Beyond LDL: A Functional Medicine Approach to Cardiovascular Health

Cardiovascular disease is the leading cause of death for women and men, yet much of it is preventable. Advances in cardiovascular screening—including advanced lipid testing, inflammation markers, blood sugar assessment, and imaging—now allow us to identify risk earlier and personalize prevention more effectively than ever before.

Cardiovascular disease (CVD) is still often thought of as something that happens suddenly or later in life. In reality, cardiovascular disease develops quietly over decades, shaped by genetics, lifestyle, metabolic health, and inflammation long before symptoms ever appear. My family had an up and close encounter this past year with how stroke can happen to even the seemingly healthiest, young individuals, making this a very personal topic for me.

For many years, cardiovascular risk assessment has centered on a basic cholesterol panel—total cholesterol, LDL (“bad”) cholesterol, HDL (“good”) cholesterol, and triglycerides. While these markers remain useful, modern research shows they only scratch the surface. To truly understand cardiovascular risk, particularly in women who are historically under-diagnosed and under-treated, we need a more complete and personalized view.

Rather than relying on a single number, today’s approach to heart health looks at lipoprotein particles, inflammation, blood sugar regulation, and even early imaging to identify risk earlier and intervene more effectively.

Looking Beyond LDL: Why Particle Number and ApoB Matters

One of the most important advances in cardiovascular science is the recognition that cholesterol content and cholesterol particles are not the same thing. LDL-cholesterol (LDL-C), what your doctor is measuring in your annual panels, measures how much cholesterol is carried inside LDL particles, but it does not tell us how many particles are circulating in the bloodstream.

This distinction matters because it is the particles themselves that penetrate the arterial wall and drive plaque formation. Advanced lipid testing, such as Nuclear Magnetic Resonance (NMR) panels, builds on this information by evaluating particle size and number. You can have an LDL-C of 80 lets say (we want it under 100), but have a high level of smaller, dense LDL particles, which are more likely to enter the arterial wall and oxidize, increasing cardiovascular risk.

Apolipoprotein B (ApoB) is found on every atherogenic particle—LDL, VLDL, IDL, and lipoprotein(a). Measuring ApoB gives a direct count of the particles capable of contributing to atherosclerosis.

Research consistently shows ApoB to be a stronger predictor of cardiovascular events than LDL-C alone, particularly in people with insulin resistance, metabolic syndrome, elevated triglycerides, or those who have “normal” cholesterol levels but ongoing risk. For many individuals, ApoB helps explain why heart disease can develop even when standard labs appear reassuring.

These insights are especially helpful when traditional cholesterol numbers don’t align with a patient’s clinical picture or family history.

Lp(a): The Genetic Risk Factor You Should Know About

Another key marker gaining well-deserved attention is lipoprotein(a), or Lp(a). Lp(a) is largely genetically determined and can significantly increase cardiovascular risk independent of LDL, ApoB, or lifestyle factors. Structurally similar to LDL but with an added protein that promotes clotting and inflammation, elevated Lp(a) is associated with earlier and more aggressive cardiovascular disease.

Because diet and exercise have little effect on Lp(a) levels, identifying this risk early is critical. Knowing someone has elevated Lp(a) allows clinicians to focus on aggressively optimizing other modifiable factors and to consider earlier or more frequent monitoring—particularly in individuals with a family history of early heart disease or stroke. The good news is there are some newer medications on the horizon that show promise of reducing lp(a) in high risk individuals.

Inflammation: The Silent Driver of Atherosclerosis

We now understand atherosclerosis not simply as a cholesterol storage problem, but as a chronic inflammatory process. Inflammation influences how plaques form, grow, and ultimately rupture.

High-sensitivity C-reactive protein (hsCRP) is commonly used to assess overall systemic inflammation, but it does not tell the whole story. An additional and often overlooked marker is lipoprotein-associated phospholipase A2 (Lp-PLA2).

Lp-PLA2 is produced by inflammatory cells within atherosclerotic plaques themselves, making it a more vascular-specific marker of inflammation. Elevated Lp-PLA2 levels are associated with plaque instability and a higher risk of heart attack and stroke. In some individuals, this marker can uncover active arterial inflammation even when cholesterol levels look acceptable.

Blood Sugar and Metabolic Health: A Critical Connection

Cardiovascular health is tightly intertwined with blood sugar regulation. Elevated blood sugar, insulin resistance, pre-diabetes, and diabetes all accelerate vascular damage by increasing inflammation, oxidative stress, and dysfunction of cholesterol particles.

Importantly, cardiovascular risk rises well before someone meets criteria for diabetes. Markers such as fasting glucose, fasting insulin, hemoglobin A1c, and triglyceride-to-HDL ratio provide valuable insight into metabolic health. Even mildly elevated blood sugar levels can meaningfully increase cardiovascular risk, particularly in women.

Supporting healthy blood sugar through nutrition (think fiber, antioxidants and healthy fats), regular movement, stress management, quality sleep, and targeted medical care is one of the most powerful and modifiable ways to protect long-term heart health.

Seeing Risk Early: Coronary Artery Calcium Scoring

While blood markers provide essential information, imaging can sometimes reveal what labs cannot. Coronary artery calcium (CAC) scoring uses a low-dose CT scan to detect calcified plaque within the coronary arteries, offering a direct look at atherosclerotic burden.

A CAC score of zero can be reassuring, while higher scores may justify more intensive prevention strategies—even in individuals without symptoms or with otherwise borderline lab results. CAC scoring is particularly helpful for people with a strong family history of cardiovascular disease or those whose risk is unclear based on labs alone.

Why Prevention and Screening Matter

The most encouraging truth about cardiovascular disease is that the majority of it is preventable. Lifestyle factors—including nutrition quality, physical activity, smoking status, sleep, stress, blood sugar control, and inflammation—play a profound role in determining risk.

Early and thoughtful screening allows us to identify risk years or even decades before a heart attack or stroke occurs. When prevention is guided by individualized data rather than population averages, even small, sustainable changes can significantly alter long-term outcomes.

When cardiovascular risk is evaluated through a broader, more personalized lens, prevention becomes not only possible—but powerful.

**By combining advanced lipid testing, inflammatory markers, blood sugar assessment, imaging when appropriate, and personalized lifestyle and Naturopathic support, cardiovascular care can shift from reactive to proactive. Genetics, family history, hormonal changes, pregnancy history, metabolic health, and lifestyle all interact uniquely for each person—especially for women, who are often under-screened and may not fit traditional risk profiles.**

Looking beyond basic cholesterol allows us to protect heart health earlier, more effectively, and with greater precision—for women and for people of all genders.

Taking the Next Step: Personalized Support for Heart Health

At Foundations Family Medicine, cardiovascular prevention is approached through a functional and individualized lens. A comprehensive functional medicine assessment with Dr. Jessie Miller looks at the full picture—advanced lipid markers, inflammation, blood sugar regulation, family history, hormones, lifestyle factors, and root contributors—to create a plan tailored specifically to you. This plan can range from basic lifestyle changes and nutrition, tailored herbs and supplements, to referring out for pharmaceuticals if needed.

Nutrition is a cornerstone of cardiovascular health, and translating lab results into everyday food choices can feel overwhelming. Kelsey, our nutritionist, works closely with patients to personalize nutrition strategies based on labs, metabolic needs, preferences, and real-life schedules. Rather than one-size-fits-all diets, she helps build practical, nourishing approaches that support heart health, blood sugar balance, and inflammation reduction.

Whether you are looking to be proactive, have a family history of cardiovascular disease, or want deeper insight into your heart health, working with a team that integrates advanced screening with personalized nutrition and functional medicine care can make prevention both achievable and effective.

If you are interested in learning more, consider scheduling a functional medicine consultation or a nutrition visit to explore what a truly individualized approach to cardiovascular health—especially women’s cardiovascular health—could look like for you.

About the Author

Dr. Jessie Miller is a Naturopathic doctor and founder of Foundations Family Medicine. She specializes in women’s health, advanced lipid testing, hormones, metabolic and blood sugar regulation, digestion, and functional medicine approaches to prevention and chronic disease. Her work focuses on identifying root contributors to cardiovascular risk and supporting patients with personalized, sustainable strategies for long-term heart health.