Fellow physicians,

For decades, we’ve relied on LDL as the primary marker for assessing cardiovascular disease (CVD) risk. However, recent research and patient outcomes are prompting us to reconsider this approach. Cardiovascular health is multifaceted, and addressing root causes rather than singular markers like LDL can guide us to better patient outcomes, particularly in our current environment of rising metabolic and liver disease.

1. GLP-1 Medications: A Bridge, Not a Solution

While medications like Rybelsus (a GLP-1 receptor agonist) offer short-term weight-loss benefits, they come with limitations. Long-term use is costly and can bring side effects such as nausea, diarrhea, and gallbladder issues. Our patients may be drawn to the “quick fix,” but as we know, sustainable health often demands a lifestyle overhaul.

GLP-1s should be viewed as a temporary tool—a way to kick-start weight loss and motivate patients while emphasizing that lifestyle adjustments provide a sustainable path. Ideally, these medications serve as a bridge to instill healthier habits rather than a permanent solution.

2. The Real Culprit: Insulin Resistance and NAFLD

While elevated LDL is traditionally seen as a red flag for CVD, the underlying issue for many patients is actually insulin resistance. Insulin resistance is at the heart of metabolic syndrome, which drives non-alcoholic fatty liver disease (NAFLD)—a condition increasingly common, even among adolescents.

By focusing on insulin resistance rather than LDL alone, we tackle the metabolic issues that lead to NAFLD. Evidence shows that low-carb diets like keto can reverse fatty liver by lowering triglycerides and reducing liver fat, often leading to improved liver enzyme levels and overall liver health.

3. Better Metrics for Cardiovascular Health: TG/HDL Ratio and LDL Particle Size

Assessing cardiovascular risk requires a broader perspective. Rather than fixating on LDL, consider the triglyceride-to-HDL (TG/HDL) ratio—a stronger indicator of metabolic health. A lower TG/HDL ratio typically correlates with better heart health. Studies have shown that keto and low-carb diets improve this ratio by raising HDL and lowering triglycerides.

Additionally, while LDL levels may not change dramatically on a low-carb diet, LDL particles often shift to a larger, safer size, further reducing cardiovascular risk. These changes are more predictive of positive outcomes than LDL levels alone.

Moving Forward: An Integrated Approach to Patient Health

Incorporating GLP-1s can help patients get started, but it’s lifestyle modifications that will sustain them. Addressing insulin resistance with targeted lifestyle changes like low-carb eating can help reverse NAFLD, improve metabolic health, and reduce the risk of CVD.

Our role is to guide patients not only toward initial success but also to long-term, sustainable health. By shifting the focus from LDL to insulin resistance, we can empower them to achieve better outcomes and transform their health for the future.