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ANNOUNCEMENT: If you are looking to be a part of a community, connect with a small group of like-minded practitioners, and receive guidance on navigating the nuances of real-world functional medicine, click on of the buttons below to learn more or apply for the Functional Medicine Collective mentorship!
Note, for a short time, there's an option to purchase just one month and try it out!
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This week's topic: ApoB and Lp(a)
If you're like most mainstream medical clinicians, you have limited knowledge about what these are and how to address these if abnormal. Let's change that today!
Overview of today's email:
- Overview of ApoB and Lp(a)
- Practical clinical tips
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1. Overview of ApoB and Lp(a)
To provide more context on today's topics, a quick reminder of cholesterol physiology and testing:
- Water and oil don't mix, right? So cholesterol (which is hydrophobic) is carried through the blood because of lipoproteins (which are hydrophilic)
- Traditional lipid calculations do not evaluate particles, since most companies use the inexpensive method of evaluation (via the Friedwald equation, which is a low cost way of estimating cholesterol as long as someone is fasting - so chylomicrons don't get measured - and/or triglycerides are not over 400 mg/dL)
- Thus, two patients can have the same LDL-C, but different particle count (LDL-P).... higher particle count is repeatedly shown to be more predictive of CVD
The 2018 AHA/ACC cholesterol guidelines recommend evaluating risk-enhancing factors in patients who are borderline or at intermediate risk for developing ASCVD (atherosclerotic cardiovascular disease). Apolipoprotein B and Lipoprotein(a) are part of these "risk enhancing factors" (see the other factors here: 2018 ACC/AHA Hyperlipidemia Guidelines).
APOLIPOPROTEIN B
This is a structural protein that carries hydrophobic lipoproteins through the blood. There is one molecule of ApoB per atherogenic lipoprotein particle: VLDL, IDL, LDL, and Lp(a).
- A patient can have low or normal LDL-C but have a high ApoB
- More atherogenic particles = more ApoB
- Optimal ApoB = Under 60 mg/dL (under 40 mg/dL if history of CVD)
LIPOPROTEIN(a)
Lipoprotein(a) is an LDL particle that also has an apolipoprotein(a) bound to it, and in functional medicine training organizations, we are taught that levels of Lp(a) are genetically determined (I've seen otherwise, though, in clinical practice!).
- Physiology of this is unknown, but it’s structurally similar to plasminogen (so it’s thought that this interferes with fibrinolysis and thus contributes to thrombus formation) (reference)
- Associated with increased risk of endothelial dysfunction and cardiovascular disease, and also increases LDL susceptibility to oxidation (reference)
- Elevated levels seen in end stage renal disease, post-menopausal women, African Americans (1 out of 3), certain inflammatory states (e.g. Covid and post-Covid), and in those with genetic reasons for elevation
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2. Practical Clinical Tips
Addressing ApoB:
- Those with an ApoE 4 allele are more likely to have elevated ApoB levels (reference)
- Unfortunately, the only way we know of lowering ApoB is via pharmaceuticals (PCSK9 Inhibitors can lower it the best, by 50-70% reduction)
- I spent a few years experimenting with other lifestyle factors that could lower ApoB (and tracking patient labs), and found that strength training with heavier weights 2-3x/week for at least 15 minutes per day lowered this more than any other lifestyle intervention (no literature to support this)
Addressing Lp(a):
- Elevated homocysteine levels in someone with high Lp(a) need to be addressed, since homocysteine promotes fibrin binding to Lp(a)
- Fibrinolytic enzymes such as lumbrokinase seem to lower Lp(a) more than anything (although I tend to see a transient rise in ApoB for the first 6 months while on these)
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I hope this was clinically useful! If you want more education and clinical tips on ApoB, this is the topic of the "Focused Mastery Workshop" this month in the mentorship. The workshop will also be available for purchase separate from the mentorship at the end of the month.
Also, would you mind filling out a one question survey to let me know which topics you found most helpful? Thank you!
Meg
Additional resources that may be helpful
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