"Average predicted 10-year risk of CVD based on the Framingham risk score was lowest in the eastern Indian state of Jharkhand (13.2%) and highest in the southern state of Kerala (19.5%)".

"Kerala, a state in southern India, uses coconut oil in meal preparations, and citizens of this state were found to have the highest rates of CAD in India [8]"

"Saturated Fat (SAFA): .. Kerala, renowned for the universal use of coconut, not only has the highest level of TC in India, but also the highest rate of CAD in India (Table 1). The proportion of subjects with high TC (>239 mg/dL) in Kerala is almost double that of U.S. (32% versus 18%).[167] In Sri Lanka, which also has a very high rate of CAD, about 80% of the fat in the habitual diet comes from coconut.[168] Since the coconut milk and oil have the highest proportion of SAFA (92%) the use of these products should be limited to less than one tablespoon a day.[168,169]"

Keralans have the highest cholesterol level in India that ranges from 197 to 229 mg/dl compared to 157 to 180 mg/dl nationally (see Figure elow).^{1, 2} Cholesterol level in Kerala is approximately 30 to 40 mg/dl higher than the national average in India, as well as in the US.^{1, 2, 5} High cholesterol level (>240 mg/dL) was found in 32% of subjects in Kerala vs. 15% in the US, where the cholesterol level has decreased to 199 mg/dl as a result of national efforts.^{1, 2, 5}

Total fat intake in Kerala is 30% of the energy with 70% of that (20% of daily energy) coming from saturated fat. Generous portions of coconut meat, milk and oil is used for preparing virtually every dishes including vegetables, fish and even meat and bread (Palappam, Vattayappam).^{3, 4}

Coconut is used throughout India as God’s food (offering to God) but as a universal ingredient for cooking in Kerala. Total fat intake in Kerala is 30% of the energy with 70% of that (20% of daily energy) coming from saturated fat.

Special efforts are needed to educate the medical community and the general public about the culturally relevant ways of reducing energy from saturated fat in the form of palm oil, coconut oil, coconut meat, coconut milk, as well as full-fat dairy products to bring cholesterol levels at least to that of the remainder of India.

International differences in heart attack rates are best explained by a difference in blood cholesterol level than any other factor.[1] The foremost determinant of high total cholesterol (TC) level is the consumption of saturated fat (SAFA), which is abundant in all edible coconut products (meat, milk, and oil).

One table spoon (14 gm) of coconut oil contains 126 calories of total fat of which 93 calories is cholesterol-raising SAFA.4 Although coconut products does raise HDL the LDL-C raising is several times higher.[9]

Kerala, renowned for the universal and liberal consumption of coconut meat, milk and oil, not only has the highest level of total cholesterol in India, but also the highest rate of CAD, diabetes, and metabolic syndrome.[13, 14] The proportion of subjects with high total cholesterol (>240 mg/dL) in Kerala is double that of the U.S. (32% versus 15%).[15] The average cholesterol in Kerala is 30-40mg higher than the rest of India (see Kerala Paradox and Kerala Heart Disease).[16, 17] The use of coconut oil as a cooking medium has not spread beyond Kerala and its adjoining areas.

In Sri Lanka, which also has a very high rate of CAD, about 80% of the fat in the habitual diet comes from coconut.[18]

Coconut meat and milk are universal ingredients of cooking in Kerala accounting for a greater proportion of saturated fat consumption than from coconut oil. 3 oz of coconut meat or 3oz of coconut milk contains 12-14g of saturated fat─ the same amount as in one tablespoon of coconut oil. This amount alone provides the saturated fat allowance for the whole day for most individuals.

One serving of coconut rich foods such as palappam, vattaappaam and vegetable thoran and even fish curry may contain no coconut oil, but may contain more than a day’s allowance of saturated fats.[19] Failure to account for the liberal consumption of coconut meat may account for the discordant results of studies from Kerala and elsewhere.4 The calories from 100 grams of fresh and dry coconut are 444 and 662 respectively with most of it being from saturated fats.[23] (for detailed info on most of the Indian foods and latest Dietary Guidelines for Indians click here)

Cholesterol-raising effects of coconut oil are similar or higher than that of butter and meat.[7, 20] In a comparative study of diets rich in beef fat vs. coconut oil, the plasma total cholesterol, LDL, and HDL responses were lower with beef fat than coconut oil commensurate with the lower proportion of cholesterol-raising saturated fat in beef (29%) than coconut oil (74%).[21]

When 22% of the energy intake in a Malaysian diet, high in palm oil, was substituted with coconut oil, there was an increase of 40 mg/dL in total cholesterol, 29 mg/dL in LDL, 36 mg/dL in triglycerides and 4 mg/dL in HDL.[22]

Substituting 21% of daily energy from a high-beef American diet among medical students resulted in 13 mg/dL increase in total cholesterol (TC) with high coconut diet and 14 mg/dL decrease in TC with a high safflower oil diet.[21]

Since coconut milk and oil have the highest proportion of saturated fat, the use of these products should be limited to <1 tablespoon a day even when the diet contains no other sources of saturated fat.[4]

Liberal use of all coconut products except tender coconut water should be discouraged along with all other sources of saturated fat.