Progress in Chronic Disease Prevention
Factors Related to Cholesterol Screening and Cholesterol Level
Awareness -- United States, 1989
Since November 1985, when the National Cholesterol Education
Program (NCEP) was initiated by the National Heart, Lung, and
Blood Institute, cholesterol screening and awareness of
cholesterol levels have increased substantially in the United
States (1,2). However, cholesterol screening and awareness
patterns vary by state (2). To assess whether these variations
may be related to demographic differences between states, data
from the Behavioral Risk Factor Surveillance System (BRFSS) for
1989 were analyzed. Differences in cholesterol screening and
awareness in relation to cardiovascular disease (CVD) risk
factors other than elevated cholesterol level were also
evaluated.
Health departments in the 39 participating states and the
District of Columbia use a standardized questionnaire when
conducting monthly random-digit-dialed telephone surveys of
persons greater than or equal to 18 years of age (3). In 1989,
respondents were asked whether they had ever had their
cholesterol "checked." If so, they were asked to provide the
duration since their last test and whether they had been told
their cholesterol level. Persons who reported being 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.
The state-specific survey results were weighted according to the
age, sex, and race distribution of adults in each state. Combined
data were also weighted according to the population size in each
state and are therefore representative of the total population in
the participating states. To allow comparisons between states and
within demographic categories, state-specific and combined
results were standardized by age, sex, race, and educational
attainment using 1980 U.S. census data. SESUDAAN, a computer
software program for analyzing complex sample survey data, was
used to calculate standard errors for the prevalence estimates
(4).
The overall percentage of adults who reported ever having had
their cholesterol level checked ranged from 48% in Alabama and
New Mexico to 64% in Connecticut, Florida, and Washington (Table
1). The percentage of adults who reported knowing
their cholesterol level ranged from 12% in the District of
Columbia to 33% in Washington. After standardization of the
state-specific estimates for age, sex, race, and educational
attainment using 1980 census data, cholesterol screening and
awareness still varied between states.
Cholesterol screening and awareness were slightly higher among
women than among men (Table 2). Younger persons (18-34 years of
age), blacks, and persons with lower educational attainment (less
than or equal to 12 years of education) were less likely to have
had their cholesterol level checked and were less likely to
report knowing their cholesterol level. Differences by race
declined after standardization for age, sex, and educational
attainment. However, differences by sex, age, and educational
attainment remained unchanged or increased when standardized by
the other demographic factors.
Persons with diabetes, hypertension, or obesity were more likely
to have had their cholesterol level checked and were more likely
to know their cholesterol level than were persons who did not
report having these risk factors for CVD (Table 3). However,
cholesterol screening and awareness were lower among persons who
reported having a sedentary lifestyle and among persons who
reported smoking than among persons who did not report having
these CVD risk factors. Differences were less marked after
standardization for age, sex, race, and educational attainment
but remained statistically significant (p less than 0.05,
z-test).
Reported by: the following state BRFSS coordinators: L Eldrige,
Alabama; J Contreras, Arizona; W Wright, California; M Adams,
Connecticut; A Peruga, District of Columbia; S Hoecherl, Florida;
J Smith, Georgia; A Villafuerte, Hawaii; J Mitten, Idaho; B
Steiner, Illinois; S Joseph, Indiana; S Schoon, Iowa; K
Bramblett, Kentucky; J Sheridan, Maine; A Weinstein, Maryland; L
Koumjian, Massachusetts; J Thrush, Michigan; N Salem, Minnesota;
J Jackson-Thompson, Missouri; M McFarland, Montana; S Spanke,
Nebraska; K Zaso, L Powers, New Hampshire; L Pendley, New Mexico;
J Marin, O Munshi, New York; C Washington, North Carolina; M
Maetzold, North Dakota; E Capwell, Ohio; N Hann, Oklahoma; J
Grant-Worley, Oregon; C Becker, Pennsylvania; R Cabrel, Rhode
Island; M Mace, South Carolina; S Moritz, South Dakota; D Riding,
Tennessee; J Fellows, Texas; L Post-Nilson, Utah; J Bowie,
Virginia; K Tollestrup, Washington; D Porter, West Virginia; M
Soref, Wisconsin. 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: BRFSS data for 1989 indicate that cholesterol
screening and awareness of cholesterol levels continue to
increase in the United States. Among states participating in the
BRFSS, the median proportion of adults who reported having had
their cholesterol tested increased from 47% in 1987 to 56% in
1989. Similarly, the median proportion of adults who reported
knowing their cholesterol level increased from 6% in 1987 to 21%
in 1989.
In this analysis, cholesterol screening and awareness were
strongly associated with age, race, and educational attainment,
and variations by state persisted after adjustment for
demographic differences between states. Thus, other factors were
likely to be associated with variations by state, including
differences in 1) time of implementation and intensity of
cholesterol education and screening programs and 2) availability
and quality of clinical preventive services.
NCEP goals are for all adults to 1) have their 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 (5). The lower level of cholesterol testing and
awareness among the youngest age group (18-34 years of age) is of
particular concern: considerable evidence suggests that
atherosclerosis is present by early adulthood (6-8) and that
early atherosclerotic lesions may be related to elevated
cholesterol levels during childhood and adolescence (9). Through
identification and treatment of high blood cholesterol in early
adulthood, younger persons may be able to prevent or delay the
development of atherosclerosis. Increased identification and
treatment of high blood cholesterol among blacks and persons in
low socioeconomic groups is also important.
Multiple CVD risk factors increase the risk for CVD-related
morbidity and mortality. For example, hypertensive smokers have a
three to six times greater risk for CVD-related mortality than do
normotensive nonsmokers (5). Additionally, a given reduction in
blood cholesterol may produce a greater reduction in risk for CVD
among persons with multiple CVD risk factors than among persons
without these risk factors (5). Therefore, persons with risk
factors for CVD should have their cholesterol level tested. These
persons can substantially reduce their risk for CVD by working
with their health-care provider to reduce an elevated cholesterol
level and other CVD risk factors. Since cholesterol screening and
awareness were lower among smokers and those with a sedentary
lifestyle, special efforts are needed to reach these high-risk
populations. In an effort to increase federal, state, and local
activities supporting cholesterol awareness, September 1990 has
been designated National Cholesterol Education Month by the NCEP
Coordinating Committee.
References
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.
CDC. State-specific changes in cholesterol screening and
awareness--United States, 1987-1988. MMWR 1990;39:304-5,311-4.
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.
Shah BV. SESUDAAN: standard errors program for computing of
standardized rates from sample survey data. Research Triangle
Park, North Carolina: Research Triangle Institute, 1981.
The Expert Panel. Report of the National Cholesterol Education
Program Expert Panel on Detection, Evaluation, and Treatment of
High Blood Cholesterol in Adults. Arch Intern Med 1988;148:36-69.
McNamara JJ, Molot MA, Stremple JF, Cutting RT. Coronary
artery disease in combat casualties in Vietnam. JAMA
1971;216:1185-7.
Enos WF, Holmes RH, Beyer J. Coronary disease among United
States soldiers killed in action in Korea. JAMA 1953;152:1090-3.
Berenson GS, Srinivasan SR, Freedman DS, Radhakrishnamurthy B,
Dalferes ER. Review: atherosclerosis and its evolution in
childhood. Am J Med Sci 1987;294:429-40.
Newman WP, Freedman DS, Voors AW, et al. Relation of serum
lipoprotein levels and systolic blood pressure to early
atherosclerosis: the Bogalusa Heart Study. N Engl J Med
1986;314:138-44.
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