Is your cholesterol really normal? The hidden danger behind the heart disease crisis in India

For many Indians, a cholesterol report comes down to a simple question: “Is this normal?” If the total cholesterol count falls within the laboratory’s reference range, the report is often put aside without further thought. But the risk of cardiovascular disease is rarely that simple. Cholesterol has more than one number.

A standard lipid profile measures several components, including total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides. For specific patients, doctors may also consider additional markers such as non-HDL cholesterol, apolipoprotein B (ApoB) or lipoprotein(a) to better understand cardiovascular risk. These tests are not necessarily required for everyone, but they can be helpful when a standard lipid profile doesn’t tell the full story or when there is a strong family history. Each presents a different part of the cardiovascular risk picture.

The Indian Council of Medical Research-Diabetes in India (ICMR-INDIAB) study, a cross-sectional population-based survey, evaluated a representative sample of 1,13,043 individuals aged 20 years and above, selected from urban and rural areas of 31 states and union territories, and found dyslipidemia in 81.2%.

Low HDL cholesterol accounts for the majority of the burden of dyslipidemia in the country, with an overall prevalence of 66.9%. Previous research has shown that low concentrations of HDL cholesterol are more common among Asian Indians or South Asians than other ethnic groups.

This phenomenon appears to be a component of the Asian Indian phenotype, which also includes increased visceral fat, increased waist circumference, and increased insulin resistance. Both low HDL cholesterol and high triglycerides were uniformly prevalent across India in this study.

These findings challenge one of the most persistent misconceptions about cholesterol: that it is primarily a problem for people who are overweight, diabetic, or otherwise visibly unhealthy.

You can have a normal body weight, normal blood sugar and no obvious symptoms, and still have an unhealthy lipid profile that quietly increases your risk of heart disease.

LDL cholesterol is especially important because LDL particles play a major role in atherosclerosis — the gradual buildup of fatty deposits within the walls of your arteries. Over the years, these plaques can narrow the arteries or become unstable, which can lead to heart attacks or strokes. But focusing only on LDL cholesterol can miss important abnormalities. Hypertriglyceridemia is closely associated with obesity, metabolic syndrome, and diabetes. Nearly half of all patients with diabetes have high blood triglycerides. Non-HDL cholesterol and apolipoprotein B (ApoB) are other risk markers for atherosclerosis. Long-term exposure to high levels of LDL-C and TG can significantly increase the likelihood of developing atherosclerosis, leading to reduced life expectancy and decreased quality of life.

Lp(a) is a genetic, independent and causal risk factor for coronary artery disease. Epidemiological studies have shown an association between increased Lp(a) levels and the incidence of myocardial infarction, aortic stenosis, ischemic stroke, heart failure, and all-cause and cardiovascular mortality. Lp(a)-mediated cardiovascular risk is mediated through pro-inflammatory, pro-thrombotic, and pro-atherosclerotic processes. An Lp(a) level >50 mg/dL is observed in 1 in 5 people worldwide. In South Asia, the prevalence is higher: 1 in 4. High Lp(a) is genetically determined. An Indian study reported an association between an Lp(a) level >50 mg/dL and severe coronary artery disease.

The increasing incidence of dyslipidemia among young people has emerged as a major public health concern due to its associated risk of long-term cardiovascular complications. Atherosclerosis begins early in childhood. Its presence and severity are associated with cardiovascular risk factors including dyslipidemia. Genetic causes of dyslipidemia are common but remain largely undiagnosed. All individuals should have their lipid profile assessed at age 18 years.

The US National Institutes of Health (NIH) recommends selective screening of children ages 2 to 9 years, especially those with a positive family history, high BMI or cardiovascular risk factors, and universal screening of children ages 9 to 11 years. Screening may be of particular benefit in identifying young people with high LDL cholesterol due to an unrecognized hereditary dyslipidemia.

Lifestyle modifications, including diet and exercise, are as important as drug treatments and should not be underestimated in the management of dyslipidemia, as they work together to improve long-term health outcomes. A comprehensive approach that combines early detection, lifestyle modification, and medical treatment is necessary to mitigate long-term complications of dyslipidemia.

Severe restrictions on total fat in the diet are not supported by evidence. It is recommended to increase the intake of unsaturated fat group as in the Mediterranean diet. Omega-3 polyunsaturated fat (PUFA) supplements may be beneficial in reducing cardiovascular events in moderate to high-risk individuals with high triglycerides. Plasma saturated fat is associated with increased intake of dietary refined carbohydrates. Low-density lipoprotein (LDL) cholesterol increases slightly with increased saturated fat intake, but restriction has no significant effect on ASCVD incidence or mortality in randomized trials. Atherosclerotic dyslipidemia is best managed by restricting excess calories, sugars, refined carbohydrates, fried foods, and trans fats while maintaining ideal body weight.

Isolated high LDL cholesterol is managed by restricting trans fats and saturated fats. The healthiest oils appear to be those high in monounsaturated fats (MUFA) and PUFA with a high N-3/N-6 ratio. Combining oils containing MUFA and PUFA is a good option. Trans fats should be avoided completely. Trans fats are found in fried foods and are affected by cooking practices. Refined carbohydrates, sugar-sweetened beverages, and processed foods should be severely restricted and replaced with healthy grains and fiber. Dairy fats are controversial. Given recent data suggesting a neutral association with cardiovascular disease, these foods may be advocated to replace unhealthy foods such as refined carbohydrates or processed foods.

Healthy diets are plant-based, but an omnivorous diet containing eggs, dairy products, and occasional eating of unprocessed meat is acceptable. In ASCVD patients, egg yolks and red meat should be restricted. The focus is on eating fruits, vegetables, whole grains, legumes, poultry, fish and nuts. Modest consumption of nuts reduces the risk of cardiovascular disease. A healthy distribution of calories is achieved by reducing carbohydrates to approximately 50% of total calories (restricting sugars and refined carbohydrates) and adding some healthy fats and proteins.

Hypertriglyceridemia is managed by treating the underlying causes and associated risk factors, lifestyle modification, use of statins to lower HDL-C, diabetes control and drug therapy in selected cases. Although omega-3 fatty acids can lower triglyceride levels, only icosapent ethyl has been shown to reduce cardiovascular disease.

Early diagnosis and intervention is crucial. Advances in treatment options beyond statins, including newer medications such as PCSK9 inhibitors and cholesterol absorption inhibitors, have expanded the therapeutic landscape and provided more effective ways to manage dyslipidemia.

The appropriate LDL cholesterol target depends on the individual’s overall cardiovascular risk. A person who has already had a heart attack or developed cardiovascular disease is in a completely different risk category than a young person who has no known disease.

The cholesterol problem in India is no longer limited to people who know they have high cholesterol. The most difficult challenge is identifying the millions who do not know they are at risk. So the real question isn’t just, “Is my cholesterol normal?” but, “What does my cholesterol level mean in the context of my overall heart risk?” This distinction could make the difference between detecting cardiovascular disease early and discovering it only when the first heart attack occurs.

The author is Senior Consultant and Interventional Cardiologist at BMH Kannur.

The opinions expressed in this article are those of the author and are not intended to reflect the opinions or views of The Week.