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.

Quote: How to Lower APOB for Cholesterol Management and Cardiovascular 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.

Infographic: How to Lower APOB for Cholesterol Management and Cardiovascular Health

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.