3 tables omitted
High blood cholesterol (HBC) (i.e., total cholesterol ≥240 mg/dL)
is a major risk factor for heart disease, the leading cause of death in the
United States.1 As a result, public health agencies and their partners
have attempted to reduce the prevalence of HBC through screening and by increasing
public awareness of HBC and strategies for reducing it. A national health
objectives of Healthy People 2010 is to increase
to 80% the proportion of adults aged ≥20 years who have been screened for
HBC within the preceding 5 years.2 For this report, data from the
Behavioral Risk Factor Surveillance System (BRFSS) collected during 1991-2003
were analyzed to examine trends in the percentage of adults screened for HBC
and the percentage of those screened who were told they had HBC. The findings
indicated that both percentages increased during 1991-2003 but that few states
had achieved the national health objective for screening. Further emphasis
on cholesterol screening is needed, particularly among Hispanic and Asian/Pacific
Islander populations and young adults.
BRFSS is a state-based, random-digit–dialed telephone surveillance
system that samples the noninstitutionalized, U.S. civilian population aged
≥18 years. For this report, CDC analyzed BRFSS data from 1991, 1993, 1995,
1997, 1999, 2001, and 2003 for 1,027,793 persons aged ≥20 years. Response
rates for BRFSS surveys ranged from 71.4% in 1993 to 51.1% in 2001.3 Survey participants were asked whether they had ever had a blood cholesterol
screening and, if so, how long it had been since their last screening. Those
who reported having ever been screened were asked whether they had ever been
told by a health-care professional that they had HBC. Data were weighted to
account for age, race/ethnicity, and sex distributions of the population in
each state. Statistical software was used to account for the complex sampling
design. The results were age-standardized to the 2000 U.S. standard population.4 Percentage change was calculated as the 2003 prevalence minus the
1991 prevalence divided by the 1991 prevalence multiplied by 100.
During 1991-2003, the prevalence of cholesterol screening during the
preceding 5 years and the percentage of persons screened who were told they
had HBC increased overall and among all age, sex, and racial/ethnic groups.
The percentage of those screened within 5 years increased from 67.6% (95%
confidence interval [CI] = 67.2-68.1) in 1991 to 73.1% (CI = 72.7-73.4) in
2003. Although the prevalence of cholesterol screening within 5 years was
higher among women than men in all years represented, the percentage change
in prevalence was smaller for women than men. In 2003, the prevalence of cholesterol
screening was lowest among Hispanics (65.5%; CI = 64.1-67.0) and Asians/Pacific
Islanders (69.6%; CI = 66.9-72.4). The largest percentage changes in prevalence
of cholesterol screening were among American Indians/Alaska Natives and non-Hispanic
blacks. The overall percentage of those screened who had been told they had
HBC increased from 25.3% (CI = 24.7-25.8) in 1991 to 31.1% (CI = 30.7-31.5)
in 2003. The percentage change among men told they had HBC was more than twice
that among women. The percentage of those screened who were told they had
HBC was higher in all racial/ethnic groups in 2003 than in 1991, with the
greatest increase observed among Hispanics. Similarly, reporting of HBC increased
among all age groups, with the largest percentage change in prevalence among
those aged ≥65 years.
In 46 states and the District of Columbia (DC), the prevalence of screening
increased from 1991 to 2003, with percentage change ranging from 0.3% in Iowa
to 17.5% in Kentucky. However, by 2003, only DC and Massachusetts had achieved
the Healthy People 2010 objective for cholesterol
screening, with rates of 80.2% and 80.6%, respectively. The proportion of
screened adults who had been told they had HBC increased in 44 states and
DC, with increases ranging from 1.1% in Vermont to 47.5% in DC.
AE Saddlemire, CH Denny, PhD, KJ Greenlund, PhD, JN Coolidge, MPH, AZ
Fan, MD, PhD, JB Croft, PhD, Div for Heart Disease and Stroke Prevention,
National Center for Chronic Disease Prevention and Health Promotion, CDC.
The findings in this report indicate that the overall percentage of
adults who had had their cholesterol checked during the preceding 5 years
increased during 1991-2003. However, in most states, increases in screening
were moderate; by 2003, only DC and Massachusetts had achieved the Healthy People 2010 objective of 80% screening prevalence. Among those
persons who had ever undergone cholesterol screening, the percentage told
that they had HBC also increased during 1991-2003. The largest increase in
the prevalence of HBC screening occurred during 1999-2001 (5.1%), and in most
states, the prevalence of screening continued to increase during 2001-2003.
The overall increase in cholesterol screening might have been attributable,
in part, to (1) implementation of state heart-disease and stroke-prevention
programs by CDC beginning in 19985; (2) release, in 2000, of Healthy People 2010, with the objective to increase the
proportion of adults who have had their blood cholesterol checked during the
preceding 5 years2; and (3) publication of the National Cholesterol
Education Program Adult Treatment Panel (ATP) II (1993) and ATP III (2001)
reports, which updated clinical guidelines for cholesterol testing and management.6,7 In addition, the large increase in prevalence of screening among
American Indians/Alaska Natives might be the result of a campaign by the Indian
Health Service to improve cholesterol screening, particularly among persons
at high risk for cardiovascular disease, including those with diabetes (JM
Galloway, MD, Indian Health Service, personal communication, 2004).
The increase in percentage of persons ever screened who were told that
they had HBC might reflect either an increased prevalence of cholesterol screening
or an increase in the prevalence of HBC in the population. However, data based
on actual serum cholesterol levels indicate that the percentage of the U.S.
population aged ≥20 years with HBC decreased slightly between the 1988-1994
and 1999-2002 National Health and Nutrition Examination Surveys.8
The findings in this report are subject to at least two limitations.
First, BRFSS data are based on respondent self-reports; respondents might
have been unaware, forgotten, or not been told that they had been screened
for cholesterol or had HBC, resulting in an underestimation of the prevalence
of screening and HBC. Second, BRFSS excludes households without telephones.
HBC is one of the major modifiable risk factors for heart disease and
stroke. One approach to reducing blood cholesterol levels has been to increase
public awareness and reinforce educational messages about the risks of HBC.5,6,9 Cholesterol levels can be reduced through dietary changes (e.g.,
reduced intake of saturated fats and dietary cholesterol), increased physical
activity, and drug treatment.7 Although substantial progress has
been made in reducing cholesterol levels since the mid-1980s,9 an
increased emphasis on cholesterol screening is necessary if more states are
to achieve objectives set forth in Healthy People 2010.
The public health community and health-care systems should emphasize cholesterol
screening of young adults and Hispanic and Asian/Pacific Islander populations
to meet the national health objective and the overall Healthy
People 2010 goal of eliminating health disparities.
This report is based, in part, on contributions by A Tsai, PhD, Minnesota
Dept of Health.
REFERENCES: 9 available
Trends in Cholesterol Screening and Awareness of High Blood Cholesterol—United
States, 1991-2003. JAMA. 2005;294(16):2021-2022. doi:10.1001/jama.294.16.2021