Why this heart surgeon thinks metabolic health is crucial to cardiac health

Dr. Philip Ovadia on why heart disease almost always stems from metabolic dysfunction and the changes to our medical systems that could help


Dr. Philip Ovadia has been a cardiothoracic surgeon for more than 20 years and runs a metabolic health practice called Ovadia Heart Health aimed at helping patients avoid ending the operating table. He spoke with us about how he sees poor metabolic health as the root cause of nearly all his cardiac patients and about his awakening to the importance of metabolic health.

​​Q: What inspired you, as a heart surgeon, to start focusing on metabolic health?

I attended a Society of Thoracic Surgeons meeting where author Gary Taubes was the guest lecturer. That was also around the time when his book The Case Against Sugar came out. It was the first time I had heard this information about low-carb nutrition. We’d been taught the narrative that excess caloric intake causes obesity. “Eat less, move more” was always the mantra, which—on a personal level—had failed me significantly.

Q: What was your health like at that time?

At the time, I was obese and had prediabetes. In the past, counting calories and going to the gym had helped me lose weight, but I always gained it back—something that happens to most people.

The concept of metabolic health was unknown to me. In medical school, we had the standard four-hour course on nutrition that focused on the dietary guidelines. Coupled with my training as a heart surgeon, I bought into the idea that cholesterol is the cause of heart disease. To hear Gary’s talk was eye-opening. As a result, it helped me make personal changes. I eliminated sugar from my diet and eventually got into a carnivore diet. Following a carnivore diet is not how I tell everyone to eat, but it works for me. I’ve lost 100 pounds and have maintained that weight loss for more than five years.

“In medical school, I was taught that cholesterol was the cause of heart disease. Over time, I came to believe that the real root cause of heart disease is metabolic health. Cholesterol plays a part in the process, but it’s not the entire story.”

Q: In the past, how much were you, as a cardiothoracic surgeon, thinking about metabolic health?

It was not on my radar at all. Everything was purely cholesterol-focused. Even back then, I realized that many of my surgery patients had diabetes, and many were obese. In retrospect, I wish I picked up on the fact that many didn’t have high cholesterol. And that’s not something that only I noticed. It turns out we have data on this going back many years.

Unfortunately, in medical school, I was taught that cholesterol was the cause of heart disease. And yet, the people who were on medications for cholesterol still developed heart disease. Over time, I came to believe that the real root cause of heart disease is metabolic health. Cholesterol plays a part in the process, but it’s not the entire story.

My goal with my patients now is to prevent them from needing heart surgery. I hope that I and others can influence the system enough to focus on metabolic health as both the cause and way to prevent heart disease.

Q: Looking back, why do you think that the focus on LDL cholesterol was a favored approach, even over insulin or triglycerides?

I graduated medical school in 1998, right when statins were becoming dogma. But one or two decades earlier, the narrative was completely different. When you look at the literature (in the 70s and 80s) on heart disease, you see a mixed picture between cholesterol and metabolic issues as drivers of heart disease.

I believe that what drove that narrative toward cholesterol-only was the introduction of statins. I don’t think it was nefarious. It was the first time we had a successful drug therapy for anything related to heart disease.

Heart disease isn’t that much different from other areas of medicine in that there’s no focus on prevention. We focus on treating. As stents, surgery, and statins became mainstream in the 80s and 90s, and we improved techniques, we improved survival rates. And prevention fell by the wayside even more.

Q: Have you felt any shift in the medical community, particularly the cardiac space, toward metabolic health as a cause of heart disease?

I’m certainly an outlier in the heart community. I’m not the only one, but there are certainly fewer cardiologists and cardiac surgeons who talk about metabolic health compared to those who talk about cholesterol. For me, the one thing that’s evolved over the past year or two is that I’m not shy about discussing this any longer.

There’s a fundamental lack of acknowledgment that what we eat influences our health. It’s hard to start making recommendations around improving metabolic health if you’re not going to admit that what we eat affects our health. And, our diet is the primary determinant of our health. When you go through the top 10 causes of death every year in this country, seven are directly related to poor metabolic health. With COVID, we know that poor metabolic health led to worse outcomes and a greater risk of death.

Q: How do you educate patients on metabolic health

I continue to function as a heart surgeon and, to be honest, it’s challenging for me to focus on metabolic health in that role. I do as best I can. I tell patients, “Listen. I know you’ve always heard about cholesterol. And I know you’ve always heard you have to be on a low-fat diet. But new data is emerging.”  I talk to them about some dietary changes that I recommend that are different from the mainstream recommendations.

But I make rounds every morning. Many of my patients are being served food that is horrible for their metabolic health while simultaneously being on insulin drips to manage the high blood sugar. It’s typically some pancakes, orange juice, and oatmeal. This meal is very much in line with the dietary guidelines, and there’s nothing I can do about it because the hospital is beholden to those guidelines.

It’s tough to make headway. So, I chose to set up a private concierge telemedicine practice where I work with clients on metabolic health and heart disease prevention.

Q: What do you hope to teach your patients in your private practice?

My practice focuses on dietary and lifestyle interventions that help people get off medications. I’m a big fan of continuous glucose monitors (CGMs). Our standard nutritional advice has a poor feedback mechanism because weight changes can be inconsistent and delayed. The CGM helps people make a concrete connection between what they eat and their health. Metabolic health is what I try to improve, and the weight loss and diabetes reversal (that everyone’s seeking) tend to come with it.

Q: When you look at someone’s labs, what do you pay attention to?

The first step is a good assessment, including measures like insulin level, which primary care physicians rarely check. Then, there’s the cholesterol panel. For many physicians, LDL is all they look at, and if it’s higher than the guidelines, the patient gets a statin.

To me, LDL is the least meaningful number. I care about triglycerides and HDL. The ratio between the two is a good indicator of metabolic health. Ideally, a person’s Triglycerides divided by their HDL cholesterol level should be one or less.  A ratio under two, though, is usually indicative of good metabolic health. If you get your fasting insulin level checked, the goal is to be under 20 uIU/ml with normal fasting glucose (under 100 mg/dL).

I also tell people: I’m not putting you on a diet. We’re working together to change the way you eat sustainably. This isn’t about losing X number of pounds. It’s about getting metabolically healthy. And the weight loss comes with it. And the diabetes reversal comes with it.

Q: What are you seeing in your patients in the relationship between cardiac health and metabolic health?

Heart disease is metabolic disease until proven otherwise as far as I’m concerned. And that’s in comparison to the cholesterol issue; when you look at the data for patients who undergo coronary artery bypass grafting, somewhere between 50% and 70% of them have LDL levels that are within the guidelines.

Now, a lot of those are because they’re on statins. But many of them are not. But we still focus only on cholesterol. Over the past three years is when I made the connection. And so, now, in my heart surgery practice, I look at these patients’ metabolic health.

For the past three years, I’ve been trying to find a patient with a normal triglyceride to HDL ratio and a normal A1C who’s a non-smoker that’s having coronary artery bypass grafting. I’ve yet to see one.

Metabolic dysfunction can be caused by the foods we eat and other environmental factors such as smoking and pesticides. This contributes to the development of heart disease through at least two mechanisms. The high blood sugar that occurs with metabolic dysfunction damages the lining of the blood vessels (so does smoking). Additionally, metabolically unhealthy people have more oxidized (abnormal) cholesterol that is more likely to accumulate in the plaques that build up at the site of the damage to the blood vessels.

The vast majority of the time, they are there because of poor metabolic health. And the only question is whether or not that’s been recognized. It’s not unusual that the first time a patient hears they have diabetes is when the cardiac surgeon walks in and says, “Oh, by the way, you have diabetes.”

And, unfortunately, I know now that if doctors had checked the right things, they could have picked this up earlier. Insulin resistance starts to become apparent probably a decade before the development of atherosclerotic disease. If we just start looking for this earlier, we can do a much better job of minimizing its effects.

Q: How can the system change as a whole?

The people who go into medicine want to help and are good people, but the healthcare system works against them. The unfortunate reality is that it’s built on people being unhealthy. Hospitals need unhealthy people to keep them full and pay the bills. The pharmaceutical industry needs unhealthy people to sell drugs to. The food industry’s incentives are to get people to eat more food. It’s not that these people are evil, but the goal of every business is to create more business for themselves. The healthcare industry, you could argue, should not be a business. It should be there to serve the people.

As healthcare professionals, we get educated on how to manage sick people. We don’t get educated on how to keep people healthy. And then we go into practice, and the whole system is geared toward treatment, not prevention.

To counter the narrative takes personal cognitive change. As I’ve found, when you start to question it and look around, you’re all alone. It’s almost set up so you start thinking you’re the crazy one.

However, I do think there’s change coming from grassroots efforts. Physicians and patients need to partner to start to challenge this, and I do see it happening. There is some momentum, including through organizations like the Society of Metabolic Health Practitioners. There’s a future for this, but it’s going to have to be a ground-up movement.