Laboratory examinations of blood lipid levels are part of routine examinations in practice. The most commonly determined are LDL cholesterol and HDL cholesterol. But what do these values tell us? What is the story about “bad” and “good” cholesterol? Why are the blood lipid values one important cornerstone for your longevity and why Dr. Peter Attia a whole chapter on this topic in his new book? You can find out all of this in this article.
Background – where do the blood lipid levels come from?
In order to better understand the laboratory values, it is worth taking a closer look at our own fat metabolism, also known as lipid metabolism. Fats are distributed throughout the body and come in different forms. As phospholipids they form the shell of cells and 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. We absorb fatty acids through our intestines every day with food and then distribute the individual molecules with the help of the blood to every corner of our body - ideally, especially where they are actually needed. What is particularly important is the correct composition of fatty acids and a sufficient intake of Omega-3 fatty acids.
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 body. They are also contained in chocolate, ice cream, margarine and cosmetic products. In medicine, they are used as a component of food supplements to increase bioavailability.
You can see what effect this use can have using the example of Quercesome. MoleQlar's specially formulated Quercetin-C complex is around 20 times more bioavailable than conventional Quercetin powder. The main performers are Phospholipids from sunflower and the clever combination with natural vitamin C - a bio-amplifier of Quercetin. With Berbersome – the berberine mineral complex from MoleQlar – the Plus amounts to Berberine bioavailability through phospholipids increased 10-fold.
Fat and water – the transport challenge
Fats are chemically insoluble in water (hydrophobic). This phenomenon can be clearly seen by adding a few drops of oil to water. The oil does not mix with the water, but floats on the surface in droplets. How does our body do that when blood consists largely of water? In order to overcome this challenge, there are so-called apolipoproteins. These surround the fatty acids and form a water-soluble (hydrophilic) shell. You can imagine the whole thing as a small ball. The water-soluble proteins are on the outside and the water-insoluble fats are on the inside. Apolipoproteins and fatty acids together are also called lipoproteins and form the basis for the laboratory measurements of lipid metabolism.
Which blood lipid values can be measured?
Lipoproteins are divided into different categories based on their density. The following parameters are usually measured:
- LDL cholesterol
- HDL cholesterol
- Total cholesterol
- Triglycerides
- Non-HDL cholesterol
These two values also appear in some laboratory findings:
- ApoB
- Lp(a)
In Germany blood lipid levels in healthy adults are usually examined once as part of a health examination. From the 35th Blood lipid levels can be checked every three years. In the southern neighboring country Austria the statutory health insurance companies are somewhat more generous. A laboratory examination is possible here every year as part of the preventive examination.
Which standard blood lipid values exist?
The normal values vary depending on age and personal risk. The European Society of Cardiology (ESC) defines the following limit values for people under 65 with low risk:
| Total cholesterol | <190 mg/dL (5mmol/L) |
| HDL cholesterol | In men >40 mg/dL (1mmol/L)
In women >45 mg/dL (1.2mmol/L) |
| Non-HDL cholesterol | <145 mg/dL (3.8mmol/L) |
| LDL cholesterol | <115 mg/dL |
| apoB | <100 mg/dL (1.0mmol/L) |
| Lp(a) | <50 mg/dL |
| Triglycerides | Fasting: <150 mg/dL (1.7mmol/L)
Non-fasting: <175 mg/dL (2.0mmol/L) |
Did you know? This can sometimes happen in patients with far too many fatty acids in the blood, a so-called hypertriglyceridemia see with the naked eye. If the patient's blood is separated into liquid (serum) and solid blood components (cells) using a centrifuge, the serum looks milky-white. Normally the serum is clear and yellow in color.
Triglycerides – more than just fat
Triglycerides do not contribute directly to vascular calcification. For this reason, they are not always given sufficient attention. But the triglyceride levels are just as important for your longevity.
Values above 800 mg/dL can, for example, trigger pancreatitis at any time. And even if, unlike LDL, triglycerides cannot be stored directly in the vessel wall, they have an indirect effect on arteriosclerosis via IDL particles (more on this later ). For this reason, your triglyceride levels should not exceed the limits listed above.
In addition to exercise and a healthy, Mediterranean diet, the ESC mentions two supplements that can lower triglyceride levels. One of these 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 normal berberine powder .
Blood lipid levels: The myth of “good” and “bad” cholesterol
If you would like 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 little high, but your good cholesterol (HDL) compensates for that.“ Metaphors such as “don’t do that” (LDL) and “love you” (HDL) are also often used. Or they just tell you that your blood lipid levels are normal. But what does normal actually mean and why is the good and bad cholesterol actually just a fairy tale?
To understand this in more detail, we have to take another look at cholesterol metabolism. Cholesterol is absolutely vital for our body. To put it simply, it is a special fat molecule that we need for every cell in our body. In very short terms, you can imagine cholesterol metabolism like this:
- Cholesterol is made in the liver. The body's cholesterol, triglycerides and apolipoproteins are then linked together. This is how VLDL particles (Very-low-density lipoproteins) are created
- These VLDL molecules are quite large and are now transported in the blood.
- In the body these VLDL molecules release triglycerides (for example to muscle cells) and thereby become smaller. They are now called VLDL remnants or IDL molecules.
- The more cholesterol or triglycerides the VLDLs release, the smaller they become. Via the intermediate stage of IDLs they finally become the well-known LDL molecules.
- The LDL molecules can ultimately be absorbed by cells via receptors. These are located, for example, in the liver, muscle cells or lipid cells.
- HDL molecules have a different purpose. If too much cholesterol accumulates outside the liver, HDL collects it and transports it back to the liver.
The cholesterol egg untruth
Cholesterol occurs naturally in our food (eggs in particular are rich in cholesterol). However, the majority of our cholesterol in the blood is produced by us. It is therefore called endogenous or body cholesterol. Exogenous cholesterol supplied from outside contributes very little to increasing cholesterol levels.
For a long time it was believed that eggs would lead to a sharp increase in LDL levels and thus to a higher risk of cardiovascular disease. Recent studies have shown that eggs cause a slight increase in LDL, but of a subgroup of LDL molecules that are too large to be stored in the vessel wall. This means that eggs are healthier than expected because they contain tons of vitamins and other healthy substances. (Blesso & Fernandez, 2018)
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 requires all forms of cholesterol molecules. LDL transports vital cholesterol from the liver to the rest of the body and HDL can pick up excess cholesterol. However, if there is an excess of LDL or an LDL/HDL imbalance, this initially leads to vascular deposits and, over a long period of time, to arteriosclerosis.
Arteriosclerosis – the number one killer in the western world
Arteriosclerosis – or, colloquially, vascular calcification – is a silent killer. For decades, small fat molecules have been stored in our vessel walls and gradually become larger. This leads to inflammatory reactions, plaque formation and ultimately to the narrowing of entire vessels. You usually only notice arteriosclerosis when a vessel is almost completely closed. The result is a lack of oxygen in the supplied tissue (ischemia). Those with severely calcified coronary arteries can feel “ischemia pain” when they exert themselves. The vessels are too narrow for the blood due to the “calcifications”. There is a undersupply of oxygen and those affected notice a stabbing pulling sensation in their chest. In the worst case, a heart attack or stroke occurs when parts of the plaques come off and entire vessels become blocked. (Khatana et al., 2020)
Did you know? When we talk about vascular calcification, we often mean the fatty deposits caused by the LDL particles. It's not just LDL that plays a role, but also calcium. Too much calcium in the vessels can lead to significantly more “calcification”. This is counteracted by Vitamin K2. Several studies have shown that vitamin K2-dependent proteins could reduce the calcification of vessels. (Halder et al., 2019)
According to one of the world's largest studies (Global Burden of Disease), which was published in the Journal of the American College of Cardiology, cardiovascular diseases, which include arteriosclerosis, are the most common cause of death worldwide. Millions of people die from it every year. The authors estimate that up to a third of the population worldwide dies from cardiovascular diseases and arteriosclerosis is one of the most important factors. (Roth et al., 2020)
High LDL values are a modifiable, i.e. changeable, risk factor for cardiovascular diseases. This is where the colloquial term used to come from: “bad” cholesterol. But researchers have only discovered in recent years why this falls short.
In addition to high LDL values, high blood pressure and high blood sugar are at least as big risk factors. You can find out what insulin resistance is and why it is so important to deal with it for your longevity in our article on insulin resistance.
Why is LDL cholesterol measurement so important - and at the same time prone to errors?
Quick warning, in this section we need to delve a little deeper into some studies. Admittedly, the topic is complex, but at 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 arteriosclerosis. In healthy adults the value should not exceed 115mg/dL .
Imagine for a moment that your vessel walls are not a perfectly tight tube. Instead, they are full of little “holes” that we need to allow nutrients and cells to travel freely between our blood system and other compartments of our body.
The LDL particles are so small that they can push through our blood vessel walls. HDL molecules, on the other hand, are too large and cannot penetrate the vessel wall. Small errors naturally occur when passing through the vessel wall, which means that an LDL molecule does not get through the holey wall in your blood vessel and gets “stuck”. If this happens too often, “vascular limescale” is created via complex degradation mechanisms. The more LDL molecules there are in your blood, the greater the risk of these “natural errors”. For this reason, LDL cholesterol is used as a laboratory parameter. But it is not only LDL molecules that 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 measuring LDL cholesterol. It's simply just part of the fat truth.
LDL – Estimating and Measuring
What makes the topic of blood lipid levels even more complex is the fact that there are different types of measurements. Classically, LDL cholesterol (LDL-C) is estimated using the Friedwald formula. (Martin et al., 2013). That's right, the LDL value in common laboratory findings is usually based on an estimate.
However, there is also the possibility of measuring the LDL particles numerically (LDL-P). This is a direct measurement and is much more accurate. But what is missing here too are the other molecules, especially IDLs.
In a large overview study, different measurement methods were compared with each other. (Mora et al., 2014) Concordant and discordant measured values are shown here. What does that mean? Let's assume your LDL cholesterol is an unremarkable 105mg/dl. As a reminder, this estimates the cholesterol in your LDL particles. You can now also count the LDL particles directly, then you get the LDL-P value. If this is the same as your LDL-C value, then it is called concordance. However, if your LDL-P value is significantly higher/lower, this is referred to as discordant values.
Discordant values are deceptive because a “normal” LDL-C can appear in normal routine laboratory tests even though your LDL-P is elevated. However, based on the findings, your doctor would tell you: “Everything is fine.“
But is it really like that?
This study showed that women in particular have an increased risk of death if they have discordant LDL values. In addition to the LDL-P values, apoB and non-HDL cholesterol were also compared as a measurement method. For all three blood lipid parameters, discordant values were associated with a higher risk compared to LDL-C.
In brief: Measuring LDL cholesterol alone can suggest a false sense of security due to the measurement method.
Arteriosclerosis (also called atherosclerosis) is the number 1 silent killer. The vessels become increasingly narrower until sufficient blood flow is no longer possible.
ApoB – the better measurement than LDL?
We have seen that measuring LDL cholesterol alone, using the estimation formula, simply does not give us enough information. For this reason, among other things, Dr. Peter Attia in his book “Outlive: The Science and Art of Longevity” for a different measurement for blood lipid levels : ApoB
ApoB is an apolipoprotein - a complex of fatty acids and a water-soluble shell, if you still remember the introduction. ApoB binds triglycerides and cholesterol to make them water-soluble. The genius of ApoB is that every lipoprotein (except HDL) has exactly one molecule of ApoB. With the help of ApoB, it is possible to determine much more precisely how many lipoproteins are in our bloodstream. For this reason, longevity doctor Dr. Attia to focus more on the determination of ApoB.
The role of ApoB has been known in the scientific community for some time and has been discussed by, among others, Dr. Sniderman described in a review. (Sniderman et al., 2019)
The European Society of Cardiology also recognizes the role of ApoB in its 2019 guidelines and currently recommends it as an additional diagnosis in high-risk patients.
Should we measure ApoB in all people?
Should everyone now have their apoB level measured? This is currently still up for debate. On the one hand, supporters argue that the risk of cardiovascular disease can be assessed much better with this value. On the other hand, it is argued that LDL-C is sufficient since it is more than 90% responsible for the underlying “vascular calcification”.
Low ApoB levels are usually associated with a low probability of cardiovascular disease. So it can definitely make sense to determine your level and base your therapy accordingly.
In addition to apoB, there is another risk factor that indicates a high risk of arteriosclerosis. We are talking about Lp(a).
Lp(a): a familial risk factor
Lp(a) (pronounced: lipoprotein small a) is a genetic risk factor. People with high levels of Lp(a) have a significantly increased risk of cardiovascular disease, independent of LDL cholesterol and ApoB. Lp(a) has similar properties to LDL and is therefore quickly deposited in the vessel wall. Similar to ApoB, there is currently a discussion about how useful the measurement is for everyone in the population.
Blood sampling - for some a necessary evil, for others an important component of one's own longevity.
Blood lipid levels – the lower the better?
Disclaimer: This article cannot give you precise medical recommendations on target values. You should always discuss these steps only with doctors!
The European Society of Cardiology has published various limit values for LDL-C and ApoB in its guidelines. These vary greatly depending on your personal risk.
The lowest LDL-C target values are around 40mg/dl and the lowest ApoB target values are below 65mg/dl. Currently, such strict limits are only recommended for people who are already seriously ill.
It is currently being discussed whether an early reduction in LDL and ApoB levels is beneficial. The idea behind it is this. It is now known that arteriosclerosis is a disease that progresses slowly over decades. Unnoticed, small fat particles build up in the walls of our blood vessels every day. If you were to cut open the vessels of those affected, you could see the “fatty plaques” with the naked eye. However, such plaques only develop after a long time; this is also referred to as a cumulative LDL load over a lifetime.
One idea is to never reach this cumulative LDL load and thus never develop enough arteriosclerosis to provoke disease. Dr. Braunwald, one of the leading cardiologists in America, even put forward the hypothesis that by lowering LDL levels early, you can live to be 100 years old without ever developing cardiovascular disease. Since cardiovascular diseases are the number one cause of death, early reduction of LDL and ApoB would bring about a dramatic improvement in both quality of life and life expectancy.
