The TL;DR
While ApoB and Lp(a) are the heavy hitters, a truly optimized lipid strategy looks deeper. Remnant Cholesterol (the cholesterol left in triglyceride-rich particles) is arguably more atherogenic than LDL. Oxidized LDL measures the actual damage to the particles. Sterol Absorption markers tell you if you are an “over-absorber” (need Ezetimibe) or an “over-producer” (need Statins).
Accessibility Level
Level 3 (Advanced): Requires specialty labs (Boston Heart, Cleveland HeartLab) or careful calculation from standard results.
The Hidden Risks
1. Remnant Cholesterol (RLP-C)
- What it is: Cholesterol contained in VLDL and IDL particles (triglyceride carriers).
- Why it matters: Unlike LDL, remnants can penetrate the arterial wall and get stuck more easily, causing massive inflammation.
- Calculation: Total Cholesterol - HDL - LDL = Remnants.
- Target: < 15-20 mg/dL. If high, check insulin resistance and triglycerides.
2. Oxidized LDL (OxLDL)
- What it is: An LDL particle that has been damaged by free radicals (rusted).
- Why it matters: The immune system (macrophages) doesn’t recognize normal LDL as a threat, but it eats OxLDL avidly, turning into “Foam Cells”—the start of plaque.
- Fix: Lower inflammation, eat antioxidants, avoid seed oils (prone to oxidation).
3. Omega-3 Index
- What it is: Percentage of EPA/DHA in red blood cell membranes.
- Why it matters: High index (>8%) correlates with lower risk of sudden cardiac death and better brain health.
- Target: > 8%. (Average American is ~4%).
Phenotyping: Absorber vs. Producer
Not everyone has high cholesterol for the same reason.
- Hyper-Absorbers: Gut absorbs cholesterol efficiently. They respond well to Ezetimibe (Zetia) or fiber, but poorly to statins. Marker: High Campesterol/Sitosterol.
- Hyper-Producers: Liver makes too much. They respond well to Statins. Marker: High Desmosterol/Lathosterol.
Knowing your phenotype allows for precision medicine, minimizing drugs and maximizing effect.
Evidence Matrix
| Source | Verdict | Notes |
|---|---|---|
| Thomas Dayspring | Expert | Lipidologist who champions the “Absorption vs Production” model. |
| Copenhagen Heart Study | Strong | Showed elevated remnant cholesterol causes ischemic heart disease and mortality. |
| Bill Harris | Pioneer | Co-inventor of the Omega-3 Index; established >8% target. |
References
Varbo, A., et al. (2013). Remnant cholesterol as a causal risk factor for ischemic heart disease. Journal of the American College of Cardiology.
Harris, W. S., et al. (2018). The Omega-3 Index and relative risk for coronary heart disease mortality: Estimation from 10 cohort studies. Atherosclerosis.