Key takeaways:

• The number of adults with elevated LDL increased from 2.5 billion to 4.6 billion since 1990.
• The burden of elevated LDL now affects more middle-income countries, despite lower LDL-related mortality.

The number of adults with elevated LDL increased from 2.5 billion in 1990 to 4.6 billion in 2023, with 6% of all global deaths attributable to high LDL in 2023, according to study findings published in JAMA.

Although age-standardized deaths and disability-adjusted life-years associated with elevated LDL decreased since 1990, the LDL burden shifted and now affects more middle-income countries, researchers reported.

Data derived from GBD 2023 LDL Cholesterol Collaborators. JAMA. 2026;doi:10.1001/jama.2026.8628.

“LDL is one of the most established, modifiable drivers of ASCVD, yet most data track population lipid trends in isolation from actual outcomes,” Christian Razo, PhD, acting assistant professor in the department of health metrics sciences at the Institute for Health Metrics and Evaluation and University of Washington, told Healio. “We wanted to quantify the ischemic heart disease and stroke burden attributable to elevated LDL globally and identify where that burden is growing fastest and why.

“LDL’s causal role has been settled for decades, and there are well-known, effective lifestyle and medical interventions available. Despite decades of knowledge, surveillance, testing and treatment still aren’t reaching most people at risk,” Razo told Healio. “The findings function less as a discovery and more as a measurement of a known, preventable problem that isn’t being acted on at the scale the evidence has demanded for years.”

For the present study, the Global Burden of Disease 2023 LDL Cholesterol Collaborators used data from 204 countries and territories to estimate population-level LDL exposure, data from 806 studies across 161 countries to calculate mean LDL levels and data from 38 randomized trials to assess relative risk for ischemic heart disease and stroke related to elevated LDL.

Trends from 1990 to 2023 in LDL burden and its impact on mortality and DALYs were reported.

During that time, the global number of adults aged at least 25 years with LDL of 54 mg/dL or higher increased from approximately 2.5 billion to 4.6 billion, according to the study.

Researchers reported that countries with the lowest age-standardized mean LDL levels — less than 80 mg/dL — included Burkina Faso, Lesotho, Somalia and Rwanda. Countries with the highest age-standardized mean LDL levels — more than 135 mg/dL — included Serbia, Slovenia, Russia, Norway and Austria.

From 1990 to 2023, sharp increases in age-standardized mean LDL were reported in countries with low LDL levels at baseline, such as São Tomé and Príncipe, Cameroon and Bangladesh, whereas consistent declines in LDL levels were observed in several high sociodemographic index countries such as Belgium, the Netherlands, Norway, Finland, Germany, Switzerland and Sweden.

In 2023, elevated LDL accounted for 3.6 million deaths, or 6% of global mortality, and 90.7 million DALYs; however, rates of age-standardized death decreased 45.6% and rates of age-standardized DALYs decreased 39.5% since 1990, according to the study.

“Our results can be used to inform regional- and country-level policies that strengthen surveillance systems and position primary care as the delivery point for cholesterol screening and treatment,” Razo told Healio. “They also can serve as a benchmark. Country- and region-level breakdowns show where health systems are losing ground, whether from rising exposure, an aging population or stalled care quality or other factors, compared against similar peers rather than the global average. That specificity can guide where to prioritize resources, from promoting lifestyle interventions to expanding healthcare and treatment access.”

After omitting risk related to other modifiable risk factors, researchers reported that DALY rates associated with elevated LDL shifted toward middle-sociodemographic areas since 1990.

“The larger shift needed is from treating CVD after it presents to catching cardiometabolic risk decades earlier, starting with baseline lipid screening in childhood rather than waiting for a first cardiac event,” Razo told Healio. “Because obesity, high BP, high fasting plasma glucose and high LDL often coexist in the same patients, health systems also need combined approaches that screen for and manage these risk factors jointly, rather than in isolation.”

For more information:

Christian Razo, PhD, is acting assistant professor in the department of health metrics sciences at the Institute for Health Metrics and Evaluation and University of Washington. Razo can be reached at razoc@uw.edu.