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

Laboratory testing of blood lipid levels is part of routine tests in the practice. LDL cholesterol and HDL cholesterol are the most commonly determined. But what do these values ​​tell us? What is the truth behind the story of “bad” and “good” cholesterol? Why are blood lipid levels an important cornerstone for your longevity and why does Dr. Peter Attia this topic a whole chapter in his new book? You will find out all about it in this article.

Background – where do 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 occur in different forms. They form phospholipids the shell of cells, are basis for the synthesis of various hormones, like the cortisol or testosterone and serve us in the form of triglycerides as an energy store. We absorb fatty acids through our intestines every day with our food and then distribute the individual molecules with the help of the blood to every corner of our body - ideally to where they are actually needed. The right composition of fatty acids and a sufficient supply 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 as part of dietary supplements used to increase bioavailability.

You can see what effect this use can have by looking at the example of Quercesome. MoleQlar's specially formulated Quercetin-C complex is around 20 times more bioavailable than conventional quercetin powderThe key performers are Phospholipids from the sunflower and in addition the clever combination with natural vitamin C – a bio-enhancer of quercetin. At Berbersome – the Berberine Mineral Complex from MoleQlar – the Plus berberine bioavailability through phospholipids up to 10 times.

Fat and water – the transport challenge

fats are chemically insoluble in water (hydrophobic). This phenomenon can be easily recognized if you put a few drops of oil in water. The oil does not mix with the water, but floats on the surface in the form of drops. How does our body do this when blood is also mostly made of water? To overcome this challenge, 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 designated and form the basis for the laboratory measurements of lipid metabolism.

Which blood lipid levels 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

In some laboratory results, these two values ​​also appear:

• ApoB
• Lp(a)

In Germany The blood lipid levels of healthy adults are usually checked once as part of a health check-up. From the age of 35, the blood lipid levels can be checked every three years. In the southern neighbouring country Austria The statutory health insurance companies are somewhat more generous. Here, an annual laboratory test is possible as part of the preventive medical examination.

What are the normal values ​​for blood lipid levels?

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

Did you know? In patients with far too many fatty acids in the blood, a so-called hypertriglyceridemia, this can sometimes be seen 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 directly contribute to arteriosclerosis.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 though triglycerides, unlike LDL, cannot be deposited 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 mentioned above.

In addition to exercise and a healthy, Mediterranean diet, the ESC mentions two supplements that can lower triglyceride levelsOne of these is berberine, which has been shown in studies to lower both LDL cholesterol and triglycerides. MoleQlar is Berberine in phospholipid form available, which is a 10 times better bioavailability than normal 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, HDL cholesterol, LDL cholesterol and triglycerides. As a patient, you often hear sentences like: "Your bad cholesterol (LDL) is a little high, but your good cholesterol (HDL) balances it out.Metaphors such as “don’t do that” (LDL) and “love you” (HDL) are also often used. Or you are simply told that your blood lipid levels are normal. But what does normal and why is the good and bad cholesterol actually just a fairy tale?

To understand this in more detail, we need to take another look at cholesterol metabolism. Cholesterol is absolutely vital for our body. Put simply, it is a special fat molecule that we need for every cell in our body. In very brief terms, cholesterol metabolism can be imagined as follows:

• Cholesterol is produced in the liverThe body's own cholesterol, triglycerides and apolipoproteins are then combined with each other. VLDL particles (very low density lipoproteins)
• These VLDL molecules are quite large and are now transported with the blood.
• In the body these VLDL molecules release triglycerides (for example, on muscle cells) and thus 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 the IDLs they eventually become the well-known LDL molecules.
• The LDL molecules can ultimately be absorbed by cells via receptors. These are found, 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 Eggs Untruth

Cholesterol occurs naturally in our food (eggs in particular are rich in cholesterol). However, the majority of the cholesterol in our blood is produced by ourselves. It is therefore 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 led to a strong increase in LDL levels and thus a higher risk of cardiovascular disease. More recent studies have shown that eggs do cause a slight increase in LDL, but that they cause a subgroup of LDL molecules that are too large to be deposited 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 needs all forms of cholesterol molecules. LDL transports vital cholesterol from the liver to the rest of the body and HDL can pick up excess cholesterolHowever, if there is an LDL excess or LDL/HDL imbalance, this initially leads to vascular deposits and, over the long term, to arteriosclerosis.

Arteriosclerosis – the number one killer in the Western world

Arteriosclerosis – or colloquially known as arteriosclerosis – is a silent killer. Over decades, small fat molecules accumulate in our blood vessel walls and gradually become larger. Inflammatory reactions, plaque formation and ultimately narrowing of entire vessels occur. You usually only feel arteriosclerosis when a vessel is almost completely blocked. The result is a lack of oxygen in the tissue supplied (ischemia). People 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 oxygen deficiency and those affected notice a stabbing pain in the chest. In the worst case, a heart attack or stroke occurs when parts of the plaque break off and block entire vessels. (Khatana et al., 2020)

Did you know? When we talk about arteriosclerosis, we often mean the fatty deposits caused by LDL particles. But not only LDL plays a role, but also calciumToo much calcium in the vessels can lead to a significantly stronger “calcification”. This is counteracted by vitamin K2. Several studies have shown that vitamin K2-dependent proteins could reduce vascular calcification. (Halder et al., 2019)

According to one of the world's largest studies (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 every year. The authors estimate that up to a third of the world’s population dies from cardiovascular diseases and arteriosclerosis is one of the most important factors. (Roth et al., 2020)

High LDL levels are a modifiable risk factor for cardiovascular diseaseThis is where the colloquial term “bad” cholesterol came from. However, it is only in recent years that researchers have discovered why this is an understatement.

In addition to high LDL levels, high blood pressure and high blood sugar at least as big risk factors. You can find out what insulin resistance is and why it is so important for your longevity to deal with it 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 have to delve a little deeper into some studies. Admittedly, the topic is complex, but by the end of this section, hopefully it will 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 115mg/dL lay.

Imagine for a moment that your blood vessel walls are not a perfectly sealed tube. Instead, they are full of little “holes” that we need to allow nutrients and cells to move 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 big and cannot get into the blood vessel wall. Small errors naturally occur when passing through the blood vessel wall, meaning that an LDL molecule cannot get through the porous wall in your blood vessel and gets "stuck". If this happens too often, complex remodeling mechanisms lead to the formation of "vascular calcium". 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 not only LDL molecules have this so-called atherosclerotic effect, but also the IDLsThese would not be “counted” in a measurement. This is the first "blind spot" in the measurement of LDL cholesterol. It's simply only part of the fat truth.

LDL – Estimating versus Measuring

What makes the topic of blood lipid levels even more complex is the fact that there are different types of measurement. LDL cholesterol (LDL-C) estimated using the Friedwald formula. (Martin et al., 2013) That's right, the LDL value in common laboratory results is usually based on an estimate.

However, it is also possible to measure the number of LDL particles (LDL-P). This is a direct measurement and much more accurate. What is missing here, however, are the other molecules, especially IDLs.

In a large review study, different measurement methods were compared. (Mora et al., 2014) Concordant and discordant measurements are shown here. What does that mean? Let's assume your LDL cholesterol is at an unremarkable 105 mg/dl. As a reminder, the cholesterol in your LDL particles is estimated here. You can now also directly count the LDL particles, then you get the LDL-P valueIf 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, as a "normal" LDL-C may appear in a routine laboratory test even though your LDL-P is elevated. However, your doctor would tell you based on the findings: "Everything is fine."

But is that really the case?

This study showed that women in particular have an increased risk of death if they have discordant LDL levelsIn addition to the LDL-P values, apoB and non-HDL cholesterol were also compared as measurement methods. For all three parameters for blood lipid values, discordant values ​​compared to LDL-C are associated with a higher risk.

In short: Measuring LDL cholesterol alone can give a false sense of security due to the measurement method.

Arteriosclerosis (also called atherosclerosis) is the number one silent killer. The vessels become increasingly narrower until sufficient blood flow is no longer possible.

ApoB – a 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, Dr. Peter Attia in his book “Outlive: The Science and Art of Longevity” for another measurement of blood lipid levels: ApoB

ApoB is an apolipoprotein - a complex of fatty acids and a water-soluble shell, if you 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 ApoBWith 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 advocates placing more focus on determining ApoB.

The role of ApoB has been known in the scientific community for some time and was described in a review by Dr. Sniderman, among others. (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 have their apoB levels measured? This is currently still under debateOn the one hand, proponents argue that this value provides a much better estimate of the risk of cardiovascular disease.On the other hand, it is argued that that LDL-C is sufficient, because it is more than 90% responsible for the underlying “arteriosclerosis”.

Low ApoB levels are usually associated with a low risk of cardiovascular disease. It can therefore make sense to determine your level and tailor 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 ApoBLp(a) has similar properties to LDL, meaning it is quickly deposited in the vessel wall. Similar to ApoB, there is currently a debate about how useful the measurement is for everyone in the population.

Blood sampling - for some a necessary evil, for others an important building block for their 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 exclusively with doctors!

The European Society of Cardiology has published different threshold values ​​for LDL-C and ApoB in its guidelines. These vary greatly depending on personal risk.

The lowest LDL-C target values ​​are around 40 mg/dl and the lowest ApoB target values ​​are below 65 mg/dl. Currently, such strict limits are only recommended for people who already have serious pre-existing illnesses.

There is currently a debate about whether an early reduction in LDL and ApoB levels is beneficial. The idea behind it is as follows. We now know that arteriosclerosis is a disease that progresses slowly over decades. Small fat particles accumulate unnoticed in the walls of our blood vessels every day. If you were to cut open the vessels of those affected, you would be able to see the “fat plaques” with the naked eye. However, such plaques only develop after a long time, and are also referred to as a cumulative LDL burden over life.

One idea is to never reach this cumulative LDL load and thus never develop enough atherosclerosis to provoke disease. Dr. Braunwald, one of the leading cardiologists in America, has even hypothesized that by lowering LDL levels early on, one can live to the age of 100 without ever getting cardiovascular disease.Since cardiovascular diseases are the number one cause of death, early reduction of LDL and ApoB would bring a tremendous improvement in both quality of life and life expectancy.