Trends in ATP-III-Defined High Blood Cholesterol Prevalence, Awareness, Treatment and Control Among U.S. Adults

doi:10.1016/j.annepidem.2007.01.032

Annals of Epidemiology

Volume 17, Issue 7, July 2007, Pages 548-555

https://doi.org/10.1016/j.annepidem.2007.01.032 Get rights and content

Purpose

We sought to determine trends in the prevalence, awareness, treatment and control of high low-density lipoprotein (LDL) cholesterol among U.S. adults.

Methods

Data from 6497 participants of the Third National Health and Nutrition Examination Survey (NHANES) conducted in 1988−1994 and 5626 participants of NHANES 1999−2004 were compared. High LDL cholesterol was defined using risk-specific cut-points from the National Cholesterol Education Program's Adult Treatment Panel III guidelines.

Results

The age-standardized percentage of U.S. adults with high LDL cholesterol was 26.6% in 1988−1994 and 25.3% in 1999−2004 (P = 0.28). Between 1988−1994 and 1999−2004, awareness increased from 39.2% to 63.0%, and use of pharmacologic lipid-lowering treatment increased from 11.7% to 40.8% (each p < 0.001). LDL cholesterol control increased from 4.0% to 25.1% among those with high LDL cholesterol (p < 0.001). In 1999−2004, rates of LDL cholesterol control were lower among adults ages 20−49 years compared with those age 65 years or older (13.9% vs. 30.3%; p < 0.001); non-Hispanic blacks and Mexican-Americans compared with non-Hispanic whites (17.2% and 16.5% vs. 26.9%, respectively; p = 0.05 and p = 0.008); and males compared with females (22.6% vs. 28.0%; p = 0.01).

Conclusions

Continued efforts are needed to lower the burden of high LDL cholesterol and increase LDL cholesterol control, especially among populations with low control rates.

Introduction

A major modifiable risk factor in the development of atherosclerosis and subsequent coronary heart disease (CHD) is increased levels of low-density lipoprotein (LDL) cholesterol (1). Statin therapy has been shown to lower LDL cholesterol by 30% to 40% and reduce CHD incidence by 23% to 31% 2, 3. The National Cholesterol Education Program's third Adult Treatment Panel (ATP-III), along with an update including results from five major lipid-lowering clinical trials, provide guidelines for the diagnosis and treatment of high blood cholesterol 3, 4.

Previous analyses have identified trends in higher awareness, treatment, and control of total cholesterol. However, the ATP-III guidelines recommend LDL cholesterol as the primary target of clinical lipid management. Therefore, it may be more relevant to characterize trends in high LDL cholesterol for U.S. adults.

The primary aim of the present analysis was to determine trends in the percentage of U.S. adults ages 20 years and older with high LDL cholesterol in 1988−1994 and 1999−2004 using serial National Health and Nutrition Examination Surveys (NHANES) and cut-points derived from the ATP-III guidelines. Additionally, trends in high LDL cholesterol awareness, treatment and control were calculated over this same time period.

Section snippets

Study Population

Data from the current study were derived from NHANES III for 1988 through 1994 and NHANES 1999−2004. These surveys, conducted by the National Center for Health Statistics of the Centers for Disease Control and Prevention, are nationally representative samples of the noninstitutionalized civilian U.S. population identified through a stratified, multistage probability sampling design. In each survey, participants were asked to complete in-home interviews followed by a visit to a mobile

Results

Compared with 1988−1994, the age-standardized mean total- and LDL-cholesterol levels were significantly lower in 1999−2004 (Table 1). Additionally, there was a shift in the distribution of US adults into lower ATP-III-defined total- and LDL-cholesterol groupings. In contrast, significant increases in HDL cholesterol and triglyceride levels occurred between 1988−1994 and 1999−2004.

The prevalence of CHD, including risk equivalents, did not significantly change from 1988−1994 (15.5%) to 1999−2004

Discussion

Although the prevalence of high LDL cholesterol in U.S. adults did not change significantly between 1988−1994 and 1999−2004, substantial increases in the awareness, treatment, and control of high LDL cholesterol occurred during this time period. In 1999−2004, more than half of individuals with high LDL cholesterol were aware of this condition, and a majority of those aware were treated with pharmacologic lipid-lowering medication. However, the most impressive observation may be that, between

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Associations of Late Adolescent or Young Adult Cardiovascular Health With Premature Cardiovascular Disease and Mortality
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Citation Excerpt :
Undertreatment of young adult risk factors is further compounded by clinical guidelines that focus primarily on adults ≥40 years of age or utilize 10-year CVD risk calculators that are heavily weighted on age (39). Together, these factors result in low rates of ambulatory care use; preventive health guideline adherence; and awareness, treatment, and control of established risk factors among young adults in the current system (39–43). Another major implication of our data is that CVH in late adolescence or young adulthood may serve as a valid intermediate or surrogate outcome for investigations of early life determinants of premature CVD and mortality risks.
When measured in adolescence or young adulthood, cardiovascular health (CVH) is associated with future subclinical cardiovascular disease (CVD), but data are lacking regarding CVD events or mortality.
This study examined associations of CVH at ages 18 to 30 years with premature CVD and mortality.
This study analyzed data from the CARDIA (Coronary Artery Risk Development in Young Adults Study). CVH was scored at baseline (1985 to 1986) using Life’s Simple 7 metrics and categorized as high (12 to 14 points), moderate (8 to 11), or low (0 to 7). CVD events and cause-specific mortality were adjudicated over 32 years of follow-up. Adjusted associations were estimated using Cox models and event rates and population attributable fractions were calculated by CVH category.
Among 4,836 participants (mean age: 24.9 years, 54.8% female, 50.5% Black, mean education: 15.2 years), baseline CVH was high (favorable) in 28.8%, moderate in 65.0%, and low in 6.3%. During follow-up, 306 CVD events and 431 deaths occurred. The adjusted hazard ratios for high (vs. low) CVH were 0.14 (95% confidence interval [CI]: 0.09 to 0.22) for CVD and 0.07 (95% CI: 0.03 to 0.19) for CVD mortality, and the population attributable fractions for combined moderate or low (vs. high) CVH were 0.63 (95% CI: 0.47 to 0.74) for CVD and 0.81 (95% CI: 0.55 to 0.92) for CVD mortality. Among individuals with high CVH, event rates were low across sociodemographic subgroups (e.g., CVD rates per 1,000 person-years: age 18 to 24 years, 0.64; age 25 to 30 years, 0.65; men, 1.04; women, 0.36; Blacks, 0.90; Whites, 0.50; up to/through high-school education, 1.00; beyond high-school education, 0.61).
High CVH in late adolescence or young adulthood was associated with very low rates of premature CVD and mortality over 32 years, indicating the critical importance of maintaining high CVH.
Associations of Blood Pressure and Cholesterol Levels During Young Adulthood With Later Cardiovascular Events
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Citation Excerpt :
However, young adults are difficult to reach by way of traditional, clinic-based preventive programs: they are transitioning between pediatric and adult-centered models of care (36); they often lack health insurance or experience frequent gaps in insurance coverage (37); and their use of ambulatory medical care and adherence to preventive health guidelines are the lowest of any age group (36,38). Data from National Health and Nutrition Examination Surveys showed that young adults lagged behind in awareness, treatment, and control of high BP and LDL compared with middle-aged and older adults (39,40), and were especially unlikely to be aware of borderline levels of BP and cholesterol, which were associated with future risk of CHD and HF in our study (41). Even when informed about a cholesterol screening result that indicates they are at high risk for future CVD, young adults may discount the importance of such results for their current health, believing they have time to change their health behaviors and mitigate their risk (42).
Blood pressure (BP) and cholesterol are major modifiable risk factors for cardiovascular disease (CVD), but effects of exposures during young adulthood on later life CVD risk have not been well quantified.
The authors sought to evaluate the independent associations between young adult exposures to risk factors and later life CVD risk, accounting for later life exposures.
The authors pooled data from 6 U.S. cohorts with observations spanning the life course from young adulthood to later life, and imputed risk factor trajectories for low-density lipoprotein (LDL) and high-density lipoprotein cholesterols, systolic and diastolic BP starting from age 18 years for every participant. Time-weighted average exposures to each risk factor during young (age 18 to 39 years) and later adulthood (age ≥40 years) were calculated and linked to subsequent risks of coronary heart disease (CHD), heart failure (HF), or stroke.
A total of 36,030 participants were included. During a median follow-up of 17 years, there were 4,570 CHD, 5,119 HF, and 2,862 stroke events. When young and later adult risk factors were considered jointly in the model, young adult LDL ≥100 mg/dl (compared with <100 mg/dl) was associated with a 64% increased risk for CHD, independent of later adult exposures. Similarly, young adult SBP ≥130 mm Hg (compared with <120 mm Hg) was associated with a 37% increased risk for HF, and young adult DBP ≥80 mm Hg (compared with <80 mm Hg) was associated with a 21% increased risk.
Cumulative young adult exposures to elevated systolic BP, diastolic BP and LDL were associated with increased CVD risks in later life, independent of later adult exposures.
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Cardiovascular disease is the leading cause of death in women in the United States. Although awareness of coronary artery disease (CAD) risk and presentation in women has increased over the last 3 decades, sex-related disparities persist. Women continue to be underrepresented in clinical trials, and this affects the accuracy of cardiovascular risk assessment models, diagnostic modalities, and treatments for this population. More women than men present with atypical symptoms during an acute coronary syndrome, and this may be attributed to a gender-specific pathophysiology of disease. Nonobstructive CAD and plaque erosion is more common in women who present with acute myocardial infarction compared to men. Further studies are needed to determine whether sex-based diagnostic modalities and therapy can improve the morbidity and mortality of women with CAD. However, until these studies are performed, it is imperative that the current, gender-neutral guidelines be applied for women just as for men. This chapter reviews the differences in awareness, risk factors, pathophysiology, clinical presentation, diagnostic evaluation, and management between men and women with CAD.
A genome-wide search for gene-by-obesity interaction loci of dyslipidemia in Koreans shows diverse genetic risk alleles
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Dyslipidemia is a well-established risk factor for CVD. Studies suggest that similar fat accumulation in a given population might result in different levels of dyslipidemia risk among individuals; for example, despite similar or leaner body composition compared with Caucasians, Asians of Korean descent experience a higher prevalence of dyslipidemia. These variations imply a possible role of gene-obesity interactions on lipid profiles. Genome-wide association studies have identified more than 500 loci regulating plasma lipids, but the interaction structure between genes and obesity traits remains unclear. We hypothesized that some loci modify the effects of obesity on dyslipidemia risk and analyzed extensive gene-environment interactions (G×Es) at genome-wide levels to search for replicated gene-obesity interactive SNPs. In four Korean cohorts (n = 18,025), we identified and replicated 20 gene-obesity interactions, including novel variants (SCN1A and SLC12A8) and known lipid-associated variants (APOA5, BUD13, ZNF259, and HMGCR). When we estimated the additional heritability of dyslipidemia by considering G×Es, the gain was substantial for triglycerides (TGs) but mild for LDL cholesterol (LDL-C) and total cholesterol (Total-C); the interaction explained up to 18.7% of TG, 2.4% of LDL-C, and 1.9% of Total-C heritability associated with waist-hip ratio. Our findings suggest that some individuals are prone to develop abnormal lipid profiles, particularly with regard to TGs, even with slight increases in obesity indices; ethnic diversities in the risk alleles might partly explain the differential dyslipidemia risk between populations. Research about these interacting variables may facilitate knowledge-based approaches to personalize health guidelines according to individual genetic profiles.
World Heart Federation Cholesterol Roadmap
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The World Heart Federation has undertaken an initiative to develop a series of Roadmaps.
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Through a review of published guidelines and research papers, and consultation with a committee composed of experts in clinical management of cholesterol and health systems research in LMIC, this Roadmap identifies (1) key interventions for primordial, primary and secondary prevention of CVD through detection, treatment, and management of elevated cholesterol and familial hypercholesterolemia (FH); (2) gaps in implementation of these interventions (knowledge-practice gaps); (3) health system roadblocks to treatment of elevated cholesterol in LMIC; and (4) potential strategies for overcoming these.
Despite strong evidence of the importance of cholesterol levels in primary or secondary prevention of CVD, and the effectiveness of statin therapy for cholesterol lowering and reduction of CVD risk, gaps exist in the detection, treatment, and management of high cholesterol globally. Some potential roadblocks include poor access to laboratory facilities or trained professionals for cholesterol management, low awareness of FH among the general population and health professionals, unaffordability of statins for patient households, and low awareness of the importance of persistent adherence to lipid-lowering medication. Potential solutions include point-of-care testing, provision of free or subsidized lipid-lowering medication, and treatment adherence support using text message reminders.
Known effective strategies for detection, treatment, and management of elevated cholesterol and FH exist, but there are barriers to their implementation in many low-resource settings. Priorities for health system intervention should be identified at the national level, and the feasibility and effectiveness of proposed solutions should be assessed in specific contexts. Many solutions proposed in this Roadmap may apply to other cardiovascular conditions and present opportunities for integration of CVD care in LMIC.
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2017, Canadian Journal of Cardiology
Comparative cardiovascular risk factor care across North America is unknown. We aimed to determine current performance in Canada and the United States (US).
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A total of 127 studies reporting on 10,510,324 individuals across North America were included. Hypertension awareness (84.3%) and treatment (82.0%) rates in Canada and the US (82.7% and 75.6%, respectively) were above target, whereas control in both nations was below target (68.1% vs 51.8%, respectively). Canadian awareness, treatment, and control rates for dyslipidemia (42.7%, 40.9%, and 41.5%, respectively) were suboptimal, and American indicators were generally below target (61.5%, 43.0%, and 63.6%, respectively). Canada and the US showed diabetes awareness (88.2% vs 86.8%) and treatment rates (82.3% vs 82.5%) above target. However, glucose control was suboptimal in Canada (35.3%), and below target in the US (58.8%). There was a modest decline in absolute smoking prevalence rates in Canada from 1999 to 2013 (25.2% to 14.6%). Screening for tobacco use (72.2%) and counselling rates (73.8%) in the US were above target.
Substantial variation exists in cardiovascular risk factor care across North America. Standardized reporting, dissemination of practice guidelines, and setting explicit goal-directed targets for performance might facilitate improvement.
La prise en charge des facteurs de risque cardiovasculaire en Amérique du Nord n’a pas fait l’objet d’études comparatives. Nous avions pour objectif de déterminer la performance actuelle au Canada et aux États-Unis (É.-U.).
Nous avons procédé à un examen systématique de Medline et d’EMBASE (jusqu’au 1^er juin 2014). Les études admissibles faisaient état des taux de dépistage, de sensibilisation, de traitement ou de maîtrise de l’hypertension, de la dyslipidémie, du diabète et du tabagisme. Nous avons utilisé les « cotes » de performance catégoriques s’appuyant sur les régimes de santé les plus prospères des É.-U. pour classifier les taux comme étant sous-optimaux (< 50 %), sous les cibles (50 %-70 %), au-dessus des cibles (70 %-90 %), ou optimaux (> 90 %).
Nous avons inclus un total de 127 études faisant état de 10 510 324 individus de l’Amérique du Nord. Pour ce qui est de l’hypertension, les taux de sensibilisation (84,3 %) et de traitement (82,0 %) au Canada et aux É.-U. (82,7 % et 75,6 %, respectivement) se situaient au-dessus des cibles, tandis que les taux de maîtrise dans les deux pays se situaient sous les cibles (68,1 % vs 51,8 %, respectivement). Pour ce qui est de la dyslipidémie au Canada, les taux de sensibilisation, de traitement et de maîtrise (42,7 %, 40,9 % et 41,5 %, respectivement) étaient considérés comme étant sous-optimaux, alors que les indicateurs des É.-U. se situaient généralement sous les cibles (61,5 %, 43,0 % et 63,6 %, respectivement). En ce qui concerne le diabète, le Canada et les É.-U. montraient des taux de sensibilisation (88,2 % vs 86,8 %) et de traitement (82,3 % vs 82,5 %) au-dessus des cibles. Cependant, la maîtrise de la glycémie était sous-optimale au Canada (35,3 %), et sous les cibles aux É.-U. (58,8 %). Les taux de prévalence absolue du tabagisme au Canada ont connu un déclin modeste de 1999 à 2013 (25,2 % à 14,6 %). Le dépistage de l’utilisation du tabac (72,2 %) et les taux de counseling (73,8 %) aux É.-U. se situaient au-dessus des cibles.
Il existe une variation substantielle entre la prise en charge des facteurs de risque cardiovasculaire en Amérique du Nord. Les rapports normalisés, la diffusion des lignes directrices de pratique et l’établissement de cibles explicites orientées vers l’objectif de performance aideraient à l’amélioration.

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Trends in ATP-III-Defined High Blood Cholesterol Prevalence, Awareness, Treatment and Control Among U.S. Adults

Purpose

Methods

Results

Conclusions

Introduction

Section snippets

Study Population

Results

Discussion

Coronary heart disease prediction from lipoprotein cholesterol levels, triglycerides, lipoprotein(a), apolipoproteins A-I and B, and HDL density subfractions: The Atherosclerosis Risk in Communities (ARIC) Study

Circulation

The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Major outcomes in moderately hypercholesterolemic, hypertensive patients randomized to pravastatin vs usual care: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT-LLT)

JAMA

Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults. Executive summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)

JAMA

Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines

Circulation

Prediction of coronary heart disease using risk factor categories

Circulation

The diagnosis of ischaemic heart pain and intermittent claudication in field surveys

Bull World Health Organ

National Center for Health Statistics. National Health and Nutrition Examination Survey III Manual for Medical Technicians

Estimation of the concentration of low-density lipoprotein cholesterol in plasma without use of the preparative ultracentrifuge

Clin Chem

NHANES 1999–2000 Addendum to the NHANES III Analytic Guidelines