Original Article
Trends in Serum Cholesterol Levels from 1980 to 1987 — The Minnesota Heart Survey
N Engl J Med 1991; 324:941-946April 4, 1991
- Abstract
- Abstract
Background and Methods.
We assessed community trends in the awareness, treatment, and control of hypercholesterolemia (defined as a serum cholesterol level ≥6.21 mmol per liter [240 mg per deciliter]) during the 1980s in the Minneapolis—St. Paul (Twin Cities) metropolitan area. Twin Cities residents 25 to 74 years old participated in independent, cross-sectional, population-based surveys of risk factors for cardiovascular disease in 1980–1982 (n = 3365) and 1985–1987 (n = 4545).
Results.
Mean serum total cholesterol levels, as adjusted for age, decreased significantly (P<0.01) from 1980–1982 to 1985–1987 in men (from 5.30 mmol per liter [205 mg per deciliter] to 5.16 mmol per liter [200 mg per deciliter]) and women (from 5.19 mmol per liter [201 mg per deciliter] to 5.04 mmol per liter [195 mg per deciliter]). The prevalence of hypercholesterolemia as adjusted for age decreased significantly (P<0.05) in men (17.8 to 15.1 percent) and women (17.1 to 13.6 percent). The ratio of total cholesterol to high-density lipoprotein (HDL) cholesterol was unchanged during this period, because of a concurrent decline in the level of HDL cholesterol. Participants with hypercholesterolemia in the 1985–1987 survey were more likely than those in the 1980–1982 survey to be aware of their condition (32.6 vs. 25.4 percent), to be treated with lipid-lowering agents (4.3 vs. 1.9 percent), and to have their condition controlled (1.9 vs. 0.3 percent). Among those who reported treatment by a physician for hyperlipidemia, changes were observed in the type of treatment recommended. A significant increase (P<0.05) was noted from 1980–1982 to 1985–1987 in the percentage of men being treated for hyperlipidemia with lipid-lowering medication (5.2 vs. 11.6 percent) and with exercise programs (10.3 vs. 20.1 percent). In women being treated for hyperlipidemia, a nonsignificant increase was noted in the use of lipid-lowering medication (8.2 vs. 13.9 percent), and a significant increase (P<0.05) was observed in the number of exercise prescriptions (4.1 vs. 12.0 percent).
Conclusions.
We found a substantial decline in the prevalence of hypercholesterolemia in the Twin Cities between 1980–1982 and 1985–1987 that may be attributed to changes in lifestyle, such as diet and exercise, and to a lesser extent to more aggressive intervention with lipid-lowering drugs by physicians. (N Engl J Med 1991; 324: 941–6.)
Media in This Article
Figure 1
Distribution of Serum Cholesterol Levels in Survey Participants in 1980–1982 and 1985–1987.Figure 2
Trends in the Prevalence of Hypercholesterolemia in Survey Participants in 1980–1982 and 1985–1987.Article Activity
- Article
NUMEROUS prospective studies have documented that higher serum cholesterol levels are associated with an increase in subsequent morbidity and mortality from coronary heart disease.1 2 3 4 5 6 7 8 Clinical trials of agents that lower cholesterol levels have reported fewer coronary heart disease events in intervention groups whose cholesterol levels were reduced than in controls.9 Since the results of the Lipid Research Clinics Trial were released in the early 1980s, there has been an increase among both physicians and the general public in awareness of the importance of reducing elevated cholesterol levels.10 11 12 13 14 More recently, the National Cholesterol Education Program was initiated to improve awareness, treatment, and control of hypercholesterolemia in the United States.15 , 16 We have previously reported a decline in serum cholesterol levels from the mid-1970s to the early 1980s in residents of the Minneapolis—St. Paul metropolitan area (the Twin Cities).17 Virtually no information has been reported on community trends in the detection, treatment, and control of hypercholesterolemia from the early to the mid-1980s.
This paper describes community trends in mean serum cholesterol levels, the prevalence of hypercholesterolemia, awareness of elevated cholesterol levels, and treatment patterns in two independent population-based samples of residents of the Twin Cities surveyed in 1980–1982 and 1985–1987. These data provide base-line information documenting reported patterns of treatment by physicians, changes in lifestyle, and their associations with the prevalence of hypercholesterolemia in a community before and during the early phase of implementation of the National Cholesterol Education Program.
Methods
The Minnesota Heart Survey was initiated in 1979 to examine concurrent community trends in mortality, morbidity, risk factors, and risk behaviors for coronary heart disease to help determine the causes and components of the decrease in mortality due to coronary heart disease. The methods and early findings of the risk-factor survey have previously been described.17 18 19 20 The seven-county Twin Cities metropolitan area was divided into 704 clusters of approximately 1000 households each (on the basis of information from the 1970 census), and 40 clusters were randomly selected for surveillance. In 1980–1981, all household members of an eligible age were selected, and in 1981–1982 and 1985–1987, one person 25 to 74 years old was randomly selected per household. Participants were interviewed briefly (15 to 20 minutes) in the home and then invited to attend a neighborhood clinic for a 1-hour examination that included assessments of diet, use of medications, and health-related behavior by interview and the measurement of blood pressure, nonfasting serum lipid levels, and body size (height and weight). More than 3400 people participated in the 1980–1982 survey, and more than 4600 participated in the 1985–1987 survey (no one participated in both). The use of independent samples allows better quantification of community risk-factor trends, and in addition, statistical regression to the mean is not a problem with this design. Rates of participation were similar in the two surveys, with approximately 90 percent of the eligible persons completing a household interview and 70 percent completing both the interview and the examination at the clinic. To assess the possibility of selection bias due to the 30 percent prevalence of those who did not attend the clinic, we compared the prevalence of reported hypercholesterolemia in those who attended and those who did not. No selection bias over time was detected, since those who attended the clinic reported a consistently higher prevalence of hypercholesterolemia in both periods than those who did not attend (9 vs. 7 percent in 1980–1982 and 10 vs. 7 percent in 1985–1987).
Blood specimens were obtained from nonfasting participants during the clinic examination according to the protocol of the Lipid Research Clinics Trial.21 Serum total and high-density lipoprotein (HDL) cholesterol levels were measured with an AutoAnalyzer II (Technicon Instruments, Tarrytown, N.Y.) by the Minnesota Lipid Research Clinics laboratory.22 During both surveys the laboratory participated in the standardization program conducted by the Centers for Disease Control (CDC). We assessed the influence of laboratory drift on observed trends in serum cholesterol levels, using data collected as part of the CDC standardization program. Measurements at the Minnesota laboratory were an average of 0.14 mmol per liter (5.5 mg per deciliter) lower than the CDC standards in 1980–1982 (280 comparisons) and 0.06 mmol per liter (2.2 mg per deciliter) lower in 1985–1987 (298 comparisons). This trend toward more accurate measures over time was present at both lower cholesterol standards (3.67 mmol per liter [19 mg per deciliter]) and higher cholesterol standards (6.38 mmol per liter [270 mg per deciliter]). These data suggest that the observed decline in serum cholesterol levels from 1980–1982 to 1985–1987 in the Twin Cities was not attributable to laboratory drift and probably underestimated the actual decrease during this period by approximately 0.08 mmol per liter (3.3 mg per deciliter). No adjustment for this difference has been made in this paper.
All current medications taken by the participants, including lipid-lowering medications, were recorded by a trained interviewer using standardized protocols in 1980–1982 and 1985–1987. Participants were also asked about nonpharmacologic strategies recommended by their physicians to lower cholesterol levels. The use of cholesterol-lowering medications was validated with information from a medication questionnaire that required participants to bring all medications to the clinic for documentation.
Analyses were performed with the SAS software package23 and were restricted to participants 25 to 74 years of age who completed both the home interview and a clinic visit. Simple descriptive statistics (means, standard errors, 95 percent confidence intervals, and percentages) were used to describe trends in mean serum cholesterol levels, the prevalence of hypercholesterolemia, and treatment patterns. Analysis of covariance was used to determine age-adjusted trends over time in levels, awareness, and treatment. We calculated all P values using the assumption of potential two-sided differences. Hypercholesterolemia was defined as either a serum cholesterol level≥6.21 mmol per liter (240 mg per deciliter) or the current use of lipid-lowering agents. Hypercholesterolemia in persons taking lipid-lowering drugs at the time of examination was defined as treated and controlled if the serum cholesterol level was less than 6.21 mmol per liter.
Results
Trends in Serum Total Cholesterol Levels and Hypercholesterolemia
Table 1Table 1
Participants in the 1980–1982 and 1985–1987 Risk-Factor Surveys of Residents of the Twin Cities, According to Aqe and Sex.* shows the participants in the 1980–1982 and 1985–1987 surveys according to age and sex. Table 2Table 2
Mean Serum Total Cholesterol and HDL Cholesterol Levels in Residents of the Twin Cities in the Minnesota Heart Survey, According to Age, Sex, and Year. shows the trends in mean serum total and HDL cholesterol levels from 1980–1982 to 1985–1987. Serum cholesterol levels decreased over this five-year period in virtually all age and sex categories. The greatest decline in serum total cholesterol was observed in the 65-to-74-year-olds (0.22 mmol per liter [8.5 mg per deciliter] in the men, and 0.25 mmol per liter [9.7 mg per deciliter] in the women). The overall mean level, as adjusted for age, declined by 0.14 mmol per liter (5.2 mg per deciliter) in the men and 0.15 mmol per liter (5.8 mg per deciliter) in the women. This decrease was observed across the entire distribution of cholesterol levels (Fig. 1Figure 1Distribution of Serum Cholesterol Levels in Survey Participants in 1980–1982 and 1985–1987.). In both men and women, the cholesterol levels shifted toward lower values from 1980–1982 to 1985–1987, indicating that the decline was not restricted to those with elevated levels. In addition, the decline was observed across educational strata (data not shown). Although cholesterol levels were lower in participants with more education, the decline from 1980–1982 to 1985–1987 was similar in participants reporting educational levels of high school or less, those with some college education, and college graduates. Levels of HDL cholesterol declined slightly in virtually all age groups, although the age-adjusted decreases were statistically significant only in the men (0.04 mmol per liter [1.6 mg per deciliter], as compared with 0.02 mmol per liter [0.9 mg per deciliter] in the women). Because of the concurrent declines in total and HDL cholesterol, the ratio of total to HDL cholesterol was unchanged.To monitor trends over time in persons at high risk, the prevalence of hypercholesterolemia was assessed (Fig. 2Figure 2
Trends in the Prevalence of Hypercholesterolemia in Survey Participants in 1980–1982 and 1985–1987.). Like the trend in the mean serum level of cholesterol, the prevalence of hypercholesterolemia decreased between 1980–1982 and 1985–1987 in each category of age and sex. The age-adjusted prevalence of hypercholesterolemia declined significantly in the 1980s, by 2.7 percentage points in men and 3.5 percentage points in women. The prevalence of hypercholesterolemia rose with increasing age in women but peaked at the age of 55 to 64 in men.Treatment of Hypercholesterolemia
Table 3Table 3
Awareness, Treatment, and Control of Hypercholesterolemia in Residents of the Twin Cities in the Minnesota Heart Survey.* shows the level of awareness, treatment (defined as drug treatment), and control of hypercholesterolemia in men and women in the Twin Cities from 1980–1982 to 1985–1987. The proportion of women with hypercholesterolemia who were unaware of their condition decreased significantly (by 13.5 percentage points, P<0.001), whereas no change was observed in the men. Nevertheless, nearly two thirds of the participants with serum cholesterol levels ≥6.21 mmol per liter (240 mg per deciliter) in 1985–1987 were unaware of it. Both the percentage of participants with hypercholesterolemia who reported being treated with lipid-lowering medication and the percentage in whom the condition was treated and controlled increased significantly from 1980–1982 to 1985–1987. Similar improvements were seen across educational strata.To document medical practice in the treatment of hyperlipidemia, we assessed the community prevalence of nonpharmacologic and pharmacologic treatments initiated by physicians. The percentage of all participants, regardless of cholesterol level, who reported that their physician had recommended a cholesterol-lowering regimen (including medication, low-fat diets, weight-loss programs, exercise programs, or surgery) is shown in Table 4Table 4
Prevalence of Cholesterol-Lowering Treatment of Any Type in Residents of the Twin Cities in the Minnesota Heart Survey.*. The prevalence of cholesterol-lowering treatment rose with increasing age, and the prevalence as adjusted for age increased by approximately 2 percentage points from 1980–1982 to 1985–1987 in both men and women. The percentage of the entire population undergoing treatment increased over time in every age group, with the largest increase in men 45 to 54 years old and in women 55 to 64 years old. The overall prevalence of the use of cholesterol-lowering medication increased significantly, from 0.3 percent of the population in 1980–1982 to 0.9 percent in 1985–1987. Specific medications used in 1980–1982 included clofibrate (82 percent) and dextrothyroxine (18 percent), whereas in 1985–1987 niacin (55 percent), gemfibrozil (20 percent), cholestyramine (11 percent), probucol (11 percent), clofibrate (7 percent), and colestipol (2 percent) were used.Table 5Table 5
Trends in Type of Treatment Used for Hypercholesterolemia in the Twin Cities.* shows the trends in cholesterol-lowering treatments recommended by physicians to the participants who reported having been told by a physician that they had high levels of blood lipids. The use of medication increased from 1980–1982 to 1985–1987, but it was reported by only 12 to 14 percent of the participants treated by a physician. The majority of those being treated (90 to 100 percent) were receiving at least one type of nonpharmacologic treatment. More than 80 percent of the participants treated for elevated cholesterol levels reported following a low-fat diet, and this percentage changed very little between the two surveys. Slightly more than 20 percent of those being treated reported following a weight-loss diet in both 1980–1982 and 1985–1987. The prevalence of the prescription of exercise increased from 10.3 to 20.1 percent in the men and from 4.1 to 12.0 percent in the women from 1980–1982 to 1985–1987. Surgical intervention (jejunoileal bypass) was used relatively infrequently.Knowledge of Serum Cholesterol Level
Information on the participants' knowledge of their serum cholesterol levels is shown in Table 6Table 6
Prevalence and Accuracy of Self-Reported Serum Cholesterol Levels in Residents of the Twin Cities in the Minnesota Heart Survey.. The ability to provide a value increased with age. In 1985–1987, for example, the percentage ranged from less than 5 percent of those 25 to 34 years old to approximately 20 percent of those 65 to 74 years old. More striking was the dramatic increase from 1980–1982 to 1985–1987 in the number able to provide a cholesterol value. Significant increases were detected in each age and sex group. A comparison of the self-reported cholesterol levels with the levels measured during the survey is shown in Table 6. Very little difference in the accuracy of the values reported by the participants was detected with increasing age in either period. The values were less accurate in the men (difference from measured value, 1.29 mmol per liter [50 mg per deciliter]) than in the women (0.94 mmol per liter [36 mg per deciliter]) in 1980–1982. The difference between reported and measured values improved significantly in the men (by 0.45 mmol per liter [18 mg per deciliter]) but not in the women (0.07 mmol per liter [2.6 mg per deciliter]) from 1980–1982 to 1985–1987. In 1985–1987 a similar degree of accuracy was observed in men and women. No systematic differences (values consistently higher or lower than our AutoAnalyzer II measurements) were observed between reported and measured cholesterol levels. Despite these improvements in the 1980s, a large number of people still did not know their cholesterol level or reported a number substantially different from that measured by our laboratory.Discussion
These data show a sizable decrease in both mean serum cholesterol levels and the prevalence of hypercholesterolemia in the Twin Cities population in the 1980s. An increase consistent with these changes was observed in the prevalence of intervention by physicians in the treatment of hypercholesterolemia. In addition, the decline in serum cholesterol values across the entire distribution of cholesterol levels is consistent with dietary changes we have observed during this period. We have reported that the Keys score, an index of dietary cholesterol and fat intake, decreased during the period.24 , 25 The observed changes would be expected to have a major role in trends in mortality due to coronary heart disease. If one assumes a 2 percent decrease in such mortality for each 1 percent decrease in serum cholesterol, cholesterol lowering alone would be expected to produce a 5 percent decline in coronary heart disease mortality in this community.26 The exact effect of these lower serum cholesterol levels on mortality due to coronary heart disease is unknown, given that the ratio of total to HDL cholesterol was unchanged during the period.
We have previously reported a decrease of 0.13 mmol per liter (5 mg per deciliter) in mean serum cholesterol levels from 1973–1974 to the early 1980s in the Twin Cities.17 A similar decline was observed nationally from the 1970s through 1980,27 although cholesterol levels were approximately 0.21 to 0.26 mmol per liter (8 to 10 mg per deciliter) lower in residents of the Twin Cities than nationally. If one assumes parallel trends, the findings in Minnesota residents in the 1980s may be indicative of an ongoing nationwide decrease in cholesterol levels and hypercholesterolemia.
Community awareness of serum cholesterol levels increased dramatically during the 1980s. The effect of cholesterol screening is evident from the increased numbers of men and women of all ages who knew their own cholesterol values. Awareness was greatest in older participants, either because they were more motivated or because they had had more measurements performed. In addition, the accuracy of self-reported values improved by 0.45 mmol per liter (18 mg per deciliter) in the men and 0.07 mmol per liter (2.6 mg per deciliter) in the women. It must be noted, however, that despite these improvements a substantial number of participants remained unaware of their cholesterol level or reported it inaccurately in the mid-1980s. Other investigators have detected similar improvements in public knowledge and awareness of high cholesterol levels in national probability samples from 1983 to 1986.10 , 28
The National Cholesterol Education Program has recommended a stepped program of dietary and pharmacologic intervention for patients at high risk.15 , 16 Nonpharmacologic interventions (low-fat diets and weight-loss programs) are recommended as initial treatment for at least the first six months after diagnosis. Drug treatment is recommended for patients whose lipid levels are persistently elevated. Our data show that Minnesota physicians seem to be following these recommendations. Low-fat diets and weight-loss programs were recommended to the majority of patients whose hypercholesterolemia was being treated. It must be noted, however, that up to two thirds of the participants with elevated cholesterol levels were not aware of their hyperlipidemia and were not undergoing treatment. The overall prevalence of treatment increased significantly, by approximately 2 percentage points, from 1980–1982 to 1985–1987, with much larger increases in the older age groups. In addition, the pattern of treatment changed. There was, for example, a nearly twofold increase in the use of medication and exercise programs over the five-year period. It should be noted that these data were collected before the newer cholesterol-lowering agents became widely available, and they may not accurately reflect current prescription patterns.29 Similar improvements in physicians' awareness and treatment of elevated cholesterol levels have been observed nationally. 11
Estimates of hypercholesterolemia in the Minnesota Heart Survey were derived from a single measurement of serum cholesterol. The National Cholesterol Education Program has recommended that a level of 6.21 mmol per liter (240 mg per deciliter) or higher be used as the screening level for subsequent assessment of low-density lipoprotein (LDL) and other risk factors for cardiovascular disease, to determine treatment priorities.15 , 16 Our use of a single serum total cholesterol value without a measurement of LDL cholesterol may have led us to overestimate the prevalence of persons at high risk. Because we used the same cutoff point and a standardized laboratory in both surveys, however, there should be no systematic bias in our estimates of trends over time. The decline in serum cholesterol levels we observed was not attributable to laboratory drift. On the basis of CDC standardization data, the estimates presented here may actually be lower by 0.08 mmol per liter (3.3 mg per deciliter) than the average decrease in serum cholesterol levels.
The data of the Minnesota Heart Survey provide a comprehensive assessment of community trends in awareness of cholesterol levels and in patterns of treatment by physicians in the 1980s before the full implementation of the National Cholesterol Education Program. The decline in serum cholesterol levels in the 1980s can be attributed at least in part to an increased prevalence of treatment by physicians. Despite increased awareness and treatment in the 1980s, however, up to two thirds of those with hypercholesterolemia remained unaware of their condition in 1985–1987. Thus, this study shows both an improvement in treatment and the need for continued programs to identify and treat hypercholesterolemia effectively.
Supported in part by a research grant (R01–23727) from the National Heart, Lung and Blood Institute.
Source Information
From the Department of Public Health Sciences, Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, N.C. (G.L.B.), and the Division of Epidemiology, University of Minnesota School of Public Health, Minneapolis (J.M.S., A.R.F., L.P.H., R.V.L., H.B.). Address reprint requests to Dr. Burke at the Department of Public Health Sciences, Bowman Gray School of Medicine, 300 S. Hawthorne Rd., Winston-Salem, NC 27103.
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Karen L. Graves, Paul G. McGovern, J. Michael Sprafka, Aaron R. Folsom, Gregory L. Burke. (1993) Contribution of dietary lipid change to falling serum cholesterol levels between 1980 to 1982 and 1985 to 1987 in an urban population The Minnesota heart survey. Annals of Epidemiology 3:6, 605-613
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