In my clinic, I don’t prescribe statins. That might sound shocking, but the more we learn about metabolic health, the clearer it becomes that these drugs don’t deliver on their promise for everyone with “high” cholesterol. Many people, especially those on a ketogenic diet, see their cholesterol numbers—particularly LDL—shoot up and start to panic. They hear the message that if statins aren’t the answer, then maybe they don’t have to worry about heart disease at all. Is that true? While I don’t worry about high cholesterol in the same way other doctors do, I absolutely worry about heart disease. The key is understanding that high cholesterol isn’t the disease; it’s often just a symptom. The real problem is something much more sinister: insulin resistance. Let me show you how I think through this and guide my patients back to true metabolic health. (Based on the insights of Dr. Annette Bosworth)
Key Takeaways
- Heart disease is not primarily a cholesterol problem; it’s a symptom of an unhealthy metabolism driven by chronically high insulin (insulin resistance).
- Instead of a standard lipid panel, a more advanced test called an LP-IR score provides a much better prediction of your future heart attack risk by measuring how your body handles fats.
- Activating your body’s cellular cleanup process, known as autophagy, is critical for reversing damage. This can be measured and achieved by lowering your Dr. Boz Ratio (glucose divided by ketones).
- For high-risk individuals, specific medications can act as a temporary “bridge to safety” while you work on reversing the underlying metabolic issues.
1. Reverse the Real Culprit: Insulin Resistance
Let’s start with the root cause. That high total or LDL cholesterol you see on your lab report isn’t the villain it’s made out to be. Think of those circulating fat droplets as passengers in a car. The real danger is the driver: high insulin. It’s no coincidence that heart disease and diabetes almost always show up together in a patient’s chart. So why do we treat them as separate issues, calling diabetes a “risk factor”? The truth is, they are both symptoms of the same underlying disease—an unhealthy metabolism that has been fueled by too much insulin for far too long.
Here’s how it works. Every time your blood sugar spikes (from eating carbs and sugar), your pancreas releases insulin to manage it. When this happens multiple times a day, every day, for years or decades, your insulin levels become chronically high. This state is profoundly inflammatory. Inside your blood vessels, you have a beautiful, slippery gel coating called the glycocalyx. Think of it as the Teflon lining of your circulatory system, keeping everything flowing smoothly. The constant inflammation from high insulin acts like sandpaper, eroding this protective layer.
Once that Teflon is worn off, those LDL cholesterol particles, which should be gliding by, can get stuck in the vessel walls where they don’t belong. These trapped fatty droplets trigger an inflammatory reaction, creating a sticky environment that leads to the buildup of fat and debris we call plaque. This is the start of atherosclerosis, or hardening of the arteries.
So, what should you test instead of just looking at a standard cholesterol panel? I want to know the level of insulin resistance in my patients. The best way to do that is with an LP-IR score, which stands for Lipoprotein Insulin Resistance. This advanced test uses nuclear magnetic resonance (NMR) to measure how efficiently your body delivers nutrients from those circulating fat particles and, crucially, how well it recycles them back to the liver. This process is directly and hugely impacted by insulin.
A high LP-IR score tells me your body is struggling to clear these particles, leaving them to hang around in your bloodstream for too long, where they can become damaged and cause trouble. This score predicts future heart attacks better than any other metric I can measure. For patients with an LP-IR score under 25, I can assure them their body is recycling cholesterol efficiently, leaving very little chance for it to get stuck in their arteries. Maintaining this sexy score is no easy task, but it begins with two fundamental changes: cutting your total daily carbohydrate intake down to 20 grams and compressing your eating window to less than 8 hours, making sure you finish all meals before sunset.
2. Activate Autophagy: Your Body’s Deep-Cleaning Crew
What if you already have signs of heart disease, or your LP-IR score just isn’t improving despite your best efforts? This is where we go to the next level of healing. We need to activate a powerful process called autophagy. To do this, you need to lower your Dr. Boz Ratio.
The Dr. Boz Ratio is a simple calculation you can do at home: just take your morning blood glucose reading and divide it by your morning blood ketone reading. This ratio simplifies the more complex Glucose Ketone Index (GKI) and gives you a real-time snapshot of how much insulin your body is making. A low ratio means low insulin. For healing deep metabolic problems like heart disease, you want to aim for a ratio under 40, first thing in the morning.
But how do you get there? You need to simultaneously lower your blood sugar and raise your ketones. This is where the real work begins. Don’t guess—measure. Get a simple blood meter that checks both glucose and ketones, and test yourself with a finger prick right when you wake up. Spoiler alert: if you have serious health issues and truly want to move the needle, you will need to use powerful tools to get your numbers into that therapeutic range. For many of my insulin-resistant patients, a “sardine fast” for a few days works far better than a traditional water-only fast. By day three of eating only sardines, you will be well on your way to healing as your ketones rise and glucose falls.
The ultimate goal of this work is to activate autophagy. The word literally means “to eat thyself” in Greek. Think of it as your body’s internal housekeeping service. In patients with high insulin, cells are constantly stuck in “growth mode.” The problem is that unhealthy, damaged cells grow right along with the healthy ones. Autophagy flips the switch from growing to repairing. Your cells begin to clean house, consuming old, damaged parts and clearing out the inflammatory garbage that has been building up for decades. This is how you truly reverse the damage.
Ketones are only half of the puzzle. Getting your morning fasting glucose under 100 mg/dL is a struggle for many of my patients, but getting it consistently under 80 mg/dL is where I see them reaching a state of autophagy most days of the month. Don’t be discouraged. This is a step-by-step process. Your body will adapt to each improvement you make. The goal is to make slow, steady progress that you can sustain.
3. Bridge to Safety: A Smart Use of Medication for High-Risk Cases
Now, let’s talk about the worst-case scenario. There are people who do everything right—they follow the diet, they fast, they exercise—and their numbers still aren’t where they need to be. This also applies to my high-risk patients, those who have already had a heart attack, a stroke, or have had a stent placed. It is critical to understand that I am not anti-medication; I am pro-getting-people-healthy. For these individuals, we can use powerful medical tools to act as a “bridge to safety” while their body is healing from the underlying metabolic dysfunction.
So, what’s my checklist for considering medication? First, I need clear evidence that the body is not recycling fats well. I need proof that LDL particles are hanging out in the circulation for too long, becoming oxidized (damaged) and dangerous. In these serious cases, I consider two main types of drugs, neither of which are statins.
The first is a medication called ezetimibe (brand name Zetia). This drug works by reducing cholesterol absorption in your intestines. It specifically binds to the cholesterol found in your bile, preventing your body from reabsorbing and recycling it as it normally would. For some patients, this can lower their numbers dramatically by forcing the body to clear more cholesterol from the blood.
The second is a class of injectable drugs called PCSK9 inhibitors (like Repatha). To understand how these work, you need to picture your liver. In a state of chronic high insulin, the liver often becomes a “fatty liver,” stuffed with fat, glycogen, and triglycerides. As a consequence, the number of LDL receptors—think of them as “catcher’s mitts” for pulling LDL out of the blood—dwindles dramatically. There’s just no more room on the liver’s surface for them. A protein called PCSK9 is responsible for destroying these catcher’s mitts. Drugs like Repatha block the PCSK9 protein, stopping this destruction. With more catcher’s mitts on duty, the liver can pull a massive amount of LDL out of the bloodstream, often dropping levels by 50% or even 60%. This provides a powerful safety net, buying us the precious time we need to reverse the underlying metabolic disease for good.
Your Path to True Heart Health
The conversation around heart disease has been dominated by cholesterol for far too long. While cholesterol plays a role, it is not the primary driver of the disease. By shifting your focus away from a single number on a lab report and toward your overall metabolic health, you can take back control. Reversing insulin resistance, activating your body’s natural repair processes through autophagy, and, when necessary, using targeted medications as a temporary bridge are the key steps on the path to lasting wellness. This approach empowers you to address the root cause of heart disease, ensuring you’re not just managing symptoms but building a foundation for a long and healthy life.
Source: Dr. Annette Bosworth