A 49-year-old woman, who is usually in good health, recently discovered, as the result of a routine medical examination, that her overall cholesterol was 6.5mmol/l (millimoles/ litre). At about the same time her optician reported that the appearance of the retina of her eyes suggested that she had a high level of blood fats (lipids). The reader was reassured that the tests revealed an HDL of 2.4. HDL, or high-density lipoprotein cholesterol, is the “good”, cardioprotective constituent of the overall cholesterol. The reader’s LDL was 3.8.
LDL, low-density lipoprotein cholesterol, is the pernicious constituent of the overall cholesterol that damages the coronary and other arteries. The other routinely measured blood fat is triglycerides. Her triglyceride level was 3.8.
The reader says that she considers the practice of reporting all the different levels of the lipids to be confusing, and suggests it would be enough to know her HDL level. If the level of HDL was satisfactory, surely all would be well? I hope that our reader will have a long and healthy life and that when she has reached a ripe old age her arteries will remain atheromafree and that the blood will flow freely along them. However, ignoring a raised LDL, which should certainly be no higher than three, and high triglyceride levels, which should be under 1.9, won’t help her to achieve this goal. The total cholesterol should be less than 5 (the reader’s, at 6.5, is appreciably raised).
The reader hasn’t told us about any other factors that could have an influence on her liability to cardiovascular disease. There are several other common risk factors, as well as raised cholesterol levels, to consider when estimating the likelihood of developing coronary arterial disease, stroke, kidney disease or other vascular troubles.
Some are related to lifestyle — smoking, lack of exercise, excessive weight, too much salt and excessive stress. There are also physical hazards that the doctor can measure easily but that may not initially give rise to symptoms: a raised blood pressure, increased cholesterol levels, reduced kidney function and too large a waist.
The presence of more than one risk factor does not so much have an additive effect on the patient — more a multiplying one.
A patient with high blood fats is three times more likely than someone with normal cholesterol level to develop cardiovascular disease. If the patient also has a high blood pressure, he or she is three times three — nine times — more liable to cardiovascular disease. If someone is also suffering from a third important burden, such as smoking, there is 27 times more risk. Hence the importance of eradicating each individual risk factor.
Elevation of the LDL level is the most important predictor in the lipid profile of trouble ahead. Too often, when cholesterol levels are discussed, those chatting about their cholesterol levels mention only the overall cholesterol. I always try to persuade patients to know both their total cholesterol level and their LDL. The guidelines are becoming more stringent but most doctors now recommend that people aim for a total cholesterol below 5. The LDL should certainly be below 3, but already the majority of doctors realise that this is too high and suggest a figure for LDL of under 2.6.
Triglyceride levels are also important and anything over 1.9 is looked at askance. Our reader’s, 3.8, would certainly be considered too high.
How much the reader’s abnormal lipids will matter is likely to depend on her family history and how many other risk factors she has. If lifestyle changes don’t bring her cholesterol profile to normal, she should consult her doctor to discuss taking a statin.
Two years ago a male reader now aged 67 developed eczema. Applying Daktacort, a steroid and anti-fungal mixture, cleared it. His doctor also suggested that he stop using soap, shower gel and any additives in his bath. Encouraged by Matthew Parris’s praise of the advantages of avoiding shampoos, he has also thrown these away. With his new regime of water only, except when washing his hands, his skin is clear, his scalp has stopped itching and his dandruff has disappeared. Is his regime compatible with good personal hygiene?
A reaction to the scent in soaps is only one reason why some soaps may irritate a sensitive skin. Soaps not only remove dirt, but also the naturally protective oils that contribute to the barrier effect of skin.
The irritant effect of a soap varies according to its acidity. The pH-neutral soaps are less irritant than acidic ones. The nature of the oil or fat used, for example, olive oil or animal fat, may make a difference. Sensitive skins may react unfavourably to medicated soap.
Most people’s skin allows them to enjoy scented soaps without difficulty. And they can usually also withstand medicated soaps — which is fortunate, since medicated soaps and alcohol gels may be lifesaving if avian flu finally reaches us. (To stop the virus, constant hand-washing is necessary.) For the minority, soap substitutes are available, especially aqueous creams, which clean the skin without irritating it.
Most effective shampoos include an anti-fungal element, because dandruff is usually the result of a fungal infection, often coupled with an eczematous tendency.
Medicated shampoos such as Nizoral are excellent for dandruff in which fungal infection is a factor. Psoriasis is similar in appearance and symptoms to dandruff and responds to Betnovate or Dermovate scalp lotion.
Bubble baths or bath oils may be great fun, but they sometimes produce a rash, and in women are a relatively frequent cause of genital inflammation and discharge.
Send Dr Thomas Stuttaford your questions on impotence www.timesonline.co.uk/talkingpoint
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