How can diet changes help lower Apolipoprotein B (APO B) levels?

Dietary Strategies to Lower Apolipoprotein B (APO B) Levels

A diet that emphasizes vegetables, fruits, whole grains, low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils, and nuts while limiting saturated fats, trans fats, red meats, and sugar-sweetened beverages is most effective for lowering Apolipoprotein B (APO B) levels. 1, 2

Understanding APO B and Cardiovascular Risk

• APO B is the major apolipoprotein of atherogenic lipoprotein families (VLDL, IDL, and LDL) and provides a good estimate of the number of these particles in plasma 1
• Elevated APO B levels (≥130 mg/dL) are a strong predictor of cardiovascular disease risk 2
• APO B appears to be at least as good a risk factor as LDL-C and a better index of the adequacy of LDL-lowering therapy 1
• For patients at very high cardiovascular risk, the European Society of Cardiology recommends an APO B target <80 mg/dL 1, 2
• For patients at high cardiovascular risk, the target APO B level is <100 mg/dL 1, 2

Dietary Modifications to Lower APO B

Reduce Saturated Fat Intake

• Decreasing saturated fat intake is one of the most effective dietary changes for lowering APO B levels 1, 2
• Aim for a dietary pattern that achieves 5%-6% of calories from saturated fat 1
• Replace saturated fats with unsaturated fats from non-tropical vegetable oils, nuts, and fish 1
• Stearic acid (found in some plant sources) does not increase total cholesterol levels unlike other saturated fatty acids (lauric, myristic, and palmitic) 1, 3

Eliminate Trans Fats

• Reduce percent of calories from trans fat as much as possible 1
• Trans fatty acids have similar LDL-raising effects as saturated fats but also decrease HDL cholesterol more significantly 3
• Avoid partially hydrogenated oils, which are the major source of trans fatty acids in the diet 1

Increase Fiber Intake

• Certain soluble fibers (oat products, psyllium, pectin, and guar gum) reduce LDL cholesterol and can help lower APO B levels 1
• For every gram increase in soluble fiber, LDL cholesterol would be expected to decrease by an average of 2.2 mg/dL 1
• Focus on whole grains, legumes, fruits, and vegetables as sources of dietary fiber 1

Optimize Carbohydrate Quality and Quantity

• Very high carbohydrate diets (>60% of energy) can lead to elevated triglycerides and reduced HDL cholesterol, especially in insulin-resistant individuals 1
• Choose complex carbohydrates from whole foods rather than simple sugars 1
• Limit intake of monosaccharides (particularly fructose) which may have more adverse metabolic effects than oligosaccharides or starch 1
• In insulin-resistant individuals, high carbohydrate intake may increase circulating levels of saturated fatty acids, particularly palmitate (C16:0), which is associated with increased metabolic syndrome risk 1

Increase Omega-3 Fatty Acids

• Foods rich in omega-3 polyunsaturated fatty acids (EPA and DHA) confer cardioprotective effects beyond improvements in lipoprotein profiles 1
• Consume at least 2 servings of fish per week, especially fatty fish such as salmon 1
• Plant sources of omega-3 fatty acids include flaxseed, flaxseed oil, canola oil, soybean oil, and nuts 1

Follow Established Dietary Patterns

• The DASH (Dietary Approaches to Stop Hypertension) dietary pattern, USDA Food Pattern, or American Heart Association Diet are recommended approaches 1
• These patterns emphasize vegetables, fruits, whole grains, low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils, and nuts 1
• They limit intake of sweets, sugar-sweetened beverages, and red meats 1

Weight Management and Physical Activity

• A drop in LDL-C concentration of 0.2 mmol/L (8 mg/dL) is observed for every 10 kg of weight loss 1
• Regular physical activity, while having a smaller effect on LDL-C levels than weight loss, contributes to overall cardiovascular health 1
• For lipid benefits, engage in aerobic physical activity 3-4 sessions per week, lasting on average 40 minutes per session, involving moderate to vigorous-intensity physical activity 1

Medication Considerations

• For patients not achieving target APO B levels with lifestyle modifications alone, statins are the first-line pharmacological approach 2, 4
• Ezetimibe can be added to statin therapy to further reduce APO B levels by an additional 15-19% 5
• The combination of ezetimibe with statins reduces APO B more effectively than statins alone 5

Monitoring and Follow-up

• APO B can be measured in non-fasting samples, which is convenient for monitoring 1
• APO B measurement is particularly useful when triglycerides are elevated (≥200 mg/dL) 2
• Regular monitoring of APO B levels is recommended to assess response to dietary interventions 4

Important Clinical Considerations

• The ratio of APO B to APO A1 provides additional risk information, with a higher ratio indicating increased cardiovascular risk 1, 2
• Focus on lowering the APO B component (numerator) of the APO B/APO A1 ratio, as evidence for this approach is stronger than for raising APO A1 2, 4
• In patients with elevated Lipoprotein(a), APO B may underestimate cardiovascular risk 6