the skeptical cardiologist weighs in
dairy fat, saturated fat, cholesterol, tests to order and more
Dr. Anthony Pearson calls himself The Skeptical Cardiologist — and the story of how he earned that title is one I think many of you will find both surprising and deeply validating.
For three decades, Dr. Pearson practiced conventional cardiology and counseled his patients accordingly. Then came a lunch that changed everything.
“For 30 years, I followed and counseled my patients on dietary guidelines that I assumed were solidly based in science. I drank skim milk, ate low or no-fat yogurt, avoided butter like the plague, and had egg-white omelets.”
In 2013, he found himself lecturing his lunch companion — his now-wife, whom he affectionately calls “the eternal fiancée of the skeptical cardiologist” — on her decision to order a croissant slathered with butter.
“When she challenged my supporting evidence, I went on a quest to discover the scientific sources underpinning my recommendations.”
What he found — or more precisely, what he didn’t find — sent him down a path that would fundamentally reshape how he thinks about diet, cholesterol, and heart health.
I’ve been looking forward to this conversation for a long time. Dr. Pearson brings an evidence-based, genuinely skeptical perspective and is refreshingly willing to say “I was wrong.”
Beth: How has your practice of cardiology changed since you shifted your own dietary approach? What do you tell patients now versus what you told them 15 years ago?
Dr. Pearson: My focus shifted from emphasizing low fat to emphasizing eliminating added sugar and minimizing refined carbohydrates and ultra-processed food.
There are five things that I used to believe that I no longer teach medical students or tell my patients
Dietary dairy fat increases the risk of cardiovascular disease
Dietary cholesterol should be limited
All saturated fats are bad for you
All unsaturated fats are good for you
Because a gram of fat has 9 calories and a gram of carbohydrates has 4 calories, substituting carbs for fat will lead to weight loss.
Beth: You’ve published over 100 research papers and been a principal investigator on clinical trials. How has that experience shaped your “healthy skepticism” toward medical and scientific information?
Dr. Pearson: I was an academic cardiologist for the first 10 years of my career, and I got to see the machinations behind the curtain
There is a complex relationship between the doctors who help develop new technology or drugs and the industries that want to make lots of money off these products. These relationships create not only financial conflicts of interest but subtle biases in the way studies are performed, analyzed, and interpreted.
In addition, the need for publication to advance academic careers drives the production of poor-quality science and misleading conclusions.
It takes a lot of effort to detect these biases and sort the wheat from the chaff in the scientific literature
One of my favorite perks of being a paid subscriber at Nest Wellness is access to our community chat — and Dr. Pearson has kindly answered our community questions below!
community questions
Ann asks: How can a low glycemic diet help cardiovascular health, and can it reverse or slow existing conditions? What’s the connection between blood sugar control and heart disease that most people don’t understand? You emphasize being more concerned about low-quality carbs and hidden sugar than about the type of fat. Can you explain why?
Dr. Pearson: I wrote a post on my WordPress Blog in 2014 entitled Sugar in the Morning, Sugar in the Evening, Sugar at Suppertime
Which begins with these lines:
Added sugar is everywhere you turn in America. The skeptical cardiologist visited Home Depot recently to buy a rake and was confronted by row upon row of candy and processed treats at the check-out counter.
I’m pretty sure I could have raked leaves for an hour and not burned off the useless calories from one of those Kit Kat bars.
Whole Foods, self-proclaimed “America’s healthiest grocery store,” always has vast rows of useless “function drinks” full of added sugar (and useless chemicals) prominently displayed at strategic spots throughout their stores.
The easy target in the battle against obesity and cardiovascular disease would seem to be added sugar. Sugar-sweetened beverages, which have no nutritional value and just contribute empty calories, are the easiest target of all.
Because of the lack of nutritional value, foods that are rich in sugar are empty calories. If sugary foods and beverages are a large part of our diet, we are likely to miss out on important nutrients, vitamins, and minerals.
Added sugar is believed to contribute to obesity.
Sugar promotes tooth decay by optimizing growth conditions for bacteria.
Recent evidence from epidemiological studies suggests that high intake of sugar-sweetened beverages increases the risk for metabolic syndrome, type 2 diabetes, coronary heart disease, and stroke (1).
Studies show that sugar-sweetened beverages increase the accumulation of fat in the liver, muscle, and the visceral fat depot. Most of the studies support the fact that fructose is the main driver of these metabolic aberrations because it drives fat production and fat release from the liver (2).
A large survey published in 2014 showed a significant relationship between added sugar consumption and risk of death from cardiovascular disease
Giving up sugar leads to eating low glycemic index foods.
Lynne asks: What do you think should be the protein requirement for optimal cardiovascular health? For women in perimenopause and menopause experiencing metabolic changes, what cardiovascular risks should they be most aware of, and how can nutrition support heart health during this transition?
Dr. Pearson: We have many wellness influencers loudly proclaiming the need for very high protein intake for most individuals, for example, 2 grams per kilogram.
Unfortunately, with respect to cardiovascular disease, this is a fairly data-free zone.
Traditionally, the minimum daily intake of protein has been set at 0.8 grams per kg.
I think if you are actively working on maintaining muscle strength or building muscle strength, it is reasonable to go above that level up to around 1.2 grams per kg.
Above that level, the evidence is mixed, and we start entering protein intake ranges that are hard to achieve with a real food diet. Thus, witness the appearance and proliferation of ultraprocessed sources of protein like the David bar I just wrote about:
Melissa asks: I’ve seen with patients and myself that lowering saturated fats seems to help cholesterol, including decreased particle size, which goes against a lot of modern advice around cholesterol. Can you speak to this? Also, when do you think it’s appropriate to be concerned about blood cholesterol levels?
Dr. Pearson: One thing that is underemphasized in the dietary space is how there are marked variations in how individuals react to various diets. For example, in the keto world, about 20% of lean individuals see a marked rise in their LDL on a very high saturated fat diet.
Around 15-20% of individuals are “hyperabsorbers” of cholesterol and are sensitive to the amount of cholesterol in their diet.
And in general, for any particular diet, we will see a spectrum of weight loss and metabolic response ranging from worsening to improvement, depending on the individual.
I just published on Substack an article (below) which updates what I’ve been saying for a dozen years. There are many different saturated fatty acids. Some (typically even/long chain SFAs) have adverse metabolic and lipid effects, others (the even chain SFAs) have beneficial effects. The profile of fatty acids in dairy fat despite 2/3 saturated fats has not been associated with increased cardiometabolic risk.
For some individuals who respond differently from the average of the population, there might be a worsening of the atherogenic lipid profile. If this is what you have found on a careful analysis of the effects of diet on your lipid profile, then it is reasonable to continue with the diet that provides the improved profile.
The last part of this question, I have spent the last dozen years writing about in various ways, including a series I call Profiles in Prevention.
The very short answer is that we care about cholesterol levels only when they are increasing your risk of atherosclerosis, the disease that leads to heart attacks and most strokes.
I typically utilize imaging to help us decide how much your lipids are increasing plaque formation in your arteries.
Nancy asks: I have good metabolic health, good weight and muscle mass, good HDL, triglycerides, and homocysteine, but slightly elevated LDL plus elevated ApoB (91) and Lp(a), yet a cardiac calcium scan of zero. Do you think it’s important to reduce ApoB? If so, what’s the best way?
Dr. Pearson: This is a great question.
The answer is very much dependent on your age. I also take family history into account, especially for younger individuals.
And it is related to the imaging I mentioned in question 3
If you are 70 with a zero CAC score, I would not be recommending lipid-lowering therapy. You are in a very very low risk category.
I would be comfortable with doing nothing additional in your case.
I would have a discussion about super aggressive options for those who are interested in making 100% sure they never develop atherosclerotic cardiovascular disease.
Such options would include either
1) starting either a very low dose of rosuvastatin (5 mg three times per week or ezetimibe 10 mg daily) or
2) performing a coronary CT angiogram to assess for noncalcified plaque and determining treatment based on those findings.
If you are 40, the zero CAC is much less reassuring, as plaque calcification is a later development in the progression of atherosclerosis. Options would be
1) Continue to optimize diet and lifestyle. Consider adding psyllium.
2) Obtain a Coronary CT angiogram and base the decision on those findings.
3) Empirically start the medication choice I mentioned earlier.
If you are somewhere in between those ages, there would be a gradual shift in the options.
more in depth questions
Beth: Can you explain ApoB and Lp(a) for those unfamiliar with these markers? Why are they important, and when should people be concerned about them?
Dr. Pearson:
ApoB counts the number of artery-clogging lipoprotein particles in your blood — a more accurate risk signal than standard LDL cholesterol. Aim for under 90 mg/dL (or 70 if high-risk). It responds to diet, exercise, and medication.
Lp(a) is a genetically inherited “super-LDL” that promotes inflammation and clotting. About 1 in 5 people have elevated levels, and most don’t know it. This can be measured in nm/L or mg/dl and you will see variation from lab to lab in what is considered the upper limits of normal
Both markers reveal cardiovascular risk that a standard cholesterol panel misses. Worth asking your doctor to test, especially with a family history of heart disease.
Lp(a) needs only be measured once if it is low.
Beth: There’s a lot of confusion around LDL cholesterol—some experts say it matters, others say it doesn’t. What’s your take, and what should people actually pay attention to when looking at their cholesterol numbers?
Dr. Pearson: LDL matters. There are multiple lines of evidence which have convinced me over the last ten years that lowering LDL reduces the risk of heart attack and stroke. The evidence comes from animal and mechanistic studies, to Mendelian randomization to randomized controlled trials.
In the last ten years we have had the emergence of multiple cholesterol lowering therapies working by different approaches that all lower LDL (and apoB) and concordantly lower the risk of major atherosclerotic cardiovascular events.
Beth: What role does inflammation play in cardiovascular disease, and how can diet influence it?
Dr. Pearson: Once the ApoB particle enters the lining of the arteries, it sets up a cascade of events that result in inflammation which enlarges coronary plaque and makes it more prone to be unstable. Thus, inflammation is a critical component of the pathway in atherosclerosis.
Inflammation may also contribute to the vulnerability of the arterial lining to ApoB entry.
I’d say the best evidence for dietary influence on inflammation is by its effects on visceral fat. Fat that builds up alongside the organs in the abdomen and around the heart. The fat cells produce hormones that are directly inflammatory.
Whatever diet we can get on that allows us to shed excess fat is going to be an anti-inflammatory diet. Along with these benefits, fat loss lowers insulin resistance, which is also anti-inflammatory.
dietary fat + heart health
Beth: You now eat full-fat yogurt, cheese, butter, and whole eggs after years of avoiding them. What does the research actually show about saturated fat and heart disease?
Dr. Pearson: The most up to date research shows mixed effects of saturated fat consumption on cardiovascular disease, diabetes and obesity.
The concept that all saturated fats behave similarly and should be minimized or avoided is outdated.
In a series I have been writing for Substack recently (Is Butter Back?) I describe the multiple fatty acids in dairy fat. They all have different effects on important cardiometabolic factors.
Studies beginning in dolphins and including human prospective cohorts show that odd-chain saturated fatty acids, like pentadecanoic acid, may be essential and extremely beneficial for cardiometabolic health and longevity.
Beth: Is there a difference between saturated fat from dairy versus meat? Should people make distinctions between sources?
Dr. Pearson: Yes. There is a different breakdown of the various fatty acids between meat and dairy. Most observational studies of dairy fat consumption, especially in fermented forms like yogurt and cheese, show beneficial effects. Whereas animal saturated fats are neutral to detrimental.
Of course, saturated fat is never consumed by itself, and how it affects an individual’s body depends on the food matrix it is delivered in, the overall health of the rest of the diet, and cooking/processing processes.
Beth: What about seed oils and vegetable oils? Where do you stand on this controversial topic?
Dr. Pearson: I think seed and vegetable oils are a marker for ultraprocessed food. If you minimize UPF, you will be consuming less of them and that is a good thing.
Beth: What dietary changes have you seen make the biggest difference in your patients’ cardiovascular health?
Dr. Pearson: For many patients the most important change is one that results in slow, sustainable and steady weight loss to reduce visceral fat.
Weight loss often reduces BP, improves diabetic markers and improves their atherogenic lipid profile. I’ve seen multiple diets be successful, ranging from very low carb to very low fat to intermittent fasting. They generally all have in common minimizing added sugar and ultraprocessed foods.
cardiac testing + prevention
Beth: When should someone get a cardiac calcium scan, and what does a score of zero really mean?
Dr. Pearson: I would recommend a calcium scan for those who desire a better understanding of their risk for cardiovascular disease. This includes those who are on the fence about the treatment of high cholesterol.
Calcium scans are less valuable at the extremes of age.
Younger individuals can have a zero score and still be at high risk.
Older individuals:
If you have had a heart attack, stent or coronary bypass surgery they are not useful.
Once you have a coronary scan that is nonzero there is no value in repeating it.
Beth: What cardiovascular screening tests do you think are most valuable for preventive cardiology, and which ones are overused or unnecessary?
Dr. Pearson: Coronary calcium scans and coronary CT angiograms are most valuable.
Stress tests, especially nuclear stress tests or PET/CT stress tests least valuable.
Beth: For someone with no symptoms but concerning lipid markers, how do you decide whether to recommend medication versus lifestyle changes?
Dr. Pearson: We personalize risk by looking directly at the amount of subclinical atherosclerosis buildup in their arteries. If there is already much coronary plaque for age we lean toward lipid-lowering medication; if not and overall low risk then we can work on lifestyle changes.
what are 3 things you would never do or eat when it comes to heart health?
Cigarette smoking
Cocaine
Braunschweiger
what are 6 things you’re loving right now?
I just finished reading Steinbeck’s East of Eden. It is fantastic. My wife was reading it at the same time and we ended up reading the last 50 pages out loud to each other while sitting on a bench in the delightful San Diego Botanical Gardens.
Anza-Borrego Desert State Park
Pickleball
Beach/cliff walks in Encinitas with my wife
Jamming with my Moog Sub37 and my Osmose Espressive synthesizers
Vermicomposting
if you could give one piece of actionable advice to someone concerned about their heart health, what would it be?
Go beyond the traditional risk factors utilized to determine your risk and ask your doctor to personalize your risk by checking the biomarkers lipoprotein (a), apolipoprotein B, and high sensitivity CRP, and, if appropriate, a coronary artery calcium scan.
working with Dr. Pearson
Beth: You see patients via telemedicine in North Carolina, Missouri, and California. What does a consultation with you typically look like?
Dr. Pearson: I see SoCal patients in person typically.
For both in person and telemedicine visits
I spend an hour going over the patient’s medical history, family history, symptoms, diet, physical activity, prior testing, reviewing relevant labs, and discussing options for further diagnostic testing or treatment.
If in person, we do a detailed physical exam and vitals.
Beth: Who would be a good fit for working with you?
Dr. Pearson:
Those who are stoked to be very proactive about their cardiovascular health and want to eliminate the possibility of atherosclerotic complications like heart attack and stroke from their future.
For telemed, the best fit is patients who won’t necessarily benefit from an in-person examination and who are comfortable with the virtual concept.
Beth: What types of patients do you enjoy helping most?
Dr. Pearson: The more I can help the patient I see, whether it be by education, listening, answering questions, diagnosing the cause of their problems, or improving their symptoms and long term health with treatment, the happier I am.
Beth: Where can people find you and learn more about your practice and your writing?
Dr. Pearson: I’m at United Medical Doctors. I write actively The Skeptical Cardiologist Archives of all my writing on my original Wordpress Blog site is free and searchable.
my takeaways — and what we can do with this information
I’m so grateful to Dr. Pearson for showing up so generously for this community — answering your questions thoughtfully in our subscriber chat and sharing decades of hard-won clinical wisdom with all of us. There is so much here to absorb.
Let’s walk through what landed most for me, and what this actually looks like in our kitchens and daily lives.
Sugar, refined carbs, and ultra-processed food are the real villains. Dr. Pearson spent 30 years telling patients to avoid fat — and what he found when he actually dug into the research changed everything for him. If you take nothing else from this conversation, let it be this: cutting added sugar, refined carbohydrates, and ultra-processed food is the single most impactful dietary shift you can make for your heart. This is exactly why every recipe I develop is refined sugar-free and low glycemic. It’s not a trend — the evidence has been building for decades.
Full-fat real food belongs on your plate. Butter, whole eggs, full-fat yogurt, cheese — Dr. Pearson eats all of these now, and the research supports why. Not all saturated fats behave the same way in the body, and the idea that all saturated fat is harmful is simply outdated. Fermented dairy in particular — yogurt, cheese, kefir — shows up favorably in the research, and dairy fat has a unique fatty acid profile that is genuinely different from the saturated fat in meat. The practical takeaway: don’t fear real, whole-food sources of fat. Fear the processed stuff pretending to be healthy.
Dietary cholesterol is not the enemy we were told it was. Whole eggs are back. Full-fat yogurt is back. The blanket guidance to limit dietary cholesterol has quietly shifted in the research, and Dr. Pearson — someone who followed those guidelines for 30 years — is among the voices now saying so. What matters far more is the overall quality of your diet: how much added sugar, how much ultra-processed food you’re actually consuming.
Know your numbers beyond basic cholesterol. Ask your doctor to test ApoB and Lp(a). They reveal cardiovascular risk that a standard cholesterol panel can completely miss. Dr. Pearson considers these among the most important numbers you can know. Knowledge is the beginning of everything.
Losing visceral fat may be the most anti-inflammatory thing you can do. Dr. Pearson put it so clearly: fat around your organs produces hormones that drive inflammation directly. Whatever way of eating helps you shed that fat — low glycemic, lower carb, intermittent fasting — the common thread is always less sugar and less ultra-processed food. That’s the foundation I build every recipe on.
You are an individual. One of the most validating things Dr. Pearson said is that people respond differently to the same diet. This is exactly why I wear a CGM — not to give you my numbers as gospel, but to show you that testing your own response matters. What spikes my blood sugar may be fine for you, and vice versa. Use the data as a starting point, not a verdict.
This is where I come in. Dr. Pearson gives us the clinical picture — and it’s a powerful one. My job is to help you build a healthy plate that actually reflects it. That means anchoring meals in foundational protein and fiber-rich whole foods: quality meat, fish and seafood, eggs, full-fat dairy, vegetables, legumes, nuts, seeds, and low glycemic fruit. Protein stabilizes blood sugar and supports the muscle mass that keeps our metabolism strong as we age. Fiber slows glucose absorption and feeds a healthy gut. Together, they’re the foundation under every recipe I develop — even the desserts!
The science Dr. Pearson has spent decades studying points in a clear direction: real food, stable blood sugar, less sugar, less processing. That’s not a diet. That’s a way of living — and it’s one we can build together, one meal at a time.
You don’t need a cardiology degree to eat in a way that protects your heart. You just need a little guidance — and a kitchen.
want to go deeper? here are some helpful resources:
The Skeptical Cardiologist — Dr. Pearson’s Substack, highly recommend bookmarking it
what is a CGM and should you try one? — Dr. Pearson mentioned personalizing your data; this is where to start
build a healthy bowl framework — putting today’s takeaways into a real meal, every day
how to hit 30g fiber a day without metamucil — fiber is one of our most powerful tools for metabolic and heart health
low glycemic for longevity: your guide — the big picture on why this way of eating matters long term
low glycemic dessert roundup — because Dr. Pearson also loves food, and so do we
The Blood Sugar Method — ready to go all in? this is the place to start
This newsletter wouldn’t be possible without YOU! A huge THANK YOU to all who support my work here on Substack.
If you know someone with pre-diabetes, diabetes, PCOS, metabolic syndrome, or anyone eating for blood sugar balance, low carb, keto, grain-free, gluten-free, or just eating whole food for better health, will you forward my Substack to them? I would love it if you would share my page with a friend or restack to your notes. Thank you!
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For a deep dive into the scientific decision making of diets for diabetics, read Gary Taubes book “Rethinking Diabets” and his Substack. 40 year type 1 diabetic here who followed teachings of Richard K Bernstein MD (to a degree) with relative low carb diet for 20yrs which has saved my life, e.g. HbA1c 5.3. I am also a physician who thought that he had gone to the dark side 20 yrs ago when I did this. Sad that the ADA and AHA continues to suggest low fat, though they have moderated a bit. How many people have been maimed and/or killed by this dogma?
RE: timeline of plaque calcification
You state that calcification is a later development in plaque, but what about the microcalcifications not seen via CT, but seen with newer technology in plaques? That questions the etiology of CAC, the causes and course of its development and, coincidentally, statins appear to be positively linked with CAC development.
What about the roles of vitamin K2 in all this? More dietary K2 is associated with better cardiovascular health/fewer events, K2 actions are inhibited by statins, K2 (K in all forms, really) directly affects calcium deposition and the enzyme essential to synthesize MK-4 - UBIAD1- controls cellular calcium and cholesterol. More K2, less diabetes. More statins, more diabetes.