic and skinny, eat well, have a resting heart rate in the 40s, but was recently prescribed a statin at 30, due to my very high LDL cholesterol and lipoprotein A.
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.
You're probably a "lean mass hyper-responders", a phenotype which is actively investigated, initial paper:
Elevated LDL-cholesterol levels among lean mass hyper-responders on low-carbohydrate ketogenic diets deserve urgent clinical attention and further research
Seems a bit unfair sometimes how arbitrary genetics can be. I've fought my weight all my life, only recently achieving consistent success with the assistance of GLP1s. I can't claim to be consistent with exercise either. Yet my numbers are great, I've done some of these deeper tests and everything comes back beautiful. My parents were overweight their whole life and both lived deep into their 80s (and my dad only died because he got an unlucky gall bladder infection and then ignored all the rapidly accumulating evidence that he was getting quite sick; he'd have gone another few years most likely). I don't recall anyone in my immediate ancestors having a heart attack. Seems it's just not in our genetics.
My father-in-law is more like you. Athletic, skinny, been that way all his life. Heart attack and quad bypass in his 40s.
They have me on blood pressure meds and do the usual blood tests, the tests I considered have been elective and I requested them explicitly. Just haven’t followed through due to aforementioned hesitations. I’m very much aware heart issues run in the family and that I have symptoms.
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.
- 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.
Health guidelines take into account when screening/testing is a net harm or benefit for patients in general, and when they move from being a net harm to a net benefit conditional on specific factors like existing diseases, obesity, etc.
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.
Well “fortunately” I’m forced to have a strict diet due to some sort of IBS issues. For that, I use the MacroFactor app and talk through my daily recipes with ChatGPT, making sure to hit the macros and calories targets while also optimizing for heart health and IBS. Fat, protein, carbs, fiber. Taking AG1 to fill gaps.
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.
There are specific recommended minimums in the physical activity guidelines about strength training and endurance training where meeting them is likely to significantly reduce your disease risk and improve your health: https://www.barbellmedicine.com/blog/where-should-my-priorit...
The discussion seems unduly focused on lipids, whereas I would think that blood pressure would be a, if not the, primary concern.
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.
I was also surprised by that. It is relatively cheap to measure as you can just buy BP monitor and do it yourself at home. Considering that high BP is very often asymptomatic, I, for example, even feel better with high BP, many people walking around accumulating damage for years. Not to mention it also goes with a baggage of other side-effects like increased chances of a stroke and kidney failure.
For some reason it hits differently when you go eat something salty or drink coffee or get all stressed out for now reason and then see increased BP with your own eyes. That was what motivated me to stick to a better diet, cut caffeine and chill out.
I'm not sure that non-medically indicated CT scans are a great idea, as you're at least doubling your yearly dose of radiation in the year of the CT scan. Perhaps it's warranted, but the article doesn't seem to balance that at all against doing a CT scan "every 1-5 years".
Yes - in addition, medical professionals warn against “overdiagnosis” from unnecessary screenings.
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.
I agree. As a physician, this is sticking out to me as bad / dangerous advice. By getting unneeded regular CT scans, you’re dramatically increasing your risk of developing cancer. Beyond the radiation exposure itself, there is also the very real possibility of incidental findings that can lead to further testing, invasive biopsies, and unnecessary interventions, all of which compound your overall risk. You might solve one problem, but you’ve just guaranteed a much bigger, more explosive one down the line.
My good friend just died from a heart attack at 60. 90% blockage in 2 arteries, even though he exercised regularly and appeared perfectly healthy. This triggered my exploration of my own risk and I came to the realization that although my lipid panels were ok, I could also have a 90% blockage and be completely unaware. I ended up getting a Calcium CT scan which showed no blockages, but I realized that without my friends death, I’d have no idea of my score. In the US, insurance doesn’t cover the screening. I’m now a believer of all people having a scan at 50, and likely every 5 or 10 years afterwards.
I’m not even a few screens into this and I’m already nodding my head in agreement. Having parents of the age where hospital trips are now a yearly occurrence at least, the level of care a patient gets is so much better if relatives are involved and knowledgeable. The medical system does not give a shit about you, they just want to make sure you don’t die in their care.
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.
Fabulous information, but lacking information isn’t the issue. The behavioral changes are obvious and well evangelized : lose weight, regular activity (walking), and if necessary, take meds. (Yes I know your marathon runner cousin who died suddenly of a heart attack, but these are still your best odds)
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.
This site isn't necessarily meant to have a big sociological impact; it provides enough information that someone with sufficient motivation, but a lack of resources and expertise can take concrete steps to reduce their risk. That seems useful to me.
in this case “useful” means applying the facts and making changes. A detailed map that goes unused is useless. A hand drawn map that gets you home is priceless.
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.
“Stress” is so abused and nebulous that it’s impossible to define. Nearly every condition is worsened by “stress” but there’s no way to measure it. And there’s no conclusive way to manage stress either. Medication, psychotropics, self medication, meditation. Nearly all of those are more broadly abused and yet stress “worsens”.
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.
Fortunately, as you mention in your last sentence, stress is introspectable.
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 :)
True that “sleep better, eat better, exercise” is generic advice ignoring constraints. Like telling someone with insomnia, three kids, and a night shift to “sleep better” or telling someone broke to “have more money.”
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.
> The behavioral changes are obvious and well evangelized : lose weight, regular activity (walking), and if necessary, take meds.
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.
Great post but quite surprised there is no mention of cutting red meat. There is a lot of evidence that especially the American diet is dangerously high in red meat to the point of elevating Heart Disease risk.
IMO, I think that is more of a saturated fat issue, and only a subset of the population is like that. Others solve their health issues through eating a lot of red meat.
Yeah it's definitely more about saturated fat from animal sources.
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.
No, I mean for some, a high saturated fat diet can do amazing wonders. And for others, it causes horrible issues. The studies are not well segmented genetically and by body state since that is signficantly more expensive and genetics only got cheap in the past 10 years or so, so they wash out these large sub-population dynamics.
It's the sort of thing you can just experiment with and see for yourself.
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.
Also processed red meats or processed meats in general. Processed meats are the ones strongly linked with heart disease. At least for those who dont want to go vegetarian.
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.
these are extremely outdated recommendations that make no sense. most of the basis for those are studies that took direct correlation as causality. the problem is a crappy lifestyle which incidentally typically includes processed and red meats in large quantities in the western world. saturated fats are hardly a good indicator of anything when you disassociate them from the lifestyle and foods they come with for most people. blue zones are now finally coming out as simply just the places where records sucked. there are plenty of populations with centenarians that had meat rich diets.
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.
In general, when science is done, recruitment requirements force the experimenters to bucket the participants. One thing that often happens is an open bucket, say 35+.
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.
If you start exercising in your 20s, and never stop, it will be so much easier to maintain fitness in 40s 50s etc. The challenge is that the benefits are not yet visible in your 20s (when you’ll probably be healthy and at a proper weight regardless). Gotta lay that foundation for older age though!
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.
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.
The title of the article says "don't die of heart disease", but given that we all have to die at some point, if you could choose what natural cause to die of, wouldn't you pick heart disease? It is the best way to die. The worst is stroke. So once you cross a certain age, say 60, don't worry about heart disease, worry instead about stroke.
I agree, but both are heart disease and both can be prevented in similar ways. My dad and my father in law both died from heart disease. My fil was on the surface less healthy. He had an extreme high stress job with exposures to environmental factors that made it worse, was partially disabled with bad knees, etc. i believe he was on blood thinners for almost 20 years.
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.
Yes but there are habits that are especially important for preventing stroke, such as getting 7-9 hours of sleep, monitoring and controlling risk factors related to blood vessel health that affect the brain uniquely, such as preventing irregular heart rhythms (atrial fibrillation), anti-inflammatory diet choices focused on brain health, and so on.
If you have a massive banger and die immediately that is a pretty good way to go.
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.
If you made a Venn diagram for the non-genetic risk factors for heart disease and Alzheimer's, they'd basically be a circle.
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.
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.
Sometimes I think the way this type of thing is framed is misleading. There's a list of putative causes of death and there's an assumption that they're equally systemically impactful, and you can go down the list and just lower the probability of each and lower your overall likelihood of death.
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.
You assume that you'll die at X years old, and get to pick the disease. In reality, you might die of heart disease at 60, or cancer at 70, or alzheimer's at 80. Which one do you pick?
What I want is a long life of doing what I want. when I must die how doesn't matter, but if I can extend my lifespan (well span) by not getting a heart attack that is good: more years to enjoy life. If I can also extend my life by not getting cancer even better. Even if I must die if I can delay that with a good life that is what I want.
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.
I think you are confusing "getting a stroke" and "dying from stroke". If you get a heart attack and don't die from it you might become a burden on your family too.
Curious about how accessible these tests are in Europe. Living in a country (NL) that doesn't value annual checkups makes me assume detailed, preventative blood testing like this is hard, let alone possible to get in non-extreme situations.
You can order all blood tests you want online in NL. E.g. bloedwaardentest.nl, mijnlabtest.nl, perfectlab.nl. But it isn't cheap so you need to know what to test for to keep the price reasonable.
Merck has a promising pill (enlicitide) coming that blocks PCSK9, lowering LDL-C:
- 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).
> All of these can be accessed through bloodwork and urinalysis and can be done at a local Quest Labs (I’d venture to bet there’s one within a 10-mile radius of your home), prescribed by your doctor, and will likely cost anywhere between $80-$120 out of pocket.
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).
I didn't stop changing doctors until I found one that would work with me. I didn't go to a fancy concierge doctor - I just shopped around. I didn't go through a string all at once, but when I needed to go to the doctor, if I hadn't liked the last one, I went to the new one. After 4-5 years of this, I found one.
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 means regular exercise (both strength training, ideally 3x per week, and cardio training that helps to improve V02 max like Zone 2 training)"
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.
Is V02 max still the best predictor in people optimizing for it specifically above everything else, or only in people that train generally and have a high V02 max as a side effect?
He might be talking about zone 2 in a 3-zone model? Otherwise, I agree, zone 2 in a 5- or 7-zone model is not intense enough to provide VO2 adaptation.
There is an old pharmaceutical product that was available in Germany, but can not be obtained anymore. Ouabain /Strophanthin
"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.
A recent report from the American College of Cardiology emphasizes the prediction power of hsCRP:
"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."
The primary thing I did was ask a cardiovascular surgeon in my network to send the lab requisition form to a lab. This is the gate for much of this stuff, even if you pay out of pocket. If someone knows a simple “pay and play” testing service that would be fantastic.
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.
Eat healthier (less processed foods, more fruit and veg, healthy carbs, low sugar and alcohol), exercise regularly and get enough sleep. Take a blood pressure measurement every week / month or so. Track your weight. React if either start going up. Don’t go start getting uneasy ct scans.
> I experienced this repeatedly. We were admitted to the hospital for over a week when my daughter contracted viral meningitis (the scariest experience of my life). Even while working with incredible infectious disease doctors, I still had to fight and constantly remind people what the next steps were during our admission. Nobody is watching over you - it’s your job to organize things and ensure they’re on track. I had to coordinate between the infectious disease departments and neurology departments and make sure the people doing the lumbar puncture on my 9-month-old daughter weren’t just residents practicing on my child but experts who had conducted the procedure countless times before. You must Advocate for yourself and the ones you love.
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.
You're conflating advocacy, which indeed he is entitled to, with how the hospital is allocating resources and if and how they apply competent resources.
Life or death procedures aren't a time for "you get what you get and don't have a fit."
How do people become experts on doing dangerous procedures on infants if they're not allowed to do dangerous procedures on infants until they're experts?
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.
Hospitals are full of 'life and death' situation. If everyone were to behave like that, things would stop working or be severely slowed because you can't work correctly when you got that guy breathing on your neck constantly. You lose time answering to load of demands from people getting angrier and angrier because they feel that they don't get the care they need. That makes you angry. Other people are getting less attention, they get angrier.. Etc etc.
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 think you really pretty fundamentally missed the point of what he's saying. Perhaps you've never had to confront the full brunt of the bureaucracy of a large-scale medical provider.
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 don't know, maybe it's just me seeing things differently.
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.
> what most primary care physicians will do with patients to help them avoid heart disease is not enough. The status quo simply does not work
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.
Heart disease is the leading cause for death, but the root cause is definitely obesity. There’s a an obesity-pandemic that no one’s talking about it, there should be a national program that encourages people getting fit and discourages them from getting obese. And by encouraging/discouraging I don’t mean some random posters posted around, no, things like tax cut for fit people, free access to xyz if your bmi is less then abc, cheaper flights and insurance if you are fit, and so on.
A lot of good information but bordering on neurotic. If everyone just did lipids, walked 3x a week, and got on glp drugs it would significantly reduce the number of heart attacks.
Ordinary people don’t need to be obsessing to do better.
The value of the biomarkers are they applicable for all age range? What if someone already had a heart attack, then what should be the normal values post incident?
AFAIU, for LDL and ApoB, the real danger lies in the area under the curve. Lifetime exposure. That's not to say that lifestyle improvement can't help in other ways, but the damage caused by LDL is very difficult (impossible) to reverse.
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.
Unfortunately, the time in our lives when we need to most pay attention to these things is when ageism kicks in and yeets us completely off of health insurance.
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 you dig into research and follow the low-risk experiments that people do online to reduce their Lp(a), you can find techniques and evidence to do so. It doesn't have to be an impossible-to-fix issue.
> It's not sexy, and as a result an overwhelming majority of the population is unaware about how to avoid succumbing to it
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.
I asked a heart doctor for a calcium scan. He said I didn't need that, but he wanted me to wear a Holter monitor for a few days (reasons unknown). I did not.
That was years ago. I have different doctors now but still no calcium scan. Time to ask again possibly.
My dad would disagree--he's 84, was on statins for years and they did terrible things to his body. I'm sure the drugs kept him alive, but the side effects, as he describes them, particularly to his legs and kidneys, were pretty severe. He only got better when he stopped taking them.
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 believe statins reduce risk by about 30%, so there's a roughly 30% chance the statins have done good things for your dad.
(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 now have a cardiologist and just had an MRI to check on the state of my aorta, as a recent calcium scan brought up concerns.
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.
IMO the war on dietary saturated fat and dietary cholesterol is misplaced big time. It's minority view though. What's worse is that avoiding saturated fat and cholesterol may partly fuel your progress to heart disease.
Anyone note where to get this full blood panel done in the UK? I’ve got issues with high blood pressure and swelling in the lower extremities. Blood tests and ECG showed nothing.
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.
> I’ve got issues with high blood pressure and swelling in the lower extremities
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).
The "be an advocate" thing is both true but also incredibly selfish and egotistical.
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 assumption was that we have to be our own advocate because the system itself is non-ideal.
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."
> 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.
Yeah insisting that you are qualified to choose the members of the medical staff qualified to do X or Y procedure isn't advocating, it's being a prick.
Not an ad but I use https://www.walkinlab.com to order labs then get them done easily without a doctor. I have regular health insurance but it doesn't cover as many labs as I want done.
My dad went to doctor who was like his friend as long as I can remember. Always received a clean bill of health. Until he suddenly got heart disease and a stroke on the operating table. His doctor basically said that he had seen this coming. Doctors secretary, probably twenty years his junior was a stunner.
I didn’t know who this author was previously (Jared Hecht) but I looked up pictures of him and he definitely does not look like he exercises regularly. He’s skinny (e.g. not overweight) but if I passed by him on the street I would not peg him for someone who exercises seriously.
I'd argue that even the CT scan is unnecessary for a lot of people who want to start a preventative regimen to tackle heart disease. Especially if you're in your 20s or 30s with no family history of heart disease and no absurdly high ApoB results combined with really high lp(a).
Unless you're willing to take pills the rest of your life, spending a ton of money to study your risk of heart disease is always going to lead you to the same conclusion: Don't smoke, don't drink, eat healthy and exercise regularly.
> Even while working with incredible infectious disease doctors, I still had to fight and constantly remind people what the next steps were during our admission.
Can't help but feel this is a factor of the sleep deprivation that doctors seem to celebrate.
So your doctor won't agree that you have heart disease but you need to be on a statin but statins are by prescription only... So if you're not going to hire an expensive doctor what can a normal person actually do?
I recently did a comprehensive panel of my own volition with Quest Labs and was pleasantly surprised by the entire process. It was super easy to schedule, affordable, and their online platform is surprisingly sleek.
It is a long read and I want to make time for it. Quick search check and calc (for calcify etc.) and diet appear alot in the article which is not surprising based on other things I have watched on the subject.
Depends on the doctor. My doctor at One Medical proactively ordered an ApoB test just to be safe after I successfully got my LDL in check through diet and exercise.
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.
they are to me. I'm very light skinned and thus have had sigificant sunburn more than once, skin checks have found and removed somewhat likely to turn into cancer. Probably useless if you are 20, but by 50 they can find and prevent cancer and so should become common
Actually, there is. You have to search for "pressure". For example, "Other Tests: There are some other things that are important to know as well. You must know your blood pressure".
As much as the HN trend is against AI features in client software, this is an excellent use of Gemini-in-Chrome. Instead of wracking your brain for English synonyms, you can just ask it if the page discusses hypertension, a kind of weapons-grade ctrl+f. Mine said
"Yes, the article discusses hypertension, referring to it as "high blood pressure.""
It seems to be nearly impossible for me to advocate for myself at a place like a hospital.
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.)
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?
You're almost certainly going to die by or before 110, anyway. (Ir)Regardless of your efforts, or lack thereof, our bodies typically give out in the 100-110 year range with very few exceptions.
Please strictly cease and desist from accusing material of being written by an LLM, whether on this site or on any other site. If you want to criticize the material, do so under the good faith assumption that it is written by a human.
I think it’s absolutely fair to criticize something for potentially being generated via an llm or heavily utilized by such especially when it comes to medial claims.
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.
No. It is false criticism. It is like calling one a witch in historical times. Anyone gets accused of it without hard evidence. For all I know, your comment was AI generated. You relied on AI and are now passing that along. It's not helpful.
We don't really know the author. For all I know, the LLM is more accurate than the specific human, in which case I'd want the article to be written by an LLM.
Saying "LLM bad, human good" is both false and uninteresting.
Genuinely, why? More people than ever are using LLMs to flood the internet with textual slop far faster than humans who have respect for the craft of writing can generate their own text.
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?
Because the signs are only in your head. There is no hard evidence. It is a disingenuous and false way to attempt to discredit someone. Anyone can be accused of it for writing anything at all. The argument that the writing started after the invention of ChatGPT is simply horrible because everyone starts sometime.
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.
Of course there is no "hard evidence" unless someone leaves evidence of the prompt or AI response in their blog post. There are certain clues and syntax. Your comment seems like it would fit in much better on Reddit than on HN.
Negative. You're the one making unproven bad-faith assertions, trying to discredit someone on the basis of witch-hunting logic. Your comment belongs nowhere.
I honestly think we should live more for the now than the far future. Rather than focusing on how to optimally extend my lifespan I'd rather focus on living the life where I'd be satisfied if I dropped dead the next day.
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.
What if heart disease saves me from dementia? I'm not just being contrarian. I think about this a lot of the time. I'm already 40. I'm being healthy now, but whatever damage has already been done is baked in. (plus whatever is in my genetics) A quick death at 65-70 might be much more preferable to a slow terrible decade-long decline.
New medical discoveries happen regularly; you might also die right before the discovery of a preventative/cure for dementia. Living people have options, dead people have none.
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.
Heart disease can be a slow decade long death, where you become incapable of physically doing anything. It's not just a heart attack out of nowhere and you're dead.
My grandfather always said "there's something to be said for a good coronary." He was in his 70's when he said it, and his point was that he had a good run, and there's an argument for going out while things are still good rather than slowly dying over six months in a nursing home (which is what actually happened).
ChatGPT is amazing for interpreting test results. Of course you should back it up with a doctor.
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.
Yeah its a self-made-help article, if you don't know any better this is what you do. It doesn't make it the best choice overall though.
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.
Hey, just a friendly reminder that this is HackerNews, not The Lancet.
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.
This is all very interesting, but far too detailed and technical for 99% of people. The TLDR should include an easy to understand summary without jargon like "VO2" and "a set of HIIT at Zone 4".
My first thought after reading: where does a guy like Peter Attia fit into the mix? Is he motivated and communicating in legitimate ways? Just a promotion machine at this point? Somewhere in between?
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.
Stop drinking. Replace cheese and butter with olive oil in copious amounts. Only eat fish meats. Don’t smoke or vape. Eat salads and other prebiotics. Get some cardio - even walking your dog is great. Your brain fog will lift, your skin will clear, your mood will improve and your doctor will gasp at how clear your carotids are next time they’re ultrasounded.
Love the chart at the bottom--it really puts on display media bias and lack of integrity and using fear to push idiotic policies which area really just a way to put everyone in the pocket of government and keep them there permanently with zero real improvement to public health. Fear get eyeballs. the Covid mass hysteria proves that, too.
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.
Walking and eating sensibly is free. Even a balance oatmeal, rice & beans with infrequent meat servings would defend against heart disease better than expensive medicine, at less than $1 / day.
Funny you should use the word "bang". My last experiment with lentils years ago began one evening with 3 excellent bowls of very tasty lentil soup and ended slowly with 2 days' worth of "bangs", quickly followed by ostracism by my house buddies. So bad!
Promoting good habits is good but this is health advice from an unlicensed commenter to say rice and beans is better than taking a statin. Consult your doctor if you’re curious what to do.
You right. You don't need statins. Nobody does. But look at the statistics. You might also drop dead tomorrow. It's hard to know. If you think eating and exercising would solve heart disease, you are mis-informed. It's the number one killer. If we all died at 30, the drugs would not need to exist. I'm sure you would like to live as long as you can. Taking statins is cheap and simple for most people.
Yes, our system is most definitely stacked against the poor, but it's important to also remember that we all have free will and that some choices fully within our power are much better than others.
nicotine is likely one of the best appetite-control , cognative-enhancing and anti-anxiety medications ever known to man. A large driver of obesity , anxiety and psychotropic abuse was smoking cessation.
Giving out nicotine gum , would decimate the drugs industry, but likely resolve a lot of our chronic health and depression issues.
tonymet says >nicotine is likely one of the best appetite-control , cognative-enhancing and anti-anxiety medications ever known to man.<
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".
I think the point is it is cheap to prevent. The weird tip is doing a different test to the standard one, which costs little for typical HNers (but admit every $ counts for many people esp. with current inflation, poverty, bad governance) but sounds like on par with a dentist doing anything beyond a checkup.
You have to be able to get the prescription. HMOs (Kaiser specifically) will generally not provide any sort of preventative care in this area unless your numbers are very high. You can’t get access to a cardiologist unless you’ve already had an adverse event.
If you can get time off work and have a PPO, you can get the preventative care.
$10 is the cash price. Your doctor diagnoses, not insurance, and you don't need a specialist to get diagnosed regardless of what your insurer wants. Even a nurse practitioner can prescribe you a statin.
Really surprised at the last few paragraphs! Read with caution this is not Real medical advice!
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!
I don't like this kind of content. The author might have a personal motivation for it, but for the general public, it's just more mental load.
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.
I share your general emotional reaction, but to be fair, heart disease is far and away more important than other type of disease. More people die of it in the US than die of all cancers combined: https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm
> We all know the good practices. Don't be a dumbass
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.
I am not a statin skeptic--or rather, I don't want to be a statin skeptic. I've done the research and it makes sense to me, but I still feel some social and psychological pressures to reject statins.
When I see that it is widely accepted that ApoB is better to measure than LDL-C, but the industry continues to measure LDL-C, but not ApoB, I wonder why. It makes me skeptical.
When I see that the purpose of statins is to reduce plaque buildup in the arteries, and that we have the ability to measure these plaque buildups with scans, but the scans are rarely done, I wonder why. Like, we will see a high LDL-C number (which, again, we should be looking at ApoB instead), and so we get worried about arterial plaque, and we have the ability to directly measure arterial plaque, but we don't, and instead just prescribe a statin. We're worried about X, and have the ability to measure X, but we don't measure X, and instead just prescribe a pill based on proxy indicator Y. It makes me skeptical.
In the end statins reduce the chance of heart attack by like 30% I think. Not bad, but if you have a heart attack without statins, you probably (70%) would have had a heart attack with statins too. That's what a 30% risk reduction means, right?
As you can see, I'm worried about cholesterol and statins.
If you fix it without statins through better lifestyle and diet, that is the preferrable route.
As to why medicine is like this, it's because it's conservative, usually about 17 years behind university research[0], and doctors are shackled to guidelines in most health systems or risk losing their licenses. It isn't a coincidence that the article author had his out-of-pocket concierge doctor tell him the more up-to-date stuff.
[0] https://pmc.ncbi.nlm.nih.gov/articles/PMC3241518/
I have an objection to the "better lifestyle and diet" approach.
Sure, it is absolutely true that better lifestyle and diet has a huge effect. However it is absolutely certain that the vast majority of people who are told to improve their lifestyle and diet, won't.
The result is doctors giving advice that they know won't be followed. And thereby transferring potential fault from the doctor to the patient, with no improvement in actual outcomes. "I told the patient to lose weight and maintain that with a controlled diet." And yet, most people when told to diet, won't. Most people who start a diet won't complete it. And most people who lose weight on a diet, have the weight back within 5 years. Where each "most" actually is "the overwhelming majority". And the likelihood of the advice resulting in sustained weight loss probably being somewhere around a fraction of a percent.
What, then, is the value of the doctor giving this lecture?
(Disclaimer. I have lost 20 of the pounds I gained during COVID, and am making zero progress on the remaining 30. A few months ago I successfully started a good exercise routine. Given my history, I would expect to only follow it for a few years before falling off the wagon. I believe that this poor compliance puts me well above average. But do you know what I do reliably? Take my prescribed medicine!)
Your health is ultimately your own responsibility - it's your body. You have free will, and your appetite for risk is yours alone. You can choose to ignore expert advice and refuse to wear a seatbelt, skip your rehabilitation exercises, invest all-in on crypto, or smoke cigarettes. None of this responsibility should fall on the expert if they communicated the risks clearly.
What you're communicating here, perhaps unintentionally, is that what matters is not results, but blame. If the doctor said what to do but the patient didn't do it, all that matters is the patient is to blame.
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?
It's hard to help someone that doesn't want to be helped.
Struggling to change is different from not wanting to change. People seem to have trouble with basic distinctions like this when they're heavy into moralizing failure to change.
Profound point. My mother struggled with alcoholism and ultimately succumbed to that disease. In philosophy of mind they use “akrasia” and “akratic thinking” for acting against ones better judgement. It helped me somewhat getting to understand what my mother was going through at that time.
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.
I find it helps to explicitly abandon the expectation that each person has a unitary and consistent will.
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.
Reading this thread it seems like you're the only one moralizing and looking down on people. I don't see anyone here shaming people for their choices. But somehow you seem to have read the worst interpretation of every reply.
Drugs expand what helping yourself means to the point where people will actually do so.
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.
Not that hard in this case. Just give them a pill.
Or, as we're becoming aware with GLP-1 drugs, an injection. (For now!). It's better to help people behave better with drugs than moral condemnation. Almost infinitely better, as it turns out, regarding a lot of problematic behavior regarded as "untreatable" previously.
Why not both?
It may not be the case for statins specifically, but my main concern is side effects. If there was a panacea, I would support giving it to everyone, but lifestyle changes are usually more available, if not easier.
The old adage "You can lead a horse to water but you can't make it drink" applies here.
Yeah this prickles my hackles too. It took a fairly high dosage of zepbound and many months for me to get to a normal set of eating habits after a couple of decades of bad, but a prediabetes scare surprise on my labs pushed me into the program, but I would not have done it by "white knuckling". I needed some medication to help me along. All these people just saying "calories in and calories out" "just start exercising dude" are making a complex issue into a "simple solution" that almost never works because change takes time; a lot of time that many people don't feel on a deep level that they have to apply to it. So, they just give up after a couple of weeks of "grit" and "will-power". Isn't it like maybe 1-3% succeed over time, while the rest fail when trying to lose significant weight or other health issues that could be resolved with habit only?
To me the terms mix and it helps to separate the things that are externally manageable from the things that are not. The physical is complex but straightforward - the body biochemistry operates on material in, biochemistry mix, expenditure out. The brain is physical - neurons, pathways, etc. The mind, OTOH, is a virtual little candle isolated in a prison of meat and bone trying to understand how to interact with the world around it. External forces can alter the body and brain, but only the mind can change the mind. And does, in ways that are very difficult to control because the sole operator is part of the mechanism. People who try to change on their own and can't aren't failing or weak, it's just really f-ing hard.
If my health is my responsibility, then shouldn't the treatment that I receive be to the standard that I request?
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?
> 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
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.
Maybe 80-90% of people should take doctors at face value, but it is easy and only getting easier to at least access the knowledge to better advocate for your own healthcare (thanks to LLMs), with better outcomes. Of course, this requires doctors that respect your ability to provide useful inputs, which in your case did not happen.
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.
You should have bought some illegal street diet and exercise or cholesterol meds or whatever.
What if you have an intrinsically lower ability to perform temporal discounting?
Is that really something intrinsic and fixed or can you improve it over time with deliberate effort?
Open to evidence either way. I haven't seen people improve it even with what seems to be terrible negative consequences associated with poor temporal discounting ability, but I'd love to read differing perspectives.
Research on heritability have found that the amount of temporal discounting we do is moderately heritable. With twin studies ranging from 30-60% of our natural variability explained by genes.
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.
> This strongly suggests that genetics definitely slips a thumb on the scale, but ultimately we are able to also impact our personal behavior.
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...
That is why I said "strongly suggests" instead of "guarantees".
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.
What would be the upper bound of the effect of heritability where responsibility is no longer assumed?
> Sure, it is absolutely true that better lifestyle and diet has a huge effect.
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).
> 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 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.
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.
both of my parents have low cholesterol, my mom's cholesterol is naturally under 200, my dad is on statins but the highest he ever got was about 230. they are in their 80s. Nobody on any side of my family (for which I have about 25 first cousins) has ever had any heart disease of any kind, no bypass surgeries, no heart attacks, nothing.
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.
Diet and exercise are hugely important to health in general, and can make a significant impact on lipids.
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.
Your anecdotal report that diet and exercise did not have a huge effect on your cholesterol does not discount the mountain of evidence that we have showing that diet and exercise has a huge effect on health and lifespan.
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.
yeah I read all that and it's why i did "diet" (already exercised) first.
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.
i think diet an exercise can get you 20 points lower but you needed 150 or so and no diet claims that.
i don't know how to source that but I recall a few 20 points lower diets making the news over the years
I think people use it as cudgel to blame people and as a crutch to avoid action. And we ignore the psychological and other factors that make improving lifestyle and eating better difficult.
No doctor wants their patient to have a stroke. But they also only get to meet patients where they are.
You're arguing against a strawman. The reality is that most doctors will tell the patient their options and let them pick. While statins have some significant side effects in many patients, there is 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. And if that doesn't work for whatever reason then prescribe the drugs.
> While statins have some significant side effects in many patients
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.
Are you sure that this is a strawman?
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.
Yes, I'm sure you were arguing against a strawman. The majority of doctors will tell patients about the available options which are generally safe, and allow them to pick. And they don't usually blame patients. Your personal experience might have been different but it was atypical and just an anecdote.
First, if I'm basing it on things that actually happened, then by definition it cannot be a strawman argument. And your insisting otherwise is just plain rude.
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.
> While statins have some significant side effects in many patients
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.
That is because dietary advice they give is actually bad. It mostly boils down to "limit calories while eating standard western diet" but that is impossible to follow long-term as SWD and similar (e.g. food pyramid) diets are nutrient-deficient.
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...
Sure it's absolutely true (I stopped reading there.)
>doctors are shackled to guidelines
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.
You are conflating two different things. The standard of care in a malpractice lawsuit is not necessarily the same as clinical practice guidelines. In reality doctors are free to rapidly adopt incremental improvements, especially when they are evidence based.
17 years is far from rapid or move fast and break things. ApoB has been known about for quite a long time, since the 90s its effects have been obvious, and showed up in research in the 70s-80s!!! It's still not part of standard testing!!!
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.
There is virtually zero chance that a doctor will lose their medical license for diverging from the from the usual clinical practice guidelines around statins. Check the state medical board disciplinary records.
But if they're employed by a health system and fail to follow company policy then yes, they could be fired.
Different countries are different, some are far more trigger happy about it like Canada. What you suggest as an alternative other than 'git gud' diet & exercise also changes it.
You can only do things to reduce your risk. And whatever intervention would be based on overall population statistics, since it's difficult to know your own personal risk. Heart disease kills marathon runners. You can't just "fix it". Someone who has naturally high cholesterol won't magically be okay by changing their lifestyle and diet.
Licensing but also insurance.
I think only recently have insurance companies started covering APoB testing in your annual exams (or that may just be my insurance…).
Many commercial health plans will only cover an ApoB blood test for patients with certain conditions or risk factors. But if you want it you can pay out of pocket for like $70.
> When I see that it is widely accepted that ApoB is better to measure than LDL-C, but the industry continues to measure LDL-C, but not ApoB, I wonder why. It makes me skeptical.
ApoB is shaping up to be an incremental improvement in measurements, but health and fitness influencers have taken the marginal improvement and turned it into a hot topic to talk about.
This happens with everything in fitness: To remain topical and relevant, you always need to be taking about the newest, most cutting edge advances. If it’s contrarian or it makes you feel more informed than your doctor, it’s a perfect topic to adopt for podcasts and social media content.
ApoB is good, but it’s not necessarily the night and day difference or some radical medical advancement that obsoletes LDL-C. For practical purposes, measuring LDL-C is good enough for most people to get a general idea of the direction of their CVD risk. The influencers like to talk about edge cases where LDL-C is low but then ApoB comes along and reveals a hidden risk, but as even this article shows there isn’t even consensus about where the risk levels are for ApoB right now. A lot of the influencers are using alternative thresholds for ApoB that come from different sources.
> In the end statins reduce the chance of heart attack by like 30% I think. Not bad, but if you have a heart attack without statins, you probably (70%) would have had a heart attack with statins too. That's what a 30% risk reduction means, right?
30% reduction in a life threatening issue is huge. I don’t see why you would want to diminish that.
If you were given the choice of two different dangerous roads where one road had a 30% lower chance of getting into a life-threatening car crash, you would probably think that the choice was obvious, not that the two roads were basically the same.
numbers often quoted in favor of statins use relative instead of absolute risk. when seen in absolute terms there is little case for statins except in some possible particular cases. they also do little, if anything, when it comes to life extension — the expected lifespan of a statin user is often estimated to be four days longer than that of those who do not use them. not only is this essentially statistical noise, it discounts the lowered quality-of-life side effects experienced by many who have been put on statins.
This is all true. If you take a statin and it causes no issues, you're... maybe (30%, yay!) better off for it.
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.
> There are many types of statins to try though
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.
AFAIK statins show better numbers for secondary prevention. For primary prevention its a toss up.
>If you were given the choice of two different dangerous roads where one road had a 30% lower chance of getting into a life-threatening car crash, you would probably think that the choice was obvious, not that the two roads were basically the same.
You could absolutely think that they were basically the same, depending on the base rate. The differece between a one-in-a-million and 0.7-in-a-million is 30%, but it wouldn't be humanly perceivable. We're all likely faced with situations like that regularly. Differing airlines probably have much greater variances in their crash statistics, but it just doesn't matter in 99.99999% of flights.
There is an xkcd for that:
https://xkcd.com/1252/
https://jamanetwork.com/journals/jamainternalmedicine/fullar...
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.
A meta-analysis that only includes 11 studies on statins is immediately suspect.
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.
Have you read their methodology and understood how they did their selection? You could critique their actual methodology. Maybe their selection is backed by strong arguments, right? And if you think their methodology is weak, then please explain why.
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.
That’s fair.
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.
How many studies is enough? There were approx. 60k+ participants in them. If I got it right…
Ah, you were so close...
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
[5] https://pmc.ncbi.nlm.nih.gov/articles/PMC10203693/
> There have been a lot of studies on statins
Financed by who?
Lots of people. Statins are fairly cheap and a lot of people are on them. Cholesterol is also cheap to measure. As a result the two are commonly studied. Even if your goal isn't the above it is probably in the study data.
https://www.lipidjournal.com/article/S1933-2874(25)00317-4/f...
Guidance from the National Lipid Association, based on a review of the current understanding of the science across quite a few different meta-studies, analysis, etc. Many of the referenced studies are meta-studies significantly larger than the one here.
We have mountains of studies showing the negative impact of LDL-C (and inflammation! Which statins also reduce) on health. We have mountains of studies showing positive impact from statins. We have specific mechanistic understanding of how LDL-C and other atherogenic particles cause heart disease. We have mountains of studies show that statins directly lower the amount of atherogenic particles you have.
This has been studied enough and sliced enough ways that yeah, there is evidence on both sides. But one side is effectively a mountain range, and the other is a small hill. I know which way I'm going to land on it.
Concentration of ApoB-carrying lipoproteins in the bloodstream as the driver of heart disease is one of the most strongly proven facts in medicine. Statins are proven to lower LDL (a close-enough substitute for ApoB in most situations) by about 30%. I can't look at the study now, but most likely it's a situation where patients' cholesterol has not been lowered enough by medication to make a meaningful difference. If you have an LDL of 160, statins aren't going to be sufficient. The issue is doctors/patients not targeting a sufficiently low cholesterol level.
> When I see that it is widely accepted that ApoB is better to measure than LDL-C, but the industry continues to measure LDL-C, but not ApoB, I wonder why. It makes me skeptical
Because this is a recent understanding and healthcare tends to be a conservative industry that moves slowly. Sometimes too slowly.
And also because LDL remains an excellent measure. The risk with LDL isn’t false positives. If someone has high LDL they likely have an elevated risk of heart disease. The problem with LDL testing is that someone with low LDL may still have a high risk of heart disease which may be captured in APoB testing.
> When I see that it is widely accepted that ApoB is better to measure than LDL-C, but the industry continues to measure LDL-C, but not ApoB, I wonder why. It makes me skeptical.
Part of this is just that insurance coverage lags science. We've known that ApoB is more accurate than LDL since the 1990's or 2000's, but to be covered by insurance, several more steps have to happen.
First, the major professional societies (like the American College of Cardiology or National Lipid Associations) have to issue formal guidelines.
Then, the USPSTF (US Preventive Services Task Force) needs to review all of the evidence. They tend to do reviews only every 5 or 10 years. (Countries aside from the US have different organizations that perform a similar role.)
If the USPSTF issues an "A" or "B" rating, then insurance companies are legally obligated to cover ApoB testing. But that also introduces a year or two lag since medical policies are revised and apply to the next plan year.
The net effect is that the entire system is 17 years, on average, behind research.
ApoB blood tests are relatively cheap. You can pay out of pocket about $70 if you really want one and insurance won't cover it.
Most commercial health plans will cover an ApoB test for members with certain cardiac risk factors or medical conditions. But they generally won't cover it as a preventive screening for all members. I don't think we have enough evidence to justify broad screening yet, although that may be coming.
> When I see that the purpose of statins is to reduce plaque buildup in the arteries, and that we have the ability to measure these plaque buildups with scans, but the scans are rarely done, I wonder why.
I'd love to know where to get the right advice on this topic.
I have high LDL-C, had a heart CT in hospital last week, yet the hospital's cardiologist phoned me yesterday to cancel a scheduled appointment to discuss the results(!), because she said I have zero arterial plaques and there's simply no need for us to meet.
I feel really quite lost with this stuff :/
If it was a calcium scan, it is expected to be zero until mid 40s. It doesn't really start to give a signal until then.
A zero is still a zero though, and is associated with low risk of heart disease in the near future.
> If it was a calcium scan, it is expected to be zero until mid 40s.
I turned 50 fairly recently...
How old are you? I was told that they're not considered diagnostic until somewhat later in life (>50) because the plaque may not have calcified yet, which could cause a false negative.
I turned 50 recently
I was found to have high cholesterol in my late 20s. At the time the doctors (my cardiologist, then a second one brought in for advice) determined that the source was hereditary, but the effects would be the same. So they put me on statins. It's been 40 years now. I changed the statins three times since, when the actual one, at a specific time was no longer able to keep the values within acceptable limits. Approximately 8-9 years ago (I think) I ended up on Rosuvastatin 20mg, which I'm still taking every day. I do not maintain any diet (it'd be very hard, as I'm a heavy meat eater) and cholesterol levels are still staying within acceptable limits. Of course YMMV
No heart attacks or strokes? I'm in the same boat (hereditary issue), and altering my diet has never had any substantial effect on my numbers. I'm not overweight and rarely eat red meat, but have had trouble keeping onto a primary care physician long term (the people I keep picking seem to move between clinics constantly) in order to retain consistent access to a statin prescription, but as I continue to age I've been getting increasingly anxious that my time is coming.
So far everything is good. I only had more of a logistic issue, once, when moving to France from the US, a few years back (retirement) and when my new doctor told me that the French do not recommend statins for people at my age and overall good shape (active, fit, etc. ), even if the numbers are high. I asked her to give me a referral to a cardiologist, to whom I mentioned my 35 years of statins in the US, and who was of the opinion that after such a long time and with no apparent side effects, he would recommend continuing on this type of médication. And that was it, so I'm now getting the prescription renewals almost "automatically", even as my cholesterol is staying within limits (under the assumption that it may increase, should I stop, especially considering the amazing cuisine and products to which I now have access :) )
I haven't had to touch statins to get my lipids profile much better. I used zepbound to lose about 50lbs and then weaned myself off that. I was a little afraid my “completely normal after 8 months of weight loss” blood panel status at the end of my zepbound journey would go back to the “bad” region, but I have maintained going on a year with a much better whole foods/lean meats based diet and moderate exercise (I do let myself have some red meat on Saturdays, otherwise I would explode from hamburger desires). So it was done through a combination of lifestyle changes and zepbound to help me bury the hunger monster long enough to learn new habits and get to a new normal. Him suggesting that “probably” most people should be on statins whether they need them or not seems like covering up the source of the problem. I do know that some people just naturally have lipid issues even when doing “all the healthy things” though. My mom is one of them.
I ALSO want to not be a statin-skeptic but, like you, these things look very weird to me. The most prescribed drugs in the country and we don't even try to check if they are addressing the actual problem?
We have checked to see if they are addressing the problem more than probably any drug in history. The idea that we haven't is the result of skeptics cherry picking results that back up their point while ignoring the huge quantities of evidence supporting the efficacy of statins and other LDL lowering medications like ezetimibe, pcks9 inhibitors, etc.
Statins are so good at what they do they even reduce the risk in people who are already at low risk for heart disease.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6...
There is a financial incentive not to look.
Whose incentive? All the major drugs are generic now and (at least my) insurance pays for them without even asking for a co-pay.
That's fair. I know a lot of generic drugs are imported too, so maybe there isn't much pressure within the USA there. Unless the big domestic pharmaceutical companies are still making a lot of money on it even if generic options exist? I don't know.
There are plenty of statin skeptics and for good reasons; see prior discussion here: https://news.ycombinator.com/item?id=45430939
> and for good reasons
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.
What the BMJ has to say on this very topic of statins:
https://www.bmj.com/campaign/statins-open-data
So no settled science here.
Unless you consider the BMJ a trash journal of course.
note: > individuals at low risk of cardiovascular disease
Yes, you're right.
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.
Yeah, for each level of cardiovascular risk (in America, probably calculated with PREVENT) there is a target LDL which should guide whether you should start or not a statin.
I recently went on a statin (atorvastatin) and found I have the WILDEST dreams of my life if I don't take them in the morning, and my doctor said my liver readings were elevated after use but not enough he wants to switch it yet. Which alternative statins should I be looking at, or do they have even harder side effects to deal with?
I have intense anxiety attacks on atorvastatin. Rosuvastatin at the low dose (5mg) doesn’t do much, but at 10mg and 20mg it caused the same effects. It took years and multiple cycles of going on and off the drugs to become confident this was the problem. I switched to Repatha which doesn’t have this problem (it does make me a bit hungry though) but it’s expensive and it took a while for my insurance to approve it.
> Statins are well-tolerated drugs with little to no noticeable side effects.
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...
No, your post is nonsense. You link a random article that doesn't even make the argument that you're making - that it's low cholesterol causing the memory loss - or that statins are causing the memory loss at all.
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...
Memory loss and confusion have been reported with statin use. The FDA makes note of this here:
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.
> Memory loss and confusion have been reported with statin use.
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.
You can do a "study" to prove anything you want. And study outcomes often do vary depending on who is paying for it. The FDA is a neutral party. I recommend prioritizing the FDA warnings over "studies".
The FDA errs on the side of placing more warnings rather than fewer. They'd rather have false positives than false negatives. The warning is also clear that there is not a definitive causal link.
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'm a big statin sceptic so just putting that up front.
I think things haven't changed because most people underestimate how slow institutional scale change is. There is a reason why HR departments and consultants have Change Management experts. The inertia is huge. Young people don't appreciate this because they thrive on new ideas. Old folks don't and will subconsciously push back, like a form of institutional homeostasis.
Also, while I believe your heart attack stats are correct, I'm more interested in all cause mortality. I believe there statins are a net negative.
Statins also raise your blood sugar and lower your GLP-1, increasing your risk of diabetes?
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.
A single study showed a single statin reducing GLP-1 levels and ascribed it to gut microbiome changes that could be totally resolved with UDCA supplementation.
If this even ends up being reproduced it at most says there is an easy fix for people taking atorvostatin and that it might be a concern with other statins, but this should be treated with the same health skepticism of any other single study finding.
Not all statins raise blood sugar either - pitavastatin usually shows an improvement in insulin sensitivity.
How many doctors are cycling through all the statin classes to find the least-bad option for each patient?
(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.
If you go and tell your doctor you're having trouble with a statin, they should have you try a new one, yeah. Some might need to get clued in on pitavastatin, as it only recently went generic and insurance companies really didn't want to approve it before this due to the cost and wide field of generic statins, but it tends to have one of the best profiles when it comes to side effects.
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.
Statins can be effective for many patients (and there are multiple different statins with varying effects) but there are also alternative or additional drugs such as Leqvio (inclisiran) and Repatha (evolocumab). Patients should do their research and talk to their doctors. It might take some trial and error to figure out what works best.
one better simple indicator than large panels, if you can't get access to them or don't have them is simply your triglycerides/hdl ratio. aim to be under 2 if using mg/dl and under 0.87 if using mmol/L. it's one of the strongest correlated indicators of cardiovascular disease. way better than any classic cholesterol ratios.
5mg daily Crestor (a very small dose) cut my ApoB in half from ~130 mg/dL to 61. I’ve had no negative side effects.
The general advice is that the scans are only useful sometimes. That is, they can show a problem. But a clear scan doesn’t mean you’re fine. So don’t base anything on a clean scan, be proactive with all the rest of it. My two cents, by the way: Repatha is pretty amazing.
There is no reason take statins, ever. They will destroy your muscles, then cause diabetes and thus indirectly kill you. They will prevent a heart attack by... four days.
If biomarkers are elevated, the question must always be, "why is this elevated", and "is there a natural change in habit and diet that can reverse this elevation".
Artifically lowering the marker with a drug is like pasting duct tape on a leaking pipe - the leak is still there and it will likely quietly get worse over time and then eventually kill you anyways.
I find it unbelievable that our society swallows any drug without second thought. You body produces cholesterol on purpose. There must be reason why it produces it. "Ah well, who cares, let's just throw in a wrench and make it stop producing the cholesterol" and hope for the best...
Arguing against nonsense like this gets so exhausting.
Statins do not destroy your muscles. Newer statins make this already exceedingly rare side effect even rarer, but let's look at them as a general class:
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 feel like statins are harder to accept than vaccines. With vaccines we can say it is just training our existing immune system to recognize and fight something. So how would you straightforwardly explain statins to a scientifically literate adult so they can make an informed decision. But part of that means honestly acknowledging whatever scientific unknowns and uncertainties there are in this area of human biology.
> When I see that it is widely accepted that ApoB is better to measure than LDL-C, but the industry continues to measure LDL-C, but not ApoB, I wonder why.
That's pretty simple to explain. No conspiracy.
LDL-C is much much cheaper to measure. ApoB costs 36x times as much, so Insurance Companies don't like to pay for it
> 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...
How about moderate cardio and more fats in your diet
My wife had high cholesterol numbers, so her doctor wanted to give her statins. She asked about a scan, he begrudgingly said well, I guess you could do that. Her scan showed 0 plaque.
Plaque won't show as calcium until it has been in your arteries for decades and has calcified. It is a delayed indicator.
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.
Is there any way to get rid of the calcification? Experimental techniques?
Sure, surgery and several other risky and/or invasive treatments.
Or you could take statins and prevent it from becoming an issue in the first place.
Amlodipin
Was it a CAC or CTA?
It was almost certainly the former, and the former is is basically an indicator that the damage is already done.
Soft plaque takes a long time to calcify. But soft plaque is the stuff that ruptures, and will clog up your arteries just as much.
Statins are best used as a preventative measure - once the plaque is there it's difficult to regress it even while soft, and as far as we know effectively impossible once it is calcified.
I’m sensing a potentially significant misallocation of resources. My mental model is that there’s a hypothetical quantification of not just your time and money, but your anxiety, attention bandwidth, mental energy, etc.
I think, in some ways, the trick is being able to short circuit the entire journey represented by this website in favour of some form of, “I’m 40. I should be more mindful of heart disease. I should add a 30 min walk to my mornings.” And then move on with your life.
I think many cultures, but especially American healthcare culture, foment a growing background noise of constant anxieties and stressors. Life is sufficiently complex but there’s always a peddler eager to throw you a new ball to juggle (and pay for).
I think the article makes a valid point: stop worrying about 90% of the other stuff and focus on the thing that will almost certainly kill you - heart disease - for which there are easy diagnostic and preventative measures. I think they're arguing for a better allocation of resources, if anything.
Isn't the global population like 50% obese? What is your actual risk of dying from it if you are relatively in shape and in your 40s?
The most current and up-to-date risk calculator for heart disease risk is the PREVENT score.
https://professional.heart.org/en/guidelines-and-statements/...
Thanks for posting this. I was able to plug in all the required values from my last checkup and blood work. Even EGFR was there, I've never paid attention to that before.
I learned about it on the Barbell Medicine podcast! They had an episode dedicated to it.
Highly recommended to search their episodes for anything about health or fitness you've been curious about.
It depends. Overall, lowest all-cause death indexed on BMI seems to be around 27 plus or minus [0]. Interestingly, for all subjects (not just healthy non-smokers), BMI 30-32 isn't really associated with a dramatic increase in all cause mortality.
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.
[0] https://pmc.ncbi.nlm.nih.gov/articles/PMC10321632/
We don't know how to treat obesity 100% though
GLP-1s are remarkably effective.
Absolutely true, but it seems there is a lot of reluctancy in prescribing them
I'm not sure that's true? Insurance is hesitant to cover their expense for less extreme cases, and they're very expensive. But I haven't heard of prescribing being a real bottleneck. They're not controlled substances and the side effect profile is pretty mild (other than price).
Yep because the system around you wants you to consume to obesity.
Are you joking? We do know how to treat eating disorders. Same as we know how to treat opioid addiction or alcoholism.
No I'm not, as far as I'm aware "diet" is one of the "drugs" with highest failure rate ever
Heart disease is a big one, but so is cancer.
I think people should be mindful of it since they were 18 - it's something that progresses over decades. You can have a lot bigger impact making changes when you're young rather than at 40
But yeah I agree with your message. Focus on the big impact macro level things. Hyper-optimizing it is a waste of energy
If I'm not wrong, it takes 20 years to revert the damage of smoking. I don't think you need to care at 18, but the effects will be seen over the course of 20 years
Lots of the damage done can't be undone when it comes to heart diseaese.
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...
Seriously there is too much shit to worry about to micro manage each facet, unless your like a Bryan Johnson billionaire with a staff.
Beyond just heart disease & cancer taking you out entirely its: my eyesight is going, my hearing, every joint in my body could fail, my brain is slowing, etc.
There is just way too much shit to do anything other than be like: sleep, exercise, eat better and don't drink too much.
And even him doesn’t know what’s working and what’s making things worse. He claims to have really good biomarkers but that’s when cherry-picking numbers from studies made in a range of more than two years (!!).
You’ll never see a published set of tests from him. What you’ll see is ads to buy his supplements.
> Beyond just heart disease & cancer taking you out entirely its: my eyesight is going, my hearing, every joint in my body could fail, my brain is slowing, etc.
Absolutely right. You can’t fix everything. But if you can only dedicate time, money, and attention to one thing, cardio health is probably highest impact for most people. This article makes that case. Also it makes the case that there are a few things that will have an outsized positive effect on cardio health and we’d be wise to focus on them.
[dead]
Right.
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 strongly suspect the truth is both are "right", but they're both optimized answers to slightly different problems.
Mainstream medicine is hyper optimized for the most common 80% of cases. At a glance it makes sense: optimize for the common case. Theres some flaws in this logic though - the most common 80% also conveniently overlaps heavily with the easiest 80%. If most of the problems in that 80% solve themselves, then what actual value is provided by a medical system hyper focused on solving non-problems? The real value from the medical system isnt telling people "it's probably just a flu, let's just give it a few days and see" it's providing a diagnosis for a difficult to identify condition.
So if your question is "how do we maximize value and profit in aggregate for providing medical care to large groups of people", mainstream medicine is maybe a good answer.
But if your question is "how do we provide the best care to individual patients" then mainstream medicine has significant problems.
Part of providing good care is not burdening the patient with tests or treatments that are very unlikely to yield benefit. Put another way, the mission of healthcare is not "health at any cost."
The mission of healthcare in the eyes of those who provide it, isn't "health at any cost".
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.
Cost here doesn't just include financial cost, but also time. As an extreme example, you could surely catch diseases earlier by visiting a doctor for an hour or two every day - getting tests for all sorts of things you might have conceivably developed. But that would make your life worse, and so most people wouldn't do that even if it was free.
The actual question should be "how do we have the fewest patients"
The National Lipid Association and American Heart Association have both been advocating that lower cholesterol numbers are better, e.g. https://www.lipidjournal.com/article/S1933-2874(25)00317-4/f...
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.
Thanks for the astute and informed comment. So re-reading that portion of the article, it seems to me the answer to my question is not that any general or consensus guidelines are wrong, but that a company called Forward Health is doing lipid panels and providing an incorrect interpretation of the results.
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.
I would agree that this article overstates a lot of things.
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.
Really great context, thanks!
The claim on an individual level is not objectionable to me. The question is that if we extrapolate it out to the population and actually take this action for everyone, do we make people better off? This is what clinical trials (or at least large observational studies) try to achieve. Right now, it is not clear.
His evidence is also kinda weak. And appeal to authority largely about someone who he's paying to tell him he has health problems. The incentives aren't aligned.
I also disagree that the 50the percentile is the breakpoint between healthy and unhealthy. There's a lot more to deciding those ranges beside "well half of the population has better numbers"
ApoB is a better indicator of heart problems and his ApoB was bad, unlike his LDL-C. ApoB is not some imaginary thing made up by a quack doctor.
Even his LDL-C is bad. 116/119 are both out of range by most lab testing standards and the top end of range already allows for plaque deposition.
That LDL-C is considered normal, what are you talking about. 160 is when doctors start being concerned.
That is an out of range value for the two largest testing labs in the USA - Quest and Labcorp. Their upper end is 100.
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.
You may have missed the stat that 30% of the population that’s the median of will die of heart disease. You don’t want to be at the median.
100% of the population will die of something.
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.
Cardiovascular diseases are huge risk factors for dementia, so if your goal is to avoid dementia you should try to have a healthy cardiovascular system.
If health science was as simple as health outcomes are proportional to one or two measurement percentiles, sure. But that's hardly true. Health is a lot more complex than that and the disease risk cannot be quantified by a small number of parameters
The plural of anecdote is not data.
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.
We went through this with Oprah in 2007. She did a show about her CT scan and how wonderful it was.
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.
> But then he went to another, very expensive concierge doctor, who did special extra tests, and discovered that he was likely to develop heart disease and have a heart attack.
It’s scarily common in medicine for doctors to start specializing in diagnosing certain conditions with non-traditional testing, which leads them to abnormally high diagnosis rates.
It happens in every hot topic diagnosis:
When sleep apnea was trending, a doctor in my area opened her own sleep lab that would diagnose nearly everyone who attended with apnea. Patients who were apnea negative at standard labs would go there and be diagnosed as having apnea every time. Some patients liked this because they became convinced they had apnea and frustrated that their traditional labs kept coming back negative, so they could go here and get a positive diagnosis. Every time.
In the world of Internet Lyme disease there’s a belief that a lot of people have hidden Lyme infections that don’t appear on the gold standard lab tests. Several labs have introduced “alternate” tests which come back positive for most people. You can look up doctors on the internet who will use these labs (cash pay, of course) and you’re almost guaranteed to get a positive result. If you don’t get a positive result the first time, the advice is to do it again because it might come back positive the second time. Anyone who goes to these doctors or uses this lab company is basically guaranteed a positive result.
MCAS is a hot topic on TikTok where influencers will tell you it explains everything wrong with you. You can find a self-described MCAS physician (not an actual specialist) in online directories who will use non-standard tests on you that always come back positive. Actual MCAS specialists won’t even take your referral from these doctors because they’re overwhelmed with false cases coming from the few doctors capitalizing on a TikTok trend.
The same thing is starting to happen with CVD risks. It’s trendy to specialize in concierge medicine where the doctor will run dozens of obscure biomarkers and then “discover” that one of them is high (potentially according to their own definition of too high). Now this doctor has saved your life in a way that normal doctors failed you, so you recommend the doctor to all of your friends and family. Instant flywheel for new clients.
I don’t know where this author’s doctor fits into this, but it’s good to be skeptical of doctors who claim to be able to find conditions that other doctors are unable to see. If the only result is someone eating healthier and exercising more then the consequences aren’t so bad, but some of these cases can turn obsessive where the patient starts self-medicating in ways that might be net negative because they think they need to treat this hard to diagnose condition that only they and their chosen doctor understand.
It's important to note that there's geographic variability in guidelines. Also, the article doesn't give enough information about the author's other risk factors. For a similar patient (based on the initial lab results), treated by a doctor adhering to the European guidelines, at least the following items would have been considered:
- Lipid lowering drugs
- ApoB testing
- Coronary CT (if the pre-test likelihood of obstructive coronary artery disease was estimated to be > 5%)
- Diabetes tests
- Kidney tests
If there are two contradictory conclusions you should ask for the third one, independent on the previous ones.
The year is 1846, and a doctor has a radical new idea: doctors should wash their hands between performing autopsies and delivering babies!
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.
Are you implying that every new, unproven idea is a good one?
You’re right. My comment doesn’t make sense.
That seems like a super dumb reason to me. "We don't look because we might misinterpret the results"?? Fix the interpretation then!
It's crazy that we haven't optimised MRI scans so that they can be routine.
Not sure I follow or maybe you skipped typing a word.
You listed the risks and concluded “all generally minor.” The benefit is absolutely nonzero. So, what’s the hold up?
And how have the data not caught up? People outside the US are getting the CT scans, while US doctors prefer to lick their finger to guess the weather.
My wife’s last interaction with a doctor: patient presents with back and chest pain accompanied by occasional shortness of breath at the age of 39, doctor reluctantly asks for a EKG - which takes 5-10 minutes and is done in the next room, right away and covered by insurance with a small copay - and has the gall to be surprised when EKG showed subtle abnormalities. If she hadn’t advocated for herself, as the OP argues, doctor would just skip the EKG.
This experience left me thinking maybe doctors are discouraged from asking for imaging and guidelines are there to protect their criminally negligent behavior. I have no proof or even proxy data for the claim about doctors being discouraged from asking for imaging. But it is objectively criminally negligent to not ask for imaging in a case like this.
"Smaht" people continuously parrot things they read elsewhere, usually in a contrarian way, to assert themselves in a futile and shallow way.
There is absolutely nothing wrong with getting one CT at a specific point in your life to right a disease which, as TFA states, has a 25% incidence rate.
The smaht ones will now point me to that study of 1-5% of cancers being linked to CT scans. Yeah, sure, but those are not from people who got one-two in their lives.
A CIMT scan is another option. It uses ultrasound to measure carotid artery wall thickness.
There's something I deeply don't understand about this.
> I shared these results with a leading lipidologist who proclaimed: “Not sure if the lab or the primary care doc said an LDL-C of 116 mg/dL was fine but that concentration is the 50th percentile population cut point in the MESA study and should never ever be considered as normal.
> It’s also important to note that, according to a lipidologist friend, an ApoB of 96 is at a totally unacceptable 50th percentile population cutpoint from Framingham Offspring Study.
So... the exact median value is "totally unacceptable" and "should never ever be considered as normal"? I'm open to the possibility that the US population is so deeply unhealthy that this is true, but then that needs to be argued for or at least mentioned. Like, you can't say "you're exactly average in this respect" and expect your and that's terrible to be taken seriously without any followup.
Or if I'm misunderstanding what's meant by "50th percentile population cut point" then again, I think this jargon should be explained, as it's plainly not the usual meaning of "50th percentile".
I had assumed "the MESA study population" was a particularly unhealthy bunch in terms of this measurement, meaning the 50th percentile puts one in the worst half of an already bad off group.
I don't know the exact details, but I thought the Framingham survey was just a cross-section of the population. So getting upset about a 50th percentile score makes no sense at a population level.
A quick Google says that the Mesa study was actually of people without cardiovascular disease at the beginning of the study. So again, these conclusions don't make any sense to me.
Of course it makes sense. 30% of this population will die of heart disease. You don’t want to be at the median of that population if you can avoid it. And as a society we need to move the median, not just accept it. Which means giving people better advice based on better data.
That would make sense, but again, should be mentioned as context for why the number is bad. It's not as though we're skimping on wordcount here.
The other thing these number chasers don’t tell you is that extremely low LDL numbers are also associated with anger management issues. The stuff is used in your body to build things. You need some, and probably at least half of the number this doc is trying to say is scary. In fact in a different test he is advised to talk to his doctor about whether a 29 is safe.
Has the guidance changed that you want LDL less than 2.5x (or was it 2x?) your HDLs?
Every organ in your body that utilizes LDL can synthesize it de novo. Some of the heaviest users, like your brain, literally can't get it from your serum LDL levels - they do not pass the blood brain barrier. It is all synthesized locally.
PKCS9 inhibitors and mendelian randomization studies show that people function just fine with <10 LDL-C. (Other comments I have made in here have links to all the relevant studies)
Googling for statin and aggression links I find a fairly small set of studies with fairly disparate outcomes.
I believe there was a time they thought statins were causing mood disturbances, but I was talking about unmedicated individuals with naturally low serum levels.
Going deep on biomarkers, blood tests, and debates about optimal levels is okay for some people who derive motivation from obsessing over topics, but I’m starting to notice a trend where people obsess about these things for a couple years before burning out and moving on to the next topic.
The best thing you can do for yourself is to establish healthy diet and lifestyle habits that are sustainable. A lot of people who jump from obsession to obsession do a great job at optimizing for something for a few years, but when their life changes they drop it completely and fall back to forgetting about it.
Fad diets are the original example of this: They work while the person is doing it, but they’re hard to maintain for years or decades. CrossFit and other exercise trends have the same problem where some people get extremely excited about fitness for a couple years before falling off completely because it’s unsustainable for them. Some people are able to continue these things for decades, but most people do it for a short while and then stop.
I’m now seeing the same pattern with biomarker obsessives: They go a few years obsessing over charts and trying things for a few months at time, but when the interest subsides or they get busy with life most of it disappears.
The most successful people over a lifetime are those who establish healthy habits that are easy to sustain: Eating well enough, reducing bad habits like frequent alcohol or fast food consumption, some light physical activity every day, and other common sense things.
The most important factor is making it something easy to comply with. The $300 biomarker panels are interesting, but most people don’t want to pay $300 every year or more to get snapshots that depend largely on what they did the past week. Some people even get into self-deceiving habits where they eat well for a week before their blood tests because the blood test itself has become the game.
Right on spot. Find a regime for body and mind that you can sustain without any significant mental effort, after some time lack of good behavior be it sports of healthy food makes one uneasy. Bonus points from getting happy from it / making it a passion, this helps a lot with coming back after some hiatus (ie injury, sickness, long travel etc.).
Personal story - I used to be super sporty, 4x gym training during work week - cardio & free weights, climbing over evenings after work, hiking/climbing/ski touring over weekends. Vacations were mostly more extreme variants of the same. Last year broke my both ankles with paragliding, one leg much worse, so took me some 8 months to be able to walk straight again, with some time in wheelchair, then crutches. All strength & stamina gone, flexibility 0, so had to rebuild from scratch and I mean deep bottom scratch from which you bounce very slowly, not some 1 month stop when things come back quicker. If all above weren't my proper passions I would have a hard time coming back to being again more active than most(sans that paragliding, took the lesson and have 2 small kids). That ankle won't ever be same but so far so good, ie managed some serious hike&via ferrata mix 2 days ago.
Getting happy from it is 100% the most effective way to change habits. Unfortunately it’s also very subjective and hard to find out what makes you happy…
> starting to notice a trend where people obsess about these things for a couple years before burning out and moving on to the next topic.
Really spot on with one of my besties. He does all the tests. He has a concierge doctor. He reads extensively on the topics of fitness and nutrition. And yet he doesn't do any of it. It's just an intellectual exercise for him. And he has had two heart attacks in the last several years. It's so frustrating. I just wanna shake him.
Warn him before you do. Don’t want to scare him.
I learnt a great trick about exercise: find a podcast or audio book that you really enjoy listening to. Here's the trick: you're only allowed to listen when you're exercising.
Also with food and drink: place friction between the treat and yourself. The easiest example is to not have biscuits / alcohol in the house.
Bonus tip: alcohol free beer is really good these days.
Alcohol free beer was a game changer for me. Also if I can’t avoid it alternating alcohol-containing and alcohol-free drinks.
For exercise your tip doesn’t help me at all. I hate audiobooks and podcasts so that would turn me off more from exercising. Also I want to concentrate on the exercise and not do it halfhearted.
What helped me was to realise how much better I feel after exercising - since then i kinda got addicted to it because I notice how much worse I feel after not doing it for a couple of days.
I agree on the friction. Just not having access to cigarettes is the best way for me to not smoke. I just don’t buy them and bumming one from someone else comes with a degree of personal shame for me that makes me avoid them (in almost all cases).
I naturally don’t like sweet stuff that much - however since I moved from EU to America (not US) it’s been really hard to avoid sugar. Y’all put that stuff into everything it’s crazy; I gotta watch out like a hawk and go to special stores. In Europe it was so much easier, there are always cheap sugar free whole foods available in every supermarket.
It's not just sugar. Emulsifiers affect the gut bacteria in a negative way.
I live in the UK and emulsifiers seem to be added to everything: sauces, yogurt, bread.
I push hard enough during cardio that I can't really follow a podcast properly. On the upside, it's only 30 minutes.
While lifting weight I do that since I rest for 90 seconds in between sets, which is actually very boring. I started reading books during that time and that has been a big improvement.
Fiere-lmsaho says< >Bonus tip: alcohol free beer is really good these days.<
Could you recommendation some good alcohol-free beers, please?!
Sure:
[https://luckysaint.co]
[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.
Thank you!
If you're exercising for cardio, and you're able to follow your book or podcast, you're probably not doing good cardio. OTOH, it's not a bad way to do interval training while watching sports, go hard when they're yammering, slow down when the sports are happening (or, if you're watching soccer, you can go hard most of the time and then slow down for the replay if anything happens, which is unlikely)
> If you're exercising for cardio, and you're able to follow your book or podcast, you're probably not doing good cardio
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.
This is completely wrong.
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.
Maybe our brains work differently, but I have absolutely no problem following a podcast while running, and my race times indicate that I'm doing good cardio.
I do have a hard time with mind muscle connection during weight training if I'm listening to something other than music, though.
You are completely wrong and don't know what you are talking about.
You are confusing two different things.
I lift weights, so there's lots of pauses between the sets!
However I can definitely listen to a podcast when using a static bike... As long as your heart rate is 75‰
> If you're exercising for cardio, and you're able to follow your book or podcast, you're probably not doing good cardio.
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.
Giving people cardio advice while being completely unaware of what zone 2 training is.
Peak HN right here. The epitome of confidently incorrect
I did this with Dungeon Crawler Carl, but now I finished all 7 and have to find something new.
Guarantee this guy had wearing a CGM as a hobby a few years ago when metabolic health was popular among the tech dork set.
> Sticking to a Mediterranean diet that is light on carbohydrates and saturated fats is almost always the safest bet. Almost every health diet is some permutation of this.
A permutation that's currently making the rounds in the press (even though the original research is from 20 years ago) is the "portfolio diet":
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...
This is a lot of words to say eat a plant-based/vegan diet.
Lowering LDL cholesterol is arguably the most evidence-backed longevity intervention available today. Mendelian randomization studies suggest that each standard deviation of lifelong LDL reduction translates to roughly +1.2 years of additional lifespan, implying ~+2.4 to +3.6 years from sustained, meaningful lowering alone.
Pair this with tight blood-pressure control (aim systolic <130 mmHg) and a healthy BMI—every incremental improvement helps. Together, LDL, BP, and BMI form the most potent triad of interventions most people can implement now and expect to see substantial benefits 20–40 years down the line.
A few references: https://mylongevityjourney.blogspot.com/2022/08/a-short-summ...
Long story short care about your health. If you don't do already, maybe now is a good time to start.
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!
Everyone knows the recipe for healthy living, it's the same as for similar issues such as personal finance (spend less than you earn, save, etc.).
They seem simple on the surface but hard part is execution for most people, due to life circumstances and other factors. Unhealthy choices persist because society isn't built around healthy lifestyles.
So while the comment seems helpful on the surface, it misses the forest for the trees.
I think that there needs to be a bigger discussion here, regarding why have we engineered a society that inflicts suffering and illness on so many?
Not all things labeled "processed foods" are bad, it seems. There are enough scientists that say the distinction is often hypocritical (example from an article: a factory-made carrot cake is labeled UPF, but a home-baked one isn't, even though they're practically the same thing). Sugar, fats, and lack of fiber make factory-food unhealthy, they say. Others add that we can't feed the growing metropolitan areas without it.
Just expanding on a peer post, but industrial made food tends to have a large number of preservatives, stabilizers, coloring agents, and much more added for commercial reasons. An obvious example of this is in something as simple as bread. If you've ever made homemade bread. It goes stale in a day or two, and it's hard as a rock shortly thereafter.
But that loaf you buy at the store? It'll generally be covered in mold before it gets hard, and that's quite the achievement since it also tends to be more resistant to mold as well! Bread should get hard. This is where a ton of old recipes come from. The Ancient Greeks would dip it in wine for breakfast, Euroland has bread soup/puddings, and even stuff in the US like Thanksgiving stuffings or croutons.
>a factory-made carrot cake is labeled UPF, but a home-baked one isn't, even though they're practically the same thing).
Actually they are not. "Practically" is carrying a lot of weight there. The factory baked cake will have a lot more extraneous ingredients and usually has a larger quantity of sugar and fat. Similar to how restaurant food generally has a lot more salt and fat than home cooked food.
Yes, right off the bat a factory made carrot cake will very likely contain dough conditioners, colors, and preservatives that no home cook would put in their scratch made version.
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.
Yep just a glance at the ingredients shows obvious differences. Other issues I've seen studies about include contaminants from conveyor belts, and for many snack foods, processing into smaller particles, effectively making them partially pre-digested.
> : a factory-made carrot cake is labeled UPF, but a home-baked one isn't, even though they're practically the same thing
If you stepped inside a food factory you would see how false that statement is
WRT the carrot cake, I will say that while there is only a minimal physical difference, there is a practical difference. Making a carrot cake at home is a commitment, and most people won't frequently go to the trouble except on special occasions... But one from the grocery store can be acquired casually and without effort, and it's easy to eat a lot more of something when it requires no effort.
Every time I cook (and thats quite often) I put a bit different ingredients that some factory would put in since they are the cheapest variant.
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).
I dunno! My favorite carrot cake recipe had a full cup of vegetable oil in it! I'm not sure that fits into anyone's guidelines.
You’re not wrong but it is not a fair TLDR. TFA has a TLDR which says
> If you only read one thing here, make it the “How to not die of heart disease” section.
Which itself is still quite long but it emphasizes:
> Every lipidologist I’ve spoken with has stressed the importance of measuring and managing ApoB above all else – it’s a far better predictor of cardiovascular disease than LDL-C (which is what physicians are most familiar with). Every standard deviation increase of ApoB raises the risk of myocardial infarction by 38%. Yet because guidelines regularly lag science, the AHA still recommends LDL-C over ApoB. Test for it regularly (ideally twice a year) and work to get it as low as possible (longevity doctor Peter Attia recommends 30-40mg per deciliter). Many lipidologists will say to focus on this above all else.
And:
> I asked several leading lipidologists to stack rank what they believe are the most important biomarkers for people to measure and manage. […], and will likely cost anywhere between $80-$120 out of pocket.
That’s a pretty interesting and relevant part of TFA. Omitting that is not a fair “long story short”, but rather just “different story”.
> lots of variety of veggies and fruits, little meat
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.
This is wrong. Our bodies evolved to eat a diverse omnivorous diet and complex carbs + the antioxidants present in vegetables and fruits are anti-oxidative.
This is wrong.
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.
I've taken courses in primitive wilderness survival, and one of the staple foods was grass seed.
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.
Interesting. So its possible to gather enough of these food to get eg ~200+g carbs per day (speaking in ancestral context, a tribe)?
Also how much must you eat of these to get enough in order to get enough digestable carbs due to the high fiber content?
What's possible depends on where you are. But for example:
> 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...
>Our bodies evolved to eat a diverse omnivorous diet and complex carbs
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.
Vegetables aren't "carb-heavy". And we don't need to recreate blindly the circumstances evolution had to adapt us to. E.g., our bodies evolved when the population was much smaller, but I don't think you want to argue for mass extinction.
>Our bodies evolved to rend flesh and eat meat.
is that why we have flat molars? for eating meat?
(spoilers: no, the flat molars are not for eating meat)
And our canines?
My genes gave me pretty big ones.
sharp canines for meat, flat molars for plants.
>They are optimized by millions of years of evolution to process and run on meat.
We are omnivores, we are optimized to eat everything
podcast science is a bit low-brow for hn brother
"Long story short" should probably be followed by a short version of the long story.
I might just be tired, but this seems highly repetitive. The author mentions friends in the field and concierge doctors multiple times in as much as I read.
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".
Right? It started okay even if a bit too verbose, then there was a second introduction. There I lost interest.
It’s also demonizing doctors and the healthcare system a bit too much for my liking.
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?
In the US my best doctors produce out of date advice about obvious things, have a very distinct gap between "everyday" (stuff they actually see) and "incredibly rare" (stuff unique enough to be a case study they heard about) in their knowledge/understanding and rarely advise things that require me to be a proactive and rational person (because they don't serve these often), so they'll spend two seconds being like "diet and exercise" without a discussion on how that'd work or what adjustments I'd actually make (leaving me to do this research myself) and then suggest a prescription (because even their least proactive patient will probably take a pill). They'll wait until things become a disorder before addressing them (or discussing with me how to address them).
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).
I'm in the US, and my experience has been similar. My doctor is good, and while we're usually limited to 30 minutes at my appointment, we have good conversations and rarely is his answer "here is another pill" or "go take this random test."
I'm in the us and my doctors have all done the same. Though it is obvious most people are not listening to them.
Somewhat related, one of my thoughts was “what if these concierge doctors just keep running tests until they find something, anything, to justify their fees”?
The author says this about smoking:
> 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.
The inconvenient truth that the vast majority of adults refuse to acknowledge is that there is no safe level of alcohol. Any drink is going to damage you, marginal though it may be. Unfortunately the healthiest thing you can do is simply never drink alcohol.
> no safe level of alcohol
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.
For alcohol, the default is social drinking which is why you don't have widespread alcoholism in most countries where people consume plenty of alcohol. For smoking the default is constant nicotine top up(the nicotine delivery is instant, lasts seconds to minutes and the withdrawal symptoms starts in an hour). Both harmful of course but the alcohol has much less harmful defaults.
“Alcoholism” is outdated and has been widely replaced by AUD (Alcohol Use Disorder).
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.
The top 20% consumers consume a large majority of the alcohol, which means there are many Germans who consume reasonable amounts.
And yet, the Germans are having long and healthy lives just like other drinkers like France, Spain and Italy. So maybe just relax and have a drink.
Average German lifespan is about 80 years. What if it was 70 years for an 80th percentile drinker and 90 years for a 20th percentile drinker, I assume that changes your conclusion? These are of course entirely made up numbers, and the data doesn't even exist as far as I'm aware, but goes to show how useless averages may be.
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.
The question is could they have longer healthier lives without. Evidence is they can, and non drinkers have good social lives and fun too.
sure if you want to risk it fine, but don't try to claim there is no risk when there is.
Straw man argument
> Why is it unreasonable to tell people not to drink alcohol, but reasonable to tell people to stop smoking?
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-...
The risk factor of conventional cigarette smoking is much higher than drinking. All other forms of smoked tobacco consumption are extremely niche.
If you tell people they cant drink they kill you.
I've never told anyone to stop drinking alcohol, yet drunk people keep killing sober people all the time. So what would the difference be?
[dead]
Summarizing:
- 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".
You really should push for an ApoB test in general - most people are bit by LDL-C and not other atherogenic particles like Lp(a), but it's still common enough to find out. The good news is Lp(a) is largely genetic so if you know you have low levels you likely don't need to test again anytime soon.
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.
A regular lipid panel won't test for Lp(a) which is genetic. So you need to test specifically for Lp(a) once in your lifetime because you need to know your risk factors. The test was $35.20 when I had it done by LabCorp last year. 20-30% of the population (including me) have high Lp(a). Statins don't reduce Lp(a).
I was planning to start getting scans ordered for specific risks like aneurysm or heart attack but what holds me back is the idea the scans will harm me worse than those things.
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.
A relevant anecdote. I’m very athletic and skinny, eat well, have a resting heart rate in the 40s, but was recently prescribed a statin at 30, due to my very high LDL cholesterol and lipoprotein A.
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.
You're probably a "lean mass hyper-responders", a phenotype which is actively investigated, initial paper:
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.
Interesting, thanks for sharing!
Seems a bit unfair sometimes how arbitrary genetics can be. I've fought my weight all my life, only recently achieving consistent success with the assistance of GLP1s. I can't claim to be consistent with exercise either. Yet my numbers are great, I've done some of these deeper tests and everything comes back beautiful. My parents were overweight their whole life and both lived deep into their 80s (and my dad only died because he got an unlucky gall bladder infection and then ignored all the rapidly accumulating evidence that he was getting quite sick; he'd have gone another few years most likely). I don't recall anyone in my immediate ancestors having a heart attack. Seems it's just not in our genetics.
My father-in-law is more like you. Athletic, skinny, been that way all his life. Heart attack and quad bypass in his 40s.
They have me on blood pressure meds and do the usual blood tests, the tests I considered have been elective and I requested them explicitly. Just haven’t followed through due to aforementioned hesitations. I’m very much aware heart issues run in the family and that I have symptoms.
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.
That makes sense! Its easy I think to also go overboard and analyze too much, causing stress as you suggest.
> scans will harm me worse than those things
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.
Health guidelines take into account when screening/testing is a net harm or benefit for patients in general, and when they move from being a net harm to a net benefit conditional on specific factors like existing diseases, obesity, etc.
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...
As someone who would like to do this but has generally been choosing the easy paths - curious what your diet and exercise regime looks like.
Well “fortunately” I’m forced to have a strict diet due to some sort of IBS issues. For that, I use the MacroFactor app and talk through my daily recipes with ChatGPT, making sure to hit the macros and calories targets while also optimizing for heart health and IBS. Fat, protein, carbs, fiber. Taking AG1 to fill gaps.
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.
There are specific recommended minimums in the physical activity guidelines about strength training and endurance training where meeting them is likely to significantly reduce your disease risk and improve your health: https://www.barbellmedicine.com/blog/where-should-my-priorit...
The discussion seems unduly focused on lipids, whereas I would think that blood pressure would be a, if not the, primary concern.
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.
Blood lipids and blood pressure are both significant risk factors for heart disease.
It makes zero sense to prioritize one over the other, any more than it makes sense to ignore diet and exercise.
I was also surprised by that. It is relatively cheap to measure as you can just buy BP monitor and do it yourself at home. Considering that high BP is very often asymptomatic, I, for example, even feel better with high BP, many people walking around accumulating damage for years. Not to mention it also goes with a baggage of other side-effects like increased chances of a stroke and kidney failure. For some reason it hits differently when you go eat something salty or drink coffee or get all stressed out for now reason and then see increased BP with your own eyes. That was what motivated me to stick to a better diet, cut caffeine and chill out.
I'm not sure that non-medically indicated CT scans are a great idea, as you're at least doubling your yearly dose of radiation in the year of the CT scan. Perhaps it's warranted, but the article doesn't seem to balance that at all against doing a CT scan "every 1-5 years".
Yes - in addition, medical professionals warn against “overdiagnosis” from unnecessary screenings.
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.
[1]https://pmc.ncbi.nlm.nih.gov/articles/PMC4077659/
[2]https://pmc.ncbi.nlm.nih.gov/articles/PMC6135119/
I agree. As a physician, this is sticking out to me as bad / dangerous advice. By getting unneeded regular CT scans, you’re dramatically increasing your risk of developing cancer. Beyond the radiation exposure itself, there is also the very real possibility of incidental findings that can lead to further testing, invasive biopsies, and unnecessary interventions, all of which compound your overall risk. You might solve one problem, but you’ve just guaranteed a much bigger, more explosive one down the line.
You won't die of heart diesease if you die of cancer first. So I guess it sortof checks out, but not what I would choose.
My good friend just died from a heart attack at 60. 90% blockage in 2 arteries, even though he exercised regularly and appeared perfectly healthy. This triggered my exploration of my own risk and I came to the realization that although my lipid panels were ok, I could also have a 90% blockage and be completely unaware. I ended up getting a Calcium CT scan which showed no blockages, but I realized that without my friends death, I’d have no idea of my score. In the US, insurance doesn’t cover the screening. I’m now a believer of all people having a scan at 50, and likely every 5 or 10 years afterwards.
I’m not even a few screens into this and I’m already nodding my head in agreement. Having parents of the age where hospital trips are now a yearly occurrence at least, the level of care a patient gets is so much better if relatives are involved and knowledgeable. The medical system does not give a shit about you, they just want to make sure you don’t die in their care.
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.
Fabulous information, but lacking information isn’t the issue. The behavioral changes are obvious and well evangelized : lose weight, regular activity (walking), and if necessary, take meds. (Yes I know your marathon runner cousin who died suddenly of a heart attack, but these are still your best odds)
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.
This site isn't necessarily meant to have a big sociological impact; it provides enough information that someone with sufficient motivation, but a lack of resources and expertise can take concrete steps to reduce their risk. That seems useful to me.
in this case “useful” means applying the facts and making changes. A detailed map that goes unused is useless. A hand drawn map that gets you home is priceless.
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
Managing stress shouldn't be overlooked
“Stress” is so abused and nebulous that it’s impossible to define. Nearly every condition is worsened by “stress” but there’s no way to measure it. And there’s no conclusive way to manage stress either. Medication, psychotropics, self medication, meditation. Nearly all of those are more broadly abused and yet stress “worsens”.
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.
Fortunately, as you mention in your last sentence, stress is introspectable.
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 :)
it’s bad in the way of “don’t think about elephants” makes you think about elephants.
“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?
Managing cortisol shouldn't be overlooked
“Sleep better, eat better, get less stress, get more activity” is about as helpful as saying “don’t die”.
True that “sleep better, eat better, exercise” is generic advice ignoring constraints. Like telling someone with insomnia, three kids, and a night shift to “sleep better” or telling someone broke to “have more money.”
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.
> The behavioral changes are obvious and well evangelized : lose weight, regular activity (walking), and if necessary, take meds.
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.
i agree. Under-eating with baseline activity is better than overeating with excessive activity, excluding the extremes.
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Great post but quite surprised there is no mention of cutting red meat. There is a lot of evidence that especially the American diet is dangerously high in red meat to the point of elevating Heart Disease risk.
IMO, I think that is more of a saturated fat issue, and only a subset of the population is like that. Others solve their health issues through eating a lot of red meat.
Yeah it's definitely more about saturated fat from animal sources.
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.
No, I mean for some, a high saturated fat diet can do amazing wonders. And for others, it causes horrible issues. The studies are not well segmented genetically and by body state since that is signficantly more expensive and genetics only got cheap in the past 10 years or so, so they wash out these large sub-population dynamics.
It's the sort of thing you can just experiment with and see for yourself.
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.
Also processed red meats or processed meats in general. Processed meats are the ones strongly linked with heart disease. At least for those who dont want to go vegetarian.
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.
these are extremely outdated recommendations that make no sense. most of the basis for those are studies that took direct correlation as causality. the problem is a crappy lifestyle which incidentally typically includes processed and red meats in large quantities in the western world. saturated fats are hardly a good indicator of anything when you disassociate them from the lifestyle and foods they come with for most people. blue zones are now finally coming out as simply just the places where records sucked. there are plenty of populations with centenarians that had meat rich diets.
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.
Especially the red meat pumped up with hormones...
Very interesting, but do the numerous mentions of taking action in your 20s, 30s and 40s mean it's too late for someone in their 50s?
Nitpick: he mentions LDL-C but the test results don't mention that at all. Only later do I see that is "LDL Cholesterol".
No, it is never too late to take action. Even taking action after a stent procedure reduces further risk:
https://www.nhs.uk/conditions/coronary-heart-disease/treatme...
In general, when science is done, recruitment requirements force the experimenters to bucket the participants. One thing that often happens is an open bucket, say 35+.
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.
If you start exercising in your 20s, and never stop, it will be so much easier to maintain fitness in 40s 50s etc. The challenge is that the benefits are not yet visible in your 20s (when you’ll probably be healthy and at a proper weight regardless). Gotta lay that foundation for older age though!
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.
It's a bit like saving money.
It's like time in the market.
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.
The title of the article says "don't die of heart disease", but given that we all have to die at some point, if you could choose what natural cause to die of, wouldn't you pick heart disease? It is the best way to die. The worst is stroke. So once you cross a certain age, say 60, don't worry about heart disease, worry instead about stroke.
I agree, but both are heart disease and both can be prevented in similar ways. My dad and my father in law both died from heart disease. My fil was on the surface less healthy. He had an extreme high stress job with exposures to environmental factors that made it worse, was partially disabled with bad knees, etc. i believe he was on blood thinners for almost 20 years.
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.
> worry instead about stroke.
You say that as if stroke is orthogonal to heart disease. Much of what prevents one prevents the other.
Yes but there are habits that are especially important for preventing stroke, such as getting 7-9 hours of sleep, monitoring and controlling risk factors related to blood vessel health that affect the brain uniquely, such as preventing irregular heart rhythms (atrial fibrillation), anti-inflammatory diet choices focused on brain health, and so on.
If you have a massive banger and die immediately that is a pretty good way to go.
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.
Funnily enough, the things you can do to prevent stroke line up entirely with the things you can do to avoid heart disease.
The article doesn't mention antioxidants at all, which help prevent atherosclerosis.
Dementia seems a pretty awful outcome too. I hope my heart gives out before my brain.
Alzheimer's too.
If you made a Venn diagram for the non-genetic risk factors for heart disease and Alzheimer's, they'd basically be a circle.
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...
> "wouldn't you pick heart disease? It is the best way to die."
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.
Sometimes I think the way this type of thing is framed is misleading. There's a list of putative causes of death and there's an assumption that they're equally systemically impactful, and you can go down the list and just lower the probability of each and lower your overall likelihood of death.
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.
You assume that you'll die at X years old, and get to pick the disease. In reality, you might die of heart disease at 60, or cancer at 70, or alzheimer's at 80. Which one do you pick?
What I want is a long life of doing what I want. when I must die how doesn't matter, but if I can extend my lifespan (well span) by not getting a heart attack that is good: more years to enjoy life. If I can also extend my life by not getting cancer even better. Even if I must die if I can delay that with a good life that is what I want.
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.
Why is heart disease a “good” cause of death?
Less suffering. Stroke on the other hand... you become partially disabled, which causes suffering not just for you, but also for your loved ones.
I think you are confusing "getting a stroke" and "dying from stroke". If you get a heart attack and don't die from it you might become a burden on your family too.
>> given that we all have to die at some point, if you could choose what natural cause to die of, wouldn't you pick heart disease?
Monty Python, "The Meaning of Life", Part VII.
Curious about how accessible these tests are in Europe. Living in a country (NL) that doesn't value annual checkups makes me assume detailed, preventative blood testing like this is hard, let alone possible to get in non-extreme situations.
You can order all blood tests you want online in NL. E.g. bloedwaardentest.nl, mijnlabtest.nl, perfectlab.nl. But it isn't cheap so you need to know what to test for to keep the price reasonable.
Merck has a promising pill (enlicitide) coming that blocks PCSK9, lowering LDL-C:
- 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...
> All of these can be accessed through bloodwork and urinalysis and can be done at a local Quest Labs (I’d venture to bet there’s one within a 10-mile radius of your home), prescribed by your doctor, and will likely cost anywhere between $80-$120 out of pocket.
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).
I didn't stop changing doctors until I found one that would work with me. I didn't go to a fancy concierge doctor - I just shopped around. I didn't go through a string all at once, but when I needed to go to the doctor, if I hadn't liked the last one, I went to the new one. After 4-5 years of this, I found one.
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.
> 'mycin' means it's Penicillin-variant, which is usually used to treat bacterial infection
This isnt even remotely correct. Penicillin is derived from a fungus, the -mycin antibiotics are derived from various Streptomyces bacteria.
For the blood tests, at least, you can get them directly from a lab with no physician gatekeeping.
"This means regular exercise (both strength training, ideally 3x per week, and cardio training that helps to improve V02 max like Zone 2 training)"
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.
Is V02 max still the best predictor in people optimizing for it specifically above everything else, or only in people that train generally and have a high V02 max as a side effect?
My guess is the latter
He might be talking about zone 2 in a 3-zone model? Otherwise, I agree, zone 2 in a 5- or 7-zone model is not intense enough to provide VO2 adaptation.
There is an old pharmaceutical product that was available in Germany, but can not be obtained anymore. Ouabain /Strophanthin
"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.
A recent report from the American College of Cardiology emphasizes the prediction power of hsCRP:
"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/...
The primary thing I did was ask a cardiovascular surgeon in my network to send the lab requisition form to a lab. This is the gate for much of this stuff, even if you pay out of pocket. If someone knows a simple “pay and play” testing service that would be fantastic.
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.
I got all the same labs through Function Health. That’s the standard pay-to-play these days, but there are others.
Perfect. Looks like everything I’d get from Ulta for $800 but for much less. The self serve model is great. Thank you.
Eat healthier (less processed foods, more fruit and veg, healthy carbs, low sugar and alcohol), exercise regularly and get enough sleep. Take a blood pressure measurement every week / month or so. Track your weight. React if either start going up. Don’t go start getting uneasy ct scans.
Read the article, felt worried.
Came back here and read all the cynical and critical comments, felt a lot better.
Thanks guys.
> I experienced this repeatedly. We were admitted to the hospital for over a week when my daughter contracted viral meningitis (the scariest experience of my life). Even while working with incredible infectious disease doctors, I still had to fight and constantly remind people what the next steps were during our admission. Nobody is watching over you - it’s your job to organize things and ensure they’re on track. I had to coordinate between the infectious disease departments and neurology departments and make sure the people doing the lumbar puncture on my 9-month-old daughter weren’t just residents practicing on my child but experts who had conducted the procedure countless times before. You must Advocate for yourself and the ones you love.
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.
You're conflating advocacy, which indeed he is entitled to, with how the hospital is allocating resources and if and how they apply competent resources.
Life or death procedures aren't a time for "you get what you get and don't have a fit."
How do people become experts on doing dangerous procedures on infants if they're not allowed to do dangerous procedures on infants until they're experts?
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.
Hospitals are full of 'life and death' situation. If everyone were to behave like that, things would stop working or be severely slowed because you can't work correctly when you got that guy breathing on your neck constantly. You lose time answering to load of demands from people getting angrier and angrier because they feel that they don't get the care they need. That makes you angry. Other people are getting less attention, they get angrier.. Etc etc.
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 think you really pretty fundamentally missed the point of what he's saying. Perhaps you've never had to confront the full brunt of the bureaucracy of a large-scale medical provider.
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 don't know, maybe it's just me seeing things differently.
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.
> what most primary care physicians will do with patients to help them avoid heart disease is not enough. The status quo simply does not work
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
I love this sort of documentation-style guide to medical issues. Reminds me of https://www.fourmilab.ch/hackdiet/e4/
> You should be scared of heart disease.
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.
Heart disease is the leading cause for death, but the root cause is definitely obesity. There’s a an obesity-pandemic that no one’s talking about it, there should be a national program that encourages people getting fit and discourages them from getting obese. And by encouraging/discouraging I don’t mean some random posters posted around, no, things like tax cut for fit people, free access to xyz if your bmi is less then abc, cheaper flights and insurance if you are fit, and so on.
A lot of good information but bordering on neurotic. If everyone just did lipids, walked 3x a week, and got on glp drugs it would significantly reduce the number of heart attacks.
Ordinary people don’t need to be obsessing to do better.
The value of the biomarkers are they applicable for all age range? What if someone already had a heart attack, then what should be the normal values post incident?
AFAIU, for LDL and ApoB, the real danger lies in the area under the curve. Lifetime exposure. That's not to say that lifestyle improvement can't help in other ways, but the damage caused by LDL is very difficult (impossible) to reverse.
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.
Unfortunately, the time in our lives when we need to most pay attention to these things is when ageism kicks in and yeets us completely off of health insurance.
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 you dig into research and follow the low-risk experiments that people do online to reduce their Lp(a), you can find techniques and evidence to do so. It doesn't have to be an impossible-to-fix issue.
I like this list of experiments by Greg Muschen: https://x.com/gregmushen/status/1924676651268653474
> It's not sexy, and as a result an overwhelming majority of the population is unaware about how to avoid succumbing to it
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.
I asked a heart doctor for a calcium scan. He said I didn't need that, but he wanted me to wear a Holter monitor for a few days (reasons unknown). I did not.
That was years ago. I have different doctors now but still no calcium scan. Time to ask again possibly.
A key takeaway is: don't be afraid of taking statins if you need them. I fell for the "statins are bad" BS for years and have paid the price.
My dad would disagree--he's 84, was on statins for years and they did terrible things to his body. I'm sure the drugs kept him alive, but the side effects, as he describes them, particularly to his legs and kidneys, were pretty severe. He only got better when he stopped taking them.
Obviously we all differ in how we respond to medications -- apparently it's 10% - 15% that have issues with statins.
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 believe statins reduce risk by about 30%, so there's a roughly 30% chance the statins have done good things for your dad.
(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.)
The risk reduction is relative risk not absolute
You're right. The absolute risk reduction would be more appropriate here.
What price have you paid?
I now have a cardiologist and just had an MRI to check on the state of my aorta, as a recent calcium scan brought up concerns.
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 recommend the same. There are other interventions, but these two medications are straightforward to obtain with low or no side effects.
IMO the war on dietary saturated fat and dietary cholesterol is misplaced big time. It's minority view though. What's worse is that avoiding saturated fat and cholesterol may partly fuel your progress to heart disease.
Anyone note where to get this full blood panel done in the UK? I’ve got issues with high blood pressure and swelling in the lower extremities. Blood tests and ECG showed nothing.
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.
> I’ve got issues with high blood pressure and swelling in the lower extremities
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).
The "be an advocate" thing is both true but also incredibly selfish and egotistical.
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 assumption was that we have to be our own advocate because the system itself is non-ideal.
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."
> 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.
Behaving like docile, compliant cattle benefits only the farmer.
Perhaps you could feed the cattle with your strawman instead.
Yeah insisting that you are qualified to choose the members of the medical staff qualified to do X or Y procedure isn't advocating, it's being a prick.
For what it's worth, this article by the doctors at Barbell Medicine has been my go to recommendation for what to prioritize for health and longevity: https://www.barbellmedicine.com/blog/where-should-my-priorit...
<quote>
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...
Not an ad but I use https://www.walkinlab.com to order labs then get them done easily without a doctor. I have regular health insurance but it doesn't cover as many labs as I want done.
My dad went to doctor who was like his friend as long as I can remember. Always received a clean bill of health. Until he suddenly got heart disease and a stroke on the operating table. His doctor basically said that he had seen this coming. Doctors secretary, probably twenty years his junior was a stunner.
I didn’t know who this author was previously (Jared Hecht) but I looked up pictures of him and he definitely does not look like he exercises regularly. He’s skinny (e.g. not overweight) but if I passed by him on the street I would not peg him for someone who exercises seriously.
I'd argue that even the CT scan is unnecessary for a lot of people who want to start a preventative regimen to tackle heart disease. Especially if you're in your 20s or 30s with no family history of heart disease and no absurdly high ApoB results combined with really high lp(a).
well that inspired me to research getting those tests in Germany.
=> heart panel plus
https://en.minu.synlab.ee/heart-panel-plus/
I don't need doctors, I can get ChatGPT to analyse the results.
Unless you're willing to take pills the rest of your life, spending a ton of money to study your risk of heart disease is always going to lead you to the same conclusion: Don't smoke, don't drink, eat healthy and exercise regularly.
> Even while working with incredible infectious disease doctors, I still had to fight and constantly remind people what the next steps were during our admission.
Can't help but feel this is a factor of the sleep deprivation that doctors seem to celebrate.
I was a bit distracted by the capitalization of the word "Advocate". Both when used as a noun and a verb. Peculiar.
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.
All of this advice seems really good. The only one I am reluctant to follow is getting a CT or CTA scan.
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?
This reminded me of the other extreme to health consciousness: the 109 year old that smoked cigars and ate ice cream every night [0].
[0] https://youtu.be/BXyfCGDnuWs?t=332
So your doctor won't agree that you have heart disease but you need to be on a statin but statins are by prescription only... So if you're not going to hire an expensive doctor what can a normal person actually do?
Ask another regular doctor?
But the whole premise of this article is that the regular doctors won't get it or do it
I think the article is flawed in many ways.
> To help manage inflammation, there are new medications like colchicine that are normally only used in very high-risk patients.
Clarification: Colchicine has been used by humans for over 3000 years. What's new is its use for cardiovascular disorders.
I recently did a comprehensive panel of my own volition with Quest Labs and was pleasantly surprised by the entire process. It was super easy to schedule, affordable, and their online platform is surprisingly sleek.
It is a long read and I want to make time for it. Quick search check and calc (for calcify etc.) and diet appear alot in the article which is not surprising based on other things I have watched on the subject.
Triglyceride-to-HDL Ratio (TG/HDL)
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.
Depends on the doctor. My doctor at One Medical proactively ordered an ApoB test just to be safe after I successfully got my LDL in check through diet and exercise.
There are some points on this post that confuse me.
> 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?
> Are routine skin checks a thing?
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.
they are to me. I'm very light skinned and thus have had sigificant sunburn more than once, skin checks have found and removed somewhat likely to turn into cancer. Probably useless if you are 20, but by 50 they can find and prevent cancer and so should become common
Yes, you should probably visit a dermatologist regularly (once every year or two) for a routine skin check.
There doesn't seem to be any mention of hypertension on that page.
Actually, there is. You have to search for "pressure". For example, "Other Tests: There are some other things that are important to know as well. You must know your blood pressure".
Good point.
I've forgotten that blood pressure is another word for it, as all medical papers use hypertension.
Thanks!
If you're going to press ctrl+f and post a critique, I recommend including a synonym or two in your search terms.
As much as the HN trend is against AI features in client software, this is an excellent use of Gemini-in-Chrome. Instead of wracking your brain for English synonyms, you can just ask it if the page discusses hypertension, a kind of weapons-grade ctrl+f. Mine said
"Yes, the article discusses hypertension, referring to it as "high blood pressure.""
It seems to be nearly impossible for me to advocate for myself at a place like a hospital.
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.)
That would be useful for me too, similar problem
> Don’t Die!
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?
If you prevent every ailment you don’t become frail and just take care of yourself.
You're almost certainly going to die by or before 110, anyway. (Ir)Regardless of your efforts, or lack thereof, our bodies typically give out in the 100-110 year range with very few exceptions.
Did you take a look at empirical health and what they are doing? Their goal is to prevent 1 million cardiac deaths by 2030.
yeah, always the usual: eat better and do physical activity
unfortunately, depression cripples my motivation to do physical activity
I still do some, but it's never enough
Do you treat your depression?
yes
> The best time to make the decision to not die of heart disease and start taking action is in your 30s and 40s.
And the second best time is now.
Probably best to start in childhood anyway, not your 30s or 40s.
Was this written via LLM? There’s a link early on to some ai search tool which kinda made me question the validity of everything mentioned.
It has many markers of that, including being about ten times longer than it needed to have been.
Please strictly cease and desist from accusing material of being written by an LLM, whether on this site or on any other site. If you want to criticize the material, do so under the good faith assumption that it is written by a human.
I think it’s absolutely fair to criticize something for potentially being generated via an llm or heavily utilized by such especially when it comes to medial claims.
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.
No. It is false criticism. It is like calling one a witch in historical times. Anyone gets accused of it without hard evidence. For all I know, your comment was AI generated. You relied on AI and are now passing that along. It's not helpful.
We don't really know the author. For all I know, the LLM is more accurate than the specific human, in which case I'd want the article to be written by an LLM.
Saying "LLM bad, human good" is both false and uninteresting.
It's a wall of poorly written text. Whether it was a human or LLM is kind of not the main problem.
Genuinely, why? More people than ever are using LLMs to flood the internet with textual slop far faster than humans who have respect for the craft of writing can generate their own text.
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?
Because the signs are only in your head. There is no hard evidence. It is a disingenuous and false way to attempt to discredit someone. Anyone can be accused of it for writing anything at all. The argument that the writing started after the invention of ChatGPT is simply horrible because everyone starts sometime.
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.
Of course there is no "hard evidence" unless someone leaves evidence of the prompt or AI response in their blog post. There are certain clues and syntax. Your comment seems like it would fit in much better on Reddit than on HN.
Negative. You're the one making unproven bad-faith assertions, trying to discredit someone on the basis of witch-hunting logic. Your comment belongs nowhere.
You should always have questioned the validity, but now you feel the need because of LLMs.
I honestly think we should live more for the now than the far future. Rather than focusing on how to optimally extend my lifespan I'd rather focus on living the life where I'd be satisfied if I dropped dead the next day.
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.
You can run a full blood panel on your whoop by clicking a button and showing up at a quest diagnostics
What if heart disease saves me from dementia? I'm not just being contrarian. I think about this a lot of the time. I'm already 40. I'm being healthy now, but whatever damage has already been done is baked in. (plus whatever is in my genetics) A quick death at 65-70 might be much more preferable to a slow terrible decade-long decline.
New medical discoveries happen regularly; you might also die right before the discovery of a preventative/cure for dementia. Living people have options, dead people have none.
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.
Heart disease can be a slow decade long death, where you become incapable of physically doing anything. It's not just a heart attack out of nowhere and you're dead.
My grandfather always said "there's something to be said for a good coronary." He was in his 70's when he said it, and his point was that he had a good run, and there's an argument for going out while things are still good rather than slowly dying over six months in a nursing home (which is what actually happened).
If you don't die of heart disease you will die from something else.
I cannot judge the science in most of the article since I'm not a medical doctor.
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.
ChatGPT is amazing for interpreting test results. Of course you should back it up with a doctor.
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.
Yeah its a self-made-help article, if you don't know any better this is what you do. It doesn't make it the best choice overall though.
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.
Hey, just a friendly reminder that this is HackerNews, not The Lancet.
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!
This is all very interesting, but far too detailed and technical for 99% of people. The TLDR should include an easy to understand summary without jargon like "VO2" and "a set of HIIT at Zone 4".
My first thought after reading: where does a guy like Peter Attia fit into the mix? Is he motivated and communicating in legitimate ways? Just a promotion machine at this point? Somewhere in between?
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.
Attia's one of those expensive concierge doctors. But his public youtube recommendations are basically sound.
I enjoyed Outlive. Rather technical (for me) but made sense.
Stop drinking. Replace cheese and butter with olive oil in copious amounts. Only eat fish meats. Don’t smoke or vape. Eat salads and other prebiotics. Get some cardio - even walking your dog is great. Your brain fog will lift, your skin will clear, your mood will improve and your doctor will gasp at how clear your carotids are next time they’re ultrasounded.
step 1 to avoid heart disease: do NOT inject yourself with untested mRNA gene therapy with questionable safety profiles
Love the chart at the bottom--it really puts on display media bias and lack of integrity and using fear to push idiotic policies which area really just a way to put everyone in the pocket of government and keep them there permanently with zero real improvement to public health. Fear get eyeballs. the Covid mass hysteria proves that, too.
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.
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Tl;dr be affluent enough to be able to afford great medical care and have enough free time for preventative actions
Walking and eating sensibly is free. Even a balance oatmeal, rice & beans with infrequent meat servings would defend against heart disease better than expensive medicine, at less than $1 / day.
Lentils/legumes are cheap. There is probably no better bang for the buck. Yogurt is also cheap.
Funny you should use the word "bang". My last experiment with lentils years ago began one evening with 3 excellent bowls of very tasty lentil soup and ended slowly with 2 days' worth of "bangs", quickly followed by ostracism by my house buddies. So bad!
lol, you probably just need time for your gut bacteria to adjust. My family makes lentils for at least one meal almost every day.
Agree. All the best foods are cheap. It’s a myth that healthy food is expensive. Most of the produce isle is decorative.
Promoting good habits is good but this is health advice from an unlicensed commenter to say rice and beans is better than taking a statin. Consult your doctor if you’re curious what to do.
It’s safer than taking unlicensed tech advice from an Internet forum
Most people aren't on and don't need statins. Everyone would be well served to eat well and exercise regularly. It's not a replacement.
You right. You don't need statins. Nobody does. But look at the statistics. You might also drop dead tomorrow. It's hard to know. If you think eating and exercising would solve heart disease, you are mis-informed. It's the number one killer. If we all died at 30, the drugs would not need to exist. I'm sure you would like to live as long as you can. Taking statins is cheap and simple for most people.
What are you talking about. People who need statins should take statins; this is informed by a basic metabolic panel, something every doctor does.
And not smoking or drinking saves you money!
Yes, our system is most definitely stacked against the poor, but it's important to also remember that we all have free will and that some choices fully within our power are much better than others.
nicotine is likely one of the best appetite-control , cognative-enhancing and anti-anxiety medications ever known to man. A large driver of obesity , anxiety and psychotropic abuse was smoking cessation.
Giving out nicotine gum , would decimate the drugs industry, but likely resolve a lot of our chronic health and depression issues.
I've actually considered taking nicotine for these reasons. But I don't because it appears you build tolerance very quickly.
i know a number of people with moderate ADHD who use it instead of Adderall.
tonymet says >nicotine is likely one of the best appetite-control , cognative-enhancing and anti-anxiety medications ever known to man.<
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".
I think the point is it is cheap to prevent. The weird tip is doing a different test to the standard one, which costs little for typical HNers (but admit every $ counts for many people esp. with current inflation, poverty, bad governance) but sounds like on par with a dentist doing anything beyond a checkup.
A colleague of mine was a vegan, took care of himself, still died of pancreatic cancer. It is what it is.
90 day supply of Atorvastatin costs $10. Running costs a pair of shoes.
You have to be able to get the prescription. HMOs (Kaiser specifically) will generally not provide any sort of preventative care in this area unless your numbers are very high. You can’t get access to a cardiologist unless you’ve already had an adverse event.
If you can get time off work and have a PPO, you can get the preventative care.
$10 is the cash price. Your doctor diagnoses, not insurance, and you don't need a specialist to get diagnosed regardless of what your insurer wants. Even a nurse practitioner can prescribe you a statin.
You should try www.betterbrain.com/insurance! It covers this set of bloodwork and 92% of covered patients pay $0
Wall of text, jeez. This reads as neurotic.
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.
Really surprised at the last few paragraphs! Read with caution this is not Real medical advice!
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!
we’re not far from the point where ChatGPT is superior than going to the doctor in terms of cost, accessibility, speed, and quality
it’s honestly not as bad as y’all think
ChatGPT isn’t perfect but neither is your doctor (or your lawyer or accountant)
It’s not as bad as you think until OpenAI begins selling it’s data profile they’ve been collecting on you.
I don't like this kind of content. The author might have a personal motivation for it, but for the general public, it's just more mental load.
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.
I share your general emotional reaction, but to be fair, heart disease is far and away more important than other type of disease. More people die of it in the US than die of all cancers combined: https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm
> We all know the good practices. Don't be a dumbass
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.
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