Asian Indian Dyslipidemia
- The excess burden of CAD (coronary artery disease) among South Asians appears to be primarily due to dyslipidemia that is characterized by: high levels of apolipoprotein (apo) B, triglycerides (TG), lipoprotein(a), borderline high levels of LDL (low-density lipoprotein) cholesterol, low levels of HDL (high-density lipoprotein) cholesterol, and apo A1.1-3 Asian Indians have the lowest HDL and the highest ratio of total cholesterol to HDL and apo B to Apo A1─ the two best lipid predictors of heart disease as shown in Table 018.4-7
- Nearly half of Asian Indians (but not Pakistanis or Bangladeshis) are lifelong vegetarians. Unlike in other populations, Asian Indian vegetarians and non-vegetarians have a nearly similar pattern of dyslipidemia and similar rates of CAD.3, 8, 9
- Similar to diabetes and heart disease, dyslipidemia occurs at lower levels of BMI and body fat in South Asians than in Whites.10-12
- An elevated level of total cholesterol is the strongest risk factor for CAD.13 The mean level of total cholesterol in cord blood of newborns worldwide is 75 mg/dL, which rises to 120 mg/dL in two weeks and remains at that level until approximately 20 years of age, when it starts to gradually rise again.14
- Total cholesterol levels among Asian Indians are similar or lower than in Europids.3, 15 Long term prospective studies have shown an 8-fold higher CAD mortality with an increase in total cholesterol from <160 to >280 mg/dL among young Americans.16
- The optimum level of total cholesterol appears to be <160 mg/dL,especially for Asian Indians, much lower than the 200 mg/dL considered desirable in the Western society.2 Contrary to common belief, very low levels of total cholesterol and LDL-C are not associated with increased risk of stroke or cancer.17-19
- Asian Indians around the globe have high triglycerides, and low HDL but LDL-C levels that are similar or lower than in the Europid population.4, 8, 20-30 This appears to be due to widespread insulin resistance even in the absence of obesity.
- Total cholesterol levels correlate well with the presence and severity of CAD in Asian Indians similar to whites.31, 32 At a given total cholesterol, Asian Indians have greater risk due to low HDL and high total cholesterol/HDL ratio.3, 15, 19
- Asian Indians have a high prevalence of high triglycerides, which appears to be due to obesity and high glycemic load on aback ground of insulin resistance. 7 An 88 mg/dL increase in triglyceride levels significantly increases the risk of CAD by 30% in men and 75% in women.33-35
- Despite high levels of TG, several studies fail to show a preponderance of small dense LDL among Asian Indians.7, 36-39
- Among men and women, high TG/HDL-C ratio is a powerful independent predictor of small dense LDL, metabolic syndrome, myocardial infarction, cardiovascular events and all-cause mortality.40, 41
- More than 40% of Asian Indians have high levels of Lipoprotein(a) which provides a genetic predisposition to premature CAD among Asian Indians. Elevated Lp(a) becomes particularly dangerous in the presence of low HDL and high total cholesterol/HDL ratio and account for the malignant heart disease in young Asian Indians.42
1. Enas E.A., Hancy Chennikkara Pazhoor MD, Arun Kuruvila MBBS, Krishnaswami Vijayaraghavan MD F. Intensive Statin Therapy for Indians:Part II Risks. Indian Heart J (In press). 2011.
2. Enas E.A., Hancy Chennikkara Pazhoor MD, Arun Kuruvila MBBS, Krishnaswami Vijayaraghavan MD F. Intensive Statin Therapy for Indians:Part I Benefits. Indian Heart J 2011; 63: 211-227.
3. Enas EA, Senthilkumar A, Chacko V, Puthumana N. Dyslipidemia among Indo-Asians: Strategies for identification and management. Brit J of Diabetes and Vascular Dis. 2005;5:81-90.
4. McQueen MJ, Hawken S, Wang X, et al. Lipids, lipoproteins, and apolipoproteins as risk markers of myocardial infarction in 52 countries (the INTERHEART study): a case-control study. Lancet. Jul 19 2008;372(9634):224-233.
5. Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. Sep 11 2004;364(9438):937-952.
6. Joshi P, Islam S, Pais P, et al. Risk factors for early myocardial infarction in South Asians compared with individuals in other countries. Jama. Jan 17 2007;297(3):286-294.
7. Enas EA, Chacko V, Pazhoor SG, Chennikkara H, Devarapalli HP. Dyslipidemia in the South Asian Patient. Current Atherosclerlosis Report. 2007;9:367-374.
8. Enas EA, Garg A, Davidson MA, Nair VM, Huet BA, Yusuf S. Coronary heart disease and its risk factors in first-generation immigrant Asian Indians to the United States of America. Indian Heart J. Jul-Aug 1996;48(4):343-353.
9. Yagalla MV, Hoerr SL, Song WO, Enas E, Garg A. Relationship of diet, abdominal obesity, and physical activity to plasma lipoprotein levels in Asian Indian physicians residing in the United States. J Am Diet Assoc. 1996;96(3):257-261.
10. Misra A, Khurana L. Obesity and the metabolic syndrome in developing countries. J Clin Endocrinol Metab. Nov 2008;93(11 Suppl 1):S9-30.
11. Misra A., Athiko D, Sharma R, Pandey RM, Khanna N. Non-obese hyperlipidemic Asian northern Indian males have adverse anthropometric profile. Nutr Metab Cardiovasc Dis. Aug 2002;12(4):178-183.
12. Misra A., Vikram NK. Clinical and pathophysiological consequences of abdominal adiposity and abdominal adipose tissue depots. Nutrition. May 2003;19(5):457-466.
13. Brown MS, Goldstein JL. Heart attacks: Gone with the century? Science. 1996;272(5262):629.
14. Roberts WC. Preventing and arresting coronary atherosclerosis. Am Heart J. 1995;130:580-600.
15. Enas EA, Chacko V, Pazhoor SG, Chennikkara H, Devarapalli HP. Dyslipidemia in South Asian patients. Curr Atheroscler Rep. Nov 2007;9(5):367-374.
16. Stamler J, Daviglus ML, Garside DB, Dyer AR, Greenland P, Neaton JD. Relationship of baseline serum cholesterol levels in three large cohorts of younger men to long-term coronary, cardiovascular, and all-cause mortality and to longevity. JAMA. 2000;284(3):311-318.
17. Enas E.A., Hancy Chennikkara Pazhoor MD, Arun Kuruvila MBBS, Krishnaswami Vijayaraghavan MD F. Intensive Statin Therapy for Indians:Part II Risks.Indian heart journal. 2010;(In press).
18. Suh I, Jee SH, Kim HC, Nam CM, Kim IS, Appel LJ. Low serum cholesterol and haemorrhagic stroke in men: Korea Medical Insurance Corporation Study. Lancet. 2001;357(9260):922-925.
19. Enas E.A., Hancy Chennikkara Pazhoor MD, Arun Kuruvila MBBS, Krishnaswami Vijayaraghavan MD F. Intensive Statin Therapy for Indians:Part I Benefits. Indian heart journal. 2010;(In press).
20. Dhawan J, Bray C, Warburton R, Ghambir D, Morris J. Insulin resistance, high prevalence of diabetes,and cardiovascular risk in immigrant Asians. Genetic or environmental effect. Br Heart J. 1994;72:413 – 421.
21. Raji A, Seely EW, Arky RA, Simonson DC. Body fat distribution and insulin resistance in healthy Asian Indians and Caucasians. J Clin Endocrinol Metab. 2001;86(11):5366-5371.
22. Chandalia M, Abate N, Garg A, Stray-Gundersen J, Grundy SM. Relationship between generalized and upper body obesity to insulin resistance in Asian Indian men. J Clin Endocrinol Metab. 1999;84(7):2329-2335.
23. Ajjan R, Carter AM, Somani R, Kain K, Grant PJ. Ethnic differences in cardiovascular risk factors in healthy Caucasian and South Asian individuals with the metabolic syndrome. J Thromb Haemost. Apr 2007;5(4):754-760.
24. McKeigue PM, Marmot MG, Syndercombe Court YD, Cottier DE, Rahman S, Riemersma RA. Diabetes, hyperinsulinaemia, and coronary risk factors in Bangladeshis in east London. Br Heart J. 1988;60(5):390-396.
25. Pollard T. M., Unwin N, Fischbacher C, Chamley JK. Differences in body composition and cardiovascular and type 2 diabetes risk factors between migrant and British-born British Pakistani women. Am J Hum Biol. Sep-Oct 2008;20(5):545-549.
26. Lear S. A., Toma M, Birmingham CL, Frohlich JJ. Modification of the relationship between simple anthropometric indices and risk factors by ethnic background. Metabolism. Oct 2003;52(10):1295-1301.
27. Barnett AH, Dixon AN, Bellary S, et al. Type 2 diabetes and cardiovascular risk in the UK south Asian community. Diabetologia. Oct 2006;49(10):2234-2246.
28. Anand SS, Yusuf S, Vuksan V, et al. Differences in risk factors, atherosclerosis, and cardiovascular disease between ethnic groups in Canada: the Study of Health Assessment and Risk in Ethnic groups (SHARE). Lancet. 2000;356(9226):279-284.
29. Bhatnagar D, Anand IS, Durrington PN, et al. Coronary risk factors in people from the Indian subcontinent living in west London and their siblings in India. Lancet. 1995;345(8947):405-409.
30. Karthikeyan G, Teo KK, Islam S, et al. Lipid profile, plasma apolipoproteins, and risk of a first myocardial infarction among Asians: an analysis from the INTERHEART Study. J Am Coll Cardiol. Jan 20 2009;53(3):244-253.
31. Dhawan J, Bray C, Bennet D, Miller J, Fragher B. Lipid abnormalities in British Asian and White patients and in Asian patients in India with coronary artery disease. Br Heart J. 1991;66:65.
32. Hughes LO, Wojciechowski AP, Raftery EB. Relationship between plasma cholesterol and coronary artery disease in Asians. Atherosclerosis. 1990;83(1):15-20.
33. Cullen P. Evidence that triglycerides are an independent coronary heart disease risk factor. Am J Cardiol. 2000;86(9):943-949.
34. Hokanson J E, Austin MA. Plasma triglyceride level is a risk factor for cardiovascular disease independent of high-density lipoprotein cholesterol level: a meta- analysis of population-based prospective studies. J Cardiovasc Risk. 1996;3(2):213-219.
35. Bainton D, Miller N, Bolton C, et al. Plasma triglyceride and high density lipoprotein cholesterol as predictors of ischemic heart disease; The Carephilly and Speedwell Collaborative Heart Studies. Br Med J. 1992;68:60 – 66.
36. Kulkarni KR, Markovitz JH, Nanda NC, Segrest JP. Increased prevalence of smaller and denser LDL particles in Asian Indians. Arterioscler Thromb Vasc Biol. 1999;19(11):2749-2755.
37. Abate N, Garg A, Enas EA. Physico-chemical properties of low density lipoproteins in normolipidemic Asian Indian men. Horm Metab Res. 1995;27(7):326-331.
38. Superko HR, Enas EA, Kotha P, Bhat N. Impaired cholesterol transport in Asian Indians. J Am Coll Cardiol. 2001;37:300A.
39. Raschke V, Elmadfa I, Bermingham MA, Steinbeck K. Low density lipoprotein subclasses in Asian and Caucasian adolescent boys. Asia Pac J Clin Nutr. 2006;15(4):496-501.
40. Bittner V, Johnson BD, Zineh I, et al. The triglyceride/high-density lipoprotein cholesterol ratio predicts all-cause mortality in women with suspected myocardial ischemia: a report from the Women’s Ischemia Syndrome Evaluation (WISE). Am Heart J. Mar 2009;157(3):548-555.
41. Gaziano JM, Hennekens CH, O’Donnell CJ, Breslow JL, Buring JE. Fasting triglycerides, high-density lipoprotein, and risk of myocardial infarction. Circulation. 1997;96(8):2520-2525.
42. Enas EA, Chacko V, Senthilkumar A, Puthumana N, Mohan V. Elevated lipoprotein(a)–a genetic risk factor for premature vascular disease in people with and without standard risk factors: a review. Dis Mon. Jan 2006;52(1):5-50.