Search tips
Search criteria 


Logo of ijclbiowww.springer.comThis journalToc AlertsSubmit OnlineOpen Choice
Indian J Clin Biochem. 2009 October; 24(4): 343–355.
Published online 2009 December 30. doi:  10.1007/s12291-009-0063-5
PMCID: PMC3453058

Reference intervals for serum total cholesterol, HDL-cholesterol, LDL-cholesterol, triglycerides, Lp (a), apolipoprotein A-I, A-II, B, C-II, C-III, and E in healthy South Indians from Andhra Pradesh


The incidence of cardiovascular and cerebrovascular disease is steadily increasing in South East Asian countries including Indian sub continent. Many lipids, apolipoproteins and Lp (a) except HDL-C and apo A-I, A-II are implicated as risk factors for coronary artery disease and cerebrovascular disease. There is great need to have national guidelines for each country like the ATP III guidelines recommended for U.S. population. For recommending appropriate medical decision limits, it is mandatory that each country establishes reference intervals pertaining to their population due to dietary, genetic and environmental diversity. In the present study, reference intervals for serum lipids, apolipoproteins and Lp (a) were established in a total of 1923 healthy Indian reference individuals comprising 1161 healthy men and 762 healthy women from Andhra Pradesh. For each analyte viz., serum total cholesterol, HDL-C, LDL-C, triglycerides, Lp (a), Apo A-I, Apo A-II, B, C-II, C-III and E, mean, two SD, median, confidence limits of mean, different percentile values are presented. The study also includes decade wise changes in each analyte and comparison of lipids, lipoproteins and Lp (a) among few populations covering U.S., India, Japan, Sweden, Finland and China. Reference Intervals for all lipid and lipoprotein parameters will immensely help in assessing associated risk for cardiovascular and cerebrovascular diseases in India. Additionally, the results will be beneficial in formulating our own guidelines pertaining to Indian population.

Key Words: Blood Lipids, Cholesterol, Triglycerides, Apolipoproteins, Reference Intervals, South Indian Population

Full Text

The Full Text of this article is available as a PDF (160K).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.
1. Tunstall-Pedoe H., Kuulsmaa K., Amouyel P., Arveiler D., Rajakangas A.M., Pajak A. Myocardial infraction and coronary deaths in the world Health Organization MONICA Project: Registration procedures, event rates, and case-fatality rates in 38 populations from 21 countries in four continents. Circulation. 1994;90:583–612. [PubMed]
2. O’Flaherty, Ford E., Allender S., Scarborough P., Capewell S. Coronary heart disease trends in England and Wales from 1984 to 2004: concealed leveling of mortality rates among young adults. Heart. 2008;94:178–181. doi: 10.1136/hrt.2007.118323. [PubMed] [Cross Ref]
3. Marmot M.G., Syme S.L., Kagar A., Kato H., Cohen J.B., Belsky J. Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii and California: Prevalence of coronary and hypertensive heart disease and associated risk factors. Am J Epidemiol. 1975;102:514–525. [PubMed]
4. Howard B.V., Lee E.T., Cowan L.D., Fabsitz R.R., Howard W.J., Oopik A.J., Robbins D.C., Savage P.J., Yeh J.L., Welty T.K. Coronary heart disease prevalence and its relation to risk factors in American Indians: the strong heart study. Am J Cardiol. 1996;78:1400–1405. doi: 10.1016/S0002-9149(96)00642-X. [PubMed] [Cross Ref]
5. Bhopal R., Unwin N., White M., Yallop J., Walker L., Alberti K.G.M.M., et al. Heterogeneity of coronary heart disease risk factors in Indian Pakistani, Bangladeshi and European origin populations: cross sectional study. Brit Med J. 1999;319:215–220. [PMC free article] [PubMed]
6. Coronary heart disease statistics. London: British Heart Foundation; 2007.
7. Berenson G.S., Srinivasan S.R., Bao W., Newman W.P., III, Tracy R.E., Wattigney W.A. Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults. N Eng J Med. 1998;338:1650–1656. doi: 10.1056/NEJM199806043382302. [PubMed] [Cross Ref]
8. Mc Gill H.C., Jr, Mc Mahan C.A., Malcolm G.T., Oilman M.C., Strong J.P. Effects of serum lipoprotein and smoking on arthrosclerosis in young men and women. Arterioscleroses Thromb Vasc Biol. 1997;17:95–106. [PubMed]
9. Stamler J., Daviglus M.L., Garside D.B., Dyer A.R., Greenland P., Neaton J.A. Relationship of baseline serum cholesterol levels in three large cohorts of younger men to coronary, cardiovascular and all cause mortality and to longevity. JAMA. 2000;284:311–318. doi: 10.1001/jama.284.3.311. [PubMed] [Cross Ref]
10. Strong J.P., Malcom G.T., Mc Mahan C.A., Tracy R.E., Newman W.P., III, Hedrick E.E., Cornhill J.F. Prevalence and extent of atherosclerosis in adolescents and young adults’ implications for prevention from pathobiological determinants of atherosclerosis in youth study. JAMA. 1999;281:727–735. doi: 10.1001/jama.281.8.727. [PubMed] [Cross Ref]
11. Austin M.A., McKnight B., Edwards K.L., Bradley C.M., McNeely M.J., Psaty B.M., Brunzell J.D., Motulsky A.C. Cardiovascular disease mortality in familial forms of hypertriglyceridemia: a 20 year prospective study. Circulation. 2000;101:2777–2782. [PubMed]
12. Ingelsson E., Schaefer E.J., Contois J.H., McNamara J.R., Sullivan L., Keyes M.J., Pencina M.J., Schoonmaker C., Wilson P.W., D’Agostino R.B., Vasan R.S. Lipid measures for prediction of coronary heart disease in men and women. JAMA. 2007;298:776–785. doi: 10.1001/jama.298.7.776. [PubMed] [Cross Ref]
13. Cutri B.A., Hime N.J., Nicholls S.J. High-density lipoproteins: an emerging target in the prevention of cardiovascular disease. Cell research. 2006;16:799–808. doi: 10.1038/ [PubMed] [Cross Ref]
14. Chien K.L., Hsu H.C., Su T.C., Sung F.C., Chen M.F., Lee Y.T. Lipoprotein (a) and Cardiovascular Disease in Ethnic Chinese: The Chin-Shan Community Cardiovascular Cohort Study. Clin Chem. 2008;54:285–291. doi: 10.1373/clinchem.2007.090969. [PubMed] [Cross Ref]
15. Chopra V., Wasir H.S. Implications of lipoprotein abnormalities in Indian patients. J Assoc Physicians India. 1998;46:814–818. [PubMed]
16. Hippisley-Cox J., Coupland C., Vinogradova Y., Robson J., Minhas R., Sheikh A., Brindle P. Predicting Cardiovascular risk in England and Wales: prospective derivation and validation of QRISK2. Brit Med J. 2008;336:1475–1482. doi: 10.1136/bmj.39609.449676.25. [PMC free article] [PubMed] [Cross Ref]
17. Grundy S.M., Parternak R., Greenland P., Smith S., Jr, Fustex V. Assessment of cardiovascular risk by use of multiple risk factor assessment equation: a statement for health care professional from the American Heart Association and the American College of Cardiology. Circulation. 1999;100:1481–1492. [PubMed]
18. Misra A., Luthra K., Vikram N.K. Dyslipidemia in Asian Indians: determinants and significance. JAPI. 2004;52:137–142. [PubMed]
19. O’Connor P.J., Gary R.J., Maciosek M.V., Fillbrandt K.M., DeFor T.A., Alexander C.M., Weiss T.W., Teutsch S.M. Cholesterol Levels and Statin Use in Patients with Coronary Heart Disease treated in Primary Care settings (CDC Original research document) Preventing Chronic Disease, Public Health Research, Practice and policy. 2005;2:1–17.
20. Rifai N, Warnick GR. Lipids, lipoproteins, Apolipoproteins, and other cardiovascular risk factors. In Burtis CA Ashwood ER Bruns DE eds. Tietz Textbook of clinical Chemistry and Molecular Diagnostics 4th Ed 2006; 903–981. Elsevier Saunders.
21. Bennet A.M., Angelantonio E.D., Ye Z., Wensley F., Dahlin A., Ahlbom A., Keavney B., Collins R., Wiman B., Faire U., Danesh J. Association of apolipoprotein E genotypes with lipid levels and coronary risk. JAMA. 2007;298:1300–1311. doi: 10.1001/jama.298.11.1300. [PubMed] [Cross Ref]
22. Kottke B.A., Zinsmeister A.R., Holmes D.R., Kneller R.W., Hallaway B.J., Mao S.J.T. Apolipoproteins and Coronary Artery Disease. Mayo Clinic proceedings. 1986;61:313–320. [PubMed]
23. Lamarche B., Moorjani S., Lupien P.J., Cantin B., Bernard P.M., Dagenais G.R., Despres J.P. Apolipoprotein A1 and B levels and the risk of ischemic heart disease during a five year follow up of men in Quebec cardiovascular study. Circulation. 1996;94:273–278. [PubMed]
24. Suzuki M., Wada H., Maeda S., Saito K., Minatoguchi S., Saito K., Seishima M. Increased Plasma Lipid-Poor Apolipoprotein A-I in Patients with Coronary Artery Disease. Clin Chem. 2005;51:132–137. doi: 10.1373/clinchem.2004.041012. [PubMed] [Cross Ref]
25. Tilly P., Sass C., Vincent-Viry M., Aguillon D., Siest G., Visvikis S. Biological and genetic determinants of serum Apo C-III concentration: reference limits from the Stanislas cohort. J Lipid Res. 2003;44:430–436. doi: 10.1194/jlr.M200006-JLR200. [PubMed] [Cross Ref]
26. Walldius G., Jungner I., Holme I., Aastveit A. H., Kolar W., Steiner E. High Apolipoprotein B, low Apolipoprotein A-I, and improvement in the prediction of fatal myocardial infarction (AMORIS study): a prospective study. Lancet. 2001;358:2026–2033. doi: 10.1016/S0140-6736(01)07098-2. [PubMed] [Cross Ref]
27. Rahmani M., Raiszadeh F., Allahverdian S., Kiaii S., Navab M., Azizi F. Coronary artery disease is associated with the ratio of apolipoprotein A-I/B and serum concentration of apolipoprotein B, but not with paraoxonase enzyme activity in Iranian subjects. Atherosclerosis. 2002;162:381–389. doi: 10.1016/S0021-9150(01)00715-8. [PubMed] [Cross Ref]
28. Fulwood R, Kalsbeek W, Rifkind B. National Center for Health Statistics, Total serum cholesterol levels of adults 20–74 years of age; United States, 1976–80 Vital and Health Statistics. Series11. no. 236 DHHS Pub No (PHS) 86-1686 Public Health Service, Washington U.S. Government Printing Office, May 1986;pp 59.
29. Kronmal R.A., Cain R.C., Ye Z., Omenn G.S. Total serum Cholesterol levels and mortality risk as a function of age. Arch Intern Med. 1993;153:1065–1073. doi: 10.1001/archinte.153.9.1065. [PubMed] [Cross Ref]
30. Kastelein J.J.P., Akim F., Stroes E.S.G. Effect of the Combination of Ezetimibe and Simvastatin versus Monotherapy Simvastatin on Arterial Intima-Media Thickness in Familial Hypercholesterolemia (ENHANCE): a randomized controlled trial. N Engl J Med. 2008;358:1431–1443. doi: 10.1056/NEJMoa0800742. [PubMed] [Cross Ref]
31. Pekkanen J., Lenn S., Heiss G., Suchindran C.M., Leon A., Rifkind B.M., Tyroler H.A. Ten year mortality from cardiovascular in relation to cholesterol level among men with and without preexisting cardiovascular disease. N Engl J Med. 1990;322:1700–1707. doi: 10.1056/NEJM199006143222403. [PubMed] [Cross Ref]
32. Saddlemire A.E., Denny C.H., Greenlund K.J., Coolidge J.N., Fan A.Z., Croft J.B. Trends in Cholesterol Screening and Awareness of High Blood Cholesterol — United States, 1991–2003. CDC Mortality and Morbidity weekly report. 2005;54:865–870.
33. Bansal S., Buring J.E., Rafai N., Samia M., Sacks F.M., Ridker P.M. Fasting compared with nonfasting Triglycerides and risk of Cardiovascular events in women. JAMA. 2007;298:309–316. doi: 10.1001/jama.298.3.309. [PubMed] [Cross Ref]
34. Iso H., Naito Y., Sato S., Kitamura A., Okamura T., Sankai T. Serum triglycerides and risk of coronary heart disease among Japanese men and women. Am J Epidemiol. 2001;153:490–499. doi: 10.1093/aje/153.5.490. [PubMed] [Cross Ref]
35. McBride P.R. Triglycerides and risk for coronary heart disease. JAMA. 2007;298:336–338. doi: 10.1001/jama.298.3.336. [PubMed] [Cross Ref]
36. Warnick R.G., Nakajima K. Fasting versus Nonfasting Triglycerides: Implications for Laboratory Measurements. Clin Chem. 2008;54:14–16. doi: 10.1373/clinchem.2007.098863. [PubMed] [Cross Ref]
37. Sacks F.M., Alaupovic P., Moye L.A., Cole T.G., Sussex B., Stampfer M.J., Pfeffer, Braunwald E. VLDL, Apolipoprotein B, CIII and E. Risk of recurrent coronary events in the cholesterol and recurrent events (CARE) trial. Circulation. 2000;102:1886–1892. [PubMed]
38. Bennet A.M., Angelantonio E., Erqou S., Eiriksdottir G. Lipoprotein(a) Levels and Risk of Future Coronary Heart Disease: Large-Scale Prospective Data. Arch Intern Med. 2008;168:598–608. doi: 10.1001/archinte.168.6.598. [PubMed] [Cross Ref]
39. Gaw A., Murray H.M., Brown E.A., the PROSPER study group Plasma lipoprotein (a) [Lp (a)] concentrations and cardiovascular events in the elderly: evidence from the Prospective Study of Pravastatin in the Elderly at Risk (PROSPER) Atherosclerosis. 2005;180:381–388. doi: 10.1016/j.atherosclerosis.2004.12.015. [PubMed] [Cross Ref]
40. Ohira T., Schreiner P.J., Morrisett J.D., Chambless L.E., Rosamond W.D., Folsom A.R. Lipoprotein (a) and incident ischemic stroke: the Atherosclerosis Risk in Communities (ARIC) study. Stroke. 2006;37:1407–1412. doi: 10.1161/01.STR.0000222666.21482.b6. [PubMed] [Cross Ref]
41. Smolders B., Lemmens R., Thijs V. Lipoprotein (a) and Stroke A Meta-Analysis of Observational Studies. Stroke. 2007;38:1959–1966. doi: 10.1161/STROKEAHA.106.480657. [PubMed] [Cross Ref]
42. Singh I.M., Shishehbor M.H., Ansell B.J. High-density lipoprotein as a therapeutic target: a systematic review. JAMA. 2007;298:786–798. doi: 10.1001/jama.298.7.786. [PubMed] [Cross Ref]
43. Frohlich J., Fodor G., McPherson R., Genest J., Langner N. Dyslipidemia working group of health Canada. Rationale for and outline of the recommendations of the working group on hypercholesterolemia and other dyslipidemias. Interim report. Can J Cardiol. 1998;14(suppl):17A–21A. [PubMed]
44. Hata Y., Mabuchi H., Saito Y., Itakura H., Egusa G., Ito H., Teramoto T., Tsushima M., Tada N., Oikawa S., Yamada N., Yamashita S., Sakuma N., Sasaki J. Report of the Japan Atherosclerosis Society (JAS) Guideline for Diagnosis and Treatment of Hyperlipidemia in Japanese Adults. J Atherosclerosis and Thrombosis. 1998;9:1–27. [PubMed]
45. O’Connor P.J. Public health research, practice and policy cent. Preventing Chronic Diseases. CDC document. 2005;2:3–13.
46. Prevention of coronary heart disease: Scientific backgroundnew clinical guidelines. Recommendations of the European Atherosclerosis Society prepared by the International Task Fore for Prevention of Coronary Heart disease. Nutr Metab Cardiovas Dis. 1992;2:113–156.
47. The Expert Panel report of the National Cholesterol Education Programme Expert Panel on detection, Evaluation and Treatment of high blood cholesterol in adults. Arch Intern Med. 1988;148:36–39. doi: 10.1001/archinte.148.1.36. [PubMed] [Cross Ref]
48. National Cholesterol Education Program Expert Panel on Detection Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II) JAMA. 1993;269:3015–3023. doi: 10.1001/jama.269.23.3015. [PubMed] [Cross Ref]
49. National Cholesterol Education Program Second Report of the Expert Panel on Detection Evaluation, and Treatment of High Blood cholesterol in Adults (Adult treatment Panel II) Circulation. 1994;89:1333–1445. [PubMed]
50. Bachorik P.S., Ross J.W. National Cholesterol Education Program recommendations for measurement of low-density lipoprotein cholesterol: executive summary. Clin Chem. 1995;41:1414–1420. [PubMed]
51. Warnick R.G., Wood P.D. National cholesterol Education Program recommendations for measurement of High density lipoprotein cholesterol: executive summary. Clin Chem. 1995;41:1427–1433. [PubMed]
52. Stein E.A. National Cholesterol Education Program recommendations for Triglycerides measurement: executive summary. Clin Chem. 1995;41:1421–1426. [PubMed]
53. National Cholesterol Education Program Expert Panel Executive summary of the third report of the NCEP expert panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) JAMA. 2001;285:2486–2497. doi: 10.1001/jama.285.19.2486. [PubMed] [Cross Ref]
54. Warnick G.R., Myers G.L., Cooper G.R., Rifai N. Impact of the Third Cholesterol Report from the Adult Treatment Panel of the National Cholesterol Education Program on the Clinical Laboratory. Clin Chem. 2002;48:11–17. [PubMed]
55. Patel K., Bhopal R. The epidemic of coronary heart disease in South Asian populations: causes and consequences. Birmingham: South Asian Health Foundation; 2004. p. 164.
56. D’Agostino R.B., Sr., Vasan R.S., Pencina M.J., Wolf P.A., Cobain M., Massaro J.M., et al. General cardiovascular risk profile for use in primary care: the Framingham heart study. Circulation. 2008;117:743–753. doi: 10.1161/CIRCULATIONAHA.107.699579. [PubMed] [Cross Ref]
57. Ashavaid T.F., Kondkar A.A., Todur S.P., Dherai A.J., Morey J., Raghavan R. Lipids, lipoporteins, Apolipoprotein and Lipoprotein (a) levels: reference intervals in a Healthy Indian Population. J Atheroscl Thromb. 2005;12:251–259. [PubMed]
58. Reddy K.S., Prabhakaran D., Chaturvedi V., Jeemon P., Thankappan K.R., Ramakrishnan L., et al. Methods for establishing a surveillance system for cardiovascular diseases in Indian industrial populations. Bulletin of the World Health Organization. 2006;84:461–467. doi: 10.2471/BLT.05.027037. [PubMed] [Cross Ref]
59. Carroll M, Sempos C, Briefel R. Serum lipids of adults 20-74 years, United States, 1976–80, National Center for health Statistics. Vital Health Stat 1993; 11(2242).
60. Li J., Wang J., Li P., Niu Q., Wang S., Jiang L. The investigation of serum lipids and lipoproteins in Beijing (Chinese) Chin Med J. 1988;68:327–331.
61. Li Z., Yang R., Xu G., Xia T. Serum Lipid Concentrations and Prevalence of Dyslipidemia in a Large Professional Population in Beijing. Clin Chem. 2005;51(1):144–150. doi: 10.1373/clinchem.2004.038646. [PubMed] [Cross Ref]
62. Noma A., Hata Y., Goto Y. Quantitation of serum Apolipoprotein A-1, A-II, B, C-II, C-III and E in healthy Japanese by turbidimetric immunoassay: reference values and age — and sex related differences. Clin Chim Acta. 1991;199:147–158. doi: 10.1016/0009-8981(91)90106-M. [PubMed] [Cross Ref]
63. Sakurabayashi I., Saito Y., Kita T., Matsuzawa Y., Goto Y. Reference intervals for serum apolipoproteins A-I, A-II, B, C-II, C-III, and E in healthy Japanese determined with a commercial immunoturbidimetric assay and effects of sex, age, smoking, drinking, and Lp(a) level. Clin Chim Acta. 2001;312:87–95. doi: 10.1016/S0009-8981(01)00591-5. [PubMed] [Cross Ref]
64. Sekimoto H., Goto Y., Goto Y., Naito C., Yasugi T., Okido M., et al. Changes of serum total cholesterol and triglyceride levels in normal subjects in Japan in the past twenty years. Jpn Circ J. 1983;47:1351–1358. [PubMed]
65. Wang S., Man Y., Li H., Dong J., Tang W., Guo H. Changes in serum total cholesterol levels of Beijing professional population during 1981–2001 (Chinese) Chin J Arterioscler. 2003;11:435–438.
66. Pajak A., Williams O.D., Broda G., Baczynska E., Rywik S., Davis C.E., et al. Changes over time in blood lipids and their correlates in Polish rural and urban populations: the Poland-United States Collaborative Study in cardiopulmonary disease epidemiology. Ann Epidemiol. 1997;7:115–124. doi: 10.1016/S1047-2797(96)00125-1. [PubMed] [Cross Ref]
67. Ichihara K., Itoh Y., Lam C.W.K., Poon P.M.K., Kim J.H., Kyono H., Chandrawening N., Muliaty D. Sources of variation for commonly measured serum analytes among 6 Asian cities and consideration of common reference intervals. (Science committee for the Asian Pacific Federation of Clinical Biochemistry) Clin Chem. 2008;54:356–365. doi: 10.1373/clinchem.2007.091843. [PubMed] [Cross Ref]
68. Okayama A., Ueshima H., Marmot M.G., Elliott P., Yamakawa M., Kita Y. Different trends in serum cholesterol levels among rural and urban populations aged 40–59 in Japan from 1960 to 1990. J Clin Epidemiol. 1995;48:329–337. doi: 10.1016/0895-4356(94)00146-H. [PubMed] [Cross Ref]
69. Contois J.H., McNamara J.R., Lammi-Keefe C.J., Wilson P.W., Masov T., Schaefer E.J. Reference intervals for plasma Apolipoprotein A-I determined with a standardized commercial immunoturbidimetric assay: results from the Framingham Offspring Study. Clin Chem. 1996;42:507–514. [PubMed]
70. Contois J.H., McNamara J.R., Lammi-Keefe C.J., Wilson P.W., Masov T., Schaefer E.J. Reference intervals for plasma Apolipoprotein B determined with a standardized commercial immunoturbidimetric assay: results from the Framingham Offspring Study. Clin Chem. 1996;42:515–523. [PubMed]
71. Leino A., Impivaara O., Kaitsaari M., Jarvisalo J. Serum concentrations of apolipoprotein A-I, apolipoprotein B, and lipoprotein (a) in a population sample. Clin Chem. 1995;41:1633–1636. [PubMed]
72. Jungner I., Marcovina S.M., Walldius G., Holme I., Kolar W., Steiner E. Apolipoprotein B and A-I values in 147,576 Swedish males and females, standardized according to the World Health Organization-International Federation of Clinical Chemistry First International Reference Materials. Clin Chem. 1998;44:164. [PubMed]

Articles from Indian Journal of Clinical Biochemistry are provided here courtesy of Springer