Despite decades of awareness campaigns, cardiovascular disease (CVD) remains the leading cause of death in the United States, claiming some 2,500 lives every day.
Heart disease is largely preventable. Yet in the United States, CVD-related deaths increased 9.3 percent between 2019 and 2022, reversing years of progress. The COVID-19 pandemic may have contributed (the virus can harm blood vessels and lead to cardiovascular damage), but CVD mortality rates continued to climb even after the pandemic. This suggests deeper issues are at play — and that our prevention strategies may need improvement.
For decades, prevailing wisdom about preventing CVD focused on lowering fat intake, reducing cholesterol, and hitting the treadmill for cardio workouts. But as our understanding of heart disease has grown, so has the concern that these measures are not enough.
“In the conventional model of cardiology, we focused on lipids — and LDL [low-density lipoprotein] cholesterol in particular — as a major risk for cardiovascular disease,” says Sanjay Bhojraj, MD, FACC, an interventional cardiologist in Newport Beach, Calif. “But now we’re learning that there are factors beyond just cholesterol that are equally, if not more, significant.”
Enter the concept of cardiometabolic health. This framework considers blood pressure and lipids but also focuses on insulin sensitivity, inflammation, stress, sleep, and environmental exposure.
“Heart health and metabolic health are not really different,” explains Mimi Guarneri, MD, FACC, a functional-medicine cardiologist in La Jolla, Calif., and president of the Academy of Integrative Health and Medicine. “People who have metabolic syndrome have all the cardiac risk factors: central weight gain, high triglycerides, elevated blood sugar. They’re intrinsically linked.”
Advocates of a cardiometabolic view suspect the laser focus on cholesterol and saturated fat has been leading healthcare providers — and millions of patients — down the wrong path. Or at least an incomplete one.
In The Great Cholesterol Myth, Jonny Bowden, PhD, CNS, and Stephen Sinatra, MD, FACC, note that this approach has led us to ignore other contributors to CVD, including inflammation, oxidation, sugar, and stress.
Along with a broader view of CVD’s causes, a cardiometabolic approach offers a wide range of lifestyle-based strategies for prevention — beyond a strict focus on cholesterol levels. What follows are some powerful contributors to good cardiometabolic health.
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QUALITY FATS
We’ve long been advised to minimize fat and cholesterol for heart health. But research shows that the relationship between diet and cardiovascular health is more complex. While trans fats are demonstrably harmful, several large-scale studies have challenged low-fat orthodoxy.
Omega-3 fatty acids from fatty fish, flaxseeds, walnuts, and other sources have been consistently linked to reduced inflammation and better heart health. A landmark 2013 study published in The New England Journal of Medicine found that participants who followed a Mediterranean diet, which features plenty of extra-virgin olive oil and nuts, had fewer cardiovascular events compared with those on a low-fat diet.
Similarly, a seven-year randomized controlled trial published in The Lancet in 2022 followed 1,002 patients with established coronary heart disease. Participants ate either a Mediterranean diet rich in monounsaturated fats or a low-fat diet higher in carbohydrates. The group on the Mediterranean diet experienced a 26 percent lower risk of heart attack and stroke compared with those on the low-fat protocol.
Multiple meta-analyses, too, have shown that total saturated-fat consumption is not reliably associated with heart disease risk. What’s more, replacing fats with refined carbohydrates may increase that risk because low-fat, high-carb diets tend to elevate blood-sugar levels.
“There is some research that suggests that saturated fat can raise your LDL cholesterol, but that data shows that it’s probably more of an increase in those big, less-toxic LDL than the more dangerous smaller ones,” says Bhojraj. (For more on LDL, see below.)
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WHOLE FOODS
Don’t obsess over specific macronutrients in isolation, says Joseph Marine, MD, FACC, a clinical cardiac electrophysiologist at Johns Hopkins Hospital. He offers simpler advice: Eat more fresh whole food and stay away from highly processed stuff. “Focusing too much on specific ingredients is more confusing than it needs to be,” he says.
Plant-forward diets with plenty of healthy fats are associated with a reduced risk of a variety of diseases, including heart disease. The Mediterranean diet is the best studied and is backed by substantial research. The protocol is relatively low in processed carbohydrates, emphasizing vegetables, fruits, whole grains, beans and lentils, nuts, garlic, and olive oil. It also includes seafood — especially small, fatty fish, such as sardines — and meat in moderation. (For more healthy plant-forward food traditions from other cultures, check out “5 Heritage Diets and Their Health Benefits.”)
“Whole, unprocessed foods are pretty anti-inflammatory by default,” says Bhojraj. “And the different colors in plant-based foods come from phytonutrients and phytochemicals that have specific roles in combating inflammation.”
In addition to their abundant antioxidants and healthy fats, plant-forward diets are rich in fiber, which binds to cholesterol in the gut and carries it from the body. Fiber helps stabilize insulin levels, nourish the gut microbiome, and reduce the oxidative stress that can lead to vascular damage.
Guarneri recommends some supplements, but only as complements to a healthy diet. Deficiencies in vitamin D and antioxidants are common, and vegetarians may require extra B vitamins.
Supplements can also be used therapeutically: Omega-3 can lower inflammation and triglycerides; red yeast rice can lower cholesterol; and berberine can lower blood sugar. These are potent treatments — red yeast rice contains a naturally occurring statin, for instance — so work with your healthcare provider if you plan to take them.
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RESTORATIVE SLEEP
Sleep has a powerful impact on heart health. Chronic sleep deprivation and disrupted sleep patterns have been linked to elevated blood pressure, insulin resistance, inflammation, and an increased risk of heart disease. (Research also shows that sleep significantly influences metabolism, appetite, and weight management. Learn more at “How Does Sleep Influence Weight Gain?“)
A 12-year prospective study of 20,432 healthy men and women in the Netherlands found that those who slept poorly for six hours or less per night had a 79 percent higher risk of heart disease than those who slept well for seven or eight hours per night. And a recent Swedish study reported that just three nights of restricted sleep (about four hours per night) triggered higher blood levels of inflammatory proteins known to damage blood vessels and raise CVD risk.
The prevalence of poor sleep in the U.S. may be one reason the rate of CVD continues to climb. According to the American Academy of Sleep Medicine, approximately 5.9 million U.S. adults have been diagnosed with obstructive sleep apnea, and an estimated 23.5 million remain undiagnosed. The condition disrupts breathing and hampers sleep quality.
“Anyone who’s waking up in the middle of the night, even if they think it’s just to go to the bathroom, or [who] is tired during the day — we should be checking them for sleep apnea,” says Guarneri. Left untreated, sleep apnea can contribute to high blood pressure, arrhythmia, and even heart failure.
Once you’ve ruled out sleep apnea, aim for a consistent bedtime routine and prioritize getting seven to nine hours of sleep per night. (Reducing your screen time in the evenings can make falling asleep easier.) As Bhojraj notes, “When you reset the body’s sleep rhythm, everything else starts to fall into place.”
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BALANCED INSULIN
Insulin may not be among the first hormones you associate with heart health, but growing evidence suggests it deserves to be. In addition to being a hallmark of type 2 diabetes, insulin resistance has been linked to hypertension, stroke, and buildup of arterial plaque.
When insulin is properly regulated, it circulates in the bloodstream before being taken up by the cells. If the body becomes insulin resistant, the cells stop responding to insulin’s signals, leaving glucose lingering in the blood. This leads to a traffic jam of excess glucose, which can trigger the inflammation and oxidative stress that promote the oxidation of LDL particles. Oxidation damages the particles’ structure, and they become the “bad” LDL cholesterol that is more likely to get trapped in artery walls.
“This is where cardiometabolics come into play,” Bhojraj explains. “Because when you are insulin resistant, you have a lot more circulating damaged LDL particles. That accelerates atherosclerosis.”
You can detect early insulin resistance by having your elevated fasting insulin or A1c levels tested. And continuous glucose monitors can offer real-time insight into how different foods, sleep patterns, and stressors affect your blood sugar.
Ultimately, keeping insulin in check is about consistency, Guarneri says. “What reverses insulin resistance? Intermittent fasting, getting the weight down, and getting off [added] sugar and simple carbs. If you get your habits right, the ripple effects on heart health can be profound.”
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PLENTY OF MOVEMENT
Physical activity has a positive influence on nearly every biomarker associated with cardiovascular health: It helps lower blood pressure, improve cholesterol, and reduce inflammation.
“Exercise is really the best medicine,” says Marine. “If you look at the benefits that have been documented in study after study, it’s hard to find any intervention in all of medicine that is more effective in improving cardiovascular health.”
Aerobic exercise — think walking, running, cycling, or swimming — has long been the centerpiece of cardiac rehabilitation and prevention. It strengthens the heart muscle, improves circulation, and enhances the body’s ability to use oxygen. The American Heart Association recommends at least 150 minutes of moderate-intensity aerobic exercise per week, which breaks down to about 30 minutes a day, five days a week.
Strength training offers key benefits too. Greater muscle mass improves glucose metabolism and reduces the risk of insulin resistance and inflammation.
Finally, regular movement supports emotional well-being, reduces stress, and enhances sleep — all of which are key for cardiometabolic health. Marine notes that mind-body practices, like yoga, can be especially powerful in this regard. “There are a number of intriguing studies showing that yoga can reduce and mitigate heart disease,” he says.
If you’ve experienced a cardiac event, return to exercise slowly, in a supervised program.
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GOOD ORAL HEALTH
It receives less attention than other factors, but poor oral health has long been correlated with a risk of CVD, says Marine. Chronic oral inflammation creates a persistent source of harmful bacteria that can gain direct access to the bloodstream through damaged gums. Once these microbes are in circulation, they can wreak havoc on blood-vessel linings, contribute to arterial plaque formation, and amplify systemic inflammation.
Poor oral hygiene also increases the risk of heart infections, including endocarditis, a rare but serious condition in which bacteria infect the inner lining of the heart. This risk is especially high for those with existing heart conditions or artificial heart valves, where novel bacteria can quickly take hold.
Fortunately, the remedy is simple: Brush, floss, and see your dentist regularly. (To learn more about the oral microbiome, visit “Everything You Need to Know About the Oral Microbiome.”)
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HEAT THERAPY
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LESS STRESS
Chronic stress is the enemy of a healthy heart. It raises blood pressure and promotes systemic inflammation. It also leads to the overproduction of cortisol, a stress hormone that stimulates the body to store more visceral fat — a key feature of metabolic syndrome and a risk factor for CVD.
“Stress is probably a key root cause of heart disease in 95 percent of patients that I work with,” Bhojraj says.
“By its nature, stress is an adaptive response to help us,” he continues. “But it’s supposed to be brief exposures to stress, not chronic, long-term stress — which is what our modern lifestyles deliver. These normal, physiologic responses then start to have unintended consequences that really put our bodies out of balance.”
Social connection is a powerful stress reducer and proven supporter of heart health. Studies have shown that people with strong, supportive relationships are less likely to develop CVD and more likely to recover well after cardiac events.
So connect with your friends and family. Enjoy relaxed, convivial meals. “Loneliness is as toxic to the heart as smoking or obesity,” Guarneri says.
Dramatic actions like quitting a job or moving to another country may feel like the best way to break the stress cycle, but simple, daily practices are probably more effective. Breathwork, meditation, prayer, gentle movement, and time in nature have all been shown to activate the parasympathetic nervous system, helping shift the body into rest-and-digest mode. Seek out ways to slow the pace of life.
Guarneri encourages patients to identify daily rituals that offer holistic support. “Ask yourself: What did I do today for my body, mind, emotions, and spirit?”
It could be meditation, yoga, journaling, or just sitting calmly with a cup of tea. Any quiet, peaceful activity that settles your mind can support your heart.
WHAT’S UP WITH LDL CHOLESTEROL?
The distinction between high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol was first explored in the 1950s. Since then, multiple studies have shown that having higher “good” HDL and lower “bad” LDL cholesterol is associated with a lower risk of heart attack.
Statin drugs that lower LDL cholesterol do appear to reduce the risk of cardiac events, particularly in those who already have heart disease. Yet recent research suggests the relationship between cholesterol and heart health is more nuanced, and that the complexity lies in the type and behavior of the LDL particles themselves. “LDL itself is not inherently harmful,” explains integrative cardiologist Mimi Guarneri, MD, FACC.
The risk comes when LDL particles are small, dense, and oxidized, making them more likely to penetrate blood-vessel walls and contribute to plaque formation. In the presence of inflammation, these particles become particularly damaging.
“We’ve learned that two people could have had the exact same LDL level, but if one had inflammation, that’s the one who did worse,” Guarneri says.
Because of this, many integrative practitioners now favor advanced lipid and inflammation testing. The following tests consider factors beyond total LDL.
- LDL particle number (LDL-P): Even when total LDL cholesterol appears normal, a high number of LDL particles might indicate a greater risk of plaque formation, especially if they’re small and dense.
- Apolipoprotein B (ApoB): This is a measure of the number of plaque-forming lipoprotein particles.
- High-sensitivity C-reactive protein (hs-CRP): This marker of systemic inflammation can make otherwise-benign LDL particles more damaging.
- Lipoprotein(a) (Lp(a)): A form of LDL, elevated Lp(a) levels are associated with an increased risk of heart attack and stroke, regardless of other lipid markers. Some people have a genetic variant that predisposes them to elevated Lp(a).
- Triglyceride-to-HDL ratio: A high ratio (typically above 2:1) can signal insulin resistance and metabolic dysfunction.
These more granular markers help practitioners get a clearer sense of a patient’s cardiovascular risk and offer more targeted, personalized prevention strategies.
While LDL isn’t off the hook, it’s no longer the lone villain in the cholesterol story. It’s part of a much larger picture that includes inflammation, metabolic health, and lifestyle.
WHEN LIFESTYLE ISN’T QUITE ENOUGH
Even with optimal diet, exercise, and stress management, some cardiovascular risks may be hardwired into your DNA. It’s possible to carry a genetic variant that makes you more susceptible to higher levels of lipoprotein(a) (Lp(a)), a specific LDL particle that carries unique risks for heart health.
Lp(a) includes an added protein that makes it extra sticky, inflammatory, and clot-promoting. It can silently increase the risk for heart disease, even if other lipid levels look normal. Levels below 50 nanomoles per liter are generally considered within the optimal range, while levels above 125 nanomoles per liter are associated with a higher risk of cardiovascular disease.
Unlike traditional LDL, Lp(a) is not directly affected by diet or exercise, making it frustratingly resistant to the usual heart-health strategies. Statin drugs do not lower Lp(a) levels and can sometimes even increase them, though statins’ overall LDL-lowering effects may still provide a net benefit for those with elevated Lp(a).
Currently, there’s no proven treatment for lowering Lp(a) that alters CVD outcomes. “We don’t have clear evidence yet that manipulating or reducing Lp(a) changes risk, but the pharmaceutical industry has developed drugs that lower Lp(a), and large-scale clinical trials are being done right now,” says Joseph Marine, MD, FACC, a clinical cardiac electrophysiologist at Johns Hopkins Hospital.
In the meantime, there’s increasing consensus among experts that it’s worth having your levels tested. “Everyone should have Lp(a) measured at least once in their life,” says integrative cardiologist Mimi Guarneri, MD, FACC.
Because elevated levels are usually genetically determined and not subject to much fluctuation, a one-time test can offer valuable insight into your baseline cardiovascular risk. The European Society of Cardiology already includes it in its guidelines; U.S. guidelines may soon follow suit.
While pharmaceutical interventions are in development, some functional-medicine practitioners have used supplements to address elevated Lp(a), including niacin, CoQ10, estrogen (in women), and aronia berry. Responses to these supplements are highly individual and not always clinically significant, notes Guarneri.
What is clear is that elevated Lp(a) acts as a force multiplier, compounding the risks of high LDL, inflammation, and insulin resistance. The presence of elevated Lp(a) is a good reason to double down on anti-inflammatory habits and take a comprehensive approach to managing all other risk factors for heart health, including using a statin to lower overall LDL if your provider recommends it.
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