Normal Cholesterol But Still Getting Heart Disease? Here's Why | Dr. Mark Hyman

Let me ask you this. If cholesterol were truly the main cause of heart disease, then why do half the people who have heart attacks have normal LDL levels? And there was a study like 136,000 people who had heart attacks went to the ER and 75% had a quote normal LDL level. So that begs the question, then what the hell is going on here? So today I want to talk about something I've changed my mind about over the years. Cholesterol and heart disease. Now heart disease is

the number one killer of Americans since the 1950s. And yet so many are still approaching it with the same outdated framework that we've used for decades now. For a long time, cholesterol was seen as the enemy. You got to get it as low as possible. You got to avoid fat. You got to take a statin. And that was what we're all told. That's what doctors are trained in. And that's the story most people still believe. You go to your doctor, they check your labs, they do a cholesterol test, and they do the wrong one, by the way. And that's why at function health we do the right ones including ones you never get from your doctor like apo B which is far more important than all the other cholesterol tests and LP little A which most people don't check which is highly important genetic marker. So you got to know your numbers but the right numbers. So doctors check your old cholesterol number. They see your LDL's high. They go LDL high let's get lower take a statin without really much thought. And that's unfortunate because it's a much more nuanced problem than just a statin deficiency that's causing heart disease. Now, the latest research shows that we need to think about this differently with my patients. I've also learned a lot and how variable people respond to different things. I've had people with extremely high cholesterol that do extremely well on an extremely highfat ketogenic diet and lower their cholesterol and other people who are the opposite who will take a keto diet and actually make their cholesterol worse. So, you've got to really look at individuals and figure out what's going on. This episode is brought to you by Function Health, empowering you to live a 100 healthy years with over 160 lab tests at just $365 a year. Sign up today at functionhealth. com/mark and use the code mark2026 to get $50 toward your membership. Here's what I used to believe. I got trained like every other doctor that LDL was the issue. That you had a high cholesterol, high LDL that causes heart attacks, cause and effect. And the goal

was to lower your LDL no matter what at all costs. Get as low as possible. We also learned that saturated fat is bad because it can raise your cholesterol, particularly LDL cholesterol. So the message is pretty simple, but it wasn't accurate for most people. Real life clinical work really changed that simplicity. When you graduate from medical school, you think you know everything, but you start practicing medicine and after 30 or 40 years, you really don't know that much. And how everybody's different. And there's not the simplicity that we think buys to certain things like LDL, heart disease, statin, cure. It's just not so simple. We've treated cholesterol like a billin, but the truth is really way more nuanced. What did the old model get wrong? Well, the new science that's emerging has identified a couple of key problems. The first is that total cholesterol is actually a poor predictor of heart disease. up to 50% or even more in some of the studies of people who have heart attacks have a quote normal LDL level. The risk really comes from something that's not being tested by almost every doctor in the country. I mean, I asked Quest, who is our lab testing partner at Function Health, how many cholesterol tests use the right cholesterol test, which looks at the quality and the size and the number of your cholesterol particles, not just the weight of them, which is what you get with your normal cholesterol test, but the quality and the size, whether they're small or big, whether they're dense or not, and how many of those particles do you have? And you know what they said? Less than 1% of the tests do this. The second big aha that came actually since I graduated from medical school probably in the late 1990s maybe early 2000s was the insight particularly from Harvard and the scientist Paul Ritker who wrote a very seinal paper in the New England Journal of Medicine that it was inflammation that was causing heart disease not cholesterol. even showed that if you had a high cholesterol and low inflammation, your risk was pretty low. But if you had a high cholesterol and a high inflammation, your risk was higher. Even if you had a high inflammation and a normal cholesterol, your risk was higher. So the inflammation is what's going on. So your arteries are inflamed and that's what causes the cholesterol to get deposited. Cholesterol isn't bad. It's bad when it gets oxidized or turns rancid. When you look at data from Harvard Cleveland Clinic and these large met analysis actually the CRP this is another test your doctor's own check and it's on the function panel this high sensitivity C reacttor protein is important maybe more important than LDL and predicting heart disease now what is causing this inflammation and this is what most people don't realize aside from a certain subset of the population who has a genetic cholesterol disorder which is independent of your metabolic health and who do get heart disease and that's a very small number maybe it's 10% the real problem is what we call metabolic dysfunction. This means pre-diabetes, insulin resistance, anywhere along the spectrum where your body is not dealing with sugar and insulin very well because you're eating a high starch and sugar diet and you're not exercising or you have extra belly fat. I mean, you have a little bit of belly fat, you're starting to get this problem and you get high insulin resistance and that means your cells don't respond to insulin. So, you need to be more and more to make it work. And that causes what we call aoggenic dysipidemia. And that's a mouthful, but

what it means is a means plaque. So arogenesis means plaque, athoscerotic, vascular disease, hardening the arteries, whatever you want to call it, clogs in your arteries from plaque from cholesterol deposits that is caused by these small dense cholesterol particles. It's not the cholesterol itself. It's when they're when you have insulin resistance and that drives inflammation. What's really important to understand is that LDL is an LDL. There are different types of LDL. There's large, there's medium, and there's small sizes. And then there's the number of particles. So, think about like, you know, the weight of a cholesterol would be if you get your cholesterol number of 100 or one LDL 130. And that just means the weight of your cholesterol. But it doesn't tell you how many LDL particles that is made up of. It could be a thousand small particles or 100 large particles. But you don't know that unless you do the right test. And that's really again why we did function health. Now, we have to understand it's not just cholesterol as a simple problem. It's nuanced. And there's many different types of cholesterol. There's different sizes. There's different types of HDL and LDL. And so you have to really have a more nuanced understanding and what's causing it. But the real takehome here is that here's the headline. It's sugar, not fat, that's causing you to die of heart attacks. It's sugar, not fat. That's the problem. And that's why I wrote a book called Eat Fat Get Thin. The Blood Sugar Solution. Why I written a day detox. Sugar is the boogeyman, not fat. Now, that doesn't mean that some people don't respond well to fat. They don't. Some people don't. So, there's a lot of variation in the population, but in general, this is the big issue. It's a metabolic dysfunction that affects 93% of the population that's causing this heart attack epidemic. So

it's not that cholesterol doesn't matter. We're just asking the wrong questions. All right. So, what is the new science? What's really causing heart disease? One of the friends of mine sent me this uh email. He's an older I was like 78 and he sent me this email like, "Hey, this great new discovery, this new lab test that you can get that tells you your risk of heart disease. It's more predictive than any other testing possibly you could get for heart disease. " And I'm like, "Wow, this is interesting. I wonder if I'm going to learn something. " I click on it and I'm like, "Oh, okay. Well, I've been testing this for 40 years. Well, probably 30 plus years. " And this is called Apo B. Again, it's not part of a regular cholesterol panel, but it is the most reliable marker of your risk of heart attacks. Why? Because it's a surrogate marker for poor metabolic health, meaning insulin resistance, pre-diabetes, blood sugar issues, belly fat. This is what goes up when you have some degree of this. And it's shows you all the bad cholesterol particles in your blood almost in the same time. Now, in 2023, 2024, the guidelines for cardiology have finally recognized, I've been doing this for 30 years, guys, finally recognized APOB is a causal factor for heart disease. It's not just associated with it. And the beautiful thing about it, you can do the lipoprotein fractionation which is important, but I think it's also important to track Apo B and we do that with function health. These Apo B really shows you how many of these damaging little cholesterol particles, these small dense LDL particles like BBs that go and damage the lining of your arteries and allows the cholesterol to deposit. Another really important test that I mentioned earlier called lipoprotein little A or LP little A. one in five people which is 20% of the population have an elevation of this particular number. It's a genetic problem. There are drugs coming that can help it. There are ways to lower it through lifestyle supplements and certain other treatments. But when you have it is really important to regulate and address all the other heart disease risk factors. Your blood sugar, your blood pressure. Obviously don't smoke. Got to exercise. Don't eat sugar starch. Get rid of belly fat. get your cholester other cholesterol numbers optimized through a whole set of definite interventions we're going to talk about but really important because you can't directly change it right now very well so but it is a very strong independent risk factor of heart disease and it's especially worse if your cholesterol is abnormal medication's coming but metabolic and lifestyle health are really the key as I said earlier the real problem causing our epidemic of heart disease is not a highfat diet it's sugar and it's insulin resistance that results from eating a lot of starch and Sugar. When I say

sugar, I mean any like anything that's got sugar or starch. It could be bread. It could be rice. It could be potatoes. Or though they're not so bad if you eat the little small ones. Anything that's starchy. If you're someone who's susceptible, and most of us are, you can get insulin resistance. I mean, I'm pretty healthy. My body fat's about 10%. I exercise every day. I eat pretty good. Occasionally have a cookie or ice cream, but it's not my staple. And I and I'm pretty lean. But when I went to Italy, you know, last summer, I kind of went crazy and I had, you know, wine and I had lots of pasta and whatever, bread, and uh I gained like 5 or 10 pounds and it went right to my belly and then as soon as I came home, it went right away because I went back to my basic habits. But most people don't do that. And when you look at the data, this is from TUS, 93. 2% of Americans have some degree of metabolic dysfunction. and it shows up as high blood pressure, high cholesterol, or abnormal cholesterol, high blood sugar, having had a heart attack or stroke, or being overweight or obese. That means that only 6. 8% of Americans don't have that. Think about it. Research shows also that insulin resistance is a problem even if your cholesterol is normal. And I kind of want to just touch base on this for a minute. And I talked about this study in my book, Eat Fat, Get Thin, but it was a very interesting study where they mentioned where they took 136,000 people who showed up in the ERS across the country for heart attacks and they measured their total cholesterol, LDL, triglycerides, HDL. And what they found was really fascinating. 75% had normal

LDL, but almost nobody had normal triglycerides or HDL. And the higher your triglycerides and the lower your HDL, the more you had a higher risk for heart attack. Now, what do those numbers mean? Those numbers are a great and simple way to test your degree of insulin resistance. Your triglyceride divided by your HDL. Your HDL should be over 60, ideally, over 50 if you can manage it. Your triglyceride should be less than 100, and even under 70 is better. And if your ratio of triglycerides to HDL is one, that's great. If it start to go to two or three or four or five, that's bad. So if your triglycerides are 150 and your HDL's 30, that's a ratio of 5:1. That's a disaster. Even if your total and LDL cholesterol are perfectly normal, you will have an extremely high risk of having heart attack. Here's the thing about springtime. It's not just a change in weather. It's a season designed for your body to accelerate. Your immune system shifts. Your energy picks up. But you can only launch if your foundation is solid. Are your nutrients depleted? Are your hormones balanced? Now, with more outdoor activity, with more stress, more travel, this is your moment to check in. And this is our reason for building function. It gives you over 160 lab tests for your heart, your hormones, nutrients, toxins, metabolism, and lots more. And all in one check for your entire body, trusted by hundreds of thousands of members for $365 a year. That's a dollar a day. Get your data at functionhealth. com so your body's ready to go. Let's talk about the other piece here, the inflammation model. Why is

there inflammation? And there's a lot of reasons. Environmental toxins, your microbiome, stress, infections, lots of reasons. The main reason, sugar. I know it sound like a broken record, but this is the problem. The biggest driver of inflammation in our society is our starch and sugary diet. 60% of our calories is junk food. The average American eats about a pound of sugar and flour a day. It's about 152 lbs of sugar, 133 pounds of flour a year. That's almost 3/4 of a pound of flour and sugar per person per day. Now, I'm not eating that much. So, some of y'all are eating a lot more. The key is if you eat that, it's going to drive the deposition of belly fat, visceral fat. We call visceral atapost tissue. This is angry fat. It's not just regular fat holding up your pants. It's angry fat and it's inflamed fat. And it's spewing out tons of inflammation. When you have inflammation, guess what happens? You oxidize the LDL. Like, you know, when your oil goes rancid or nuts go rancid, that rancid fat is dangerous. is harmful. It's oxidized fat. It's like a car rusting. And that causes damage to your blood vessel lining and that leads to the ability for the cholesterol to enter the arteries and form these plaques that end up causing heart attacks. There's a lot of other markers of inflammation that you can see. HSCP we talked about feritin something that is can go up in certain people particularly if you have severe insulin resistance. Isle 1 which is a cytoine homocyine also can be elevated. So, a lot of clues you can get for inflammation. So, just to reiterate a little bit on diet. There are people who are sensitive to saturated fat. And I want to just be clear that not everybody responds the same to the same diet. We're all different. On the whole, if you're overweight, if you have belly fat, you're more likely to do better on a highfat diet than a low-fat diet. You're more better likely to do better on a low sugar starch diet than a low-fat diet. Really important. And large studies have shown this. large met analysis pure the pure study framingham data show that dietary saturated fat is not the primary driver of heart disease. I think there was a study I reviewed in my book. There was like 72 different studies. There were randomized control trials, population studies. They blood levels of fats. They look at dietary intake. I was really quite extensive study and they could show no correlation at all with saturated fat. Trans fat for sure increase the risk. That's hydrogenated fat. And omega-3 fats lowered it a little bit, but saturated fat were neutral. Now, that doesn't mean for some people it's not a problem, but it's in general that's the case. Now, as I mentioned, the thing that's far more dangerous is refined starches and sugar. So, bottom line, think of sugar as a recreational drug. Okay. So, what do I

think now? I think now that heart disease is primarily for most people without these genetic lipid disorders is primarily a metabolic meaning blood sugar regulation and inflammatory disease. First, cholesterol is just a bystander in this whole process. And it what matters most to check for you now is something called apo lipoprotein B or apo B and what we call lipoprotein fractionation which we do on function health panel and lipoprotein little A which we do on the function health panel and HSCP measure of insulin resistance which we check fasting insulin again I asked question how many tests that you get from doctors around the country include insulin took less than 1%. never checked, almost never checked. It's probably the most important test for understanding your health and longevity. There's an even better test we offer through function, which is an insulin resistance score, which uses newer technology to get a very predictive result that's better than even taking a glucose tolerance test. The other thing I mentioned, you want to look at triglyceride to HL ratio. That's your triglycerides HL should be 1 one or even less. And then there's a really easy test. It's uh the tape measure test. You basically get a tape measure and you remember measure around your fattest part of your belly and if it's too much fat there and you're not your waist isn't good, you're in trouble. And there are some benchmark numbers we can give you. But basically, you know, if you got that in there, it's just you could use a mirror test. You don't even need a tape measure. Just jump in front of the mirror up and down. If your stomach jiggles, you probably have this problem. Let's kind of reiterate the things that make the most important are the quality of the diet you're eating, whole foods, low glycemic, anti-inflammatory, good fats, exercise, managing stress, getting enough of sleep. All those things are critical. Those matter. What matters less than we thought is the total cholesterol. Is your LDL alone in the dietary fat intake is not as important as we thought. The cholesterol in your

food is certainly not important. In 2015, the dietary guidelines committee said, "Listen guys, we got it wrong. " They said cholesterol is no longer a nutrient of concern. Meaning, eat your eggs. Don't worry about it. In functional medicine, we don't really treat the numbers. We treat the whole body. We treat the system. And the system that drives heart disease is your metabolic health. And people who have poor metabolic health have heart disease. Guys, there's always more studies coming out, but there's an amazing study in 2024 uh looking at metabolic cardiology. And they showed that metabolic syndrome pre-diabetes increases your heart disease risk by four-fold. That's 400% independent of your LDL cholesterol. We're always focused on LDL cholesterol, but your doctors aren't checking your insulin. They're not checking your A1C. blood sugar. They're not looking insulin resistance scores. They're not looking your triglyceride to HL ratio. They're not looking at HCRP. all the things that matter. And again, that's why I co-ounded Function Health because people need to get access to their own biology and know their numbers and know their data. And they're not getting that from their doctors, sadly. Next thing I learned which I think is really important is that people think, "Oh, if you're normal weight, you're fine. " But there is a problem that we call tophi. Thin on the outside, fat on the inside. Or I like to call it skinny fat. You look skinny on the outside, but you're fat on the inside. And this means you can be normal weight. Your body mass index can be normal, but your body composition is bad. Meaning you have more body fat than muscle, particularly belly fat. 20% of people who are normal weight have insulin resistance and have the same heart disease risk as obesity. And that is why we see the data that 75% of Americans are overweight. When we check their blood tests, 93% of Americans have poor metabolic health, meaning they're insulin resistant. That's the 20% right there. So, it's really a problem. Now, the good news is we have new technologies that can help us understand what's happening with our metabolic health and blood sugar, like a continuous glucose monitor. I really love those because they can help you understand what's happening and how your different foods affect you and everybody needs to do this at least for a short period of time because when you understand what your body's doing and how it's reacting different foods then you can modify your diet. Then we'll say well you know if I eat a orange it's fine but plum it goes way up or if I have this bread I'm fine but if I have that bread I'm not fine. So you can actually see how your body responds and it's much better predictor of heart disease risk than just a static blood sugar. What can you do about this today? First thing you do is get the right test. Tests don't guess. You can

ask your doctor for these tests and they may or may not do them, but you can get all of them on your basic panel at functionhealth. com. So, just to reiterate, the tests you want to get are apo lipoprotein B or Apo B, lipoprotein little A, HSCRP, fasting insulin. Of course, you want to know your triglyceride HDL ratio. And also I would really recommend a lipoprotein fractionation. It's part of the basic panel of function. It looks at your particle size, particle number, quality of your cholesterol, really important. And then a calcium score, which I think is important for most people as a baseline. Again, we offer that through function health through our partner Ezra, which you can do imaging. It's very cheap, very quick, uh very safe, and you get a quick idea of whether or not you have plaque development, and then you can manage it. Cuz cholesterol is just a surrogate marker. It doesn't tell you if you have the disease. You have to actually image to see if you have the disease, right? It's not like if you have high blood sugar, really, you know, you have diabetes. That's pretty black and white. If you have high cholesterol, I've had people with the worst cholesterol profiles you could possibly imagine. And they have completely clean arteries. You have to actually image to figure out what's going on. When you test, you have

to remember you want to track your trends over time, not just one point in time. And that's what's so beautiful about a function membership. It's every year a dollar a day. You track your numbers over time. You get twice your testing and you see what's going on and you can modify things. You can change things. You can adjust your diet, lifestyle, see what changes happen and that really helps you manage things. So you got to really understand what you're doing in order to manage it. I think some investor dude said, you know, what gets measured gets managed. So if you don't measure it, you can't manage it. The second thing you want to do is eat in a way that lowers inflammation and helps to correct insulin resistance. How do you do that? Cut out the biggest source of both, which is sugar and

starch. Refined starches. Eat more whole foods. Eat more inflamm anti-inflammatory foods. Lots of colorful fruits and vegetables. Lots of omega-3 fats. Get rid of ultrarocessed food. They're not even food. Food is defined as something that supports the health and development and growth of an organism. Ultrarocessed food does the exact opposite. So, it technically isn't even food. We shouldn't be eating it. It looks like food, but it ain't food. Next, you know, work on your lifestyle. Exercise, building muscle, really important. I was in the gym this morning for an hour. It was really painful. My trainer was crushing me, but I know it's helping me and it helps to build muscle. It helps to lower APOB, corrects insulin resistance, your muscles become a better sink. Also, strength training is not the only thing. Cardio is also important. Learning to regulate stress because that can also affect heart disease risk. Sleep really important. All those things are really important. And just keep going, moving throughout the day. Get your steps in. Now, what about supplements? Well, I want to be really

clear here. Supplements are not one sizefits-all. They're not a replacement. They're called supplements for a reason, not placements. and you need really understand what's going on to get a personalized prescription. What you need depends on your health history, your medications you're taking, your labs, your unique biology, your genetics. Not medical advice here, but you should basically check with your doctor before starting anything new. But there's some basic principles that are pretty safe. First, you want a good high quality omega-3 fish oil triglycerides and inflammation and your blood pressure. I recommend Omega-3 rejuvenate by Big Bold Health. I'm an investor in the company transparently. is started by my mentor Jeffrey Bland who's a father of functional medicine. Extremely high quality, very pure. Really important to get the right one. Next, you want a good quality multivitamin and mineral. Cover all the gaps. Folate, zinc, magnesium. CoQ10 is also really important for heart health. Really supports mitochondria, vascular health, really helps blood pressure and mitochondria. Magnesium really important. Helps to relax your blood vessels. Helps with insulin, blood sugar regulation, heart rhythm also has helped by that. I like magnesium glycinate or if you're constipated, you can use magnesium citrate. There's also plant compounds that work really well. Fiber is great. Plant steriles also are other compounds that come from food like soy can be very helpful in lowering LDL cholesterol and just balancing your lipids. And you can get, you know, fiber as a supplement or just eat more fibrous foods, which I do. I've changed my mind about cholesterol because the science has changed. And the truth is when we look deeper, when we look at things like inflammation, insulin resistance, APOB, metabolic health, we actually are finally getting a clear picture, what really causes heart disease, it ain't cholesterol by itself. It's all these cascading factors. Here's the most important part. By understanding your numbers, by knowing what's going with your biology, you have the power to change your heart health right now. You're not really at the mercy of your genetics or your numbers. You can understand your biology. You can take charge of it. And sometimes, yeah, you might need a medication, but you can regulate everything in such a powerful way using these foundational principles. So, I'm sure you know someone who's had a heart attack or has heart disease. Please share with them. Share it with anybody who's worried about their cholesterol, who's on a statin. The more we understand the whole picture, the healthier we're all going to become, the better our societyy's going to be, and obviously we're going to lower our healthcare costs, and everybody's going to do