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

Dr. Hyman strongly advocates for a comprehensive panel of tests that go beyond the typical total cholesterol and LDL measurements. He emphasizes that these standard tests only provide a 'weight' of cholesterol, not the crucial details about particle number, size, and quality. The recommended tests include ApoB, which is a surrogate marker for poor metabolic health and indicates the number of damaging cholesterol particles. Lipoprotein(a) or Lp(a) is a genetic marker affecting 20% of the population and is an independent risk factor. High-sensitivity C-reactive protein (HSCRP) measures inflammation, a key driver of heart disease. Fasting insulin is critical for assessing insulin resistance, which he considers one of the most important tests for health and longevity, yet it's rarely ordered. He also recommends lipoprotein fractionation to analyze LDL particle size and number, and the triglyceride-to-HDL ratio as a simple indicator of insulin resistance. Finally, a calcium score is suggested as a baseline imaging test to directly check for plaque development in arteries.

Dr. Hyman unequivocally states that sugar and refined starches are the 'boogeyman,' not fat, when it comes to heart disease. He explains that these carbohydrates lead to insulin resistance, which in turn drives inflammation and the production of small, dense LDL particles. He defines 'sugar' broadly to include anything with sugar or starch, such as bread, rice, and potatoes, especially for susceptible individuals. He notes that 60% of American calories come from junk food, and the average American consumes a pound of sugar and flour daily. This excessive intake promotes the deposition of visceral fat (belly fat), which is metabolically active and spews out inflammatory compounds, further oxidizing LDL and damaging blood vessels. He advises treating sugar like a 'recreational drug' due to its detrimental effects.

Beyond simply cutting out sugar and starches, Dr. Hyman emphasizes the importance of actively consuming a diet composed of whole, unprocessed foods. This includes a wide variety of colorful fruits and vegetables, which are rich in antioxidants and anti-inflammatory compounds. He also advocates for 'good fats,' aligning with his view that dietary fat is not the primary problem. The goal is to create an anti-inflammatory, low-glycemic eating pattern that supports overall metabolic health. He explicitly states that ultra-processed foods are 'not even food' because they do not support health and should be eliminated.

Dr. Hyman highlights exercise as a critical lifestyle intervention. He specifically mentions strength training, noting his own commitment to it despite the difficulty, because it helps build muscle. Muscle acts as a 'sink' for glucose, improving insulin sensitivity and lowering ApoB levels. He also stresses that cardio exercise is important, indicating a balanced approach to physical activity is beneficial for heart health and metabolic regulation. Regular movement throughout the day, including getting steps in, is also encouraged.

Dr. Hyman highly recommends using a continuous glucose monitor (CGM), even if only for a short duration. He believes CGMs are invaluable tools for understanding one's unique metabolic response to various foods. By observing how blood sugar levels fluctuate after eating specific items, individuals can identify which foods cause spikes and which are well-tolerated. This personalized feedback empowers people to modify their diet effectively, moving beyond generic advice to make choices that are optimal for their own body's physiology. He states that this real-time data is a much better predictor of heart disease risk than a static blood sugar measurement.

Dr. Hyman explains that his own understanding of cholesterol and heart disease has evolved significantly. He was initially trained, like most doctors, to believe that high LDL directly caused heart attacks and that lowering it was the primary goal. However, clinical experience and emerging research have revealed a more nuanced picture. He points out that nearly half of people who have heart attacks have 'normal' LDL levels, and a study of 136,000 ER patients found 75% had normal LDL. This discrepancy led him to question the prevailing paradigm. He now views cholesterol as a 'bystander' in a process primarily driven by metabolic and inflammatory issues, rather than the root cause itself.

Dr. Hyman asserts that the real problem causing the heart disease epidemic is metabolic dysfunction, which encompasses prediabetes and insulin resistance. This condition arises from diets high in starch and sugar, lack of exercise, and excess belly fat. Insulin resistance leads to 'atherogenic dyslipidemia,' characterized by small, dense cholesterol particles that are prone to oxidation and inflammation. These small, dense particles, rather than cholesterol itself, are what damage artery linings and form plaque. He cites research showing that inflammation, measured by HSCRP, can be a more important predictor of heart disease than LDL. The primary driver of this inflammation, he argues, is the modern diet rich in sugar and refined starches, which constitute 60% of American calories.

Dr. Hyman criticizes the standard cholesterol tests, stating that they only measure the 'weight' of cholesterol (e.g., LDL-C) but fail to provide crucial information about the number, size, and quality of cholesterol particles. He explains that small, dense LDL particles are far more atherogenic than large, fluffy ones, and the standard test doesn't differentiate. He advocates for tests like ApoB, which he has been using for over 30 years and which cardiology guidelines are finally recognizing as a causal factor. Lp(a) is another critical genetic marker affecting 20% of the population. Fasting insulin and HSCRP (high-sensitivity C-reactive protein) are also vital for assessing insulin resistance and inflammation, which are the true underlying drivers of heart disease. He co-founded Function Health to provide access to these comprehensive tests, as they are rarely ordered by conventional doctors.

Dr. Hyman introduces the concept of TOFI, or 'Thin Outside, Fat Inside,' also known as 'skinny fat.' This refers to individuals who appear to be at a healthy weight based on their BMI but have a poor body composition, meaning they carry excessive body fat, especially visceral fat around their organs, and insufficient muscle mass. He states that 20% of normal-weight individuals exhibit insulin resistance, putting them at the same elevated risk for heart disease as those who are obese. This phenomenon highlights that metabolic health is not solely determined by external appearance or BMI, but by internal body composition and metabolic function.