He literally rolls into my office every three months, shoes still clipped to his carbon-fiber lifestyle. Lycra damp, Apple Watch buzzing, resting heart rate of 42. He is fit, smart, and tightly wound.

“Doc,” he begins, eyes wide, “I read that morning workouts burn more fat and lower clotting factors. Should I move my rides earlier? Or maybe late evening is better for heart rate variability?”

This is a man who, when …

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I see it every week in my practice: Patients obsessed with their cholesterol numbers. LDL, HDL, triglycerides, the full alphabet soup. They have been trained to believe these numbers hold the keys to life and death.

But here is something I cannot stop thinking about: When you look under the microscope, an atherosclerotic plaque (the thing that clogs arteries and leads to heart attacks) looks an awful lot like a tuberculosis …

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I am an internist and, once upon a time, a card-carrying lipidologist. I have spent years watching medicine’s “standards of care” quietly stretch like elastic waistbands. What begins as a targeted therapy for a small group of high-risk patients slowly expands until everyone and their grandmother is expected to be on it. That phenomenon has a name: guideline creep.

How it works

The cycle is simple:

• A landmark trial shows benefit in …

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