When it comes to heart disease prevention, most of the conversation revolves around one number: LDL cholesterol.
We’ve been told that LDL clogs arteries like grease in a pipe — and that lowering LDL is the key to preventing heart attacks.
But what if LDL isn’t the strongest predictor of heart disease risk?
Let’s look at what the evidence actually shows.
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The LDL Paradox
In a study of over 136,000 people hospitalized with coronary artery disease, nearly half had LDL cholesterol below 100 mg/dL — a level considered normal by most guidelines.
Even more striking:
Nearly 18% had LDL below 70 mg/dL.
Among people experiencing their first heart event, over 40% had LDL under 100.
These weren’t people with sky-high cholesterol finally facing consequences. Many had LDL levels that would be considered ideal.
This doesn’t mean LDL is irrelevant. It does contribute to risk.
But it’s clearly not the whole story.
The Real Driver: Insulin Resistance
When researchers compare biomarkers side by side, insulin resistance consistently outperforms LDL cholesterol as a predictor of cardiovascular disease — especially premature heart disease.
In a long-term study following nearly 28,000 individuals:
Markers of insulin resistance were associated with a greater than 6-fold increased risk of premature heart disease.
LDL cholesterol, by comparison, showed only about a 1.4-fold increase in risk.
Type 2 diabetes — the most severe form of insulin resistance — was associated with a 10-fold increased risk in younger individuals.
Metabolic syndrome — high triglycerides, low HDL, elevated blood pressure, abdominal obesity — carried roughly a 6-fold increased risk.
These metabolic markers were in an entirely different league compared to LDL alone.
A Simple Marker You Can Check Today
There’s one number that often predicts metabolic risk better than LDL cholesterol:
The Triglyceride-to-HDL Ratio
Triglycerides ÷ HDL cholesterol
Using mg/dL units:
- Above 2 suggests metabolic dysfunction
- Above 3 is a significant red flag
- Around 3.5 or higher strongly suggests insulin resistance
Why does this ratio matter?
Because insulin resistance drives triglycerides up and HDL down. This ratio reflects the underlying metabolic environment — not just cholesterol transport.
Multiple studies show this ratio predicts cardiovascular events more powerfully than LDL in many populations.
What About Statins?
Statins do lower LDL. And they can modestly reduce cardiovascular events.
But in primary prevention (people who have never had a heart attack), you often need to treat 60 to 100+ people for five years to prevent one event.
This doesn’t mean statins have no role. It means lowering LDL addresses only one contributor — and perhaps not the strongest one.
If insulin resistance remains unaddressed, cardiovascular risk may persist even when LDL is well controlled.
What This Means for You
If your goal is protecting your heart, don’t just ask:
“What’s my LDL?”
Also ask:
- What’s my triglyceride-to-HDL ratio?
- Do I have signs of insulin resistance?
- Is my fasting insulin elevated?
- Do I meet criteria for metabolic syndrome?
Metabolic dysfunction is often the stronger predictor of cardiovascular disease — especially in younger individuals.
Improving insulin sensitivity through:
- Reducing refined carbohydrates
- Improving diet quality
- Increasing physical activity
- Prioritizing sleep
- Achieving healthy body composition
…addresses the root metabolic drivers in ways that LDL reduction alone cannot.
The Bottom Line
LDL cholesterol matters.
But metabolic health matters more.
Heart disease is not simply a cholesterol problem — it is very often a metabolic problem.
If we shift our focus from being LDL-centric to metabolism-centric, we move closer to addressing the true drivers of cardiovascular risk.
More knowledge. Better health.