For the first half of my career as a heart surgeon, I was heading toward becoming one of my own patients.
I had struggled with my weight since childhood. I became morbidly obese. My hemoglobin A1c reached 5.9, putting me in the pre-diabetic range. And despite spending my career treating people with advanced heart disease, the advice I had been trained to give them wasn’t working for me either.
Eat less. Move more. Avoid fat. Lower your cholesterol.
I eventually had to confront a difficult question: What if we were focusing on the wrong things?
My own health transformation started somewhat unexpectedly. I went gluten-free with my wife, began losing weight, and then heard Gary Taubes speak at a Society of Thoracic Surgeons meeting.
That sent me down a path that completely changed how I think about heart disease.
I ultimately lost 100 pounds, reversed my pre-diabetes, and became healthier in my 50s than I had been in my 30s.
More importantly, I began to recognize what I believe we are missing in far too many patients with cardiovascular disease: metabolic dysfunction and insulin resistance.
I recently joined Dr. Jeffrey Gladden on the Gladden Longevity Podcast to discuss why preventing heart disease requires a different paradigm, and why waiting for clogged arteries before taking action is already far too late.
What we get into
- How I went from morbidly obese and pre-diabetic to losing 100 pounds
- Why insulin resistance changed the way I think about cardiovascular disease
- Why cholesterol is only one piece of a much larger heart health picture
- How metabolic dysfunction can damage the endothelium and contribute to atherosclerosis
- Why heart surgery and stents can save lives without addressing why disease developed
- What hospitals continue to get wrong about nutrition and metabolic health
- How Cleerly and AI-enhanced coronary CT angiography are changing cardiovascular screening
- Why identifying and tracking plaque earlier could transform heart disease prevention
- What I want every patient to understand after heart surgery
Cholesterol isn’t the whole story
One of the biggest disagreements I have with the conventional approach to cardiovascular disease is the amount of attention given to cholesterol in isolation.
Cholesterol matters. But I don’t believe it tells us the whole story of why someone develops heart disease.
Before cholesterol becomes involved in an atherosclerotic plaque, important changes have already taken place in the vascular system. The glycocalyx and endothelium, the protective structures lining our blood vessels, can become dysfunctional and damaged.
Insulin resistance can contribute to that environment through multiple pathways.
It can impair endothelial function, reduce nitric oxide availability, increase inflammation, and contribute to changes in the cells of the vascular wall.
That is why I believe metabolic health needs to be part of the conversation when assessing cardiovascular risk.
If we only look at cholesterol, we risk overlooking the conditions that may have allowed cardiovascular disease to progress in the first place.
Heart surgery doesn’t fix heart disease
Heart surgery saves lives.
I know that firsthand because I have spent decades performing it.
Stents save lives too. These interventions are essential when someone has advanced cardiovascular disease or is experiencing an acute event.
But there is an important distinction between treating the consequences of disease and addressing why the disease developed.
When I perform bypass surgery, I can restore blood flow around a blockage. I cannot surgically remove the metabolic dysfunction that may have contributed to that patient’s disease over the previous 10, 20, or 30 years.
That work has to happen elsewhere.
Unfortunately, our healthcare system often waits until patients reach the operating room before treating cardiovascular disease with the seriousness it deserves.
I have watched patients eat pancakes while receiving an insulin drip in the hospital.
Think about that contradiction.
We are using medication to control a patient’s blood glucose while simultaneously giving them food that can send it higher.
That is one example of why I have come to view every patient who reaches my operating table as, in some sense, a failure of our healthcare system.
We should have intervened years earlier.
We need to find heart disease before symptoms appear
One of the most exciting parts of my conversation with Dr. Gladden was our discussion about advances in cardiovascular imaging.
For decades, one of the problems with heart disease has been our inability to easily see exactly what is happening inside the coronary arteries before someone becomes symptomatic.
That is beginning to change.
Technologies such as Cleerly use AI-enhanced analysis of coronary CT angiography to characterize and quantify coronary plaque.
Instead of simply asking whether an artery looks blocked, we can potentially get a much more detailed picture of plaque burden and composition.
That matters because cardiovascular disease develops over decades.
If we can identify disease earlier and measure how it changes over time, we have an opportunity to shift the conversation from crisis management toward actual prevention.
Rather than waiting for chest pain, a heart attack, a stent, or bypass surgery, we can ask a much better question:
What can we do today to keep you from ever reaching that point?
The goal is to stay off the operating table
My first book, Stay Off My Operating Table, grew directly from what I had learned through my own transformation and from treating thousands of patients with cardiovascular disease.
My second book, Stay Off My Kitchen Table, takes that message into the place where many of our daily health decisions are made: the kitchen.
I give these books to my patients after surgery for a simple reason.
I don’t want to see them in my operating room again.
Surgery may give someone another opportunity, but what they do with that opportunity matters.
Improving metabolic health means looking beyond one cholesterol number. It means understanding blood sugar regulation, insulin resistance, body composition, nutrition, movement, sleep, and the other factors that influence cardiovascular health long before a crisis occurs.
We have incredible technology for treating advanced heart disease.
Now we need to become equally serious about preventing people from needing that technology in the first place.
That is the paradigm shift.