I am not a statin skeptic--or rather, I don't want to be a statin skeptic. I've done the research and it makes sense to me, but I still feel some social and psychological pressures to reject statins.
When I see that it is widely accepted that ApoB is better to measure than LDL-C, but the industry continues to measure LDL-C, but not ApoB, I wonder why. It makes me skeptical.
When I see that the purpose of statins is to reduce plaque buildup in the arteries, and that we have the ability to measure these plaque buildups with scans, but the scans are rarely done, I wonder why. Like, we will see a high LDL-C number (which, again, we should be looking at ApoB instead), and so we get worried about arterial plaque, and we have the ability to directly measure arterial plaque, but we don't, and instead just prescribe a statin. We're worried about X, and have the ability to measure X, but we don't measure X, and instead just prescribe a pill based on proxy indicator Y. It makes me skeptical.
In the end statins reduce the chance of heart attack by like 30% I think. Not bad, but if you have a heart attack without statins, you probably (70%) would have had a heart attack with statins too. That's what a 30% risk reduction means, right?
As you can see, I'm worried about cholesterol and statins.
If you fix it without statins through better lifestyle and diet, that is the preferrable route.
As to why medicine is like this, it's because it's conservative, usually about 17 years behind university research[0], and doctors are shackled to guidelines in most health systems or risk losing their licenses. It isn't a coincidence that the article author had his out-of-pocket concierge doctor tell him the more up-to-date stuff.
I have an objection to the "better lifestyle and diet" approach.
Sure, it is absolutely true that better lifestyle and diet has a huge effect. However it is absolutely certain that the vast majority of people who are told to improve their lifestyle and diet, won't.
The result is doctors giving advice that they know won't be followed. And thereby transferring potential fault from the doctor to the patient, with no improvement in actual outcomes. "I told the patient to lose weight and maintain that with a controlled diet." And yet, most people when told to diet, won't. Most people who start a diet won't complete it. And most people who lose weight on a diet, have the weight back within 5 years. Where each "most" actually is "the overwhelming majority". And the likelihood of the advice resulting in sustained weight loss probably being somewhere around a fraction of a percent.
What, then, is the value of the doctor giving this lecture?
(Disclaimer. I have lost 20 of the pounds I gained during COVID, and am making zero progress on the remaining 30. A few months ago I successfully started a good exercise routine. Given my history, I would expect to only follow it for a few years before falling off the wagon. I believe that this poor compliance puts me well above average. But do you know what I do reliably? Take my prescribed medicine!)
To expand, one of the coverage pillars of malpractice insurance (in the US) is the "standard of care". This is basically what most doctors and their associations consider acceptable, which by definition excludes new, better techniques.
This is both a bug and a feature. A move fast and break things philosophy would cause more harm than good, but it also prevents rapid adoption of incremental improvements.
There is virtually zero chance that a doctor will lose their medical license for diverging from the from the usual clinical practice guidelines around statins. Check the state medical board disciplinary records.
But if they're employed by a health system and fail to follow company policy then yes, they could be fired.
No, actually, you should improve your lifestyle and diet and also take statins.
Ever cardiologist ever will tell you that statins work best when you make diet and lifestyle changes. They tell you that, to your face. It's not a secret. This actually goes for A LOT of medications. Usually, medication + diet and exercise is better than medication alone. They also test medications like this.
You can only do things to reduce your risk. And whatever intervention would be based on overall population statistics, since it's difficult to know your own personal risk. Heart disease kills marathon runners. You can't just "fix it". Someone who has naturally high cholesterol won't magically be okay by changing their lifestyle and diet.
> When I see that it is widely accepted that ApoB is better to measure than LDL-C, but the industry continues to measure LDL-C, but not ApoB, I wonder why. It makes me skeptical.
ApoB is shaping up to be an incremental improvement in measurements, but health and fitness influencers have taken the marginal improvement and turned it into a hot topic to talk about.
This happens with everything in fitness: To remain topical and relevant, you always need to be taking about the newest, most cutting edge advances. If it’s contrarian or it makes you feel more informed than your doctor, it’s a perfect topic to adopt for podcasts and social media content.
ApoB is good, but it’s not necessarily the night and day difference or some radical medical advancement that obsoletes LDL-C. For practical purposes, measuring LDL-C is good enough for most people to get a general idea of the direction of their CVD risk. The influencers like to talk about edge cases where LDL-C is low but then ApoB comes along and reveals a hidden risk, but as even this article shows there isn’t even consensus about where the risk levels are for ApoB right now. A lot of the influencers are using alternative thresholds for ApoB that come from different sources.
> In the end statins reduce the chance of heart attack by like 30% I think. Not bad, but if you have a heart attack without statins, you probably (70%) would have had a heart attack with statins too. That's what a 30% risk reduction means, right?
30% reduction in a life threatening issue is huge. I don’t see why you would want to diminish that.
If you were given the choice of two different dangerous roads where one road had a 30% lower chance of getting into a life-threatening car crash, you would probably think that the choice was obvious, not that the two roads were basically the same.
numbers often quoted in favor of statins use relative instead of absolute risk. when seen in absolute terms there is little case for statins except in some possible particular cases. they also do little, if anything, when it comes to life extension — the expected lifespan of a statin user is often estimated to be four days longer than that of those who do not use them. not only is this essentially statistical noise, it discounts the lowered quality-of-life side effects experienced by many who have been put on statins.
>If you were given the choice of two different dangerous roads where one road had a 30% lower chance of getting into a life-threatening car crash, you would probably think that the choice was obvious, not that the two roads were basically the same.
You could absolutely think that they were basically the same, depending on the base rate. The differece between a one-in-a-million and 0.7-in-a-million is 30%, but it wouldn't be humanly perceivable. We're all likely faced with situations like that regularly. Differing airlines probably have much greater variances in their crash statistics, but it just doesn't matter in 99.99999% of flights.
Meta-analysis conclusion: This literature-based meta-analysis did not find evidence for the benefit of statin therapy on all-cause mortality in a high-risk primary prevention set-up.
Guidance from the National Lipid Association, based on a review of the current understanding of the science across quite a few different meta-studies, analysis, etc. Many of the referenced studies are meta-studies significantly larger than the one here.
We have mountains of studies showing the negative impact of LDL-C (and inflammation! Which statins also reduce) on health. We have mountains of studies showing positive impact from statins. We have specific mechanistic understanding of how LDL-C and other atherogenic particles cause heart disease. We have mountains of studies show that statins directly lower the amount of atherogenic particles you have.
This has been studied enough and sliced enough ways that yeah, there is evidence on both sides. But one side is effectively a mountain range, and the other is a small hill. I know which way I'm going to land on it.
Concentration of ApoB-carrying lipoproteins in the bloodstream as the driver of heart disease is one of the most strongly proven facts in medicine. Statins are proven to lower LDL (a close-enough substitute for ApoB in most situations) by about 30%. I can't look at the study now, but most likely it's a situation where patients' cholesterol has not been lowered enough by medication to make a meaningful difference. If you have an LDL of 160, statins aren't going to be sufficient. The issue is doctors/patients not targeting a sufficiently low cholesterol level.
> When I see that it is widely accepted that ApoB is better to measure than LDL-C, but the industry continues to measure LDL-C, but not ApoB, I wonder why. It makes me skeptical
Because this is a recent understanding and healthcare tends to be a conservative industry that moves slowly. Sometimes too slowly.
And also because LDL remains an excellent measure. The risk with LDL isn’t false positives. If someone has high LDL they likely have an elevated risk of heart disease. The problem with LDL testing is that someone with low LDL may still have a high risk of heart disease which may be captured in APoB testing.
> When I see that it is widely accepted that ApoB is better to measure than LDL-C, but the industry continues to measure LDL-C, but not ApoB, I wonder why. It makes me skeptical.
Part of this is just that insurance coverage lags science. We've known that ApoB is more accurate than LDL since the 1990's or 2000's, but to be covered by insurance, several more steps have to happen.
First, the major professional societies (like the American College of Cardiology or National Lipid Associations) have to issue formal guidelines.
Then, the USPSTF (US Preventive Services Task Force) needs to review all of the evidence. They tend to do reviews only every 5 or 10 years. (Countries aside from the US have different organizations that perform a similar role.)
If the USPSTF issues an "A" or "B" rating, then insurance companies are legally obligated to cover ApoB testing. But that also introduces a year or two lag since medical policies are revised and apply to the next plan year.
The net effect is that the entire system is 17 years, on average, behind research.
ApoB blood tests are relatively cheap. You can pay out of pocket about $70 if you really want one and insurance won't cover it.
Most commercial health plans will cover an ApoB test for members with certain cardiac risk factors or medical conditions. But they generally won't cover it as a preventive screening for all members. I don't think we have enough evidence to justify broad screening yet, although that may be coming.
> When I see that the purpose of statins is to reduce plaque buildup in the arteries, and that we have the ability to measure these plaque buildups with scans, but the scans are rarely done, I wonder why.
I'd love to know where to get the right advice on this topic.
I have high LDL-C, had a heart CT in hospital last week, yet the hospital's cardiologist phoned me yesterday to cancel a scheduled appointment to discuss the results(!), because she said I have zero arterial plaques and there's simply no need for us to meet.
How old are you? I was told that they're not considered diagnostic until somewhat later in life (>50) because the plaque may not have calcified yet, which could cause a false negative.
I was found to have high cholesterol in my late 20s. At the time the doctors (my cardiologist, then a second one brought in for advice) determined that the source was hereditary, but the effects would be the same. So they put me on statins. It's been 40 years now. I changed the statins three times since, when the actual one, at a specific time was no longer able to keep the values within acceptable limits. Approximately 8-9 years ago (I think) I ended up on Rosuvastatin 20mg, which I'm still taking every day. I do not maintain any diet (it'd be very hard, as I'm a heavy meat eater) and cholesterol levels are still staying within acceptable limits. Of course YMMV
No heart attacks or strokes? I'm in the same boat (hereditary issue), and altering my diet has never had any substantial effect on my numbers. I'm not overweight and rarely eat red meat, but have had trouble keeping onto a primary care physician long term (the people I keep picking seem to move between clinics constantly) in order to retain consistent access to a statin prescription, but as I continue to age I've been getting increasingly anxious that my time is coming.
I haven't had to touch statins to get my lipids profile much better. I used zepbound to lose about 50lbs and then weaned myself off that. I was a little afraid my “completely normal after 8 months of weight loss” blood panel status at the end of my zepbound journey would go back to the “bad” region, but I have maintained going on a year with a much better whole foods/lean meats based diet and moderate exercise (I do let myself have some red meat on Saturdays, otherwise I would explode from hamburger desires). So it was done through a combination of lifestyle changes and zepbound to help me bury the hunger monster long enough to learn new habits and get to a new normal. Him suggesting that “probably” most people should be on statins whether they need them or not seems like covering up the source of the problem. I do know that some people just naturally have lipid issues even when doing “all the healthy things” though. My mom is one of them.
I ALSO want to not be a statin-skeptic but, like you, these things look very weird to me. The most prescribed drugs in the country and we don't even try to check if they are addressing the actual problem?
We have checked to see if they are addressing the problem more than probably any drug in history. The idea that we haven't is the result of skeptics cherry picking results that back up their point while ignoring the huge quantities of evidence supporting the efficacy of statins and other LDL lowering medications like ezetimibe, pcks9 inhibitors, etc.
Statins are so good at what they do they even reduce the risk in people who are already at low risk for heart disease.
That prior discussion gives no good reasons. The linked medium posts are, to be frank, trash.
Statins are well-tolerated drugs with little to no noticeable side effects. You might have to try a few. You may need to combine ezetimibe to maintain a moderate statin dosage level, and that's it. (Like the author of this article)
Source: Leading cardiologists worldwide, and doctors of the rich and famous.
I'm a big statin sceptic so just putting that up front.
I think things haven't changed because most people underestimate how slow institutional scale change is. There is a reason why HR departments and consultants have Change Management experts. The inertia is huge. Young people don't appreciate this because they thrive on new ideas. Old folks don't and will subconsciously push back, like a form of institutional homeostasis.
Also, while I believe your heart attack stats are correct, I'm more interested in all cause mortality. I believe there statins are a net negative.
A single study showed a single statin reducing GLP-1 levels and ascribed it to gut microbiome changes that could be totally resolved with UDCA supplementation.
If this even ends up being reproduced it at most says there is an easy fix for people taking atorvostatin and that it might be a concern with other statins, but this should be treated with the same health skepticism of any other single study finding.
Not all statins raise blood sugar either - pitavastatin usually shows an improvement in insulin sensitivity.
one better simple indicator than large panels, if you can't get access to them or don't have them is simply your triglycerides/hdl ratio. aim to be under 2 if using mg/dl and under 0.87 if using mmol/L. it's one of the strongest correlated indicators of cardiovascular disease. way better than any classic cholesterol ratios.
Statins can be effective for many patients (and there are multiple different statins with varying effects) but there are also alternative or additional drugs such as Leqvio (inclisiran) and Repatha (evolocumab). Patients should do their research and talk to their doctors. It might take some trial and error to figure out what works best.
The general advice is that the scans are only useful sometimes. That is, they can show a problem. But a clear scan doesn’t mean you’re fine. So don’t base anything on a clean scan, be proactive with all the rest of it. My two cents, by the way: Repatha is pretty amazing.
There is no reason take statins, ever. They will destroy your muscles, then cause diabetes and thus indirectly kill you. They will prevent a heart attack by... four days.
If biomarkers are elevated, the question must always be, "why is this elevated", and "is there a natural change in habit and diet that can reverse this elevation".
Artifically lowering the marker with a drug is like pasting duct tape on a leaking pipe - the leak is still there and it will likely quietly get worse over time and then eventually kill you anyways.
I find it unbelievable that our society swallows any drug without second thought. You body produces cholesterol on purpose. There must be reason why it produces it. "Ah well, who cares, let's just throw in a wrench and make it stop producing the cholesterol" and hope for the best...
Arguing against nonsense like this gets so exhausting.
Statins do not destroy your muscles. Newer statins make this already exceedingly rare side effect even rarer, but let's look at them as a general class:
Blinded RCT/Meta-analysis shows about 11 complaints per 1k patient years, with 90% of them not actually being due to the statin. But because people act like they're common, they mistakenly believe it was the statin, which just reinforces this idea. And that's for muscle pain.
For actual significant muscle injury? Even lower. 1 or less per 10,000 patient years.
Effectively, you might get one muscle ache per year per 100 people and at most a 1 in 10,000 chance of serious myotoxicity.
As for diabetes, rosuvstatin usually has a neutral to positive impact on insulin sensitivity, and pitvastatin almost always has a positive impact. Some statins do have negative impact, but it's not universal.
It's not like duct tape on a leaking pipe - it's like removing items in a pipe that damage the pipe walls. Yeah, ideally they're not in the pipe to begin with, but removing them is better than letting them stay, and diet and exercise only do so much to remove said items.
Your body can synthesize LDL de novo in the organs that use it, and one of the heaviest users, the brain, can't get cholesterol out of your diet/serum levels at all - LDL cannot pass the blood brain barrier.
There are people with genetic mutations that mean they don't produce LDL, or at least not at high levels - their increased longevity and incredibly rare incidents of ASCVD is what drove the creation of PKCS9 inhibitors.
Statins also lower LDL-C levels - they don't make your body stop producing cholesterol in general, or even LDL-C. Even if your body couldn't make it on-demand where needed, statins aren't going to drop your serum levels to 0.
> When I see that it is widely accepted that ApoB is better to measure than LDL-C, but the industry continues to measure LDL-C, but not ApoB, I wonder why.
That's pretty simple to explain. No conspiracy.
LDL-C is much much cheaper to measure. ApoB costs 36x times as much, so Insurance Companies don't like to pay for it
My wife had high cholesterol numbers, so her doctor wanted to give her statins. She asked about a scan, he begrudgingly said well, I guess you could do that. Her scan showed 0 plaque.
It was almost certainly the former, and the former is is basically an indicator that the damage is already done.
Soft plaque takes a long time to calcify. But soft plaque is the stuff that ruptures, and will clog up your arteries just as much.
Statins are best used as a preventative measure - once the plaque is there it's difficult to regress it even while soft, and as far as we know effectively impossible once it is calcified.
I’m sensing a potentially significant misallocation of resources. My mental model is that there’s a hypothetical quantification of not just your time and money, but your anxiety, attention bandwidth, mental energy, etc.
I think, in some ways, the trick is being able to short circuit the entire journey represented by this website in favour of some form of, “I’m 40. I should be more mindful of heart disease. I should add a 30 min walk to my mornings.” And then move on with your life.
I think many cultures, but especially American healthcare culture, foment a growing background noise of constant anxieties and stressors. Life is sufficiently complex but there’s always a peddler eager to throw you a new ball to juggle (and pay for).
I think the article makes a valid point: stop worrying about 90% of the other stuff and focus on the thing that will almost certainly kill you - heart disease - for which there are easy diagnostic and preventative measures. I think they're arguing for a better allocation of resources, if anything.
I think people should be mindful of it since they were 18 - it's something that progresses over decades. You can have a lot bigger impact making changes when you're young rather than at 40
But yeah I agree with your message. Focus on the big impact macro level things. Hyper-optimizing it is a waste of energy
If I'm not wrong, it takes 20 years to revert the damage of smoking.
I don't think you need to care at 18, but the effects will be seen over the course of 20 years
Seriously there is too much shit to worry about to micro manage each facet, unless your like a Bryan Johnson billionaire with a staff.
Beyond just heart disease & cancer taking you out entirely its: my eyesight is going, my hearing, every joint in my body could fail, my brain is slowing, etc.
There is just way too much shit to do anything other than be like: sleep, exercise, eat better and don't drink too much.
And even him doesn’t know what’s working and what’s making things worse. He claims to have really good biomarkers but that’s when cherry-picking numbers from studies made in a range of more than two years (!!).
You’ll never see a published set of tests from him. What you’ll see is ads to buy his supplements.
There are roughly 5 areas of which combined cover 80+% of things you can control.
1. Exercise (aerobic and strength, doesn’t have to be much but more is better).
2. Diet (mostly whole foods, mostly plants, low saturated fat).
3. Prevention (regular check ups and following doctor’s advice).
4. Meaning / purpose (either being passionate about your job or having such hobbies outside of it).
5. Friends and community.
This isn’t too much. By many that’s the bare minimum for having a satisfactory life.
> Beyond just heart disease & cancer taking you out entirely its: my eyesight is going, my hearing, every joint in my body could fail, my brain is slowing, etc.
Absolutely right. You can’t fix everything. But if you can only dedicate time, money, and attention to one thing, cardio health is probably highest impact for most people. This article makes that case. Also it makes the case that there are a few things that will have an outsized positive effect on cardio health and we’d be wise to focus on them.
Key Takeaway: Get a CT or CTA scan, and if you can afford it go for the CTA with Cleerly.
There is a reason that we don't recommend getting imaging for everyone, and that reason is uncertainty about the benefit vs the risks (cost, incidentalomas, radiation, etc, all generally minor). Most guidance recommends calcium scoring for people with intermediate risk who prefer to avoid taking statins. This is not a normative statement that is meant to last the test of time: it may well be the case that these tests are valuable for a broader population, but the data haven't really caught up to this viewpoint yet.
The central point of his article is that he went to a doctor who followed the guidelines, tested him and found he wasn't at risk for heart disease.
But then he went to another, very expensive concierge doctor, who did special extra tests, and discovered that he was likely to develop heart disease and have a heart attack.
Therefore he is arguing that THE STANDARD GUIDELINES ARE WRONG AND EVEN IF YOU DO EVERYTHING RIGHT AND YOUR DOCTOR CONFIRMS IT YOU MAY BE LIKELY TO DIE OF HEART DISEASE ANYWAY, SO ONLY THE SPECIAL EXTRA TESTS CAN REVEAL THE TRUTH.
I want a second opinion from a doctor. Is this true? Is this for real? Because it smells funny.
I strongly suspect the truth is both are "right", but they're both optimized answers to slightly different problems.
Mainstream medicine is hyper optimized for the most common 80% of cases. At a glance it makes sense: optimize for the common case. Theres some flaws in this logic though - the most common 80% also conveniently overlaps heavily with the easiest 80%. If most of the problems in that 80% solve themselves, then what actual value is provided by a medical system hyper focused on solving non-problems? The real value from the medical system isnt telling people "it's probably just a flu, let's just give it a few days and see" it's providing a diagnosis for a difficult to identify condition.
So if your question is "how do we maximize value and profit in aggregate for providing medical care to large groups of people", mainstream medicine is maybe a good answer.
But if your question is "how do we provide the best care to individual patients" then mainstream medicine has significant problems.
Research science in this area has been in agreement for a long time now that ApoB is a more informative indicator than just LDL-C, because there are a variety of different atherogenic particles, not all LDL particles are created the same, etc.
His ApoB numbers are quite readily and apparently out of range. Hell, even his LDL is out of range for the two largest lab providers in the US - Labcorp and Quest both have <100 for their reference range. But the science shows that plaque progression is still generally occurring at levels above 70 LDL-C even with low Lp(a) and other atherogenic particles - the reference ranges are likely to get moved lower and lower as practice catches up with research.
His numbers are well within the range of concern based on pretty universal consensus across the research in this area over the past couple of decades. Preventative cardiologists and lipidologists would almost certainly agree with this concierge doctor.
The claim on an individual level is not objectionable to me. The question is that if we extrapolate it out to the population and actually take this action for everyone, do we make people better off? This is what clinical trials (or at least large observational studies) try to achieve. Right now, it is not clear.
His evidence is also kinda weak. And appeal to authority largely about someone who he's paying to tell him he has health problems. The incentives aren't aligned.
I also disagree that the 50the percentile is the breakpoint between healthy and unhealthy. There's a lot more to deciding those ranges beside "well half of the population has better numbers"
Maybe he got missed--let's concede that. What about the other 10 or 100 or 1000 or subjected themselves to tests and didn't find anything? Where are their stories?
If you have enough people, the tests, themselves are eventually going to harm somebody.
For example, certain scans require contrasts like gadolinium that bioaccumulates. That's not a big deal if we only pump it into people 2 or 3 times in their lives when something in their body is about to explode. It's a lot bigger deal if we're doing that to them every year.
The bottom line is these tests aren't some sort of one-size-fits-all panacea, and nor can they perfectly predict the future. In fact Oprah herself backtracked on it, via an article by Dr. Oz in her magazine in 2011: https://www.oprah.com/health/are-x-rays-and-ct-scans-safe-ra...
A good rule of thumb is don't take medical advice from Oprah or Dr. Oz. But in the case of the latter article, he wasn't wrong.
> But then he went to another, very expensive concierge doctor, who did special extra tests, and discovered that he was likely to develop heart disease and have a heart attack.
It’s scarily common in medicine for doctors to start specializing in diagnosing certain conditions with non-traditional testing, which leads them to abnormally high diagnosis rates.
It happens in every hot topic diagnosis:
When sleep apnea was trending, a doctor in my area opened her own sleep lab that would diagnose nearly everyone who attended with apnea. Patients who were apnea negative at standard labs would go there and be diagnosed as having apnea every time. Some patients liked this because they became convinced they had apnea and frustrated that their traditional labs kept coming back negative, so they could go here and get a positive diagnosis. Every time.
In the world of Internet Lyme disease there’s a belief that a lot of people have hidden Lyme infections that don’t appear on the gold standard lab tests. Several labs have introduced “alternate” tests which come back positive for most people. You can look up doctors on the internet who will use these labs (cash pay, of course) and you’re almost guaranteed to get a positive result. If you don’t get a positive result the first time, the advice is to do it again because it might come back positive the second time. Anyone who goes to these doctors or uses this lab company is basically guaranteed a positive result.
MCAS is a hot topic on TikTok where influencers will tell you it explains everything wrong with you. You can find a self-described MCAS physician (not an actual specialist) in online directories who will use non-standard tests on you that always come back positive. Actual MCAS specialists won’t even take your referral from these doctors because they’re overwhelmed with false cases coming from the few doctors capitalizing on a TikTok trend.
The same thing is starting to happen with CVD risks. It’s trendy to specialize in concierge medicine where the doctor will run dozens of obscure biomarkers and then “discover” that one of them is high (potentially according to their own definition of too high). Now this doctor has saved your life in a way that normal doctors failed you, so you recommend the doctor to all of your friends and family. Instant flywheel for new clients.
I don’t know where this author’s doctor fits into this, but it’s good to be skeptical of doctors who claim to be able to find conditions that other doctors are unable to see. If the only result is someone eating healthier and exercising more then the consequences aren’t so bad, but some of these cases can turn obsessive where the patient starts self-medicating in ways that might be net negative because they think they need to treat this hard to diagnose condition that only they and their chosen doctor understand.
It's important to note that there's geographic variability in guidelines. Also, the article doesn't give enough information about the author's other risk factors. For a similar patient (based on the initial lab results), treated by a doctor adhering to the European guidelines, at least the following items would have been considered:
- Lipid lowering drugs
- ApoB testing
- Coronary CT (if the pre-test likelihood of obstructive coronary artery disease was estimated to be > 5%)
Not sure I follow or maybe you skipped typing a word.
You listed the risks and concluded “all generally minor.” The benefit is absolutely nonzero. So, what’s the hold up?
And how have the data not caught up? People outside the US are getting the CT scans, while US doctors prefer to lick their finger to guess the weather.
My wife’s last interaction with a doctor: patient presents with back and chest pain accompanied by occasional shortness of breath at the age of 39, doctor reluctantly asks for a EKG - which takes 5-10 minutes and is done in the next room, right away and covered by insurance with a small copay - and has the gall to be surprised when EKG showed subtle abnormalities. If she hadn’t advocated for herself, as the OP argues, doctor would just skip the EKG.
This experience left me thinking maybe doctors are discouraged from asking for imaging and guidelines are there to protect their criminally negligent behavior. I have no proof or even proxy data for the claim about doctors being discouraged from asking for imaging. But it is objectively criminally negligent to not ask for imaging in a case like this.
"Smaht" people continuously parrot things they read elsewhere, usually in a contrarian way, to assert themselves in a futile and shallow way.
There is absolutely nothing wrong with getting one CT at a specific point in your life to right a disease which, as TFA states, has a 25% incidence rate.
The smaht ones will now point me to that study of 1-5% of cancers being linked to CT scans. Yeah, sure, but those are not from people who got one-two in their lives.
There's something I deeply don't understand about this.
> I shared these results with a leading lipidologist who proclaimed: “Not sure if the lab or the primary care doc said an LDL-C of 116 mg/dL was fine but that concentration is the 50th percentile population cut point in the MESA study and should never ever be considered as normal.
> It’s also important to note that, according to a lipidologist friend, an ApoB of 96 is at a totally unacceptable 50th percentile population cutpoint from Framingham Offspring Study.
So... the exact median value is "totally unacceptable" and "should never ever be considered as normal"? I'm open to the possibility that the US population is so deeply unhealthy that this is true, but then that needs to be argued for or at least mentioned. Like, you can't say "you're exactly average in this respect" and expect your and that's terrible to be taken seriously without any followup.
Or if I'm misunderstanding what's meant by "50th percentile population cut point" then again, I think this jargon should be explained, as it's plainly not the usual meaning of "50th percentile".
I had assumed "the MESA study population" was a particularly unhealthy bunch in terms of this measurement, meaning the 50th percentile puts one in the worst half of an already bad off group.
I don't know the exact details, but I thought the Framingham survey was just a cross-section of the population. So getting upset about a 50th percentile score makes no sense at a population level.
A quick Google says that the Mesa study was actually of people without cardiovascular disease at the beginning of the study. So again, these conclusions don't make any sense to me.
The other thing these number chasers don’t tell you is that extremely low LDL numbers are also associated with anger management issues. The stuff is used in your body to build things. You need some, and probably at least half of the number this doc is trying to say is scary. In fact in a different test he is advised to talk to his doctor about whether a 29 is safe.
Has the guidance changed that you want LDL less than 2.5x (or was it 2x?) your HDLs?
Every organ in your body that utilizes LDL can synthesize it de novo. Some of the heaviest users, like your brain, literally can't get it from your serum LDL levels - they do not pass the blood brain barrier. It is all synthesized locally.
PKCS9 inhibitors and mendelian randomization studies show that people function just fine with <10 LDL-C. (Other comments I have made in here have links to all the relevant studies)
Googling for statin and aggression links I find a fairly small set of studies with fairly disparate outcomes.
Going deep on biomarkers, blood tests, and debates about optimal levels is okay for some people who derive motivation from obsessing over topics, but I’m starting to notice a trend where people obsess about these things for a couple years before burning out and moving on to the next topic.
The best thing you can do for yourself is to establish healthy diet and lifestyle habits that are sustainable. A lot of people who jump from obsession to obsession do a great job at optimizing for something for a few years, but when their life changes they drop it completely and fall back to forgetting about it.
Fad diets are the original example of this: They work while the person is doing it, but they’re hard to maintain for years or decades. CrossFit and other exercise trends have the same problem where some people get extremely excited about fitness for a couple years before falling off completely because it’s unsustainable for them. Some people are able to continue these things for decades, but most people do it for a short while and then stop.
I’m now seeing the same pattern with biomarker obsessives: They go a few years obsessing over charts and trying things for a few months at time, but when the interest subsides or they get busy with life most of it disappears.
The most successful people over a lifetime are those who establish healthy habits that are easy to sustain: Eating well enough, reducing bad habits like frequent alcohol or fast food consumption, some light physical activity every day, and other common sense things.
The most important factor is making it something easy to comply with. The $300 biomarker panels are interesting, but most people don’t want to pay $300 every year or more to get snapshots that depend largely on what they did the past week. Some people even get into self-deceiving habits where they eat well for a week before their blood tests because the blood test itself has become the game.
Right on spot. Find a regime for body and mind that you can sustain without any significant mental effort, after some time lack of good behavior be it sports of healthy food makes one uneasy. Bonus points from getting happy from it / making it a passion, this helps a lot with coming back after some hiatus (ie injury, sickness, long travel etc.).
Personal story - I used to be super sporty, 4x gym training during work week - cardio & free weights, climbing over evenings after work, hiking/climbing/ski touring over weekends. Vacations were mostly more extreme variants of the same. Last year broke my both ankles with paragliding, one leg much worse, so took me some 8 months to be able to walk straight again, with some time in wheelchair, then crutches. All strength & stamina gone, flexibility 0, so had to rebuild from scratch and I mean deep bottom scratch from which you bounce very slowly, not some 1 month stop when things come back quicker. If all above weren't my proper passions I would have a hard time coming back to being again more active than most(sans that paragliding, took the lesson and have 2 small kids). That ankle won't ever be same but so far so good, ie managed some serious hike&via ferrata mix 2 days ago.
Getting happy from it is 100% the most effective way to change habits.
Unfortunately it’s also very subjective and hard to find out what makes you happy…
> starting to notice a trend where people obsess about these things for a couple years before burning out and moving on to the next topic.
Really spot on with one of my besties. He does all the tests. He has a concierge doctor. He reads extensively on the topics of fitness and nutrition. And yet he doesn't do any of it. It's just an intellectual exercise for him. And he has had two heart attacks in the last several years. It's so frustrating. I just wanna shake him.
I learnt a great trick about exercise: find a podcast or audio book that you really enjoy listening to. Here's the trick: you're only allowed to listen when you're exercising.
Also with food and drink: place friction between the treat and yourself. The easiest example is to not have biscuits / alcohol in the house.
Bonus tip: alcohol free beer is really good these days.
Alcohol free beer was a game changer for me. Also if I can’t avoid it alternating alcohol-containing and alcohol-free drinks.
For exercise your tip doesn’t help me at all. I hate audiobooks and podcasts so that would turn me off more from exercising. Also I want to concentrate on the exercise and not do it halfhearted.
What helped me was to realise how much better I feel after exercising - since then i kinda got addicted to it because I notice how much worse I feel after not doing it for a couple of days.
I agree on the friction. Just not having access to cigarettes is the best way for me to not smoke. I just don’t buy them and bumming one from someone else comes with a degree of personal shame for me that makes me avoid them (in almost all cases).
I naturally don’t like sweet stuff that much - however since I moved from EU to America (not US) it’s been really hard to avoid sugar.
Y’all put that stuff into everything it’s crazy; I gotta watch out like a hawk and go to special stores. In Europe it was so much easier, there are always cheap sugar free whole foods available in every supermarket.
I push hard enough during cardio that I can't really follow a podcast properly.
On the upside, it's only 30 minutes.
While lifting weight I do that since I rest for 90 seconds in between sets, which is actually very boring.
I started reading books during that time and that has been a big improvement.
If you're exercising for cardio, and you're able to follow your book or podcast, you're probably not doing good cardio. OTOH, it's not a bad way to do interval training while watching sports, go hard when they're yammering, slow down when the sports are happening (or, if you're watching soccer, you can go hard most of the time and then slow down for the replay if anything happens, which is unlikely)
> Sticking to a Mediterranean diet that is light on carbohydrates and saturated fats is almost always the safest bet. Almost every health diet is some permutation of this.
A permutation that's currently making the rounds in the press (even though the original research is from 20 years ago) is the "portfolio diet":
Lowering LDL cholesterol is arguably the most evidence-backed longevity intervention available today. Mendelian randomization studies suggest that each standard deviation of lifelong LDL reduction translates to roughly +1.2 years of additional lifespan, implying ~+2.4 to +3.6 years from sustained, meaningful lowering alone.
Pair this with tight blood-pressure control (aim systolic <130 mmHg) and a healthy BMI—every incremental improvement helps. Together, LDL, BP, and BMI form the most potent triad of interventions most people can implement now and expect to see substantial benefits 20–40 years down the line.
Everyone knows the recipe for healthy living, it's the same as for similar issues such as personal finance (spend less than you earn, save, etc.).
They seem simple on the surface but hard part is execution for most people, due to life circumstances and other factors. Unhealthy choices persist because society isn't built around healthy lifestyles.
So while the comment seems helpful on the surface, it misses the forest for the trees.
I think that there needs to be a bigger discussion here, regarding why have we engineered a society that inflicts suffering and illness on so many?
Not all things labeled "processed foods" are bad, it seems. There are enough scientists that say the distinction is often hypocritical (example from an article: a factory-made carrot cake is labeled UPF, but a home-baked one isn't, even though they're practically the same thing). Sugar, fats, and lack of fiber make factory-food unhealthy, they say. Others add that we can't feed the growing metropolitan areas without it.
Just expanding on a peer post, but industrial made food tends to have a large number of preservatives, stabilizers, coloring agents, and much more added for commercial reasons. An obvious example of this is in something as simple as bread. If you've ever made homemade bread. It goes stale in a day or two, and it's hard as a rock shortly thereafter.
But that loaf you buy at the store? It'll generally be covered in mold before it gets hard, and that's quite the achievement since it also tends to be more resistant to mold as well! Bread should get hard. This is where a ton of old recipes come from. The Ancient Greeks would dip it in wine for breakfast, Euroland has bread soup/puddings, and even stuff in the US like Thanksgiving stuffings or croutons.
>a factory-made carrot cake is labeled UPF, but a home-baked one isn't, even though they're practically the same thing).
Actually they are not. "Practically" is carrying a lot of weight there. The factory baked cake will have a lot more extraneous ingredients and usually has a larger quantity of sugar and fat. Similar to how restaurant food generally has a lot more salt and fat than home cooked food.
WRT the carrot cake, I will say that while there is only a minimal physical difference, there is a practical difference. Making a carrot cake at home is a commitment, and most people won't frequently go to the trouble except on special occasions... But one from the grocery store can be acquired casually and without effort, and it's easy to eat a lot more of something when it requires no effort.
You’re not wrong but it is not a fair TLDR. TFA has a TLDR which says
> If you only read one thing here, make it the “How to not die of heart disease” section.
Which itself is still quite long but it emphasizes:
> Every lipidologist I’ve spoken with has stressed the importance of measuring and managing ApoB above all else – it’s a far better predictor of cardiovascular disease than LDL-C (which is what physicians are most familiar with). Every standard deviation increase of ApoB raises the risk of myocardial infarction by 38%. Yet because guidelines regularly lag science, the AHA still recommends LDL-C over ApoB. Test for it regularly (ideally twice a year) and work to get it as low as possible (longevity doctor Peter Attia recommends 30-40mg per deciliter). Many lipidologists will say to focus on this above all else.
And:
> I asked several leading lipidologists to stack rank what they believe are the most important biomarkers for people to measure and manage. […], and will likely cost anywhere between $80-$120 out of pocket.
That’s a pretty interesting and relevant part of TFA. Omitting that is not a fair “long story short”, but rather just “different story”.
This is wrong. Our bodies evolved to eat a diverse omnivorous diet and complex carbs + the antioxidants present in vegetables and fruits are anti-oxidative.
Vegetables aren't "carb-heavy". And we don't need to recreate blindly the circumstances evolution had to adapt us to. E.g., our bodies evolved when the population was much smaller, but I don't think you want to argue for mass extinction.
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.
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...
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).
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.
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.
> 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’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.
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.
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.
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.
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.
> 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.
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).
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.
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.
>> Sticking to a Mediterranean diet that is light on carbohydrates and saturated fats is almost always the safest bet.
Majority of calories on a Mediterranean diet come from carbohydrates. I think the author meant “light on processed sugars (unless warranted by a high endurance training volumes)”.
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.
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."
> 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.
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.
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.
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.
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.
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).
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'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).
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.
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.
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.
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.
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.
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.""
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.
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.
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.)
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.
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?
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.
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.
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.
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!)
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>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.
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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.
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No, actually, you should improve your lifestyle and diet and also take statins.
Ever cardiologist ever will tell you that statins work best when you make diet and lifestyle changes. They tell you that, to your face. It's not a secret. This actually goes for A LOT of medications. Usually, medication + diet and exercise is better than medication alone. They also test medications like this.
You can only do things to reduce your risk. And whatever intervention would be based on overall population statistics, since it's difficult to know your own personal risk. Heart disease kills marathon runners. You can't just "fix it". Someone who has naturally high cholesterol won't magically be okay by changing their lifestyle and diet.
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…).
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> When I see that it is widely accepted that ApoB is better to measure than LDL-C, but the industry continues to measure LDL-C, but not ApoB, I wonder why. It makes me skeptical.
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.
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>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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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one better simple indicator than large panels, if you can't get access to them or don't have them is simply your triglycerides/hdl ratio. aim to be under 2 if using mg/dl and under 0.87 if using mmol/L. it's one of the strongest correlated indicators of cardiovascular disease. way better than any classic cholesterol ratios.
Statins can be effective for many patients (and there are multiple different statins with varying effects) but there are also alternative or additional drugs such as Leqvio (inclisiran) and Repatha (evolocumab). Patients should do their research and talk to their doctors. It might take some trial and error to figure out what works best.
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.
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> When I see that it is widely accepted that ApoB is better to measure than LDL-C, but the industry continues to measure LDL-C, but not ApoB, I wonder why.
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.
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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?
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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
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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.
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There are roughly 5 areas of which combined cover 80+% of things you can control.
1. Exercise (aerobic and strength, doesn’t have to be much but more is better). 2. Diet (mostly whole foods, mostly plants, low saturated fat). 3. Prevention (regular check ups and following doctor’s advice). 4. Meaning / purpose (either being passionate about your job or having such hobbies outside of it). 5. Friends and community.
This isn’t too much. By many that’s the bare minimum for having a satisfactory life.
> Beyond just heart disease & cancer taking you out entirely its: my eyesight is going, my hearing, every joint in my body could fail, my brain is slowing, etc.
Absolutely right. You can’t fix everything. But if you can only dedicate time, money, and attention to one thing, cardio health is probably highest impact for most people. This article makes that case. Also it makes the case that there are a few things that will have an outsized positive effect on cardio health and we’d be wise to focus on them.
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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.
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.
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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.
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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"
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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.
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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.
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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.
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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.
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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?!
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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)
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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.
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> : 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.
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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.
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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)
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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.
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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.
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> 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?
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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.
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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.
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> 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...
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).
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.
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.
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> 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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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.
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.
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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.
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> "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.
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>> 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.
> 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.
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...
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.
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.
>> Sticking to a Mediterranean diet that is light on carbohydrates and saturated fats is almost always the safest bet.
Majority of calories on a Mediterranean diet come from carbohydrates. I think the author meant “light on processed sugars (unless warranted by a high endurance training volumes)”.
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.
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/...
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.
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.
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.)
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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.
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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.
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...
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).
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'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).
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.
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.
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.
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.
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.
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.
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.
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
> 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.
> 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.
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?
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
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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.
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.""
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.
> 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.
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
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
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.
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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?
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You should always have questioned the validity, but now you feel the need because of LLMs.
> 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.
Did you take a look at empirical health and what they are doing? Their goal is to prevent 1 million cardiac deaths by 2030.
You can run a full blood panel on your whoop by clicking a button and showing up at a quest diagnostics
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).
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.
If you don't die of heart disease you will die from something else.
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.
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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.
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And not smoking or drinking saves you money!
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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.
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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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