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September 25, 1991, Vol 266, No. 12 >
ARTICLE | September 25, 1991

Estimating an Individual's True Cholesterol Level and Response to Intervention FREE

Les Irwig, MBBCh, PhD, FFCM; Paul Glasziou, MBBS, PhD; Andrew Wilson, BMedSci, MBBS(Hons), FRACP; Petra Macaskill, BA(Hons), MAppStat
[+] Author Affiliations

Reprint requests to Department of Public Health, University of Sydney, New South Wales, Australia 2006 (Dr Irwig).


JAMA. 1991;266(12):1678-1685. doi:10.1001/jama.1991.03470120080037
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References

An individual's blood cholesterol measurement may differ from the true level because of short-term biological and technical measurement variability. Using data on the within-individual and population variance of serum cholesterol, we addressed the following clinical concerns: Given a cholesterol measurement, what is the individual's likely true level? The confidence interval for the true level is wide and asymmetrical around extreme measurements because of regression to the mean. Of particular concern is the misclassification of people with a screening measurement below 5.2 mmol/L who may be advised that their cholesterol level is "desirable" when their true level warrants further action. To what extent does blood cholesterol change in response to an intervention? In general, confidence intervals are too wide to allow decision making and patient feedback about an individual's cholesterol response to a dietary intervention, even with multiple measurements. If no change is observed in an individual's cholesterol value based on three measurements before and three after dietary intervention, the 80% confidence interval ranges from a true increase of 4% to a true decrease of 9%.

(JAMA. 1991;266:1678-1685)

REFERENCES

1 +
Cooper GR, Myers GL, Smith SJ, Sampson EJ.  Standardization of lipid, lipoprotein, and apolipoprotein measurements. Clin Chem . 1988;;34:B95-B105.
2 +
Byers T.  Two-test cholesterol screening: computer simulation of a strategy to reduce within-person variance in mass screening programs. Am J Epidemiol . 1989;;130:853.
3 +
Weissfield JL, Weissfield LA, Holloway JJ, Bernard AM.  A mathematical representation of the Expert Panel's guidelines for high blood cholesterol case-finding and treatment. Med Decis Making . 1990;;10:135-146.
4 +
Thompson SG, Pocock SJ.  The variability of serum cholesterol measurements: implications for screening and monitoring. J Clin Epidemiol . 1990;;43:783-789.
5 +
 Current status of blood cholesterol measurement in the United States: a report from the Laboratory Standardization Panel of the National Cholesterol Education Program. Clin Chem . 1988;;34:193-201.
6 +
Naito HK.  Reliability of lipid, lipoprotein, and apolipoprotein measurements. Clin Chem . 1988;;34:B84-B94.
7 +
 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.
8 +
Demacker PNM, Schade RWB, Jansen RTP, Van't Laar A.  Intra-individual variation of serum cholesterol, triglycerides and high density lipoprotein cholesterol in normal humans. Atherosclerosis . 1982;;45:259-266.
9 +
Rotterdam EP, Katan MB, Knuiman JT.  Importance of time interval between repeated measurements of total or high-density lipoprotein cholesterol when estimating an individual's baseline concentrations. Clin Chem . 1987;;33:1913-1915.
10 +
Roberts L.  Measuring cholesterol is as tricky as lowering it. Science . 1987;;238:482-483.
11 +
Gardner MJ, Heady JA.  Some effects of within-person variability in epidemiological studies. J Chronic Dis . 1973;;26:781-795.
12 +
Morrison JA, Laskarzewski P, deGroot I, et al.  Diagnostic ramifications of repeated plasma cholesterol and triglyceride measurements in children: regression toward the mean in a paediatric population. Pediatrics . 1979;;64:197-201.
13 +
Belsey R, Baer DM.  Cardiac risk classification based on lipid screening. JAMA . 1990;;263:1250-1252.
14 +
Fulwood R, Kalsbeek W, Rifkind B, et al. Total Serum Cholesterol Levels of Adults 20-74 Years of Age: United States, 1976-80 . Washington, DC: National Center for Health Statistics. US Dept of Health and Human Services publication PHS 86-1686. Vital and Health Statistics, ser 11, No. 236.
15 +
Jacobs DR, Barrett-Connor E.  Retest reliability of plasma cholesterol and triglycerides. Am J Epidemiol . 1982;;116:878-885.
16 +
Keil U, Kuulasmaa K.  WHO MONICA Project: risk factors. Int J Epidemiol . 1989;;18( (suppl 1) ):S46-S55.
17 +
Mann JI, Lewis B, Shepherd J, et al.  Blood lipid concentrations and other cardiovascular risk factors: distribution, prevalence, and detection in Britain. BMJ . 1988;;296:1702-1706.
18 +
Tunstall-Pedoe H, Smith WC, Tavendale R.  How-often-that-high graphs of serum cholesterol. Lancet . 1989;;1:540-542.
19 +
Hjermann I, Velve Byre K, Holme I, Leren P.  Effect of diet and smoking intervention on the incidence of coronary heart disease. Lancet . 1981;;2:1303-1313.
20 +
Kinlay S, Heller RF.  Effectiveness and hazards of case finding for a high cholesterol concentration. BMJ . 1990;;300:1545-1547.
21 +
Tyroler HA.  Review of lipid-lowering clinical trials in relation to observational epidemiological studies. Circulation . 1987;;76:515-522.
22 +
Enholm C, Huttunen JK, Pietinen P, et al.  Effect of diet on serum lipoproteins in a population with a high risk of coronary heart disease. N Engl J Med . 1982;;307:850-855.
23 +
Roberts WC.  Lipid-lowering therapy after an atherosclerotic event. Am J Cardiol . 1989;;64:693-695.
24 +
 The Lipid Research Clinics Coronary Prevention Trial results, II: the relation of reduction in incidence of coronary heart disease to cholesterol lowering. JAMA . 1984;;251:365-374.
25 +
Manninen V, Elo O, Frick MH, et al.  Lipid alterations and decline in the incidence of coronary heart disease in the Helsinki Heart Study. JAMA . 1988;;260:641-651.
26 +
O'Brien R, Simon LA, Clifton P, et al.  Comparison of simvastatin and cholestyramine in the treatment of primary hypercholesterolaemia. Med J Aust . 1990;;152:480-483.
27 +
Naughton MJ, Luepker RV, Strickland D.  The accuracy of portable cholesterol analyzers in public screening programs. JAMA . 1990;;263:1213-1217.
28 +
Kaufman HW, McNamara JR, Anderson KM, Wilson PWF, Schaefer EJ.  How reliably can compact chemistry analyzers measure lipids? JAMA . 1990;;263:1245-1249.
29 +
Berger J. Statistical Decision Theory and Bayesian Analysis . New York, NY: Springer-Verlag NY Inc; 1985;.
30 +
DeGroot MH. Probability and Statistics . 2nd ed. Reading, Mass: Addison-Wesley Publishing Co; 1986;.
31 +
Nunnally JC. Psychometric Theory . New York, NY: McGraw-Hill International Book Co; 1967;.
32 +
Shepard DS.  Reliability of blood pressure measurements: implications for designing and evaluating programs to control hypertension. J Chronic Dis . 1981;;34:191-209.
33 +
Hjermann I.  Smoking and diet intervention in healthy coronary high risk men: methods and 5 year follow-up of risk factors in a randomisation trial. J Oslo City Hosp . 1980;;30:3-17

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1 +
Cooper GR, Myers GL, Smith SJ, Sampson EJ.  Standardization of lipid, lipoprotein, and apolipoprotein measurements. Clin Chem . 1988;;34:B95-B105.
2 +
Byers T.  Two-test cholesterol screening: computer simulation of a strategy to reduce within-person variance in mass screening programs. Am J Epidemiol . 1989;;130:853.
3 +
Weissfield JL, Weissfield LA, Holloway JJ, Bernard AM.  A mathematical representation of the Expert Panel's guidelines for high blood cholesterol case-finding and treatment. Med Decis Making . 1990;;10:135-146.
4 +
Thompson SG, Pocock SJ.  The variability of serum cholesterol measurements: implications for screening and monitoring. J Clin Epidemiol . 1990;;43:783-789.
5 +
 Current status of blood cholesterol measurement in the United States: a report from the Laboratory Standardization Panel of the National Cholesterol Education Program. Clin Chem . 1988;;34:193-201.
6 +
Naito HK.  Reliability of lipid, lipoprotein, and apolipoprotein measurements. Clin Chem . 1988;;34:B84-B94.
7 +
 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.
8 +
Demacker PNM, Schade RWB, Jansen RTP, Van't Laar A.  Intra-individual variation of serum cholesterol, triglycerides and high density lipoprotein cholesterol in normal humans. Atherosclerosis . 1982;;45:259-266.
9 +
Rotterdam EP, Katan MB, Knuiman JT.  Importance of time interval between repeated measurements of total or high-density lipoprotein cholesterol when estimating an individual's baseline concentrations. Clin Chem . 1987;;33:1913-1915.
10 +
Roberts L.  Measuring cholesterol is as tricky as lowering it. Science . 1987;;238:482-483.
11 +
Gardner MJ, Heady JA.  Some effects of within-person variability in epidemiological studies. J Chronic Dis . 1973;;26:781-795.
12 +
Morrison JA, Laskarzewski P, deGroot I, et al.  Diagnostic ramifications of repeated plasma cholesterol and triglyceride measurements in children: regression toward the mean in a paediatric population. Pediatrics . 1979;;64:197-201.
13 +
Belsey R, Baer DM.  Cardiac risk classification based on lipid screening. JAMA . 1990;;263:1250-1252.
14 +
Fulwood R, Kalsbeek W, Rifkind B, et al. Total Serum Cholesterol Levels of Adults 20-74 Years of Age: United States, 1976-80 . Washington, DC: National Center for Health Statistics. US Dept of Health and Human Services publication PHS 86-1686. Vital and Health Statistics, ser 11, No. 236.
15 +
Jacobs DR, Barrett-Connor E.  Retest reliability of plasma cholesterol and triglycerides. Am J Epidemiol . 1982;;116:878-885.
16 +
Keil U, Kuulasmaa K.  WHO MONICA Project: risk factors. Int J Epidemiol . 1989;;18( (suppl 1) ):S46-S55.
17 +
Mann JI, Lewis B, Shepherd J, et al.  Blood lipid concentrations and other cardiovascular risk factors: distribution, prevalence, and detection in Britain. BMJ . 1988;;296:1702-1706.
18 +
Tunstall-Pedoe H, Smith WC, Tavendale R.  How-often-that-high graphs of serum cholesterol. Lancet . 1989;;1:540-542.
19 +
Hjermann I, Velve Byre K, Holme I, Leren P.  Effect of diet and smoking intervention on the incidence of coronary heart disease. Lancet . 1981;;2:1303-1313.
20 +
Kinlay S, Heller RF.  Effectiveness and hazards of case finding for a high cholesterol concentration. BMJ . 1990;;300:1545-1547.
21 +
Tyroler HA.  Review of lipid-lowering clinical trials in relation to observational epidemiological studies. Circulation . 1987;;76:515-522.
22 +
Enholm C, Huttunen JK, Pietinen P, et al.  Effect of diet on serum lipoproteins in a population with a high risk of coronary heart disease. N Engl J Med . 1982;;307:850-855.
23 +
Roberts WC.  Lipid-lowering therapy after an atherosclerotic event. Am J Cardiol . 1989;;64:693-695.
24 +
 The Lipid Research Clinics Coronary Prevention Trial results, II: the relation of reduction in incidence of coronary heart disease to cholesterol lowering. JAMA . 1984;;251:365-374.
25 +
Manninen V, Elo O, Frick MH, et al.  Lipid alterations and decline in the incidence of coronary heart disease in the Helsinki Heart Study. JAMA . 1988;;260:641-651.
26 +
O'Brien R, Simon LA, Clifton P, et al.  Comparison of simvastatin and cholestyramine in the treatment of primary hypercholesterolaemia. Med J Aust . 1990;;152:480-483.
27 +
Naughton MJ, Luepker RV, Strickland D.  The accuracy of portable cholesterol analyzers in public screening programs. JAMA . 1990;;263:1213-1217.
28 +
Kaufman HW, McNamara JR, Anderson KM, Wilson PWF, Schaefer EJ.  How reliably can compact chemistry analyzers measure lipids? JAMA . 1990;;263:1245-1249.
29 +
Berger J. Statistical Decision Theory and Bayesian Analysis . New York, NY: Springer-Verlag NY Inc; 1985;.
30 +
DeGroot MH. Probability and Statistics . 2nd ed. Reading, Mass: Addison-Wesley Publishing Co; 1986;.
31 +
Nunnally JC. Psychometric Theory . New York, NY: McGraw-Hill International Book Co; 1967;.
32 +
Shepard DS.  Reliability of blood pressure measurements: implications for designing and evaluating programs to control hypertension. J Chronic Dis . 1981;;34:191-209.
33 +
Hjermann I.  Smoking and diet intervention in healthy coronary high risk men: methods and 5 year follow-up of risk factors in a randomisation trial. J Oslo City Hosp . 1980;;30:3-17

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