Mediocre Dad
8.3K posts
We have focused on relentlessly reducing ApoB burden across our population for the past 50 years
Lower targets, more meds, earlier start
Great! Important. But…
WHY is ASCVD INcreasing? It’s such a basic question that is answered by annoying mental gymnastics
Maybe because we’re missing a key point
ApoB AND insulin resistance are important. In today’s society, it’s rare to see the two separated. Rarely is someone so metabolically unhealthy that their ApoB is elevated but their insulin sensitivity is pristine. And vice versa, rarely do I see people who have amazingly well controlled lipids but their IR is crazy high
Sure YOU are different. You’re the n=1. Good for you.
But for > 50% of patients, these things are inextricably linked
Is it so crazy in medicine to realize that two conditions are somewhat dependent on one another? So crazy that the body is interconnected?
All I ask is for a little humility and nuance as we care for patients. They depend on that subtly from us, not dogmatic researchers clutching to their funding pearls
Sandeep Palakodeti, MD MPH@DrDeepMD
It’s so weird to see “expert” academic cardiologists have zero idea that insulin resistance can CAUSE elevated ApoB IR is not a mere bystander that makes things worse (although it does) It actually —> ⬆️ApoB like this: 1. Fat cells become insulin-resistant → excess free fatty acids flood the liver Normally insulin tells fat tissue to stop releasing stored fats. In IR, that “stop” signal fails, so free fatty acids pour into the bloodstream and get delivered straight to the liver. This gives the liver way too much raw fat to work with. 2. The liver gets overloaded with fat and keeps making more (even though insulin signaling is broken) High insulin levels (hyperinsulinemia) still turn on the liver’s “fat factory” genes (via SREBP-1c). The liver starts cranking out its own triglycerides through de-novo lipogenesis. So now you have extra fat coming in from the bloodstream PLUS extra fat made inside the liver. 3. Insulin can no longer break down ApoB inside the liver cells Normally insulin helps destroy extra ApoB protein before it can be packaged into lipoproteins. In hepatic IR, this cleanup step fails, so more ApoB survives and is available to build new particles. 4. The liver ramps up MTP (microsomal triglyceride transfer protein) → it packages fat + ApoB into VLDL super-efficiently Insulin normally keeps MTP turned down. In IR, MTP stays high, so the liver rapidly coats all that extra ApoB with triglycerides and cholesterol and spits out huge numbers of VLDL particles (the triglyceride-rich precursors to LDL). 5. In the bloodstream, VLDL turns into LDL – often the small, dense, more dangerous kind These VLDL particles lose triglyceride and become LDL. High triglycerides also let CETP swap fats around, and hepatic lipase then shrinks the LDL particles. Result: you get more LDL particles overall (higher ApoB) that are smaller and denser – the exact pattern seen in metabolic syndrome. So even if you pray to the alter of ApoB, then you should be just as aggressive about IR as well. And. If you can’t articulate these pathways with humility, you don’t really understand the full picture and should probably stop lecturing everyone else from your high horse
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@MichaelAlbertMD Why are you so afraid of loosing control of the sheep? Shepard Syndrome?
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People don't realize how dangerous this peptide moment is. There are millions of people taking untested drugs with no manufacturing standards.
This is far worse than Thalidomide.
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@DrBrittaniJ You’re an absolute moron if you don’t get that ITS ALL ABOUT THE FOOD!!! Wake up idiots!!!
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The entire healthcare system is on fire and THIS is what you’re fixating on?
we’re absolutely cooked ya’ll 😭
Secretary Kennedy@SecKennedy
Hospital food is notoriously appalling; So why do we serve it to patients who are trying to recover? @DrOzCMS and I are changing that system, by telling hospitals across the nation to serve REAL FOOD and remove the ultra-processed junk. Thank you, FL Agriculture Commissioner @WiltonSimpson and @Nicklaus4Kids President & CEO Matthew A. Love for leading by example in Miami.
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This week, the "AI replacing doctors" debate is back. The CEO of America's largest public hospital system says he's ready to replace radiologists with AI. The Stanford-Harvard NOHARM study shows top models outperforming generalists. The discourse is moving fast.
I run AI at @UHN, the largest hospital in Canada. Here's what I actually see.
We've developed AI models across imaging, pathology, and clinical decision support. In controlled conditions, the accuracy numbers are real. In some narrow tasks, models genuinely outperform. That's not hype. But the operational reality of running these systems inside a large hospital teaches you things benchmarks never will.
The errors that hurt patients aren't the confident wrong answers. They're the quiet omissions, i.e., the thing the model didn't flag
because it wasn't in the training distribution. NOHARM found 76.6% of AI errors were omissions. We see this too. And in a hospital, a missed finding doesn't just affect one case. It propagates: the downstream physician trusts the AI read, the patient waits, the window closes.
The accountability structure also doesn't exist yet. When an AI-assisted diagnosis leads to harm, who is responsible: the physician, the hospital, the vendor? In Canada, we don't have a clear answer. No hospital system deploying AI at scale does. That's not a regulatory delay. That's a fundamental gap in the infrastructure for AI-in-medicine.
What I'm genuinely optimistic about: AI is already changing how our radiologists work. Not replacing them, but changing the shape of the job. Routine reads get faster. Their time shifts toward complex cases, clinical correlation, cases where the AI flags uncertainty. That's the right direction.
But "ready to replace radiologists" skips 10 hard years of work on deployment infrastructure, liability frameworks, clinician training, and failure mode monitoring that nobody wants to talk about because it's less exciting than accuracy benchmarks.
The capability question is nearly answered. The deployment question has barely been asked.
CEO story:
beckershospitalreview.com/radiology/nyc-…
NOHARM paper:
arxiv.org/abs/2512.01241
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"Your LDL is high. We should discuss statins."
Cool. Let's also discuss:
- Your HDL (up)
- Your triglycerides (down)
- Your triglyceride/HDL ratio (excellent)
- Your fasting insulin (normal)
- Your blood pressure (textbook)
- Your inflammation markers (low)
- Your waist circumference (good)
- Your energy, sleep, and mood (transformed)
Or we could just look at the one number that confirms the hypothesis your doctor learned in 1994.
Either way.
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The HHS Secretary is lying. Nutrition and biochemistry content is already 10-15% of USMLE Step 1 for physicians.
The ROOT CAUSE of poor diet is COMPLIANCE. We cannot educate patients into adherence if they are unwilling.
So much BS.
Secretary Kennedy@SecKennedy
Last month, I had the pleasure of meeting with medical students from across the country to discuss the importance of nutrition education in medical schools. Nutrition is a key component in addressing the chronic disease epidemic to Make America Healthy Again.
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@SukritBhatia1 @ifixhearts This is what I’ve always said to my patients. LDL lowering drugs are given by sick doctors, using a sick studies in a sick profit system to sick patients. Wake up
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Insulin resistance is a much bigger risk factor for heart disease than LDL cholesterol.
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@NutritionMadeS3 This is ONLY true in sick metabolically unhealthy people. Fix our food system & no one needs these crap ass big pharma drugs 🙄
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The scientific support for atherogenic lipoproteins causing heart disease has become overwhelming
If this isnt´t clear to you, you´re not being exposed to solid sources, I encourage you to make a radical change
Your life and your family´s depend on it
Michael Albert, MD@MichaelAlbertMD
The cholesterol wars are over. LDL won. New guidelines. Four landmark trials. An oral PCSK9 inhibitor that matches injectables. And data proving we should be treating patients we currently aren't. Here's everything clinicians need to know. 🧵
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@MichaelAlbertMD This is a study by sick people, on sick people & for sick people. Us metabolically healthy folks with fasting insulins <5, hsCRP’s < 0.7 & high LDL’s are all good. Thanks sick doctor 🙄
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The cholesterol wars are over.
LDL won.
New guidelines. Four landmark trials. An oral PCSK9 inhibitor that matches injectables. And data proving we should be treating patients we currently aren't.
Here's everything clinicians need to know. 🧵
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@matthewbaszucki Add fermented foods & your labs will thank you 💪🏻
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Carnivore is SO GOOD....but I do love heavy cream & butter, so I do include that....... 🥩 🥓 🍖 one or two meals/day, no more!
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@DrBrittaniJ Fixing food is more important than nursing ratios. Why do you idiots always want to fix a broken toilet in a house that’s on fire 🙄
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Fixing nursing ratios will save countless more lives than changing hospital vending machines.
And yet…crickets.
That’s why I’m frustrated.
MAHA Action@MAHA_Action
“It makes no sense that 90% of pediatric wards in America… have full sugar soda machines.” Calley Means says it’s completely backwards that hospitals treating chronic illness are still serving patients unhealthy food and sugary drinks. “It makes absolutely no sense that hospitals are serving sugary drinks and processed food, inflammatory food, to patients.” “CMS… is saying hospitals treating patients with chronic diseases should not be serving sugary drinks, should not be serving refined carbohydrates, and should not be serving ultra-processed food.” “There's actually been historic progress, which the media doesn't seem to want to cover.” “This is uniting.” @calleymeans
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@Manderville_RD I eat ketovore & my LDL is high, but my ApoB is 58, but the reason is my fasting insulin is 4. RD? Eyeroll
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People who claim LDL doesn't matter never seem to explain what to do if ApoB is high.
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Why aren’t any of these at risk hospitals publishing their full accounting so everyone can see where they spend their money ?
All but one group of hospitals that I have looked at potentially investing in, spend so much on consultants and fees that it’s no wonder they are at risk
Plus, I have NEVER seen an industry that is worse than hospitals when it comes to buying medications and items like implants, screws, other devices. They overpay for everything.
And then when you show them how to save money, their “supply chain” employees resist any change.
They are so set in their ways, it’s a shock more don’t go out of business.
Prove me wrong.
NBC News@NBCNews
More than 400 hospitals across the U.S. are at high risk of closing or cutting services because of the Medicaid cuts in President Trump’s “big, beautiful bill,” according to an analysis from the progressive watchdog group Public Citizen. nbcnews.com/health/health-…
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Let me help rephrase for you Bernie.
Need a loan for college so you can party for a semester and drop out? Taxpayers will loan you money for it.
Need an SBA loan for your business ? Taxpayers will guarantee it.
For a house ? Taxpayers will guarantee it. And local gov will give you money for your first down payment !
Get sick or are in an accident and you can’t afford your deductible, insurance company denied prescribed care or are uninsured ?
You are on your own 😤
Let me add Bernie, the one debt not a single one of us will ever pay off till the day we die ? Our health insurance premiums
And before you go in and on about single payer, ask @claudeai to take a look at your proposed Single Payer legislation.
You want the Sec of HHS to run it. You can’t have a political appointee run an apolitical position
And you expect every provider and doctor to accept whatever rate is set by Medicare. Big hospitals don’t know their costs. They couldn’t do a BOM for any procedure. They have negligible transparency.
If they don’t know their costs, and you don’t know their costs, how is it possible for taxpayers, caregivers and patients to get a fair deal ?
And the concept of “every other country does it “ ignores the fact that they all converted decades and decades ago, long before you and your peers allowed the extreme vertical integration we face now.
Which leads to the question. @BernieSanders , why have you not advocated for the Break Up Big Medicine Bill ?
Bernie Sanders@BernieSanders
Health care? "You're on your own." Housing? "Nothing we can do." Grocery prices? "You're out of luck." $200 billion for another war? "No problem!" Americans—Democrats, Republicans, independents—are SICK AND TIRED of endless wars. We need to invest here at home.
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@ScottAppliedSci Same as the the percentage left of your hair & testosterone
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For the pedants, your brain is still under 20% cholesterol by dry weight. Still not "mostly cholesterol". Time to stop this statin-phobe nonsense like whack-a-mole.
Andrew Scott@ScottAppliedSci
Only 2-3% of the human brain is made of cholesterol. Like other organs, the brain is about 70% water.
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@marklevinshow You are a coward, sir. Go debate him if you’re not afraid
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You’re an evil lowlife
Dave Smith@ComicDaveSmith
Those damn Nazis and their non-interventionist foreign policy! Fucking clown.
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@donwinslow Get in line comrade or your out of the leftist love fest 😂
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...A massive and epic fucking disappointment.
Esta@TheOnlyEsta
Fill in the blanks John Fetterman is a _________
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