Progress in Chronic Disease Prevention State-Specific Changes in Cholesterol Screening and Awareness -- United States, 1987-1988

High blood cholesterol is a major risk factor for coronary heart disease (1), which is the leading cause of death for persons of all ages and the third leading cause of years of potential life lost before age 65 in the United States (2). To reduce the prevalence of elevated blood cholesterol levels in the United States, the National Heart, Lung, and Blood Institute (NHLBI) initiated the National Cholesterol Education Program (NCEP) in November 1985. NCEP goals are for all adults greater than or equal to 20 years of age to 1) have their blood cholesterol level measured at least once every 5 years, 2) know their cholesterol level, and 3) take steps to lower their cholesterol level if it is elevated (3).* To measure state-specific progress toward these goals, questions regarding cholesterol screening and awareness were included in the Behavioral Risk Factor Surveillance System (BRFSS) during 1987 and 1988.

Health departments participating in the BRFSS conduct monthly random-digit-dialed telephone surveys of persons greater than or equal to 18 years of age using a standardized questionnaire (5). In 1987 and 1988, respondents were asked whether they had ever had their cholesterol "checked" and, if so, how long had it been since their cholesterol level was last checked and whether they had been told their cholesterol level. Persons who reported they had been told their cholesterol level were asked to state their level; those who reported a number from 100 mg divided by L through 450 mg divided by L were considered to know their cholesterol level. Survey results were adjusted according to the age, sex, and race distribution of adults in each state. Prevalence estimates using combined data were adjusted according to the population size in each state and are therefore representative of the total population in these states. SESUDAAN, a computer software program for analyzing complex sample survey data (6), was used to calculate standard errors for the prevalence estimates.

In 1988, the percentage of adults who reported ever having their cholesterol checked ranged from 40% in New Mexico to 58% in Maine (median: 50%) (Table 1). From 1987 to 1988, statistically significant increases in cholesterol screening occurred in 17 (52%) of 33 states (median difference: 4%). Of the remaining 16 (48%) states, four had negligible decreases (likely the result of variability due to sampling), one had no change, and 11 had small increases in cholesterol screening.

In 1988, the percentage of adults who reported ever being told their cholesterol level ranged from 18% in South Carolina and Tennessee to 40% in Wisconsin (median: 28%) (Table 2, page 311). All states had increases in the percentage of adults who were ever told their cholesterol level; these increases were statistically significant for 32 (97%) states (median difference: 8%).

In 1988, the percentage of adults who reported knowing their cholesterol level ranged from 6% in the District of Columbia to 21% in Maine, Washington, and Wisconsin (median: 13%) (Table 3). In all states, the percentage of adults who reported knowing their cholesterol level increased (median difference: 7%); for 32 (97%) states, this increase was statistically significant.

When the data for all states were combined, 54% of persons surveyed in 1988 who reported having their cholesterol level checked during the previous year were told their cholesterol level; in contrast, 40% of those surveyed in 1987 had been told their cholesterol level during the previous year. Similarly, 54% of those surveyed in 1988 who were told their level reported knowing their level, compared with 36% of those surveyed in 1987. As a result, the proportion of persons who knew their cholesterol level among those who reported having their cholesterol checked during the previous year increased from 15% in 1987 to 29% in 1988. Reported by: The following state BRFSS coordinators: L Eldrige, Alabama; J Contreras, Arizona; P Sanchietti, California; S Hoecherl, Florida; JD Smith, Georgia; A Villafuerte, Hawaii; J Mitten, Idaho; B Steiner, Illinois; S Joseph, Indiana; K Bramblett, Kentucky; R Schwartz, Maine; A Weinstein, Maryland; L Koumijian Yandel, Massachusetts; N Salem, Minnesota; J Jackson-Thompson, Missouri; M McFarland, Montana; R Thurber, Nebraska; K Zaso, New Hampshire; L Pendley, New Mexico; J Marin, New York; C Washington, North Carolina; M Maetzold, North Dakota; E Capwell, Ohio; R Cabrel, Rhode Island; M Mace, South Carolina; S Moritz, South Dakota; D Riding, Tennessee; J Fellows, Texas; B Neiger, Utah; K Tollestrup, Washington; A Peruga, Washington, DC; J Criniti, West Virginia; M Soref, Wisconsin. R Stark, MD, C Mastrantuono, American Heart Association. C Haines, MPH, National Heart, Lung, and Blood Institute, National Institutes of Health. A Levy, PhD, Div of Consumer Studies, Food and Drug Administration. Behavioral Surveillance Br, Office of Surveillance and Analysis and Div of Chronic Disease Control and Community Intervention, Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The proposed health objectives for the nation state that by the year 2000 at least 90% of persons aged greater than or equal to 18 years should have had their cholesterol checked within the previous 5 years and at least 75% should be able to report their cholesterol level (7). Data from the BRFSS indicate that substantial progress was made in most states toward meeting these objectives from 1987 to 1988. National surveys conducted by the NHLBI and the Food and Drug Administration (FDA) have also demonstrated substantial increases in cholesterol screening and awareness. In these surveys, the proportion of persons who reported ever having their blood cholesterol checked rose from 35% in 1983 to 58% in 1988, and the proportion who reported knowing their cholesterol level rose from 3% in 1983 to 17% in 1988 (8 ; NHLBI and FDA, unpublished data).

Cholesterol screening and awareness varied substantially by state. Factors that account for this variation may include state-specific differences in 1) times of imple mentation and intensity of cholesterol education and screening programs, 2) the availability and quality of clinical preventive services, and 3) age, race/ethnicity, and socioeconomic status of residents.

Potential explanations for the increase in the percentage of adults who reported ever having their blood cholesterol checked include greater public interest in cholesterol (8), increased quantity and quality of screening services offered by health-care providers, and more extensive efforts by health-care providers to educate patients regarding cholesterol (9). Greater public and health-care-provider awareness regarding cholesterol is reflected by increases in the proportion of persons who were told their cholesterol level after they were screened and by increases in the proportion who could remember their cholesterol level after they were told.

Educational efforts of the NCEP, the American Heart Association (AHA), and state and local public health agencies have likely contributed to increased cholesterol testing and awareness in the United States. In October 1987, guidelines for the detection, evaluation, and treatment of high blood cholesterol were announced by the Adult Treatment Panel of the NCEP and were subsequently distributed to more than 200,000 physicians in the United States. After the release of the Adult Treatment Panel guidelines, the AHA initiated a national campaign to educate physicians about cholesterol. Other NCEP and AHA efforts have included national media campaigns and the distribution of patient-education brochures and cholesterol fact sheets. Many state and local public health agencies have also developed cholesterol screening and education programs.

References

1. Consensus Development Conference. Lowering blood cholesterol to prevent heart disease. JAMA 1985;253:2080-6.

2. CDC. State and sex-specific premature mortality due to ischemic heart disease--1985. MMWR 1988;37:313-4,320-3.

3. National Heart, Lung, and Blood Institute. Recommendations regarding public screening for measuring blood cholesterol: summary of a National Heart, Lung, and Blood Institute workshop. Bethesda, Maryland: National Heart, Lung, and Blood Institute, 1988.

4. Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. The Expert Panel. Arch Intern Med 1988;148:36-69.

5. Remington PL, Smith MY, Williamson DF, Anda RF, Gentry EM, Hogelin GC. Design, characteristics, and usefulness of state-based behavioral risk factor surveillance: 1981-87. Public Health Rep 1988;103:366-75.

6. Shah BV. SESUDAAN: Standard errors program for computing of standardized rates from sample survey data. Research Triangle Park, North Carolina: Research Triangle Institute, 1981.

7. Public Health Service. Promoting health/preventing disease: year 2000 objectives for the nation (Draft). Washington, DC: US Department of Health and Human Services, 1989.

8. 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.

9. Schucker B, Wittes JT, Cutler JA, et al. Change in physician perspective on cholesterol and heart disease: results from two national surveys. JAMA 1987;258:3521-6. *A serum cholesterol level of greater than or equal to 240 mg divided by L is considered "high"; 200-239 mg divided by L is considered "borderline high"; and less than 200 mg divided by L is considered "desirable" (4).

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