European Journal of Cardiovascular Medicine

Cardiovascular disease (CVD) has emerged as the leading cause of mortality worldwide, and India contributes disproportionately to this global burden, accounting for nearly one-fifth of all CVD deaths [1]. Dyslipidemia, characterised by abnormal levels of total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and triglycerides, is one of the most important and modifiable risk factors for atherosclerotic cardiovascular disease [2].

Indians are known to have a distinct ‘atherogenic dyslipidemia’ phenotype, characterised by low HDL-cholesterol and raised triglycerides, along with small dense LDL particles, which confers a higher cardiovascular risk even at relatively lower levels of total cholesterol compared with Western populations [3,4]. The landmark ICMR-INDIAB study reported that nearly four-fifths of the Indian adult population had an abnormality in at least one lipid parameter, with low HDL-cholesterol being the commonest abnormality [2]. Similarly, a cross-sectional study among urban Asian Indians reported a high prevalence of hypercholesterolemia and hypertriglyceridemia across all age groups [5].

Enas et al. have repeatedly highlighted the epidemic of premature coronary artery disease among Indians, occurring nearly a decade earlier than in Western populations, and have called for aggressive screening and management of dyslipidemia as a national health priority [6,7]. Despite this substantial burden, awareness regarding lipid disorders among the general population remains poor, with several studies reporting low rates of awareness, treatment and control of hypercholesterolemia in urban and rural India [8,9].

Poor awareness translates into delayed screening, late diagnosis and suboptimal control of dyslipidemia, thereby increasing the risk of premature myocardial infarction and stroke. Given the rapid epidemiological transition, changing dietary patterns, sedentary lifestyle and rising prevalence of obesity and diabetes in India, there is a pressing need to assess community awareness regarding lipid disorders so that targeted health education strategies can be designed [10,11].

With this background, the present study was undertaken to assess the level of awareness regarding lipid disorders and their role in cardiovascular disease prevention among adults attending a tertiary care hospital, and to determine its association with the actual lipid profile of the study population.

Study design and setting

This hospital-based, observational, cross-sectional study was conducted in the Department of General Medicine in collaboration with the Department of Biochemistry of a tertiary care teaching hospital in India, over a period of Six months after obtaining approval from the Institutional Ethics Committee. Written informed consent was obtained from all participants prior to enrolment.

Study population and sample size

Adults aged 20-65 years attending the medicine outpatient department and health check-up clinic, willing to participate, were included in the study. Patients with known dyslipidemia already on lipid-lowering therapy, pregnant women, and those with chronic kidney disease, hypothyroidism or hepatic dysfunction likely to secondarily alter the lipid profile were excluded. Taking the expected prevalence of adequate awareness regarding dyslipidemia as 40% (based on previous regional studies), with an absolute precision of 5% and 95% confidence interval, the minimum required sample size was calculated to be 369, which was rounded off to 400 to account for non-response. Participants were selected by systematic random sampling from the outpatient registration list.

Study tool

A pre-designed, pre-tested, structured questionnaire, prepared after review of similar published literature and validated by subject experts, was administered by face-to-face interview. The questionnaire included three sections: (a) socio-demographic details (age, sex, residence, education, occupation, family history of CVD); (b) awareness regarding normal lipid levels, risk factors, symptoms, complications and preventive/lifestyle measures for dyslipidemia (15 items, each scored as 1 for a correct response and 0 for an incorrect/'do not know' response); and (c) personal history of smoking, alcohol use, physical activity and dietary habits. Based on the total awareness score (maximum score 15), awareness was categorised as poor (<50% score), moderate (50-74%) and adequate (≥75%).

Biochemical investigations

A 5 ml venous blood sample was collected from each participant after a 12-hour overnight fast. Serum total cholesterol, triglycerides and HDL-cholesterol were estimated by standard enzymatic colorimetric methods on a fully automated biochemistry analyser, and LDL-cholesterol was calculated using the Friedewald formula (in participants with triglycerides <400 mg/dl). Dyslipidemia was defined as per NCEP-ATP III criteria: total cholesterol ≥200 mg/dl, LDL-cholesterol ≥130 mg/dl, triglycerides ≥150 mg/dl, and HDL-cholesterol <40 mg/dl in men and <50 mg/dl in women [12].

Statistical analysis

Data were entered in Microsoft Excel and analysed using SPSS software version 20.0 (IBM Corp.). Descriptive statistics were expressed as mean ± standard deviation for continuous variables and as frequency and percentage for categorical variables. The Chi-square test was used to determine the association between awareness level and socio-demographic variables/lipid abnormalities. A p-value <0.05 was considered statistically significant.

A total of 400 participants were enrolled in the study, comprising 218 (54.5%) males and 182 (45.5%) females, with a mean age of 42.6 ± 11.4 years. The socio-demographic profile of the study population is summarised in Table 1.

Table 1: Socio-demographic profile of the study population (n=400)

On assessment of awareness regarding lipid disorders, only 138 (34.5%) participants had adequate awareness, 154 (38.5%) had moderate awareness, and 108 (27.0%) had poor awareness (Table 2). Awareness regarding normal cholesterol levels and dietary sources of saturated fat was particularly low.

Table 2: Overall awareness level regarding lipid disorders (n=400)

Table 3: Item-wise awareness regarding lipid disorders and CVD risk (n=400)

The association between awareness level and socio-demographic variables is shown in Table 4. Adequate awareness was significantly higher among participants with graduate-level education (52.5%), urban residents (41.0%) and those with a positive family history of CVD (46.3%) as compared with their counterparts (p<0.05 for all).

Table 4: Association between awareness level and socio-demographic factors

On analysis of the fasting lipid profile, dyslipidemia (abnormality in one or more parameters) was found in 245 (61.2%) participants. The commonest abnormality was low HDL-cholesterol (46.5%), followed by hypertriglyceridemia (34.0%), raised LDL-cholesterol (28.7%) and raised total cholesterol (24.2%) (Table 5), a pattern consistent with the atherogenic dyslipidemia described in earlier Indian studies [2,5].

Table 5: Pattern of dyslipidemia among the study population (n=400)

A significant inverse association was observed between the level of awareness and the presence of dyslipidemia. Among participants with poor awareness, 68.3% had dyslipidemia, compared with 58.4% in the moderate awareness group and 48.9% in the adequate awareness group (χ²=14.26, p=0.001) (Table 6).

Distribution of selected lifestyle risk factors among the study population is shown in Table 7. Sedentary lifestyle was reported by 42.5% of participants, current tobacco use by 21.5%, regular alcohol consumption by 18.0%, and a diet rich in fried/fatty food by 48.0%. Each of these behavioural risk factors was more prevalent among participants in the poor awareness group as compared with the adequate awareness group.

Table 7: Distribution of lifestyle risk factors among the study population (n=400)

Table 8 compares the prevalence of dyslipidemia observed in the present study with that reported in earlier Indian studies, showing a broadly comparable pattern of atherogenic dyslipidemia dominated by low HDL-cholesterol and hypertriglyceridemia across different regions of the country.

Table 8: Comparison of prevalence of dyslipidemia with other Indian studies

Table 6: Association between awareness level and presence of dyslipidemia

χ² = 14.26, p = 0.001 (statistically significant)

The present study found that only about one-third of the study population had adequate awareness regarding lipid disorders, which is consistent with previous Indian studies reporting poor awareness, treatment and control of hypercholesterolemia among both urban and rural populations [8,9]. This low level of awareness is of particular concern given that Indians are genetically predisposed to an atherogenic dyslipidemia phenotype dominated by low HDL-cholesterol and hypertriglyceridemia, as reported in the ICMR-INDIAB study and other large Indian cohorts [2,5].

In the present study, dyslipidemia was detected in 61.2% of participants, with low HDL-cholesterol being the commonest abnormality (46.5%), closely mirroring the pattern reported in the ICMR-INDIAB study, where nearly four-fifths of subjects had at least one lipid abnormality and low HDL-cholesterol was similarly the predominant finding [2]. This atherogenic pattern, characterised by low HDL-cholesterol and raised triglycerides even at near-normal total cholesterol levels, has previously been highlighted by Enas et al. as a key contributor to the premature coronary artery disease epidemic among Indians, occurring nearly a decade earlier than in Western populations [6,7].

Awareness in the present study was significantly higher among participants with higher educational attainment, urban residence and a positive family history of cardiovascular disease. This finding is in agreement with earlier observations that educational status is strongly associated with better cardiovascular risk-factor knowledge and healthier lifestyle practices in Indian populations [10,13]. The higher awareness among urban participants may be attributed to greater exposure to mass media, health camps and easier access to diagnostic facilities as compared with rural counterparts, a disparity also reported in other Indian community-based studies [9,14].

Interestingly, participants with a family history of CVD demonstrated better awareness, possibly because personal exposure to a family member's illness acts as a strong motivator for seeking health-related information. However, despite this better awareness, the overall prevalence of dyslipidemia in this subgroup remained high, suggesting that awareness alone, without translation into actual behaviour change and regular screening, may be insufficient to reduce cardiovascular risk [11,15].

The significant inverse association observed between awareness level and the presence of dyslipidemia in the present study (68.3% in the poor awareness group versus 48.9% in the adequate awareness group) reinforces the importance of health education as a cost-effective strategy for primary prevention of cardiovascular disease. Similar associations between poor risk-factor awareness and higher prevalence of metabolic risk factors have been reported from other regions of India, underscoring the need for structured, community-based lipid screening and awareness programmes, particularly in rural and less-educated populations [9,16].

Given the rising burden of obesity, diabetes and sedentary lifestyle-related disorders in India, integrating lipid awareness and opportunistic screening into existing non-communicable disease control programmes, along with school- and workplace-based health education, may help bridge this awareness gap and facilitate early detection and management of dyslipidemia [10,11].

A high prevalence of sedentary lifestyle, tobacco use and consumption of fried/fatty foods was noted in the present study, and these behavioural risk factors were more common among participants with poor awareness. This is consistent with earlier reports linking urbanisation, dietary transition and reduced physical activity with the rising burden of dyslipidemia and metabolic risk factors in India [10,11,16]. It reinforces the concept that awareness and lifestyle behaviour are closely interlinked, and health education interventions must simultaneously address knowledge gaps as well as practical barriers to adopting a heart-healthy lifestyle, such as time constraints, dietary preferences and lack of safe spaces for physical activity.

Limitations

This being a single-centre, hospital-based study, the findings may not be entirely generalisable to the general community. Awareness was assessed using a structured questionnaire, which, despite prior validation, is subject to recall and social-desirability bias. The cross-sectional design precludes establishment of a causal relationship between awareness and dyslipidemia. Multicentric, community-based studies with a longitudinal design are recommended to  these findings.

The present study demonstrates that awareness regarding lipid disorders among adults attending a tertiary care hospital in India remains inadequate, particularly among rural, less-educated participants. A significant proportion of the study population had undetected dyslipidemia, predominantly characterised by low HDL-cholesterol and hypertriglyceridemia, the typical atherogenic pattern seen in Indians. Poor awareness was significantly associated with a higher prevalence of dyslipidemia, highlighting the crucial role of health education in the primary prevention of cardiovascular disease. Strengthening community awareness programmes, promoting regular lipid screening, and encouraging healthy dietary and lifestyle practices should be prioritised as key public health strategies to reduce the growing burden of cardiovascular disease in India.

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