Cholesterol Chronicles - The Indian Disadvantage

Dr Sanjana SN
January 2, 2024

Are you aware that Indians have unique BMI cut-off points compared to their Western counterparts? When you review your blood reports, have you ever wondered if the referenced ranges are specifically tailored to align with your genetic makeup and ethnic health risks? There's a scarcity of long-term studies focusing on the South Asian population. 

This raises an important question:

Can we reliably apply the 'normal' ranges, predominantly derived from extensive research on Western populations, to Indian individuals as well

Research has indicated that the heart disease rate among Indians / South Asians is double that of the national averages of the western world.[1] In the landscape of our heart health, cholesterol plays a pivotal role and for Indians the plot (or should i say curry) thickens due to the blend of our diet , culture and genes. 

Let's start with an example

Case 1: A 42-year-old Indian male, occasional smoker, poor exercise habits, moderate alcohol consumption and a non-vegetarian, with a BMI of 25.

Case 2: A 55-year-old European male, smoker, consumed alcohol occasionally with poor exercise habits and a non-vegetarian, with a BMI of 31.

Who's at a higher risk for heart disease or diabetes? 

Now, here's the twist: both have nearly the same risk!!

When it comes to heart disease, Indians often face it much earlier, almost 33% sooner than other demographics, and without much warning. 62% of all cardiovascular deaths in Indians are premature [2]

A complex interplay of a wide range of determinants play a role in heart health, out of which a key independent risk factor has been abnormal lipid or fat metabolism

Heart diseases are a result of both modifiable and non modifiable risk factors

Abnormal lipid profiles contribute to the buildup of fat or plaques in your blood vessels. This process sets the groundwork for cardiovascular events, including angina, heart attacks, and strokes.[2]

So, dyslipidaemia isn't just an independent lab finding—it's a significant part of the narrative, playing a crucial role in how heart health unfolds.

To understand the mystery of cholesterol and its role in our body click here-

NCEP Guidelines for normal ranges for Cholesterol (3)

Decoding Cholesterol Standards: Bridging the Gap for South Asians

Ever wondered how we landed on the standard or normal values for cholesterol? The journey involves the scientific expertise of bodies like the National Cholesterol Education Program (NCEP) (4)

The NCEP's latest report, known as ATP III (Adult Treatment Panel 3), is a milestone in clinical guidelines. It's not just a compilation of recommendations; it's the result of extensive research, evaluation, and a rigorous exploration of existing evidence for the adult population in the United States.[5]

Here's the catch: while these guidelines are widely referenced by clinicians around the globe, including India, we need to approach them with a critical lens. Why? Because these recommendations are predominantly tailored to the western population.[6]

South Asians, including our Indian community, often exhibit different patterns of cholesterol metabolism and cardiovascular risks.[7] Factors like genetics, lifestyle, and dietary habits contribute to this uniqueness. It's not a one-size-fits-all scenario.

As we absorb and apply these guidelines, it's crucial to recognize that what may be considered "normal" for one population might not seamlessly align with the health dynamics of another. South Asians, in particular, may need a more nuanced approach.[7]

What did we find? At Eka

In the journey towards tailor-made standards, technology tools emerge as invaluable companions. The Eka care app provides a unique experience, wherein uploading your medical record, gives you a smart report with insights on where you stand among others of your age and gender. Leveraging these tools empowers individuals to understand their lipid profile within the context of their age and gender.

Insights from the Eka care cohort are a prime example of how data insights at a large population level can illuminate the nuances that challenge conventional norms. 

We studied nearly 3 lakh records of lipid profile and this is what we found :

1. Unique Dyslipidemia Pattern:

A distinctive pattern - high triglycerides, low HDL, and a shift of the peak to the right in total cholesterol distribution was observed. This sets the stage for atherogenic conditions in our population, creating an environment ripe for clot formation and plaque development in the blood vessels.[8]

2.Rethinking norms for Indians

The LDL and HDL bell curves tell a compelling story, which defies Western standards. Around 45% of the population falls below the recommended HDL cutoff of 40mg/dl with the curve peaking at 40. Similarly over 55% surpass the normal range of 100mg/dl for LDL cholesterol.

With the updated guidelines for diabetic patients to target an LDL of less than 70mg/dl, the prevalence of dyslipidemia is anticipated to rise further.[9]There is a pressing need to gather more population-specific evidence and arrive at lipid profile goals better set to align with our genetics, lifestyle, and cultural practices.

55% of the population surpassed the normal range for LDL of 100mg/dl

45% of the population had a HDL less than the favourable cut off of 40mg/dl

The Indian disadvantage

Multiple studies on migrant South Asian populations have cast light on a concerning reality: a 3-5 fold increase in the risk of heart attacks or cardiac-related deaths compared to other ethnic groups.[10] Heart disease strikes Indians a decade earlier than their Western counterparts. [11]

Here's the stark truth: Indians lead the charts when it comes to deaths attributed to cardiovascular disease, surpassing six other ethnic groups.[1] But why this distinct disadvantage? Our susceptibility is a result of the delicate interplay between genetics and environment. Let's explore more.

> Altered cholesterol biochemistry

The LDL cholesterol in Indians was found to be smaller and hence more atherogenic than Western counterparts although the levels remained the same.[10] Even when it came to HDL, Indians not only have lower levels, but even among them the less protective kind of HDL cholesterol was predominant.[10]

> Smaller Coronary Arteries:

There exists a theory that Indians may have smaller coronary blood vessels, making them more prone to blockages and subsequent heart-related catastrophes.[1]

> Fat Distribution Patterns:

Indians often exhibit distinctive fat distribution patterns, labeled as "pear-shaped" or "apple-shaped" obesity wherein fat predominantly settles around the waist and hip region.[8]The accumulation of excess fat around the waist and hips leads to abdominal obesity, in turn increasing insulin resistance, metabolic diseases, and diabetes.[11]

> Altered Biomarkers of Inflammation:

Biomarkers associated with clot formation, such as adipokines, CRP, and homocysteine, are identified at higher levels in South Asians compared to Western populations.[10] This heightened inflammation adds another layer to the complexity as it triggers plaque destabilizing pathways within our blood vessels.[12]

It's crucial to acknowledge these non-modifiable risk factors, but equally important is the recognition that modifiable risk factors hold significant sway in altering cardiac outcomes. While our genetic predispositions set the stage, lifestyle modifications and proactive healthcare play a pivotal role.

Understanding the disadvantages is the first step toward tailored and effective preventive measures.

What are the risk factors under your control?

1. Obesity:

Indians, exhibit a 3-5% higher body fat percentage compared to their European counterparts.[11] It was found that we develop complications from obesity at a much lower value when compared to our western counterparts. As a result, the BMI cut off is recommended to be less than 23kg/m2 as opposed to the 25 in the other ethnic groups.[9]

Indians also tend to have a more central distribution of fat, contributing to increased risk factors for metabolic diseases like diabetes and cardiovascular issues.Increased abdominal obesity is one of the strongest indicator of high visceral fat and increased insulin resistance.[6]

 Cut-offs for waist circumference in Indian women and men is 80cm and 90cm respectively.

2. Dietary Changes:

India is undergoing a nutritional shift marked by reduced consumption of healthy foods like coarse cereals, pulses, fruits, and vegetables. Conversely, there's a rise in the intake of red meat, processed foods, and energy-dense options, along with a prevalence of high saturated fats and carbohydrates.

3. Lifestyle Changes:

Urbanization, changing occupational patterns, and increased stress levels contribute to a sedentary lifestyle and heightened tobacco consumption. These lifestyle factors directly impact cholesterol and metabolic health, necessitating a proactive approach to counteract their effects.

We need to understand and acknowledge that higher risk in South Asians, especially Indians, is a result of the complex interplay between these modifiable and nonmodifiable risk factors where neither has an upper hand. But what we can do is take charge of factors under our control. Small, consistent changes in your daily choices can pave the way for a healthier cardiovascular future.

It takes just 3 simple steps   

1. Healthy Lifestyle Habits:

Balanced Meals, regular exercise , stress management and avoiding tobacco consumption.

Incorporate at least two fistfuls of vegetables, one fistful of fruit, and a daily portion of 12 nuts into your diet.

Say no to sugared drinks to further enhance your nutritional choices.

2. Educate Yourself:

Knowledge is your ally. Educate yourself about the nuances of dyslipidemia, the unique patterns in the Indian context, and the impact of lifestyle choices  to make mindful decisions about your health.

3. Early Screening for Early Intervention:

Take charge of your health by getting evaluated regularly post the age of 30 years, at least once a year. Talk to your doctor, find out what are the tests which will help you understand your overall metabolic health

Prioritizing your health is not a one-time effort but a continuous journey.

By incorporating these simple yet impactful steps into your daily life, you pave the way for optimal lipid health and overall well-being.Each one of us owes it to ourselves and our dear ones , to go that extra mile and prioritize health, prioritize well being and most importantly prioritize lipids !


1.A. Kalra et al., “The burgeoning cardiovascular disease epidemic in Indians – perspectives on contextual factors and potential solutions,” The Lancet Regional Health - Southeast Asia, vol. 12. Elsevier BV, p. 100156, May 2023. doi: 10.1016/j.lansea.2023.100156. Available:

2.An International Atherosclerosis Society Position Paper 2013,Global Recommendations for the Management of Dyslipidemia [Full report] 

3.Zampelas and Magriplis, “New Insights into Cholesterol Functions: A Friend or an Enemy?,” Nutrients, vol. 11, no. 7. MDPI AG, p. 1645, Jul. 18, 2019. doi: 10.3390/nu11071645. Available:

4.S. Misra, T. Lyngdoh, and R. Mulchandani, “Guidelines for dyslipidemia management in India: A review of the current scenario and gaps in research,” Indian Heart Journal, vol. 74, no. 5. Elsevier BV, pp. 341–350, Sep. 2022. doi: 10.1016/j.ihj.2022.07.009. Available:

5.National Cholesterol Education Program Expert Panel. (2001). Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA, 285(19), 2486-2497.

6.Narasingan ,Newer lipid guidelines: Interpretation and applications for Indians

7.Masala Study. (2017, April 3). Have You Ever Wondered What the Healthiest Weight for You Should Be? [Blog post]. Retrieved from here

8.Joshi SR, Anjana RM, Deepa M, Pradeepa R, Bhansali A, et al. (2014) Prevalence of Dyslipidemia in Urban and Rural India: The ICMR–INDIAB Study. PLoS ONE 9(5): e96808. doi:10.1371/journal.pone.0096808 

9.An International Atherosclerosis Society Position Paper 2013,Global Recommendations for the Management of Dyslipidemia [Full report] 

10. M. Gupta, N. Singh, and S. Verma, “South Asians and Cardiovascular Risk,” Circulation, vol. 113, no. 25. Ovid Technologies (Wolters Kluwer Health), Jun. 27, 2006. doi: 10.1161/circulationaha.105.583815. Available:

11.Indian Heart Association. (n.d.). Cholesterol and South Asians. Retrieved from here.

12.Bharadwaj SP, Patel AT, Rana DA, Malhotra SD, Patel TM. Linking of different ethnicities, races and religions to lipid profile patterns and hypolipidaemic drug usage patterns in coronary artery disease patients. Int J Basic Clin Phar- macol. 2019;8(8):1707.