Cardiovascular disease continues to be the top cause of mortality globally. Among the various cardiac laboratory markers I frequently test to assess my patients' risk for heart conditions, Apolipoprotein B (ApoB) stands out as particularly significant.

A standard lipid panel typically includes measurements of total cholesterol, HDL-C (high-density lipoprotein cholesterol), LDL-C (low-density lipoprotein cholesterol), and triglycerides, as well as cholesterol ratios. While total cholesterol, HDL-C, and triglycerides are measured directly, the levels of LDL-C are usually calculated based on these measurements.

LDL cholesterol has traditionally been the marker of choice for evaluating cardiovascular disease (CVD) risk and is often used as a proxy for CVD risk in clinical studies. However, LDL-C is not a foolproof predictor, as numerous individuals with normal LDL-C levels still experience CVD.

A study based on a sample of the population revealed that ApoB was more effective than non-HDL-C in identifying a greater number of individuals with a higher risk of cardiovascular issues. In fact, about half of the patients who experience recurring coronary syndrome maintain normal cholesterol levels according to standard lipid profiles. Even when they meet the recommended LDL-C levels, these patients remain at a significant risk for cardiovascular events.

In people with diabetes and metabolic syndrome, even if their LDL-C levels are normal, their overall lipid profile tends to be risky for heart disease, with high triglycerides and low HDL-C. They also have more small, dense LDL particles, which add to the risk. This can lead to more heart problems, but because their LDL-C levels seem normal, doctors might miss the need for treatment to lower lipid levels.

If your physician is not including ApoB, this is simply "unacceptable" if you are serious about determining your cardiovascular risk.

You may in fact have a normal lipid panel but an elevated ApoB and be at an elevated cardiovascular risk.

In 2019, the European Society of Cardiology/European Atherosclerosis Society stated that apolipoprotein B (apoB) was a more accurate indicator of cardiovascular risk than low-density lipoprotein cholesterol (LDL-C) and non–high-density lipoprotein cholesterol.

Fundamentals of Understanding Apolipoprotein B (ApoB).

ApoB is a vital structural protein found in all significant atherogenic lipoproteins. It serves various functions in managing lipid metabolism and is seen as a crucial indicator of the actual count of atherogenic lipid particles.

ApoB stands out among the various apolipoproteins as a key element of VLDLs, along with their byproducts IDLs and LDLs, as well as chylomicrons and their remnants. It acts as a framework, playing a pivotal role in maintaining the structural integrity of the lipoprotein.

ApoB is a key protein in LDL, the 'bad' cholesterol, and it moves fats and cholesterol around the body. Excess of this protein is harmful because it can get into artery walls. ApoB is now seen as a critical factor in the development of heart disease due to its role in carrying lipids.

It turns out that measuring ApoB might tell us more about someone's risk of heart disease than the usual tests for cholesterol and triglycerides. Recent studies suggest that ApoB is a more reliable indicator for identifying people at high risk.

ApoB particles can cause plaque to build up in the arteries, raising the risk of heart disease and stroke. Measuring ApoB gives a count of these harmful particles, offering a clearer picture of heart disease risk from cholesterol.

High levels of ApoB can shorten lifespan and increase the risk of heart disease, stroke, and even diabetes, beyond what's indicated by LDL cholesterol levels alone.

What can be done to lower ApoB?

Weight Loss: Reducing body weight can significantly impact ApoB levels. A healthy weight loss regimen can lead to better cholesterol management and lower ApoB levels.
Dietary Patterns: Adopting a Mediterranean Diet, which emphasizes plant-based foods, whole grains, and healthy fats, can be effective in controlling ApoB levels. This diet pattern is known for its heart-healthy benefits.
Switching Fats: Replacing saturated fats with unsaturated fats is beneficial. Foods like avocados, walnuts, flaxseed, and wild salmon are rich in monounsaturated fats and can help in managing ApoB levels.
Soluble Fibers: Consuming foods high in soluble fiber, such as apples, okra, eggplant, oats, berries, barley, and psyllium husk, can aid in reducing ApoB. These fibers help in binding cholesterol in the digestive system, thereby lowering its levels in the blood. Daily goal should be over 30 grams. 
Phytosterols: These are found in nuts and seeds and are known to reduce cholesterol levels, subsequently impacting ApoB levels positively.
Avoid High Fructose Corn Syrup: This sweetener, commonly found in many processed foods, can increase ApoB levels. Avoiding or reducing intake of foods containing high fructose corn syrup is beneficial for ApoB management.
Avoid Trans Fats: Often found in processed foods, trans fats can raise ApoB levels. Minimizing the consumption of foods with trans fats can help in maintaining healthy ApoB levels.
Increase Soy Protein: Incorporating soy protein into your diet can lower ApoB levels. Soy protein is found in foods like tofu, soy milk, and edamame.
Omega-3 Fatty Acids: Found in fish like salmon, mackerel, and sardines, as well as in flaxseeds and walnuts, Omega-3 fatty acids can lower ApoB levels and improve overall heart health. Incorporating these into your diet can be beneficial in managing ApoB.

Here is a great overview of nutritional interventions

If you're keen on thoroughly understanding your lipid-related health concerns, it's crucial to opt for a comprehensive lipid panel. This detailed assessment will provide an in-depth analysis of your lipid profile, enabling you to accurately evaluate your risks and tailor your healthcare approach accordingly