You’ve probably heard that a high apolipoprotein (ApoB) score means you’re at a high risk for heart disease. While ApoB does indeed play a role in cardiovascular health, its relationship with plaque isn’t as simple as some make it out to be.
If lowering cholesterol were all we needed to do for our hearts, the heart health crisis would be practically over. Average cholesterol levels have been dropping for decades and yet deaths from heart disease have surged over the past 30 years, chronic illness is becoming more common, and more than nine out of 10 US adults aren’t considered cardiometabolically healthy.
Here’s why your high ApoB score may not matter as much as you think.
First, a quick description of ApoB
Apolipoprotein B-100, more commonly referred to as ApoB, is a substance in your blood that can contribute to plaque blockages at high levels. It’s essentially a transportation system for LDL (or ‘bad’ cholesterol), so if there’s a high volume in your blood, there may be a high volume of blockage-inducing LDL.
The reference range for a ‘healthy’ ApoB score is below 110 mg/dL. Anything higher than that may indicate an unhealthy amount of LDL present, and therefore a higher number of atherogenic particles that gather in the arteries.
That’s because ApoB is a more reliable metric of heart disease than total cholesterol readings. A complete lipid test can help you judge overall cholesterol numbers, for example, but ApoB measures the total number of particles that could be dangerous to the heart within said cholesterol, which is a more accurate measure of risk.
And good thing, too: considering three in four heart attack patients have ‘normal’ cholesterol ranges, it’s high time we had a better metric for calculating heart disease.
Now, the caveat here is that ‘bigger’ isn’t always ‘worse.’ Having a high ApoB score means you might want to do more testing, not necessarily lower your numbers.
So is a high ApoB score bad?
Not necessarily, despite what you may have heard online.
Even though ApoB can and does correlate with a higher risk of cardiovascular disease, it’s the size and quality of the lipid particle that has the biggest impact.
I won’t get into the specifics here, since I’ve already written a breakdown of advanced lipid metrics. But for context:
- There are two different sizes of LDL cholesterol: small dense, and large fluffy.
- They also occur in different ratios. Pattern A indicates someone has a large amount of large fluffy LDL, while pattern B refers to those with mostly small dense LDL.
- Small dense LDL has a 3x cardiovascular risk compared to large fluffy LDL, and patients with a Pattern B ratio (aka, small dense LDL) have a 3.4x higher risk of heart disease.
This is why many people with increased ApoB/LDL do not develop heart disease. If you’re a lean mass hyperresponder following a low-carb diet, for example, studies show you’re not at higher risk for developing heart disease even if you have high cholesterol and a high ApoB.
You can read more about this in Plaque Begets Plaque, ApoB Does Not: Longitudinal Data From the KETO-CTA Trial.
This again highlights the point that cholesterol and ApoB cannot be reviewed in a vacuum. Many people who suffer from naturally high cholesterol (familial hypercholesterolemia) and high LDL and ApoB live a normal lifespan or longer without developing cardiovascular disease. Case in point: studies have shown that “older adults with LDL cholesterol levels above 130 mg/dL live longer than older adults with LDL cholesterol levels below 130 mg/dL.”
We haven’t even discussed other biomarkers for metabolic syndrome yet, including homocysteine, LP(a), fasting insulin, and CRP.
So while yes, ApoB is a better measure than LDL (which isn’t saying much), a high score may not necessarily mean you’re closer to heart disease than others.
Which begs the question…
Do I personally need to lower my ApoB to be healthy?
This entirely depends on your individual risk factors.
And even though it’s possible, it doesn’t necessarily mean it’s better for you.
For example, to ‘lower’ your ApoB the conventional way, you might need to:
- Take statins. Statin monotherapy (meaning statins taken by themselves) can lower ApoB levels by 19% to 42%. But we also know that statins can introduce serious side effects, like induced diabetes, Alzheimer’s, and muscle wasting via myopathy.
- Change fat sources. Saturated fat can increase ApoB levels, so your doctor might advise you to avoid foods like red meat and milk. Their recommendation may be to replace these with ‘heart-healthy’ seed and vegetable oils. Unfortunately, we also know the tradeoff is incredibly high. You can read my breakdown on omega-6 oxidation if you’re interested in the specifics.
- Adjust carbohydrate levels. The typical doctor’s response to a high ApoB or LDL score is a recommendation to consume more fiber. This is usually in the form of whole grains like oats, wheat, cereals — which you can find promoted on just about every packaged cereal brand, breakfast bar, and ‘healthy’ bread in the store. Eating high-carb foods may help reduce your ApoB score, but at the cost of increasing your blood sugar, disrupting your gut microbiota, and more.
You don’t need to be a cardiac surgeon to realize the tradeoff for a lower score may not necessarily make you healthier. There’s a very good chance it may actually make you sicker, which will put you at greater risk for metabolic disease.
The dos and don’ts for a healthy ApoB score
America’s hyperfixation on lowering ApoB is often the wrong focus for metabolic health. We’ve been trying the same low-fat, high-carb, vegetable oil approach for 40+ years and, at best, it does little, and at worst, it results in individual and population-level harm.
So before taking drastic measures to reduce your ApoB, you want to make sure you’re adequately at risk.
First, evaluate your numbers in context. If you’re above the 130 mg/dL reference range, you’ll want to dig deeper.
Now, let’s look at your numbers in context. Is homocysteine elevated? What about LP(a)? You can ask your doctor for a referral, or order an at-home test.
If you do have multiple risk factors, you’ll need to weigh the risks and benefits of medications. Other ways to lower ApoB besides statins include:
- Exercise, which lowers ApoB over time
- Omega-3 oils, which can lower ApoB by 15% to 45%
- Ezetimibe, which can help reduce your numbers with potentially fewer side effects
You deserve to know which of your biomarkers do and don’t affect your health.
And if you want to dig deeper, I cover more in the following resources:
- What it takes to reverse heart plaque
- The most accurate measures of heart disease risk
- ApoB heart disease risk
