Skip Navigation LinksSkip Navigation Links
Centers for Disease Control and Prevention
Safer Healthier People
Blue White
Blue White
bottom curve
CDC Home Search Health Topics A-Z spacer spacer
Blue curve MMWR spacer

Progress in Chronic Disease Prevention Factors Related to Cholesterol Screening and Cholesterol Level Awareness -- United States, 1989

Since November 1985, when the National Cholesterol Education Program (NCEP) was initiated by the National Heart, Lung, and Blood Institute, cholesterol screening and awareness of cholesterol levels have increased substantially in the United States (1,2). However, cholesterol screening and awareness patterns vary by state (2). To assess whether these variations may be related to demographic differences between states, data from the Behavioral Risk Factor Surveillance System (BRFSS) for 1989 were analyzed. Differences in cholesterol screening and awareness in relation to cardiovascular disease (CVD) risk factors other than elevated cholesterol level were also evaluated. Health departments in the 39 participating states and the District of Columbia use a standardized questionnaire when conducting monthly random-digit-dialed telephone surveys of persons greater than or equal to 18 years of age (3). In 1989, respondents were asked whether they had ever had their cholesterol "checked." If so, they were asked to provide the duration since their last test and whether they had been told their cholesterol level. Persons who reported being told their cholesterol level were asked to state their level; those who reported a number from 100 mg divided by L through 450 mg divided by L were considered to know their cholesterol level. The state-specific survey results were weighted according to the age, sex, and race distribution of adults in each state. Combined data were also weighted according to the population size in each state and are therefore representative of the total population in the participating states. To allow comparisons between states and within demographic categories, state-specific and combined results were standardized by age, sex, race, and educational attainment using 1980 U.S. census data. SESUDAAN, a computer software program for analyzing complex sample survey data, was used to calculate standard errors for the prevalence estimates (4). The overall percentage of adults who reported ever having had their cholesterol level checked ranged from 48% in Alabama and New Mexico to 64% in Connecticut, Florida, and Washington (Table 1). The percentage of adults who reported knowing their cholesterol level ranged from 12% in the District of Columbia to 33% in Washington. After standardization of the state-specific estimates for age, sex, race, and educational attainment using 1980 census data, cholesterol screening and awareness still varied between states. Cholesterol screening and awareness were slightly higher among women than among men (Table 2). Younger persons (18-34 years of age), blacks, and persons with lower educational attainment (less than or equal to 12 years of education) were less likely to have had their cholesterol level checked and were less likely to report knowing their cholesterol level. Differences by race declined after standardization for age, sex, and educational attainment. However, differences by sex, age, and educational attainment remained unchanged or increased when standardized by the other demographic factors. Persons with diabetes, hypertension, or obesity were more likely to have had their cholesterol level checked and were more likely to know their cholesterol level than were persons who did not report having these risk factors for CVD (Table 3). However, cholesterol screening and awareness were lower among persons who reported having a sedentary lifestyle and among persons who reported smoking than among persons who did not report having these CVD risk factors. Differences were less marked after standardization for age, sex, race, and educational attainment but remained statistically significant (p less than 0.05, z-test). Reported by: the following state BRFSS coordinators: L Eldrige, Alabama; J Contreras, Arizona; W Wright, California; M Adams, Connecticut; A Peruga, District of Columbia; S Hoecherl, Florida; J Smith, Georgia; A Villafuerte, Hawaii; J Mitten, Idaho; B Steiner, Illinois; S Joseph, Indiana; S Schoon, Iowa; K Bramblett, Kentucky; J Sheridan, Maine; A Weinstein, Maryland; L Koumjian, Massachusetts; J Thrush, Michigan; N Salem, Minnesota; J Jackson-Thompson, Missouri; M McFarland, Montana; S Spanke, Nebraska; K Zaso, L Powers, New Hampshire; L Pendley, New Mexico; J Marin, O Munshi, New York; C Washington, North Carolina; M Maetzold, North Dakota; E Capwell, Ohio; N Hann, Oklahoma; J Grant-Worley, Oregon; C Becker, Pennsylvania; R Cabrel, Rhode Island; M Mace, South Carolina; S Moritz, South Dakota; D Riding, Tennessee; J Fellows, Texas; L Post-Nilson, Utah; J Bowie, Virginia; K Tollestrup, Washington; D Porter, West Virginia; M Soref, Wisconsin. Behavioral Surveillance Br, Office of Surveillance and Analysis and Div of Chronic Disease Control and Community Intervention, Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: BRFSS data for 1989 indicate that cholesterol screening and awareness of cholesterol levels continue to increase in the United States. Among states participating in the BRFSS, the median proportion of adults who reported having had their cholesterol tested increased from 47% in 1987 to 56% in 1989. Similarly, the median proportion of adults who reported knowing their cholesterol level increased from 6% in 1987 to 21% in 1989. In this analysis, cholesterol screening and awareness were strongly associated with age, race, and educational attainment, and variations by state persisted after adjustment for demographic differences between states. Thus, other factors were likely to be associated with variations by state, including differences in 1) time of implementation and intensity of cholesterol education and screening programs and 2) availability and quality of clinical preventive services. NCEP goals are for all adults to 1) have their cholesterol level measured at least once every 5 years, 2) know their cholesterol level, and 3) take steps to lower their cholesterol level if it is elevated (5). The lower level of cholesterol testing and awareness among the youngest age group (18-34 years of age) is of particular concern: considerable evidence suggests that atherosclerosis is present by early adulthood (6-8) and that early atherosclerotic lesions may be related to elevated cholesterol levels during childhood and adolescence (9). Through identification and treatment of high blood cholesterol in early adulthood, younger persons may be able to prevent or delay the development of atherosclerosis. Increased identification and treatment of high blood cholesterol among blacks and persons in low socioeconomic groups is also important. Multiple CVD risk factors increase the risk for CVD-related morbidity and mortality. For example, hypertensive smokers have a three to six times greater risk for CVD-related mortality than do normotensive nonsmokers (5). Additionally, a given reduction in blood cholesterol may produce a greater reduction in risk for CVD among persons with multiple CVD risk factors than among persons without these risk factors (5). Therefore, persons with risk factors for CVD should have their cholesterol level tested. These persons can substantially reduce their risk for CVD by working with their health-care provider to reduce an elevated cholesterol level and other CVD risk factors. Since cholesterol screening and awareness were lower among smokers and those with a sedentary lifestyle, special efforts are needed to reach these high-risk populations. In an effort to increase federal, state, and local activities supporting cholesterol awareness, September 1990 has been designated National Cholesterol Education Month by the NCEP Coordinating Committee.


  1. Schucker B, Bailey K, Heimbach JT, et al. Change in public perspective on cholesterol and heart disease: results from two national surveys. JAMA 1987;258:3527-31.

  2. CDC. State-specific changes in cholesterol screening and awareness--United States, 1987-1988. MMWR 1990;39:304-5,311-4.

  3. Remington PL, Smith MY, Williamson DF, Anda RF, Gentry EM, Hogelin GC. Design, characteristics, and usefulness of state-based behavioral risk factor surveillance: 1981-87. Public Health Rep 1988;103:366-75.

  4. Shah BV. SESUDAAN: standard errors program for computing of standardized rates from sample survey data. Research Triangle Park, North Carolina: Research Triangle Institute, 1981.

  5. 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.

  6. McNamara JJ, Molot MA, Stremple JF, Cutting RT. Coronary artery disease in combat casualties in Vietnam. JAMA 1971;216:1185-7.

  7. Enos WF, Holmes RH, Beyer J. Coronary disease among United States soldiers killed in action in Korea. JAMA 1953;152:1090-3.

  8. Berenson GS, Srinivasan SR, Freedman DS, Radhakrishnamurthy B, Dalferes ER. Review: atherosclerosis and its evolution in childhood. Am J Med Sci 1987;294:429-40.

  9. Newman WP, Freedman DS, Voors AW, et al. Relation of serum lipoprotein levels and systolic blood pressure to early atherosclerosis: the Bogalusa Heart Study. N Engl J Med 1986;314:138-44.

Disclaimer   All MMWR HTML documents published before January 1993 are electronic conversions from ASCII text into HTML. This conversion may have resulted in character translation or format errors in the HTML version. Users should not rely on this HTML document, but are referred to the original MMWR paper copy for the official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC 20402-9371; telephone: (202) 512-1800. Contact GPO for current prices.

**Questions or messages regarding errors in formatting should be addressed to

Page converted: 08/05/98


Safer, Healthier People

Morbidity and Mortality Weekly Report
Centers for Disease Control and Prevention
1600 Clifton Rd, MailStop E-90, Atlanta, GA 30333, U.S.A


Department of Health
and Human Services

This page last reviewed 5/2/01