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June 16, 1993, Vol 269, No. 23 >
ARTICLE | June 16, 1993

Declining Serum Total Cholesterol Levels Among US Adults: Title and subTitle BreakThe National Health and Nutrition Examination Surveys FREE

Clifford L. Johnson, MSPH; Basil M. Rifkind, MD; Christopher T. Sempos, PhD; Margaret D. Carroll, MSPH; Paul S. Bachorik, PhD; Ronette R. Briefel, DrPH, RD; David J. Gordon, MD, PhD; Vicki L. Burt, ScM, RN; Clarice D. Brown, MS; Kenneth Lippel, PhD; James I. Cleeman, MD
[+] Author Affiliations

Reprint requests to National Cholesterol Education Program, National Heart, Lung, and Blood Institute, National Institutes of Health, Bldg 31, Room 4A-05, Bethesda, MD 20892 (Dr Cleeman).


JAMA. 1993;269(23):3002-3008. doi:10.1001/jama.1993.03500230084034
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Published online
Article
References

Objective.  —To examine the secular trend in serum total cholesterol levels of the US adult population.

Design.  —Nationally representative cross-sectional surveys with both an inperson interview and a medical examination that included the measurement of blood lipid levels.

Setting/Participants.  —Between 6000 and 13000 adults aged 20 through 74 years examined in each of four separate national surveys during 1960 through 1962, 1971 through 1974, 1976 through 1980, and 1988 through 1991.

Results.  —Mean serum total cholesterol levels in US adults aged 20 through 74 years have consistently declined over the time period 1960 through 1991. More than half of the decline occurred during the time period 1976 through 1991. This decline occurred across the entire distribution of serum cholesterol levels and in all age-sex groups. High-density lipoprotein cholesterol and very low-density lipoprotein cholesterol levels have not changed, suggesting that the decline in total cholesterol levels is due to a decline in low-density lipoprotein cholesterol levels.

Conclusions.  —These results document a continuing and substantial decline in serum cholesterol levels among US adults. They suggest that public health programs, designed to reduce cholesterol levels, are proving successful. The observed downward trend in serum cholesterol levels has coincided with a continuing decline in coronary heart disease mortality. These observations suggest that the Healthy People 2000 goal of reducing the mean serum cholesterol level of US adults to no more than 200 mg/dL (5.17 mmol/L) is attainable.(JAMA. 1993;269:3002-3008)

REFERENCES

1 +
Fulwood R, Rifkind BM, Havlik RJ, Briefel RR, Lippel K, Sempos C.  Trends in serum cholesterol levels among US adults aged 20-74 years. JAMA . 1987;;257:937-942.
2 +
Woteki CE, Briefel RR, Hitchcock D, et al.  Selection of nutrition status indicators for field surveys: the NHANES III design. J Nutr . 1990;;120: 1440-1445.
3 +
Nutrition and Your Health: Dietary Guidelines for Americans . 3rd ed. Washington, DC: US Dept of Agriculture and Dept of Health and Human Services; 1990;.
4 +
Lenfant C.  A new challenge for America: The National Cholesterol Education Program. Circulation . 1986;;73:855-856.
5 +
Cleeman JI.  The National Cholesterol Education Program. Clin Lab Med . 1989;;9(No. (1) ):7-15.
6 +
The Surgeon General's Report on Nutrition and Health . Washington, DC: US Dept of Health and Human Services; 1988;. PHS publication 89-50210.
7 +
National Research Council. Diet and Health: Implications for Reducing Chronic Disease Risk . Washington, DC: National Academy Press; 1989;.
8 +
Truswell AS.  Evolution of dietary recommendations, goals, and guidelines. Am J Clin Nutr . 1987;;45:1060-1072.
9 +
Rizek RL, Jackson EM. Current Food Consumption Practices and Nutrient Sources in the American Diet . Hyattsville, Md: US Dept of Agriculture, Consumer Nutrition Center-Human Nutrition Sciences and Education Administration; 1980;.
10 +
Schucker B, Wittes JT, Santanello NC, et al.  Change in cholesterol awareness and action: results from national physician and public surveys. Arch Intern Med . 1991;;151:666-673.
11 +
Burkman RT.  Lipid and lipoprotein changes in relation to oral contraception and hormonal replacement therapy. Fertil Steril . 1988;;49( (suppl J) ):39S-50S.
12 +
National Cholesterol Education Program.  Report of the Expert Panel on Population Strategies for Blood Cholesterol Reduction. Circulation . 1991;; 83:2154-2232.
13 +
National Cholesterol Education Program.  Report of the NCEP Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Arch Intern Med . 1988;;148:36-39.
14 +
National Center for Health Statistics.  Plan and initial program of the Health Examination Survey. Vital Health Stat 1 . 1965;; No. (4)
15 +
National Center for Health Statistics.  Plan and operation of the Health and Nutrition Examination Survey, United States, 1971-73. Vital Health Stat 1 . 1973;; No. (10) .
16 +
McDowell A, Engle A, Massey J, et al.  Plan and operation of the second National Health and Nutrition Examination Survey, 1976-80. Vital Health Stat 1 . 1981;; No. (15) .
17 +
Ezzati TM, Massey JT, Waksberg J, Chu A, Maurer KR.  Sample design: third National Health and Nutrition Examination Survey. Vital Health Stat 2 . 1992;; No. (113) .
18 +
National Center for Health Statistics.  Plan and operation of the Hispanic Health and Nutrition Examination Survey, 1982-84 . Vital Health Stat 1 . 1985;; No. (19) .
19 +
Carroll M, Sempos CT, Fulwood R, et al.  Serum lipids and lipoproteins of Hispanics, 1982-84 . Vital Health Stat 11 . 1990;; No. (240) .
20 +
Forthofer RN.  Investigations of nonresponse bias in NHANES II. Am J Epidemiol . 1983;;117:507-515.
21 +
A Comparison and Analysis of Examined and Nonexamined Persons on Medical History Characteristics for the First Round of the Health and Nutrition Examination Survey . Washington, DC: US Dept of Health, Education, and Welfare; 1974;. Publication HSM-110-73-371.
22 +
The HANES Study: Final Report . Washington, DC: Health Services and Mental Health Administration; 1975;.
23 +
Miller H, Williams P.  Factors related to response in the Health Examination Survey: United States, 1960-62. Vital Health Stat 6 . 1969;; No. (6) .
24 +
Ezzati T, Khare M. Nonresponse adjustments in a national health survey. 1992 Proceedings of the Survey Research Methods Section of the American Statistical Association; August 11, 1992; Boston, Mass. In press.
25 +
Myers GL, Cooper GR, Winn CL, Smith SJ.  The Centers for Disease Control—National Heart, Lung, and Blood Institute Lipid Standardization Program. Clin Lab Med . 1989;;9:105-135.
26 +
Moore FE, Gordon T.  Serum cholesterol levels of adults, United States, 1960-62. Vital Health Stat 11 . 1967;; No. (22) .
27 +
Abell L, Levy GB, Brodie BB, et al.  A simplified method for the estimation of total cholesterol in serum and demonstration of its specificity. J Biol Chem . 1952;;195:357-366.
28 +
Abraham S, Johnson CL, Carroll MD.  Total serum cholesterol levels of adults 18-74 years: United States, 1971-74. Vital Health Stat 11 . 1978;; No. (205) .
29 +
Lipid Research Clinics Program. Manual of Laboratory Operations: Lipid and Lipoprotein Analysis . Bethesda, Md: National Institutes of Health; 1974;;1. Revised 1982. DHEW publication NIH 75-628.
30 +
Carroll M, Sempos C, Briefel R, et al.  Serum lipids of adults 20-74 years, United States, 1976-80. Vital Health Stat 11 . 1993;; No. (242) .
31 +
Bachorik PS, Wood DDS, Kuchmak J, et al.  Automated determinations of total plasma cholesterol: a serum calibration technique. Clin Chim Acta . 1979;;96:145-153.
32 +
Allain CC, Poon LS, Chan CSG, Richmond W, Fu PC.  Enzymatic determination of total serum cholesterol. Clin Chem . 1974;;20:470-475.
33 +
Fulwood R, Kalsbeek W, Rifkind B, et al.  Total serum cholesterol levels of adults 20-74 years of age: United States, 1976-80. Vital Health Stat 11 . 1986;; No. (236) .
34 +
Bachorik PS, Walker RE, Virgil DG.  High density lipoprotein cholesterol in heparin-MnCl2 supernates determined with the Dow enzymic method after precipitation of Mn2+ with HCO3-. Clin Chem . 1984;;30:839-842.
35 +
Friedewald WT, Levy RI, Fredrickson DS.  Estimation of the concentration of low density lipoprotein cholesterol in plasma without use of the preparative ultracentrifuge. Clin Chem . 1972;;18:499-502.
36 +
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults.  Summary of the Second Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). JAMA . 1993;;269:3015-3023.
37 +
Ellerbe P, Myers GL, Cooper GR, et al.  A comparison of results for cholesterol in human serum obtained by the reference method and by the definitive method of the national reference system for cholesterol. Clin Chem . 1990;;36:370-375
38 +
Hainline A, Karon JM, Winn CL, et al.  Accuracy and comparability of long-term measurements of cholesterol. Clin Chem . 1986;;32:611-615.
39 +
Lippel K, Ahmed S, Albers JJ, Bachorik P, Muesing R, Winn C.  External quality control survey of cholesterol analyses performed by 12 Lipid Research Clinics. Clin Chem . 1978;;24:1477-1484.
40 +
Ahmed S, Lippel K, Bachorik PS, Muesing R, Weidman S, Winn C.  External quality control survey of triglyceride (triacylglycerol) analyses performed by 12 lipid research clinics. Clin Chem . 1979;;25:880-888.
41 +
Sprafka JM, Burke GL, Folsom AR, Luepker RV, Blackburn H.  Continued decline in cardiovascular disease risk factors: results of the Minnesota Heart Survey, 1980-1982 and 1985-1987. Am J Epidemiol . 1990;;132:489-500.
42 +
Burke GL, Sprafka JM, Folsom AR, Hahn LP, Luepker RV, Blackburn H.  Trends in serum cholesterol levels from 1980 to 1987. N Engl J Med . 1991;;324:941-946.
43 +
Frank E, Winkleby MA, Fortmann SP, Rockhill B, Farquhar JW.  Improved cholesterol-related knowledge and behavior and plasma cholesterol levels in adults during the 1980s. JAMA . 1992;;268:1566-1572.
44 +
Stephen AM, Wald NJ.  Trends in individual consumption of dietary fat in the United States, 1920-1984. Am J Clin Nutr . 1990;;52:457-469.
45 +
Life Sciences Research Office, Federation of American Societies for Experimental Biology. Nutrition Monitoring in the United States—An Update Report on Nutrition Monitoring . Prepared for the US Dept of Agriculture and the US Dept of Health and Human Services. Washington, DC: Public Health Service; 1989;. DHHS publication PHS 89-1255.
46 +
Interagency Board for Nutrition Monitoring and Related Research, Wright J, ed. Nutrition Monitoring in the United States: The Directory of Federal and State Nutrition Monitoring Activities . Hyattsville, Md: Public Health Service; 1992;.
47 +
Pietinen P, Huttunen JK.  Dietary determinants of plasma high-density lipoprotein cholesterol. Am Heart J . 1987;;113( (2) ,pt 2):620-625.
48 +
Briefel RR, Ezzati TM, Fulwood R, Perlman JA, Murphy RS.  Cardiovascular risk status and oral contraceptive use: United States, 1976-1980. Prev Med . 1986;;15:352-362.
49 +
Davis CE, Rifkind BM, Brenner H, et al.  A single cholesterol measurement underestimates the risk of coronary heart disease: an empirical example from the Lipid Research Clinics mortality follow-up study. JAMA . 1990;;264:3044-3046.
50 +
Sempos C, Cooper R, Kovar MG, McMillen M.  Divergence of the recent trends in coronary mortality for the four major race-sex groups in the United States. Am J Public Health . 1988;;78:1422-1427.
51 +
Goldman L, Cook EF.  The decline in ischemic heart disease mortality rates. Ann Intern Med . 1984;;101:825-836.
52 +
Lipid Research Clinics Program.  The Lipid Research Clinics Coronary Primary Prevention Trial results, I: reduction in incidence of coronary heart disease. JAMA . 1984;;251:351-354.
53 +
National Heart, Lung, and Blood Institute Consensus Development Conference.  Lowering blood cholesterol to prevent heart disease. JAMA . 1985;; 253:2080-2086.
54 +
Dept of Health and Human Services. Healthy People 2000: National Health Promotion and Disease Prevention Objectives for the Nation . Washington, DC: Public Health Service; 1991;.

Figures

Tables

Interactive Graphics

Video

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 +
Fulwood R, Rifkind BM, Havlik RJ, Briefel RR, Lippel K, Sempos C.  Trends in serum cholesterol levels among US adults aged 20-74 years. JAMA . 1987;;257:937-942.
2 +
Woteki CE, Briefel RR, Hitchcock D, et al.  Selection of nutrition status indicators for field surveys: the NHANES III design. J Nutr . 1990;;120: 1440-1445.
3 +
Nutrition and Your Health: Dietary Guidelines for Americans . 3rd ed. Washington, DC: US Dept of Agriculture and Dept of Health and Human Services; 1990;.
4 +
Lenfant C.  A new challenge for America: The National Cholesterol Education Program. Circulation . 1986;;73:855-856.
5 +
Cleeman JI.  The National Cholesterol Education Program. Clin Lab Med . 1989;;9(No. (1) ):7-15.
6 +
The Surgeon General's Report on Nutrition and Health . Washington, DC: US Dept of Health and Human Services; 1988;. PHS publication 89-50210.
7 +
National Research Council. Diet and Health: Implications for Reducing Chronic Disease Risk . Washington, DC: National Academy Press; 1989;.
8 +
Truswell AS.  Evolution of dietary recommendations, goals, and guidelines. Am J Clin Nutr . 1987;;45:1060-1072.
9 +
Rizek RL, Jackson EM. Current Food Consumption Practices and Nutrient Sources in the American Diet . Hyattsville, Md: US Dept of Agriculture, Consumer Nutrition Center-Human Nutrition Sciences and Education Administration; 1980;.
10 +
Schucker B, Wittes JT, Santanello NC, et al.  Change in cholesterol awareness and action: results from national physician and public surveys. Arch Intern Med . 1991;;151:666-673.
11 +
Burkman RT.  Lipid and lipoprotein changes in relation to oral contraception and hormonal replacement therapy. Fertil Steril . 1988;;49( (suppl J) ):39S-50S.
12 +
National Cholesterol Education Program.  Report of the Expert Panel on Population Strategies for Blood Cholesterol Reduction. Circulation . 1991;; 83:2154-2232.
13 +
National Cholesterol Education Program.  Report of the NCEP Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Arch Intern Med . 1988;;148:36-39.
14 +
National Center for Health Statistics.  Plan and initial program of the Health Examination Survey. Vital Health Stat 1 . 1965;; No. (4)
15 +
National Center for Health Statistics.  Plan and operation of the Health and Nutrition Examination Survey, United States, 1971-73. Vital Health Stat 1 . 1973;; No. (10) .
16 +
McDowell A, Engle A, Massey J, et al.  Plan and operation of the second National Health and Nutrition Examination Survey, 1976-80. Vital Health Stat 1 . 1981;; No. (15) .
17 +
Ezzati TM, Massey JT, Waksberg J, Chu A, Maurer KR.  Sample design: third National Health and Nutrition Examination Survey. Vital Health Stat 2 . 1992;; No. (113) .
18 +
National Center for Health Statistics.  Plan and operation of the Hispanic Health and Nutrition Examination Survey, 1982-84 . Vital Health Stat 1 . 1985;; No. (19) .
19 +
Carroll M, Sempos CT, Fulwood R, et al.  Serum lipids and lipoproteins of Hispanics, 1982-84 . Vital Health Stat 11 . 1990;; No. (240) .
20 +
Forthofer RN.  Investigations of nonresponse bias in NHANES II. Am J Epidemiol . 1983;;117:507-515.
21 +
A Comparison and Analysis of Examined and Nonexamined Persons on Medical History Characteristics for the First Round of the Health and Nutrition Examination Survey . Washington, DC: US Dept of Health, Education, and Welfare; 1974;. Publication HSM-110-73-371.
22 +
The HANES Study: Final Report . Washington, DC: Health Services and Mental Health Administration; 1975;.
23 +
Miller H, Williams P.  Factors related to response in the Health Examination Survey: United States, 1960-62. Vital Health Stat 6 . 1969;; No. (6) .
24 +
Ezzati T, Khare M. Nonresponse adjustments in a national health survey. 1992 Proceedings of the Survey Research Methods Section of the American Statistical Association; August 11, 1992; Boston, Mass. In press.
25 +
Myers GL, Cooper GR, Winn CL, Smith SJ.  The Centers for Disease Control—National Heart, Lung, and Blood Institute Lipid Standardization Program. Clin Lab Med . 1989;;9:105-135.
26 +
Moore FE, Gordon T.  Serum cholesterol levels of adults, United States, 1960-62. Vital Health Stat 11 . 1967;; No. (22) .
27 +
Abell L, Levy GB, Brodie BB, et al.  A simplified method for the estimation of total cholesterol in serum and demonstration of its specificity. J Biol Chem . 1952;;195:357-366.
28 +
Abraham S, Johnson CL, Carroll MD.  Total serum cholesterol levels of adults 18-74 years: United States, 1971-74. Vital Health Stat 11 . 1978;; No. (205) .
29 +
Lipid Research Clinics Program. Manual of Laboratory Operations: Lipid and Lipoprotein Analysis . Bethesda, Md: National Institutes of Health; 1974;;1. Revised 1982. DHEW publication NIH 75-628.
30 +
Carroll M, Sempos C, Briefel R, et al.  Serum lipids of adults 20-74 years, United States, 1976-80. Vital Health Stat 11 . 1993;; No. (242) .
31 +
Bachorik PS, Wood DDS, Kuchmak J, et al.  Automated determinations of total plasma cholesterol: a serum calibration technique. Clin Chim Acta . 1979;;96:145-153.
32 +
Allain CC, Poon LS, Chan CSG, Richmond W, Fu PC.  Enzymatic determination of total serum cholesterol. Clin Chem . 1974;;20:470-475.
33 +
Fulwood R, Kalsbeek W, Rifkind B, et al.  Total serum cholesterol levels of adults 20-74 years of age: United States, 1976-80. Vital Health Stat 11 . 1986;; No. (236) .
34 +
Bachorik PS, Walker RE, Virgil DG.  High density lipoprotein cholesterol in heparin-MnCl2 supernates determined with the Dow enzymic method after precipitation of Mn2+ with HCO3-. Clin Chem . 1984;;30:839-842.
35 +
Friedewald WT, Levy RI, Fredrickson DS.  Estimation of the concentration of low density lipoprotein cholesterol in plasma without use of the preparative ultracentrifuge. Clin Chem . 1972;;18:499-502.
36 +
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults.  Summary of the Second Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). JAMA . 1993;;269:3015-3023.
37 +
Ellerbe P, Myers GL, Cooper GR, et al.  A comparison of results for cholesterol in human serum obtained by the reference method and by the definitive method of the national reference system for cholesterol. Clin Chem . 1990;;36:370-375
38 +
Hainline A, Karon JM, Winn CL, et al.  Accuracy and comparability of long-term measurements of cholesterol. Clin Chem . 1986;;32:611-615.
39 +
Lippel K, Ahmed S, Albers JJ, Bachorik P, Muesing R, Winn C.  External quality control survey of cholesterol analyses performed by 12 Lipid Research Clinics. Clin Chem . 1978;;24:1477-1484.
40 +
Ahmed S, Lippel K, Bachorik PS, Muesing R, Weidman S, Winn C.  External quality control survey of triglyceride (triacylglycerol) analyses performed by 12 lipid research clinics. Clin Chem . 1979;;25:880-888.
41 +
Sprafka JM, Burke GL, Folsom AR, Luepker RV, Blackburn H.  Continued decline in cardiovascular disease risk factors: results of the Minnesota Heart Survey, 1980-1982 and 1985-1987. Am J Epidemiol . 1990;;132:489-500.
42 +
Burke GL, Sprafka JM, Folsom AR, Hahn LP, Luepker RV, Blackburn H.  Trends in serum cholesterol levels from 1980 to 1987. N Engl J Med . 1991;;324:941-946.
43 +
Frank E, Winkleby MA, Fortmann SP, Rockhill B, Farquhar JW.  Improved cholesterol-related knowledge and behavior and plasma cholesterol levels in adults during the 1980s. JAMA . 1992;;268:1566-1572.
44 +
Stephen AM, Wald NJ.  Trends in individual consumption of dietary fat in the United States, 1920-1984. Am J Clin Nutr . 1990;;52:457-469.
45 +
Life Sciences Research Office, Federation of American Societies for Experimental Biology. Nutrition Monitoring in the United States—An Update Report on Nutrition Monitoring . Prepared for the US Dept of Agriculture and the US Dept of Health and Human Services. Washington, DC: Public Health Service; 1989;. DHHS publication PHS 89-1255.
46 +
Interagency Board for Nutrition Monitoring and Related Research, Wright J, ed. Nutrition Monitoring in the United States: The Directory of Federal and State Nutrition Monitoring Activities . Hyattsville, Md: Public Health Service; 1992;.
47 +
Pietinen P, Huttunen JK.  Dietary determinants of plasma high-density lipoprotein cholesterol. Am Heart J . 1987;;113( (2) ,pt 2):620-625.
48 +
Briefel RR, Ezzati TM, Fulwood R, Perlman JA, Murphy RS.  Cardiovascular risk status and oral contraceptive use: United States, 1976-1980. Prev Med . 1986;;15:352-362.
49 +
Davis CE, Rifkind BM, Brenner H, et al.  A single cholesterol measurement underestimates the risk of coronary heart disease: an empirical example from the Lipid Research Clinics mortality follow-up study. JAMA . 1990;;264:3044-3046.
50 +
Sempos C, Cooper R, Kovar MG, McMillen M.  Divergence of the recent trends in coronary mortality for the four major race-sex groups in the United States. Am J Public Health . 1988;;78:1422-1427.
51 +
Goldman L, Cook EF.  The decline in ischemic heart disease mortality rates. Ann Intern Med . 1984;;101:825-836.
52 +
Lipid Research Clinics Program.  The Lipid Research Clinics Coronary Primary Prevention Trial results, I: reduction in incidence of coronary heart disease. JAMA . 1984;;251:351-354.
53 +
National Heart, Lung, and Blood Institute Consensus Development Conference.  Lowering blood cholesterol to prevent heart disease. JAMA . 1985;; 253:2080-2086.
54 +
Dept of Health and Human Services. Healthy People 2000: National Health Promotion and Disease Prevention Objectives for the Nation . Washington, DC: Public Health Service; 1991;.

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