60. Cholesterol Myths You Still Believe (And What to Track Instead)

In this episode of Extend, we're rethinking everything you've been told about cholesterol. For decades, the focus has been on lowering LDL, but that's only part of the story. The truth? LDL and total cholesterol are outdated metrics. If you're still relying on those alone to assess your heart health, you're missing the bigger picture. I'll break down why ApoB is the single most important number to track when it comes to cardiovascular disease, and how it gives a much clearer view of your real risk. You'll learn how plaque forms, why inflammation and metabolic dysfunction matter just as much as cholesterol, and how to approach your heart health with precision. I'll also cover how to lower ApoB naturally, when medication might make sense, and how advanced scans like CLEARLY can help guide your strategy. ➡️If longevity is your goal, this episode is a must-listen. Let's move beyond outdated labs and into next-gen heart prevention. I Also Discuss: Why LDL Is Outdated (And What to Track Instead) The Real Cause of Plaque in Your Arteries ApoB: The #1 Biomarker for Heart Health How to Lower Cholesterol Without Statins The Longevity Approach to Cardiovascular Disease Thank you for our Sponsors: Deliverance: Give your liver the care it deserves! Deliverance is a powerful plant-based formula designed to support and restore liver health. Get 10% off your first order with code DRSHAH at loveyourliver.com https://loveyourliver.com Timeline: Upgrade your energy from within! MitoPure by Timeline helps power up your cells, supporting muscle strength, mental clarity, and overall vitality. Stay active, sharp, and strong at any age! Claim 10% off your first order now at timeline.com/DrShah http://timeline.com/DrShah Learn more about Dr. Shah: Website: https://www.drshah.com/ Clinic: https://www.next-health.com/ Instagram: https://www.instagram.com/darshanshahmd/

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:03Dr. Darshan Shah?

  Welcome to Extend with me, Dr. Darshan Shah, a podcast dedicated to cutting-edge science, research, tools, and protocols designed to help you extend your health span. Having become one of the youngest doctors in the country at the age of 21 and trained and board certified at the Mayo Clinic, I've accumulated three decades of practice as a board certified surgeon and longevity expert. Over that time, I've discovered that a mere 20% of health knowledge yields 80% of the results when it comes to your health span. We're living in a new era where we are creating a new healthcare system, no longer focused on disease management, but achieving optimal health and vitality. Join me as I interview world renowned experts offering you a step-by-step guide to proactively avoid disease and most importantly, extend your health span.

• 0:49Dr. Darshan Shah?

  Hello, everyone. This is Dr. Darshan Shah and welcome to another episode of the Extend Podcast. Today's episode is actually a solo sode where you hear from me solo about topics that are extremely important for your health. And today's topic is all about dissecting and rethinking cholesterol levels and talking about some of the more advanced biomarkers in your cardiovascular risk and what do they really mean? And the reason I'm doing this is because I feel like there's been decades of us focusing on LDL and total cholesterol and really, in my opinion, that's practicing 1980s medicine. We need to update all of you, all of the listeners and all of just the medical system in general about the newer biomarkers of cholesterol and why they can be incredibly

• 1:33Dr. Darshan Shah?

  more valuable and serve as not just a better predictor of cardiovascular disease, but also help you monitor your particular N equals one risk of having heart disease. So let's jump right into it. So as I previously stated, most of us are used to going to the doctor and getting a cholesterol panel. And usually that includes HDL, LDL, cholesterol, and triglycerides. And I'm not saying these markers are not important. However, in my opinion, they're pretty scientifically obsolete right now. And let me dive into some of the reasons why. So I think most of us know, if you're a listener of this podcast, that cardiovascular disease, specifically atherosclerotic

• 2:10Dr. Darshan Shah?

  Cardiovascular disease, which is just another way of saying plaque in your arteries, is the leading cause of global mortality for both men and women. According to the CDC, every forty seconds, someone in the US experiences a heart attack. Strokes also kill approximately one person every three point five minutes. When you add up the number of heart attacks and the number of strokes in the United States every single year, that total number is a greater cause of death than all of the other causes of death combined. And then if you add in the number of people with Alzheimer's disease and kidney disease and liver disease, which also have some root in cardiovascular disease, vascular disease in particular,

• 2:51Dr. Darshan Shah?

  you really round out the entire top ten causes of death. So this is an incredibly important topic. Let's talk a little bit about what causes cardiovascular disease. And cholesterol levels is, in my opinion, not the inciting cause of cause of cardiovascular disease. It's definitely one of the risk factors and also contributory. But when you have disease in your blood vessels, particularly plaque formation in your blood vessels, you're really combining a few different factors. One of those factors is high cholesterol. But prior to that, it also involves inflammation inside of your body and your entire blood vessel system. It also involves metabolic disease, and it also involves damage to the interior of the blood vessel wall. That layer is called the endothelium, and it can be damaged with toxins.

• 3:36Dr. Darshan Shah?

  It can be damaged by high blood pressure. It can even be damaged by chronic stress. And so, as you can see, plaque formation is a multifactorial problem, and we need to really attack all of these factors, not just the high cholesterol. I think it's important also for everyone to really understand what is plaque? Plaque is actually a buildup of a complex structure of lipids. So that's cholesterol, for example, that is oxidized. It's also cholesterol esters, inflammatory cells, other proteins that are malformed, and then eventually calcium deposits. The reason we get calcium deposits in our blood vessels is that's our body's attempt to stabilize the plaque, so it doesn't grow or rupture. And we talked about this in a prior episode, where we talked about how we can quantify these calcium deposits

• 4:20Dr. Darshan Shah?

  using a calcium score, which is obtained with a CAT scan of your heart. So once you have this perfect storm of damage to your blood vessel wall and inflammation and metabolic disease, and you also have high cholesterol levels, that cholesterol starts depositing into that blood vessel wall, causing what's called an unstable plaque to start with. And unstable plaques are particularly dangerous because when they're unstable, they can cause a major blockage that leads to stroke or heart attacks. And this is why we follow cholesterol numbers, because we want to make sure that if you do have damage to your blood vessel wall, and you have some of these other issues, that if your cholesterol is high, it can build up quite easily in those plaques. Now, the opposite is also true. We have large studies like the Framingham Heart Study and

• 5:04Dr. Darshan Shah?

  the multi-ethnic study of atherosclerosis, or the MESA study, that show that there are significant populations of people that have cardiovascular events. However, they have what would be considered normal LDL levels. So obviously, we know there's something else at play here, besides just high cholesterol levels. And that brings me to a vastly superior biomarker of cholesterol, which is ApoB. That's APOB. ApoB is the particle count that really matters. And the reason for that is that ApoB is actually a structural protein that is in every single atherogenic lipoprotein. What do I mean by that? Is that your lipids are wrapped with proteins that allow them to float around in your blood vessels. ApoB

• 5:49Dr. Darshan Shah?

  is that protein that wraps around all the bad forms of cholesterol: LDL, VLDL, IDL, and LP little a. All of these particles have one ApoB molecule per particle. So measuring ApoB gives you the total number of cholesterol delivery vehicles capable of penetrating that endothelium, the interior wall of the blood vessel, and then depositing there. So that's why you really need to know what your ApoB level is. LDL, on the other hand, only tells you how much cholesterol is being carried inside of the particles, not how many particles there are. ApoB gives us, once again, a true particle count of atherogenic particles, and that's the number that you need to know. We have numerous studies like the INTER Heart Study and the

• 6:34Dr. Darshan Shah?

  Quebec cardiovascular study that demonstrate that ApoB is a stronger predictor of cardiovascular events than LDL-C. And ApoB also captures that elusive particle LP little a. Now, I'm going to be doing another episode on LP little a because it is that important. But just know that LP little a is a cholesterol particle that we never use to test for because it's not in our standard LDL HDL measurements and it is a particularly bad form of cholesterol because it's very sticky and very pro-inflammatory. And there's 20% of us that have clinically significant high levels of LP little a and we don't know. You can catch this in your ApoB measurement.

• 7:15Dr. Darshan Shah?

  So I'm 52 right now, but I'm still pushing all of my limits. I'm running long distances. I travel across many time zones to support my work and I just want to live my life to the fullest. Staying active as I age isn't just about willpower. It's about supporting my mitochondria, the powerhouses of my cells with the energy that they need to recharge my muscles and recharge my brain. Mitopure is a supplement that I take. It's backed by solid research showing that it can boost cellular energy, increase muscle strength and support overall healthy aging. Personally, I take Mitopure every single day. This helped me continue my active lifestyle, whether it's a high intensity workout or keeping up with my kids. So if you are looking to support your

• 7:59Dr. Darshan Shah?

  body and want to feel younger from the inside out, my friends at Timeline are offering you a 10% discount on your first order. Go to timeline.com/drsah to get started. That's timeline.com/drsah. Your future self will thank you.

• 8:21Dr. Darshan Shah?

  At my practice at Nex Health, I'm often amazed by how many of my patients have liver health issues. It turns out that 38% of Americans have fatty liver disease and most people have no idea. You wouldn't really know until you do something like a liver scan using ultrasound shear wave technology, which we offer to all of our patients at Nexel to get a good idea of how much damage has been done from metabolic disease and alcohol consumption. This is where a new product called Deliverance comes in. Invented by Siggi Clavien, it uses natural plant extracts that you drink as a liquid shot, which have been shown in studies to prevent and reverse fatty liver disease. I personally have a history of metabolic disease, which I work really hard to keep at bay.

• 9:03Dr. Darshan Shah?

  I use Deliverance myself, three times a day, to prophylactically make sure that my liver stays healthy. It's super easy to use and actually tastes good, too. You can save 10% on your first order when you use the code DRSHAH, that's D R S H A H, at the website loveyourliver.com.

• 9:27Dr. Darshan Shah?

  So now that we've established that ApoB is the marker that you want to track, and you can probably even become less concerned with your LDL, HDL, et cetera, if you're following your ApoB. And I know there's other tests out there that measure particle counts and things like that. And although they're interesting, I really like to get my patients to just remember one number and understand what that number means, because it is the most important number. You want to try to get your ApoB level to somewhere under 90 to 100. This is considered generally an acceptable amount of risk by most practitioners, but also this is really dependent upon what your other risk factors are. So if you have other risk factors, like maybe you're a smoker, or you have metabolic syndrome, or maybe you have obesity, these could be indicators you want your ApoB to be even lower,

• 10:12Dr. Darshan Shah?

  or you at least want to work for a lower ApoB with lifestyle changes. Also, it's important to note that an ApoB level less than 90 to 100 is good enough to avoid overt chronic disease and potentially having cardiovascular events, but it's definitely not ideal if you're trying to look for longevity, in which cases you might want to aim even lower. So most functional medicine experts, to prevent chronic disease, try to aim for an ApoB level of less than 80 mg per deciliter. This is associated with the lowest risk of atherosclerotic cardiovascular events. And then, if you have an ApoB level of less than 65, but you have diabetes or high calcium scores, that's even better.

• 10:53Dr. Darshan Shah?

  In fact, an ApoB of less than 65 is what's endorsed by the European Society of Cardiology and some American guidelines if you have other risk factors of cardiovascular disease, and especially if you have a coronary calcium score that's elevated. And then you can aim for an ApoB level of less than 50. This is what we call the longevity optimization zone, or the pretertia zone that he recommends. This is based on the concept that literally any ApoB-containing particles are potentially bad and can infiltrate into the endothelium and cause atherosclerosis in any blood vessel in your body. And getting to an ApoB level that low really will involve aggressive lifestyle interventions, but probably even some medical interventions as well, and maybe some supplements or nutraceuticals

• 11:36Dr. Darshan Shah?

  like niacin, fiber, or Redi's rice, et cetera. And so this is where you really want to look at you and your personal biology and your personal approach to healthcare and medicine in general. Where are you on the bell-shaped curve? Are you someone that wants to aggressively protect against any atherosclerotic particles? Or do you just want to mitigate risk factors of disease that you have? And that's where you need to aim for your ApoB level to sit. There are certain tests that you can do to delineate where you want to be on this curve. And one of them, like I mentioned, is a coronary calcium score. But what's even better than that, in my opinion, is a clearly heart scan. If you remember, this is a scan that we can look at each one of your heart blood vessels and see exactly how much plaque is in each one, and how much of that plaque is stable or unstable plaque.

• 12:20Dr. Darshan Shah?

  And this can help us guide our therapeutic interventions. So what do you do if you have a high ApoB? Maybe it's at a level that you don't want it to be at. Well, obviously, the first and foremost should always be lifestyle interventions. The number one lifestyle intervention that you can do is modify your diet. And at the top of that list is eliminate ultra-processed foods from your diet. They are not only causing high cholesterol levels, but also leading to metabolic disease and inflammation. After that, if your ApoB is a problem, you might want to swap your saturated fats for unsaturated fats. And this can get kind of controversial, depending on what dietary camp that you're under. But I can tell you, after doing 20 years of practice, that people who have a lower saturated fat diet, many people will lower their cholesterol just by doing this.

• 13:04Dr. Darshan Shah?

  And the reason it works is because it reduces the hepatic production of LDLs and VLDL forms of cholesterol by doing so. This means focusing on fats like olive oils, avocados, nuts and fatty fish, and avoiding saturated fats in things like very heavy fatty meats or processed meats or full fat dairy, even butter. Now, this doesn't work for everybody. I've seen some people that have a very high saturated fat diet and do not have high ApoB levels. Those people are genetically blessed, but most people, their ApoB levels are high. This can make a significant impact. Number two, increased amount of fiber you take in. Fiber increases the amount of bile you have.

• 13:46Dr. Darshan Shah?

  More cholesterol used to make bile, therefore you have lower ApoB. Fiber comes from chia seeds, cilium, legumes, oats, lots of different places you can get fiber, especially in green leafy vegetables and more. You should target somewhere between 20 to 40 grams a day of fiber. And there are large meta-analyses that show that having a target of more than just 10 grams a day of soluble fiber can lead to a 5 to 10% reduction in ApoB just by itself. Number three is incorporating both zone two and resistance training into your workouts. You want to get at least 150 minutes of zone two activity. Zone two, remember, is walking or light cycling and two to three sessions of resistance training in a week.

• 14:28Dr. Darshan Shah?

  Exercise has been shown to lower ApoB by 10 to 15 points even without weight loss. And so there's a very powerful mechanism of lowering your ApoB. Number four is reducing alcohol. 30-day alcohol holidays or cutting down to less than two drinks a week has been shown to drop ApoB by another 10%. And then number five, if you're a candidate for it, you might want to try time-restricted eating or intermittent fasting in something like a 16, eight-hour fast. This has also been shown to reduce ApoB and LDL over a 12-week protocol of intermittent fasting.

• 15:07Dr. Darshan Shah?

  As I mentioned in previous podcast episodes, intermittent fasting is not for everybody. So definitely make sure you listen to one of those episodes before you embark on an intermittent fasting journey. Let's talk about other ways you can reduce your cholesterol levels, specifically what are some of the pharmaceutical interventions? And this is where I do want to qualify that I do not believe that everyone needs to be on a statin. In fact, statins, in my understanding, are one of the most over prescribed medications in history. And that's because a lot of people are using statins for what we call primary prevention. And really, life cell interventions and other medications are available with less side effects that can also help you achieve lower ApoB levels. Specifically, I'm a big believer in using what's called Zetia or ezetimibe.

• 15:50Dr. Darshan Shah?

  This medication inhibits a transporter in the colon and it prevents the absorption of cholesterol through your colon for people that are hyper absorbers of cholesterol through their gut. And many people, especially South Asians, are hyper absorbers of cholesterol. So how do you know if you should be on ezetimibe or not? Well, there's a test you can do, and that test is called the sterol test. So before going on any cholesterol medications, I highly suggest testing for sterols. So this way you can see if you are a hyper absorber, maybe you can use Zetia versus a statin. And one of the best ways to do this is to get a panel of laboratories called the Boston Heart Diagnostics. There's many other panels out there that you can do, but this is the one that I use because I find it to be the most complete.

• 16:32Dr. Darshan Shah?

  Not only does it test for ApoB, LP little a, but also markers of inflammation that we mentioned previously can lead to heart disease and also sterols. And it can really help guide therapeutic intervention for high cholesterol. All of these tests should be readily available to you through your doctor's office. So before you get put on any cholesterol medications, press your doctor and ask them, should I be doing a Boston Heart Diagnostics to help guide therapy here? Also, I would definitely press your doctor to check an ApoB level every time you get blood work done. This is readily available through every lab. And is not expensive and your insurance should cover it. Some of the other cholesterol lowering medications out there are of course statins.

• 17:13Dr. Darshan Shah?

  Statins work by increasing the number of LDL receptors you have. They decrease the production of cholesterol by your liver. And they also reduce inflammation, which is also very valuable. However, there are common side effects such as myopathy, which is pain in your muscles. Your liver enzymes can go up and sometimes you can also get worsening of your metabolic disease and higher insulin resistance. And if you have some of these side effects, it's important to know that there are ways of mitigating these side effects. You can change the medication around, you can lower the dose. There are a lot of options available if you're having side effects statins. Another high tech, commonly used medication right now is what's called a PCSK9 inhibitor. This is an injectable medication that you can use once a week, or there are some you

• 17:56Dr. Darshan Shah?

  can even spread out even longer, that actually have antibodies that prevent LDL receptors from degrading. And so the way that works in the liver is that the liver is pulling in LDL from your bloodstream and these PCSK9 inhibitors create more of these receptors on your liver to pull these in. They're incredibly effective, but unfortunately they're also expensive. And let's face it, most people would probably not want to inject themselves weekly unless that's something you're already used to, but it is available. And then there's other medications that reduce inflammation, things like low dose colchicine that can also become part of your medical routine if lowering inflammation is needed as well. What I advise most of my patients to do if they have risk factors of cardiovascular

• 18:38Dr. Darshan Shah?

  disease, and especially if they have a positive clearly scan or calcium score, is let's use some sort of medical intervention to immediately drop the cholesterol while you're undergoing lifestyle changes. Now, some people don't ever want to be on medications and I understand that, but I tell them, give the lifestyle interventions a 60 to 90 day trial before we talk again. And the reason for this is the damage is building up over time. Many people go years and sometimes even a decade without managing their cholesterol and they end up with a lot of blockages and arteries and also the consequences of those blockages. And therefore I believe temporary medical intervention is usually a good idea while you're getting your lifestyle in order. In fact, I believe almost all medication should be considered temporary because it's really about reversing risk factors of chronic disease and getting off pharmaceuticals,

• 19:23Dr. Darshan Shah?

  if at all possible. I think we're no longer in the era of good versus bad cholesterol. We're really in the era of precision medicine, especially in cardiovascular disease. When we look at cardiovascular disease, we have to stop this knee jerk reaction of just looking at cholesterol levels and then prescribing a statin. We really need to look at it as multifactorial and look at how do we improve all of the factors simultaneously? Inflammation, metabolic disease, high cholesterol, high blood pressure, all of it needs to be considered. However, these are all factors that need to be modified while we're keeping the cholesterol levels low so we prevent future damage. The best way to know where our cholesterol is, is to look at the biomarker ApoB.

• 20:06Dr. Darshan Shah?

  Obviously, your doctor might want to check more biomarkers than just that, and I recommend you do so. But you need to track your own ApoB, know where it is at least every four to six months, and understand what direction it's headed in. My next episode is going to be about another cardiovascular biomarker called LP little A, so make sure you tune into that one because it's extremely important. If you know anyone that's struggling with understanding their cholesterol levels, or is on statins, or is going to be put on any type of cholesterol lowering medication, forward them this quick episode, just so they get a good overview. And please do me a favor and give me a star rating and a comment on the podcast platform that you're listening to this on. It really helps us to do more episodes. Thank you for joining the Extend Podcast.

• 20:50Dr. Darshan Shah?

  Thank you so much for listening to the podcast today. Please remember to subscribe if you liked this episode, and give us a good review and share a link with your friends. It really helps to support all of our efforts. I also want to remind you that the information shared on this podcast is for educational purposes only and is not intended to replace professional medical advice, diagnosis, or treatment. Please consult with your healthcare provider or physician before making any decisions or taking any action based on what you hear today, especially if you have any underlying health conditions or on any medications. Your doctor knows your personal health situation the best, and it's always important to seek their guidance.