A Tennessee family physician with a large online following is challenging one of the most familiar assumptions in heart-disease prevention: that LDL cholesterol should dominate the conversation.

Dr. Ken Berry, a family physician and low-carbohydrate diet advocate, argues in a widely viewed YouTube presentation that doctors and patients often focus too heavily on LDL cholesterol while giving less attention to larger cardiovascular risk factors, including type 2 diabetes, metabolic syndrome, hypertension, obesity, smoking, high triglycerides and insulin resistance.

Berry’s argument is blunt. In the video, he says patients should focus first on the “biggest pieces of the pie” when trying to reduce heart-attack risk. He points to a 2021 JAMA Cardiology study that examined more than 50 clinical and biomarker risk factors for coronary heart disease among women.

The study does not prove Berry’s full dietary argument. It does, however, support one of his central claims: metabolic dysfunction was strongly associated with premature coronary heart disease, and in that analysis, several metabolic risk factors had larger relative associations than LDL cholesterol alone.

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Diabetes and Insulin Resistance Stood Out

The JAMA Cardiology study followed 28,024 women aged 45 or older who were enrolled in the Women’s Health Study and had no known cardiovascular disease at baseline. The median follow-up was 21.4 years. Researchers examined more than 50 risk factors and biomarkers, including standard lipids, inflammatory markers, metabolic markers and lipoprotein particle measures.

The strongest clinical risk factor was diabetes. Among women who developed coronary heart disease before age 55, diabetes was associated with an adjusted hazard ratio of 10.71. That means women with diabetes in that group had more than ten times the relative risk of coronary heart disease compared with women without diabetes, after adjustment for selected factors.

Other major clinical risk factors also showed strong associations in women under 55. Metabolic syndrome had an adjusted hazard ratio of 6.09. Hypertension was 4.58. Obesity was 4.33. Smoking was 3.92.

The study also found that a lipoprotein insulin resistance score, known as LPIR, had the strongest association among approximately 50 measured biomarkers. For coronary heart disease onset before age 55, LPIR had an adjusted hazard ratio of 6.40.

That finding matters because LPIR is not a standard cholesterol number. It reflects an insulin-resistant lipoprotein pattern, often involving high triglyceride-rich particles, altered LDL particle patterns and metabolic dysfunction.

LDL Was Associated, But Lower on the List

LDL cholesterol was not irrelevant in the JAMA analysis. It was associated with increased coronary heart disease risk. But the size of the association was smaller than the major metabolic factors.

For women under 55, LDL cholesterol had an adjusted hazard ratio of 1.38 per standard deviation increase. Non-HDL cholesterol was 1.67. Apolipoprotein B, or ApoB, was 1.89. Triglycerides were 2.14.

That distinction is where Berry’s argument gains traction but also requires caution.

It is fair to say the study showed diabetes, metabolic syndrome, hypertension, obesity, smoking and insulin resistance had stronger relative associations with premature coronary heart disease than LDL cholesterol alone. It is not fair to say the study proved LDL does not matter.

The study’s authors specifically noted that LDL cholesterol and non-HDL cholesterol were associated with premature coronary heart disease risk. They also found that LDL particle number, small LDL particles and smaller average LDL size showed stronger associations than LDL cholesterol alone.

That is an important wrinkle. The study does not simply clear LDL from suspicion. It suggests that particle patterns, insulin resistance and metabolic context may matter more than a single LDL cholesterol number.

Berry’s Diet Claim Goes Beyond the Paper

Berry uses the study to argue for a very-low-carbohydrate, ketogenic or carnivore-style diet, saying such diets can improve or reverse many of the largest risk factors: type 2 diabetes, metabolic syndrome, high triglycerides, obesity and hypertension.

The JAMA study did not test keto, carnivore or any specific diet intervention. It was an observational cohort study. It identified associations between risk factors and later coronary heart disease, but it was not designed to prove which diet prevents heart attacks.

Still, the diet connection is not random. Low-carbohydrate diets are often associated with lower triglycerides, improved blood sugar control, weight loss and better insulin dynamics in people with metabolic disease. Those are several of the same risk categories highlighted in the JAMA paper.

The stronger conclusion is therefore narrower: if a diet improves diabetes, insulin resistance, triglycerides, blood pressure and obesity, it is acting on several of the highest-risk categories identified in the study.

Whether carnivore is the best or safest way to do that for the broader public remains a separate question.

The Practical Takeaway

Berry’s video is confrontational, but the underlying challenge is reasonable: heart-disease prevention should not be reduced to LDL cholesterol alone.

The 2021 JAMA Cardiology study supports a broader risk model. In women, especially those with earlier-onset coronary heart disease, diabetes and insulin resistance stood out as major risk signals. Hypertension, obesity, metabolic syndrome and smoking also ranked high.

For patients, the practical questions may be broader than “What is my LDL?”

They may include: What is my A1C? What are my triglycerides? What is my blood pressure? Do I have metabolic syndrome? What is my waist-to-height ratio? Do I smoke? What is my ApoB? Do I have high small LDL particle burden? Is there evidence of inflammation? Has imaging, such as coronary artery calcium scoring, shown plaque?

Berry’s claim should not be read as permission to ignore LDL or ApoB. But the JAMA data undercuts the idea that LDL cholesterol alone is the master key to heart-risk prediction.

The more accurate message is sharper: metabolic disease is not a side issue in cardiovascular risk. For many patients, it may be the main event.

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Dave Soulia | FYIVT

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