Recognizing the importance of comprehensive cardiovascular risk assessment, this article narrows in to review the newly recognized lipid screening strategies within the 2026 Dyslipidemia Guidelines from the American College of Cardiology/American Heart Association Joint Committee.¹
For diabetes care professionals, these updates are especially relevant, as cardiovascular disease remains the leading cause of mortality in individuals with both type 1 and type 2 diabetes.
Current ADA Standards of Care recommend statin therapy for most adults aged 40–75 with diabetes, with treatment intensity guided by overall cardiovascular risk.
- For primary prevention, at least moderate-intensity statin therapy is recommended, with a goal of ≥50% reduction in LDL cholesterol (LDL) and a target LDL level <70 mg/dL.²
- For individuals with established atherosclerotic cardiovascular disease (ASCVD), high-intensity statin therapy is advised, aiming for an LDL reduction ≥50% from baseline and a target LDL level <55 mg/dL for secondary prevention.² But are there additional labs that may better individualize and refine cardiovascular risk assessment?
Decoding the Different Types of Lipids
While a standard lipid profile remains the foundational marker in estimation of ASCVD risk (PREVENT-ASCVD equations), the 2026 Dyslipidemia guidelines2 highlight that additional lipid measures that may provide a more complete assessment of individual atherogenic risk.
Specifically,
- Non-high-density lipoprotein cholesterol (non-HDL),
- Apolipoprotein B (apoB), and
- Lipoprotein-A [Lp(a)].
In the following sections, we will review what each of these lipid components represents and how they contribute to a more comprehensive understanding of cardiovascular risk.
Non-HDL is part of a standard lipid profile.
It represents all atherogenic, plaque-forming particles in the blood and correlates with ApoB.¹ It is easily calculated by subtracting high-density lipoprotein (HDL) from total cholesterol.
Non-HDL may add risk prediction beyond LDL, especially if triglycerides exceed 150 mg/dL, and is reported to be a better predictor of ASCVD risk than LDL.
Non-HDL Targets:
- Primary prevention targets are typically <130 mg/dL,
- A lower target of <100 mg/dL is recommended for those at higher risk (PREVENT score >10%).
This threshold also applies to individuals with diabetes who have ASCVD or diabetes-specific risk factors.1 In those with subclinical or clinical atherosclerosis, an optional, even more intensive Non-HDL goal of <85 mg/dL is advised.¹
LDL and ApoB
While LDL estimates the amount of cholesterol carried within LDL particles, apoB reflects the total number of atherogenic lipoproteins and provides a more direct measure of the number of atherogenic particles in circulation.
Each atherogenic particle, including LDL, very-low-density lipoprotein (VLDL), intermediate-density lipoprotein, and Lp(a), contains a single apoB molecule,1 meaning apoB serves as a one-to-one marker of total particle number.4
In contrast, LDL particles vary in size and composition. Larger LDL particles tend to carry more cholesterol, while smaller, denser LDL particles carry less cholesterol per particle but are considered more atherogenic. These small, dense LDL particles easily penetrate the arterial wall, are more susceptible to oxidation, and have a longer circulating half-life, all of which increase their potential to promote atherosclerosis.5
An individual may have an LDL value at goal yet still have a high number of small, dense LDL particles and higher cardiovascular risk. This discordance is more common in individuals with ASCVD, cardiometabolic kidney syndrome, elevated triglycerides (>150 mg/dL), or diabetes.
In these cases, apoB can provide better insight into individual risk and therapeutic guidance. A higher particle number is strongly associated with an increased risk of myocardial infarction and other ASCVD events.
ApoB goals for individuals with diabetes are stratified as follows:
- < 90 mg/dL
- < 70 mg/dL with ASCVD or diabetes-specific risk factors.
- In the presence of subclinical or clinical atherosclerosis, the target is lowered to <55 mg/dL.
Dyslipidemia Measurement Guidelines for Lp(a)
The Dyslipidemia guidelines recommend that Lp(a) should be measured at least once in all adults to identify inherited cardiovascular risk.3
- Lp(a) is an LDL-like particle but it carries a single apoprotein(a) strand bound to ApoB-100.1
- A high Lp(a) (over 125 nmol/L) has been associated with a 40% relative risk increase for ASCVD, with risk increasing progressively at higher concentrations.6
- This makes testing especially valuable for those with premature ASCVD, a family history of early cardiovascular disease, familial hypercholesterolemia, or unexplained elevated LDL despite treatment.
- Since Lp(a) levels are genetically determined, repeat testing is usually unnecessary, though secondary causes of elevated Lp(a) do exist.3
Role of Diabetes Professionals
As diabetes care providers committed to person-centered care, the 2026 Dyslipidemia Guidelines emphasize additional assessment strategies (see footnote) to better individualize cardiovascular risk.
While achieving LDL targets remains an important therapeutic goal; incorporating non–HDL-C, apoB, and Lp(a) into lipid monitoring may help identify residual risk, particularly in individuals with diabetes, elevated triglycerides, or other cardiometabolic conditions.
With the ADA endorsing these guidelines, we are encouraged to consider when expanded lipid testing is appropriate, advocate for comprehensive risk assessment, and use these insights to guide shared decision-making for therapeutic interventions.
Christine Craig, MS, RDN, CDCES
Founder: Nutrition for Daily Living
Footnote:
2026 Dyslipidemia Guidelines recommends use of CPR. Calculating 10 year risk using the PREVENT equation (https://professional.heart.org/en/guidelines-and-statements/prevent-calculator), Personalizing the estimated risk for the individual and Reclassifying and Reassessing treatment recommendations with additional tools such as the Coronary artery calcium.
References:
- Blumenthal, R, Morris, P, Gaudino, M. et al. 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. JACC. https://doi.org/10.1016/j.jacc.2025.11.016
- American Diabetes Association Professional Practice Committee for Diabetes*; 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2026. Diabetes Care 1 January 2026; 49 (Supplement_1): S216–S245. https://doi.org/10.2337/dc26-S010
- Lichtenstein AH, Khera A, Anderson CAM, et al. 2026 dietary guidance to improve cardiovascular health: a scientific statement from the American Heart Association. Circulation. Published online March 31, 2026. doi:10.1161/CIR.0000000000001435
- Learn Your Lipids. Apolipoprotein B (ApoB). Foundation of the National Lipid Association. Accessed April 19, 2026 at https://www.learnyourlipids.com/lipid-disorders/apolipoprotein-b/
- Vekic J, Zeljkovic A, Cicero AFG, Janez A, Stoian AP, Sonmez A, Rizzo M. Atherosclerosis Development and Progression: The Role of Atherogenic Small, Dense LDL. Medicina (Kaunas). 2022 Feb 16;58(2):299. doi: 10.3390/medicina58020299
- American Heart Association. Lipoprotein(a). Accessed April 19, 2026. https://www.heart.org/en/health-topics/cholesterol/genetic-conditions/lipoprotein-a
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