Kamal Ghorui
In Part 1 and Part 2, we covered how to calculate your cardiovascular risk in the Cardiovascular-Kidney-Metabolic (CKM) framework and what markers and risk factors to measure. In Part 3 (#70) of this four-part series, I cover what one can actually do about it. The eight pillars of cardiovascular health from the American Heart Association’s 2022 Life’s Essential 8 Advisory form the backbone of this post: diet, physical activity, weight, blood pressure, blood sugar, sleep, smoking cessation, and psychological health. Let’s go over all eight, with my personal recommendations in italics added at the end of that section, wherever I have a viewpoint.
Diet
The guideline endorses three dietary patterns with consistent evidence: the Mediterranean diet (olive oil, fish, nuts, legumes, fruits, vegetables, whole grains), which has the strongest evidence for overall cardiovascular outcomes; the DASH diet (fruits, vegetables, whole grains, low salt, low fat), developed specifically for blood pressure management; and a plant-based or vegan diet, which produces the most consistent LDL reduction — roughly 12–15 mg/dL more than Mediterranean in head-to-head trials. All three are substantially better than a Western diet. Choosing among them matters less than committing to one.
Across all three, the single highest-impact change for LDL is replacing saturated fat with unsaturated fat. Saturated fat — in red meat, butter, full-fat dairy, ghee, coconut oil, and palm oil — raises LDL directly. The practical swap: olive oil instead of butter, fish or legumes instead of red meat most nights, nuts and avocado as snacks. This one change moves the needle more than reducing dietary cholesterol does.
For triglycerides, the problem is different. Added sugar, refined carbohydrates, and alcohol are the dominant drivers, not fat. If you have elevated triglycerides, switching to olive oil alone won’t fix it. Cutting sugar and alcohol is what works. For triglycerides above 500 mg/dL fasting, the guideline is explicit: eliminate alcohol entirely and see a dietitian.
One question that always follows dietary advice: can supplements fill the gaps? The 2026 guideline has an unusually direct answer.
Seven supplements receive the guideline’s strongest “do not use” rating for LDL or triglyceride management: fish oil capsules, red yeast rice, berberine, garlic, turmeric, cinnamon, and plant sterols. In the SPORT trial (A 2024 study published in 2024 in the Journal of the American College of Cardiology where six popular supplements were tested head-to-head against a low-dose statin), none produced meaningful LDL reduction versus placebo. A low-dose statin in the same trial cut LDL by 38%. Coenzyme Q10 (a natural compound your cells need to produce energy) for statin-related muscle aches is separately ruled out — no trial evidence supports it either.
This matters practically because many people at CKM Stage 1 or 2, exactly where intervention has the most impact, spend time and money on these while delaying approaches that actually work.
That said, several supplements have genuine evidence for specific purposes beyond lipid management:
High-dose prescription omega-3 (EPA at 4g/day), as used in the REDUCE-IT trial, reduced major heart events by 25% in people with high triglycerides already on statins. This is not the same as an over-the-counter fish oil capsule — different dose, different formulation, prescription only. The distinction matters.
Vitamin D is supported for people with a confirmed deficiency, which is particularly common among South Asians — a group flagged in Part 2 as already carrying elevated baseline risk.
Magnesium has consistent evidence for modest blood pressure reduction in people with low dietary intake. The evidence for magnesium glycinate specifically for sleep quality is also reasonably strong.
Coenzyme Q10 has evidence for one specific use: improving symptoms and outcomes in heart failure (Q-SYMBIO trial). This is entirely separate from statin muscle aches, where it doesn’t help.
The principle across all of these: supplements work when they’re addressing a specific deficiency, a known genetic variant, or a defined condition.
Beyond the guidelines – My take:
Follow a diet you can sustain over years, not one you follow perfectly for three months. I use many elements of the Mediterranean diet but wouldn’t claim to follow it strictly. My practical anchors: high-fibre foods, lean protein at most meals, unsaturated fats where possible, and keeping dessert to the end rather than eliminating it. On supplements, the list above is specifically about LDL and triglycerides. There are other legitimate reasons to supplement. If you follow a vegan or vegetarian diet, B12 deficiency is a real risk and supplementing is important, not optional. Evaluate each supplement for what it actually claims to do, not as a general insurance policy.
Exercise
The guideline target: at least 150 minutes per week of moderate aerobic activity (brisk walking, cycling, swimming) or 75 minutes of vigorous exercise (running, fast cycling), plus resistance training at least twice a week. These two types of exercise do different jobs.
Aerobic exercise raises HDL, lowers triglycerides, and modestly reduces LDL. Resistance training works differently: muscle is where your body absorbs most of its blood sugar, so building it improves how your body handles glucose. This is especially relevant if you are at CKM Stage 2 with pre-diabetes or blood sugar creeping up.
For resistance training specifically: 2–4 sets per major muscle group (chest, back, shoulders, arms, core, legs), 8–12 repetitions at a weight that feels genuinely hard by the final rep, twice a week at minimum. Gradually increasing the weight over time is what drives ongoing benefit. Doing the same thing indefinitely eventually stops working.
Beyond the guidelines – My take:
150 minutes is the floor where heart benefits become meaningful, not the target to stop at. A 2022 study in Circulation found 26–31% lower death rates in people exercising at 2–4 times the recommended minimum. Benefits keep accumulating up to around 300–400 minutes per week. The level where problems begin to appear, mainly irregular heart rhythms in a small subset of lifelong endurance athletes, is around 600 minutes per week of vigorous exercise. That is not a concern for most people. Do more than 150 minutes if you can.
Weight
Losing 5–10% of body weight produces measurable lipid improvements: roughly 4 mg/dL per kilogram for triglycerides and 0.3–1.7 mg/dL per kilogram for LDL. Two drug classes come up here and are often confused. GLP-1 drugs (semaglutide, Wegovy) reduce triglycerides and LDL more than other weight-loss medications and have demonstrated heart benefits in the right populations. SGLT2 inhibitors are a different class entirely; their main evidence is for protecting the kidneys and reducing heart failure risk in people with diabetes or kidney disease. They are not interchangeable.
Beyond the guidelines – My take:
The conversation around GLP-1 drugs has become almost tribal. The evidence suggests a more nuanced picture. For people with a BMI above 30–32, they’re a legitimate tool. They help fast-track enough weight loss to make exercise and better eating feel achievable rather than overwhelming. The risk is treating them as a standalone solution. When appetite drops sharply, most people under-eat protein and move less, meaning a significant portion of the lost weight comes from muscle rather than fat. That worsens insulin sensitivity over time and makes weight regain more likely when the drug is stopped. The non-negotiables if you go this route: resistance training and adequate protein from day one, and a doctor who monitors body composition, not just the number on the scale..
Blood pressure
Target: below 120/80 mmHg; risk rises continuously above this, and it is the threshold where active management is formally recommended. Lifestyle changes alone, such as the DASH diet, cutting sodium below 2,300 mg/day, aerobic exercise, losing weight, and limiting alcohol, can reduce the systolic (higher) number by 4–11 points, which is enough to avoid medication for some people. When medication is needed, the right choice depends on your individual profile and should be decided with your doctor.
Blood sugar
Measured via HbA1c: below 5.7% is normal, 5.7–6.4% is pre-diabetes, and 6.5%+ is diabetes. Pre-diabetes alone doubles cardiovascular risk; something that doesn’t get enough attention. Diet management overlaps with the triglyceride advice: cut sugar, refined carbs, and ultra-processed foods. A 20–30 minute walk after a meal measurably reduces the blood sugar spike that follows and is hence one of the most immediate and tangible lifestyle habits I keep pushing for.
Beyond the guidelines – My take:
As noted in Part 2, I recommend adding fasting insulin to your panel if you have belly fat, elevated triglycerides, or a family history of diabetes. Insulin resistance can be significant well before HbA1c rises; fasting insulin is an earlier signal, sometimes by several years, giving you a meaningful window to intervene before the standard tests catch up.
Smoking and nicotine cessation
There is no safe level of smoking. Even fewer than five cigarettes a day carries heart risk out of proportion to the amount smoked because it damages blood vessel walls, speeds up the build-up of arterial plaque, and makes blood more likely to clot. Vaping is not a safe alternative; the 2026 guideline makes no exception for it. Nicotine itself, regardless of how it’s delivered, raises your heart rate, narrows your blood vessels, and increases clotting risk.
The guideline explicitly recommends combining quit-smoking medication with behavioral support: counselling, support groups, or structured programs, rather than attempting to quit alone. The evidence that this combination outperforms either approach on its own is strong. Varenicline (sold as Champix in India), a prescription tablet that reduces nicotine cravings and withdrawal symptoms, is the most effective single medication option. Heart benefits start within hours of quitting, and within a year your excess heart disease risk is roughly halved.
Sleep and psychological health
Target: 7–9 hours per night. Poor sleep is now formally linked to high blood pressure, worse blood sugar control, and higher rates of heart disease; not just associated with them. Untreated sleep apnoea is an independent heart risk factor; if you snore heavily or consistently wake up tired, it’s worth getting assessed.
The 2022 Life’s Essential 8 Advisory also formally recognises chronic stress, depression, and anxiety as upstream heart risk factors rather than as soft lifestyle concerns. Research suggests depression roughly doubles the risk of a heart event in people with existing heart disease and is underdiagnosed in this context. The framework traces directly how prolonged psychological stress raises blood pressure, disrupts blood sugar, and increases the tendency for blood to clot. Your mental health and your heart health are not separate systems.
Beyond the guidelines – My take:
It has taken far too long for sleep to make it into the guidelines. Looking back, my own poor sleep almost certainly contributed to my heart disease. For better sleep: keep your bedroom cool (research supports that a lower ambient temperature meaningfully improves sleep onset and quality), go to bed at a consistent time every night, eat an early and light dinner, and avoid too much sensory overloading (blue light, social media just before bedtime) as non-negotiable rather than optional. Most people underestimate how much sleep quality, not just duration, affects metabolic and cardiovascular health.
The bottom line from Part 3
These eight pillars account for the majority of modifiable heart risk. Medications work best when built on this foundation, which is exactly where we go next. In Part 4, I will cover the medications, the coronary calcium scan, who qualifies for treatment regardless of their calculated risk score, and a practical checklist for your next doctor’s appointment.
As always, I welcome your thoughts and would love to hear your experiences in the comments.
Nickhil Jakatdar is the CEO of GenePath Diagnostics and the founder of PreventiveHealth.ai, working to make advanced diagnostics and credible health guidance more accessible, affordable, and actionable. A PhD in EECS from UC Berkeley and the youngest recipient of the UC Berkeley Distinguished Alumnus Award, he has founded and led multiple tech companies. He holds 60 patents, and serves on several academic, healthcare, and innovation boards. To follow his thinking on preventive health, technology, and systems that scale expertise, join his private WhatsApp community and subscribe to his Substack.
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