Elevated LDL-C and non-HDL-C in U.S. adults with normal total serum cholesterol

Serum total cholesterol (TC) <200 mg/dL is considered normal for adults in laboratory reporting and public health messaging, although low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (non-HDL-C) may be elevated within this range.

Determine the prevalence of elevated LDL-C and non-HDL-C among adults with normal TC.

We used 2011-2020 National Health and Nutrition Examination Survey data to determine survey-weighted prevalence of elevated LDL-C, non-HDL-C, and statin eligibility among adults without atherosclerotic cardiovascular disease (ASCVD) who had TC <200 mg/dL without lipid-lowering therapy.

Among 9163 participants representing 82.6 million adults, 47.5% (95% CI, 45.2%-49.8%) had LDL-C ≥100 mg/dL and 30.8% (29.4%-32.1%) had non-HDL-C ≥130 mg/dL. Elevated LDL-C or non-HDL-C was highest among adults with elevated triglycerides or metabolic syndrome. Prevalence decreased with lower TC, and no participants with TC <150 mg/dL had LDL-C ≥100 mg/dL or non-HDL-C ≥130 mg/dL. Among adults aged 40 to 75 years, 43.3% were statin-eligible based on 2018 U.S.

Nearly half of ASCVD-free U.S. adults with 'normal' TC have elevated LDL-C or non-HDL-C, supporting greater emphasis on atherogenic cholesterol measures for public health and individual risk stratification.