Dear Doctor;
I am a 42-year-old Cat. 2 racer with a history of lifelong fitness and no significant health problems. I recently had a blood cholesterol screening done at a health fair while I was out of town.My levels were:total cholesterol 142 mg/dLHDL = 42mg/dlLDL = 80mg/dlTotal/HDL Ratio = 3.38The doctor on hand told me that I should see a cardiologist when I return home, because my ratio – total to HDL - was 3.38, well below the target value of 4.0. Despite the fact that my overall level was low, he felt I might be developing harmful plaque deposits in my blood vessels.

Upon return home I saw my family doctor and relayed the aforementioned. My family doctor told me to forget about the advice I got at the health fair, because my overall score was so low that I have nothing to worry about. Do you recommend that I see a cardiologist?
Tom

Dear Tom;
No.
Best wishes,
Prentice

Wait! If only it were that simple. I agree with your family physician, but let me elaborate:

Cholesterol is a small molecule produced by your liver and which serves to transport fats around your body for energy use and storage. When the level of cholesterol gets too high, it can build up on the inner walls of your arteries. These build-ups of cholesterol are called atherosclerotic plaques. As they get bigger they restrict blood flow and have a tendency to break off chunks that float downstream, get caught at a narrow point and completely block blood flow to the body tissues supplied by the artery involved.

When a coronary artery that supplies blood to the heart is involved, we're talking about an acute myocardial infarction (AMI or "heart attack"). If it's a cerebral artery that gets blocked, it's a cerebrovascular accident (CVA or "stroke"). In a recent question I talked about the blockage of mesenteric arteries which supply blood to the intestines; a blockage there causes abdominal pain in a process called mesenteric ischemia.

So preventing these cholesterol plaques is obviously pretty important. An elevated blood cholesterol level is one of the classic risk factors for this problem. The others are diabetes, hypertension, smoking, obesity and the all-important family history of heart problems. Others include physical inactivity and cocaine use. Anabolic steroid use will also accelerate the accumulation of cholesterol plaques in arteries. As well, men are generally more susceptible than women to this unhealthy process.

When you look at these risk factors, you can see that all but two of them can be controlled to a considerable extent. A healthy diet, not smoking and physical activity will take care of all but the diabetes and the genetic influence. The diabetes that is unavoidable is the type called Type 1 or juvenile-onset diabetes. This is in direct contrast to Type 2 or adult-onset diabetes which is due to obesity and therefore very controllable.

So because of bad genetics even people like you who are fit, active, don't smoke and eat right can still be at risk for high cholesterol the resulting heart attacks and strokes. That's one reason why cholesterol screening is so important.

The importance of screening
In 1985 the National Institutes of Health (NIH) established the National Cholesterol Education program and they recommend cholesterol screening for everyone every five years starting at the age of 20. Other groups recommend screening every five years for men over the age of 35 and women over 45 years old. Even children who are overweight, smoke or have a parent with elevated cholesterol are advised to undergo screening.

The screening test itself is done by testing a drop of blood from a fingerstick. This can be done at your doctor's office, a clinic, a health fair or even at home with a simple commercial test device. An important factor that may be relevant in your case is that only the total cholesterol level can be tested at any time without regard to whether or not you've eaten recently. This is quite different from High Density Lipoprotein (HDL, "good cholesterol") and Low Density Lipoprotein (LDL, "bad cholesterol”) levels which require 12 hours of complete fasting before the blood test.

So for screening purposes, it's all about the total cholesterol level:Below 200mg/dl = Desirable200-239mg/dl = Borderline high riskAbove 240mg/dl = High riskBased on the total cholesterol level, a proper blood test preceded by 12 hours of fasting is the next step. Total cholesterol, HDL, and LDL will be measured.

HDL levels and associated level of risk are:Above 60mg/dl = Desirable40-59mg/dl = BorderlineBelow 40mg/dl = High riskLDL levels and associated level of risk are: Below 100mg/dl = Optimal100-129mg/dl = Near optimal130-159mg/dl = Borderline high160-189mg/dl = HighAbove 190mg/dl = Very highYour doctor can go over the numbers with you and then discuss the treatment options with you. These will be diet and exercise, followed by cholesterol-lowering medication if needed.

So to answer your question specifically, your total cholesterol is so low that nothing else really matters. Your HDL and LDL numbers are fine though it's unclear that they are accurate because it's unlikely you hadn't eaten for 12 hours before the test.

As to the cholesterol/HDL ratio, some medical types look at it but most, including the American Heart Association, recommend looking at absolute levels NOT ratios. As a result, I'm solidly with your family doctor.

If you're interested in more information, the NationalInstitues of Health and the American Heart Association have really good websites that go into much greater detail about all this and will certainly answer any further questions that you or anyone else may have relating to cholesterol and lipoprotein levels.

Best wishes and thanks for raising a really important public health question.
Prentice

---

Dr. Prentice Steffen, board certified in both Emergency Medicine and Sports Medicine, is currently serving as team doctor for the Prime Alliance Cycling team. He has served as team doctor for several teams including Mercury, Spago and U.S. Postal. Steffen has also served as medical director and event physician for major races including the Tour Du Pont, New York City Marathon and the Tour de Trump. Steffen also serves as the Sports Medicine section editor for the Journal of Emergency Medicine. His services are outlined in detail at www.pdssportsmed.com Please send your sports-related medical questions to "Ask the Doctor" in care of WebLetters@7Dogs.com. We will forward a selection of questions to one of three physicians currently working with this site.Important Notice:
The information provided in the ASK THE DOCTOR column does not constitute formal medical advice. The information provided on this public web site is provided solely for general interest of the visitors to the site. The information contained in this column applies to general medical practice and may not reflect current medical developments or be interpreted as medical advice. Understand that reading the information contained in this column does not mean that you have established a doctor-patient relationship with Dr. Prentice Steffen. Readers of this column should not act upon any information contained in the web site without first seeking medical advice from their personal physician.