Question

I have just been told that I have high cholesterol and need to be treated, but I don't want to take drugs. Do I really need to?

Answer

The reason for wishing to treat high lipid levels is that they are a risk factor for certain conditions, particularly cardiac disease. Within populations, there is an exponential relationship between serum cholesterol and the incidence of coronary heart disease. This depends on LDL cholesterol, which usually comprises some 70-80% of total cholesterol in men and a little less in women. The rest of the cholesterol in serum is HDL. A high serum HDL cholesterol does not increase the risk of coronary heart disease, but just the opposite and may be associated with longevity.

HDL is therefore the goody and LDL the baddy. In other words, if total cholesterol is high, but a high proportion of that is HDL, then there may be little pathological elevation of lipids and the total cholesterol is not a good indication of cardiovascular risk in that person. Conversely, a low HDL may be a problem if the total serum cholesterol and triglycerides are elevated.

The normal cholesterol level is based on the risk of coronary heart disease by the National Institute of Health in United States and the European Atherosclerosis Society. The optimal serum cholesterol is 200mg/dL or less. A level of 250 is considered to indicate a moderate risk, and 270 a high risk. For serum HDL cholesterol, a lower limit of normality of 40mg/dL, and an ideal level above 60 mg/dL is desirable.

However, some caution is needed in using this concept; there can be no single cholesterol level which demands a particular therapeutic response. Cholesterol values must always be viewed in the context of the individual's overall cardiovascular risk. This is because, although each risk factor for cardiac disease is important, the presence of more than one more than doubles the importance. Therefore, for example, if you just have high lipid levels on their own, there might be less of an indication to treat you than if you had high lipid levels and, say, high blood pressure too.

Always remember that the reason for identifying risk factors is to reduce the risk that these factors suggest. It is therefore a little bit of a pity if one identifies a risk factor for which the treatment is relatively simple, and then does nothing about it. However, one final point is that medication might not be indicated in the first instance and dietary and other means of control could well be tried first.