Unlike the association of higher LDL and apoB and lower HDL and apoA1 with a higher risk of ALS in the presymptomatic literature, higher levels of total and LDL cholesterol as well as triglycerides (and in some cases lower HDL) are associated with less rapid disability progression and better respiratory function and survival.36–39 Whether this is a protective effect of lipids or a proxy for other factors portending poor prognosis such as lower BMI is not resolved.6 However, this highlights the need to distinguish the symptomatic and presymptomatic phases of ALS as much as possible. This evidence concerns the gene APOA1 and amyotrophic lateral sclerosis.