Fasting lipids: the carrot in the snowman.

The current paradigm for the management of lipids is focused almost entirely on fasting lipid levels. However, most of the day is spent not in a fasting state, but in a postprandial state. Meals high in animal fat impair endothelial function for 4 h, an effect that can be minimized by pretreatment with antioxidant vitamins. Dietary cholesterol (one egg yolk), though it increases fasting low density lipoproteins by only about 10%, increases oxidized low-density lipoproteins by 34%. Two studies in coronary patients, the Lyon Diet Heart Study and the IndoMediterranean Diet study, have shown that, despite no difference in fasting lipid levels, a Mediterranean diet reduced myocardial infarction and death by 60% in four years and by 50% in two years compared with diets amounting to the American Heart Association diet that is usually prescribed to coronary patients. It is time to stop focusing only on fasting lipid levels and to begin paying more attention to outcomes.