Barry Rotman, MD

The Ultimate Workout: How Rowing Machine Benefits Transform Your Fitness

The other day, a patient asked me about the most efficient means of exercise for someone with limited time and joint issues. Without hesitation, I recommended a rowing machine.

The benefits of rowing machines include comprehensive muscle engagement, cardiovascular improvements, joint protection, maintenance of spinal bone density, and mental wellness, making rowing ideal for almost anyone.

Top Rowing Machine Benefits: A Full-Body Workout

When evaluating any exercise, I first consider muscle engagement.

One of the primary benefits of rowing machines is that they engage 86% of your muscles simultaneously. The arms, legs, back, and core all work together in a synchronized motion that few other exercises can match.

Let’s compare muscle engagement across different activities:

• Walking: Engages only 30–40% of muscle groups, primarily lower body
• Cycling: Activates 40–50% of muscle groups, mainly legs with some core
• Running: Uses 60–70% of muscle groups with upper body involvement
• Swimming: Engages 80–90% of muscles, approaching rowing’s effectiveness
• Rowing: Tops the list at 86% muscle engagement

Swimming comes close to rowing in terms of full-body engagement, but it’s much easier to fit a rowing machine in your basement than install a swimming pool.

This comprehensive muscle recruitment makes rowing time-efficient. Rather than isolating muscle groups across different exercises, rowing engages nearly everything at once.

Another benefit of rowing machines is their low-impact nature, which is advantageous for individuals with joint issues. Unlike running or jogging, which pound your knees against pavement, rowing offers resistance without impact stress. Your joints move through their natural range of motion without the trauma of repeated impact.

Cardiovascular Benefits of Rowing Machines

The cardiovascular benefits of rowing machines deserve special attention. I particularly appreciate rowing’s adaptability to different training zones.

Want a steady Zone 2 cardio workout that builds endurance? Row at a consistent, moderate pace using a heart rate of power output to keep you in Zone 2.

Prefer high-intensity interval training? Alternate between sprint efforts and recovery periods.

Need a tempo workout? Find that middle ground with sustained challenging effort.

The rowing machine adapts to your cardiovascular goals, making it versatile for different training phases and fitness levels.

Mental Benefits: Another Advantage of Rowing Machines

Like most forms of exercise, rowing relieves stress and boosts mental well-being.

Rowing’s rhythmic nature puts many people in a peaceful state. I’ve had numerous patients report that their rowing sessions become a form of moving meditation, clearing their minds while strengthening their bodies.

Posture and Core Strength: The Hidden Rowing Machine Benefits

We live in an increasingly sedentary society. The resulting epidemic of poor posture contributes to numerous chronic pain issues.

The many benefits of rowing machines include strengthening your upper back, spine, and core muscles, which support proper posture. This strengthening protects your back from injury and improves how you stand and position your body throughout the day.

The strong core development from consistent rowing translates to better body mechanics in all daily activities.

The Solo-Community Balance

For home workouts, rowing machines are remarkably space-efficient. A single machine tucked in a corner provides a complete fitness solution.

Meanwhile, group rowing classes provide motivation, instruction for proper technique, and the social benefits that often help maintain exercise consistency.

This balance between solo exercise and community involvement makes rowing adaptable to different personality types and lifestyles. Whether you prefer solitary exercise or thrive in group settings, rowing accommodates your preferences.

Proper Technique: Maximizing Rowing Machine Benefits

Proper technique remains essential for maximizing rowing’s benefits while minimizing injury risk.

The best approach to learning proper rowing technique is working with an expert who can observe your form and provide real-time corrections. Video tutorials are a good starting point, but nothing replaces personalized instruction.

To that end, I’m excited to announce that Banner Peak Health will partner with CRUfit, a specialized rowing gym. This partnership will give our members access to expert instruction and a supportive community to enhance their rowing experience.

Today’s Takeaways

If exercise were a pill, it would be the safest, most powerful drug ever created. And if exercises were ranked by efficiency and effectiveness, rowing would be near the top of that list.

If you have limited time, joint concerns, or a desire for maximum efficiency in your workout routine, explore rowing as a primary exercise modality. The benefits of rowing machines include unparalleled muscle engagement, joint protection, cardiovascular adaptability, and mental wellness.

Whether you’re just beginning your fitness journey or looking to optimize an established routine, few other exercises can match the benefits of rowing machines. Your heart, muscles, joints, and mind will all thank you for giving rowing a try.

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by Barry Rotman, MD

Benefits of Continuous Glucose Monitoring: My Journey With Stelo CGM

I see them everywhere — small white dots on triceps at the gym, the beach, and even medical conferences. Continuous glucose monitors have become the latest health trend, with Dexcom’s new over-the-counter Stelo leading the charge.

As a physician committed to preventative health, I embrace “me-search” — using myself as a subject in N=1 trials to better understand the latest healthcare technologies.

My latest experiment? Testing Stelo for myself to understand the benefits of continuous glucose monitoring (CGM).

The Metric-Driven Empowerment Cycle

Human nature drives us to improve what we measure. When we assign a number to something, we try to beat it. The Metric-Driven Empowerment Cycle (MDEC) leverages this tendency to create lasting health improvements.

Let’s break it down:

• Metric — The quantifiable number that measures your current state.
• Driven — The motivation to improve that number.
• Empowerment — The active process of making changes. You have the power to change these numbers — this isn’t passive.
• Cycle — This isn’t a one-time measurement but a repeating process. You measure, improve, and feel accomplished, which motivates you to continue.

We see this cycle in action every day. My wife tries to take 10,000 steps a day. Patients step on our scale, motivated by the number they see. These metrics create measurable paths toward improvement.

This cycle is particularly powerful when combined with the benefits of continuous glucose monitoring, as CGM provides immediate feedback that drives behavior change.

Why I Tried Stelo CGM

With borderline glucose levels in my own tests (fasting glucose of 104–106 and A1c of 5.6), I was a perfect candidate for Stelo.

While my numbers fell within the “normal” range, they sat at the upper boundary. Research shows cardiovascular risks begin increasing at A1c levels as low as 5.4 — meaning a population with “high-normal” results still faces health risks.

Until recently, CGMs required prescriptions. Dexcom previously manufactured only the G7 device (prescription only) but now offers Stelo for over-the-counter purchase, with key differences:

• Stelo lasts 15 days (G7 lasts 10).
• Stelo reads glucose levels every 15 minutes (though my device gave five-minute readings).
• Stelo reads glucose levels between 70–250 mg/dL (G7 ranges from 40–400).
• Stelo targets pre-diabetics or those wanting to optimize metabolic health.

From Static to Dynamic Health Monitoring

Traditional testing offers a snapshot — a single moment frozen in time. Consider the difference between an EKG and a stress test. One shows a photo; the other displays the whole movie.

One of the key benefits of continuous glucose monitoring is the shift from static to dynamic measurement. While traditional glucose monitoring only provides occasional snapshots (e.g., finger-stick tests, which show your level at one moment), the benefit of continuous glucose monitoring is that it reveals how your body responds to food, stress, sleep, and exercise in real time.

Over 100 million Americans have either diabetes or pre-diabetes, and most don’t know it. One study examined 60 individuals who tested normal through traditional measurements. When evaluated with CGM, 25% showed pre-diabetic patterns.

My Stelo Me-Search Findings

Stelo attaches to the back of your arm — the visible dot that’s becoming common — and pairs with a smartphone app. I learned a lot:

1. Food combinations matter more than individual foods

The glycemic index, describing how much blood sugar rises with each food, is inadequate in that it fails to account for what other foods are consumed at the same time. I tested this directly by eating my favorite dessert (halva, a Middle Eastern sweet made from glucose and sesame) on an empty stomach, causing a dramatic glucose spike. Eating the same treat after a meal produced a much smaller increase. Protein, fat, and fiber slow glucose absorption, dampening spikes.

2. Fiber matters

For example, apples and apple juice create different glucose responses. The fiber in whole fruit slows absorption and reduces spikes. I wore my Stelo during the Jewish holiday of Passover and followed the tradition of eating matzah, unleavened flatbread. The white matzah is made from refined wheat with less than one gram of fiber per piece. These shot my glucose up way higher than the whole wheat variety with 3 grams per piece.

3. We are all unique

The glycemic index also fails to account for individual variation. Yes, certain sugar-containing foods, especially beverages, will spike nearly everyone’s serum glucose. However, each of us processes our own response to different foods. My blood sugar response to a banana may not be that of yours.

4. Lifestyle factors impact glucose

Family stress elevated my glucose levels even with identical food intake. Sleep deprivation similarly increased my numbers. During a recent flight, the call went out for a doctor on the plane. I volunteered and assisted a young man who had fainted. My Stelo logged a spike beginning the exact moment of the call. Our metabolic health responds to everything, not just what we eat.

5. Intense exercise can RAISE glucose in the short term

Overall, exercise is one of the best methods for improving metabolic health. I was surprised to see elevations above the normal range during maximum biking efforts. The body’s hormonal efforts to provide enough energy for intense exercise can transiently raise the blood sugar until it is utilized by the muscles.

6. Post-meal movement is powerful medicine

After one lunch that raised my glucose levels, I took a walk. My numbers dropped by half in less than 30 minutes.

This dramatic response visually confirmed that walking after meals improves glucose control — 80–90% of glucose goes to muscles, so movement accelerates this process.

These insights demonstrate the comprehensive benefits of CGM for understanding personal metabolism. Continuous glucose monitoring reveals patterns that occasional blood tests could never detect, empowering users to make informed health decisions.

The Stelo App Experience

The Stelo app connects with Dexcom’s Clarity platform, allowing patients and physicians to analyze patterns and correlations. We can examine time in target range, daily patterns, and specific responses to foods or activities.

The note-keeping feature lets you record what you ate, stressful events, or exercise, creating a picture of your metabolic health.

Why Banner Peak Health Embraces Stelo

At Banner Peak Health, we look for nooks and crannies of cardiovascular risk that conventional medicine often misses. Insulin resistance is a significant yet often-overlooked risk factor we can now identify and mitigate, lowering the risk for atherosclerosis as well as progression to diabetes.

The benefits of continuous glucose monitoring are now a powerful tool for preventative medicine, even in non-diabetics — not just treating disease but preventing it through real-time feedback and targeted lifestyle modifications.

Today’s Takeaways

You don’t know something until you experience it yourself. My time with Stelo taught me more about my metabolic health than years of occasional blood tests.

As those little white dots become increasingly visible on arms everywhere, consider adding your own. The benefits of glucose monitoring could change your understanding of your body and empower you to make more informed health decisions.

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by Barry Rotman, MD

Zone 2 Training Benefits: The Complete Guide to Metabolic Health and Performance

Zone 2 training benefits include:

• Improved mitochondrial function
• Enhanced metabolic flexibility
• Better fatty acid utilization
• Increased endurance performance
• Diabetes prevention and management

While it’s common knowledge that exercise is good for you, the specific advantages of Zone 2 training are less understood. In this comprehensive guide to Zone 2 training benefits, we’ll explore:

• How Zone 2 training transforms your body’s energy systems
• The optimal “dose” of Zone 2 training for maximum benefits
• How to measure and track your Zone 2 training progress
• The scientific evidence behind Zone 2 training benefits

The intensity of cardiovascular exercise can be divided into zones, ranging from no exertion to complete exhaustion. While there are various training zones, Zone 2 stands out for its unique benefits and powerful effects on metabolic health.

Let’s explore why Zone 2 training has become a cornerstone of both elite athletic performance and metabolic health improvement.

Understanding Zone 2 Training Benefits: The Science Behind Cardiovascular Exertion

I’m a huge fan of the Tour de France bike race. Two hundred of the world’s best bike riders pedal over 2,000 miles in three weeks. The competition is so intense that after scores of hours of racing, the top three finishers may be only minutes, or even seconds, apart.

As a recreational bicyclist, I’m fascinated by the bike handling skills and tactics of racing. As a physician, I’m awestruck observing the best endurance athletes on the planet.

Even among the world’s best riders, there are once-in-a-generation athletes. Tadej Pogacar, a Slovenian, won his first Tour de France at 21, the youngest champion since 1904. He won the Tour in 2020, 2021, and 2024.

Watching Tadej take off up a mountain, leaving behind the world’s best riders, is awe-inspiring. In addition to winning the one-in-a-billion genetic lottery, Tadej trains with Dr. Inigo San Millan, a top sports physiologist and coach.

Dr. San Millan raced as an amateur cyclist in the Basque region of Spain before earning a medical degree. He is now a research scientist at the University of Colorado in Boulder.

In addition to sports physiology, Dr. San Millan’s research focuses on metabolic disorders. Much of his work focuses on mitochondrial function, which is prominent in metabolic disorders and sports physiology.

In “Outlive,” Peter Attia cites a 2017 study by Dr. San Millan and George Brooks, which describes the foundational ideas behind Zone 2 training. The authors examined the mitochondrial function of three groups: world-class cyclists, recreational cyclists, and inactive people with pre-diabetes or diabetes.

By comparing how mitochondria function in the world’s best endurance athletes as opposed to diabetics, the study sheds light on metabolic flexibility — what fuel sources the mitochondria can “burn” for energy.

The Metabolic Benefits of Zone 2 Training: Energy Systems Explained

A brief discussion of energy metabolism biochemistry will help us understand Dr. San Millan’s study.

The mitochondria consume either fatty acids or glucose to produce energy. Fatty acids are the preferred fuel source. They have twice the energy density of glucose, 9 kcal/gram, compared to 4 kcal/gram.

Thus, a kilogram of fat (2.2 lbs) provides approximately 9,000 kcal of energy. The average person has many kilograms of fat, which can be mobilized for energy, providing a vast “gas tank.”

In contrast, the body’s storage of glucose in the form of glycogen is limited to around 600 grams, or approximately 2,400 kcal of energy — less than the energy from a quarter of a kilogram of fat. Food sources provide additional glucose, but the digestive system can’t effectively absorb many nutrients during intense exercise.

The liver produces glucose through a process known as gluconeogenesis, but it has a limited capacity and isn’t as energy-efficient as other fuel sources. Gluconeogenesis doesn’t contribute much energy for exercise but prevents low blood sugar during low food intake.

Not only are fatty acids a more plentiful and efficient fuel source for exercise, but their combustion byproducts are also “cleaner” than glucose ones.

Glucose metabolism generates lactic acid, which contains a lactate molecule and a hydrogen ion. Lactic acid has been described as the “bad” waste product from exercise. For example, we used to think that after an intense workout, your thighs burned because of lactic acid buildup.

This is only partially true.

The lactate molecule is beneficial, functioning as an energy source that adjacent muscle cells can consume. The associated hydrogen ion remains a bad factor, lowering the pH in the region and impairing further muscle functioning. The hydrogen ions from glucose metabolism generate a ceiling on muscular energy production’s quantity and duration. In contrast, fatty acids burn cleaner, generating only carbon dioxide and water.

However, the body’s ability to metabolize fatty acids has a finite capacity. With increased energy demand, the systems available to metabolize fatty acids become saturated. Less efficient glucose metabolism is recruited and added to fatty acid consumption to increase energy production further.

Back to the Study...

Inigo San Millan and George Brooks wanted to explore how efficiently each group of people used fatty acids, the preferred fuel source, before using glucose.

Each participant rode an exercise bike with a step-up protocol requiring progressively more power output every 10 minutes. At each step, each participant’s oxygen consumption, carbon dioxide production, power production, and serum lactate levels were recorded.

By analyzing this data, the researchers could calculate the composition of fuel sources used at each power level. For example, because lactic acid is a metabolite of glucose but not fatty acids, it would remain in the low range at lower power levels when fatty acids were the predominant fuel and climb at higher levels as more glucose was used.

Each participant started with more fatty acids burned than glucose. As power increased, additional glucose was consumed, and the percentage of fatty acids burned became smaller.

However, the key finding was the vast differences between the study groups.

The world-class cyclists produced staggering amounts of power while maintaining a stable serum lactate level, meaning they were extremely efficient at burning fatty acids and processing any lactate generated from the glucose they burned. They possessed the best mitochondria on the planet, derived from fortunate genetics and effective training regimens. (More on that topic later.)

In contrast, the deconditioned participants with pre-diabetes or diabetes had the opposite response. These participants had higher lactate levels at rest than the world-class cyclists had while producing large amounts of power. Even before exercising, these participants couldn’t readily access fatty acids and had to rely on glucose, which produced lactic acid.

With minimal exercise, the hydrogen ions from the lactic acid began rapidly building up and limiting exercise duration. This process drastically limited their power — a small fraction of the world-class cyclists. The recreational cyclists had outcomes between these two extremes.

Zone 2 Training Benefits: Evidence From Clinical Research

So, what explains the pre-diabetic and diabetic participants’ results?

Metabolic syndrome — the process of insulin resistance and other hormonal dysfunction that leads to pre-diabetes and potentially diabetes — degrades mitochondrial function through various mechanisms, such as fewer mitochondria and fewer proteins within each mitochondria. These processes limit the ability to metabolize fatty acids and effectively generate power for exercise.

Fortunately, these changes are reversible.

Zone 2

How does the study relate to Zone 2?

Dr. Inigo San Millan defines zones based on the body’s fuel source.

• Zone 1: An intensity that allows mitochondria to use fatty acids but doesn’t exceed their capacity.
• Zone 2: The intensity that maximizes mitochondrial fatty acid utilization for power.
• Zone 3: Occurs when the power requirements exceed the mitochondrial capacity for fatty acid utilization and progressively more glucose utilization is required.
• Zone 4–6: The mitochondria no longer use fatty acids and are defined by other energy sources.

The study has profound implications for athletic training and improving the metabolic health of pre-diabetics and diabetics.

Dr. Inigo San Millan’s training regimen for Tadej Pogacar involved more time in Zone 2 than in any other zone. For Tadej Pogacar to become one of the world’s fastest endurance athletes, he had to spend lots of time biking relatively slowly.

What Is Zone 2?

Zone 2 is the optimal training zone for maximizing endurance and metabolic benefits. It’s characterized by a level of exertion where you can still hold a conversation, typically described as an “all-day” pace. This sweet spot of intensity is where the most powerful Zone 2 training benefits occur.

Zone 2 training intensity improves mitochondrial function by increasing the number and efficiency of mitochondria in muscle cells. In particular, it enhances metabolic flexibility, which maximizes the mitochondria’s consumption of fatty acids for fuel.

As we discussed, fatty acids are the preferred fuel because:

1. The body has tremendous fatty acid storage.
2. Fatty acid consumption burns cleanly, with no negative feedback loop blocking its metabolism.
3. Fatty acid provides a foundation for further levels of metabolism.

Zone 2-enhanced mitochondrial ability allows athletes to go farther more efficiently and reach a higher peak output. Once the power requirement exceeds the mitochondria’s ability to metabolize fatty acids, the body relies on less efficient and more time-limited substrates, such as glucose.

I think of Zone 2 as the booster stage of a multistage rocket ship. The faster and farther it moves the rocket, the less the rocket relies on smaller subsequent stages.

In prior blogs, I’ve discussed the value of measuring VO2 max at peak output, noting that it measures the ability of the entire cardiopulmonary system to function. Zone 2 training at lower intensity provides the foundation that supports other energy systems that allow the body to reach peak output. A massive booster rocket gets you into the sky faster and farther.

Paradoxically, you must go slow to get fast. This is Dr. San Millan’s message and the secret to Tadej Pogacar’s success.

This message has been lost on recreational athletes, who, like me, have limited time for training and assume they should “go hard” whenever possible. Workout apps like Garmin and Strava reinforce this ethos with features to set new personal records, measure peak power outputs, and compete against your friends.

In contrast, effective Zone 2 training requires a relatively slow and deliberate training regimen.

How to Maximize Your Zone 2 Training Benefits: Creating a Personal Program

The first step to creating a Zone 2 training program is identifying your Zone 2 parameters.

This process is more nuanced than reading the workout equipment at the gym, which identifies your “fat-burning” zone as 50–70% of your maximum heart rate. This approximation overlooks many individual characteristics.

Two more accurate techniques for identifying one’s Zone 2 include:

1. Replicate the protocol Inigo San Millan and George Brooks used. Measure fingerstick lactate levels or exhaled carbon dioxide and oxygen levels to calculate how intensely you can exercise before you leave the Zone 2 region of fatty acid metabolism. This level of intensity can be expressed in terms of heart rate or power output and can serve as a guide for further workout intensity.
2. Use your rate of perceived exertion (RPE), a 10-point scale from absolute rest to complete exhaustion. RPE scores your intensity assessment based largely on your breathing rate, which correlates with exertion. (Carbon dioxide and serum acidity rise with activity level, leading to more rapid breathing.) Zone 2 corresponds to an RPE of 5–6 out of 10 and has a breathing rate that allows you to speak in full sentences.

How much Zone 2 training you need depends on your goals. Professional and elite endurance athletes may spend 80% of their training time in Zone 2, which can be tens of hours a week. The minimum effective dose for us “time-crunched” athletes would be three hours a week, providing noticeable benefits without hurting professional or personal commitments. It may take several months for the maximum benefit to accrue.

Key Zone 2 Training Benefits for Elite and Recreational Athletes

Zone 2 training has become vital to elite athletes’ competitiveness. It can also provide a welcome boost for recreational athletes.

For decades, I’ve biked five to seven hours a week. Given the hilly terrain where I ride, most of that time has been spent above Zone 2 going uphill or below Zone 2 going downhill. I’ll ride in Zone 2 for three hours a week and observe its effects.

In addition to allowing athletes to enhance performance, I suspect the greatest potential benefit of Zone 2 training is improving the metabolic health of those with pre-diabetes and diabetes. We’re amid an unprecedented epidemic of pre-diabetes and diabetes, which correlates with an elevated body mass index. One in three adults in the U.S. is estimated to have prediabetes; another 38 million are fully diabetic!

Mitochondria are the key to understanding insulin resistance and metabolic dysfunction, which leads to pre-diabetes and diabetes. Skeletal muscle cells metabolize up to 90% of the body’s glucose. These cells’ metabolic health, including their mitochondrial function, impacts how the body uses glucose.

Whenever we consume more calories than we burn, we’re in caloric excess. Excess calories are converted to fat and distributed throughout the body. Some locations, such as the thighs and buttocks, have minimal health effects. In contrast, other locations, such as the liver and abdomen, create problems.

Fat deposited within muscle cells impairs mitochondrial function by inhibiting fatty acid use and glucose uptake into the cell, reducing mitochondrial density and efficiency, and creating localized inflammation. When muscle cells can no longer adequately metabolize glucose and fatty acids, glucose levels rise, creating a vicious cycle leading to pre-diabetes and, ultimately, diabetes.

This frightening process has a silver lining: The most effective treatment involves rehabilitating the mitochondria within muscle cells through Zone 2 exercise! No pill, injection, or drug effectively prevents diabetes as much as diet and exercise.

Diet modification is crucial to reverse caloric excess, which deposits fat into cells such as muscle cells and impairs their function. Zone 2 exercise is the most potent tool for improving muscle cell mitochondrial function and can reverse the metabolic effects of pre-diabetes and diabetes.

Final Thoughts on Zone 2 Training Benefits

So, in summary, the key Zone 2 training benefits include:

• Enhanced mitochondrial function and density
• Improved metabolic flexibility
• Efficient fat utilization
• Better endurance capacity
• Diabetes prevention and management
• Enhanced athletic performance
• Sustainable long-term fitness improvements

Three hours a week of Zone 2 training appears to be a good minimum dosage for improving metabolic health and athletic performance. More would be better, but even three hours can be a significant commitment.

Zone 2 training “magically” provides a performance boost to recreational athletes who’ve plateaued within a busy schedule. More importantly, Zone 2 training “magically” corrects the metabolic dysfunction that causes pre-diabetes and diabetes.

At Banner Peak Health, we’re committed to helping you experience these powerful Zone 2 training benefits. Our experts will help determine your optimal Zone 2 parameters, design a personalized training program, and monitor your progress to ensure maximum results. Give us a call and be part of the magic.

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by Barry Rotman, MD

How to Lower APOB for Cholesterol Management and Cardiovascular Health

One advantage of having spent 40 years in medicine is my ability to view medical information (such as how to lower APOB) not as a new idea, but as the culmination of a concept’s long-term evolution.

Inferring coronary artery risk from serum cholesterol measurements is exactly this kind of evolving story.

The Evolution of Cholesterol Understanding

In the 1950s, Ancel Keys initiated a series of epidemiologic studies that, while controversial, introduced the connection between saturated fats in the diet, cholesterol levels in the blood, and coronary artery disease.

In the 1970s and 80s, researchers began identifying low-density lipoprotein (LDL) receptors and focused on LDL mass as a more specific risk factor.

By the 1990s, diagnostic tests involving gel electrophoresis allowed us to look at particles’ cell size. In the early 2000s, NMR spectroscopy enabled us to quantitate particle size.

This multi-decade story shows a clear trajectory — from total cholesterol quality to LDL quantity, now to the size and quantities of particles within the blood.

Our understanding of how lipid metabolism impacts atherosclerotic disease has evolved alongside the progression of tests we use to clinically measure lipids. This evolution gives context for why APOB is so important.

APOB Is More Predictive Than LDL

Cholesterol doesn’t dissolve directly into our blood but resides in different particles, such as HDL, LDL, and VLDL. Each particle has attached lipoproteins that identify the particle and enable its uptake into cells, functioning like a passport.

Why is apolipoprotein B (APOB) the most predictive blood marker of coronary artery disease risk?

1. APOB resides on all particles that carry cholesterol into vessel walls and create atherosclerosis (LDL, IDL, lipoprotein(a)). It’s a more robust risk measurement than merely noting the quantity of cholesterol in LDL, which was the preferred marker for decades.
2. Only one APOB lipoprotein ever resides on each particle. This provides a headcount for the total number of dangerous particles.

Understanding How to Lower APOB

Think of your arteries as a residential street and the blood vessel wall as your yard, protected by a picket fence (the endothelial lining). Atherosclerosis occurs when fat moves from the street into your yard.

With this metaphor in mind, imagine two scenarios with the same amount of fat:

1. All your fat (cholesterol) is in one big wheelbarrow. Your picket fence can effectively keep it out.
2. The same volume of fat is distributed in thousands of little candy wrappers that blow around. These small pieces breach the fence and dump their contents onto your lawn.

When we talk about LDL, we’re just discussing total fat mass. But how that mass is distributed determines risk. A thousand small particles carrying fat are more dangerous than a few large ones.

If I tell you your LDL is 100 mg/dL, I haven’t told you whether your cholesterol is in one wheelbarrow or thousands of candy wrappers. APOB tells you the number of particles — the higher the APOB, the more particles, and the greater your risk.

This is why knowing how to lower APOB is crucial for achieving long-term health.

How to Lower APOB: Actionable Steps

1. Get Your APOB Measured

To lower your APOB, you must first have your APOB measured. Many practices won’t offer this, but it’s part of Banner Peak Health’s standard of care.

2. Assess Your Total Risk Profile

How aggressively you need to address any one risk factor depends on your constellation of all other risk factors. Have a physician carefully evaluate high blood pressure, insulin resistance, diabetes, smoking status, physical activity level, obstructive sleep apnea, family history, and more.

Understanding your total burden of risk determines how aggressively to work on lowering APOB.

3. Target Insulin Resistance to Lower APOB

Perhaps the greatest dietary advice misdirection of the last millennium occurred in the 1980s, when the healthcare establishment promoted reducing saturated fats as the goal for heart health.

In 1987, the American Heart Association recommended total fat should be reduced to 30% of total calories. By 1990, it was federally mandated that food labels quantify saturated and total fat.

Macronutrients are a zero-sum game. We get our calories from fat, carbohydrates, and proteins. The drive to reduce total fat led to an increase in carbohydrate intake.

This shift in diet played a prominent role in an obesity epidemic and, with it, insulin resistance, pre-diabetes, and diabetes. Currently, half of all adults are either insulin-resistant, pre-diabetic, or diabetic.

How does this relate to knowing how to lower APOB? The endocrinological changes associated with insulin resistance alter how we metabolize fatty acids. Cells become dysfunctional in utilizing fatty acids, and we put more triglycerides into our bloodstream.

With diabetes and insulin resistance, we have more smaller, lipid-rich particles, which increases the risk of coronary artery disease. For the same amount of LDL, a person with diabetes will have a higher APOB.

One of the great ironies is that the link between saturated fats and atherosclerotic disease is weak and controversial, while the link between diabetes and atherosclerosis is strong and well-established.

How to Lower APOB: A Step-by-Step Guide

Want to know how to lower APOB? Make these lifestyle modifications:

1. Weight reduction — Even modest weight loss can improve lipid profiles.
2. Improved aerobic fitness — Engage in regular cardiovascular exercise.
3. Increased muscle strength — Incorporate resistance training to improve metabolic health.
4. Reduced intake of refined carbohydrates and sugars — Focus on complex carbohydrates.
5. Proper sleep — Aim for 7–9 hours of quality sleep.
6. Mediterranean or DASH diet — Embrace plant-forward eating patterns with lean proteins.
7. Omega-3 supplementation — For those with borderline levels, fish oil supplements may help. (I like Nordic Naturals. They use smaller fish, which have lower mercury contamination, manufacture high-quality products, and their capsules don’t need to be refrigerated until after opening the bottle. Fish oil can degrade if stored too long in a warehouse or exposed to extreme heat during shipping, so I recommend ordering directly from Nordic Naturals — they’re careful about how they store and ship their products.)

Today’s Takeaways: How to Lower APOB

To lower your APOB effectively:

1. Get it checked — you can’t manage what you don’t measure!
2. Analyze your total atherosclerotic risk with your physician. Determine if medication is needed.
3. Focus on lifestyle modifications that address insulin resistance — weight loss, exercise, reduced carbohydrates, and improved sleep.

The most potent lifestyle tools for lowering APOB are those that combat insulin resistance and diabetes — not necessarily reducing saturated fats. This represents a shift in how we approach heart health that many people, and even physicians, haven’t fully embraced yet.

At Banner Peak Health, we understand these nuances and are excited to develop a personalized plan to lower your APOB and reduce your cardiovascular risk. Reach out today.

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by Barry Rotman, MD

Creatine Supplementation: Not Just for Bodybuilders

Recently, my best friend’s 14-year-old son presented him with a PowerPoint presentation titled “Why You Should Let Me Take Creatine Supplements.”

That’s when I knew creatine had become mainstream.

Creatine is traditionally seen as a supplement for pubescent young men eager to develop their bodies and bodybuilders aiming to look ripped. But what about the rest of us?

I looked at the research and was pleasantly surprised to discover fairly solid evidence suggesting benefits across a wide range of applications — including improved physical function in older adults and adults with chronic disease, memory enhancement, and as an adjunct to drug- and therapy-based depression treatments. (To be clear, studies didn’t show it as a stand-alone treatment for depression but as a supplement to working with a therapist and medication.)

There’s also a suggestion of benefit across many other conditions, from improving function for those with muscular dystrophy to enhancing glucose control in diabetics and improving mobility for people with knee degenerative arthritis.

What Exactly Is Creatine?

Creatine isn’t a protein, but it’s derived from three amino acids: arginine, glycine, and methionine. It plays a role in the body’s production of adenosine triphosphate (ATP), the chemical we use to move energy within our cells.

Creatine occurs naturally in animal products, and the body can manufacture some of the creatine it needs.

Taking creatine as a supplement allows the body to turbocharge its energy metabolism by enabling greater availability of ATP within cells for energy-intensive tasks. These tasks can include muscle cells lifting heavy weights or brain neurons working to consolidate memory or process complicated thoughts.

Why Muscle Mass Matters

Many young people want to improve their muscle mass for aesthetics, but as we age, the importance of preserving muscle mass goes beyond appearance.

How strong we are and how much muscle mass we have is linked to how well we preserve functional capacity and reduce fall risk as we age. We’re in the midst of an epidemic of sarcopenia — muscle mass loss. With it comes a decline in function.

Therefore, any safe, tolerable method to preserve and enhance muscle strength as we age is valuable.

How Creatine Works

Improving Muscle Energy Metabolism

Creatine improves muscle energy metabolism.

Creatine is synthesized into phosphocreatine, which helps rapidly regenerate ATP during high-intensity exercise. This allows us to train more in terms of volume and intensity, leading to more stimulus that grows and maintains our muscles.

This improved energy metabolism also enhances mitochondrial function, the energy-generating power plants within our cells.

Activating Anabolic Pathways

Creatine also activates other signals to maintain our anabolic pathway — the whole host of hormonal signals that cause us to maintain muscle mass.

It increases other hormones such as insulin-like growth factor 1 (IGF-1) as well.

Anti-Catabolic Effects

Additionally, creatine has an anti-catabolic effect — it protects muscle from being broken down.

Besides helping young bodybuilders, creatine builds and preserves muscle mass for those of us with a bit more mileage. Reducing sarcopenia has been shown to preserve functional capacity as we age.

How Creatine Boosts Brain Health

Enhanced Brain Energy Metabolism

Just as in muscle, creatine enhances brain energy metabolism.

By providing more ATP, creatine allows greater energy access for neurons’ high-energy tasks, such as cognitive processing and memory formation.

Increased Synaptic Plasticity

Creatine has also been shown to increase signals that allow for synaptic plasticity — how many connections each neuron has, which is how our brain works.

Creatine enhances the number of synaptic connections, critical for memory and learning.

Neuroprotective Effects

Creatine also activates neuroprotective pathways, protecting neurons and brain cells from hazardous oxidative stress and inflammation.

Downsides to Taking Creatine

In healthy individuals, creatine is safe when taken at low doses (3–5 grams per day). Possible mild side effects include:

• GI upset
• Muscle cramping
• About 1–2 pounds of weight gain from greater fluid content within muscle cells

Additionally, because creatine can put a greater strain on compromised kidneys, individuals with kidney impairment or risk factors for kidney problems (such as high blood pressure or diabetes) may need to discuss creatine supplementation with their physician.

Who Should Take Creatine?

I divide supplements into three categories:

1. Known risks that probably exceed benefits
2. Known benefits that probably exceed risks
3. Not enough data to assess the risks or benefits

For most people, creatine is in the second category. Try it and determine if it works for you. That’s what I’m doing, having recently started supplementation myself. I’ll see what happens.

Final Thoughts on Creatine Supplementation

There’s a vast array of supplements and medical devices available to consumers. Even for someone who’s been in the medical field for almost 40 years, like myself, it’s tough to separate the wheat from the chaff and determine what’s safe and worthwhile.

I can’t imagine how hard it would be for a non-medical person to figure this all out, which is why I love my job. I get to do the research and share the results with you.

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by Barry Rotman, MD