Explaining adverse cholesterol levels and distinct gender patterns in an Indonesian population compared with the U.S.

Cardiovascular disease is among the most common causes of death around the world. As rising incomes in low and middle-income countries are accompanied by increased obesity, the burden of disease shifts towards non-communicable diseases, and lower-income settings make up a growing share of cardiovascular disease deaths. Comparative investigation of the roles of body composition, behavioral and socioeconomic factors across countries can shed light on both the biological and social drivers of cardiovascular disease more broadly. Comparing rigorously-validated measures of HDL and non-HDL cholesterol among adults in the United States and in Aceh, Indonesia, we show that Indonesians present with adverse cholesterol biomarkers relative to Americans, despite being younger and having lower body mass index. Adjusting for age, the gaps increase. Body composition, behaviors, demographic and socioeconomic characteristics that affect cholesterol do not explain between-country HDL differences, but do explain non-HDL differences, after accounting for medication use. On average, gender differences are inconsistent across the two countries and persist after controlling observed characteristics. Leveraging the richness of the Indonesian data to draw comparisons of males and females within the same household, the gender gaps among Indonesians are not explained for HDL cholesterol but attenuated substantially for non-HDL cholesterol. This finding suggests that unmeasured household resources play an important role in determining non-HDL cholesterol. More generally, they appear to be affected by social and biological forces in complex ways that differ across countries and potentially operate differently for HDL and non-HDL biomarkers. These results point to the value of rigorous comparative studies to advance understanding of cardiovascular risks across the globe.