Heart surgeon Dr. Philip Ovadia on using data, not medicine, to improve your health

The author of Stay Off My Operating Table lost 100 pounds by improving his metabolic health; now he’s on a mission to help others do the same.


Article highlights

  • Dr. Ovadia believes heart disease is almost always a result of poor metabolic health, not just high cholesterol as commonly thought.
  • He has yet to see a heart surgery patient with optimal triglyceride/HDL ratio and A1C who was also a non-smoker.
  • The healthcare system focuses on treating disease, not prevention and metabolic health, partly due to financial incentives.
  • Physicians need better education on nutrition and metabolic health to detect insulin resistance a decade before heart disease emerges.
  • Grassroots efforts by doctors and patients partnering together may be what finally shifts the system towards preventative metabolic health.

Dr. Philip Ovadia is a board-certified cardiac surgeon and founder of Ovadia Heart Health. As a heart surgeon who was once morbidly obese himself, Dr. Ovadia has seen firsthand the failures of mainstream diets and medicine. He realized that what helped him lose over 100 pounds—focusing on his metabolic health—was the same solution that could have prevented most of the thousands of open-heart surgeries he has performed.

Dr. Ovadia’s new book, Stay Off My Operating Table: A Heart Surgeon’s Metabolic Health Guide to Lose Weight, Prevent Disease, and Feel Your Best Every Day, makes a case for a metabolic-first approach to improving heart health and overall well being. It’s not a quick-fix fad diet but a long-term solution to eating for sustained health.

Dr. Ovadia recently talked to Levels co-founder Dr. Casey Means on an episode of our podcast, A Whole New Level. Here is an edited version of that conversation.

On why medicine isn’t going to fix your health problems …

Dr. Casey Means: You are a practicing heart surgeon doing life-saving surgeries in major hospitals. You are by no means on the fringe of the medical world, you are right in the thick of it. But you say something in the book that could be slightly controversial: “Meds will never make you better.” This might come as a surprise to people since nearly 70% of American adults use prescription medications. And I bet many of them think or are led to believe that these medications make them healthier. Why won’t medicines make us healthier?

Dr. Philip Ovadia: I would like to think that I’m not on the fringe of medicine. I hope that I’m at the forefront of medicine. And we have to realize that often, those two look very much the same. But the progress we make in medicine and science comes from challenging ideas that we think are the mainstream. We shouldn’t be afraid to do that. When I say in the book that medicines will never fix your health problems, I’m referring specifically to metabolic health diseases. Those are most of the chronic diseases that we face, things like Type II diabetes, heart disease, many forms of cancer. And medications in that situation are only trying to minimize the effects of these diseases. They are not undoing the root cause of that disease. Therefore, they don’t treat the disease itself. They only help to minimize the end effects. I think that that is essentially the wrong approach.

We know that these metabolic diseases are almost exclusively related to diet and lifestyle. Those are the things we need to focus on if we want to have a meaningful impact in reversing these diseases once they occur or preventing them from occurring in the first place, which is the best approach.

Dr. Casey Means: Absolutely. And for someone who goes to the doctor and hears, “Oh, your cholesterol is this level, your blood sugar’s this level. We need to put you on a medication.” What should someone be thinking about when they get that statement? What kind of questions can they ask? And how should they be thinking about what the medication is doing if it’s not actually really reversing the disease process?

“If we address patients’ metabolic health, we can prevent their heart disease. Knowing that, as a physician, I can’t keep quiet. As much as I love doing heart surgery, I would much rather help prevent the need for having heart surgery..”

Dr. Philip Ovadia: Those are exactly the questions that people need to ask their doctors. “Why did this occur? Why is my cholesterol high? And why is that a concern? Why is my blood pressure high? And what are we going to do to address the why?” Not just address the number we’re looking at: your blood sugar level, blood pressure, cholesterol. Let’s address why this occurred. People aren’t concerned about their cholesterol number being high. People don’t feel that; it doesn’t affect them. They’re worried about developing heart disease.

We can certainly get into whether or not cholesterol is the cause of heart disease. But if we think it is, we should ask, “Does that medication prevent me from getting heart disease?” Not “does that medication lower my cholesterol?” That’s meaningless. What we care about is, am I going to get heart disease? Is this medication going to help me not get heart disease or improve the heart disease that I already have? The more that we ask those questions, the more that we can get to the root cause of these problems, and the more likely we find useful solutions.

Dr. Casey Means: One of the biggest questions that could shift healthcare in a positive direction is more people asking, “Why? Why did this happen? Why have I developed this disease?” Doctors asking “Why are healthcare costs going up but chronic diseases are increasing?” These “why” questions sent you and I down a really fulfilling path, having trained as surgeons and then stepping back and observing what’s really happening.

On his own journey from morbidly obese to metabolic health …

Dr. Casey Means: I’d like to dig into your journey a bit more, as a cardiac surgeon who became a metabolic health evangelist. Can you share a little bit about that journey?

Dr. Philip Ovadia: Ultimately, my personal journey and my professional journey are very tightly intertwined. While I think the outcome of them has been amazing, the process that I went through is demonstrative of the problem with healthcare.

I was overweight and obese as a child and essentially my entire life. And that’s something I struggled with. As I went through college and medical school, it got worse. I tried to address it by using the tools I had been taught in medical school: Eat less, move more, count my calories, eat according to the food pyramid, and eat a low-fat diet. I had some short-term success as many people do, but ultimately, I would gain back any weight I had lost and more.

I was at a crossroads about five or six years ago when I realized that I was going to end up on my own operating table. I was morbidly obese, I was prediabetic, and I didn’t have an answer. I was strongly considering getting gastric bypass surgery. Then I came across some new concepts and new ideas. My introduction to all this was from Gary Taubes—he happened to be the guest speaker at a medical conference I was at attending. And thankfully, I actually listened to him. What he said resonated with me. I read his books, and I eliminated sugar from my diet at first and then went low carb. Over the past five years, by doing that, I’ve lost over 100 pounds and optimized my metabolic health.

More importantly, on the professional side of things, that got me asking questions: Why didn’t I hear about this in medical school? Why don’t we discuss these concepts?

Then I realized that the patients I was operating on every day as a heart surgeon were not there because their cholesterol level was high. They were there because they have poor metabolic health. If we address their metabolic health, we can prevent their heart disease. Knowing that, as a physician, I can’t keep quiet. I can’t keep that information to myself. As much as I love doing heart surgery, I would much rather help prevent the need for having heart surgery, developing heart disease. I’d rather keep people off my operating table.

That’s why I’ve added this additional dimension to my career. I started my telemedicine practice and wrote the book and I’m trying to work with like-minded physicians like yourself to get this word out to the people who need to hear it.

On being a metabolic health doctor and practicing surgeon …

Dr. Casey Means:  Now you have two practices. You have your metabolic health telehealth practice and you also are practicing cardiac surgery. Tell us a little about how you split your time, how those practices differ, and how you’d like to see principles from your metabolic health practice move into the mainstream cardiac surgery world.

Dr. Philip Ovadia: I ended up changing the way I practice the heart surgery side of my professional life. I left my heart surgery position. I now work as what’s called a locums surgeon. I basically travel around the country to hospitals that need additional heart surgeons for periods of time and do either short-term or recurring assignments. That gives me a little bit better way to control my schedule.

Then I have my telemedicine practice that is certainly a non-traditional medical practice. It is completely online. Everything is done via telemedicine, at the convenience of the patients. They schedule their own appointments, and we work together one-on-one doing that.

It’s a very different model of practicing healthcare. We have seen that telemedicine is becoming more and more important. The COVID pandemic certainly accelerated that. Even before that, telemedicine was more convenient for patients. It’s more convenient for the physicians, too. It also breaks down some of the barriers that stood in the way of traditionally delivered medical care. I’m excited to be at the forefront of doing that.

On using continuous glucose monitors in all his patients …

Dr. Casey Means: In your book, you talk about how you use continuous glucose monitoring upfront for all your patients in your metabolic health practice. I’d be curious to hear how you find that data stream helpful for people in moving the needle on their diets and their lifestyles. And do you see it contributing to improving the health outcomes of your patients?

Dr. Philip Ovadia: Yes. I think continuous glucose monitors are a great example of what’s wrong with healthcare. The fact that they are not more readily available and not more widely utilized in medicine is emblematic of the problems we have. I use continuous glucose monitors in a number of ways. For the patients coming to my practice who don’t know much about metabolic health, the CGM is a great introduction to what metabolic health is. It gives them real-time feedback: I eat a food, or I do an activity, and I can see a number, a response that will help guide me.

For other patients who are into their metabolic health journey and understand some of the basics, it can be used effectively to fine-tune the foods they’re eating, as well as stress and exercise. I think CGM is incredibly underutilized in medicine. There are too many barriers to getting them in the hands of patients who could benefit from them. And quite frankly, there aren’t enough doctors around to understand how to effectively use them.

Dr. Casey Means: You mentioned that it is a challenge to get CGMs on your patients in your cardiac surgery practice. Why do you think there’s still a barrier to using these tools?

Dr. Philip Ovadia: Quite frankly, it’s hard for me to figure out why there is a block there, but the blocks are that insurance won’t cover it, and on the heart surgery side of my professional life, I am beholden to the insurance companies. For all the patients, obviously, heart surgery is expensive, and you need insurance to pay. So if those patients want something like a continuous glucose monitor, often they need to pay for it out of pocket. That’s not feasible for a lot of them.

Continuous glucose monitors are not approved for use in hospitals, which is kind of interesting. But we know in cardiac surgery—we have unbelievably good data on this—that the better you control a patient’s blood sugar around the time of surgery, the better the outcomes of the surgery. Things like infection have been dramatically improved. It’s probably one of the biggest developments in the management of heart surgery patients over the past 20 years.

And yet, we don’t continuously monitor the patient’s blood sugar in the hospital. Every hour, the nurse is actually drawing awesome blood from the patient and putting it into the machine, and checking the blood sugar. I think that’s crazy. I can have a patient walking around outside the hospital that continuously knows his blood sugar, but I can’t have a patient inside the hospital continuously know his blood sugar when we know it is so important to his outcome. Why that is gets into all of the financial and political aspects of healthcare that I don’t want to get into, but it’s a barrier. And it’s unfortunate because the patients ultimately suffer.

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On the absurdity of hospital food …

Dr. Casey Means: You mentioned post-op blood glucose management. Something you talk about in your book is the absurdity of hospital food. We have great data, as you just mentioned, that blood sugar control after surgery is deeply related to surgical outcomes. And yet, we’re walking into patients’ rooms in the morning and seeing French toast bites and bread rolls at lunch and juice.

Talk to us a little bit about what is so problematic about hospital food, why we’re serving this, and your vision for how food in the hospital could be shifted to support patient healing?

Dr. Philip Ovadia: Ultimately, the reason food is what it is in the hospital is that the hospitals are beholden to the US Dietary Guidelines. They need to follow them at an institutional level. And the US Dietary Guidelines say, “These recommendations are not intended to treat any disease.” And yet we serve that food in the hospital where all we’re doing is treating disease.

So the fact that hospitals need to pay attention to the US Dietary Guidelines is crazy to begin with. The other aspect of it, quite frankly, is that the processed foods that get incorporated into the US Dietary Guidelines are inexpensive, and hospitals are like any other business: they need to look at their bottom line. One of the places they do that is with the food that they serve. They don’t factor into the equation what effect that food is having on their patients. I think that’s very unfortunate.

Dr. Philip Ovadia: I would love to see hospitals serving whole, real food just like I talk about in my book. It’s the biggest concept around metabolic health: if we just ate more whole real food and eliminated the processed foods, all of our health would improve. That should be done in the hospital and out of the hospital.

I no longer eat in the hospital. Literally, if the choice is between eating in the hospital or fasting, I’m going to fast until I get out of the hospital and can get some good food to eat. It is very rare that I can find what I consider to be whole real food in the hospital. That’s unfortunate.

Dr. Casey Means: Just for fun after reading that chapter, I pulled up one of the diabetic menus for a hospital in the US. What’s funny is—I noticed this in residency in medical school—they don’t call it a diabetes diet. They call it a “consistent carbohydrate” diet. In that title, it implies how much the diet is focused on just managing insulin because if you keep someone at 75 grams of carbs per meal, it makes it easier to dose their medication in the hospital.

On this menu for people with diabetes, the breakfast entrees include  whole wheat pancakes, buttermilk pancakes, French toast, whole-wheat French toast, French toast sticks, breakfast burritos on a corn or flour tortilla, white bread, whole wheat bread, whole wheat English muffins, blueberry muffins, cinnamon bagel, cornflakes, cheerios, Rice Chex, Frosted Flakes, Raisin Bran, and strawberry yogurt. And then, of course, the juice options are orange, apple, grape, prune, and cranberry.

That’s just breakfast. There’s not a single thing that I just read that supports metabolic health, or supports someone with diabetes. There are a few options like eggs and breakfast meats that are lower carb, but that’s it. For anyone listening, certainly, take this into your own hands. If you’re in the hospital, see what you can do about bringing your own food, or having someone bring you food. It’s pretty abysmal.

Dr. Philip Ovadia: It really is. It’s one of the most striking examples of what is wrong with our healthcare system. If we look at the system as a whole and the outcomes we’re getting, we have to step back at some point and say, “We’re doing something wrong.”

When 88% of the adults in the United States are metabolically unhealthy, we are obviously doing something wrong. We can argue about what that might be and the nuance of how to fix it. But when we look at diet—which is obviously a major impact on our health—we at least need to start admitting that, for most people, their doctors do not talk to them about what they eat. If we could just start that conversation, if we could just acknowledge that what we eat is the primary influence on our health, maybe we can start to move forward.

On making sustainable changes in your diet …

Dr. Casey Means: In your book, you talk about seven principles of metabolic health. And four of those are things we love at Levels: Eat whole real food, move, sleep enough, and relieve stress. But then there are three principles that are more about framework and processes. One that I loved is to “make one sustainable change at a time.”

Talk about why that’s important.

Dr. Philip Ovadia: The mindset, the framework, is very important. Making one sustainable change at a time, there are two important reasons to do that. The first is that you don’t want to overwhelm yourself and you don’t want to overwhelm the people you’re working with. If you go to the average person who is not metabolically healthy and say, “Okay, tomorrow, we’re changing the way you eat, and we’re changing your exercise, and we’re looking at your sleep and your stress and trying to do all this at once,” it just becomes overwhelming.

What I have found to be most successful with people is focusing on one thing at a time. What I find happens is that becomes self-reinforcing. I talk to people about how to eat better and eat whole real food, and they’ll start to do that. Then all of a sudden, the person who never felt like exercising before now will want to start exercising. As opposed to saying, “Go exercise and change the way you eat.” That’s too much and they won’t have success in either.

The other reason it’s important to focus on one change at a time is so that you can know what’s working and what’s not working. If you change a bunch of things at a time, and you have success, you don’t really know which of those things was important and which ones weren’t necessarily useful. And if you don’t have success, again, you don’t know if it was because of the first thing I changed or the second or the third? If you do it in a more mindful matter, if you’re intentional about doing one thing at a time, and then reassessing and seeing the effects on your health, you can better figure out what you need to be doing to support your health or not.

In the book, some of those changes we talk about are setting your priorities around what you eat. The most important thing to prioritize is getting enough protein in our diet. If you make that your priority and construct the rest of what you’re eating around that, that ends up being a very useful intervention.

I also talk about substituting instead of eliminating. If there is something that you enjoy eating that doesn’t fit within your dietary strategy—say, it’s a processed version of something—find a way to make it in a more healthy manner. There are all sorts of diet websites out there, all sorts of recipe books out there that you can make a whole real food version of just about anything. And oh, by the way, it usually tastes better and is more nutritious, and is going to support your health. The only reason we tend to get the processed versions of all these things is that they’re easy and cheap. And ultimately, that’s not serving our health.

Dr. Casey Means: In the “prioritize” section as one of these suggested changes, you mentioned a great tip that I loved: Before changing what you’re putting on your plate or what you’re buying, just start changing the order in which you’re eating the food on your plate. Let’s say you have a bread roll, and some potatoes, and some chicken, and some vegetables. Start with the vegetables, whole real food, then eat the chicken, whole real food, then eat the mashed potatoes, probably getting a little bit more towards processed food in there, and then whatever is added to it, and then eat the bread roll. Just change the order.

What people might find, I think, is that by the time they get to the bread roll, they’re not quite as ravenous. Maybe they don’t want it as much.

Are there any other really high yield tips like that that have been helpful for you or your patients as they get started on this process?

More tips on eating whole real food …

Dr. Philip Ovadia: I have two rules that I give around eating whole real food. The first is that you should be eating things that grow in the ground, and you should be eating the things that eat the things that grow in the ground. If you stick to those, that is your whole real food. For the most part, your food shouldn’t require an ingredient label because you should be able to look at it and know what’s in it. It should be one ingredient or a couple of simple ingredients that have been combined, and you can still recognize what’s in it. But if it has more than three ingredients on a list, and those aren’t each whole real food, don’t eat it. And the final tip I give people is if you’re grandparents or great grandparents didn’t eat it, you shouldn’t be eating it. If it wasn’t in our food supply 100 years ago, it is probably not something that we should be eating now.

Dr. Casey Means: You mentioned in the book that just because it comes in a package doesn’t mean it’s necessarily horrible. We have to read the ingredients, though. Are the ingredients real food or processed food? It’s going to be rare to find a packaged food that really meets that criteria. But it’s worth getting familiar with labels and looking at every ingredient so you can stick to that principle of eating real food as much as possible.

Dr. Philip Ovadia: It’s always amazing to me what they can slip into food. Bacon is a great example. And you might pick up a package of bacon and say, “Looks like it’s just bacon,” and then you flip it over and they have eight things on the ingredients list between the preservatives and the sugar that they added and flavoring. And you’re like, “I just want bacon.”

People say, “Oh, are you telling me I should never eat bread again?” And I say, “Well, not necessarily.” But realize that there’s a big difference between the packaged bread that you get in your grocery store that is made who knows where, shipped from who knows where, has all of these ingredients and almost 99% have some sort of vegetable or seed oil in them. Versus making bread yourself at home with flour, water, maybe some butter, and some salt. That’s really all that should be in bread.

Or go to your local farmers market on the weekend and talk to the people there that are selling bread and say, “What’s in it?” And if they list off those same simple ingredients, then I have no problems for people who are metabolically healthy to eat it. This is a big caution because people who are not metabolically healthy clearly need to avoid carbohydrates as much as possible. But once you get yourself metabolically healthy, there are healthy carbohydrates that are still whole real food that you can eat. You just have to be very intentional about it.

Dr. Casey Means: A really useful section of your book talks about swaps and how you can find healthy swaps for anything, especially bread, by just doing a little Googling. One of my favorite breads that I eat now is a keto non-bread that is basically just organic coconut flour, a little bit of psyllium husk, water, salt, and some olive oil. And it makes a very low carb bread that can be used for really anything. And there are dozens of those recipes out there, whether it’s almond flour or whatnot. Once you get the hang of it, pretty straightforward.

On finding doctors who “get it” …

Dr. Casey Means: Another section of the book covers “12 myths that they want us to believe.” The first question I have is, who is “they”?

Dr. Philip Ovadia: Ultimately, “they” is the healthcare system, the government policies around health. The pharmaceutical industry is part of this, the food industry. “They” is not you. One of the things I try to convey in this book is that you need to take charge of your health. 88% of the adults in the United States are not metabolically healthy. That is the result of the system that has been built around us. So if you want to continue following that system, there’s no reason to expect different results. If you want different results, you need to get out of that system.

Dr. Casey Means: Reading books like this book is one of those steps. It’s educating yourself. It’s listening to podcasts. It’s asking your doctor tough questions. One of the seven principles of metabolic health that you mentioned was that “you need to find a doctor who gets it.” Just briefly, what does that mean? How should people even approach finding that type of doctor?

Dr. Philip Ovadia: Networking comes into play, connecting with people who are getting similar outcomes that you’re looking for, who are getting healthy, and asking them, “Who are the medical professionals you interact with?” This isn’t just doctors, quite honestly. It’s the whole healthcare system and all the medical practitioners. There are also a number of good online resources I talk about in the book, some directories, some communities that are built around health that have started to assemble directories of physicians who think along these lines.

Dr. Casey Means: The directories can be really helpful: low-carb-focused doctors or the Institute for Functional Medicine has a huge provider directory of people practicing functional medicine, which is more of a root cause approach.

On why you don’t have to be obese to be metabolically unhealthy …

Dr. Casey Means: Jumping back to these 12 myths, one of them is that only obese people are metabolically unhealthy. Why is this not true? And why should someone who may be of a “normal BMI” still be thinking about metabolic health?

Dr. Philip Ovadia: When we look at those statistics—88% of adults in the United States are metabolically unhealthy—this data comes from what’s called the NHANES database. The people who were normal or underweight, 40% of them were not metabolically healthy. So it’s almost a 50/50 shot that if you are not obese, you may or may not be metabolically healthy. And the only way you’re going to know is to actively measure that. From a medical standpoint, this is what’s called the thin on the outside, fat on the inside, or TOFI.

We know that for various reasons—a lot of this gets into genetics—there are certain people who will not get obese, but instead, they’ll get metabolically healthy quickly. Whereas other people, it turns out that obesity is a little bit of a protector against getting metabolically unhealthy initially because our bodies use fat as a way to shove all this extra energy we’re taking in. So it can be somewhat protective against being metabolically unhealthy for the short-term, not over the long term. Ultimately, we know that the vast majority of people who are obese are metabolically unhealthy. But just because you’re not obese, it’s not a guarantee that you are metabolically healthy, and you need to assess it, you need to measure it in order to know.

Dr. Casey Means: For those people out there who are thin or abnormal weights, based on that NHANES data, we know that it’s possible that 40% of them are actually metabolically unhealthy. That’s amazing because we have a culture very focused on weight, which we know is a poor predictor of metabolic status if you are of a normal BMI. What are the things that those people should look at in their health metrics and health data to determine where they fall on the metabolic health spectrum?

Dr. Philip Ovadia: I always start with the five basic indicators of metabolic health; the official criteria we use as physicians. The first one you can measure at home, your waist circumference. You take a tape measure just above your belly button, you measure your waist circumference. Best to measure it first thing in the morning. And if you’re a man, you want that to be less than 40 inches, if you’re a woman, you want it to be less than 35 inches. The next measurement we look at is your blood pressure. Again, you can check it at home these days, you can check it at any pharmacy or grocery store or you can go to your doctor and get it checked. If you are on medication to lower your blood pressure, that’s already an indicator that you are not metabolically healthy. Without medication, you want your blood pressure to be less than 130 over 85.

And then the final three metrics, you need to get some bloodwork checked, your fasting blood glucose level, and you want that to be less than 100, and you want it to be without the use of medications. So again, if you’re a Type II diabetic, you’ve been put on medication, you are not metabolically healthy.

And then we look at the cholesterol. But interestingly, we don’t look at the number that everyone focuses on for cholesterol, the LDL, the bad cholesterol level, as it’s called. We actually look at the other two numbers that are on your cholesterol panel, your good cholesterol, your HDL level, and as the name implies, the higher, the better. So if you’re a woman, you want that to be over 50. If you’re a man, you want that to be over 40. Then we look at the triglyceride level: the lower, the better. Under 150 is the official cut-off.

If you know those five numbers and they are all in those healthy ranges, congratulations, you’re one of the 12% in the United States that’s metabolically healthy. If three or more of those are not healthy, you actually have the diagnosis of metabolic syndrome. And we know that metabolic syndrome puts you at very high risk of developing diabetes, heart disease, high blood pressure, cancer, Alzheimer’s disease, all of these chronic conditions that plague our society.

I tell people that if one or two of those are abnormal, it’s a warning sign because we know that people that have one or two abnormal are likely to progress to metabolic syndrome and have three or more abnormal if you give them enough time. So it’s a warning sign that you need to start making some changes to avoid metabolic syndrome.

Dr. Casey Means: What’s interesting to me about some of these criteria, though, is that I think we know that these numbers are actually fairly lenient. Triglycerides of 150 for the average patient I’m trying to optimize would be very high. And an HDL of 40, I’d be pushing them hard to get that way up towards 70, 80, 90. Blood glucose of 99 would be considered metabolically healthy when we know that actually, probably lower than that in the lower normal range is better like in the 70s to 80s.

So it’s interesting that even though this is that landmark study that we’ve been talking about— 88% of people are metabolically unhealthy—is looking at these criteria. But if we really looked at optimal metabolic health, triglycerides under 100, glucose in the 70s to 80s, I bet that number, 12%, would decline quite a bit. It’s profound. It’s profound where we are right now in this country in terms of metabolic dysfunction.

On other valuable tests for metabolic health …

Dr. Casey Means: I want to drill a little bit deeper into some of the labs. Those are the five standard criteria for metabolic syndrome. What about other tests that you use to get a little deeper into metabolic health? What are some of the other tests that you order?

Dr. Philip Ovadia: The first one that I add for all of my patients is a fasting insulin level. And I think, really, if I could only look at one blood test on people, that would be it. I struggle to understand why we don’t check that level on a routine basis. Looking through the literature around heart disease, it is almost unheard of. And quite frankly, in my personal practice now that I’ve been looking for this for over three years, I have yet to find a patient who has a normal fasting insulin level, a triglyceride-to-HDL ratio less than two, and is not a smoker who develops heart disease. It just doesn’t happen. We have medical literature looking at this as well.

So insulin is a very important marker, and we should be checking that more. The markers of inflammation, things like a C-reactive protein, are another very simple, easy-to-check blood test that can give us an idea about risk. With my background, patients often come to me with concerns around heart disease, and I do those deeper dives on lipid profiles, more than just looking at your simple LDL cholesterol level. We want to know about the size of your cholesterol particles. We want to know if they’re the inflammatory, oxidized type particles. Things like that are probably underutilized because we just stop at your LDL cholesterol number is over X. And therefore, you need to be on medication to lower it. I think that’s the wrong approach.

I base that on the outcomes we are seeing from that approach. Realize that statins have now been the most prescribed medication for 20 years. They’ve been ubiquitous in our society, and we are not seeing any meaningful reduction in the incidence of heart disease over that time. So there’s got to be something wrong again with the approach that we’re taking.

Dr. Casey Means: Just to summarize, inflammatory markers like CRP, a triglyceride-to-HDL ratio ideally less than 2:1, fasting insulin in an optimal range, and potentially advanced lipid testing. Looking at the actual particle size and oxidation status of those LDL particles so we don’t just look at the blanket catch-all LDL number and make potentially wrong assumptions. I’m just curious, what would you consider to be that optimal range for fasting insulin?

Dr. Philip Ovadia: I tell people that under 10 is acceptable. I ideally like to see it under seven, but I think under 10 is acceptable. Again, it’s going to depend on where the person is on their journey. But clearly, a level of 15 to 20, which is actually considered within the normal range on most laboratory reports, is unacceptable and is not reflective of good metabolic health. That’s one of the things that I run into a lot. Even if a patient went to a doctor who checked their insulin level, often it will be high—15 to 20—and the doctor will say, “It’s fine,” because it is in the normal range as reported by the laboratory. It needs to be under 10 for optimal metabolic health.

On whether LDL levels matter …

Dr. Casey Means: It’s interesting what you said about how you have rarely, if ever, seen people on your operating table for cardiac surgery who have a healthy insulin level because it’s not something we check in standard practice. What about LDL levels in people that you’re seeing on your operating table?

Dr. Philip Ovadia: LDL level is a big variation. About half of the patients I see have LDL levels that would be considered normal, under 120. Some of those, because they’re on medication, many of them without medications. There have been many large studies looking at this. When you look at all the patients that come in with heart attacks, for instance, half of them have normal cholesterol levels.

So that really begs the question, is cholesterol the true cause of heart disease if we see many people who come in with heart disease that have low cholesterol levels? And on the flip side, we see many people walking around with high cholesterol, high LDL cholesterol levels who have no evidence of heart disease.

Full disclosure, I’m one of them. I have a high LDL cholesterol level. I have gotten the CAC scans, and I have no evidence of heart disease. So I think that there’s a definite problem with that narrative that cholesterol is the cause of heart disease. Does cholesterol play a part in the process of heart disease? Yes, it does. But I don’t think it should be our central focus. And again, the literature supports this.

A couple of months ago, there was that study out of the Women’s Health Initiative that looked at risk factors for heart disease and having an elevated LDL cholesterol level increased your risk of heart disease. The risk factor was like 1.2. Whereas being metabolically unhealthy, having insulin resistance, raised your risk six times the baseline. So why do we focus so much on cholesterol and have zero focus on metabolic health?

On why consistent short exercise is better than one big workout …

Dr. Casey Means: Going back to those 12 myths, another one that you talk about is that the best way to burn calories is exercise is a myth. Why is it important to focus on moving more throughout the day rather than just one big workout at the end of the day?

Dr. Philip Ovadia: When you look at the literature around weight loss and exercise, it is clear that exercise alone is not an effective weight-loss tool. And the old adage that you can’t out-exercise a bad diet is very much true. Is exercise helpful? Yes. Does it have utility and do I encourage people to be more active? Yes, I certainly do. But the two problems I see are what you just mentioned. If you go to the gym, and you do whatever exercise you like, whether it’s cardio, weightlifting, whatever it is for, let’s say, an hour a day, and then you spend the rest of your day sitting around, not being active, ultimately, that is not going to be a net benefit. I would rather people incorporate movements throughout their day than do the dedicated exercise sessions. If you can do both, even better. But it’s more important to just be more active throughout the day.

Practically, that can be as simple as taking the stairs instead of the elevator or the escalator, parking further away, and walking to get into work or into the store. Taking that break every hour, take 5 to 10 minutes and walk around your office. Use a stand-up desk instead of sitting all day. These are just some practical examples that are going to have more benefit, ultimately, than trying to carve out an hour of your day, which for a lot of people becomes very difficult.

The other thing is cardio versus resistance exercise. What should your priority be when you are exercising? It’s clear from the data that building and maintaining muscle as we get older is one of the best predictors of health and longevity and our quality of life. I think the priority should be resistance exercise. That can be bodyweight exercise. That can be resistance bands. It could be lifting weights if you want, but do something that’s going to help you build and maintain muscle as you get older. And then if you have more time, feel free to do the cardio.

On why resistance training is better than cardio …

Dr. Casey Means: Yeah, it’s helpful to hear the research behind it because I think a lot of us think about exercise as cardio. We have to jump on the elliptical, the Peloton, take a run. But the data really support resistance training as very, very important for metabolic health. One line in the book I wanted to follow up on was about how doing even one set of resistance training to complete exhaustion or fatigue, where your arms give out from under you,  can maybe be enough to get where you need to go. So ifI’m doing push-ups. Is just doing one set until failure, where I actually can’t do a single additional push-up, or doing a wall sit until your legs are shaking and you have to stop– is that enough to get some benefit?

Dr. Philip Ovadia: That has been shown to have a lot of benefits. Doing resistance exercises in that style can be very beneficial. Doing one set to failure  is the stimulation to your body to make more muscle. When you do things to failure, it signals your body that, “We need to build more muscle. We’re not failing at this anymore.” So for people who are time-restrained, the most effective form of exercise you can do in short periods of time is resistance exercise with one set done to complete failure. That’s more effective than spending an hour lifting some weights and not pushing yourself to that limit.

On eating for metabolic health on any dietary approach …

Dr. Casey Means: In your book, you talk about how you can be metabolically healthy on a carnivore diet, a low carb keto diet, a Mediterranean diet, a vegetarian or vegan diet, and a gluten-free diet, but you have to be really thoughtful about each one. How is it possible, from your perspective, for each of these very different diets to all lead to optimal metabolic health? What are the features that need to be true across all of them?

Dr. Philip Ovadia: When I was writing the book, I really wanted anyone to be able to use it. I didn’t want to give the “Dr. Ovadia 28-day diet plan” and say that this is the only way to get metabolically healthy. Because quite frankly, that wouldn’t be honest.

The common feature when you look at vegans and carnivores who are metabolically healthy, is the elimination of processed foods, eating whole real food. There’s just no way to get around that. We look at all the other things in between Mediterranean, paleo, Atkins, keto, but the reality is that if you eat whole real food, whatever balance between animal and plant products you want that to fall on, you’re going to get metabolically healthy

Dr. Casey Means: This call is a testament to that. We’ve got you who, I think, follows mostly a carnivore type diet, and I’m 95% plant-based. And we are both achieving metabolic health and both very committed to eating real whole food. Just get rid of the refined stuff. It takes you a lot of the way there. For me personally, it’s been even more of a refinement. I’m fairly predisposed to metabolic dysfunction. I grew up very, very overweight. So for me actually, reducing some of the grains, even if they are whole food, is important to keep things in check. Even within a plant-based diet, moving away from some of the higher carbohydrate plant-based foods is definitely a part of my journey to achieving the best metabolic health I can have.

On how to think about carbs in these diets …

Dr. Casey Means: People might look at a Mediterranean diet and say, “Oh, okay, so I can have lots of whole grains. Or if I’m on a vegan diet, I can have lots of rice and bulgur and all these vegan grains.” Do you tend to have people try to zero in on a lower carb version of each of these diets? Or does it really just come down to sticking with the unrefined foods?

Dr. Philip Ovadia: The bigger concept that I get across to people is that metabolic health needs to be your ultimate measuring stick. Any dietary strategy someone employs that keeps them metabolically healthy, I’m going to ultimately support. The carbohydrates I find variable. Depending on your level of activity, the amount of muscle that you have, and how metabolically healthy you are to start with, are going to determine how much carbohydrate you can ultimately tolerate.

The types of carbohydrates are also important. The less-processed carbohydrates are clearly better from a metabolic health standpoint. So things like sweet potatoes, the cruciferous vegetables, these are going to be better than your fruit juices, for instance. Your measuring stick needs to be your metabolic health. This gets back to the intentionality, using something like a CGM can be a great tool for helping someone figure out the nuance of, “I can eat a certain amount of this food before it becomes metabolically problematic for me.”

I, like you, am very obviously predisposed to metabolic disease. I cannot tolerate a lot of carbohydrates. But I can tolerate more carbohydrates today than I could three years ago when I was in the early stages of this journey. Paying attention to the metabolic health measurements are what should guide us about what we should and shouldn’t be eating.

Dr. Casey Means: It speaks to the point that there is not a one-size-fits-all diet. We do have to be aware of how the diet affects us and make iterative changes. I love the point that you made about how it can change over time. You’re more carb-tolerant now, it sounds like, than you were previously as your metabolic health improved, as your insulin sensitivity improved. That’s something we talked a bit on another recent episode with one of our Levels members, Betsy McLaughlin, who lost 81 pounds using Levels.

What she realized is that at the beginning of the journey, there were a lot of foods that would spike her to the moon that were healthy foods, like sweet potatoes. But after eight months, as she dropped her insulin levels from 30 to 5 and became more insulin sensitive, she was able to tolerate those. Context matters. And a carb is not a carb. The carb interacts with the physiology of the person. That’s a hopeful message because it’s not like we’re stuck in one place forever. We have to be our own advocates for understanding how food is affecting us so we can make the best choices for our own bodies.

On why diet labels like “keto” doesn’t equal healthy in packaged foods …

Dr. Philip Ovadia: The other caution I give in the book around a lot of these popularized diets is realizing that, for instance, there are lots of products that are labeled “keto” that are clearly not going to be good for our metabolic health. They are just junk food with a different label on them. They’ve been reformulated to fit within the macros of keto, but they’re not whole real food, and they’re not metabolically healthy.

That is the other reason I don’t like giving people diet plans. I like setting up a framework for metabolic health. And you get back to the seven principles. Principle number one is you need to view your health as a system, not a goal. You can’t just be focused on, “I want to lose 20 pounds,” or, “I want my LDL cholesterol level to be this.” You have to be thinking about your health as an overall system, metabolic health to keep me healthy, to prevent me from getting these chronic diseases, and let that be the guide of the choices that you’re ultimately making.

On how to eat healthy over the holidays …

Dr. Casey Means: So we’re heading into the holidays right now. We’ve got Thanksgiving, we’ve got Christmas coming up. There’s a great section of the book that talks about how to set ourselves up for success when we go to parties, events, and restaurants. I’d love for you to just give people a few pearls on how to not just totally tank our metabolic health between November and December.

Dr. Philip Ovadia: This gets back to the intentionality around how we eat and planning in advance, putting some effort into this. It might look like eating before you go to the party. Food doesn’t necessarily need to be the focus of our social interactions. Enjoy spending time with people. Eat what is going to be metabolically healthy at the party. Plan that out in advance or at the restaurant. Look at the menu and say, “This is what is good for me to eat.”

Don’t be afraid to ask questions when you go to restaurants. What is in this dish? What is it made with? Because as I said, they find surprising ways to take foods that should be simple and make them processed and unhealthy. So don’t be afraid to ask questions. I think restaurants respond well to that. If you’re going to a party and you’re not sure what the options are going to be there, eat before you go to the party. And then when you get to the party, you don’t have to be rude and say, “Oh, I’m not going to eat any of this food,” but you can have a little bit of this and that and find the stuff that is metabolically healthier to eat, and stick to that. Those are some strategies that can help people get through those situations.

The other key tip that I give in the book that I think people should realize is that, again, you are in charge of your health. We’ve all been in those situations where you’re out with people, and you’re doing your thing to stay healthy. And they’re like, “Oh, come on, enjoy yourself. Try a little bit of this, try a little bit of that.” And you just have to have the confidence in what you’re doing and the intentionality in what you’re doing to be able to say, “I know that those foods are not going to support my health long-term. And therefore, I’m choosing not to eat them. And instead, I’m going to eat this.”

I enjoy everything I eat. I never really feel deprived. I eat when I’m hungry. I eat until I’m full. And when you’re eating whole real foods, you really can do that. Your body can actually tell you, “Okay, you’ve had enough, you’re not hungry, you don’t need to eat again,” as opposed to these processed foods that literally hijack our hunger sensors, make us more hungry, but don’t get us the nutrition that we need. People are always surprised that when they eat whole real food, they end up being hungry less often, they don’t feel deprived. You enjoy the food you eat. You can actually taste the real food as opposed to the other stuff that’s in all this processed food.

Dr. Casey Means: There’s no question that it’s that upfront investment of doing something different, and then things shift in your body. Anyone who’s been on a healthy whole foods diet for a long time, anyone I know at least, loves the food they’re eating. And a lot of us used to be totally addicted to processed food. I was completely addicted to processed food growing up and would eat Nutella by the spoonful. Could eat an entire bag of chips. I don’t want that anymore at all.

It’s incredible that our bodies can really shift their preferences, but it takes these steps towards training our body to do that by exposing it to these flavors over and over again. By getting off that glucose roller coaster of the up, down, up, down, up, down, we know that will prevent the cravings because it’s that big spike and dip in glucose that we know really drives our hunger hormones and our craving—as does, of course, sleep deprivation and many of the things you talk about in the book.

There are very  empowering tips in there for going to parties and events and restaurants. One of my personal favorite strategies is to just actually show up to the event with a few metabolically healthy things that I can eat and share with others. So it’s both selfish, but also to inspire others on what healthy passed hors-d’oeuvres can look like.

I’ll usually ask the host if they want people to bring stuff and then bring one or two things. Maybe it’s like a big bowl of mixed nuts that are dry-roasted and not covered in oils. And then some sort of cooked appetizer. I’ll do vegan stuffed mushroom appetizer, or a keto crab cake, or a charcuterie board with low carb items like flax crackers and olive tapenade. . Just something that I know I can eat that’s going to be delicious but also unrefined and low carb, so I don’t feel deprived at the party.

Sure, It takes a little bit of work and preparation. But for us to achieve our goals and work towards metabolic health, it does take having to think ahead of time. But the payoff is definitely worth it.

On healthy aging …

Dr. Casey Means: One of your 12 myths about metabolic health is that health problems come with age. And you really give a compelling case of why that’s not true, why a slow decline or death is not something that’s in our fate. Can you just speak to that a little bit and what your vision of healthy aging looks like?

Dr. Philip Ovadia: We have normalized being unhealthy in our society. The statistics show that by the time we’re 50 years old, more than half of us are going to be on multiple medications. We’ve just come to assume that it’s normal to be unhealthy as we get older. But there’s really no reason that should be. And when you look at our grandparents, our great grandparent’s generation, that wasn’t the case. When you look at the few ancestral tribal populations we have in this world, that’s not the case for them either. We need to get back to that expectation of being healthy for the majority of our lifetime.

One of the other things I see around me, the people that come to me say it’s not even that I necessarily want to live longer, it’s I want to live healthier. I want to have a better quality of life for whatever time I happen to live because, in the end, we can’t predict how long we’re going to live. There are things that happen unexpectedly that can cut our life short, but we just want to be healthy to be able to enjoy our life, our children, our grandchildren, and our families. Enjoy whatever activities we choose to do. To not be in constant pain all the time.

These are the things that have been normalized in our society, but they don’t need to be. If you’re intentional about the choices that you make, if you take back control of your health and you start to do the things that are going to support your metabolic health, you can be functional and healthy for the vast majority of your life. That should be everyone’s goal.

On how many heart surgeries are in fact preventable …

Dr. Casey Means: I know that we can’t have an exact number here, but in your estimation, how much of the heart surgery and cardiac procedures that are happening in the US every year are totally preventable if diet and lifestyle were fully dialed in?

Dr. Philip Ovadia: When you’re looking specifically at coronary artery bypass grafting—not talking about the congenital malformations and stuff like that—I would say that probably 90% to 95% of that is totally preventable if we had the proper focus on health and lifestyle.

Dr. Casey Means: That is amazing especially because, obviously, heart disease right now is one of the leading cause of death in the United States, I believe. We have around 600,000 to 700,000 people per year who die of heart disease. And to know from someone who’s literally in there doing these surgeries that it is possible to greatly reduce this mortality and morbidity, that’s huge.

What is so wonderful about your book is that it’s about personal empowerment. It’s about us taking control of our health and being our own advocates. And then you give people tools to do that. So I just want to encourage every single person listening to buy the book, read it. It could save your life. It could save a family member’s life. Thank you so much for being here, Dr. Ovadia, and where can people find you or follow up with you online?

Dr. Philip Ovadia: The book is Stay Off My Operating Table. My website has all of the information on my practice. And I’m very active on social media, mostly on Twitter @ifixhearts.