Metabolic health is a term you hear a lot these days — but oddly enough, there’s no universally agreed-upon definition for what perfect metabolic health looks like.
In fact, it’s often easier to spot poor metabolic health than it is to clearly define what “optimal” metabolic health really is.
The Problem: We Often Set The Bar Too Low
Right now, in most healthcare settings, we don’t diagnose someone with a metabolic problem until they’re well down the road toward trouble.
This is where the diagnosis of Metabolic Syndrome comes in — it’s a collection of signs that cluster together to tell us a person likely has significant metabolic dysfunction.
If you meet three or more of the following criteria, you get the label of Metabolic Syndrome:
But Here’s The Catch…
Just because you don’t meet 3 of these criteria doesn’t automatically mean you’re in great metabolic health.
For example — if your triglycerides are 130 mg/dL, HDL-C is 40 mg/dL, waist circumference is 34”, and your blood pressure is 128/82 mmHg… you technically don’t meet the definition for Metabolic Syndrome.
But let’s be real — that’s not a picture of metabolic optimization.
Those numbers strongly suggest that your body has been struggling with some level of insulin resistance for years — slowly accumulating wear and tear, even if it hasn’t shown up as a disease diagnosis yet.
Why Is This A Big Deal?
Some people are more resilient to this kind of metabolic stress — their genetics allow them to coast a little longer without obvious health problems.
But for others — especially those with more delicate genetics or a family history of heart disease, diabetes, or cancer — even subtle signs of metabolic dysfunction can eventually end in disaster.
What Should We Aim For Instead?
Rather than settling for not bad, the goal should be to optimize these markers as much as reasonably possible — without making your life miserable in the process.
Better metabolic health tends to look like this:
The Bottom Line
Metabolic health isn’t just about avoiding a diagnosis — it’s about stacking the deck in your favor for the long haul.
Optimizing these markers gives your body the best chance to thrive — protecting you from chronic disease, improving energy levels, and supporting healthy aging.
And while no one needs to chase perfection, aiming higher than the “bare minimum” is usually worth the effort.
Cholesterol In The Bigger Picture
It’s easy to get tunnel vision about cholesterol — especially LDL-C — because it’s what many if not most doctors focus on.
But cholesterol — particularly the amount found in LDL particles — is just one piece of the heart disease risk puzzle.
It’s important to step back and look at the bigger picture of cardiometabolic health — because other markers may tell us even more about your overall risk.
Not All Risk Factors Are Created Equal
For example, data from the Women’s Health Study, which followed over 28,000 women for 20 years, compared the relative risk of different markers for heart disease.
Here’s what they found in women less than 55 years old:
https://pubmed.ncbi.nlm.nih.gov/33471027/
This is why cardiometabolic health — not just cholesterol — deserves much attention.
Should You Ignore LDL-C?
Absolutely not.
LDL-C likely still matters — but its importance should be put in context. Part of the reason LDL-C gets so much attention is because it’s easily measured — and we have medications to lower it that, in specific contexts, lower the risk of heart disease.
But emphasis on LDL-C at the expense of leveraging resources to address the root cause of insulin resistance, poor blood sugar control, inflammation, or high blood pressure misses the forest for the trees.
Labs And Metrics That Give A Fuller Picture
An experienced clinician — especially one familiar with low-carb or ketogenic diets — is essential to interpret your lab work properly.
Beyond a standard lipid panel, here are additional labs and metrics that can provide valuable insight:
Fasting Insulin: The Canary In The Coal Mine
Fasting insulin is one of the earliest markers to go up when your metabolism is under stress — often long before blood sugar rises.
Higher insulin levels have been independently associated with increased heart disease risk.
In one study published in The New England Journal of Medicine:
- Those with high ApoB (>119 mg/dL) but low insulin (<12 uU/mL) had a 1.8x higher risk of heart disease compared to both being low.
- But those with low ApoB but high insulin had a 3.2x higher risk.
- And those with high ApoB and high insulin? A staggering 11x higher risk.
https://pubmed.ncbi.nlm.nih.gov/8596596/
Why No Lab Beats Imaging
As powerful as lab tests are, nothing beats actually seeing whether you have heart disease.
That’s where a Coronary Artery Calcium (CAC) Score comes in.
What Is A CAC Score?
A CAC score is a non-invasive CT scan that looks for calcium buildup (plaque) in the arteries of your heart. It’s fast, safe, and often costs less than $200 out of pocket.
A CAC score of zero usually means no detectable calcified plaque — and a very low short-term risk of a heart attack (over the next 5 years), even if your labs may look less than optimal.
On the flip side — a high CAC score tells us plaque is already present and you’re likely at higher risk — regardless of how beautiful your labs look.
CAC Scores Trump Pretty Much Everything Else
Data show that a CAC score outperforms most risk factors and markers for predicting a heart attack or stroke – better than diabetes status, LDL-C, and ApoB to name a few.
For example:
- A person with diabetes but a CAC score of 0 often has >50% lower incidence of heart disease than a non-diabetic with a CAC score over 100.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5814996/
- Someone with LDL-C <70 mg/dL but a CAC >100 has almost 9x higher risk than someone with LDL-C >130 mg/dL but a CAC of 0.
https://pubmed.ncbi.nlm.nih.gov/24141324/
A CAC score over 100 tends to benefit much more from lipid lowering medications and aspirin compared to someone with a CAC<100. And a CAC score over 300 is often considered equivalent risk to someone who has already had a heart attack or stroke.
https://pubmed.ncbi.nlm.nih.gov/30409567/
https://pubmed.ncbi.nlm.nih.gov/32233663/
https://pubmed.ncbi.nlm.nih.gov/37227328/
Where A CAC Score of 0 Might Miss Risk
While a CAC score of 0 is one of the most reassuring findings we have in cardiology — it’s not bulletproof.
Age is very important when interpreting a calcium score.
In younger adults, a zero score might not be as helpful at predicting risk, simply because plaque hasn’t had time to build up. However, it’s worth noting that about 1 in 5 adults in their 30s already show signs of calcium on a scan – and when it’s there, it likely means that some heart disease has already started and may continue to progress.
For older adults, a zero score is often more reassuring, suggestive of slower disease progression or minimal plaque buildup. When calcium is present (score above 0), the level of risk usually depends on how high the number is, how many other risk factors are present, and how that score compares to others in the same age group.
https://pubmed.ncbi.nlm.nih.gov/31322693/There are certain risk factors that tend to be associated with heart attacks or stroke, even in those without evidence of calcified plaque. .
The following tend to associate with a higher risk of having a heart attack or stroke in people with a CAC of 0:
- Hypertension (high blood pressure)
- Diabetes
- Current or former smoking history
- Low HDL-C (which often signals insulin resistance or poor metabolic health)
https://pubmed.ncbi.nlm.nih.gov/36621817/
- A strong family history of early heart disease — especially in women, where CAC may underestimate risk
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8792296/
- Thoracic Aortic Calcification (TAC) — calcification in the aorta seen on the same CT scan as CAC
https://pubmed.ncbi.nlm.nih.gov/39896051/
That said, high LDL-C does not appear to strongly associate with heart events in people with a CAC score of 0 — even with long-term follow-up studies up to >16 years.
https://pubmed.ncbi.nlm.nih.gov/36621817/
This doesn’t mean LDL-C is irrelevant — but it reinforces the idea that LDL-C without plaque might be less concerning than LDL-C with plaque.
The Takeaway
Cholesterol is one piece of the puzzle — but it’s far from the whole story.
Metabolic health is a system — and the best way to lower your risk of heart disease is to keep all of the key systems working well:
- Keep insulin low.
- Keep inflammation low.
- Keep blood pressure optimized.
- Keep visceral fat down.
- Don’t smoke
- And — when appropriate — get imaging to know what’s really going on inside your arteries to determine how you could better manage your LDL-C