In the past decade the public has been warned about the dangers of high blood cholesterol, Along with cigarette smoking and high blood pressure, a high blood cholesterol has been proven to be a major cause of heart attack. These three conditions account for about 80 percent of all heart attacks, and national programs have urged the American public to modify these risk factors. In the 1960s the surgeon general warned the public of the health dangers of cigarette smoking. In the 1970s the medical community became convinced that high blood pressure causes heart attack and stroke, and treatment for this condition has now become routine. Evidence that high blood cholesterol also causes heart attack became overwhelming in the 1980s, and the national Institutes of health joined with many medical organizations, including the American Medical Association, to begin the National Cholesterol Education Program. Its purpose was to educate the medical profession and the general public about the dangers of high blood cholesterol.

The results have been impressive. Physicians are routinely measuring cholesterol levels and testing those patients with high levels. The public has greatly increased its "cholesterol awareness," and many people have modified their diets and begun to exercise regularly to control their cholesterol levels better. Recently, powerful new drugs have been introduced by the pharmaceutical industry to lower blood cholesterol in those with high levels, and at present more than 2 million American are taking these drugs. In spite of these advances, a few people have not completely bought into the cholesterol story. An article in The Dallas Morning News Oct. 20, 1992, and in other newspapers across the country reviewed the claims of researchers who questioned the wisdom of testing for and treating high cholesterol. Even these researchers do not doubt that cholesterol contributes to heart attacks or that lowering cholesterol levels helps prevent heart attacks. These are well-established facts. Instead, they raised two objections. First, they believe that with medical costs already so high, the country cannot afford the additional expense of cholesterol control. And second, they suggest that a very low cholesterol level lowering cholesterol with drugs may carry its own risk.

The cost issue is real. Testing for cholesterol costs money, and cholesterol-lowering drugs can be expensive. On the other hand, coronary heart disease imposes an enormous financial burden on the country, not to mention the element of human suffering and premature death. Moreover, the best way to control cholesterol for most people--changing the diet, losing weight and exercising more--need not cost money. On balance, the savings gains by prevention should outweigh the costs of heart disease, the No. 1 killer of Americans.

A health risk due to low blood cholesterol has by no means been proven. About 6 percent of middle-aged and older adults have very low cholesterol levels. When older adults have a very low cholesterol, below 160 milligrams per deciliter, they may have other diseases: cirrhosis of the liver, emphysema, some forms of cancer and alcohol-related conditions. They also appear to have an increase in the rate of accidents. Most researchers believe that several of theses conditions causes low blood cholesterol and not the other way around. A few scientist, however, argue that this remains an open question, and they urge caution. In any case, the problem is restricted to only a small portion of the older population; for the vast majority of Americans, the problem is a cholesterol level that is too high, not that is too low. Thus, it doesn't make sense to curtail efforts to help the majority because of an unproven possibility of a small, detrimental effect in a small minority of the population.

Another concern about cholesterol, lowering has to do with the safety of drugs. In large trials carried out to test these drugs, some patients apparently have had side effects that offset their benefit; therefore, cholesterol-lowering drugs, like other drugs, should be used only when necessary. The physician's judgment is required as to whether the potential benefits outweigh the possibility of side effects. Nonetheless, in recent years, newer cholesterol-lowering drugs appear to be safe for most people, and their use is justified for many patients who are at high risk for heart attack. These drugs are especially desirable for people with high cholesterol levels who already have had a heart attack and who are highly likely to have another one. High Cholesterol is a major cause of coronary heart disease. If the public and medical profession do not vigorously pursue cholesterol control, a great opportunity to cut down on the foremost killer of middle-aged and older Americans will be missed.

Significant progress has been made in the past decade, and there is no reason to slacken the effort now.