I am writing this article because some of the top laboratories like Metropolis Clinical Laboratories have stopped mentioning the lower limit of blood levels of total cholesterol. The normal reading mentioned in the report is "up to 200 mg". Yes, today the cholesterol hypothesis has reached the peak of its importance. Many authorities are talking about bringing down the bad LDL cholesterol level to less than 100 mg and a few of them are talking about bringing it down to 60 mg.

But it is worth remembering that at the same time research is going on to bring out drugs which will increase the level of good HDL cholesterol e.g. CETP inhibitors, which will soon reach the market within a year or two. Their aim is to increase the HDL cholesterol to around 60 mg, a level at which it will protect the patients against coronary heart disease. If this is so, then in an ideal situation the total cholesterol should be at least 120 mg, with 60 mg of LDL cholesterol and 60 mg of HDL cholesterol.

I wish to draw the attention of family physicians to the fact that a very low level of total cholesterol is also not good. Earlier it was found that patients with overweight constitution and pot belly are prone to ischaemic heart. Similarly patients with very thin and lean constitution are also more likely to suffer from ischaemic heart disease e.g. our late Prime Minister Shastri, who died of myocardial infarction in Russia.

I have read of some reports stating that patients having very low cholesterol are more prone to myocardial infarction. Such cases are now being picked up more often because of the auto-analyser blood reports, where 12-20 blood tests are being reported in a routine health check up.

Last week, I saw a patient with a routine health check up report showing total blood cholesterol of 60 mg. This is the third patient, which I have seen during the last few years. I advise such patients to take care of other risk factors like overweight and smoking, and to go for a brisk walk, one hour daily.

I often wonder that such patients may be more prone to an ischaemic heart. The only explanation I can think of is that if the total cholesterol of such patients is 60 mg, their HDL cholesterol cannot be more than 30 mg!

I have decided that the next time I see a patient with very low cholesterol, after asking for his HDL cholesterol level, I will put him on CETP inhibitors as soon as the drugs are available in the market.

I would also like to advise all my colleagues and family physicians to do the same, so that the subject of very low cholesterol levels as a cause of IHD is not neglected.

This is especially important, because often the family physicians wrongly advise patients to have boiled food (according to them, a little bit of ghee or butter increases "LDL" cholesterol) and put them on very large doses of statins to lower the LDL cholesterol. Infact, a little bit of butter or ghee spread on a slice of bread or chapatis "increases" the "HDL" cholesterol. Vice versa boiled food in the long run decreases HDL cholesterol levels.

Ex. Hon. Physician, Jaslok Hospital and Bombay Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008.