From Mary and Sally-

>  We have stated that cholesterol is a non issue--neither
>serum nor dietary cholesterol is good predictor of CHD

The clinical model, which is always under revision,  seems to be that the
progress of atherosclerosis is affected by hemodynamic factors secondary to
blood pressure and vascular anatomy, to lipid and cholesterol metabolism, to
carbohydrate metabolism,and its interactions with lipids and cholesterol,
and probably to factors having to do with clotting, and inflammatory
reactions. Some of these may have more effect on the formation of the
thrombus, some on the degradation of the vascular wall prior to the
thrombotic event. Also, various authorities (including Mary and Sally),
question one or more parts of this story.

Many people and doctors concerned with prevention or avoidance of CHD,
follow lipid profiles, blood glucose, and blood pressure, not because these
are necessarily the whole story, but because they are thought to be
relevant, they are relatively cheap and non invasive to monitor.But there is
a big unstated assumption: that the only cost to tailoring diets to optimize
these readings is the loss of pleasure. In a Puritan culture like the US,
that is almost a plus.

If cholesterol doesn't count, or at least LDL and total cholesterol taken
alone don't count, things are quite a bit different. For example there are
many diabetics, and obese people, for whom a relatively low carbohydrate
diet improves blood pressure, contributes to weight loss, and lowers blood
sugar readings. But it may well raise LDL and total cholesterol. If these
people, or more likely their doctors, feel that the degradation in
cholesterol readings dominates the other improvements, they are back to
square one. So what is being treated is a number. It is extremely important
to establish that that number is clinically important, or alternatively,
that it is not.

What would be needed, is an alternate marker, that clinicians and patients
can follow. At the present time, it may possibly expose an MD to malpractice
litigation to ignore cholesterol, the institutional acceptance of the
cholesterol - CHD hypothesis is so great.

Could Mary and Sally suggest blood chemistries, or other markers, that they
feel may be more relevant to the progress of atherosclerosis?

Thanks,

Michael Kern, MD