LDL, ApoB, HDL, cholesterol - the guide to blood lipid levels

The laboratory examination of blood lipid levels is part of the routine tests in the practice. The most commonly measured are LDL cholesterol and HDL cholesterol. But what do these values tell us? What is the story behind "bad" and "good" cholesterol? Why are blood lipid levels an important cornerstone for your longevity and why does Dr. Peter Attia dedicate an entire chapter to this topic in his new book? You will find out all this in this article.

Background – where do blood lipid levels come from?

To better understand the laboratory values, it is worthwhile to take a closer look at our own fat metabolism, also known as lipid metabolism. Fats are distributed throughout the body and come in different forms.They form as phospholipids the shell of cells, are the basis for the synthesis of various hormones, such as cortisol or testosterone and serve us in the form of triglycerides as energy storage. With our food, we absorb fatty acids daily through the intestine and then distribute the individual molecules with the help of the blood to every corner of our body – ideally especially to where they are actually needed. The right composition of fatty acids and an adequate supply of omega-3 fatty acids is particularly important.

Omega 3 fatty acids are an excellent way to shift the balance towards healthy fats.

Did you know?  Phospholipids are not only found in the cell membranes of our bodies. They are also present in chocolate, ice cream, margarine, or cosmetic products. In medicine, they are used as a component of dietary supplements to enhance bioavailability.

The effect this application can have is illustrated by the example of Quercesome. The specially formulated Quercetin-C complex from MoleQlar is about 20 times more bioavailable than conventional quercetin powder.The performance carriers are primarily  phospholipids from sunflower and additionally the clever combination with natural vitamin C – a bio-enhancer of  quercetin. With  Berbersome – the berberine mineral complex from MoleQlar – the  plus in berberine bioavailability through phospholipids amounts to ten times.

Fat and water – the transport challenge

Fats are not water-soluble from a chemical perspective (hydrophobic). This phenomenon can be well observed when a few drops of oil are added to water. The oil does not mix with the water but floats in droplets on the surface.How does our body manage this, considering that blood is mostly made up of water? To tackle this challenge, there are so-called  Apolipoproteins. These encapsulate fatty acids and form a water-soluble (hydrophilic) shell. You can imagine it like a small ball. On the outside are the water-soluble proteins and on the inside are the water-insoluble fats.  Apolipoproteins and fatty acids together are also referred to as lipoproteins  and  form the basis for the laboratory measurements of lipid metabolism.

What blood lipid values can be measured?

Lipoproteins are classified into different categories based on their density.The following parameters are usually measured:

• LDL cholesterol
• HDL cholesterol
• Total cholesterol
• Triglycerides
• Non-HDL cholesterol

In some laboratory results, these two values also appear:

• ApoB
• Lp(a)

In Germany , blood lipid levels are usually tested once as part of the health examination in healthy adults. From the age of 35, blood lipid levels can be checked every three years. In the southern neighboring country Austria , the statutory health insurance funds are a bit more generous. Here, a laboratory examination as part of the preventive check-up is possible annually.

What are the normal values for blood lipid levels?

The normal values vary depending on age and personal risk.The European Society of Cardiology (ESC) defines the following thresholds for people under 65 with low risk:

Did you know? In patients with too many fatty acids in the blood, a condition called  hypertriglyceridemia, this can sometimes be seen with the naked eye. When the blood of patients is separated into liquid (serum) and solid blood components (cells) using a centrifuge, the serum appears milky-white. Normally, the serum is clear and yellow in color.

Triglycerides – more than just fat

Triglycerides do not directly contribute to vascular calcification. For this reason, they are not always given enough attention. However,  &triglyceride levels are just as important for your longevity.

Values over 800 mg/dL can trigger pancreatitis at any time. And even though triglycerides, unlike LDL, cannot directly deposit in the vessel wall, they have an indirect effect on atherosclerosis through IDL particles (more on that later). For this reason, your triglyceride levels should not exceed the aforementioned limits.

In addition to exercise and a healthy Mediterranean diet, the ESC mentions two supplements that can lower triglyceride levels. One of them is berberine, which has been shown in studies to lower both LDL cholesterol and triglycerides.At MoleQlar,  berberine is available in phospholipid form , which has a 10 times better bioavailability than regular berberine powder.

Blood lipid levels: The myth of "good" and "bad" cholesterol

If you want to have your blood lipid levels determined, doctors will usually measure your total cholesterol, your HDL cholesterol, your LDL cholesterol, and your triglycerides. As a patient, you often hear sentences like: “Your bad cholesterol (LDL) is a bit high, but your good cholesterol (HDL) compensates for it.” Metaphors like “better avoid that” (LDL) and “I love you” (HDL) are often used. Or you are simply told that your blood lipid levels are normal.But what does normal actually mean and why is the idea of good and bad cholesterol just a myth? To understand this better, we need to take another look at cholesterol metabolism. Cholesterol is absolutely vital for our body. Simply put, it is a special fat molecule that we need for every cell in our body. Very briefly, you can imagine cholesterol metabolism like this: Cholesterol is produced in the liver. The body's own cholesterol, triglycerides, and apolipoproteins are then combined. This creates VLDL particles (Very-low-density-lipoproteins). These VLDL molecules are quite large and are now transported with the blood.

The Cholesterol Egg Myth

Cholesterol occurs naturally in our food (especially eggs are rich in cholesterol). However, most of the cholesterol in our blood is produced by our own bodies. This is why it is called endogenous or body-produced cholesterol. Exogenous cholesterol, which is supplied from outside, contributes very little to the increase in cholesterol levels.

For a long time, it was believed that eggs would lead to a significant increase in LDL levels and thus a higher risk of cardiovascular diseases. Recent studies have shown that while eggs do cause a slight increase in LDL, it is from a subgroup of LDL molecules that are too large to be deposited in the vessel wall. This means that eggs are healthier than assumed, as they contain a wealth of vitamins and other healthy substances. (Blesso & Fernandez, 2018)

Do eggs cause your cholesterol to skyrocket? According to recent scientific research, this is a myth from the past.

The moral of the story? A functioning organism needs all forms of cholesterol molecules. LDL transports vital cholesterol from the liver to other parts of the body, and HDL can pick up excess cholesterol again. However, if there is an excess of LDL or an LDL/HDL imbalance, it first leads to vascular deposits and over a long time to arteriosclerosis.

Atherosclerosis – the number one killer in the Western world

Atherosclerosis – or colloquially known as vascular calcification – is a silent killer. Over decades, small fat molecules accumulate in our vessel walls, gradually growing larger. This leads to inflammatory reactions, plaque formation, and ultimately to the narrowing of entire vessels. Most of the time, you only feel the effects of atherosclerosis when a vessel is almost completely blocked. The result is a lack of oxygen in the supplied tissue (ischemia). "Ischemic pain" can be experienced by those affected with heavily "calcified" coronary arteries when they exert themselves. The vessels are too narrow for the blood due to the "calcifications".There is an  insufficient supply of oxygen  and affected individuals feel a stabbing pain in the chest. In the worst case, this can lead to a heart attack or stroke if parts of the plaques detach and block entire vessels. (Khatana et al., 2020)

Did you know? When we talk about vascular calcification, we often mean the fat deposits caused by LDL particles.  But not only LDL plays a role, but also calcium. Too much calcium in the vessels can lead to significantly stronger "calcification." Vitamin K2 counteracts this. Several studies have shown that  vitamin K2-dependent proteins can reduce the calcification of vessels. (Halder et al.According to one of the largest studies in the world (Global Burden of Disease), published in the Journal of the American College of Cardiology, cardiovascular diseases, which include atherosclerosis, are the leading cause of death worldwide. Millions of people die from it each year. The authors estimate that up to one third of the population worldwide dies from cardiovascular diseases and atherosclerosis is one of the most important factors. (Roth et al., 2020) High LDL levels are a modifiable risk factor for cardiovascular diseases. Therefore, the colloquial term "bad" cholesterol was used in the past. However, researchers have only deciphered in recent years why this is an oversimplification.

In addition to high LDL levels,  high blood pressure and high blood sugar  are at least equally significant risk factors. What insulin resistance is and why it is so important for your longevity to address it, you can find out in our article on  insulin resistance.

Why is measuring LDL cholesterol so important – and at the same time error-prone?

A brief warning, in this section we need to dive a bit deeper into some studies. Admittedly, the topic is complex, but by the end of this section, it will hopefully be clear, why measuring LDL cholesterol alone is not enough for you.

LDL is one of the main factors in the development of atherosclerosis.In healthy adults, the value should not exceed 115 mg/dL. Imagine for a moment that your vessel walls are not a perfectly tight pipe. Instead, they are full of small "holes" that we need so that nutrients and cells can freely move between our blood system and other compartments of our body. The LDL particles are so small that they can push through our vessel walls. HDL molecules, on the other hand, are too large and cannot enter the vessel wall. When passing through the vessel wall, small errors naturally occur, meaning an LDL molecule does not get through the porous wall in your blood vessel and gets "stuck." If this happens too often, "vascular calcification" occurs through complex remodeling mechanisms. The more LDL molecules are present in your blood, the greater the risk for these "natural errors."For this reason, LDL cholesterol is used as a laboratory parameter. However, not only LDL molecules have this so-called atherosclerotic effect, but also the IDLs. These would not be "counted" in a measurement. This is the first "blind spot" in the measurement of LDL cholesterol. It is simply just a part of the fat truth.

LDL – Estimating versus Measuring

What makes the topic of blood fat values additionally complex is the fact that there are different types of measurements. Traditionally, LDL cholesterol (LDL-C) is estimated using the Friedwald formula  (Martin et al., 2013). That's right, the LDL value in common laboratory reports is mostly based on an estimate.

However, there is also the possibility to measure the LDL particles numerically (LDL-P). This is a direct measurement and significantly more accurate. What is also missing here are the other molecules, especially IDLs.