Healthy Living Blog: The Truth About Statins, LDL, and Heart Disease Risk That Most Cardiologists Won’t Tell You with Dr. Philip Ovadia

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Have you ever sat across from a doctor who told you your cholesterol was too high, handed you a prescription, and sent you on your way feeling more scared than informed? You are not alone. This is one of the most common experiences women in midlife share with me, and honestly, it is one that has been deeply personal for me too.

My own father died of a heart attack at 49. No warning. He was not overweight. He did not drink or smoke. And I have carried those genetic markers with me my entire life, including a genetically elevated LDL that has sent me down the rabbit hole of conflicting advice more times than I can count. Do I take statins? Do I avoid saturated fat? Is it Repatha? Is high LDL even the problem?

Heart disease remains the number one killer of women, yet the information we are given is often incomplete, fear-based, and focused almost entirely on one number: LDL cholesterol. After interviewing multiple cardiologists on this show, I knew I needed to bring on someone with a unique vantage point. Someone who has quite literally seen the inside of more than 3,000 human hearts and walked away asking, “Why are these people here?”

Dr. Philip Ovadiaia is a board-certified cardiothoracic surgeon, author of Stay Off My Operating Table and the forthcoming Stay Off My Kitchen Table, and a man who was nearly 100 pounds overweight while operating on other people’s hearts. His personal and professional transformation led him to question everything he had been taught and to start asking better questions about what actually drives heart disease. This conversation shifted my perspective, and I think it will shift yours too.

The Wake-Up Call That Changed How a Heart Surgeon Thinks

Early in Dr. Ovadiaia’s career, his mentors told him that heart disease was essentially going to be solved in 20 years. We had statins. The problem was on its way out. He went into the field anyway, and 25 years later, there is actually a shortage of heart surgeons in this country. Heart disease is not getting better. It is getting worse.

At the same time, Dr. Ovadiaia was living in his own body what he was watching happen to his patients. Following every piece of conventional dietary advice, eating low fat, tracking calories, moving more, he became morbidly obese and prediabetic. The advice was not working for him and it was not working for the people on his operating table.

That collision between his personal struggle and his professional observations sent him searching for different questions. What he found reshaped not just his body, which he transformed by switching to a low-carb, ultimately carnivore-leaning approach, but his entire framework for understanding heart disease.

Why LDL Cholesterol Is Not the Whole Story

Here is where this conversation gets important, especially for women in midlife who have been told their LDL is too high and handed a prescription.

Dr. Ovadiaia explains that not all LDL is the same. LDL is actually a family of particles that range from small to large in size. Small LDL particles are what we call atherogenic. They get involved in arterial plaque. Large LDL particles are not. When your doctor looks at a standard lipid panel and tells you your LDL is high, they have no idea whether that LDL is predominantly the small, problematic kind or the large, benign kind.

This matters enormously because you can have a high overall LDL with mostly large particles and essentially no meaningful risk, while someone with a low LDL made up primarily of small particles is absolutely at risk and often ends up on his operating table despite their doctor’s confidence that their numbers look great.

The test that actually tells you this is called an advanced lipid panel, and it includes particle size analysis. Most doctors are not running it. Most doctors are not even discussing it.

What Actually Creates Small, Dangerous LDL Particles

This is the part that changes everything. The reason your particles skew small and dangerous is not your LDL number. It is insulin resistance and inflammation.

When you reverse insulin resistance, when your A1C comes down and your metabolic health improves, those small particles become large particles. Dr. Ovadiaia sees this consistently in his practice. The shift is not rare or unpredictable. It is, in his words, almost universal. And I can speak to this personally: when my own A1C dropped from 5.7 to 4.9, my particle size changed. The LDL number stayed the same, but the type of LDL shifted in a protective direction.

This is why Dr. Ovadiaia says insulin resistance is a far bigger risk factor for heart disease than elevated cholesterol. He reviewed every study comparing the two, and insulin resistance wins as the driver every time. The difference is we do not have a simple pill that fixes insulin resistance, so it does not get the same attention. What does fix it is how you eat and how you live.

The Real Truth About Statins

Dr. Ovadiaia is not categorically anti-statin, and that nuance is worth understanding. Statins do provide some benefit. However, the way that benefit gets communicated to patients is where the problem lies.

The statistic you are almost never told is the difference between relative risk reduction and absolute risk reduction. Statins are presented as reducing heart disease risk by 30 to 40 percent. That figure is relative risk reduction. The absolute risk reduction, the actual difference in your individual odds of a heart attack, is closer to 1 to 4 percent. Those are very different numbers, and patients deserve to know both.

Beyond the overstated benefit, there is a significant side effect that rarely gets enough emphasis. After approximately three years of statin use, the risk of developing insulin resistance and type 2 diabetes increases considerably. Given that insulin resistance is the primary driver of heart disease, this is a deeply concerning trade-off that most patients are never walked through.

There is also a structural irony in how statins work: they disproportionately lower large LDL particles compared to small ones. So a patient on statins may have an LDL number that looks perfectly managed while still carrying a predominance of the small, dangerous particles that lead to plaque. This is why Dr. Ovadiaia routinely sees patients who have been on statins for decades, whose numbers have been “in range” the entire time, and who still end up needing surgery.

Is there ever a situation where statins make sense? Yes. If a patient is insulin resistant, has significant inflammation, and is not willing or able to address those things through diet and lifestyle, a statin does offer a modest benefit. But that conversation should happen with full transparency about both the benefit and the risk, and it should never be the first and only tool on the table.

Other Cholesterol Medications: What You Need to Know

Several other medications come up frequently in conversations about cholesterol management, and Dr. Ovadiaia walked through each one.

Ezetimibe (Zetia) works differently from statins. Rather than reducing cholesterol production in the liver, it blocks cholesterol absorption in the intestines. Its effect on overall cholesterol levels is generally weaker than statins, which is why it is often prescribed alongside another medication. However, because dietary cholesterol has very little impact on blood cholesterol levels, its usefulness is limited for most people. One exception is a specific group called lean mass hyper-responders, people who see a significant rise in cholesterol when eating saturated fat. For those individuals, ezetimibe may actually be more effective than a statin because it targets the dietary pathway driving their response.

PCSK9 inhibitors like Repatha are injectable medications that dramatically lower LDL by increasing the liver’s ability to reabsorb LDL particles. In the major clinical trial that led to their approval, LDL levels dropped by 70 to 90 percent in some patients. However, there was no difference in overall mortality between the treatment and placebo groups, and there were actually numerically more deaths in the treated group (though this did not reach statistical significance). Crucially, when researchers analyzed only the metabolically healthy patients in the study, those who were not insulin resistant, the medication showed no benefit at all. This reinforces the core message: cholesterol is not the root problem. Insulin resistance is.

The Heart Health Tests That Actually Matter

If your doctor is only running a standard lipid panel and telling you your LDL number, you are getting an incomplete picture. Dr. Ovadiaia recommends a more thorough approach.

Advanced lipid panel with particle size testing tells you whether your LDL is predominantly large (non-atherogenic) or small (atherogenic). This is far more informative than total LDL or even ApoB, which suffers from the same limitation of not telling you particle quality.

Coronary artery calcium (CAC) scan is what Dr. Ovadiaia calls the mammogram for the heart. It directly shows whether plaque is forming in your arteries, which is ultimately what we care about. If your LDL is elevated but your CAC scan is zero, that is meaningful reassurance. If it is not zero, the conversation becomes much more targeted. For women over 50 with a zero score, he recommends repeating every three to five years. With a non-zero score, he wants to see a repeat in a year to assess the trajectory.

CT angiogram (CLEARLY) shows both calcified and soft (non-calcified) plaque and provides more detail than the CAC scan, though it involves more radiation and higher cost. For most people with a zero CAC score, soft plaque is unlikely to be clinically significant, so this test is not always necessary.

Carotid intimal medial thickness (CIMT) scan is an ultrasound-based test that looks at plaque in the neck arteries. It is inexpensive, involves no radiation, and can sometimes be done at home. It offers complementary information but is more operator-dependent than other tests, meaning results can vary based on how the technician performs the scan.

The metabolic health markers Dr. Ovadiaia considers the five core measures of metabolic health are: fasting blood glucose, triglycerides, HDL cholesterol, waist circumference, and blood pressure. High triglycerides and high blood pressure are both fundamentally rooted in insulin resistance. A useful ratio to track is triglycerides to HDL. A lower ratio indicates better insulin sensitivity, while a higher ratio signals insulin resistance.

Inflammation markers including C-reactive protein, myeloperoxidase (MPO), and homocysteine are deeply underutilized in conventional cardiology. MPO in particular has meaningful connections to dental infections and chronic inflammation sources that doctors rarely connect to heart health.

How to Eat for Heart Health: Finding the Middle Ground

This is where Natalie pushed back with real nuance, and the conversation that followed was honest and worth sitting with.

Dr. Ovadiaia comes down heavily on the side of real, unprocessed food as the foundation, a position that cuts across the carnivore-versus-vegan debate. He and Dr. Joel Kahn, a prominent vegan cardiologist, agree on this: processed food, processed carbohydrates, and processed seed oils are the problem. The science on fat, which for decades was treated as the enemy, has not held up. The low-fat experiment ran for seventy years, population health worsened, and it is time for a different framework.

On the carnivore side of the ledger, Dr. Ovadiaia argues that animal products, including animal fats, are essential to the human diet, that we evolved eating them, and that fears about saturated fat driving harmful outcomes are largely rooted in the same misinterpreted science that gave us the statin obsession. He is personally carnivore-leaning, eating mostly ground beef, eggs, cheese, and seafood, with occasional vegetables or fruit.

On fiber, his position is nuanced. Fiber has shown benefit in studies largely because it substitutes for processed food. In the context of a low-carb or carnivore diet, fiber is not essential, and people on carnivore diets often move their bowels less frequently because their bodies are absorbing more of what they eat and producing less waste. This is different from constipation.

On the middle ground, his guidance is clear and affirming: if your metabolic markers look good, if you are not insulin resistant, your inflammation is low, and your plaque is stable, keep doing what is working. That might be mostly meat with a generous serving of vegetables and olive oil. That is not wrong. Bio-individuality matters.

The GLP-1 Shift and What It Tells Us

One of the most telling pieces of evidence that insulin resistance, not cholesterol, is the real driver of heart disease comes from GLP-1 medications. These medications, which have exploded in use for weight loss, have been shown in studies to reduce heart disease risk. They do not lower LDL. They actually tend to raise it slightly. And yet heart outcomes improve.

Why? Because GLP-1 medications target insulin resistance. This is beginning to shift the conversation in cardiology toward the right underlying mechanism, which is where the conversation has needed to be for decades.

What to Do If Your Doctor Isn’t Serving You

Perhaps the most important piece of advice Dr. Ovadiaia shares comes at the end of the conversation: if your doctor is not empowering you to understand your own health, find a new one.

Most doctors are not dismissing patients out of malice. They are practicing within a system that has given them a specific set of tools and told them to use them in a specific sequence. When a number is out of range, the system says prescribe. But you, the patient, are not trapped in that system. You have the ability to ask for advanced testing. You have the ability to ask what is causing the problem rather than just accepting a prescription. You have the ability to find a provider who practices metabolic medicine and will look at insulin resistance, inflammation, and particle quality alongside the standard numbers.

Push back. Ask why. Look for a doctor who welcomes the question rather than shutting it down.

 

The contents of the Midlife Conversations podcast is for educational and informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always consult with a qualified healthcare provider. Some episodes of Midlife Conversations may be sponsored by products or services discussed during the show. The host may receive compensation for such advertisements or if you purchase products through affiliate links mentioned on this podcast.

The post The Truth About Statins, LDL, and Heart Disease Risk That Most Cardiologists Won’t Tell You with Dr. Philip Ovadia appeared first on Natalie Jill Fitness.

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