In recent years we've been bombarded with information on blood cholesterol levels, the 'bad' cholesterol (that's LDL-cholesterol), the 'good' cholesterol (HDL cholesterol), and so on. Its often confusing and hard to remember, and to make matters even more complicated the US National Cholesterol Education Program has come out with a new set of guidelines, which they call ATP III (for Adult Treatment Protocol III).

The main recommendation people will seize on is that we should be bringing our cholesterol levels down even further. But there is much more than just setting a lower target. The authors of ATP III have recognized the growing importance of a collection of risk factors for heart and blood vessel disease called by various names - the metabolic syndrome, the insulin resistance syndrome, and 'syndrome-X'.

First, let's summarize the main ATP III recommendations:

• Everyone should have their blood lipids measured every 5 years, after they are 20 (and, of course, more often if the results are abnormal).
• Everyone should know whether they have any of the following 5 risk factors: smoking, high blood pressure, a low 'good' cholesterol level (below 40 mg/dL), early coronary artery disease in a close family member, being over 45 (men) or 55 (women).
• If you have only one risk factor, your target LDL cholesterol level is below 160 mg/dL (4.14 mmol/L). If you have 2 or more risk factors, your target LDL is below 130 mg/dL (3.36 mmol/L). If you already have coronary heart disease, another blood vessel disease, or diabetes, your target LDL is 100 mg/dL (2.59 mmol/L) or below.
• If your HDL cholesterol level is only 30 mg/dL (o.78 mmol/L) above your target, you can treat this by adapting what are called Therapeutic Lifestyle Changes (TLC) - a correct diet, weight control, more exercise, and stop smoking. If the difference is greater, however, your physician should give you medication (probably a 'statin' drug).

Although raised LDL cholesterol levels must be addressed first, there are other risk factors for cardiovascular disease that require attention. The most important are those that make up the metabolic syndrome:

• abdominal obesity: a girth greater than 40 inches (102 cm) in men, or 35 inches (88 cm) in women.
• blood lipid abnormalities: serum triglyceride above 150 mg/dL (1.69 mmol/L), or an HDL cholesterol below 40 mg/dL (1.03 mmol/L) in men, or 50 mg/dL (1.29 mmol/L) in women.
• high blood pressure: above 135/85 mm Hg
• an abnormal blood sugar: fasting blood glucose above 110 mg/dL (6.11 mmol/L).

When three or more of these features are present, the person is considered to have metabolic syndrome. We should note that abdominal obesity (as defined above) is more relevant for this diagnosis than the unit we commonly use to describe overweight, the Body Mass Index (BMI).

People with the metabolic syndrome should be make energetic attempts at weight reduction and increased physical activity. Loss of weight will help with lowering the LDL cholesterol, as well as reduce all the risk factors of the metabolic syndrome. Regular physical activity raises the 'good' HDL cholesterol, as well as lowering LDL cholesterol in some people; it also lowers high blood pressure, resistance to insulin, and improves the functioning of the heart and blood vessels.

There has been much talk in the USA recently of an 'epidemic of obesity', chiefly affecting young people; and a lot of it is 'abdominal obesity'. In addition, type 2 diabetes, which is partially characterized by insulin resistance, is now being discovered much more frequently than before, and in younger persons. This means we must give the metabolic syndrome top priority. Although the benefits of weight control and physical activity are well known and repeated incessantly, it is clear that we are not doing enough. TLC used to stand for Tender Loving Care in the old days of nursing. Nowadays it must stand for Therapeutic Lifestyle Changes - no more smoking, a healthy low-fat diet, weight loss, and plenty of regular exercise - if we are to withstand the temptations of modern life. And if your lipids stay out of the desired range in spite of TLC, there are now good medications that can help.