Vol 32–Don't Waste Another Day Ignoring Your Cholesterol: A Dead Simple Guide to Improving Heart Health

Quick Look 👀

1 oz of water to garden your health

1 Budding Tweet

2 Weeds to avoid

2 Websites to cultivate your garden

Random Musings

Reading Time: 7 minutes and 30 seconds.

Action to water your health

This week’s newsletter is brought to you by apolipoprotein B aka Apo(B).

I keep hearing apo(B) everywhere…yet I haven’t looked into it 👀

Is it a useful test to check for cholesterol?

Who should get this test?

Why doesn’t everyone get it?

Should I even care?

Could this test save my life?

Let’s find out. Save this next time you get your blood cholesterol blood work.

We’ll go over some basic terminology and tie everything in the end. I know it seems like a lot, but it’s your health here. Few people understand this stuff but you’re exceptional.

I am no expert in “lipidology” and there is an insane amount of information in scientific journals and experts out there. I distilled the basic fundamental concepts.

Lipoproteins. Spherical macromolecules are composed of cholesterol and other lipids (like triglycerides and phospholipids), and most importantly a variety of different proteins form a capsule around the lipid cargo.

Chylomicrons. Responsible for transporting triglycerides to muscles and adipocytes and cholesterol from the gut to the liver, and are the largest type of lipoprotein particles. They are produced by the small intestine after a meal and transported to the liver to be broken down and used or stored by the body.

Cholesterol. Is steroid alcohol. The cargo is carried by lipoproteins. Cholesterol is important for the production of steroid hormones and is a critical component of cell membranes. It’s not “bad,” without it we would not be alive. No cholesterol = no life.

If you want an in-depth explanation of the way our body absorbs cholesterol, visit Peter Attia, MD's explanation (right below the diagram labeled “lumen, enterocyte, lymph”). He does a phenomenal job explaining it.

Cholesterol can exist in two forms. One form is called "free" or "unesterified" and the other is called "esterified" or "storage form". The unesterified form is more active than the esterified form.

The body can only absorb unesterified cholesterol (UC) from food, not cholesterol esters (CE).

The body has enzymes that can convert some ingested cholesterol esters into unesterified cholesterol, which can then be absorbed.

Hydrophobic (non-polar molecules). Water hating. Substances do not mix well with water and tend to repel it. Can dissolve in non-polar solvents

Hydrophilic (polar molecules). Water loving. Mix well with water and are attracted to it. Can dissolve in polar solvents.

Cholesterol Esters (CE). Are hydrophobic, they cannot travel in the bloodstream alone and require a ride.

Enter the ride–Apoproteins. There are several, we’ll talk about two main types A&B. In general apoproteins are proteins that transport lipids in the body. When bound to lipids, they form apolipoproteins, carried by lipid-transporting particles called lipoproteins.

If that last sentence was confusing look at the picture below. Everything is held together by the lipid wrapper and it contains the “goods.” Similar to a Christmas gift.

Apoprotein A-I (apo-AI). Is the main protein component of high-density lipoprotein (HDL) cholesterol. They are microscopically tiny compared to apoB lipoproteins.

This is important as lipoprotein particles decrease in size, the number of triglycerides they contain decreases, and the amount of protein they contain increases, leading to a change in density.

Apoprotein B (apoB). Is the main protein component of low-density lipoprotein (LDL), intermediate-density lipoprotein (IDL), and very low-density lipoprotein (VLDL).

Actual cholesterol mass is greatest in the LDL particle.

LDL particles transport cholesterol back to the liver through a process called indirect reverse cholesterol transport." However, under certain circumstances, they may also deliver cholesterol to the artery walls.

Lab tests. A standard lipid panel measures total cholesterol (TC), triglycerides (TG), and high-density lipoprotein cholesterol (HDL-C), while low-density lipoprotein cholesterol (LDL-C) is often estimated.

More advanced tests, such as the nuclear magnetic resonance spectroscopy (NMR) LipoProfile, can directly measure LDL-C and the cholesterol content of other lipoproteins, as well as the size of each lipoprotein particle, which can be useful for predicting insulin resistance.

ApoB Particles: The Heart Disease Risk Factor

If the number of apoB particles (90-95% of which are LDLs) in your plasma is high, you are at risk of atherosclerosis. LDL-P (or apoB) are generally considered to be more accurate predictors of cardiovascular risk than LDL-C.

If LDL-C is low and LDL-P (or apoB) is high they are discordant. A discordant LDL pattern may indicate that the LDL particles in the blood are smaller and denser, which can increase the risk of heart disease.

How does plaque develop in the arterial wall? It starts with an increase in LDL particles aka Apo(B). They enter the arterial walls, and an all-out war begins. Your body releases its army against these invaders. It traps a large percentage of them in the arterial walls.

More and more ApoB particles enter the fight and more remain on the arterial walls. Eventually, your body sends reinforcements, making things worse. More retention and inflammation occur.

Eventually leading to plaque building from all the dead invaders and friendly forces. Over time this will cause the narrowing of the blood vessel and decrease blood flow.

Of course, this is a crude picture of the pathophysiology and we could spend years discussing the details.

Is having high-density lipoprotein (HDL) good? HDL (high-density lipoprotein) cholesterol and HDL particle number (HDL-P) are not the same thing, just as LDL (low-density lipoprotein) cholesterol and LDL particle number (LDL-P) is not the same thing.

Studies have shown that smaller HDL particles may be more protective against heart disease than larger ones and that an increase in HDL-C (HDL cholesterol) is often driven by a disproportionate increase in HDL size rather than HDL-P.

Despite this, clinical trials involving drugs that increase HDL-C have NOT shown a reduction in cardiovascular events, although some studies have suggested that larger HDL particles can be cardioprotective.

This may be because HDL particles, although they carry cholesterol, are more complex than that and may also have anti-inflammatory and anti-atherosclerotic effects.

I know that was a lot of information.

I ended up in a rabbit hole when researching this and was side-tracked so many times, by the vast amount of information.

I work in heart surgery and feel the plaque in the heart walls regularly. So I tried my best to explain this topic.

TL;DR

1. Take the Framingham Risk Score for Hard Coronary Heart Disease: Estimates 10-year risk of a heart attack.

2. >5% risk? apoB, LDL-P, Lp-PLA2, and Lp(a) are useful tests as appose to a normal cholesterol test. Better prediction as discussed above.

3. Normal lipid levels (TC, TG, and HDL-C; LDL-C is estimated) ≠ no heart disease. As we discussed these are not the best tests.

4. "LDL particle number (LDL-P) or apolipoprotein B (apoB) is the best predictor of adverse cardiac events, according to numerous major cardiovascular risk studies."

5. The journal of clinical lipidology “apoB is a more accurate marker of cardiovascular risk than non-HDL-C and that the practice of lipidology would be improved by the inclusion of apoB along with lipoprotein lipids in routine clinical care.”

I did not have the time to go into “diets.” At the time of writing this, my brain is mush. I hope this was at least a bit helpful.

More Resources (just to be sure)

• Peter Attia, MD: He was the inspiration for this post and most of the content was used from his podcast, and blog writings.

• Ninja Nerd–Metabolism lipoprotein, chylomicros, VLDL, IDL, LDL & HDL (in-depth and an hour long)

• GI Journal article on Genetic Regulation of Intestinal Cholesterol Absorption (in depth and comprehensive).

• Therapeutic Lipidology (Contemporary Cardiology)

• The Cholesterol Wars: The Skeptics vs the Preponderance of Evidence

• Subendothelial lipoprotein retention as the initiating process in atherosclerosis: update and therapeutic implications

• Lipid oxidation in pathophysiology of atherosclerosis: Current understanding and therapeutic strategies (This one is great)

Budding Tweet

This tweet has an awesome picture of LDL and ApoB. It shows that if you have large LDL particles, your LDL burden might appear high, but your particle number, which we determine by your ApoB will not be large. But if you have many smaller LDL particles, your LDL level might be normal, but your ApoB will be high.

Remember what we talked about before…I know seems like ages ago. ApoB is an important factor in heart disease (not the only one.)

Weeds to avoid

1️⃣ Not spending a significant amount of time learning your note-taking style and accompanying app.

Some people use paper and pen. Others prefer google docs or the endless suite of note-taking apps. With that said, I have one invite to tana. If you’re the first to email me it’s yours.

2️⃣ Not calculating your estimated 10-year risk of a heart attack. Doesn’t matter if you are perfectly healthy just do it. Calculator here. Do it for family members. It’s not to produce paranoia but be informative and make lifestyle/medication changes.

Websites to cultivate your garden

Sumly.AI: AI-generated podcast summaries. It’s free and awesome. The last time I tried it thought it was broken. Too many people accessing it 😢

Home Fit: With the home, workout scene exploding. I like this minimal workout set-up with dips and pulls ups. I don’t have one but would be worth getting to try out.

Random Musings

1. I have a couple of special coffee cups. Every time I drink from them, it brings joy. That comes to mind as something that helps reset my focus and bring me back to the moment.

2. I’ve been having fun tracking my habits with habitsgarden. Check out my garden and follow me if you have it as well.

3. I’m still trying to figure out this newsletter thing and what I want it to be. Email me if you have any recommendations or if anything has helped.

4. I have a plant called “plant-e” (no that’s not another cholesterol biomarker) and it finally made it to my desk. Often reminds me of my post on bioengineered plants.

You're an awesome human

Martin, CEO of braincrumbss

Stuff I created, that you might find helpful.

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2. This product is free. It is the most comprehensive tool for digital nomads who end up with diarrhea 💩. How to treat it, when to worry, and what to pack. Everything. I spend an embarrassing amount of time writing this. Yes, this was created from personal experience on an overseas trip 😮