Prevalence of Cholesterol Screening and High Blood Cholesterol Among Adults—United States, 2005, 2007, and 2009 FREE

MMWR. 2012;35:697-702. Available at http://www.cdc.gov/mmwr/PDF/wk/mm6135.pdf

2 tables omitted.

High blood cholesterol is a leading risk factor in the development of atherosclerosis and coronary heart disease (CHD).^1- 2 The risks associated with high blood cholesterol can be reduced by screening and early intervention.³ Current clinical practice guidelines provide evidenced-based standards for detection, treatment, and control of high blood cholesterol.⁴Healthy People2020 monitors national progress related to screening and controlling high blood cholesterol through the National Health Interview Survey and the National Health and Nutrition Examination Survey (NHANES). State-level estimates of self-reported cholesterol screening and high blood cholesterol prevalence are available using Behavioral Risk Factor Surveillance System (BRFSS) data. To assess recent trends in the percentage of adults aged ≥18 years who had been screened for high blood cholesterol during the preceding 5 years, and the percentage among those who had been screened within the previous 5 years and who were ever told they had high blood cholesterol, CDC analyzed BRFSS data from 2005, 2007, and 2009. The results of that analysis showed that the percentage of adults reporting having been screened for high blood cholesterol within the preceding 5 years increased overall from 72.7% in 2005 to 76.0% in 2009. In addition, the percentage who had ever been told they had high cholesterol increased from 33.2% to 35.0%. Both self-reported screening and high cholesterol varied by state and sociodemographic subgroup. To reach the Healthy People 2020 target for cholesterol screening, public health practitioners should emphasize the importance of screening, especially among younger adults, men, Hispanics, and persons with lower levels of education.

BRFSS is a state-based, random-digit–dialed telephone survey conducted annually since 1984 with assistance from CDC. The survey is conducted among noninstitutionalized, U.S. adult civilians aged ≥18 years. Cholesterol questions have been asked in odd-numbered years. In 2005, 2007, and 2009, three questions were asked: “Have you ever had your blood cholesterol checked?” “About how long has it been since you last had your blood cholesterol checked?” and “Have you ever been told by a doctor, nurse, or other health professional that your blood cholesterol is high?” Median response rates were 51.1%, 50.6%, and 52.5% in 2005, 2007, and 2009, respectively.

The percentages of respondents who reported being screened for cholesterol during the preceding 5 years were calculated, and general comparisons were made with the target for Healthy People 2020 objective HDS-6.* Because measured blood cholesterol is not available in BRFSS, direct comparison of results could not be made with two other Healthy People 2020 objectives that are based on measured results from NHANES (HDS-7, reduce the proportion of adults with high total blood cholesterol levels of >240 mg/dL; and HDS-8, reduce the mean total blood cholesterol levels among adults). However, self-reported health-care provider diagnosis of high blood cholesterol has been used previously to monitor prevalence of high blood cholesterol nationally and at the state level.⁵ Therefore, this report provides an update of the percentage of respondents who were ever told they had high blood cholesterol among those who had been screened within the preceding 5 years.

Data were analyzed by age group (18-44, 45-64, and ≥65 years), sex, race/ethnicity (white, black, Hispanic, Asian/Pacific Islander, and American Indian/Alaskan Native†), and education (less than high school diploma, high school diploma, some college, college degree or higher). All reported percentages were age-standardized using the 2000 U.S. standard projected population, distribution no. 8,⁶ except for age groups, for which age-specific percentages were reported. Linear trends across survey periods were assessed using orthogonal polynomial coefficients, and results with a p-value <0.05 were considered significant. The total number of respondents ranged from 356,112 in 2005 to 432,607 in 2009. State-specific (including the District of Columbia [DC]) sample sizes ranged from 2,432 (Alaska, 2009) to 39,549 (Florida, 2007).

From 2005 to 2009, the overall percentage of adults screened for high blood cholesterol during the preceding 5 years increased from 72.7% to 76.0%. Increases in the percentage of persons screened for high blood cholesterol were observed across all age, sex, racial/ethnic, and education categories. The percentage of respondents screened for high blood cholesterol in 2009 was significantly higher among persons aged 45-64 years (88.8%) and ≥65 years (94.7%) than 18-44 years (63.2%); women (77.6%) compared with men (74.5%); blacks (77.6%), whites (77.3%), and Asian/Pacific Islanders (77.2%) compared with Hispanics (69.2%); and those with some college (77.5%) and a college degree or higher (83.0%) compared with those with a high school diploma (71.0%) and less than a high school diploma (61.4%).

By state, in 2009, the percentage of respondents screened for high blood cholesterol ranged from 67.7% in Idaho to 84.5% in DC. From 2005 to 2009, the percentage increased significantly in most states; two states (Missouri and South Carolina) showed a decreased percentage of respondents screened, but neither difference was statistically significant. Sixteen states showed no significant change in the percentage screened. In general, prevalence of cholesterol screening was higher among residents of eastern states than western states (Figure).

Among respondents who had been screened for high blood cholesterol within the previous 5 years, the percentage who reported being told by a health-care provider that their blood cholesterol was high increased from 33.2% in 2005 to 35.0% in 2009. Increases were observed across all age, sex, and education categories and among whites, blacks, and Hispanics. The prevalence of high blood cholesterol was significantly higher among persons aged ≥65 years (54.4%) than 18–44 years (23.7%) and 45–64 years (46.1%); men (37.5%) compared with women (32.6%); Hispanics (36.3%) and Asian/Pacific Islanders (37.5%) compared with blacks (33.1%); and those with less than a high school diploma (39.9%) compared with those with some college (35.2%) and a college degree or higher (33.2%).

By state, in 2009, the prevalence of self-reported high blood cholesterol ranged from 30.5% in New Mexico to 38.8% in Texas. From 2005 to 2009, approximately one third of states showed a significant increase. Certain states showed decreased prevalence, but none of the decreases were statistically significant.

Jing Fang, MD, Carma Ayala, PhD, Fleetwood Loustalot, PhD, Shifan Dai, MD, Div for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, CDC. Corresponding contributor: Jing Fang, jfang@cdc.gov, 770-488-5142.

The results presented in this report show that during 2005-2009, the national and state-specific age-standardized percentages of adult respondents who had been screened for cholesterol during the preceding 5 years increased significantly. Also, the percentage of respondents who had been screened and who were ever told that they had high blood cholesterol increased overall and in many states. Differences in the prevalence of self-reported screening in the preceding 5 years and prevalences of self-reported high blood cholesterol were found among states and sociodemographic subgroups.

In 2005, using BRFSS data, CDC reported trends in cholesterol screening and prevalence of high blood cholesterol among adults, with a significant increase in both measures from 1991 to 2003.⁵ Similar to those findings, this report shows that from 2005 to 2009 the prevalence of respondents screened and the prevalence of self-reported high blood cholesterol increased. These results indicate that screening for high blood cholesterol was lowest among those aged 18-44 years, Hispanics, and those with lower levels of education.

The finding of increasing self-reported high blood cholesterol might be attributable to increasing awareness of the health risks posed by high blood cholesterol or increasing prevalence of high blood cholesterol among adults ever screened, or both. A recent report using nationally representative data revealed that from 1999-2000 to 2009-2010, the prevalence of high total serum cholesterol (≥240 mg/dL) among the U.S. population aged ≥20 years with measured serum cholesterol levels declined from 18.3% to 13.4%.⁷ This suggests that the increasing prevalence of self-reported high blood cholesterol was more likely a result of improved awareness of the risks of high blood cholesterol than an actual increase in the prevalence of high blood cholesterol.

The findings in this report are subject to at least three limitations. First, BRFSS includes only the noninstitutionalized U.S. population and, during 2005-2009, did not include households with no telephone or only cellular telephones. Second, BRFSS data are self-reported. Because no measurement of blood cholesterol is taken with BRFSS, self-reported high blood cholesterol cannot be substantiated, and treatment and control cannot be assessed. Third, median response rates were <55% in all 3 years. However, despite these limitations, BRFSS is a large, population-based survey that provides the only state-level assessment of high blood cholesterol screening and prevalence every 2 years.

Early detection of high blood cholesterol through screening is the first important step to treatment and reducing the risk for heart attack and stroke.⁴ To reach high blood cholesterol screening targets, public health practitioners, health-care providers, and educators should emphasize cholesterol screening, especially for young adults, men, Hispanics, and those with lower levels of education.

A wide variety of community and medical treatment activities address cholesterol screening and treatment. For example, CDC's National Heart Disease and Stroke Prevention programs support states implementing evidence-based practices in community and clinical settings, specifically highlighting cholesterol control within communities.⁸ Therapeutic lifestyle changes are an important approach that incorporates a low-fat, high-fiber diet and physical activity on most days.⁹ If cholesterol-lowering drugs are needed, they are used together with therapeutic lifestyle changes. The National Cholesterol Education Program provides evidenced-based resources and recommendations to health-care providers, and new guidelines for cholesterol are currently being developed.⁴Healthy People2020 objectives aim to increase awareness of current cholesterol recommendations and provide targets for stakeholders. The Million Hearts initiative, a federal/private partnership, is a recent, innovative alignment and coordination of clinical and community activities targeting leading causes of cardiovascular disease morbidity and mortality, including high blood cholesterol.¹⁰ These and other community and clinical activities are important measures to combat the deleterious effects of high blood cholesterol.

Cholesterol is a major risk factor for cardiovascular disease. In 2003, the percentage of adults who had their cholesterol screened during the preceding 5 years was 73.1%. Among those who had a cholesterol screening, 31.1% reported ever being told they had high cholesterol. The prevalence of cholesterol screening has been reported as higher among the elderly, women, whites, and blacks.

What is added by this report?

Behavioral Risk Factor Surveillance System data indicate that cholesterol screening increased from 72.7% in 2005 to 76.0% in 2009, whereas the percentage of those screened who reported being told they had high cholesterol increased from 33.2% to 35.0%. Previously identified demographic disparities persist.

What are the implications for public health practice?

Nationally, the percentage of adults screened for high cholesterol during the preceding 5 years remains lower than the Healthy People 2020 target of 82.1%, and the percentage of those tested reporting being told they had high cholesterol has increased. The overall and state-specific findings in this report can be used to assess current national and state trends and target resources toward at-risk populations.

*Available at http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=21.

†Persons identified as Hispanic might be of any race. Persons identified as white, black, Asian/Pacific Islander, or American Indian/Alaska Native are all non-Hispanic. The five racial/ethnic categories are mutually exclusive.