Progress in Chronic Disease Prevention Cholesterol Awareness in Selected States -- Behavioral Risk Factor Surveillance, 1987

Over the past 10 years, the association between high levels of serum cholesterol and increased risk of coronary heart disease (CHD) has been well documented (1). In addition, a growing body of evidence demonstrates that individuals with elevated cholesterol levels can reduce their risk of CHD by lowering their serum cholesterol and that a 1% decline in serum cholesterol results in a 2% decline in the risk of cardiovascular disease (2). The 3%-4% decline in serum cholesterol reported among U.S. adults from 1960 to 1980 has probably contributed to the overall decline in CHD mortality observed during this period (3).

In November 1985, the National Heart, Lung, and Blood Institute (NHLBI) initiated the National Cholesterol Education Program (NCEP), a cooperative undertaking by health organizations in the United States (4). The goal of the program is to contribute to lowering the morbidity and mortality from CHD by reducing the prevalence of elevated serum cholesterol in this country.* The NCEP focuses on public education; its central theme is "Know your blood cholesterol number." Individuals are encouraged to ask about serum cholesterol the next time they see their doctor; to have their cholesterol tested if they have not already done so; to know their number, or level; and to learn whether their cholesterol level needs to be lower.

To determine the proportion of adults who report having taken these steps, data from the 33 states (including the District of Columbia) that participated in the 1987 Behavioral Risk Factor Surveillance System (BRFSS) were analyzed. Since 1984, state health departments have collected these data by conducting telephone surveys of the adult residents of their states (5). Telephone surveys using random-digit dialing are conducted every month throughout the year, and approximately 1,500 interviews are completed annually in each state. Respondents are selected randomly from all adults living in each household. The results presented here are weighted to account for the age, race, and sex distribution of adults in each state in 1980 as well as for the respondents' probability of selection.

The 1987 survey included three questions regarding cholesterol testing and awareness. Respondents were asked whether they had ever had their cholesterol tested. If so, they were asked whether they had been told their cholesterol level, and those who had been given this information were asked what their level was.

The proportion of adults in each state who reported having had their cholesterol tested ranged from 29% to 57%, with a median of 47% (Table 1). The proportion of adults who reported being told their value ranged from 3% to 29%, with a median of 19%. Finally, the proportion of adults who were able to provide a value for their cholesterol ranged from 1% to 9%, with a median of 6% (Figure 1).

Although current levels of individual cholesterol awareness in the United States are low, they appear to be increasing. Surveys conducted by the NHLBI in 1983 and and again in 1986 show that the proportion of adults in the United States who reported that their serum cholesterol had been checked rose from 35% to 46%, and the proportion who claimed to know their cholesterol level rose from 3% to 7% (6). The proportion of U.S. adults who had had their cholesterol tested (46%) and who knew their cholesterol level (7%) in 1986 are similar to the median values of the states participating in the 1987 BRFSS (47% and 5%). Reported by: R Strickland, Alabama Dept of Public Health. T Hughes, Arizona Dept of Health Svcs. L Parker, California Dept of Health Svcs. C Mitchell, District of Columbia Dept of Human Svcs. S Hoecherl, Florida Dept of Health and Rehabilitative Svcs. JD Smith, Georgia Dept of Human Resources. E Tash, Hawaii Dept of Health. J Mitten, Idaho Dept of Health and Welfare. B Stiner, Illinois Dept of Public Health. S Joseph, Indiana State Board of Health. K Bramblett, Kentucky Cabinet for Human Resources. M Gay, Maine Dept of Human Svcs. A Winestein, Maryland State Dept of Health and Mental Hygiene. L Koumjian, Massachusetts Dept of Public Health. N Salem, Minnesota Center for Health Statistics. M Van Tuinen, Missouri Dept of Health. R Moon, Montana State Dept of Health and Environmental Sciences. R Thurber, Nebraska State Dept of Health. K Zaso, New Hampshire State Dept of Health and Welfare. L Pendley, New Mexico Health and Environment Dept. H Bzduch, New York State Dept of Health. C Washington, North Carolina Dept of Human Resources. B Lee, North Dakota State Dept of Health. E Capwell, Ohio Dept of Health. J Cataldo, Rhode Island Dept of Health. D Lackland, South Carolina Dept of Health and Environmental Control. L Post, South Dakota State Dept of Health. D Ridings, Tennessee Dept of Health and Environment. J Fellows, Texas Dept of Health. C Chakley, Utah Dept of Health. K Tollestrup, Washington Dept of Social and Health Svcs. R Anderson, West Virginia State Dept of Health. R Miller, Wisconsin Center for Health Statistics. Div of Nutrition, Center for Health Promotion and Education, CDC. Editorial Note: The proportion of adults who reported having had their cholesterol tested varied widely from state to state. This variation may reflect differences either in the availability and use of public or private cholesterol testing or in the respondents' awareness of the results of past testing.

Fewer than one in ten adults in the states participating in the BRFSS claimed to know their cholesterol value. This low level of awareness appears to result from several factors. First, fewer than half of the adults who had had their cholesterol tested said that they were told their value, and second, fewer than a third of those who were told their cholesterol level remembered it.

In recognition of the need for federal, state, and local activities supporting cholesterol awareness, April 1988 has been designated as "National Know Your Cholesterol Month" (4). Efforts such as this should be continued to encourage all adults to have their cholesterol tested, to encourage health-care providers to inform patients of their cholesterol value and its significance, and to help individuals to "know their numbers."

Continuing the downward trend of serum cholesterol levels in the United States will depend initially on improved awareness. However, long-term progress in reducing risk from elevated cholesterol will require broad, population-based changes in diet as well as adherence to drug regimens, when warranted. Data from the BRFSS can be useful in planning and monitoring the progress of population-based programs to improve cholesterol awareness. References

1. Office of Medical Applications of Research, National Institutes of Health. Lowering blood cholesterol to prevent heart disease. JAMA 1985;253:2080-6.

2. Lipid Research Clinics Program. The lipid research clinics coronary primary prevention trial results. II. The relationship of reduction in incidence of coronary heart disease to cholesterol lowering. JAMA 1984;251:365-74.

3. National Center for Health Statistics; National Heart, Lung, and Blood Institute Collaborative Lipid Group. Trends in serum cholesterol levels among U.S. adults aged 20 to 74 years: data from the National Health and Nutrition Examination Surveys, 1960 to 1980. JAMA 1987; 257:937-42.

4. Cleeman JI, Lenfant C. The U.S. National Cholesterol Education Program: raising health professional and public awareness about the importance of lowering high blood cholesterol. In: Grundy SM, Bearn AG, eds. The role of cholesterol in atherosclerosis: new therapeutic opportunities. Philadelphia: Hanley & Belfus, 1988:213-29.

5. Remington PL, Smith MY, Williamson DF, et al. Design, characteristics, and usefulness of state-based behavioral risk factor surveillance: 1981-1987. Public Health Rep (in press).

6. Schucker B, Bailey K, Heimbach JT, et al. Change in public perspective on cholesterol and heart disease: results from two national surveys. JAMA 1987;258:3527-31. *A serum cholesterol level of 240 mg/dL or greater is considered "high"; 200 to 239 mg/dL is considered "borderline-high"; and less than 200 mg/dL is considered "desirable" (4).

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