About 7 minutes of reading time.
Cholesterol has been demonized for decades, but it is complex in how it relates to AND is only ONE factor to cardiovascular disease! Simply saying “Total, LDL, or Triglycerides cholesterol is high” and even “cholesterol clogs your arteries like sludge in a pipe” is way too simplistic and archaic.
I want to break down the lipoproteins/cholesterol and their effect of cardiovascular disease and atherosclerosis in a more understandable way that many people can relate… driving!
Vehicles on the Road = ApoB Particle Number
Every pro-atherogenic (able to contribute to arterial plaque buildup) particle (LDL, VLDL, Remnants, & IDL) carries one apolipoprotein B protein. Think of each ApoB particle as a vehicle on the road.
- Few vehicles (low ApoB) = less traffic, less opportunities of wrecks with another vehicle.
- Many vehicles (high ApoB/LDL-P) = more traffic, more chances of wrecks such as some vehicles can hit guardrails (arteries) and cause pileups (plaque.)
Large durable SUVs & trucks (Large LDL) or old damaged cars (Small LDL) on their own doesn’t matter as much as the total cars out there as the total vehicles in terms of potential for collisions. However, we do want a smaller percentage of damaged vehicles (Small LDL-P & oxLDL) on the road!
Driving Behavior = Metabolic Health
Not all traffic drives the same way:
- Safe drivers: Low fasting insulin, low triglycerides & high HDL (more importantly a low Triglyceride : HDL ratio), low systemic inflammation… Calm, steady traffic.
- Reckless drivers: insulin resistance, high Triglycerides & low HDL (high TG:HDL ratio), increased Small LDL-P. These are like road-ragers driving erratically or distracted drivers, without regard, more prone to crashing, and cause pileups.
Addressing insulin resistance is a key measure of improving cardiovascular health even if Total Cholesterol or LDL-C barely changes.
Road Conditions = Lifestyle Choices
The state of the roadways greatly impacts risk. Think of the roads as your arteries…
- Smooth, maintained, wide lanes = eat wholesome food, good sleep, regular exercise, not smoking, drinking alcohol…
- Potholes, narrow lanes, heavy construction = heavily processed foods, excessive carbohydrate intake, smoking, stress…
Even a few vehicles can easily wreck on a bad road, while heavy traffic can move safely if conditions are good…
- It is possible to have more particles that are in good conditions that won’t promote disease.
- You can have “normal” cholesterol numbers, but if conditions allow, crashes are just waiting to happen. That’s why genetics isn’t the full story.
Note that there are rare genetic conditions such as where LDL is sky-high from birth and those people tend to have more “crashes”, but even then, lifestyle and “road conditions” still affect outcomes. I like the saying, “genetics loads the gun, but lifestyle pulls the trigger.”
“Mad Max” Wildcard Vehicles = Lp(a)
Lp(a) is an odd particle that has an extra attachment that makes it potentially more dangerous in the right conditions. Vehicles built for chaos that were capable of doing heavy damage… 😆 Think of Lp(a) as somewhat familiar vehicles (LDL) that are now rogue and heavily modified running around that you can’t control. However, you can control the environment in which they can simply ride along or create chaos. 😉
Lp(a) gets a bad rep:
- It binds more easily to and within the arterial wall.
- It can contribute to inflammation and clotting.
- Even on good roads, these vehicles can be a wildcard and raise risk if provoked.
- It can contribute to aortic stenosis, stiffening of the aortic valve.
Lp(a) actually might have good intentions
- It seems to be able to play a role in wound healing and tissue repair since it can easily bind to fibrin (a clot forming protein.)
If your Lp(a) is high, be aware that it is even more crucial to “have good roads, well maintained cars, and conditions” as even if it can play a helpful role, we shouldn’t rely on it because it will leave a bunch of “rough patched holes” that could end up like a very bumpy road. It’s like they do a bad job of fixing up but leaving a mess–like a cheap backyard mechanic. 😆
Traffic Incidents = Atherosclerosis or Plaque Formation
Pileups don’t happen because a car brushes up against a guardrail. It has to get stuck, can’t get out because it is damaged (glycation, oxidation, inflammation). That’s when more vehicles come on by, some wanting to help causing more stopped/congestion. Careless/distracted/wildcards by don’t see them and crash–causing more and more to pile up… there’s the plaque formation.
LDL/Lp(a) (EMS responders, good Samaritans, etc.) are sent to help to deliver the tools and goods, HDL (tow & garbage trucks) can help clear the mess… That’s right, LDL is supposed to deliver the goods to the repair site and other places that cholesterol is needed! However, if the road is constantly damaged, those same repair runs can turn into pileups.
Vehicle Maintenance & Repair = OUR Responsibility for Health
Even the best driver on the smoothest road is at risk if the vehicle itself is neglected. That’s where lifestyle and routine daily habits come in. Think of it like oil changes, new brakes, and regular tune-ups. Even if we use specialists to do these things it is OUR responsibility to make sure it happens.
That’s right, WE are responsible for maintaining our health! WE are in charge of our HEALTHcare! 😉
- Fuel & Filters = nutrition. Put in clean fuel and changing filters (real food, nutrient-dense, low junk) keeps your engine runs smooth. Sludge and junk will gum up the engine like carbohydrate overload, cooking with oil, chemically laden lab edibles, etc. Triglycerides are like unburned fuel (carbs) contaminating the rest of the fuel in the fuel tank.
- Tire tread, rotation, alignment = exercise. Tires keep you on the road. Without strength, cardio fitness, and mobility, your “vehicle” loses ability to grip and handle the road. Training is how you keep your body agile to handle the rough roads of life or cruise down easy street.
- Brakes = Stress Balance & Recovery. A car without good brakes is a wreck waiting to happen. Same with the body… if we don’t slow down, rest, and manage all stresses, we’ll skid out of control. Stress balance and recovery is our braking system and when stopped at rest is when all repairs and upgrades happen.
- Fluids & Oil Changes= Hydration & Electrolytes. Whether it be engine coolant or brake lines, our cars must have certain levels of fluids for each system to work properly. The same with us. We must have adequate water and electrolytes for our body’s systems to function. Frequent headaches could be as simple to fix as staying hydrated!
- Washes and Detailing = Inflammation control. A neglected car gets rusted and corroded. The same happens with our body when we present it to oxidative stress and let chronic inflammation build up. Antioxidant-rich foods, not smoking/vaping, etc., are like rust inhibitors for the frame and wax to keep the pain shining.
- Repairs = Medical interventions. When that check engine light comes on, you better diagnose and fix what needs fixed as soon as possible. Mine went off for years and I ignored the warnings until my heart attack. That’s when I had to get a stent and started taking care of my body. I don’t want to wreck again, and I want to keep this ole classic running as long as possible!
YOU are in charge of your vehicle. It’s ok to utilize specialists for things, but the daily operations like choosing the proper fuel at each fill up, getting it washed, not running it hard all the time, etc., are ALL our responsibility–not the mechanic’s. 😉
Traffic Cameras = Lab Testing & Imaging
I’m not speaking of the “red light” cameras, but most states have traffic cameras you can view on their department of transportation website. These provide a way we can see the traffic on the highways, and they also provide congestion details on a map.
Blood tests and imaging scans lets us see our risks of cardiovascular disease.
- CT Angiogram (if stent): This is very cool. You can get a very good look into the arteries and see calcifications and a good idea of any larger soft plaques that may show signs of arterial stenosis (narrowing of arteries).
- There is an analysis by Cleerly which I would love to get some time that analyzes the CT angiogram. Check that out!
- Coronary Artery Calcium (CAC) Scan (if no stent): Counts the amount of old repaired potholes– calcified plaque.
- These do not show the soft plaques! Even a low or 0 doesn’t mean you don’t have any plaque. The soft plaque is what ruptures, instantly clots causing heart attacks & strokes!
- Blood Tests: There are a few test we can take at regular intervals to check our vehicle and road conditions–risks of cardiovascular disease.
- NMR Lipoprotein Profile w/Insulin Markers: This is my preferred cholesterol test that counts and measures the particles and sizes. This is by far more telling than a standard/basic cholesterol test.
- Apolipoprotein B (ApoB): The Total amount of potential pro-atherogenic particles in your blood. All Remnants, VLDL, IDL, LDL, Lp(a).
- Fasting Insulin & Comprehensive Metabolic Panel: The CMP will give you a fasting glucose measurement as well as many other markers that are good to keep tabs on, but one often not measured by doctors is fasting insulin. This and glucose WILL give a good indication of metabolic health, insulin resistance and one’s ability to burn fat as fuel.
- C-Reactive Protein (hsCRP): A good indication of chronic inflammation in your body and a person’s CRP levels are related to their risk for events like heart attack or stroke.
- Lipoprotein(a): Check your genetic pre-disposition for this potentially “overly helpful” particle. Good to get at least once.
The Blunt Takeaway
ApoB = the total number of vehicles. The more vehicles, the more exposure. More vehicles doesn’t dictate there will be more crashes, but it is more crucial to have good roads and condition. Some people with higher levels live long healthy lives, because their roads are smooth and drive carefully. It doesn’t mean more vehicles are safe, it just means that context matters of who crashes.
Cholesterol isn’t the villain, but ignoring ApoB while living a “demolition-derby lifestyle” is wreckless and asking for a crash.
Metabolic Health = how those vehicles drive. Insulin sensitivity & low stress calms the traffic. Fueling with proper fuel lets us run efficiently.
Lifestyle & Inflammation = road conditions. Smooth roads let the vehicles drive well and has less wrecks.
Lp(a) = “Mad Max” vehicles. Rare, may have good intentions, but can leave a path of chaotic destruction when provoked.
Imaging & Lab Tests = traffic cameras. Shows crashes that have happened or scenarios where they are likely to occur.
Managing cardiovascular disease risk isn’t simply about genetics, demonizing cholesterol or celebrating any individual class of lipoprotein. It’s about knowing how many vehicles are on the road, how they’re being driven, and what the conditions are like. 😎
Cardiovascular Disease is Not an Accident
You may have noticed I didn’t use the word “accident” in this article. An accident suggests something that happens by chance, without cause. But with cardiovascular disease, there’s almost always a chain of events that explains it.
Let’s call it what it is… a crash caused by conditions of choices.
My own heart attack wasn’t a random accident in my timeline, it was the outcome of choices, environments, and risks stacking up over years. In my recovery process, I’ve learned that it WAS preventable and why I share my learnings with you–so you can change what needs changing and hopefully not succumb to that nightmare of an experience.
Check out my more in-depth article on Understanding Cholesterol and Cardiovascular Disease where I take a deep dive into this topic in my journey to better health after my heart attack.
Don’t necesarially copy my choices. Learn, get your numbers, clean up your lifestyle, then argue with your labs, not the internet. 😉
Cars can be fixed. Roads can be improved. Drivers can focus more. Traffic can be managed.
So can you.