When I started writing these video scripts, I led with what I already knew well. I think there was Fish Oil fatigue. This newsletter is a pivot to cholesterol and it started somewhere unexpected: berberine. I was digging into berberine, one of the most-hyped metabolic supplements, and literature demonstrated repeated modest improvements in LDL. And I realized I couldn’t honestly judge berberine without first understanding LDL, its thresholds and associated risks.
The more I read about LDL, the clearer it became that LDL only tells part of the story. A standard LDL result measures the cholesterol inside your LDL particles only, but it misses the total number of particles carrying cholesterol, and it misses other dangerous ones like Lp(a) entirely. Two people can walk out of the lab with the identical LDL and be carrying very different risk. The more cholesterol carrying particles the higher the risk. LDL is an incomplete picture, and the number that completes it is ApoB, but usually goes unmeasured.
Here’s the practical part I most want you to take away: most standard panels don’t include ApoB or Lp(a) unless you ask. Prompt your provider to check both: ApoB to see your true particle count, and Lp(a) once in your life, since it’s about 90% genetic and not modifiable with lifestyle changes.
That’s the background. From here, the next several issues will all be cardiac-focused: cumulative risks of elevated LDL, CT calcium scans, heart rate variability, VO2max and how to actually move them. I hope you find this series as helpful as I did; understanding it genuinely changed how I read my own labs and manage my own health. Today, the take-home version.
The Take-Home Points
LDL still matters. Fifty years of evidence; every point you lower it lowers your cardiovascular risk. It just isn’t the whole picture.
ApoB counts the particles; LDL only weighs the cholesterol. Every cholesterol carrying particle has exactly one ApoB tag and it is important to know the total number circulating in the blood. The higher the particle count, the greater risk of plaque formation.
A “normal” LDL can hide a high ApoB. People most likely to have a hidden elevated ApoB are those with insulin resistance, type 2 diabetes, metabolic syndrome or already on a statin.
Plaque follows the number of particles, not the size. The more cholesterol carrying particles, the greater risk that the particle penetrates through the arterial wall and initiates plaque development.
The numbers are concrete: LDL ~100 grows plaque, ~70 stabilizes it, low 70s can slightly shrink it. ApoB targets tighten from under 90 to under 60 as risk rises. And Lp(a): ~90% genetic, 5–6x more dangerous and is the inherited wildcard most panels skip.
Watch the whiteboard explainer:
That’s the foundation. In the coming issues I’ll build on it and then circle back to the supplements with a clear standard for judging whether they actually move the number that matters.
More from the Fish Oil video series:
References
Lamantia V, Sniderman A, Faraj M, Nutrition Research Reviews, 2016
Richard C, Couture P, Ooi EM, et al, Arteriosclerosis, Thrombosis, and Vascular Biology, 2014
Kim S, Shin MJ, Krauss RM, Current Atherosclerosis Reports, 2025
Blumenthal RS, Morris PB, Gaudino M, et al, Journal of the American College of Cardiology, 2026
Najjar RS, Moore CE, Montgomery BD, Clinical Cardiology, 2018
Kraus WE, Houmard JA, Duscha BD, et al, The New England Journal of Medicine, 2002
Kasiakogias A, Sharma S, Clinical Cardiology, 2020
Rogers EM, Banks NF, Jenkins NDM, Diabetes/Metabolism Research and Reviews, 2024
Ren H, Liu Z, Zhou X, Yuan G, Nutrition & Metabolism, 2018
Ren H, Zhang L, Liu Z, Zhou X, Yuan G, BMJ Open, 2019
Bos MM, Noordam R, van den Berg R, et al, Journal of Sleep Research, 2019
Ference BA, Graham I, Tokgozoglu L, Catapano AL, Journal of the American College of Cardiology, 2018