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March 17, 1993, Vol 269, No. 11 >
ARTICLE | March 17, 1993

Should We Be Measuring Blood Cholesterol Levels in Young Adults? FREE

Stephen B. Hulley, MD, MPH; Thomas B. Newman, MD, MPH; Deborah Grady, MD, MPH; Alan M. Garber, MD, PhD; Robert B. Baron, MD, MS; Warren S. Browner, MD, MPH
[+] Author Affiliations

Reprint requests to the University of California, San Francisco, Box 0886, San Francisco, CA 94143 (Dr Hulley).


JAMA. 1993;269(11):1416-1419. doi:10.1001/jama.1993.03500110084041
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References

Should we measure blood cholesterol levels in all adults, or only in those at high risk of coronary heart disease (CHD)? Most men under the age of 35 years and women under the age of 45 years—roughly half the adult population—are at very low short-term risk of CHD. One consequence is that drug treatment to lower high blood cholesterol levels in the average young adult is an extremely expensive means of prolonging life; the estimated $1 million to $10 million per year of life is 100 to 1000 times the cost of other approaches. Individualized dietary treatment is somewhat cheaper but relatively ineffective. Another consequence of the low CHD risk in young adults is the greater likelihood that intervention may have harmful effects that outweigh the benefits. Meta-analyses of primary prevention trials in middle-aged men reveal an increase in non-CHD deaths among those randomized to cholesterol interventions, an unexpected finding that is more substantial than the decrease in CHD deaths. This raises the possibility that one or more of the cholesterol interventions could have very serious adverse effects among young adults, whose risk of non-CHD death is normally 100 times their risk of CHD death. We conclude that the policy of screening and treating high blood cholesterol levels in young adults is neither cost-effective, nor does it satisfy ethical standards requiring strong evidence that preventive interventions do more good than harm. Fortunately, cholesterol screening in young adults is also not necessary: most CHD events associated with high blood cholesterol levels in this population will not occur for decades and can be prevented by treatment that is begun in middle age. Cholesterol screening and treatment in young adults should be limited to individuals with known coronary disease or other unusual factors that place them at high short-term risk of CHD death.

(JAMA. 1993;269:1416-1419)

REFERENCES

1 +
NCEP 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.
2 +
Toronto Working Group.  Asymptomatic hypercholesterolemia: a clinical policy review. J Clin Epidemiol . 1990;;43:1029-1121.
3 +
US Bureau of Census. Statistical Abstract of the US: 1990 .110th ed. Washington, DC: US Bureau of Census; 1990;.
4 +
Taylor W, Pass T, Shepard D, Komaroff A.  Cholesterol reduction and life expectancy: a model incorporating multiple risk factors. Ann Intern Med . 1987;;106:605-614.
5 +
Siegel D, Grady D, Browner W, Hulley S.  Risk factor modification after myocardial infarction. Ann Intern Med . 1988;;109:213-218.
6 +
Browner W, Hulley S.  Effect of risk status on treatment criteria. Hypertension . 1989;;13( (suppl I) ): I-51-I-56.
7 +
Tsevat J, Weinstein MC, Williams LW, Tosteson ANA, Goldman L.  Expected gains in life expectance from various coronary heart disease risk factor modifications. Circulation . 1991;;83:1194-1201.
8 +
Criqui MH.  Cholesterol, primary and secondary prevention, and all-cause mortality. Ann Intern Med . 1991;;115:973-976.
9 +
Rossouw J, Lewis B, Rifkind B.  The value of lowering cholesterol after myocardial infarction. N Engl J Med . 1990;;323:1112-1119.
10 +
Pekkanen J, Linn S, Heiss G, et al.  Ten-year mortality from cardiovascular disease in relation to cholesterol level among men with and without preexisting cardiovascular disease. N Engl J Med . 1990;; 322:1700-1707.
11 +
Brett A.  Treating hypercholesterolemia: how should practicing physicians interpret the published data for patients? N Engl J Med . 1989;;321:676-679.
12 +
Goldman L, Weinstein M, Goldman P, Williams L.  Cost-effectiveness of HMG-CoA reductase inhibition for primary and secondary prevention of CHD. JAMA . 1991;;265:1145-1151.
13 +
Kristiansen I, Eggen A, Thelle D.  Cost effectiveness of incremental programmes for lowering serum cholesterol concentration: is individual intervention worthwhile? BMJ . 1991;;302:1119-1122.
14 +
Goldman L, Gordon DJ, Rifkind BM, et al.  Cost and health implications of cholesterol lowering. Circulation . 1992;;85:1960-1968.
15 +
Oster G, Epstein MA.  Cost-effectiveness of antihyperlipemic therapy in the prevention of CHD. JAMA . 1987;;258:2381-2387.
16 +
Weinstein MC.  Economic assessment of medical practices and technologies. Med Decis Making . 1981;;1:309-330.
17 +
Ramsay LE, Yeo WW, Jackson PR.  Dietary reduction of serum cholesterol concentration: time to think again . BMJ . 1991;;303:953-957.
18 +
Krahn M, Naylor C, Basinski A, Detsky A.  Comparison of an aggressive (U.S.) and a less aggressive (Canadian) policy for cholesterol screening and treatment. Ann Intern Med . 1991;;115:248-255.
19 +
Muldoon M, Manuck S, Matthews K.  Lowering cholesterol concentrations and mortality: a quantitative review of primary prevention trials. BMJ . 1990;;301:309-314.
20 +
Newman TB, Browner WS, Hulley SB.  Childhood cholesterol screening: contraindicated. JAMA . 1992;;267:100-101.
21 +
Davey Smith G, Pekkanen J.  The cholesterol controversy. BMJ . 1992;;304:913.
22 +
Holme I.  An analysis of randomized trials evaluating the effect of cholesterol reduction on total mortality and CHD incidence. Circulation . 1990;; 82:1916-1924.
23 +
Silberberg JS, Henry DA.  The benefits of reducing cholesterol levels: the need to distinguish primary from secondary prevention. Med J Australia . 1991;;155:665-670.
24 +
Yusuf S, Furberg C.  Single factor trials: control through life-style changes.  In: Olsson AG, ed. Atherosclerosis . New York, NY: Churchill Livingstone; 1987;:389-391.
25 +
Ravnskov U.  Cholesterol lowering trials in coronary heart disease: frequency of citation and outcome. BMJ . 1992;;305:15-19.
26 +
Rossouw JE, Canner PL, Hulley SB.  Deaths from injury, violence, and suicide in secondary prevention trials of cholesterol lowering. N Engl J Med . 1991;;325:1813.
27 +
CDP Research Group.  The Coronary Drug Project: initial findings leading to modifications of its research protocol. JAMA . 1970;;214:1303-1313.
28 +
CDP Research Group.  The Coronary Drug Project: findings leading to further modifications of its protocol with respect to dextrothyroxine. JAMA . 1972;;220:996-1008.
29 +
Newman TB.  Possibly disappointing results of treatment with gemfibrozil. N Engl J Med . 1993;; 328:139-140.
30 +
Kaplan J, Manuck S, Shively C.  The effects of fat and cholesterol on social behavior in monkeys. Psychosom Med . 1991;;53:634-642.
31 +
Duffy MA. Physicians' Desk Reference . 47th ed. Montvale, NJ: Medical Economics Data; 1993;.
32 +
Jacobs D, Blackburn H, Higgins M, et al.  Report of the Conference on Low Blood Cholesterol: mortality associations. Circulation . 1992;;86:1046-1060.
33 +
Neaton J, Blackburn H, Jacobs D, et al.  Serum cholesterol level and mortality: findings for men screened in the MRFIT. Arch Intern Med . 1992;; 152:1490-1500.
34 +
Hulley SB, Walsh JMB, Newman TB.  Health policy on blood cholesterol: time to change directions. Circulation . 1992;;86:1026-1029.
35 +
Jacobs DR.  Why is low blood cholesterol associated with risk of nonatherosclerotic disease death? Annu Rev Public Health . In press.
36 +
Engelberg H.  Low serum cholesterol and suicide. Lancet . 1992;;339:727-728.
37 +
Mason RP, Herbette LG, Silverman DI.  Can altering serum cholesterol affect neurologic function? J Mol Cell Cardiol . 1991;;23:1339-1342.
38 +
National Center for Health Statistics. Vital Statistics of the United States, 1988, II: Mortality, Part A . Washington, DC: US Public Health Service; 1991;.
39 +
Klag MJ, Ford DE, Mead LA, et al.  Serum cholesterol in young men and subsequent cardiovascular disease. N Engl J Med . 1993;;328:313-318.
40 +
LRC Program.  The LRC Coronary Primary Prevention Trial results, II: the relationship of reduction in incidence of CHD to cholesterol lowering. JAMA . 1984;;251:365-374.
41 +
Davis C, Rifkind B, Brenner H, Gordon D.  A single cholesterol measurement underestimates the risk of CHD. JAMA . 1990;;264:3044-3046.
42 +
Oliver MF.  Doubts about preventing coronary heart disease. BMJ . 1992;;304:393-394.
43 +
Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical Epidemiology: A Basic Science for Clinical Medicine . Boston, Mass: Little Brown & Co Inc; 1991;:163-167.
44 +
Newman T, Browner W, Hulley S.  The case against childhood cholesterol screening. JAMA . 1990;;264:3039-3043.
45 +
Hulley S, Rosenman R, Bawol R, Brand R.  Epidemiology as a guide to clinical decisions: the association between triglyceride and CHD. N Engl J Med . 1980;;302:1383-1389.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
NCEP 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.
2 +
Toronto Working Group.  Asymptomatic hypercholesterolemia: a clinical policy review. J Clin Epidemiol . 1990;;43:1029-1121.
3 +
US Bureau of Census. Statistical Abstract of the US: 1990 .110th ed. Washington, DC: US Bureau of Census; 1990;.
4 +
Taylor W, Pass T, Shepard D, Komaroff A.  Cholesterol reduction and life expectancy: a model incorporating multiple risk factors. Ann Intern Med . 1987;;106:605-614.
5 +
Siegel D, Grady D, Browner W, Hulley S.  Risk factor modification after myocardial infarction. Ann Intern Med . 1988;;109:213-218.
6 +
Browner W, Hulley S.  Effect of risk status on treatment criteria. Hypertension . 1989;;13( (suppl I) ): I-51-I-56.
7 +
Tsevat J, Weinstein MC, Williams LW, Tosteson ANA, Goldman L.  Expected gains in life expectance from various coronary heart disease risk factor modifications. Circulation . 1991;;83:1194-1201.
8 +
Criqui MH.  Cholesterol, primary and secondary prevention, and all-cause mortality. Ann Intern Med . 1991;;115:973-976.
9 +
Rossouw J, Lewis B, Rifkind B.  The value of lowering cholesterol after myocardial infarction. N Engl J Med . 1990;;323:1112-1119.
10 +
Pekkanen J, Linn S, Heiss G, et al.  Ten-year mortality from cardiovascular disease in relation to cholesterol level among men with and without preexisting cardiovascular disease. N Engl J Med . 1990;; 322:1700-1707.
11 +
Brett A.  Treating hypercholesterolemia: how should practicing physicians interpret the published data for patients? N Engl J Med . 1989;;321:676-679.
12 +
Goldman L, Weinstein M, Goldman P, Williams L.  Cost-effectiveness of HMG-CoA reductase inhibition for primary and secondary prevention of CHD. JAMA . 1991;;265:1145-1151.
13 +
Kristiansen I, Eggen A, Thelle D.  Cost effectiveness of incremental programmes for lowering serum cholesterol concentration: is individual intervention worthwhile? BMJ . 1991;;302:1119-1122.
14 +
Goldman L, Gordon DJ, Rifkind BM, et al.  Cost and health implications of cholesterol lowering. Circulation . 1992;;85:1960-1968.
15 +
Oster G, Epstein MA.  Cost-effectiveness of antihyperlipemic therapy in the prevention of CHD. JAMA . 1987;;258:2381-2387.
16 +
Weinstein MC.  Economic assessment of medical practices and technologies. Med Decis Making . 1981;;1:309-330.
17 +
Ramsay LE, Yeo WW, Jackson PR.  Dietary reduction of serum cholesterol concentration: time to think again . BMJ . 1991;;303:953-957.
18 +
Krahn M, Naylor C, Basinski A, Detsky A.  Comparison of an aggressive (U.S.) and a less aggressive (Canadian) policy for cholesterol screening and treatment. Ann Intern Med . 1991;;115:248-255.
19 +
Muldoon M, Manuck S, Matthews K.  Lowering cholesterol concentrations and mortality: a quantitative review of primary prevention trials. BMJ . 1990;;301:309-314.
20 +
Newman TB, Browner WS, Hulley SB.  Childhood cholesterol screening: contraindicated. JAMA . 1992;;267:100-101.
21 +
Davey Smith G, Pekkanen J.  The cholesterol controversy. BMJ . 1992;;304:913.
22 +
Holme I.  An analysis of randomized trials evaluating the effect of cholesterol reduction on total mortality and CHD incidence. Circulation . 1990;; 82:1916-1924.
23 +
Silberberg JS, Henry DA.  The benefits of reducing cholesterol levels: the need to distinguish primary from secondary prevention. Med J Australia . 1991;;155:665-670.
24 +
Yusuf S, Furberg C.  Single factor trials: control through life-style changes.  In: Olsson AG, ed. Atherosclerosis . New York, NY: Churchill Livingstone; 1987;:389-391.
25 +
Ravnskov U.  Cholesterol lowering trials in coronary heart disease: frequency of citation and outcome. BMJ . 1992;;305:15-19.
26 +
Rossouw JE, Canner PL, Hulley SB.  Deaths from injury, violence, and suicide in secondary prevention trials of cholesterol lowering. N Engl J Med . 1991;;325:1813.
27 +
CDP Research Group.  The Coronary Drug Project: initial findings leading to modifications of its research protocol. JAMA . 1970;;214:1303-1313.
28 +
CDP Research Group.  The Coronary Drug Project: findings leading to further modifications of its protocol with respect to dextrothyroxine. JAMA . 1972;;220:996-1008.
29 +
Newman TB.  Possibly disappointing results of treatment with gemfibrozil. N Engl J Med . 1993;; 328:139-140.
30 +
Kaplan J, Manuck S, Shively C.  The effects of fat and cholesterol on social behavior in monkeys. Psychosom Med . 1991;;53:634-642.
31 +
Duffy MA. Physicians' Desk Reference . 47th ed. Montvale, NJ: Medical Economics Data; 1993;.
32 +
Jacobs D, Blackburn H, Higgins M, et al.  Report of the Conference on Low Blood Cholesterol: mortality associations. Circulation . 1992;;86:1046-1060.
33 +
Neaton J, Blackburn H, Jacobs D, et al.  Serum cholesterol level and mortality: findings for men screened in the MRFIT. Arch Intern Med . 1992;; 152:1490-1500.
34 +
Hulley SB, Walsh JMB, Newman TB.  Health policy on blood cholesterol: time to change directions. Circulation . 1992;;86:1026-1029.
35 +
Jacobs DR.  Why is low blood cholesterol associated with risk of nonatherosclerotic disease death? Annu Rev Public Health . In press.
36 +
Engelberg H.  Low serum cholesterol and suicide. Lancet . 1992;;339:727-728.
37 +
Mason RP, Herbette LG, Silverman DI.  Can altering serum cholesterol affect neurologic function? J Mol Cell Cardiol . 1991;;23:1339-1342.
38 +
National Center for Health Statistics. Vital Statistics of the United States, 1988, II: Mortality, Part A . Washington, DC: US Public Health Service; 1991;.
39 +
Klag MJ, Ford DE, Mead LA, et al.  Serum cholesterol in young men and subsequent cardiovascular disease. N Engl J Med . 1993;;328:313-318.
40 +
LRC Program.  The LRC Coronary Primary Prevention Trial results, II: the relationship of reduction in incidence of CHD to cholesterol lowering. JAMA . 1984;;251:365-374.
41 +
Davis C, Rifkind B, Brenner H, Gordon D.  A single cholesterol measurement underestimates the risk of CHD. JAMA . 1990;;264:3044-3046.
42 +
Oliver MF.  Doubts about preventing coronary heart disease. BMJ . 1992;;304:393-394.
43 +
Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical Epidemiology: A Basic Science for Clinical Medicine . Boston, Mass: Little Brown & Co Inc; 1991;:163-167.
44 +
Newman T, Browner W, Hulley S.  The case against childhood cholesterol screening. JAMA . 1990;;264:3039-3043.
45 +
Hulley S, Rosenman R, Bawol R, Brand R.  Epidemiology as a guide to clinical decisions: the association between triglyceride and CHD. N Engl J Med . 1980;;302:1383-1389.

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