Understanding the Hidden Markers of Heart Health
🎧 ▶️ Press the play button below to listen.
Introduction
When we think about heart health, most of us are familiar with the standard cholesterol panel—HDL (the “good” cholesterol) and LDL (the “bad” cholesterol). But scientists have identified another set of markers that may actually be better predictors of cardiovascular disease risk: apolipoproteins, specifically apolipoprotein A1 (ApoA1) and apolipoprotein B (ApoB).
I discussed them in ApoB: The Superior Marker for Guiding Cholesterol Treatment That Saves Lives and Money and other articles about them in the related articles below.
A recent large-scale Swedish study involving nearly 25,000 people set out to understand how lifestyle factors and dietary choices influence these important blood markers. The findings offer valuable insights into how our daily habits shape our cardiovascular health.
What Are Apolipoproteins?
To understand this study, we first need to understand what apolipoproteins are and why they matter.
Think of lipoproteins (like HDL and LDL) as delivery trucks that transport cholesterol and fats through your bloodstream. Apolipoproteins are the proteins that sit on the surface of these trucks. They act like keys that unlock specific receptors, telling cells where to deliver their cargo.
ApoA1 is the main protein found on HDL particles—the “good” cholesterol carriers. Higher levels of ApoA1 generally indicate better cardiovascular health because HDL helps remove excess cholesterol from tissues and transport it to the liver for disposal.
ApoB, on the other hand, is found on the “bad” cholesterol carriers—LDL, VLDL, and other atherogenic particles. Each of these particles contains exactly one ApoB molecule, so measuring ApoB gives us a direct count of all the potentially harmful cholesterol particles in your blood.
The ratio of ApoB to ApoA1 (ApoB/ApoA1 ratio) is considered by many experts to be an excellent indicator of the balance between harmful and protective lipoproteins in your body.
The Study: A Deep Dive into 25,000 Lives
Researchers from Lund University in Sweden analyzed data from the Malmö Diet and Cancer study, a population-based cohort that recruited participants between 1991 and 1996. After excluding individuals with a history of heart attack, stroke, diabetes, or those taking lipid-lowering medications, they were left with 24,984 participants—9,363 men and 15,621 women.
Participants underwent comprehensive assessments including:
- Non-fasting blood samples to measure ApoA1 and ApoB concentrations
- A modified diet history method combining a 168-item food frequency questionnaire, a 7-day food record, and a diet history interview
- Self-reported lifestyle factors, including smoking, physical activity, and alcohol consumption
- Measured height and weight to calculate BMI
- Education level as a proxy for socioeconomic status
The researchers then analyzed correlations between these various factors and apolipoprotein concentrations, using sophisticated statistical models to account for potential confounders.
What Makes ApoA1 Go Up?
ApoA1 is the “good” apolipoprotein—you want higher levels. The study identified several lifestyle factors that were strongly associated with higher ApoA1 concentrations:
Alcohol Consumption
This was the single strongest lifestyle determinant of ApoA1 levels. People who consumed more alcohol—particularly wine—tended to have higher ApoA1 concentrations. The effect showed a clear dose-response relationship: more alcohol (within moderate ranges) correlated with higher ApoA1.
However, the researchers caution that while moderate alcohol intake may offer some cardiovascular benefits, the negative health effects of excessive alcohol consumption are well-established. They advise careful consideration of risks versus benefits.
A Personal Note on the Alcohol Findings
Before we move on, I want to offer a word of caution based on more recent evidence.
The Swedish study found a clear association between higher alcohol intake and higher (better) ApoA1 levels, which might lead some readers to view drinking as a heart-healthy habit. However, this is where we need to separate statistical correlation from biological causation—and where I believe the story gets more complicated.
Over the past few years, several large-scale, well-designed studies have challenged the notion that moderate drinking is beneficial. In fact, recent research suggests that even one drink per day may have negative effects on heart structure and brain volume.
- Harvard: Light alcohol intake increases cardiac risks
- New Research Ends The Myth Of Healthy Alcohol Drinking
- Reliable Studies Agree: An Alcohol A Day Shrinks The Brain
- Alcohol And Your Body: The Truth You Need To Know!
- A drink a day shrinks the brain
So why did this Swedish study—and many others before it—show a “protective” effect?
A compelling explanation is what researchers call the healthy drinker effect. In many observational studies, people who consume moderate amounts of alcohol tend to have other lifestyle habits that are independently good for their health. They are more likely to be physically active, eat better diets, have higher socioeconomic status, and engage in regular social interactions.
Conversely, those who abstain completely often include former heavy drinkers or individuals with underlying health conditions who quit for medical reasons. This creates a statistical illusion where moderate drinkers appear healthier than abstainers—but it may not be the alcohol itself that deserves the credit.
The Swedish researchers themselves acknowledge this complexity. They note that the negative aspects of high alcohol consumption are well-known, and they “advise caution when assessing the risks versus benefits of alcohol consumption.” To my mind, that caution should extend to moderate consumption as well, especially given the mounting evidence of harm.
So while the data in this study show an association, I personally interpret it as a reminder that lifestyle factors cluster together. The health benefits seen in moderate drinkers may owe more to what they are doing besides drinking—exercising, eating well, managing stress—than to the wine or beer itself.
For those of us looking to improve our apolipoprotein profile, this suggests we might be better off focusing on those other, safer behaviors rather than reaching for a drink.
Physical Activity
Higher levels of leisure-time physical activity were consistently associated with higher ApoA1 levels. This reinforces the well-known message that staying active supports heart health.
Body Mass Index (BMI)
Lower BMI was strongly associated with higher ApoA1 levels. The relationship was inverse—as BMI increased, ApoA1 concentrations decreased.
Smoking
Smoking was associated with lower ApoA1 levels. Current smokers had the lowest ApoA1 concentrations compared to never-smokers and ex-smokers.
Education
Higher education was associated with higher ApoA1 levels in basic models. However, this relationship weakened significantly after adjusting for other lifestyle factors, suggesting that education’s effect on ApoA1 is largely mediated through healthier lifestyle choices rather than having a direct biological effect.
What Makes ApoB Go Up?
ApoB represents the “bad” apolipoprotein—you want lower levels. The main determinants of higher ApoB concentrations were:
Body Mass Index
High BMI was the most important predictor of elevated ApoB levels. The relationship was strong and dose-dependent: people with higher body weight had higher concentrations of ApoB-containing lipoproteins.
Smoking
Smoking was also strongly associated with higher ApoB levels. This effect was seen in both men and women.
Diet
Interestingly, several dietary factors showed significant correlations with ApoB levels, with sugar intake being particularly notable.
The Diet Connection: Sugar vs. Fermented Dairy
One of the most interesting findings of this study relates to specific food groups and their associations with apolipoprotein levels.
The Sugar Effect
Foods containing added sugar showed consistent and concerning associations with apolipoprotein profiles:
- Pastries, sweets, and chocolate: Higher intake was associated with lower ApoA1 and higher ApoB levels
- Jam and sugar: Similar patterns—lower ApoA1, higher ApoB
- Sugar-sweetened beverages: Higher consumption correlated with higher ApoB/ApoA1 ratios
Among all food groups analyzed, those containing added sugar had some of the strongest correlations with unfavorable apolipoprotein profiles. This finding aligns with previous research showing that added sugar intake is associated with increased cardiovascular disease risk and mortality.
The researchers noted that sucrose (table sugar) was the macronutrient most strongly correlated with apolipoprotein levels, particularly with lower ApoA1 and a higher ApoB/ApoA1 ratio.
Articles on managing after-meal blood sugar are listed in the related articles section.
The Fermented Dairy Effect
In contrast to sugar-rich foods, fermented dairy products showed opposite relationships:
- Fermented milk and cheese: Higher intake was associated with higher ApoA1 levels and lower ApoB levels
- Non-fermented milk: Showed the opposite pattern, with higher intake linked to lower ApoA1 and higher ApoB/ApoA1 ratios
This suggests that the fermentation process may be important. Scientists hypothesize that the bacteria present in fermented dairy products might help lower cholesterol levels, as supported by both animal and human studies.
The association between fermented dairy products and favorable apolipoprotein profiles was particularly strong in women and remained significant even after adjusting for other lifestyle factors.
Other Dietary Findings
Fat Intake
Total fat intake was positively correlated with ApoA1 levels—meaning people who consumed more fat tended to have higher (better) ApoA1 concentrations. Fat intake was also associated with slightly higher ApoB levels in men (though this effect was smaller). Overall, fat intake was associated with a lower (better) ApoB/ApoA1 ratio.
The strongest correlations were seen with monounsaturated fats (in men) and saturated fats (in women). This might seem surprising given that saturated fat has traditionally been viewed unfavorably. However, the researchers point out that these findings support the use of the ApoB/ApoA1 ratio in combination with other markers to assess cardiovascular risk.
- Do Red Meat and Fat Raise Blood Pressure? Not Exactly
- Is Saturated Fat Bad for Pancreatic Beta Cells?
- New Science Debunks the Dangers of Saturated Fats on Heart Disease
Carbohydrates
Total carbohydrate intake showed a negative correlation with ApoA1 (meaning higher carb intake was associated with lower ApoA1) and a positive correlation with the ApoB/ApoA1 ratio. This suggests that diets higher in carbohydrates—particularly simple carbohydrates like sugar—may be associated with a less favorable apolipoprotein profile.
Fiber
Fiber intake showed modest positive associations with better apolipoprotein profiles, though the relationships were not always statistically significant. Higher fiber intake was generally associated with lower ApoB and a lower ApoB/ApoA1 ratio.
Other Food Groups
Additional food groups that showed significant associations included:
- Fish (in women): Associated with higher ApoA1 levels
- Eggs and processed meat (in men): Associated with higher ApoA1 levels
- Potatoes (in women): Associated with higher ApoB levels and a higher ApoB/ApoA1 ratio
How Much Do Lifestyle Factors Actually Matter?
While this study identified many statistically significant associations, it’s important to put the findings in perspective. The combination of lifestyle and dietary factors explained only a modest percentage of the variation in apolipoprotein concentrations:
- ApoA1: Approximately 9-12% of variation explained
- ApoB: Approximately 5-11% of variation explained
- ApoB/ApoA1 ratio: Approximately 9-14% of variation explained
This means that while lifestyle and diet influence these markers, other factors—including genetics, which were not measured in this study—also play a significant role.
The fact that the explained variance was modest is not surprising. Apolipoprotein levels are influenced by a complex interplay of genetic, metabolic, and environmental factors.
This study demonstrates that lifestyle modifications can make a meaningful difference, even if they don’t explain everything.
Putting It in Perspective: Apolipoproteins vs. Standard Cholesterol Tests
You might be wondering: if we already measure HDL and LDL cholesterol, why do we need apolipoproteins like ApoA1 and ApoB? And do lifestyle factors affect these newer markers differently than they affect traditional ones?
The researchers explored this question in a subset of about 4,650 participants for whom they had both apolipoprotein measurements and standard cholesterol measurements (HDL-C and LDL-C). Their goal was to see how much of the variation in each type of marker could be explained by the same set of lifestyle and dietary factors—things like BMI, smoking, physical activity, alcohol, and diet.
Think of it this way: imagine you have a classroom of students, and you want to know how much their study habits predict their test scores. If study habits explain 80% of the variation in math scores but only 20% in reading scores, you’d conclude that study habits matter more for math than for reading. The researchers did something similar here—they asked: how much of the “ups and downs” in these different blood markers can be traced back to lifestyle choices?
Here is what they found:
For the “good” markers:
- Lifestyle factors explained 15–18% of the variation in HDL-C (the standard “good” cholesterol measure)
- But they explained only 9–12% of the variation in ApoA1 (the apolipoprotein equivalent)
What does this mean? Simply put, your lifestyle choices—diet, exercise, smoking, weight—have a stronger influence on your standard HDL-C number than they do on your ApoA1 level. If your HDL-C is low, changing your lifestyle might make a bigger difference to that number than it would to your ApoA1.
For the “bad” markers:
- Lifestyle factors explained only 4–6% of the variation in LDL-C (the standard “bad” cholesterol measure)
- But they explained 5–11% of the variation in ApoB (the apolipoprotein equivalent)
This tells us the opposite story: ApoB appears to be more responsive to lifestyle changes than LDL-C is. In other words, if you improve your habits, you might see a more noticeable improvement in your ApoB level than in your LDL-C number.
For the ratios (good-to-bad balance):
- Lifestyle factors explained about 10–13% of the variation in the LDL/HDL ratio (the standard way of assessing cholesterol balance)
- They explained a similar percentage (9–14%) of the variation in the ApoB/ApoA1 ratio
So when you look at the overall balance between harmful and protective particles, lifestyle factors matter about equally whether you use the traditional ratio or the apolipoprotein-based ratio.
Why This Matters
These findings are important for a few reasons:
- ApoB may be a more sensitive indicator of lifestyle change. Since ApoB showed more lifestyle-related variation than LDL-C, it might be a better marker to track if you are trying to improve your heart health through diet and exercise.
- HDL-C is more lifestyle-sensitive than ApoA1. If your goal is to raise your “good” cholesterol, traditional HDL-C might show more dramatic changes than ApoA1 when you adopt healthier habits.
- The choice of marker depends on what you care about. If you want to know how your lifestyle is affecting your cardiovascular risk, apolipoproteins give you useful information that standard cholesterol tests don’t fully capture. They are not redundant—they are complementary.
In short, the two types of tests tell overlapping but slightly different stories. Apolipoproteins are not simply a replacement for standard cholesterol tests; they offer a different angle on how your lifestyle is shaping your cardiovascular health.
The fact that ApoB appears to be more responsive to lifestyle than LDL-C is actually good news—it means the choices you make each day might show up more clearly in your ApoB numbers, giving you better feedback on whether your efforts are paying off.
Strengths and Limitations
Strengths
- Large sample size: With nearly 25,000 participants, the study had strong statistical power to detect even modest associations
- Comprehensive dietary assessment: The modified diet history method used is more detailed than typical food frequency questionnaires
- Adjustment for confounders: The researchers carefully adjusted for multiple lifestyle factors
- Exclusion of medication users: Removing participants on lipid-lowering drugs helped reduce confounding
Limitations
- Cross-sectional design: This means the study can identify associations but cannot prove cause and effect
- Measurement error: Dietary reporting is notoriously difficult and subject to recall bias
- Non-fasting blood samples: While increasingly accepted, apolipoprotein measurements in non-fasting samples may have some limitations
- Single time point: Lifestyle and dietary habits were assessed only once
Takeaway Messages
Based on this comprehensive study of nearly 25,000 individuals—and with the important caveat that more recent evidence has challenged the benefits of even moderate alcohol consumption—here are the key takeaways:
- Smoking is harmful, period. Smoking is consistently associated with lower ApoA1, higher ApoB, and a worse ApoB/ApoA1 ratio. If you smoke, stopping is one of the most powerful things you can do for your cardiovascular health. This is one of the few lifestyle changes with near-universal agreement among experts.
- Weight matters—a lot. Higher BMI is the strongest determinant of higher ApoB levels. Even modest weight loss may improve your apolipoprotein profile. Unlike alcohol, where the evidence is mixed, the relationship between excess weight and worse heart health is well-established and uncontroversial.
- Stay active. Physical activity is associated with higher ApoA1 levels, independent of other lifestyle factors. Exercise is safe, effective, and has no downside—unlike some other habits that may carry risks.
- About alcohol: proceed with caution. This study found an association between higher alcohol intake and higher (better) ApoA1 levels. However, this does not mean alcohol causes better heart health. More recent studies suggest that even one drink per day may be harmful to the heart and brain.
The apparent benefits seen in many observational studies may be due to the “healthy drinker effect”—people who drink moderately often have other healthier habits (better diets, more exercise, higher socioeconomic status) that are actually responsible for the benefits. If you currently drink, discuss the risks and benefits with your doctor. If you don’t drink, there is no compelling reason to start.
- Watch added sugar. Foods containing added sugar—sweets, pastries, sugar-sweetened beverages—are consistently associated with less favorable apolipoprotein profiles. This is a safe and well-supported dietary change that almost everyone can benefit from.
- Consider fermented dairy. Fermented milk products and cheese are associated with a more favorable apolipoprotein profile, while non-fermented milk shows the opposite association. This is a dietary tweak worth considering, though more research is needed.
- Total fat isn’t necessarily the enemy. Higher fat intake was actually associated with higher (better) ApoA1 levels, though the relationship is complex. The quality and type of fat likely matter more than total fat intake.
The Bottom Line
If you take away one thing from this study, let it be this: the most reliable, evidence-backed ways to improve your apolipoprotein profile are also the most boring—don’t smoke, maintain a healthy weight, exercise regularly, and limit added sugar.
Alcohol, by contrast, is a classic case of correlation not equaling causation. While the data show an association, the risks of drinking—even moderately—likely outweigh any potential benefits for most people. Focus your energy on the habits with clear, proven, and risk-free returns.
What This Means for You
This study reinforces many well-known cardiovascular health recommendations while adding nuance about specific dietary choices. The strongest messages remain consistent with established guidelines: don’t smoke, maintain a healthy weight, stay physically active, and limit added sugar intake.
The findings about fermented dairy products suggest that the type of dairy you consume may matter more than previously thought. Choosing fermented options like yogurt and cheese might be better for heart health than consuming large amounts of non-fermented milk products.
However, the relatively modest amount of variation explained by these lifestyle factors also reminds us that heart health is complex. Genetics, stress, sleep, and other factors—some of which are beyond our control — could also play important roles as well.
Ultimately, while lifestyle modifications can make a difference, they should be seen as one component of a comprehensive approach to cardiovascular health that includes regular medical check-ups and appropriate screening for risk factors.
Looking Forward
The researchers call for future studies, including both large cohort studies and dietary intervention trials, to better understand how dietary intake affects apolipoprotein concentrations. They note that apolipoprotein assays are expensive and not yet widely available in clinical settings, though they offer advantages over traditional cholesterol measurements—particularly the ability to measure non-fasting samples.
As our understanding of apolipoproteins and their role in cardiovascular disease continues to evolve, these markers may become increasingly important in clinical practice. In the meantime, the lifestyle and dietary recommendations emerging from studies like this one provide actionable guidance for anyone interested in optimizing their cardiovascular health.
Don’t Get Sick!
About Dr. Jesse Santiano, MD
Dr. Santiano is a retired internist and emergency physician with extensive clinical experience in metabolic health, cardiovascular prevention, and lifestyle medicine. He reviews all medical content on this site to ensure accuracy, clarity, and safe application for readers. This article is for educational purposes and is not a substitute for personal medical care.
💡 Support This Work
Creating well-researched articles, maintaining this website, and keeping the information freof charge takees time and resources.
If you found this article helpful, please consider donating to support the mission of empowering people to live healthier, longer lives, without relying on medications.
🙏 Every contribution, big or small, truly makes a difference. Thank you for your support!
Follow me on Facebook, Gab, Twitter (formerly known as X), Instagram, and Telegram.
Related:
- Conquer Sugar Spikes With A Simple Morning Green Tea Ritual
- Antioxidants And Timing: How To Reduce Blood Sugar-Related Oxidative Stress
- Health Benefits of Alpha Lipoic Acid: The Excellent Antioxidant
- Flaxseed: Lowers Sugar And Awesome Source of Valuable Omega 3
- 11 Best Morning Supplements For Energy
- Mastering Diabetes: Prevent Hypoglycemia with Smart Medication Adjustments
- 102 Easy Ways to Lower Post-Prandial Blood Sugar Without Meds
- The Simple Way To Keep Blood Sugar Low: Breakfast
- Meal Timing: A Practical Guide To Weight Loss And Better Health
- 18 Powerful Strategies To Prevent Blood Sugar Spikes During The Holidays
- Applying The Best Behavior Change Techniques At Home For Better Health
- A Toolbox of Strategies to Prevent Blood Sugar Spikes When Eating High-Glycemic- Index Foods
- The Blood Sugar Lowering and Metabolic Effects of Vinegar
- Ways to Lower After-Meal Blood Sugar when Eating White Bread
- A High-Protein Breakfast Can Lower Blood Sugar the Whole Day
- Eating rather than skipping breakfast results in lower blood sugars the whole day
- Pistachios improve insulin resistance and inflammatory markers
- Pistachios decrease after-meal blood sugar
- Veggies Meat Carbohydrate Sequence Prevents After Meal Sugar Spike
- Passing and Failing the One-Hour After-Meal Blood Sugar
- Low One-Hour Post-Prandial Blood Sugar after One Cup of Rice
- How often do you do the post-prandial sugar test?
- Blood Glucose Spike and its Prevention
- Testing Post Prandial Glucose Level after a Feast
- Intermittent fasting Reverses Endothelial Dysfunction
- Walk After Meals to Prevent Sky High Blood Sugars
References:
- Frondelius, K., Borg, M., Ericson, U., Borné, Y., Melander, O., & Sonestedt, E. (2017). Lifestyle and Dietary Determinants of Serum Apolipoprotein A1 and Apolipoprotein B Concentrations: Cross-Sectional Analyses within a Swedish Cohort of 24,984 Individuals. Nutrients, 9(3), 211. https://doi.org/10.3390/nu9030211
Disclaimer:
This article is for educational purposes and is not a substitute for professional medical advice, diagnosis, or treatment. Always consult your physician before making health decisions based on the TyG Index or other biomarkers.
© 2018 – 2026 Asclepiades Medicine, LLC. All Rights Reserved
DrJesseSantiano.com does not provide medical advice, diagnosis, or treatment
As an Amazon Associate, I earn from qualifying purchases
Discover more from Don't Get Sick!
Subscribe to get the latest posts sent to your email.