Elevated cholesterol as an athlete or on a ketogenic diet: why measure Lp(a) and ApoB?

Elevated total cholesterol is not always cause for panic, especially in athletes or people on a ketogenic diet. Still, it can be important to look beyond standard blood values. Measurements of Lipoprotein(a) and Apolipoprotein B give a much more accurate picture of your true risk of cardiovascular disease, even if you feel fit and live a healthy life.

You exercise regularly, eat consciously, maybe even follow a ketogenic diet, and you feel fit. Yet there are times when the total cholesterol in your blood is significantly elevated. That sounds alarming, but how serious is it really? And what does it really say about your actual risk of cardiovascular disease?

To find out, two additional markers are particularly valuable: Lipoprotein(a) and Apolipoprotein B. These provide a much more specific picture than the standard cholesterol panel. Especially if your cholesterol levels are elevated, but you are otherwise living healthily, these determinations can reveal whether there is real cause for concern.

Why is total cholesterol sometimes high in athletes or ketofans?

In people who exercise a lot or follow a high-fat diet, such as the ketogenic diet, total cholesterol often rises, especially the LDL. But the "good" HDL also usually rises along with it. As a result, the ratio of total cholesterol to HDL often remains favorable, as in the example below:

• Total cholesterol: 9.27 mmol/l (elevated)
• HDL: 2.59 mmol/l (very good)
• Cholesterol/HDL ratio: 3.6 (within the low-risk range)

Based on this ratio, you might think nothing is wrong. Yet this doesn't tell the whole story.

Lipoprotein(a): a genetic risk factor you don't feel

Lipoprotein(a), also called Lp(a), is an LDL-like particle with an additional protein component (apo(a)) attached. The special thing about Lp(a) is that it is 90% genetic. Your lifestyle hardly affects its value.

Elevated Lp(a) is an independent risk factor for cardiovascular disease, even in people who are otherwise healthy. Because Lp(a) is not usually measured by default, many elevated values go undetected for years.

Why measure?

• It's a one-time test: your Lp(a) value changes virtually nothing in your lifetime.
• If you're genetically high, it's important to know - especially if you already have elevated total cholesterol.
• Lp(a) increases the risk of atherosclerosis, thrombosis and early myocardial infarction.

Apolipoprotein B: the number of 'bad' particles counts

ApoB is the major structural protein on all atherogenic lipoproteins: LDL, VLDL, IDL AND Lp(a). Unlike the standard LDL measurement, which looks at the amount of cholesterol in those particles, ApoB measures how many particles are actually in circulation.

Why that matters. It's not the amount of cholesterol that matters, but the number of particles that can lodge in the vessel wall. The more ApoB particles, the greater the chance of plaque formation.

Why measure?

• ApoB gives a more accurate picture of cardiovascular risk than LDL alone.
• It's especially useful in athletes and keto followers: they sometimes have "big, airy" LDL particles that are less risky, despite high LDL numbers. ApoB helps make this distinction.
• Even with a normal LDL, ApoB can be elevated - and therefore risky.

When are Lp(a) and ApoB especially useful?

These measurements are particularly recommended if you:

• Have elevated total cholesterol despite a healthy lifestyle.
• Have a family history of cardiovascular disease.
• Following a ketogenic or low-carbohydrate diet.
• Work out fanatically and want to optimize your health.
• Take personal prevention seriously and look beyond standard values.

Conclusion: measuring is knowing

High cholesterol with an athletic or ketogenic lifestyle is not necessarily unhealthy. But to really understand whether your elevated values are cause for concern, Lipoprotein(a) and ApoB are very valuable additions.