The strategies for control of the "first-stage" complications called NIDDM, AMI, stroke and PVD, focus on addressing specific "intermediate" predictors, (for example raised serum cholesterol, hypertension, smoking), do not address the root problem that underlies the development of these risk indicators. A recent post-mortem study of 856 young American adults aged 15-34 who died of external causes, and who had normal lipoprotein profiles revealed that risk factors of hypertension, smoking, obesity and insulin resistance were all associated with atheromatous lesions (Circulation, 2001, 103, 1546). Despite having normal lipids, these young adults had moderate and in some cases advanced vascular lesions. Those risk factors looked at in that study are part of the cluster of conditions associated with metabolic syndrome and indicate that in the absence of lipid abnormalities, vascular lesions are already developing. This means that our preventive focus must be on factors that pre-date the development of dyslipidaemias.