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Apo-B is a complex particle, but basically, it’s a protein found in many lipids within the arterial walls, and too much of it can be dangerous2. 

“It is a protein that is wrapped around a class of lipoproteins that are atherogenic, meaning that they promote atherosclerosis,” says Attia. (Refresher: Atherosclerosis refers to plaque buildup in the arteries.) “The most prevalent of these is LDL, or low density lipoproteins, but they’re also found on very low density lipoproteins, intermediate density lipoproteins, and Lp(a) particles,” Attia adds. 

But here’s the thing: Most people only get their LDL cholesterol measured at the doctor. “While that’s a decent predictor of cardiovascular risk, it’s nowhere near as good as counting the number of all of those particles—and that’s what Apo-B is measuring,” says Attia. 

Essentially, your Apo-B number gives your doctor a much better understanding of the level of buildup of cholesterol on your artery walls.

“By measuring the concentration of Apo-B, you have a direct measurement of the concentration of atherogenic particles,” he adds. We should note, this test is not one typically ordered by your doctor, but you can request it as part of an advanced testing panel. 

Now, Attia mentions that Apo-B is a necessary criteria for atherosclerosis. Meaning, “You can’t get atherosclerosis without Apo-B,” he declares. “If you want to eradicate atherosclerosis, all you would have to do is eradicate Apo-B.”  

So how low should you go? Well, Attia notes that when children are born, their Apo-B is very low—we’re talking 20 to 30 milligrams per deciliter. 

“However, by the time you’re in your 20s and certainly in your 30s, the average person’s Apo-B is about 100 to 110 milligrams per deciliter. That’s already very high from the standpoint of prevention,” he adds. “In fact, only 20% of adults3 would have an Apo-B below 80 milligrams per deciliter.” But if you could reduce your Apo-B down to childlike levels, “atherosclerosis would be impossible,” he says. 

The question becomes: How do you get your Apo-B down to that 20 to 30 milligrams per deciliter range? 

“Nutrition absolutely makes a difference,” says Attia. Think: reducing saturated fat intake, eating more fiber, plus plenty of other heart-healthy dietary interventions. “But even once those things are fully optimized, very few people would be able to get their Apo-B below, say, 70 milligrams per deciliter,” he argues. 

To cross the finish line, he recommends a few pharmaceuticals. “We have classes of drugs called PCSK9 inhibitors4 or another drug called Ezetimibe that blocks the reabsorption of cholesterol in the gut that is being recirculated by the liver,” he explains. “And [there’s] even another drug that impairs cholesterol synthesis called Bempedoic Acid. These are drugs that have no side effects.” 

Full disclosure: These drugs can be expensive, but hopefully that will change with more research and exposure. “It certainly makes it now feasible to get everybody’s Apo-B to a desirable level,” Attia adds, and identifying the solution is the first step. 

Look, lifestyle interventions are key when it comes to reducing your risk of serious health outcomes. There’s no doubt about that. But according to Attia, lifestyle can only get you partially there in reducing the risk for cardiovascular disease.

If pharmaceuticals can get you to that 100%, they’re certainly worth a conversation, don’t you think? “It really just becomes a question of physician and patient education around understanding the temporal nature of the disease,” he notes. 

Let’s review: Apo-B provides a much better understanding of the level of buildup of cholesterol on your artery walls. According to Attia, Apo-B is necessary for developing heart disease, so by eradicating Apo-B, you may be able to eliminate CVD. To do so, he recommends a combination of lifestyle and pharmaceutical interventions. 

You can technically lower Apo-B naturally, but to get your levels down to childlike levels, he says you’ll likely need pharmaceuticals to cross the finish line—certainly something to consider if you’re concerned about heart disease.