229 ‒ Understanding cardiovascular disease risk, cholesterol, and apoB

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In this special episode of The Drive, we have pulled together a variety of clips from previous podcasts about cardiovascular disease to help listeners understand this topic more deeply, as well as to identify previous episodes which may be of interest. In this episode, Peter highlights the importance of understanding cardiovascular disease and why early intervention is critical. He also provides a primer on lipoproteins and explains the fallacy of the terms “good cholesterol” and “bad cholesterol.” Allan Sniderman discusses the metrics measured in routine blood work - along with the limitations of those standard panels - before explaining why apoB is a superior metric for determining risk. Additionally, Tom Dayspring explains the casual role of apoB in atherosclerotic cardiovascular disease (ASCVD) and the therapeutic goals for apoB concentration, and Peter explains how early and aggressive lowering of apoB could change the landscape of cardiovascular disease prevention.
We discuss:
-Intro [0:00]
-The importance of understanding atherosclerosis early in life [2:25];
-Defining ASCVD, its causes, and the role of cholesterol [8:00];
-Why early prevention of atherosclerosis is critical [13:45];
-Preventing atherosclerosis-two fatal flaws with the “10-Year Risk” approach [16:00];
-Intro to lipids and lipoproteins: why there is no “bad” or “good” cholesterol [23:00];
-Limitations of standard blood panels [35:45];
-How Mendelian randomization is bolstering the case for apoB as the superior metric for risk prediction [39:30];
-Therapeutic goals for apoB concentration [58:15];
-How early and aggressive lowering of apoB could change the course of ASCVD [1:10:45]; and
-More.
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About:
The Peter Attia Drive is a weekly, ultra-deep-dive podcast focusing on maximizing health, longevity, critical thinking…and a few other things. With over 45 million episodes downloaded, it features topics including fasting, ketosis, Alzheimer’s disease, cancer, mental health, and much more.
Peter is a physician focusing on the applied science of longevity. His practice deals extensively with nutritional interventions, exercise physiology, sleep physiology, emotional and mental health, and pharmacology to increase lifespan (delay the onset of chronic disease), while simultaneously improving healthspan (quality of life).
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[@PeterAttiaMD]

In this episode, we discuss: The importance of understanding atherosclerosis early in life [2:25]; -Defining ASCVD, its causes, and the role of cholesterol [8:00]; -Why early prevention of atherosclerosis is critical [13:45]; -Preventing atherosclerosis-two fatal flaws with the “10-Year Risk” approach [16:00]; -Intro to lipids and lipoproteins: why there is no “bad” or “good” cholesterol [23:00]; -Limitations of standard blood panels [35:45]; -How Mendelian randomization is bolstering the case for apoB as the superior metric for risk prediction [39:30]; -Therapeutic goals for apoB concentration [58:15]; -How early and aggressive lowering of apoB could change the course of ASCVD [1:10:45];

[@jeffrey4577]

👍❤️

[@erastvandoren]

👎💔

[@drewklingler4326]

Pp Ppp

[@bellelacroix5938]

I thought it was LPa

[@d4string367]

"In univariable mendelian randomisation, genetically elevated apoB in participants was identified to lead to a shorter lifespan in parents (fathers: 0·89 years of life lost per 1 SD higher apoB" that is a very tiny effect. also , i doubt they analyzed extremes(non linear effect) . so is a very very low apo-b good? i doubt, based on evolutionary arguments.

[@AdnAwd24]

this new format is very helpful, I've listened to all the episodes included here, and this format really helped me refresh my information and found everything in one place... thank you so much

[@hamidaabdenour9092]

As young man of 28 this informations are gold to me and my family

[@forester057]

Go check out Anthony Chaffee. He’s better.

[@kwilliams1958]

Appreciate these diverse bits of past pods ciipped together...its like Cliff Notes and a composite review of what Dr. Attia finds salient for his audience. Keep 'em coming....thanks.

[@rollingrock3480]

I eat 5-6 eggs a day (big omelette), I have a family history of heart disease, but my bloodwork is stellar. It's nice to get more information on this, especially after the dietary cholesterol limits were removed.

[@yohandsome]

While dietary cholesterol apparently has a much lower impact on the progression of cardiovascular disease than previously assumed, both animal experiments and human studies seem to support the view that dietary cholesterol may contribute to the transition from benign steatosis to the potentially fatal nonalcoholic steatohepatitis in the liver. So dietary cholesterol may be harmful to the liver, in particular when administered in combination with polyunsaturated fatty acids, which favor lipid peroxidation. www.ncbi.nlm.nih.gov/pmc/articles/PMC6726297/

[@tuna9919]

Can i ask what is your apoB?

[@bogse]

@@tuna9919 Dont be silly, he must be dead by now.

[@erastvandoren]

You are killing yourself.

[@robertusga]

How do you define "stellar"? Eating eggs does not raise cholesterol much. It's saturated fat that will do that trick in most (not all).

[@xavierbotteri1950]

Dear Peter, Could you please give us a quick update on the LpPLA2 marker? Do you still believe it is the best marker of arterial inflammation, as you once said during one of your conferences? Thank you very much.

[@steffshorr]

Such great explanations!! ASCVD and ApoB deserve our attention to lessen our risk. This isn't taught in school, why?❤

[@Pustul]

I’ve listed to a lot of podcasts from Peter on this topic but the question of how to lower your apoB level non pharmacologically, especially when you are in your 30s and still have a chance of affecting it, is never approached. I know a ton on how cholesterol works and how it kills people but nothing on how to prevent it from killing me.

[@curious_boy9092]

you need to lower saturated fat and raffined carbohydrates.

[@thecyclinggreek274]

Love this format.

[@DebiDalio]

To give you myself as a data point (since you ask why people don't want to take statins): Female, 64 yrs old. In July 2022: Cholesterol total 271, HDL 86, LDL 170, Triglycerides 48, APO A1 199, APO B 115. (I hear Peter screaming, get on a statin now!) I have recorded 26 cholesterol test results taken from 1988 to 2022. Half of them are a cholesterol total over 250. Why have I so far refused to take a statin? Side effects. I'm not willing even to risk them on a trial basis. Side effects such as: headache & dizziness (I already have a problem with vertigo and migraines), feeling unusually tired and weak (I already have enough problem with that), digestive system problems (I was recently in the hospital for two days with severe constipation problems, so I don't need to take yet another drug that has that as a side effect), sleep problems (I'm already taking two drugs that attempt to fix my sleep problems), muscle pain (I have enough pain from arthritis, I don't need more). My theory is if I have a good diet, no stress, and get some regular exercise, then I should have a low level of inflammation in my body and therefore should not be prone to having an ASCVD event. Both of my grandmothers lived into their 90s. My father died at 87. He had dementia and smoked for half his life. My mother is alive and well at 86. Nobody in my family has ever even mentioned anything about cholesterol to me. Maybe I'm just being foolish, and I am open to more arguments, but I will take a lot of convincing that I need to be on a cholesterol lowering drug for the rest of my life. Having said all that, I thought this and other podcasts on this topic were fascinating and informative. Keep 'em coming.

[@endgamefond]

Do you take it now btw? Do you the cause kf your original headeach and migrane btw?

[@DebiDalio]

@@endgamefond No, I am still not taking a statin. I got rid of most of my migraines by taking L-glutamine.

[@kiukk9288]

outstanding like in every episode! greets and blessings

[@mrbigsdaddy]

What do I have to do to get video. They’re talking about graphs, I want to see the graphs.

[@danielmccarthyy]

Subscribe.

[@adriatik7070]

Thank you , very educational!

[@MikeG-js1jt]

Why does my ApoB cosistently track exactly the same as my LDL.... is that typical?

[@pipsqueek6855]

I’m a member but have no video display on this episode…?

[@carolr.556]

What about the Apo B/Apo -A ratio? My Apo -A is 177 on the high end although Apo-B is 109 which means the ratio is 0.61 putting me a lower risk..right? My triglycerides are 52..My VLDL is 8..low..HDL is 83..high My total cholesterol 243..ugh LDL is high 146..ugh My glyc A is 295..normal range

[@timswail9507]

I was surprised not to see an excerpt on Lp(a) in this

[@rualablhor]

What is the second metric or number besides apoB shall we look at? LDL is slightly high but BP is great, HDL is ok, Trigly is ok and body fat is ~14%... Anyone?

[@seangreen8262]

In absence of apoB test availablity, could we not aggressively manage LDL levels (say less than 30 or even 15) in order to prevent the second MI?

[@danielmccarthyy]

Welcome to 1989 medicine and statin-management of LDL. 😢

[@dmackle3849]

@@danielmccarthyy I believe the extension of the analogy used mid article is; I can improve your BMI without knowing your weight, simply by surgically lengthening your legs 🤣

[@nunheadamerican6179]

​@@danielmccarthyy omg. This hit a nerve with me.

[@erastvandoren]

There is hardly any predictive difference between ApoB/LDL-C/Non-HDL-C.

[@seangreen8262]

@@erastvandoren Please explain this further: Are you saying that if I continue to monitor ldl, that should suffice?

[@edwardnino9896]

Great as always, never a bad idea to refresh the non-scientists out here who don't live and breath this level of info. One suggestion, dropping the intro/outro music would increase the flow of the program in my opinion. Cheers!!

[@dmackle3849]

I disagree: the music appears to delineate the individual articles these composite uploads are constructed from. Helps me build the collage in my head anyway.

[@itayshorek6872]

such a great format! really good

[@danielmccarthyy]

Peter, are heart attacks caused by arterial narrowing as you stated or by a plaque bursting and causing a flow-blocking clot?

[@erastvandoren]

Both. Bursting can cause a clot that can't pass a narrowing farther downstream.

[@BioStuff415]

both...

[@thomaswipf7986]

I like Tom Dayspring.

[@metalrunner4398]

I am not sure about part around 55-56 minute where the gentleman says that around age 35 you can’t do much to lower apoB. Me and couple of my family members were in the range of 110-140 and changed diet and improved exercise. It went down to range of 60-70 in all of us. I mean, we did not conduct a legit study but it tells a lot.

[@santiagojaramillo3079]

What changes did you make?

[@metalrunner4398]

@@santiagojaramillo3079 We eliminated saturated fat rich foods, increased fiber to at least 60g per day and introduced foods that are proven to lower apoB such as plant sterol rich food, soy protein (tofu, edamame, tempeh, soy milk), insoluble fiber (oats, berries, legumes) and PUFA rich foods. Also I am spending at least 3-4 hours a week in zone 2 training with 2x30 min strenght and 2xHIIT a week. What has surprised me, my HDL also increased but slightly. Tryglicerides were 98 now they are 46.

[@TheShumoby]

@@metalrunner4398 I'm on low carb and my apob is 114. My triglycerides is only 44 while HDL is 71. I might incorporate some of your suggestions.

[@metalrunner4398]

@@TheShumoby Prof. David Jenkins created “Portfolio diet” especially to lower apoB. Check it out. And you can definitely do low carb version by concentrating more on marine sources of fat.

[@TheShumoby]

@@metalrunner4398 thanks!

[@zhuhaibaker7816]

So what should be a good range for Apo B ?

[@AZ89231]

Depends on your baseline risk and goals, Peter will drive apoB to 20mg/dl sometimes. American Endo consensus is generally

[@danielmccarthyy]

And then the patient becomes retarded due to a shortage of cholesterol to keep the brain functioning.

[@AZ89231]

@@danielmccarthyy yep since you can’t measure a sterol panel and look at cholesterol synthesis markers and since plasma cholesterol tells you exactly how much brain cholesterol you have and since apoB particles cross the blood brain barrier…lol read a book bozo - listen to the podcast and do some actual science or be forever ignorant - the R word is a pejorative btw - you might want to remove from your lexicon, it’s insulting to yourself. ✌🏻

[@zhuhaibaker7816]

@@AZ89231 Thank You

[@jamesgordon8867]

The one thing I don't hear is the inflammatory response to insulin resistance.

[@dawngonzalez508]

Very helpful, thanks! Wondering if someone can provide some insight? I'm 52, not overweight, don't smoke, and have low blood pressure. My previous total cholesterol was 300! This last lab work, I had my doctor test APoB (she had no idea what it was!) and my number is high. Current results: Cholesterol, Total 244 mg/dL Triglycerides 76 mg/dL HDL Cholesterol 84 mg/dL VLDL Cholesterol Calculation 13 mg/dL LDL Cholesterol Calculation (NIH) 147 mg/dL APoB 116 mg/dL I was able to lower total cholesterol by 56 points - but this is still bad, right? Can I get APoB in a low enough range without drugs?

[@rualablhor]

@Dawn Gonzalez: My numbers are slightly worse than yours, although I haven't tested my apoB yet. My *calculated apoB is also slightly worse. .. Are you otherwise healthy?

[@dawngonzalez508]

@@rualablhor I used to be pretty healthy, but a few years ago I go I was diagnosed with Microscopic Colitis and since, I've had absorption issues (to say the least). There are a lot of healthy foods I can't really eat, so that has affected my health. Also, finally got my A1C checked and it was borderline not good. So, I have a way to go. How about you?

[@erastvandoren]

Cut LDL-C in half, then you are safe.

[@rualablhor]

@@dawngonzalez508 fwiw I'm much healthier than 2020. At the time, my ldl was over 160 and a1c 5.7. I was prescribed statin. My doctor said you are welcome to not take it, tho I have to write it up for you. I researched abit and set up some (health) metrics goals. I gave myself 4 months. If I didn't see any improvement, I'd start to take them (statin). Anyhow, I did improved enough to skipped them. My a1c is ~5.3, ldl is ~150 and my triglycerides and hdl also improved tho not "optimal". I also decreased my waist over 2 inches. My bp was always pretty good. And I'm slightly younger fwiw.

[@rualablhor]

@@erastvandoren that is very ambitious. It would take months, If not a year, at least. I don't know...if one is healthy otherwise, I'd aim for ldl 130, which is my ultimate goal. Then again, I'm not too obsessive with metrics. I just like to not watch my diet/workout all the time...ironically, 130 ldl is also my doctor's point of reference too.

[@trismegistus3461]

-Defining ASCVD, its causes, and the role of cholesterol [8:00];

[@anglosin]

Thanks for a great episode. Peter mentioned a lady patient with scary metrics who he chooses not to treat aggressively because she has zero calcium score in her 60s. Any suggestions for someone who is the opposite of that - ie athletic, good weight, low LDL-C, BP, eats healthily but mid 50’s with a CAC of 70?

[@alecto42c]

Have you had your lp(a) checked?

[@anglosin]

@@alecto42c I just requested for the first time and it came back 2.9 mg/dL. Not sure how good that is, but result sheet shows

[@alecto42c]

@anglosin Yeah, lucky you! That's great. Are you an endurance athlete, long runs? Usually elevated CAC when all other markers are good can be associated with long distance runners/swimmers, ex-smokers/heavy drinkers, or someone where endothelial dysfunction was present

[@anglosin]

@@alecto42c Interesting! Thank you so much. Yes, I do distance running in a very hot, humid climate (Singapore). I will try to find literature on that association but if there is anything you can recommend that would be much appreciated 🙏🏻 Presumably the elevated CAC carries all the same risks, even when other markers are good? Is giving up running the only way to mitigate? Endothelial dysfunction I guess will be difficult to determine…

[@erastvandoren]

Please define low LDL-C and healthy eating.

[@RiteOn]

It would be helpful if the term cholesterol were left behind once they become incased in the lipoproteins because that changes their identity. Although cholesterol is present, they are different and calling them what they no longer are makes for confusion.

[@Eldooodarino]

I don't believe that age causes BP to go up. Here's an N=1 story. Five years ago my weight had gotten a little high BMI probably 27-28 ish. I had severe sleep apnea both obstructive and central. A routine colonoscopy revealed a polyp. I was on a bipap machine for the apnea which I hated and my PCP was muttering about BP meds. Somewhere I read that "BP goes up with age but nobody knows why,." I told myself "Oh. Sounds like they're making stuff up." So I started eating 40-100 grams of fiber every day. I lowered my BMI to 25-26 and ditched the bipap machine, lost the apnea, lost my gout, lost my alcohol craving etc. My average BP over the last month is 105/67. I have no idea what works at the population level but but I know what worked for me.

[@floater81floats37]

Is it true that taking statins increases your risk of dementia?

[@floydald]

So at 74 and having a quadruple bypass, what’s one to do😊

[@danielmccarthyy]

Change the behavior that led to the bypass.

[@mikevaldez7684]

Lay down & prepare for death 💀 ☠️....💯🙋🙏

[@floydald]

@@mikevaldez7684 I think l will row and eat meat.

[@erastvandoren]

Low-fat plant-based.

[@floydald]

@@erastvandoren nope

[@johnmatthews6943]

Can anyone explain what is the difference between non-HDL cholesterol and apoB in terms of lab blood tests, meaning what is the difference between what those lab tests measure?

[@rualablhor]

Afaik ldl in the regular lipid panel is calculated, not measured. And it is not in number of particles but mass. Thus, you could have different particles bc their size/weight could differ greatly. ApoB is the actual number of particles period, it's more accurate than ldl. Ldl estimates would work for most, most of the time... except when it doesn't.

[@johnmatthews6943]

@@rualablhor Great, thank you for the reply!

[@rualablhor]

@@johnmatthews6943 np...the whole thing is quite confusing😊

[@tkorte101]

Look up what Linus Pauling said about this topic and the role of Vitamin C with respect to arterial micro tears & plaque formation.

[@Nicolailund15]

What did he say?

[@mikevaldez7684]

@@Nicolailund15 nothing. 💀☠️💯🙋🙏

[@xmenotux]

Honestly, talking about semantics of how people refer to "LDL' and "HDL" is pretentious because the "C" is implied. It's just the nomenclature that people use in discussing it.

[@burtnation1357]

🎉

[@thomaswipf7986]

What is with all the transition music? I pay for youtube premium now so i dont want to consume anything that sounds like a commercial. most of this program sounds like a commercial

[@forester057]

I guess we’re going to just ignore diabetes/metabolic health as the biggest risk for CVD.