The balance between good and bad cholesterol is an important contributor to cardiovascular and stroke risk.
Basics of cholesterol:
Cholesterol is a fat-like substance found in all cells in the body. Cholesterol travels through the body in small packages called lipoproteins. LDL or low density lipoprotein is bad because it leads to a build up of cholesterol in the body. HDL or high density lipoprotein is good because it carries cholesterol from other parts of the body back to the liver which removes the cholesterol from the blood. Total cholesterol is equal to the sum of HDL + LDL + TG/5. TG (triglycerides) is a type of fat in the blood that impacts a type of bad cholesterol called VLDL (very low density lipoprotein).
Cholesterol and South Asians:
Cholesterol problems are very common among South Asians due to genetic risk, lack of physical activity, and suboptimal dietary habits.
The likelihood of dying from heart disease in young people doubles with every 40 point increase in total cholesterol. LDL and total cholesterol levels among Indians are similar to that of whites but higher than for other Asians. However, for any given level of cholesterol, heart disease risk among South Asians is double that of other ethnic groups. Therefore, the optimal or goal level of total and LDL cholesterol is lower among South Asians.
South Asians tend to have low HDL (good cholesterol) levels which puts them at markedly increased risk for heart disease. HDL is even more important than LDL. Low HDL is three times more common than high LDL in patients with premature heart disease. Centenarian (those lucky few who live to be a 100 years of age) often have very high HDL levels, which may account for their longevity!
What are fasting cholesterol/lipid goals?
The ATP III trial from the National Cholesterol Education Program in the U.S. serves as the reference standard for cholesterol goals. The optimal LDL cholesterol in mg/dL for a person of average risk is 100 or less. 100-129 is near optimal. 130-159 is borderline high. 160 and above is high risk. However, for those individuals who are at very high risk, such as those with history of heart attack or stroke, diabetes, or peripheral vascular disease, the goal LDL is 70 or less.
As the ATP III trial primarily included Caucasians, African-Americans, and Hispanics, the Indian Heart Association believes that the numbers are not tailored towards South Asians. South Asians should have a goal LDL of less than 70 due to their markedly elevated risk for heart disease.
An HDL (good) cholesterol of 40 or less (mg/dL) is considered a risk factor for heart disease for non-South Asians. However, for South Asians, the goal HDL should be 50-60, given their elevated risk. For every 10 point increase in HDL, one is able to decrease their risk for heart disease by half!
Optimal triglyceride levels (mg/dL) are less than 150 while over 200 is considered high. In between is considered borderline risk.
Strategies to improve your cholesterol and lipid profile:
Briefly, those with increased LDL levels (bad cholesterol) should restrict saturated fat to <7% of calories and cholesterol intake to <200 mg/day. In addition, increasing soluble (viscous) fiber through dietary strategies such as increasing oats or psyllium as well as fruits and vegetables can decrease bad cholesterol. Insoluble fiber has more of an effect on digestive health such as decreasing risk for colon cancer and is found in whole-wheat flour and wheat bran.
Saturated fats can be decreased by avoiding fast foods, whole fat dairy products, fried foods, red meats, and margarine or sandwich spreads. Replacing saturated fats with healthy fats is important. Healthy monounsaturated fats include canola and olive oils as well as nuts (almonds and walnuts). Omega-3 fats found in fish such as salmons, mackerel, and tuna as well as fish oil tablets and plant sterol-based margarines (for example Take Control or Benecol) are additional great options to decrease risk for cardiovascular disease.
The most important contributor to elevated triglycerides in South Asians is processed carbohydrates such as white rice and bread products such as naan or puri. Replace white rice with brown rice or rice substitutes such as ragi (millet) or quinoa. Upma or whole-wheat chapathis are additional healthy options.
As the El Camino Hospital aptly phrases it, the goal is at least 2 fistfuls of vegetables/day, 1 fistful of fruit/day, 12 nuts/day, and zero sugared drinks.
Physical activity and weight loss
Physical activity is important for weight loss and healthy living. 30 minutes of daily physical activity, 5 days a week can work wonders for your health! Physical activity doesn’t need to require too much strain and can include walking or gardening!
Weight management is important for improving the lipid profile. South Asians are at high risk for abdominal obesity which increases total cholesterol levels and increases risk for diabetes. An abdominal circumference of 32 inches or greater in women and 36 inches or greater in men is the cutoff for obesity. In addition, the BMI cutoff (body mass index calculated as total body weight in kilograms divided by height in meters squared) for obesity in South Asians is 23 or higher (versus 25 or greater in the general population).
For those whom lifestyle changes with diet and exercise are not sufficient, effective prescription medications are available. Statins are the most potent medication to decrease LDL levels and should be prescribed to those with heart disease or stroke as well as anyone at high risk for heart disease. Statins also have an anti-inflammatory cardioprotective effect and may be helpful despite LDL at goal range. The side effect profile is generally favorable including muscle aches and liver damage in small number of patients. South Asians over 40 years should speak to their physician about potentially starting Statin therapy. Other medications include Fibrates (to decrease triglyceride levels) and Niacin (to increase HDL). A link to other medication types is provided below.
NIH ATP 3 Guidelines and overview of antilipid medications : http://www.nhlbi.nih.gov/health-pro/guidelines/current/cholesterol-guidelines/quick-desk-reference-html
Palo Alto Medical Foundation South Asians and Cholesterol: http://www.pamf.org/southasian/support/handouts/cholesterol.pdf