The latest Global Burden of Disease study has found that while the number of deaths and years lost to disability from elevated LDL-C in Australia have decreased over the last 30 years, there is still a long way to go.
It’s good news for Australia on the cholesterol and heart disease front, but we’re far from mission accomplished on a global scale.
Increased low-density lipoprotein cholesterol (LDL-C) levels are a key modifiable risk factor for atherosclerotic cardiovascular disease, primary ischaemic heart disease, and stroke. Consequently, LDL-C levels feature in several CVD risk prediction models and clinical guidelines, as well as being monitored in global noncommunicable disease trends.
“The objective of this study was to quantify the global, regional, and national burden of CVD attributable to elevated LDL-C from 1990 to 2023 and to assess the contributions of population growth, aging, changes in LDL-C exposure, and risk-deleted rates to trends in this burden,” the Global Burden of Disease Study 2023 LDL Cholesterol Collaborators wrote in JAMA.
Researchers sourced population-level LDL-C data from 806 population-based studies conducted in 161 countries. Over 4.5 billion people were included in these studies, which captured data from 1962 to 2023. GBD 2023 considered elevated LDL-C relative to the theoretical minimum risk exposure level of 35-54mg/dL.
Between 1990 to 2023 the number of adults aged ≥25 years with an LDL-C level ≥54mg/dL increased by more than two billion, from roughly 2.5 billion (95% uncertainty interval 2.4-2.6 billion) in 1990 to 4.6 billion (4.3-4.7 billion) in 2023.
Larger increases in the age-standardised mean LDL-C levels occurred in countries with lower baseline LDL-C levels (e.g., Cameroon, Bangladesh), while countries with higher sociodemographic indices (e.g., Switzerland, the Netherlands, and Germany) saw decreases in LDL-C levels over time.
The increase in the number of adults with elevated LDL-C levels was accompanied by an increase in the number of deaths (from 2.6 million [1.5-3.8 million] in 1990 to 3.6 million [2.2-5.4 million] in 2023) and disability-adjusted life years (65.5 million [41.0-92.5 million] to 90.7 million [58.9-123.2 million] in 2023) attributable to said elevations.
In addition, high LDL-C levels were the second leading cause of CVD mortality and sat in the top 10 for global all-cause disease burden in 2023. The researchers deemed elevated LDL-C levels responsible for 6.0% (3.7-8.9%) of all-cause deaths, 8.1% (5.0-11.9%) of noncommunicable disease deaths, and 18.9% (12.4-27.6%) of CVD-related deaths.
The mean LDL-C level in Australia exceeded 128.6mg/dL in 2023 despite falling between -0.10% and 0% each year between 1990 and 2023. Australian-specific data revealed also the number of deaths attributable to LDL-C fell from 15,259 (9319-21,522) in 1990 to 9380 (5691-13,786) in 2023 – a 38.5% (29.47-48.1%) decrease – while the age standardised death rate fell from 82.1 (50.0-115.8) to 17.0 (10.7-24.4), a 79.2% (76.7-81.7% decline). The reduction in age-standardised DALY rate was similar: a 76.8% (74.2-79.5%) decline over the study period from 1649.9 (1110.1-2233.6) to 382.5 (266.9-522.2).
“Our findings reveal a persistent and uneven disease burden attributable to elevated LDL-C,” the researchers concluded. “While the global age-standardised mortality and DALY rates declined, the absolute burden continues to rise due to population growth and aging, particularly in low- and middle-SDI settings.”
“This divergence between declining age-standardised rates and the rising absolute burden indicates that advances in lipid-lowering therapies and clinical management are being outpaced by demographic forces, with population growth and aging contributing nearly equally to the increase in total burden.
“At the same time, while high-SDI settings have experienced sustained declines in absolute burden, an increasing share of the burden is concentrated in middle-and low-SDI settings, where gaps in prevention, detection, and treatment remain substantial. These patterns underscore the need for context-specific strategies that explicitly account for the interaction between demographic changes and health system capacity across settings.”
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The researchers went on to highlight that statins were not being used to their full potential, and that there were many barriers to managing hypercholesterolaemia including low awareness, the costs associated with testing and treatment, and potential concerns about adverse effects.
“Addressing these gaps requires strengthening primary care systems, improving access to affordable diagnostics and medications, and standardised, guideline-based treatment,” they noted, before discussing the benefits and limitations of fixed-dose combination therapies (polypills) and other novel lipid-lowering therapies.
“Addressing the global LDL-C–related burden requires a comprehensive framework beyond pharmacological intervention,” they said.
“Primordial and primary prevention are fundamental; robust evidence supports regular physical activity and dietary patterns high in fibre and plant-based foods, alongside reduced intake of trans and saturated fats, to improve lipid profiles and cardiovascular health. However, individual behaviour change must be reinforced by population-level policies, including industrial food reformulation, nutritional labelling, and urban design that promotes active transport.”
Writing in an accompanying editorial, Professor Mark Huffman, Professor Victor Dávila-Román, and Assistant Professor Anubha Agarwal, all from the global health research program at Washington University in St Louis in the United States, said the results prompted several questions on what actionable steps could be taken to reduce the high rates of elevated LDL-C on the global scale.
“Population-wide elimination of artificial trans fatty acids through implementation of the World Health Organization’s REPLACE package provides an exemplar approach,” they said.
“Adopting policies that eliminate artificial trans fatty acids have been associated with reduction in CVD events posited to be driven by favourable lipid trends. Warning labels identifying foods high in unhealthy fats are increasingly implemented to raise consumer awareness, but other policies designed to lower LDL-C, such as Denmark’s short-lived tax on saturated fat, have less traction and sustainability.
“Broader efforts to improve the healthfulness, sustainability, and affordability of the food supply, including healthy fats, will require collective action, especially given the anticipated increase in burden of LDL-Cwith projected population growth, aging, and economic growth.”
The trio went on to highlight how the (in)ability of healthcare systems to expand their capacity could pose challenges for any attempts at reducing LDL-C levels.
“Scarcity abounds in terms of health workers, laboratory supplies to accurately measure serum cholesterol and its subfractions, and reliable accessibility of quality lipid-lowering medications.
“Simpler strategies such as polypills or even long-acting lipid-lowering medications taken twice annually offer the promise of new ways of easing strained systems and patients. Systems will need considerably more strengthening, including through collective action to lower costs of consumable testing supplies and medications to turn promises like this into reality.”
JAMA, 29 July 2026 (manuscript)
JAMA, 29 July 2026 (editorial)
