Understanding cholesterol involves more than checking if it's 'normal.' Cardiovascular risk is complex, assessed through a detailed lipid profile including LDL, HDL, and triglycerides, with additional markers like non-HDL cholesterol and apolipoprotein B providing deeper insights. Dyslipidemia, especially low HDL, is widespread in India and the Asian Indian population, often existing silently in individuals with normal weight, increasing heart disease risk. Early screening from age 18, combined with lifestyle changes and appropriate medical interventions, is vital for managing these risks and preventing serious cardiovascular complications.

Understanding cholesterol involves more than checking if it's 'normal.' Cardiovascular risk is complex, assessed through a detailed lipid profile including LDL, HDL, and triglycerides, with additional markers like non-HDL cholesterol and apolipoprotein B providing deeper insights. Dyslipidemia, especially low HDL, is widespread in India and the Asian Indian population, often existing silently in individuals with normal weight, increasing heart disease risk. Early screening from age 18, combined with lifestyle changes and appropriate medical interventions, is vital for managing these risks and preventing serious cardiovascular complications.

Understanding cholesterol involves more than checking if it's 'normal.' Cardiovascular risk is complex, assessed through a detailed lipid profile including LDL, HDL, and triglycerides, with additional markers like non-HDL cholesterol and apolipoprotein B providing deeper insights. Dyslipidemia, especially low HDL, is widespread in India and the Asian Indian population, often existing silently in individuals with normal weight, increasing heart disease risk. Early screening from age 18, combined with lifestyle changes and appropriate medical interventions, is vital for managing these risks and preventing serious cardiovascular complications.

For many Indians, a cholesterol report is reduced to a simple question: “Is it normal?” If the total cholesterol number falls within the laboratory’s reference range, the report is often put away with little further thought. But cardiovascular risk is rarely that simple. Cholesterol is more than one number.

A standard lipid profile measures several components, including total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides. For selected patients, clinicians 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 can be useful when the standard lipid profile does not tell the complete story or when there is a strong family history. Each of them provides a different piece of the cardiovascular risk picture.

Indian Council of Medical Research–India Diabetes (ICMR-INDIAB) study, a cross-sectional population-based survey, assessed a representative sample of 1,13,043 individuals aged 20 years and older drawn from urban and rural areas of 31 states and union territories and found the presence of dyslipidaemia in 81·2%. 

Low HDL cholesterol accounted for the majority of the dyslipidaemia burden in the country, with an overall prevalence of 66·9%. Previous research has shown that low concentrations of HDL cholesterol are more common in Asian Indians or South Asians compared with 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 of people who are overweight, diabetic or visibly unhealthy. 

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

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

Lp(a) is an inherited, independent and causal risk factor for Coronary artery disease. Epidemiological studies have demonstrated an association between increased Lp(a) levels and incidence of myocardial Infarction, aortic stenosis, ischemic stroke, heart failure, and cardiovascular and all-cause deaths. The Lp(a)-mediated Cardiovascular risk is mediated by pro-inflammatory,pro-thrombotic, and pro-atherogenic processes. Elevated Lp(a) >50 mg/dl is seen in 1 in 5 individuals worldwide. In South Asians, the prevalence is higher: 1 in 4. Elevated Lp(a) is genetically determined. An Indian study reported an association of Lp(a) > 50 mg/dl with severe angiographic Coronary artery disease. 

The increasing incidence of dyslipidemia among young adults has emerged as a significant public health concern due to its associated risk of long-term cardiovascular complications. Atherosclerosis begins early in childhood. Its presence and severity are linked to cardiovascular risk factors including dyslipidemia. Genetic causes of dyslipidemia are common but remain vastly underdiagnosed. All individuals should have their lipid profile evaluated by the age of 18. 

US National Institutes of Health (NIH) recommends selective screening of children 2 to 9 years, particularly in those with a positive family history, high body mass index or Cardiovascular risk factors and universal screening for children aged 9 to 11 years. Screening may be of particular benefit in identifying young adults with elevated LDL cholesterol due to unrecognised genetic dyslipidemia.

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

Severe restriction on total fats in diet is not supported by evidence. Increased intake of combination unsaturated fats as in Mediterranean diets is recommended. Omega-3 polyunsaturated fats (PUFA) supplementation may be useful in reducing cardiovascular events in moderate to high-risk individuals with high triglycerides. Plasma saturated fat is more associated with increased intake of dietary refined carbohydrates. LDL cholesterol slightly increases with higher intake of saturated fats, but restriction has no discernible effect on ASCVD incidence or mortality in randomised trials. Atherogenic dyslipidemia is best managed by restriction of excess calories, sugars, refined carbohydrates, fried foods, and trans fats while maintaining ideal body weight.

Isolated elevation of LDL cholesterol is managed by restriction of 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. The combination of MUFA- and PUFA-containing oils is a good option. Trans fats should be totally avoided. Trans fats are present in fried foods and are influenced by cooking practices. Refined carbohydrates, sugar-sweetened beverages, and processed foods should be strongly restricted and replaced with healthy grains and fibre. Dairy fats are controversial; due to recent data suggesting a neutral association with cardiovascular disease, these may be advocated to replace unhealthy foods like refined carbohydrates or processed foods.

Healthy diets are plant-based, but an omnivorous diet with eggs, dairy, and occasional intake of unprocessed meats is acceptable. In ASCVD patients, egg yolk and red meat should be restricted. The emphasis is on intake of fruits, vegetables, whole grains, legumes, poultry, fish, and nuts. Modest consumption of nuts reduces cardiometabolic risk. A healthy calorie distribution 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 treatment of underlying causes and associated risk factors, lifestyle modifications, statins to lower non-HDL-C, control of diabetes and pharmacotherapy in selected cases. Though omega-3 fatty acids can bring down triglyceride levels, only icosapent ethyl has been shown to reduce cardiovascular events.

Early diagnosis and intervention are critical. Advances in treatment options apart from statins, including newer medications such as PCSK9 inhibitors and cholesterol absorption inhibitors, have expanded the therapeutic landscape and provide more effective ways to manage dyslipidemia. 

The appropriate LDL cholesterol target depends on an individual's overall cardiovascular risk. Someone who has already experienced a heart attack or has established cardiovascular disease is in a very different risk category from a young person with no known disease.

India's cholesterol problem is no longer simply about people who know they have high cholesterol. The more difficult challenge is identifying the millions who do not know they are at risk. The real question, therefore, is not merely “Is my cholesterol normal?”It is: “What does my cholesterol mean in the context of my overall heart risk?”That distinction could make the difference between discovering cardiovascular disease early and discovering it only when the first heart attack arrives.

The author is the chief & senior consultant, interventional cardiologist at BMH Kannur. 

 

The opinions expressed in this article are those of the author and do not purport to reflect the opinions or views of THE WEEK. 

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