Indian J Med Res 158, September 2023, pp 269-275 Quick Response Code:

DOI: 10.4103/ijmr.ijmr_2683_21

Lipid profile abnormalities & 10 yr risk of CVD assessment among

adult in North East India: A cross-sectional study

Nilratan Majumder1, Rituparna Das2, Ripan Debbarma3, Nilanjan Majumder4 & Suranjana De5

Department of Paediatrics, Amaltas Institute of Medical Science, Dewas, Madhya Pradesh, Departments of
1

Community Medicine, 3Paediatrics, Agartala Government Medical College, Agartala, Tripura, 4Department of
2

Paediatrics, Tata Main Hospital, Jamshedpur, Jharkhand & 5Division of Nutrition, Indian Council of Medical
Research, New Delhi, India

Received September 3, 2021

Background & objectives: In India, lifestyle changes have contributed to increase in the number of people
suffering from lipid profile abnormalities, which is a major risk factor for coronary artery diseases.
The present study was aimed to estimate the prevalence of lipid profile abnormalities and 10 yr risk
of cardiovascular disease (CVD) among the adult population in west Tripura district and to study the
association of lipid profile abnormalities and increased CVD risk with sociodemography, body mass
index (BMI), hypertension, random blood sugar (RBS) and haemoglobin level.
Methods: This cross-sectional study was conducted amongst 445 adults of 20 to 60 yr of age from
a randomly selected block in west Tripura district. The 10 yr risk of CVD was estimated using the
Framingham Risk Assessment Tool.
Results: The study revealed that overall 83.4 per cent adult population had lipid profile abnormalities,
with 22.2, 42 and 70.3 per cent of participants having hypercholesterolaemia, hypertriglyceridaemia and
low high-density lipoprotein level, respectively. Gender (P=0.02) and BMI (P<0.001) were the significant
determinants of dyslipidaemia. Only 3.8 per cent of participants had intermediate or high risk of CVD,
with all of them being males. Gender, age, occupation and RBS were significantly associated with
increased CVD risk.
Interpretation & conclusions: The study revealed a high burden of lipid profile abnormalities in the study
population, with males having more risk of CVD. Hence, periodic screening of lipid profile abnormalities
and risk of CVD should be incorporated at the primary care level to combat the CVD epidemic in India.

Key words CVD risk - Framingham Risk Assessment - hypercholesterolaemia - hypertriglyceridaemia - lipid profile - HDL - risk

Cardiovascular diseases (CVD) contribute up to atherosclerotic modifiable risk factor for coronary
17.3 million deaths per year globally, which is estimated artery diseases. In India, changes in lifestyle have
to reach 23.6 million deaths by the year 20301. Lipid contributed to an increase in the number of people
profile abnormalities have been considered a major suffering from lipid profile abnormalities2. Again,

© 2023 Indian Journal of Medical Research, published by Wolters Kluwer - Medknow for Director-General, Indian Council of Medical Research
269
270 INDIAN J MED RES, SEPTEMBER 2023

there is emerging evidence that in Asian Indians, was dispersed over a large geographical setting with
premature CAD is occurring at least 10 yr earlier than a considerable number of population; considering the
in other ethnic groups3. Hence, estimation of CVD risk feasibility of blood sample collection in clusters, cluster
amongst adult population is vital for implementation of sampling was adopted in the study and 30 clusters were
preventive strategies at an early age. In this regard, the selected from the block using the PPS technique.
Framingham Risk Score (FRS) serves as a simplified
tool for predicting one’s chance of developing Risk scoring: The FRS was used for the assessment
cardiovascular disease in the long term4. of the risk level of CAD over 10 yr4. The FRS
considers six coronary risk factors: age, gender, total
In the northeastern State of Tripura, lipid profile
cholesterol, high density lipoprotein (HDL), smoking
abnormalities and coronary artery diseases are
habits and systolic blood pressure separately for male
commonly encountered amongst adults, and also in the
and female participants for assigning risk score point
elderly, in clinical settings. However, there is limited
and corresponding risk percentage6. Anthropometry
information regarding its burden and risk of CVD;
was recorded for BMI and blood pressure (BP)
amongst the adult population of the state. Hence, the
measurements were interpreted as per the Joint National
present study was conducted with the objective to
Committee 8 criteria7,8. For lipid profile estimation,
estimate the prevalence of lipid profile abnormalities
5 ml of venous blood was taken and serum cholesterol,
and 10 yr risk of CVD amongst the adult population
triglyceride and HDL were estimated in AutoAnalyzer
in the west Tripura district. The study was aimed to
and interpreted using National Cholesterol Education
assess the association of lipid profile abnormalities and
Program, Adult Treatment Panel III criteria9. RBS was
increased CVD risk with sociodemography, body mass
estimated using glucometer with strips and Hb was
index (BMI), hypertension, random blood sugar (RBS)
estimated using Sahli’s haemoglobinometer. Risks of
and haemoglobin (Hb) level.
developing CVD in the next 10 yr were interpreted using
Material & Methods FRS and corresponding percentage as high risk: >20
per cent, intermediate risk: 10-19 per cent and low risk:
This was a community based cross-sectional study
<10 per cent9,10. Pre-existing coronary artery disease
conducted by the department of Paediatrics, Agartala
was ruled out in the study population based on medical
Government Medical College, Tripura, India, between
history of the last one year for symptoms (chest pain,
August 2018 and July 2019, in a randomly selected
breathlessness, swelling of legs, etc.), and/or available
Dukli RD block of west Tripura district. The study
documents of investigations, hospital admissions and
was approved by the Institutional Ethics Committee
medications suggesting coronary artery disease.
and informed consent was obtained from all the study
participants.
Statistical analysis: Data were entered in Epi Info v7.0
The present study was conducted as a part of the (Centers for Disease Control and Prevention, Atlanta,
multicentre investigation titled ‘Consumption pattern USA), and statistical analysis was performed using the
of food and food products/items high in fat, salt and Chi-square test, Fisher’s exact test and unpaired t test;
sugar among selected cities/towns and rural population P<0.05 was considered significant. .
of India [HFSS (High fat salt sugar) study]’.
Results
Inclusion and exclusion criteria: The study included
adults between 20 and 60 yr of age, who consented to While about a third of the study participants
participate. Pregnant women, and those who were unfit belonged to 31 to 40 yr of age group (31.46%) and
to give valid information were excluded from the study. majority (82.47%) of them were females as female
family members were more available for random
Sample size: The sample size was estimated selection at the family level during data collection. Sixty
considering the prevalence of dyslipidaemia amongst eight per cent study participants belonged to above
adults to be 68.8 per cent5, at five per cent level of poverty line category. The study revealed that overall,
significance. Again, considering a design effect of 2 83.4 per cent of the study participants had one or other
and a non-response rate of 20 per cent, the sample size types of lipid profile abnormalities. The prevalence of
was estimated at 420. However, the study included hypercholesterolaemia, hypertriglyceridaemia and low
data collected from 445 adults residing in the area HDL level amongst adults was 22.2, 42 and 70.3 per
using pre-tested interview schedule. As the study area cent, respectively (Table I).
 MAJUMDER et al: LIPID PROFILE ABNORMALITIES & 10 YR RISK OF CVD 271

Table I. Distribution of study participants according to lipid 0.9%

profile abnormalities 3.8%
Lipid parameters Frequency (n=445), n (%)
Cholesterol (mg/dl), mean±SD 172.52±43.59
Normal cholesterol level 346 (77.8) Low risk of CVD=428

Hypercholesterolaemia 99 (22.2) intermediate risk of CVD= 17

Borderline high 74 (16.6) High risk of CVD= 4

High 25 (5.6)
HDL (mg/dl), mean±SD 43.59±12.59 96.2%
Normal HDL 132 (29.7)
Low HDL 313 (70.3)
Figure. Pie chart showing the 10 yr CVD risk among the study
Triglyceride (mg/dl), mean±SD 154.72±68.93 participants using Framingham Risk Assessment Tool. CVD,
Normal triglyceride level 258 (58) Cardiovascular disease.
Hypertriglyceridaemia 187 (42)
Borderline high 103 (23.1) increased cardiovascular risk (P<0.001). Occupation
High 84 (18.9)
was significantly affecting the risk of CVD (P<0.001),
with homemakers at low risk of CVD. The mean RBS
Any lipid profile abnormality 371 (83.4)
was found to be significantly high among those who
Cholesterol level: Borderline high ‑ 200‑239 mg/dl, are at intermediate/high risk of CVD (P<0.001).
High ‑ >200 mg/dl; Triglyceride level: Borderline high ‑
150‑199 mg/dl, High ‑ 200‑499 mg/dl. SD, standard deviation; Discussion
HDL, high density lipoprotein
The present study showed that overall 83.4
per cent of the study participants had lipid profile
Table II shows the factors associated with lipid abnormalities, with 22.2, 42 and 70.3 per cent adults
profile abnormalities amongst study participants. The having hypercholesterolaemia, hypertriglyceridaemia
study revealed that females (85.8%) had a significantly and low HDL level, respectively. However, according
higher burden of lipid profile abnormalities compared to the ICMR-INDIAB study, the overall prevalence of
to males (71.8%; P=0.002). The lipid profile dyslipidaemia was 79 per cent with 13.9, 29.5, and 72.3
abnormalities had no significant association with age per cent population having hypercholesterolaemia,
and the abnormalities were detected across all age hypertriglyceridaemia and low HDL level,
groups, including those belonging to <30 yr of age. respectively11. Again, a study conducted by Raj et al5
The mean BMI, RBS and Hb were significantly higher in rural South India showed that the prevalence of
among those who had lipid profile abnormalities
dyslipidaemia was 68.8 per cent, whereas the burden
(P<0.001, respectively).
of hypercholesterolaemia, hyper-triglyceridaemia
Figure shows the 10 yr cardiovascular risk among and low HDL level was 25.1, 40 and 63.1 per cent,
study participants and revealed that 2.9 per cent of respectively. Thus, the present study recorded a higher
participants had intermediate risk and 0.9 per cent had burden of lipid profile abnormalities comparable to
a high risk of CVD. Table III shows the descriptive other parts of India.
comparison between the genders for the FRS related
In this study, no significant association of age
variables and revealed that the two groups differed
was observed with lipid profile abnormalities, unlike
significantly in terms of low HDL levels (P=0.02) and
studies conducted by Raj et al5 in south India and
habit of tobacco smoking (P<0.001).
Sharma et al12 in Delhi where age was a significant
Table IV shows the factors associated with 10 yr of determinant. A similar finding was also obtained
risk of CVD using the Framingham Risk Assessment from studies conducted in Jordan by Khader et al13
Tool. The study revealed that 21.8 per cent of males and in China by Zhang et al14. However, the present
had intermediate or high risk of CVD, whereas all study showed that the lipid profile abnormalities were
females were at low risk (P<0.001). There was an evenly distributed across all age groups, including
increased risk of CVD after 40 yr of age and the age those belonging to <30 yr of age, highlighting the
of the participants was significantly associated with prevalence of the condition in younger adults. The
272 INDIAN J MED RES, SEPTEMBER 2023

Table II. Factors associated with lipid profile abnormalities

Sociodemographic factors Lipid profile abnormalities P
Present (n=371), n (%) Absent (n=74), n (%)
Gender
Male 56 (71.8) 22 (28.2) χ2=9.14, P=0.002
Female 315 (85.8) 52 (14.2)
Age group (yr)
<30 78 (83.9) 15 (16.1) χ2=2.86, P=0.418
31‑40 111 (79.3) 29 (20.7)
41‑50 106 (86.9) 16 (13.1)
51‑60 76 (84.4) 14 (15.6)
Education
Illiterate 79 (84.9) 14 (15.1) χ2=1.24, P=0.743
Primary education 75 (82.4) 16 (17.6)
Secondary and H/S 204 (82.6) 43 (17.4)
Graduate and above 13 (92.9) 1 (7.1)
Occupation
Homemaker 255 (85.3) 44 (14.7) χ2=2.92, P=0.571
Farmers/daily labour 82 (78.8) 22 (21.2)
Businessmen or private job 10 (83.3) 2 (16.7)
Government service 11 (84.6) 2 (15.4)
Unemployed/student 13 (76.5) 4 (23.5)
Socioeconomic status
APL 253 (82.95) 52 (17.04) χ2=0.12, P=0.72
BPL 118 (84.28) 22 (15.71)
BMI affecting lipid profile abnormalities
BMI (mean±SD) 28.98±5.45 23.75±3.34 t=7.9, P=0.001
Blood parameters by lipid profile abnormalities
RBS (mg/dl), mean±SD 119.54±3.05 109.25±5.09 t=23.29, P=0.001
Hb (g/dl), mean±SD 11.51±0.08 10.96±0.25 t=34.53, P=0.001
P calculated using Chi‑square or t test as appropriate. P<0.05 was considered as significant. APL, above poverty line; BPL, below
poverty line; RBS, random blood sugar; BMI, body mass index; SD, standard deviation; Hb, haemoglobin

present study also highlighted a higher burden of lipid the World Health Organization (WHO) risk prediction
profile abnormalities among females, which might chart. The lower prevalence in the present study might
have happened as the majority of the females were be because the present study was conducted on adults
homemakers and having sedentary lifestyles. Again, up to 60 yr age. Noticeably, those belonging to >60
the present study could re-establish that high BMI was yr age group hold more risk score in Framingham
associated with lipid profile abnormalities. risk assessment tool giving rise to higher prevalence.
Regarding the long term risk of CVD, the present The present study also showed that only males had
study revealed that 3.8 per cent of participants had intermediate or high risk of CVD, although the
intermediate/high risk of CVD. A study conducted prevalence of dyslipidaemia was high amongst females.
by Kadiyala et al15 in Mysuru, amongst adults >40 yr This could be due to the fact that 43.6 per cent of our
showed that one fifth of the population had moderate male participants were smokers and smoking was an
estimated risk and 7.4 per cent had very high risk of important contributory variable in FRSs. This study
developing CVD event in the next 10 yr, according to further identified significant association of high RBS
 MAJUMDER et al: LIPID PROFILE ABNORMALITIES & 10 YR RISK OF CVD 273

Table III. Descriptive comparison between the genders for the Framingham Risk Score (FRS) related variables
Parameters Male (n=78), n (%) Female (n=367), n (%) P
Age group (yr)
20‑34 21 (26.9) 113 (30.8) χ2=8.88, P=0.17
35‑39 12 (15.4) 70 (19.1)
40‑44 8 (10.3) 37 (10.1)
45‑49 16 (20.5) 49 (13.4)
50‑54 15 (19.2) 43 (11.7)
55‑59 3 (3.8) 38 (10.4)
60 3 (3.8) 17 (4.6)
Cholesterol (mg/dl)
<160 37 (47.4) 148 (40.3) Fisher’s
160‑199 25 (32.1) 136 (37.1) value=2.87, P=0.56
200‑239 14 (17.9) 60 (16.3)
240‑279 2 (2.6) 14 (3.8)
>280 0 9 (2.5)
HDL (mg/dl)
>60 7 (9.1) 37 (10.1) χ2=9.82, P=0.02
50‑59 7 (9.1) 62 (16.9)
40‑49 19 (24.7) 127 (34.6)
<40 44 (57.1) 141 (38.4)
Tobacco smoking
Non‑smoker 44 (56.4) 365 (99.5) χ2=160.3, P<0.001
Smoker 34 (43.6) 2 (0.5)
Systolic BP (mmHg)
<120 8 (10.3) 84 (22.9) χ2=7.74, P=0.17
120‑129 29 (37.2) 133 (36.2)
130‑139 25 (32.1) 91 (24.8)
140‑159 14 (17.9) 48 (13.1)
>160 2 (2.6) 11 (3)
P value calculated using Chi‑square or Fisher’s exact test as appropriate. P<0.05 was considered as significant.

and Hb levels with the risk of CVD. Association of the risk of CVD in the adult population, but several
CVD risk with Hb level might have occurred by play of studies revealed that these scores could not perform
chance in the present cross sectional study, as biologic as good as FRS system16. Another limitation of the
plausibility of such association is currently lacking. present study was that the random blood samples
were used rather than the blood specimen collected at
Despite high prevalence of dyslipidaemia in our
fasting state to estimate lipid profile and Hb level at
study area, only 3.8 per cent participants featured in
community settings.
the category of long-term risk of CVD. This could
be explained by the fact that this study excluded the In conclusion, the present study revealed a high
elderly, and higher age carries more weightage in burden of lipid profile abnormalities in the study area
the Framingham risk scoring system compared to with higher prevalence in females and across all age
high cholesterol and HDL levels. This is a limitation groups, including younger adults. The risk of CVD
of the FRS System. Other scoring systems such as among adults was low and it was associated with
atherosclerotic cardiovascular disease and WHO risk age, gender, and high RBS. Awareness programmes
charts could have been used for better exploration of on the risk of CVD and regular screening of the adult
274 INDIAN J MED RES, SEPTEMBER 2023

Table IV. Factors associated with the risk of cardiovascular disease

Parameters Low risk (n=428), n (%) Intermediate or high risk (n=17), n (%) P
Gender
Male 61 (78.2) 17 (21.8) Fisher’s value=83.16,
Female 367 (100) 0 (0) P<0.001
Age group (yr)
≤30 93 (100) 0 (0) Fisher’s value=21.09,
31‑40 140 (100) 0 (0) P<0.001
41‑50 114 (93.4) 8 (6.6)
51‑60 81 (90.0) 9 (10)
Education
Illiterate 89 (95.7) 4 (4.3) Fisher’s value=4.08,
Primary education 88 (96.7) 3 (3.3) P=0.21
Secondary and H/S 239 (96.8) 8 (3.2)
Graduate and above 12 (85.7) 2 (14.3)
Occupation
Homemaker 299 (100) 0 (0) Fisher’s value=40.5,
Farmers/daily labour 92 (88.5) 12 (11.5) P<0.001
Businessmen or private job 10 (83.3) 2 (16.7)
Government service 11 (84.6) 2 (15.4)
Unemployed/student 16 (94.1) 1 (5.9)
BMI (kg/m2), mean±SD 28.26±4.17 24.35±2.17 t=0.16, P=0.86
BP
Normotensive 78 (100) 0 Fisher’s value=1.65,
Pre‑hypertension and hypertension 350 (95.4) 17 (4.6) P=0.053
RBS, mean±SD 116.17±2.5 159.70±26.02 t=31.88, P=0.001
Hb level (g/dl), mean±SD 11.35±1.72 13.04±1.90 t=3.9, P=0.001
P calculated using Fisher’s exact or t test as appropriate. P<0.05 was considered as significant.

population for lipid profile abnormalities and CVD risk 2. Gupta R, Rao RS, Misra A, Sharma SK. Recent trends
factors should be conducted on a periodic basis and in epidemiology of dyslipidemias in India. Indian Heart
J 2017; 69 : 382-92.
incorporated at the primary health care level.
3. Gupta R, Misra A, Vikram NK, Kondal D, Gupta SS,
Acknowledgment: Authors acknowledge the local health Agrawal A, et al. Younger age of escalation of cardiovascular
risk factors in Asian Indian subjects. BMC Cardiovasc Disord
bodies and ASHA workers for helping us during the study.
2009; 9 : 28.

Financial support & sponsorship: The study was funded 4. Wannamethee SG, Shaper AG, Lennon L, Morris RW.
Metabolic syndrome versus Framingham risk score for
by the Indian Council of Medical Research, New Delhi (Grant no:
prediction of coronary heart disease, stroke, and type 2
5/9/7/HFSS/2018-Nut). diabetes mellitus. Arch Intern Med 2005; 165 : 2644-50.
5. Raj AS, Sivakumar K, Sujatha K. Prevalence of
Conflicts of Interest: None. dyslipidemia in South Indian adults: An urban-rural
comparison. Int J Community Med Public Health 2016; 3 :
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For correspondence: Dr Rituparna Das, Department of Community Medicine, Agartala Government Medical College, Agartala 799 006,
Tripura, India
e-mail: [email protected]