u/DadStrengthDaily

My last lipid panel came back with LDL of 60 mg/dL. That's sitting right on the line the new 2026 ACC/AHA dyslipidemia guideline drew for very-high-risk patients: <55 mg/dL. The guideline does not go lower than that.

My May 2026 lipid panel

That bothered me a little. The trial evidence keeps going lower. In FOURIER-OLE, the long-term extension of the evolocumab outcomes trial, achieved LDL kept reducing cardiovascular events all the way down past 20 mg/dL. Lower kept being better. So if 55 is good and 30 is biologically better, why did the guideline stop at 55?

The editorial that accompanies the new guideline answers this. Gregory Schwartz, JACC. The argument is a cost ladder, and I think it's the most useful piece of cardiology economics I've read this year.

The numbers come from PROVE-IT (the post-ACS lipid trial). On atorvastatin 80 mg alone, 35% of patients reach LDL <55. Add ezetimibe (also generic, $20-30 a month), and 55% get there. Roughly half of high-risk patients can hit the guideline target on two generic pills, combined cost of $20-40 a month.

Beyond that, the math gets ugly fast.

https://preview.redd.it/xgfapm4emh2h1.png?width=1536&format=png&auto=webp&s=1a30d9c76382d5a9f5e4ea478d9f4ac7f4c9a4f1

  To push below 55, 45% would need a third drug. That third drug is almost always a PCSK9 inhibitor. List price is around $6,000 a year, but the realistic cash price through GoodRx for Repatha (the most-prescribed one) runs about $2,900 a year right now. To push below 30, more than 90% would need the third drug.

The benefit you're buying for that money? FOURIER-OLE showed about 1 percentage point of absolute reduction in cardiovascular death, MI, or stroke over 5 years when you go from achieved LDL 55 down to 40. That's the trade: thousands of dollars for a year for a 1-point absolute risk reduction at 5 years.

 Schwartz's conclusion: the 55 mg/dL target is "a judicious distillation of current evidence, balancing clinical efficacy with cost and complexity of care." Translation: the guideline picked 55 because that's where two generic drugs land most people, and going lower as a population-level recommendation still costs meaningfully more than the marginal benefit justifies. For someone with high Lp(a) or strong family history of premature ASCVD, the math at $3K/year tilts more toward "yes" than the list-price math used to.

For me at LDL 60, this means I'm still done. The math doesn't support adding a PCSK9 inhibitor unless something else changes. For someone with a high Lp(a), bad family history, or established cardiovascular disease with multiple events, the math is different and the case for the third drug is stronger.

I wrote up the full 2026 guideline (PREVENT calculator, CAC scoring upgrade, ApoB targets, all the drugs in plain English) here: Reading Your Cholesterol Panel at 50. The cost ladder above is one piece of a longer story.

I see at least one of these takes in my feed every couple weeks. The reasoning shifts but the tone doesn’t. Guidelines are wrong, your doctor is hiding something, Big Pharma and the government are pushing statins on everyone, the brave skeptic has cracked the code.
I’ve gone looking for a clean rebuttal more times than I want to admit. James Stein, who ran the UW preventive cardiology program for 21 years.

His core argument is that the U-shaped mortality curve people love to cite, where low cholesterol appears to predict higher death rates, isn’t biology reversing direction. It’s confounding. Low cholesterol can mean low cardiovascular risk. It can also mean cancer, malabsorption, chronic inflammation, or frailty. Mix those people into the data and the left tail goes up. Once you exclude early deaths and adjust for illness markers, the upturn shrinks.

He also picks apart the more sophisticated version. People grab the recent NEJM paper from the Global Cardiovascular Risk Consortium that dichotomized non-HDL cholesterol at 130 mg/dL and showed modest lifetime contrasts. The authors noted the real association is J or U shaped, but the modeling choice flattened it. Read casually, it looks like cholesterol barely matters. Stein’s point: that’s an accounting exercise about one threshold at one age, not a finding about biology.
His closing line, lightly paraphrased: there is no cholesterol debate at the causal level. What keeps coming back isn’t new biology. It’s misreads of risk data.

Worth a read if you’ve ever tried to argue with this stuff: https://jamesstein18.substack.com/p/why-cholesterol-is-debunked-arguments

The “cholesterol is debunked” takes aren’t a scientific position. They’re a content strategy.​​​​​​​​​​​​​​​​

I like Rhonda Patrick, and I think microplastics are a real public-health concern. We should probably touch fewer thermal receipts, stop putting hot food and coffee in plastic, and take plastic exposure more seriously.

But this Jack Neel video is a mess. Neel’s creator/agency page describes him as the “largest horror/true crime genre influencer on TikTok,” which explains the whole vibe. This is health content packaged like a murder documentary.

The video opens with sperm counts down, testosterone down, microplastics in semen and testicles, and “chemicals quietly castrating American men.” Then it asks whether we’re raising the “least masculine generation” of men. A few minutes later, the endocrine-disruptor segment cuts into a sponsor read for “clean” men’s shampoo with “no hormone disruptors.” That is almost too perfect.

Some of the concern is real. Sperm counts do appear to have declined. Microplastics have been detected in human reproductive tissue. Thermal receipts and hot plastic packaging are reasonable things to avoid when it’s easy.

But the testosterone-collapse story is much shakier. Barbell Medicine’s recent series makes the boring point that the scary headline version is overstated, and that low testosterone in adult men is often better explained by visceral fat, poor sleep, sleep apnea, illness, medications, low energy availability, or overtraining than by one scary modern toxin.

That distinction matters. “Sperm counts are down” and “young men are being chemically castrated by receipts” are not the same claim.

So yes: digital receipts, don’t microwave plastic, avoid hot food in plastic, use glass or stainless when practical, consider a real water filter, sleep more, lift weights, eat fiber, and keep your waist under control.

That’s useful. The horror-podcast packaging is not.

I posted about ACHIEVE-3 back in February. That one was the head-to-head of Lilly's oral orforglipron against oral semaglutide in type 2 diabetes. Interesting result, not my question.

My question, after 18 months on Zepbound and now at the weight and body fat I actually want to hold, is the boring and slightly terrifying one. What does maintenance look like, and is it really lifelong.

ATTAIN-MAINTAIN, published May 13 in Nature Medicine, is the first trial that goes after that directly. Patients who finished SURMOUNT-5 on injectable tirzepatide or semaglutide came off the shot and were randomized to daily oral orforglipron or placebo for a year.

The headline says the pill worked. The numbers are more honest. People switching from tirzepatide kept 74.7 percent of their body weight reduction. People switching from semaglutide kept 79.3 percent. The pill mostly holds the line, but you give back roughly 20 to 25 percent of what you lost. The tirzepatide arm gained about 11 pounds back over the year. The semaglutide arm about 2.

For me, stopping is not on the table. The real choice is keep injecting at the current dose, drop to a lower maintenance dose, or move to the pill and accept some giveback. ATTAIN-MAINTAIN does not test a lower-dose injectable arm, which is the comparison I actually want to see. It also does not break out how much of the regain is fat versus muscle and bone.

A Lilly-funded trial at Lilly's preferred academic centers. Definitely interesting, but not the last word.

I started this sub because I wanted a place to talk about preventive health where the people on the other side of the screen both knew what they were talking about (or at least did sincere research) and wasn’t selling me anything. Pew Research dropped a study last week that confirms how rare that combination is online.

Pew analyzed nearly 13,000 health and wellness accounts with at least 100,000 followers on Instagram, TikTok, and YouTube. Forty percent of U.S. adults, and half of those under 50, now get health information from influencers and podcasts. Fewer than one in five are conventional medical professionals. Sixteen percent list no credentials at all. The rest of Pew’s “healthcare professional” bucket is padded with chiropractors, naturopaths, massage therapists, and functional medicine practitioners.

That’s the education problem. There’s a financial problem layered on top. Nearly half of these influencers describe themselves as coaches or entrepreneurs. Their business model is selling a program, a supplement, a course, or an affiliate link. Platforms reward whoever monetizes hardest, and everyone drifts toward something to sell.

A 2025 JAMA Network Open study made the mechanism concrete. Researchers at the University of Sydney analyzed 982 Instagram and TikTok posts about five popular medical tests: full-body MRI, multi-cancer early detection, AMH “egg timer,” gut microbiome, and testosterone. Sixty-eight percent of posts came from accounts with a direct financial interest in the test. Eighty-seven percent mentioned benefits. Fifteen percent mentioned harms. Six percent mentioned overdiagnosis risk. Six percent cited any scientific evidence at all.

Accounts with a financial interest were about six times more likely to take a promotional tone, and far less likely to mention harms or overdiagnosis. The selling shapes what gets said. You won’t hear that the AMH test isn’t a reliable measure of fertility from someone selling fertility consults, and you won’t hear that BPC-157 has barely any human evidence from someone selling peptide stacks.

Rachel Moran, a health misinformation researcher at UW, put it best in the NYT writeup (gift link): “They offer certainty: ‘Buy this product, take agency over your life in this way, sign up for this program of mine.’ Medicine can’t always offer you that.”

The credential problem and the financial problem are the same problem. An audience that can’t tell evidence from anecdote also can’t tell sponsored content from sincere advice. The bar should be both: does the person actually know what they’re talking about, and would they say the same thing if there were no money in it? Almost nothing online passes both.

I have basically no hobbies outside of working out, so I went into this paper ready to dismiss it.

The study looked at 3,556 adults in the UK Household Longitudinal Study and asked whether arts/cultural engagement and physical activity were associated with seven epigenetic aging clocks. Arts/cultural engagement meant things like music, dancing, painting, photography, crafts, museums, galleries, libraries, archives, historic sites, and cultural events. Physical activity was measured separately.

The results were not “art makes you live longer.” The older first-generation clocks showed basically nothing. But the newer clocks — PhenoAge, DunedinPoAm, and DunedinPACE — did show slower epigenetic aging in people who were more engaged in arts/culture and in people who were more physically active. The effect sizes were apparently similar enough that the authors compare arts/cultural engagement to physical activity.

This is where my skepticism kicks in hard.

People who go to museums, sing in choirs, take classes, dance, do photography, make things, or visit historic sites are probably different in a thousand ways from people who do none of that. They may have more money, more free time, better mobility, better mental health, stronger social ties, more education, less loneliness, and fewer life constraints. The authors adjusted for a lot, including socioeconomic factors, smoking, drinking, BMI, and health status, but this is still observational. You cannot model your way into certainty.

Also, epigenetic clocks are not the same thing as hard outcomes. I care much more about whether people avoid heart attacks, dementia, falls, frailty, disability, and early death than whether a methylation algorithm moves a little. Interesting signal, not proof.

But the annoying part is that the result is still plausible.

A lot of “longevity” culture collapses into exercise, sleep, diet, lipids, glucose, supplements, wearables, and lab work. I’m guilty of this too. My default leisure activity is just more training. This paper is a reminder that a healthy life might need something less measurable: hobbies, culture, creativity, social identity, novelty, and reasons to leave the house that are not just zone 2 or errands.

I do not think anyone should read this and force themselves into museum optimization mode. But I am taking it as a nudge that “I lift and do cardio” may not be a complete adult life.

For those of you who actually have hobbies: what has felt health-giving in a way that is not just another workout?

STAT’s new alcohol series is brutal, but the most useful part is not the giant public-health argument. It is the tiny moment in a 15-minute physical where everyone pretends “socially” is a medical answer.

Alcohol kills nearly 500 Americans a day, according to STAT. Their chart on page 7 puts alcohol-attributable deaths at 178,000 a year — more than opioid-related causes — with deaths from heart disease and stroke, alcoholic liver disease, cancer, alcohol poisoning, crashes, and other causes all stacked together. The page 3 chart shows alcohol-specific ER visits climbing to 5.4 million.
And yet at a normal checkup, alcohol often gets handled like small talk.

“How much do you drink?”

“Socially.”

Box checked. Move on.

That is insane if you think about how we treat everything else. Nobody says their LDL is “social.” Nobody says their blood pressure is “weekend-ish.” Nobody tells their doctor their A1c is “mostly with dinner.”

STAT’s second piece is about this exact failure. Alcohol screening and counseling are often rushed or skipped, even though there are evidence-backed tools that can fit into a short primary-care visit. STAT reports that in one study, 30% of people with alcohol use disorder were not asked by their clinician about drinking at all. In another example from recorded VA visits, a patient said they drank six to eight beers at a time and the clinician just changed the subject.

The fix is not complicated. AUDIT-C is three questions: how often you drink, how many drinks you usually have, and how often you have six or more in one sitting. STAT says it can identify unhealthy drinking patterns quickly, including people who do not meet criteria for alcohol use disorder but are still drinking enough to affect long-term health.

The part I would actually use: at your next physical, don’t say “socially.” Say the boring number.

“I average 8 drinks a week.”

“I have 2 most nights.”

“I usually don’t drink during the week, but I’ll have 6–8 on Saturday.”

“I use it to fall asleep.”

“I’ve tried to cut back and it was harder than I expected.”

That gives your doctor something real to work with. Blood pressure, sleep, liver enzymes, cancer risk, anxiety, depression, weight, reflux, AFib, medication interactions — alcohol touches a lot more than people want to admit.

STAT also shows this can work at scale. Kaiser Permanente Northern California built alcohol screening into primary-care workflows in 2013. Now more than 90% of patients are asked specific alcohol questions at primary-care visits. They have done over 24 million screenings and 1.4 million brief interventions. Patients who got a brief intervention had larger reductions in health care costs, including ER costs, and some analyses found fewer drinks and heavy-drinking days among people with hypertension.

This is the part of “preventive health” that does not look sexy on a podcast. No wearable. No peptide. No supplement stack. Just asking a direct question and giving a direct answer.

How much do you actually drink? Not your identity. Not your story. The number.

I didn’t really follow Liver King. He was just everywhere — hard to miss a shirtless guy gnawing on raw bull testicles — but he wasn’t my thing and I mostly scrolled past. What I couldn’t figure out was why getting completely exposed as a fraud in 2022 didn’t end his career. His supplement businesses reportedly do $100M a year. The $25M class action from his own fans got dropped. He got a Netflix documentary.

A paper just came out in Television & New Media — Alison Miller and Lee McGuigan at UNC — that gave me the framework I was missing.

Some details I didn’t know: his flagship supplement lists testicle and prostate first among its ingredients, based on the “doctrine of signatures” — a medieval and thoroughly debunked idea that consuming something resembling a body part will benefit that body part. He also sells “Barbarian Water,” laced with bull blood. His website has a section titled “Net Worth” that reads like a startup pitch deck, including this line: “You are never enough… you are never enough, and the minute you think you are, you coast, you rest, you decay, you die, you suck at life.”

The paper’s key concept is borrowed from professional wrestling: kayfabe. In wrestling, everyone knows the match is scripted but the performers maintain the fiction and the audience participates knowingly. The paper argues Liver King was running kayfabe from day one — a “porous identity” where he was never fully committed to the “100% natural” claim, and his audience was never fully credulous. They were in on a performance.

So when the leaked emails came out — $11,000 a month on steroids and HGH — it didn’t shatter a belief system so much as shift the terms of the show. He cried on camera, admitted it, came back as “Liver King 2.0” with cigars, firearms, a cowboy hat, and a golden knife he sells on his website. He admitted in August 2023 he’d resumed steroids, then turned that into content too. A heel turn, in wrestling terms.

The Peterson connection is more direct than I realized. There’s an actual TikTok in the paper captioned “Liver king eating eyeballs to pregame Jordan Peterson tonight.” The paper’s argument is that the recovery of “authentic masculinity” is the central product across all three acts — Liver King, Tate, Peterson — sold to the same audience, with different packaging.

There’s also a body horror coda: the paper notes injuries to his eye, arm, and internal organs. Growth at all costs turns out to have costs.

The reason this matters here: you can’t debunk a kayfabe act with evidence, because the audience was never operating on the assumption of literal truth. That’s why the “but the science says” response to these figures consistently fails. You can’t debunk a wrestling match.

Sam Neill announced last month that his stage 3 blood cancer is in complete remission after a CAR-T clinical trial in Sydney. The Guardian followed up this weekend with a piece on what the science means and why researchers describe it as a major step forward for cancer treatment more broadly.

CAR-T therapy takes a patient’s own immune cells, engineers them in a lab to recognize cancer, and puts them back in. It’s been around for about a decade and has produced real cures, but every approved CAR-T drug works on the same family of blood cancers, the kind that come from B-cells. Seven approved in the US, four in Australia, all for B-cell cancers or multiple myeloma. None of them work for what Sam Neill has.

Neill has angioimmunoblastic T-cell lymphoma, AITL. It’s a cancer of T-cells, the other major branch of the immune system. CAR-T didn’t work on T-cell cancers for a long time because CAR-T cells are themselves T-cells. Engineer them to kill T-cell cancer and they kill each other in the manufacturing tank, and they wipe out the patient’s healthy T-cells too, leaving them with no immune system. Researchers worked on this problem for thirty years.
AITL is brutal. Five-year survival on standard chemo is about 30 percent. When chemo stops working, which it did for Neill after three years, most patients are out of options. He told 7News he thought he was on the way out.

The trick the trial pulled off was finding a marker on the cancer that’s only on half of healthy T-cells. T-cell receptors come in two versions. Normal people have a mix. But each cancer is a clone of one cell, so every cancer cell carries the same version. Target only that version and you kill the cancer while sparing the other half of the patient’s healthy T-cells. That’s enough to keep the immune system working.

The published trial using this approach reported encouraging results in Nature Medicine in November 2024. Of ten patients with relapsed T-cell lymphoma, six responded. At the highest dose, all four patients responded. The two longest remissions, both still going past 18 months, were patients with AITL, Neill’s exact diagnosis. Small trial, early data, but for a disease with no standard treatment after first-line failure, that matters.

I can’t confirm Neill was in this exact trial. The news coverage hasn’t named his protocol, and the published trial’s sites were UK and Spain, not Australia. Several T-cell CAR-T trials are running with different targets. The point is the whole category is moving.

This is what actual cancer progress looks like, and it’s a useful contrast to the wellness internet. Thirty years of immunology to find a tiny biological difference that lets you treat a brutal cancer without destroying the patient. No supplement stack does anything close.

The Guardian piece closes with one of the researchers saying “hope is warranted, but so is impatience.” Neill got a trial slot in Australia. Most patients with relapsed AITL won’t. That gap is the part of this story that doesn’t make the entertainment pages.

A new JAMA piece on GLP-1s and exercise hit close to home for me.

I get annoyed when people act like GLP-1s are just “take a shot, get healthy.” That is not how it felt from the inside.

Yes, the drug helped. A lot. It quieted the food noise and made it easier to eat less. I’m not going to pretend that part was willpower.

But the injection didn’t make me train every day. It didn’t fix my diet. It didn’t make me prioritize protein, go to bed earlier, or keep showing up when I didn’t feel like it.

It gave me room to do those things.

The JAMA authors make a useful distinction: exercise has strong “efficacy,” meaning it works under ideal conditions. The problem is “effectiveness,” meaning what happens in real life when people are tired, busy, sore, discouraged, or just don’t stick with it.

That feels right. Exercise works. But only if you actually do it.

The same goes for GLP-1s. They can move the scale, but they don’t build muscle, fitness, or a routine for you. And since a lot of people stop these drugs and regain weight, the habits underneath matter.

So yes, the medication helped me lose weight.

But the habits are what made me healthier.