My questioning of lipids began in PA school in 2016, when a physician gave our class a lecture on evidence-based medicine. He showed us mortality data on statins. When you look at mortality alone, the number needed to treat can look underwhelming. He also explained relative risk reduction in a way that made it feel, to me at the time, like a Big Pharma manipulation of data. That lecture planted a seed. I adopted the paradigm that LDL elevation was overblown. More importantly, I convinced myself that I was the exception: lean, fit, insulin-sensitive, weight training, eating “clean,” and therefore somehow protected from the overwhelming evidence linking ApoB-containing particles to cardiovascular disease. After graduation, I kept studying lipids. In 2019, I became fascinated with arguments built around Eskimo, ancestral, and prehistoric populations. Looking back, I can see how selectively I interpreted that material. I focused on evolutionary narratives and ignored the obvious limitation: many of those populations died young, before modern atherosclerotic disease had decades to develop. Around the same time, I discovered the Quest Diagnostics Cardio IQ panel. It was still early in its life cycle, and I was excited by advanced lipid testing. I became the primary of a patient who found me at the mom and pop urgent care and somehow knew that I was open to alternative thinking and who wanted to use the same test because, like me, he was lean, fit, and a weightlifter. Neither of us wanted to believe that someone who looked metabolically healthy could still be at risk for myocardial infarction, stroke, or vascular disease. Then came 2020. During the pandemic, my questioning of medical authority intensified. I studied the disease as it moved through Asia, then Europe, and by the time it reached the United States, I felt prepared. I worked in urgent care and treated thousands of patients. I wrote to local mayors and sheriffs, pleading with them not to lock us down. I became part of the anti-lockdown resistance, protesting on the streets and am proud of that. That period changed how many of us viewed institutions, public health messaging, and medical authority. But that skepticism came with a cost. In 2021, I published a YouTube lecture on the Quest Cardio IQ test. At the time, very few clinicians were talking publicly about these advanced lipid panels. The lecture received thousands of views. In 2022, I found the Labcorp NMR panel and made another lecture. That one also reached thousands of people. I was not just studying this material anymore. I was teaching it. From 2021 through 2024, I listened to nearly every countercultural medical authority I could find. It started with keto physicians like Gary Fettke and low-carb advocates on social media. Then came the carnivore movement, organ-meat influencers, alternative medicine conferences, and the online war between lipid denialists and lipid-lowering advocates. I even met Shawn Baker at an alternative medicine conference in 2023. The movement reached peak absurdity, in my mind, with the rise and fall of Paul Saladino and Liver King. I learned that they both sourced their supplement line from a manufacturer from a businessman in the supplement industry. I had a decision to make. Do I go full in on this and make millions selling supplements and become such an absurd online personality. I recognized for the first time the meaning of grift. The carnivore influencers had capitalized on a growing health conscious and skeptical market with a “natural” supplement. It was fancied as science perhaps with loose inspiration derived from the anthropological studies of a dentist Weston A Price who found less tooth decay in ancestral populations that at a traditional meat based diet. I started Iron Direct Primary Care in 2021 as an alternative healthcare home for patients who wanted something outside the conventional system. For years, I cared for many patients who did not believe elevated lipids mattered. We ordered everything: MPO, homocysteine, hs-CRP, omega-3 testing, IL-6, Lp-PLA2, and thousands of NMR panels. Desperately searching for an answer to cardiovascular disease other than LDL and APO B burden. The pattern was always the same. Patients had elevated LDL particle number and elevated ApoB, and we often kicked the can down the road. We focused instead on insulin sensitivity, clean diet, seed-oil avoidance, exercise, nitric oxide supplements, methylated vitamins, inflammation markers, and metabolic optimization. On Instagram, X and podcasts, the lipid battle raged. I listened to lipid skeptics like MD Tro and ex-carnivore MD Paul Saladino, some were compelling. Some were charismatic. Some wore white coats and spoke with absolute confidence. I thought some of them were brilliant. I even referred patients into that ecosystem. Then reality started to break through. In 2024 and 2025, I began seeing heart attacks and strokes in my own patient population. That floored me. These were not the stereotypical patients people imagine when they think of cardiovascular risk. These were patients who avoided seed oils, lifted weights, ate clean, took nitric oxide boosters, optimized methylation, and followed the advice of wellness influencers. Yet they still had events. There are carnivore FB groups that Carnivorecringe on instagram screenshots and posts revealing a toxic subculture. These self-help groups will gaslight patients who suffer from keto and carnivore with absurd claims like “they weren’t eating enough fats” or “they didn’t give carnivore long enough.” One patient had a stroke and left my practice to pursue high-priced “natural cardiology” advice form Wolfson for $7,000. Another patient pursued an alternative cardiology path by surgeon Philip Ovadia for also $7,000 and later required triple bypass surgery. These cases forced me to confront something uncomfortable: if I continued to minimize ApoB and LDL particle burden, I might be helping patients feel reassured while their arteries continued accumulating risk. So I re-read the data. This time, I looked at the totality of evidence instead of the cherry-picked fragments that confirmed what I wanted to believe. I looked at Mendelian randomization, familial hypercholesterolemia, randomized trials, plaque regression imaging, PCSK9 biology, ezetimibe, statins, and the simple fact that lifetime exposure to ApoB-containing particles is causal in atherosclerosis. That does not mean inflammation, insulin resistance, blood pressure, smoking, sleep, strength, or diet are irrelevant. They matter. But they do not make ApoB disappear. They do not make LDL particles magically harmless. A lean body and a good fasting insulin do not give the artery immunity from particle exposure. I have now delisted my older YouTube lectures that were influenced by this lipid-denial ecosystem. I no longer want to contribute to the confusion. One of the most common patterns I now see online is a medical influencer who has moved away from ordinary patient care, sells supplements, lives in another country (likely to avoid legal consequence) sells expensive diet consults, or gives generalized advice under the protection of “no doctor-patient relationship.” Many of these figures profit from the fear and distrust that exploded during the COVID era. That distrust is real. Some of it was earned. But bad institutional behavior does not make bad science true. The people most affected by this misinformation are often conservatives. These are my people. They are skeptical of the system, suspicious of pharmaceutical companies, and deeply motivated to take responsibility for their health. I respect that. But skepticism without correction becomes a trap. A recent literature on the political polarization of health outcomes suggests that health and mortality are increasingly diverging along political and ideological lines, favoring better health in liberals. My mission now is to stop the preventable damage. I went from lipid denialist to lipid-lowering advocate because my patients, my data, and the broader evidence forced me to change. I still believe in strength training. I still believe in metabolic health. I still believe in nutrition, sleep, sunlight, and personal responsibility. But I no longer believe those things cancel out ApoB. The new message is simple: ApoB matters. LDL particle exposure matters. Prevention matters. And changing your mind when the evidence demands it is not weakness. It is clinical maturity. I was wrong before. Now I am trying to make it right. Further readings: Ference et al., 2017 — “Low-density lipoproteins cause atherosclerotic cardiovascular disease” This is probably the single best paper for the intellectual foundation of my reversal. It integrates epidemiology, Mendelian randomization, genetic disorders, and randomized trials. The authors conclude that the totality of evidence establishes LDL/ApoB-containing particles as causal in ASCVD, with risk depending heavily on magnitude × duration of exposure. Read the full open-access paper Borén et al., 2020 — the mechanistic follow-up EAS consensusThis is the one to read for how atherosclerosis happens: entry, retention, and accumulation of ApoB-containing lipoproteins in the arterial intima and the subsequent inflammatory response. It helps resolve the false choice of “cholesterol versus inflammation” both matter, but ApoB particle retention is upstream in the atherosclerotic process.Read the full open-access paper Cohen et al., NEJM 2006 — PCSK9 loss-of-function mutationsThis is one of the most persuasive natural experiments. Genetically lower LDL from PCSK9 variants produced dramatically lower coronary disease risk. In one population, roughly a 28% lifelong LDL reduction was associated with an 88% reduction in CHD; in another, a ~15% LDL reduction was associated with ~47% lower risk.Read the NEJM paper Ference et al., JACC 2012 — lifelong genetically lower LDLExtremely important because it explains why short drug trials can make LDL lowering look unimpressive compared with lifelong exposure. Genetic randomization allows us to ask what happens when LDL is lower beginning early in life.Read the PubMed article and access the full text CTT Collaboration, Lancet 2010 — 170,000 participants / 26 randomized trialsThis is an excellent paper to revisit for objection about statin statistics. Rather than focusing on one mortality NNT, it looks at outcomes per absolute LDL reduction across a huge randomized dataset.Read the complete paper free on PMC CTT Collaboration, Lancet 2012 — statins even in lower-risk populationsThis one is particularly relevant to “NNT ≈100” arguments. One important distinction: an NNT around that range can describe major vascular events in relatively low-risk people over a limited follow-up period, but it is not a universal “statin mortality NNT.” Absolute benefit necessarily looks smaller when baseline short-term risk is low.Read the paper / abstract My original skepticism was not irrational—the mistake was extrapolating a modest short-term absolute benefit in low-risk people into the conclusion that lifetime ApoB exposure was unimportant. FOURIER — Evolocumab cardiovascular outcomes, NEJM 201727,564 patients with ASCVD. PCSK9 inhibition lowered LDL dramatically and reduced cardiovascular events on top of statin therapy. This is important because it dismantles the argument that the benefit is some peculiar “pleiotropic statin effect.” Different mechanism, same direction: reduce ApoB/LDL exposure → fewer events.Read FOURIER in NEJM ODYSSEY OUTCOMES — Alirocumab, NEJM 2018Another PCSK9 inhibitor, another randomized trial, another reduction in ischemic events. Primary endpoint: 9.5% versus 11.1% after ACS.And yes. Events were lower in the alirocumab arm. Lipid denialists will say mortality wasn’t reduced enough. But these were patients already managed and in the system able to get emergency care to save from death. Primary composite (CHD death, nonfatal MI, ischemic stroke, or unstable angina hospitalization):903 patients (9.5%) vs 1,052 patients (11.1%).All-cause death:334 patients (3.5%) vs 392 patients (4.1%). That is 149 fewer first primary events and 58 fewer deaths over a median 2.8 years. The relative reduction on the primary endpoint was 15% and met the pre-specified significance threshold.Read ODYSSEY OUTCOMES IMPROVE-IT — Ezetimibe + statin, NEJM 2015Also philosophically important: lower LDL using a nonstatin mechanism, and cardiovascular outcomes improve further. Again, it is difficult to sustain a hypothesis that the benefit is merely a special property of statins.Read IMPROVE-IT GLAGOV — Evolocumab and actual coronary plaque regressionThis was one is Anti Aging Medicine. We can reverse plaque? That is regenerative medicine!. LDL reached about 36.6 mg/dL; percent atheroma volume fell, and 64.3% of evolocumab patients demonstrated regression versus 47.3% with placebo.Read GLAGOV in JAMA PACMAN-AMI — Alirocumab, JAMA 2022This is even more visually compelling because multimodality intracoronary imaging showed not only greater plaque regression but changes consistent with plaque stabilization: reduced lipid burden and thicker fibrous caps. Again, this is Anti Aging and Regenerative Medicine.Read PACMAN-AMI in JAMA ApoB vs LDL-C discordance — JAMA Cardiology 2024It demonstrates how widely ApoB can vary among people with the same LDL-C or non-HDL-C and quantifies clinically important discordance.Read the JAMA Cardiology paper There is also a 2025 systematic review of 15 discordance studies involving 593,354 people. ApoB outperformed LDL-C in all 9 studies directly comparing the two in the review. That one is particularly relevant to explaining why I moved away from obsessing over LDL subfractions/NMR toward ApoB. Read the ApoB systematic review on PubMed And REACT is especially important The REACT study was just published in NEJM on August 29, 2026. It examined almost 17,000 ostensibly healthy adults aged 18–70 in Denmark and Spain. Atherosclerosis was already detectable in the 18–29-year-old group—8.7% of men and 6.7% of women—and plaque prevalence and volume climbed dramatically with age. Read the new REACT paper in NEJM “I am young, lean and fit, therefore these lipid numbers probably do not apply to me.” REACT shows why that reasoning is dangerous: subclinical disease can already exist decades before the person looks or feels like a cardiovascular patient. The conservative-vs-liberal mortality paper Elder & O’Brian, Nature Human Behaviour, May 14, 2026 — “The political polarization of health outcomes in the USA.” They found that conservatives in their cohort experienced worsening health during the 2010s and higher mortality in the early 2020s, particularly from internal causes such as heart disease, cancer, and stroke. Read the full Nature Human Behaviour article The authors found a mortality divergence associated with political identity; they also found that changing socioeconomic composition of the coalitions, including education, income, and insurance, explained part of the difference

I’ve identified a concerning trend in the Direct Primary Care movement. The cash pay model offers a flat monthly rate for primary care. Mainstream medicine doctors are opting out of the insurance system due to layers of administrative duties and ever reducing medicare reimbursement rates. Commercial insurance companies can at a whim decline payments for services or require lengthy forms and boxes to click in order to be paid correctly. Overhead goes up for small primary care offices with billing experts and compliance officers. Mom and pop primary cares are being bought out by hospital systems that have stronger leverage to negotiate payment tiers with insurance companies or purchased Private Equity firms that see a cash cow. Overall DPC is the correct move for healthcare reform. When a DPC clinic no longer has to comply with arbitrary boxes to check and have more time to think about their patient’s problems they may naturally find themselves considering hormone replacement therapies and some functional medicine modalities. DPC rates are typically cheaper than functional medicine consult fees or “TRT clinics”. The DPC CEO will naturally consider creating price tiers for what they consider as outside conventional guideline dictated primary care. I’ve seen a DPC clinic post prices for a conventional DPC monthly rate and then offer another tier 3x the price for “functional medicine”. Take a hypothetical example of a middle aged patient on your basic DPC plan for $99/month who presents with chronic nonspecific pain, fatigue and brain fog. Conventional medicine would refer to rheumatology or in a conventional DPC you’d order some rheumatoid markers, CBC, CMP and and a1c. Results come back normal. In a busy insurance primary care clinic with 15 minute follow ups you probably refer this patient out to psych and interventional pain management. But say you are a DPC clinic and you’ve gone to the additional lengths of relearning medicine from a functional lense. You’ve taken courses like HRTPCP.com (shameless plug for my course) and you know that this patient likely has low hormones and will greatly improve their quality of life with HRT. After that basic workup do you then paywall your care? Do you then offer $599/month for “Functional medicine DPC”? How can you ethically waste that patient’s time at the $99/month rate when you knew you should probably have ordered a free and total LCMS testosterone and estradiol level. You know there’s better treatments for their fatigue, low sex drive, pain ect but paywall them. Now I must attack the functional medicine-only practice. This same patient pays a high price and is hormone optimized and has done gut testing and spent lots of money on regenerative peptides to heal their IBS, but has come down with an acute illness. Since you style yourself as functional medicine you don’t treat a common cold and you don’t repair lacerations. That is beneath you. This patient goes to an urgent care and gets some sutures placed and given ciprofloxacin prophylactically (yep that’s a real and idiotic thing that some lobotomized providers at chain urgent cares do if they know how to suture in the first place). Your patient returns to you with an achilles tendon rupture and the patient progresses over the year towards a constellation of flouroquinolone-related symptoms. This patient pays many more thousands of dollars for your workup of “mitochondrial myopathy” and expensive and research-online mitochondrial peptides. I strongly urge everyone in this DPC movement, be it if you are a strict “evidence based medicine” purist or a functional medicine guru to charge one flat rate and treat the whole patient. Patients cannot be boxed into a price tier. If we want Direct Primary Care to implement true healthcare reform, to stop the overuse of ERs, the endless specialist referral mill and the fragmented care we need to charge a flat rate and provide comprehensive care. This is how we Make Primary Care Great Again. Every DPC needs to take extreme ownership of their patient. Charge what you are worth, but please lets get rid of price-tiers and paywalls for HRT or “functional medicine”. Anti-Aging Medicine is Primary Care

Keeping older adults strong, mobile, and independent is possible with tailored exercise and personalized medical care. It's key to preserving bone health and overall function. #HealthyAging #Seniors

Trusting confident keto advocates while battling binge eating disorder can feel like a desperate search for a solution. The struggle is real. #Keto #BingeEatingDisorder

It’s a common phenomenon we see in alternative medicine for a patient to suffer with a chronic illness and then find solace in orthorexic eating patterns. We see it all the time. Eventually, when the patient learns to heal their emotional and psychological trauma, they can tolerate foods again in a variety of forms. But a pattern we commonly see in those starting their health journey is to think that their diet is the answer to everything. Be that vegan or keto, macrobiotic or Gerson, carnivore or vegetarian, pescatarian etc. Everyone seems to think their diet is the answer. Then the diet becomes a religion to them and replaces God. It’s interesting that many religions have dietary restrictive patterns. Take for example the Islamic avoidance of pork or The Ramadan fast or the healing power of wine and bread in the form of the Body of Christ during catholic mass.

When I explain what we do at Iron Direct Primary Care and my pioneering concept of anti-aging medicine as primary care it astounds and frightens those in both functional medicine and conventional medicine. It’s a bit intimidating for some HRT gurus to hear that patients have direct line of communication with their primary care and that we will do everything from sick visits, cough and cold to complex HRT and functional medicine workups and just as well order a colonoscopy and refer out for a mammogram as well as manage hyperlipidemia, along with integrative management of psychosocial, trauma, psychiatric and gastrointestinal symptoms all in the same day for the same patient for a flat monthly fee and don’t charge more for patients just because they have more complaints. What I found is many so-called “integrative medicine” practices do not truly aspire to a comprehensive treatment and holistic approach of the patient. They are not much better than the 15 minute one-complaint per visit insurance primary care. Becoming a primary care provider at Iron DPC is only for those who are truly passionate about helping people.

MASH/NAFLD treatments have improved drastically. It wasn't long ago that fatty liver disease, even causing severe issues like hepatic encephalopathy, meant a massive workup with no real treatment options. #LiverHealth #MASH #NAFLD

Anxiety-inducing food warnings are often misplaced. Prioritize cardiovascular health, early prevention, and lifestyle changes to effectively reduce heart disease risk. #HeartHealth #WellnessTips

Semaglutide drugs now have insurance approval for established CVD, not just for obesity or diabetes. The SELECT trial proved they reduce major cardiovascular events, offering a new treatment pathway. #Cardiology #Pharma

Professional identity can hinder belief revision regarding health. Advocating for evidence-based care requires a balanced approach to diet, exercise, medication, and lab results. #HealthBeliefs #EvidenceBasedCare

Nah, it’s because we still have those who don’t want to treat the whole patient. Seems there’s hardcore diet camps or HRT gurus for alt med. But no one wants to practice real integrative primary care. Why? Because it’s hard. Much easier to practice in silos or on X

Why are blood pressure targets getting lower? Because research shows lower levels reduce risks of kidney disease, strokes, heart attacks, and more. Targets for ApoB, LDL, and A1C have also been adjusted for better patient outcomes. #HealthTips #BloodPressure