Metabolic health is a better predictor of heart disease risk than LDL

The woman is holding a red heart.

A new study published online at JAMA Cardiology reports that metabolic markers are much better predictors of heart disease risk than low-density lipoprotein (LDL) cholesterol.

The study was an observational analysis of over 28,000 women followed for 21 years in the Women’s Health Study. The authors found the factors that best predicted the risk of future heart disease were type 2 diabetes, metabolic syndrome, high blood pressure, obesity, and smoking.

Usually, we don’t get too excited about observational studies because they often involve methods for collecting food intake information that are unreliable, and the studies can’t control for baseline differences between the individuals.

This means the data is of low quality and can’t provide meaningful information about cause and effect.

However, this study is not attempting to link diet to disease. Additionally, its impressive hazard ratios make it more likely that the identified relationships are reliable ones.

A hazard ratio reports how much more likely something occurs in one group compared to another. If the hazard ratio is less than two, we consider it weak or very weak evidence, depending on other methodological issues with the study.

In this case, the hazard ratios for risk of developing future heart disease are as follows:

  • Type 2 diabetes: 10.7
  • Metabolic syndrome: 6.0
  • High blood pressure: 4.5
  • Obesity: 4.3
  • Smoking: 3.9

As for blood tests, this study reports a lab measurement for insulin resistance, called the lipoprotein insulin resistance test (LPIR).

Of the laboratory tests studied as predictors of heart disease, the LPIR had the highest hazard ratio at 6.4. Triglycerides had the next highest hazard ratio at 2.1, then Apo B at 1.8, and finally, LDL cholesterol with the lowest level of 1.6.

These results suggest metabolic markers are more critical for predicting future heart disease than traditional cholesterol measurements like ApoB and LDL.

Studies like these may help clinicians focus more intensely on metabolic health as the first-line treatment for cardiac prevention.

However, as we describe in our guide on treating insulin resistance, we don’t have drugs approved for treating insulin resistance or metabolic syndrome. Instead, lifestyle interventions are the answer.

Many dietary approaches that lead to sustained weight loss could improve metabolic health. However, low-carb diets appear to be the most effective at reducing triglycerides, improving diabetes, and reversing metabolic syndrome — even without weight loss.

Studies such as this one make one thing clear: We need to focus on metabolic health to reduce our heart disease risk. It is time to break away from our narrow focus on LDL and start taking care of all the risk factors that matter.

Thanks for reading,
Bret Scher MD FACC


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