Guidelines by CDC (Center for Disease Control), USA are summarized below. These are followed by the vast majority of doctors and heart associations.

Source: Getting Your Cholesterol Checked (CDC, 2020).

However, based on Framingham Study Data (outlined in the section above) and additional sources of inquiry, Whole Food Plant-Based doctors insist that Total Cholesterol < 150 And LDL < 70 is best for primary prevention. By primary prevention is meant that we are trying to prevent the first heart attack.

Dr Enas A Enas (see his biography) is a well known cardiologist specializing in heart disease among Indian diaspora in USA, UK, Australia, Canada, …). He heads CADI Research which is a treasure trove of information on the subject. In 2009, as part of the 2nd Indo-US Health Summit, he led the publication of this research paper:

(2009) Recommendations of the second Indo-U.S. health summit on prevention and control of cardiovascular disease among Asian Indians by Enas et al, 2009 May-Jun;61(3):265-74 (PDF file).

For US populations, Total Cholesterol < 200 is considered 'desirable'. What is the equivalent threshold for Indian populations? The publication above explains that the threshold should be 160!

TC < 160 (as outlined in Dr Enas' writings) is recommended in multiple publications on South Asian populations.

An excerpt from Address ASCVD Risk in South Asians Living in the US by National Lipid Association (2021) [notice the guideline: TC < 160]:

Source: Address ASCVD Risk in South Asians Living in the US by National Lipid Association (2021).

Figure 1 from South Asian Cardiovascular Health: Lessons Learned from the National Lipid Association Scientific Statement by Kulkarni A, Mancini GBJ, Deedwania PC, Patel J, American College of Cardiology (2021).

Why is TC < 160 a good threshold for Indian sub-continent and South Asian populations? The reasoning is somewhat technical.

(2009) Recommendations of the second Indo-U.S. health summit on prevention and control of cardiovascular disease among Asian Indians by Enas et al, 2009 May-Jun;61(3):265-74 (PDF file). Key passages from this publication that explain why Asian Indians have higher risk and why Total Cholesterol thresholds need adjustments:

An excerpt from 2016 European Guidelines on cardiovascular disease prevention in clinical practice, European Heart Journal (2016) 37, 2315–2381 [For South Asians, risk should be multiplied by 1.4]:

Prevention of atherosclerotic cardiovascular disease in South Asians in the US: A clinical perspective from the National Lipid Association by Kalra et al, Journal of Clinical Lipidology, Volume 15, Issue 3, May–June 2021, Pages 402-422.

Atherosclerotic Cardiovascular Disease in South Asians in the United States: Epidemiology, Risk Factors, and Treatments: A Scientific Statement From the American Heart Association by Volgman et al; Circulation, 2018 Jul 3;138(1):e1-e34. Excerpts:

Whole Food Plant-Based doctors argue that TC < 200 is a weak guideline; a significant number of heart attacks happen in the range 150 < TC < 200. See this article: Total Cholesterol < 150 And LDL < 70?

But wait a minute! What is the equivalent guideline for Asian Indians or Indian Americans or South Asians?

What would be the equivalent of Total Cholesterol < 150 And LDL < 70? for populations in India, Indian sub-continent and South Asia? As far as I know, nobody has done these calculations. Perhaps because the equivalent of Framingham Heart Study does not exist for these populations in Asia. Some researchers have suggested that we desperately need Framingham-style studies to understand heart disease better in Indian populations. Perhaps multiple regional studies are necessary due to diversity of Indian populations.

What's my guess for 'Ideal Total Cholesterol level' for Indians? Perhaps 130. That's a pretty low value for Total Cholesterol! But given the high propensity of Indian populations for metabolic conditions like obesity, heart disease, diabetes and hypertension, it's conceivable that we need such low Total Cholesterol thresholds. Further research is needed.

Additionally, it would be helpful to do Esselstyn-style studies for Indian populations too! Do we continue to see fantastic results, as outlined in Dr Esselstyn: Can We Become Heart Disease Proof? Or would fewer people of Indian origin become 'heart attack proof' (as Esselstyn calls them)? If so, do we need additional modalities like more exercise and more stress management (via meditation, for example)? Further research is needed.

Should LDL < 50 mg/DL be encouraged for primary prevention of heart attacks in India? Dr Rajiv Bhagwat, an interventional cardiologist in Mumbai expresses his opinion in this article in Indian express (2023):