The study, published in JAMA, found that measuring apolipoprotein B (apoB) was more effective than tracking LDL or non HDL cholesterol when deciding whether to intensify cholesterol lowering therapy, including statins and other medications.

“We found that apoB testing to intensify cholesterol-lowering medication would prevent more heart attacks and strokes than current practice, and that these health benefits were achieved at a cost that represents good value for U.S. healthcare payers,” said study lead author Ciaran Kohli-Lynch, assistant professor of preventive medicine in the division of epidemiology at Northwestern University Feinberg School of Medicine.

Kohli-Lynch said this is the first comprehensive analysis to show that using apoB to guide cholesterol treatment is also cost effective.

Heart disease remains the leading cause of death in the United States and is responsible for enormous healthcare spending. Over time, tiny cholesterol carrying particles can become trapped inside artery walls, where they build up into plaques that restrict blood flow and raise the risk of heart attacks and strokes.

Why ApoB May Be a Better Measure of Heart Disease Risk

Doctors have long relied on LDL cholesterol and non HDL cholesterol levels to decide when patients should begin or intensify cholesterol lowering treatment. While those tests provide useful information, they do not fully capture a person’s cardiovascular risk.

“Research strongly shows that apolipoprotein B (apoB) is better at identifying who is at risk, because it counts the total number of harmful particles in the blood,” explained Kohli-Lynch.

Unlike standard cholesterol tests, apoB measures the number of cholesterol carrying particles that can contribute to plaque buildup. Researchers say that makes it a more direct indicator of cardiovascular risk.

Even with growing evidence supporting apoB, the test is still not commonly used in routine care. Kohli-Lynch said one reason is that measuring apoB generally requires an additional blood test beyond the standard cholesterol panel, increasing both cost and inconvenience.

“Our study asked: Is it worth spending extra money to use apoB instead of LDL to guide treatment intensification?” Kohli-Lynch said.

Computer Model Compared Three Cholesterol Testing Strategies

To answer that question, the research team created a computer simulation representing 250,000 U.S. adults who were eligible for statin therapy but did not already have cardiovascular disease.

The model compared three approaches for guiding treatment:

• LDL cholesterol (goal <100 mg/dL)
• Non-HDL cholesterol (goal <118 mg/dL)
• ApoB (goal <78.7 mg/dL)

When patients failed to meet their target, treatment was stepped up first by using stronger statins and then by adding ezetimibe if needed.

Researchers followed each strategy over a lifetime, estimating heart attacks, strokes, life expectancy, quality of life, and healthcare costs.

The results showed that using apoB to guide treatment consistently performed better than the LDL and non HDL approaches. It improved overall health outcomes, prevented more cardiovascular events, and did so in a way the researchers determined was cost effective.

New Cholesterol Guidelines Increase the Importance of Accurate Testing

The findings come as doctors have more cholesterol lowering medications available than ever before. Earlier this year, the American Heart Association and 10 other medical organizations also released updated guidelines recommending that many people begin cholesterol lowering therapy at younger ages.

“This means it is increasingly important to accurately identify who would benefit most from intensive treatment,” Kohli-Lynch said.

Other Northwestern coauthors include Drs. John Wikins and Samuel Luebbe.

The study, titled “Cost-Effectiveness of ApoB, Non-HDL-C, and LDL-C Goals for Primary Prevention Lipid-Lowering Therapy,” was supported by the American Heart Association Career Development Award 24CDA1274989 (Dr. Kohli-Lynch).

The study was led by PhD student Idan Sheizaf under the supervision of Prof. Ariel Chipman at The Hebrew University of Jerusalem. Published in Ecology and Evolution, the research describes how land dwelling isopods, relatives of crabs and shrimp that are better known as woodlice or pill bugs, abandon their normally solitary habits to join enormous circular formations containing more than 5,000 individuals.

A surprising discovery in northern Israel

The unusual behavior first came to light after amateur naturalist Eviatar Itzkovich noticed huge swirling groups of isopods during summer nights in the Golan Heights.

The researchers focused on the species Armadillo sordidus, a little studied isopod that typically spends its time hidden beneath rocks and damp leaf litter, where moisture helps prevent it from drying out.

Although woodlice commonly cluster together to conserve moisture, scientists had never documented coordinated movement on this scale. Before this work, very little was known about A. sordidus. The study also expanded the species’ known range. Previously, it had only been recorded in southern Syria and the Golan Heights. Researchers have now documented it in the Jezreel Valley for the first time.

Experiments reveal the role of artificial light

To determine what was causing the strange circular marches, the team tested several possible explanations, including magnetic fields and different types of lighting.

Strong magnets placed near the moving isopods had no effect, even though the Golan Heights is known for unusual magnetic properties. The animals continued circling uninterrupted.

Ultraviolet flashlights attracted only a small number of isopods and never triggered the swirling formations.

White light, however, consistently produced the dramatic behavior. When researchers positioned a white lamp so that its beam shone straight down, the isopods repeatedly gathered into large rotating circles.

The experiments showed that the shape of the illuminated area is what matters most. A vertical beam creates a circular boundary of light on the ground. Drawn toward that edge, the isopods begin walking along its perimeter. As more individuals join, the movement reaches a tipping point and develops into a large, self sustaining circular procession.

Reflecting on the findings, Idan Sheizaf said: “While collective movement is common in the animal kingdom, seeing it in this form in isopods was entirely unexpected. It appears that the geometry of our modern world — specifically the circular pools of light created by streetlights, is interacting with the natural instincts of these creatures to create a mesmerizing, yet potentially harmful, emergent phenomenon.”

Why the “death spirals” may be dangerous

Although the swirling formations are visually striking, researchers believe they represent an unintended trap created by artificial light at night (ALAN), not a natural social behavior.

Most of the participants were female, and many were carrying eggs, making it unlikely that the gatherings were related to mating. Instead, the evidence suggests that artificial lighting is disrupting the animals’ normal instincts.

The consequences could be severe. During one observation, a centipede preyed on the distracted isopods while they remained caught in the swirling formation. By pulling these animals out of their sheltered habitats and keeping them moving in circles, streetlights may leave them vulnerable to predators while also wasting energy needed for survival.

The findings highlight how even a simple change to the environment, such as installing a streetlight, can reshape ancient behaviors in small animals that often go unnoticed.