For most of my career as a heart surgeon, cardiovascular risk was framed largely around cholesterol. Watch your LDL. Eat less fat. Take a statin when necessary.
But after 25 years of operating on people with advanced heart disease, I’ve come to believe we need to look much earlier and much deeper.
Today, I’m routinely seeing patients in their 40s and even their 30s who need heart surgery. The disease that brought them to my operating table did not appear overnight. In many cases, the warning signs had been developing for decades.
And many of those warning signs are metabolic.
I recently joined Dr. Mariza Snyder on the ENERGIZED with Dr. Mariza Podcast to talk about what women should understand about metabolic health, insulin resistance, cholesterol, and cardiovascular risk, particularly as they enter perimenopause and menopause.
Heart disease starts long before symptoms appear
One of the most important messages I want people to understand is that it is never too early to start thinking about heart health.
By the time someone experiences chest pain, has a heart attack, or needs bypass surgery, the underlying disease process has often been progressing for years.
That is why I encourage people to pay attention to metabolic health before cardiovascular disease becomes obvious.
Insulin resistance is one of the biggest pieces of this puzzle. Long before blood sugar reaches the threshold for diabetes, the body can begin showing signs that it is struggling to process and use energy effectively.
Those signs can include increasing blood pressure, a growing waist circumference, elevated fasting insulin and glucose, higher triglycerides, and lower HDL.
Looking at these markers together can tell us much more about metabolic health than focusing on a single cholesterol number.
What women should watch during midlife
This becomes especially important for women entering perimenopause and menopause.
Hormonal changes can influence body composition, insulin sensitivity, blood sugar regulation, and other aspects of cardiometabolic health. That makes midlife an important time to establish your baseline and start tracking changes.
Blood pressure is a good example. Rather than simply waiting until your blood pressure crosses a diagnostic threshold, know what is normal for you. A meaningful increase from your usual baseline can be information worth paying attention to, even if the number has not yet reached the traditional definition of hypertension.
The same principle applies to blood sugar.
Fasting glucose and A1C are useful, but fasting insulin can sometimes reveal metabolic dysfunction earlier. If the body needs to produce increasingly large amounts of insulin to keep glucose under control, that can be an important warning sign.
Cholesterol is only one piece of the picture
We also talked about one of the most controversial subjects in heart health: cholesterol.
Cholesterol matters, but I do not believe it should be treated as the primary driver of cardiovascular disease or viewed in isolation.
A more complete assessment considers cholesterol alongside metabolic health, inflammation, insulin resistance, blood pressure, body composition, lifestyle, family history, and evidence of disease actually developing in the arteries.
Advanced lipid testing can provide additional information, but the goal should always be to understand the person rather than chase a single laboratory value.
For appropriate patients, imaging can add another layer of information. A coronary artery calcium scan, for example, can help identify calcified plaque in the coronary arteries and provide evidence about whether coronary atherosclerosis is already present.
That is a conversation worth having with your healthcare provider based on your age, history, symptoms, and individual risk.
Build metabolic health before you need heart surgery
The encouraging part of this conversation is that many of the things that support metabolic health are within your control.
Prioritize real, nutrient-dense food. Build and maintain muscle through resistance training. Protect your sleep. Stay physically active. Pay attention to how your food choices affect your blood sugar and energy.
Muscle becomes particularly important as we age because it is metabolically active tissue and plays an important role in glucose regulation and insulin sensitivity.
Technology can also help you understand what is happening inside your body.
A continuous glucose monitor, or CGM, gives you real-time feedback about how meals, exercise, sleep, stress, and other behaviors affect your glucose. You do not necessarily need to wear one forever. Even using one for a limited period can help you identify patterns that would otherwise be difficult to see.
Heart disease does not begin the day you have a heart attack.
Your body may be giving you clues years or even decades earlier.
The sooner you learn to recognize those clues and improve your metabolic health, the better chance you have of staying off my operating table.
What we get into
- Why I believe insulin resistance deserves more attention in heart disease prevention
- Five basic metabolic markers women should be tracking
- Why knowing your personal blood pressure baseline matters
- What fasting insulin can reveal before blood sugar becomes obviously abnormal
- Why cholesterol alone does not provide the complete picture of cardiovascular risk
- How perimenopause and menopause can affect cardiometabolic health
- Why muscle and resistance training become increasingly important with age
- What continuous glucose monitors can teach you about food, energy, and blood sugar
- How advanced lipid testing can provide additional cardiovascular information
- When to discuss coronary artery calcium imaging with your healthcare provider
- Why improving metabolic health today can help protect your heart for decades to come