High Cholesterol Meaningless? Using ApoB to Better Evaluate Cardiometabolic Risk

by Mike Mutzel


Standard lipid panels are actually mathematical approximations. Emerging data suggests using the very affordable ApoB to ApoA1 ratio more accurately assess cardiometabolic disease risk.



In this episode we discuss more about:

-Why fatal heart attacks are more common during the winter

-Why standard LDL cholesterol tests can be inaccurate

-Using the ApoB to ApoA1 ratio instead of standard lipid tests

-Why you should get off the omega-6 industrial seed oils if you’re on a low-carb diet


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Time Stamps

00:03 LDL is commonly elevated if you do intermittent fasting, you are on a low carb keto or carnivore style diet, or you exercise.

01:42 Lipoprotein(a) is involved in LDL oxidation and could potentially increase blood clotting.

02:06 Fatal heart attacks increase by 35% in cold dark winter months. December/January is a good time to do your bloodwork.

03:56 LDL cholesterol is a transport for triglycerides to mobilize energy systems throughout your body.

04:56 Apolipoprotein B is found on all atherogenic LDL, VLDL and remnant lipoprotein.

05:01 Oxidized LDL, oxidized remnants or oxidized VLDL can cause atherogenic particles that get into your arterial system. This can cause a macrophage infiltration and foam cell creation, that leads to the narrowing/stenosis in the diameter of the lumen of your vessels.

05:26 Every atherogenic particle has one Apolipoprotein B (APOB) on it.

05:39 Lipid Transport: LDL Remnants, VLDL and LDL take lipids, triglycerides and cholesterol from your liver and deliver it to the rest of your body. HDL takes lipids from the brain and periphery to the liver and gut.

06:06 ApoA-1 is found on your HDL particles. HDL is considered protective.

06:45 As LDL cholesterol increases with a keto or low carb diet, it is more prone to being oxidized. Your carb consumption should be balanced with exercise. HLD is increased through exercise.

07:26 Try to remove or omit omega 6 oils from your diet. They are highly oxidizable.

07:54 HDL has the ability to neutralize pro-oxidants.

08:00 ApoB to ApoA-1 ratio is a more sensitive and specific predictor then testing LDL cholesterol when it comes to assessing your potential cardiovascular disease risk. Standard LDL testing is an estimate.

10:09 ApoB to ApoA-1 ratio is an effective predictor of coronary heart disease risk in overweight and obesity.

11:16 Measuring LDL cholesterol is not sensitive or specific in predicting those with a diagnosis of heart disease.

11:26 A large subset of individuals who have fatal heart attacks have low or normal cholesterol.

12:22 ApoA-1 is a feature of your HDL cholesterol that is involved in reverse cholesterol transport, has antioxidant capacity, and positively effects the endothelium, It can also manifest antioxidant and anti-inflammatory effects, stimulating both endothelial production of nitric oxide.

13:00 Supplemental L-arginine was found to positively effect outcomes in those hospitalized with COVID 19.

13:16 ApoB to ApoA-1 ratio is a powerful predictor for the risk of future cardiovascular disease. ApoA-1 manifests several anti-atherogenic effects.

15:20 LP(a) is linked with cardiovascular disease and, potentially, blood clotting. It competes with an enzyme that degrades clots.

16:16 EPA and DHA from fish exert a lot of anti-inflammatory signaling within the immune system. They are not oxidizable in the same way at linoleic acid.

16:46 90% of oxidized lipoproteins are bound to ApoB-containing lipoproteins, are also bound to LP(a).

17:56 A standard lipid panel is insufficient for the care of a person on a high fat low carb ketogenic diet.

18:50 NLRP3 inflammasome is a signaling hub, which, when triggered, initiates downstream inflammation. BHB (beta hydroxy butyrate), the main ketone body made by your liver, turns down the NLRP3 inflammasome.

20:53 We are interested in the size, shape and number of HDL and LDL particles. Larger HDL particles are more protective. Small dense HDL particles are less protective. Structure equals function. If the structure changes, it impacts the biology of the particle.

22:16 Increase consumption of vitamin C, N-acetylcysteine, curcumin, sulforaphane or Coenzyme Q10. CoQ10 is a fat-soluble antioxidant. It may function a little better than vitamin C when dealing with oxidized LDL.

22:40 Decrease consumption of oxidation-prone polyunsaturated fats, like canola, cotton seed, soy, corn, or safflower.


  1. I look forward every week for your podcast. Very interesting info about cholesterol for us in a keto diet and exercise program. Fortunately I live in Puerto Rico and have no winter issues here.

  2. Very informative! I had to listen to it twice.
    I had a CardioIQ (Quest) test taken last year. The results show ApoB (137) and Lipoprotein (a) (24), but no ApoA1.
    Do I need to ask for a different type of test next time?
    What is the optimal ratio? ApoA1:ApoB
    Thank you, HeatherA

  3. I use to see Dr James Mickle in Santa Fe, NM,
    His practice is called, Cholesterol Studies and Treatment.
    He told us some of this back in early 2000’s, very science based from a western MD perspective. He cared tremendously about Lp(a).
    He treated my high cholesterol with niacin.
    When I moved to Seattle, my doctor said, “Niacin changes the numbers, but not the outcome.” I immediately changed doctors and stopped talking to them about cholesterol, waiting for the science.

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