ApoB: The Cholesterol Number a Standard Lipid Panel Skips, and Why It Is Rarely Ordered

Colin Renaud said the updated cardiology guidelines now treat ApoB as an important influence and say lipoprotein(a) should be measured at least once in a person's life. He was careful not to blame providers. Research takes a long time, and it has to be recognized by insurance companies before the standards change, so a provider who knows the guidelines may still not order a test the patient would be billed for. He said the guidelines are evolving but the practice is not moving that fast.

Colin Renaud said ApoB is affected by diet and metabolic health: the amount of sugar you are eating, saturated fats, carrying extra weight and visceral fat, not exercising, and being insulin resistant or pre-diabetic. Genetics matter too. He said genes set your baseline level, so an inherited condition like familial hypercholesterolemia can cause high levels from birth, and that levels rise naturally as we age. His takeaway was that it goes back to the fundamentals of diet and exercise, and that it is always the basics.

Colin Renaud said he would. Cholesterol is the building block the body uses to make hormones, testosterone included, and he said a lot of his male patients with high cholesterol who were put on a statin have low or suboptimal testosterone, because the body has less of that building block to work with. He said it runs the other way too, since an absence of sex hormones can raise cholesterol. That is why he would check hormone levels on anyone with high cholesterol, especially men over a certain age and women after menopause.

Triglycerides are a type of fat the body makes from extra calories and uses for energy. Colin Renaud said a high level can be a measure of how well the body is handling its blood sugar and carbohydrates, and he tied it to extra calories from simple sugars, refined carbs, saturated fats, too much alcohol and not exercising. He also named medical causes: diabetes, low thyroid function, kidney disease and certain medications. Too much fat in the blood, he said, adds to hardening of the arteries, stroke and heart attack risk, and to inflammation.

That is part of why Colin Renaud uses it. CRP, or C reactive protein, is a protein made by the liver that tells you inflammation is present somewhere, which matters for the heart because inflammation of the arteries is what causes plaque to form. He described cholesterol as able to float around a little bit high without forming plaque until inflammation from poor diet, blood sugar irregularity or lack of exercise gets added, at which point it sticks together. He runs a CRP at the first visit and rechecks it later, and said a number that comes down gives a better understanding that the inflammation is better. What CRP cannot do is tell you where the inflammation is or what caused it.

Very little. Colin Renaud said lipoprotein(a) is primarily determined by genetics and really cannot be lowered by standard dieting or exercise. He pointed to newer drug options and to lipoprotein apheresis, a dialysis procedure that filters lipoprotein(a) out of the blood, which the FDA has approved only for people with severe high risk genetic high cholesterol.