What does it mean if my hs-CRP keeps coming back elevated even after I lose weight and improve my diet?

It means you have not yet identified the driver that is maintaining the elevation. Visceral fat reduction and dietary improvement are the first two interventions for a reason, they address the most common causes. If both have been meaningfully achieved and hs-CRP remains above 2.0 mg/L on repeat testing, the three possibilities in order of clinical likelihood are: obstructive sleep apnea (present in a large proportion of men who "sleep fine"), periodontal disease (almost always asymptomatic in its early-to-moderate stages), and an additional inflammatory driver not yet assessed.

Less common causes of persistent hs-CRP elevation in otherwise healthy-appearing men include undiagnosed autoimmune disease, chronic kidney disease (even at GFR levels considered "normal"), undiagnosed inflammatory bowel disease, and, rarely, early malignancy. Persistent elevation above 3.0 mg/L on two measurements separated by four weeks, after the four common drivers have been systematically addressed, warrants a more thorough evaluation by a physician. The instruction at this point is not to stop looking; it is to look harder. (Heliövaara et al., Scandinavian Journal of Rheumatology, 2000)

Cardiologist's calibrated position, Solid (1) for the systematic approach. Persistent elevation despite first-line intervention always requires deeper investigation.

What to do: If hs-CRP persists above 3.0 mg/L after visceral fat reduction and dietary improvement, have a home sleep study (or STOP-BANG assessment) and a periodontal evaluation before attributing it to idiopathic cause.

For the full picture, read Inflammation's Invoice.