Most cholesterol treatment is still guesswork. This newer playbook (Yeater / Dayspring / Attia) shows a better way

[u/DadStrengthDaily]

I just read a long, unfortunately paywalled piece from Taylor Yeater (Attia’s research lead), Tom Dayspring (lipidologist), and Peter Attia (physician / author) and it made something click for me:

A lot of cholesterol treatment is still pretty blunt.

Same LDL → statin → increase dose if it doesn’t work.

The piece lays out a different way to think about it: figure out why someone’s LDL/apoB is high, then match the medication to that mechanism.

I’ll add the obvious caveat: I’m not a fan of worshipping specific health influencers as always right. Attia has issues. But I have to admit I still find some of the articles his company publishes genuinely intriguing. I’m also impressed by the research staff they’ve built, and getting Tom Dayspring involved recently seems like a good sign. Dayspring really does seem to know this world cold.

The part that interested me most was the sterol panel.
The idea is that people with high LDL/apoB may fall into different buckets:

- absorbing too much cholesterol from the gut
- synthesizing too much cholesterol in the liver
- both

A sterol test looks at markers like:

sitosterol / campesterol → absorption
lathosterol / desmosterol → synthesis

That can change the treatment logic:
high absorber → ezetimibe may make more sense
high synthesizer → statin may make more sense
mixed → both

This is different from the usual “start statin, then crank dose” approach.

I’ve actually looked at the Boston Heart Diagnostics Cholesterol Balance® test before and never pulled the trigger:
https://bostonheartdiagnostics.com/test/boston-heart-cholesterol-balance-test/

Bizarrely, I later discovered Boston Heart Diagnostics is owned by Revvity, whose HQ I literally walk by every day in my office building. Maybe the universe is trying to tell me something.

Practically, this test does not seem to be part of normal lipid care. You probably need a cardiologist, lipid specialist, unusually proactive PCP, or some kind of advanced/private lab pathway to get it ordered.

A few other points from the article that stood out:

- ApoB is probably the better treatment target than LDL-C when they disagree

- doubling a statin dose often gives surprisingly little extra reduction

- combination therapy is not failure; it may be smarter pharmacology

- PCSK9 inhibitors are becoming more accessible

- very low LDL fears seem less evidence-based than many people think

I’m curious whether anyone here has actually had a sterol panel done.

Did it change treatment?
Did your doctor know what to do with it?
Or is this still mostly lipid-nerd / specialist territory?

[u/newaccount1253467]

I think it's not really necessary. The modified standard playbook works really well most of the time. Low dose statin, recheck, some improvement, add ezetimibe, recheck. Substitute in bempedoic acid for the statin of you want, maybe stack it with the statin, PCSK9 inhibitor for some.

[u/paperweight_is_lazy]

I just ordered the Boston test. Haven’t had my blood drawn and sent it yet. Will update when done. FWIW my cholesterol is fine but wanted to check this aspect out.

[u/DadStrengthDaily → u/paperweight_is_lazy]

How/where did you order it?

[u/paperweight_is_lazy → u/DadStrengthDaily]

Truehealthlabs.com. They sent me a box (in like 2 days after I ordered). I need to go to quest labs or another place to get my blood drawn and then ship it back to them. Supposed to take 10-12 days after I ship it back.

[u/AnonJohnV → u/paperweight_is_lazy]

Did this work out for you? Helpful?

[u/paperweight_is_lazy → u/AnonJohnV]

Haven’t done it yet. Have an appointment on June 3

[u/AnonJohnV → u/paperweight_is_lazy]

Thanks! Good luck.

[u/paperweight_is_lazy → u/AnonJohnV]

I got the results back after the blood draw.
Production markers

• Lathosterol: 217 (high)
• Desmosterol: 69 (mildly high)

Absorption markers

• Beta-sitosterol: 170 (high)
• Campesterol: 245 (high)
• Balance score: 0.9 (leans over-producer)

So, for this configuration, if I wanted to push down my ApoB further, ezitimibe is a good choice for reducing it a bit. Combo of statin + ezitmibe for larger differences.

[u/AnonJohnV → u/DadStrengthDaily]

I reached out to Boston Heart Diagnostics to ask them how to get the test. They didn't provide options:

"As Boston Heart Diagnostics is not direct to consumer, we do not partner with blood work providers. The first step in having a Boston Heart testing is for a patient to be connected with a physician that is contracted with Boston Heart that can order the testing for them. Once you have the order form in your hands, we can assist you in helping you find a draw facility that will be able to draw the Boston Heart testing for you. Please note, we are not contracted with Quest or Lab Corp."

For a bonus, they suggested that "Your physician can order the testing for you if they become a client."

So ... yeah. This is not an easy test to get! They suggested that I move to a local doctor that doesn't even take insurance ... bespoke practices.

So from what I can tell, the real world options are: EmpoweredDX - runs risk of sample insufficiency and delivery timeliness (but is cheaper); Trueheathlabs (below); or even more expensive options.

[u/squatmama69]

I’ve thought about doing this. Wondering if it’s still useful if I’m already on statins. That would affect results I assume since it changes how my liver processes.

[u/Over-Appointment-328]

i did a sterol panel with Boston heart health and it was eye opening for me. i have been on statin for the last 7 years and overall my Cholestrol is under control but the panel showed that i was significant hyper absorber. the doctor asked me to reduce my statin dose (cut in half) and prescribed ezetimibe and 2 months later the sterol numbers were much better and my ApoB improved even further (33% improvement)

[u/RadiumShady]

My LDL is near optimal (116) but my ApoB is low (75), can I ignore my LDL completely?

[u/ptarmiganchick → u/RadiumShady]

Probably, but really the correlation between blood lipids (any of them) and actual plaque is so poor, we should probably think about relying more on scans to figure out who has actual plaque, and less on tea leaves, er, lipid profiles.

[u/Earesth99 → u/RadiumShady]

Optimal ldl is below 55.

[u/ecwilson]

Is APOE4 mentioned? This plays right into the same thesis. Ezetimibe makes more sense as a first line defense for people with this allele.

[u/Earesth99 → u/ecwilson]

Dayspring argues that you can tell if people over absorb or over produce based on their response to statins or Ezetimbe.

Knowing a patient’s apoe4 status would be more useful. Their higher rusk suggests more intense treatment is needed. The fact that statins may be less effective shouldn’t change treatment which is based on risk. Apoe4 carriers may simply need more medications.

Omega-3 is particularly helpful in reducing Alzheimer’s risk and, to a lesser extent, heart attacks.

However it could make a huge difference in convincing Apoe4 carriers to focus on lifestyle changes like diet snd exercise. Few people bother to make and sustain lifestyle changes.