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Cholesterol Screening and Awareness -- Behavioral Risk Factor Surveillance System, 1990

The association between high blood cholesterol and coronary heart disease (CHD) has been well documented (1), and lowering total and low-density lipoprotein cholesterol levels can reduce the incidence of CHD. For example, a 1% decrease in serum cholesterol can result in a 2% decrease in the risk for CHD (2). To reduce the prevalence of high blood cholesterol in the United States, the National Heart, Lung, and Blood Institute initiated the National Cholesterol Education Program (NCEP) in 1985 (3) to encourage all adults to have their cholesterol levels checked at least once every 5 years, know their cholesterol levels, and if it is elevated, take steps to lower their levels. This report summarizes data on the proportion of adults who have been screened and report knowing their cholesterol levels.

Data from the 44 states and the District of Columbia, which participated in CDC's Behavioral Risk Factor Surveillance System (BRFSS) during 1990, were analyzed. The BRFSS is a random-digit-dialed monthly telephone survey of persons aged greater than or equal to 18 years (4). Respondents were asked whether they had ever had their cholesterol levels checked and, if so, whether they were told their cholesterol levels. Persons who reported having been told their levels were asked to state their levels; respondents who reported a level from 100 mg/dL through 450 mg/dL were considered to know their levels.

The results were weighted to account for the age, race, and sex distribution of each state population, and to allow for comparisons between states, the results were standardized for age, race, sex, and educational attainment, using the 1980 U.S. census population. SESUDAAN was used to calculate the confidence intervals for the standardized and unstandardized prevalence estimates (5).

In 1990, the percentage of adults who reported having had their cholesterol checked ranged from 48% in the District of Columbia to 70% in Rhode Island (median: 63%) (Table 1, page 675). The percentage of adults who had been told their cholesterol levels ranged from 29% in the District of Columbia to 58% in Washington and New Hampshire (median: 48%), and those who knew their levels ranged from 12% in the District of Columbia to 37% in Rhode Island and New Hampshire (median: 29%).

After standardizing for age, race, sex, and educational attainment, persons residing in the northeast, north-central, and northwest United States were more likely to know their cholesterol levels, and those in the southeast and the Ohio River Valley were less likely to know their levels (Figure 1, page 676). Minority groups, the young (i.e., 18-34 years), and the less educated were less likely to have been screened, to have been told their cholesterol levels, or to know their levels (Table 2, page 677). Persons who were overweight, hypertensive, or diabetic were more likely to have been screened or to know their levels; persons who were sedentary or smokers were less likely. Reported by the following state BRFSS coordinators: L Eldridge, Alabama; J Contreras, Arizona; L Lund, California; M Leff, Colorado; M Adams, Connecticut; F Breukelman, Delaware; C Mitchell, District of Columbia; D McTague, Florida; JD Smith, Georgia; VF Ah Cook, Hawaii; J Mitten, Idaho; B Steiner, Illinois; R Guest, Indiana; S Schoon, Iowa; K Bramblett, Kentucky; S Kirkconnell, Louisiana; J Sheridan, Maine; A Weinstein, Maryland; R Lederman, Massachusetts; H McGee, Michigan; N Salem, Minnesota; E Jones, Mississippi; J Jackson-Thompson, Missouri; R Moon, Montana; S Spanhake, Nebraska; K Zaso, New Hampshire; MEWatson, New Mexico; C Baker, New York; CR Washington, North Carolina; M Maetzold, North Dakota; E Capwell, Ohio; N Hann, Oklahoma; J Grant-Worley, Oregon; C Becker, Pennsylvania; J Buechner, Rhode Island; M Mace, South Carolina; S Moritz, South Dakota; D Ridings, Tennessee; R Diamond, Texas; L Post-Nilson, Utah; P Brozicevic, Vermont; R Schaeffer, Virginia; R Canty, Washington; F King, West Virginia; E Cautley, Wisconsin. Cardiovascular Health Studies Br, Div of Chronic Disease Control and Community Intervention, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: Risk for CHD increases as serum cholesterol levels increase; persons whose cholesterol levels measure in the highest 10% for the U.S. population have approximately a fourfold greater risk for dying from CHD than persons with levels in the lowest 10% (6). Based on current NCEP guidelines, approximately 36% of U.S. adults need treatment for high blood cholesterol (7), and findings in this report indicate a need for increased cholesterol screening and awareness. Cholesterol awareness is a multistep process that requires 1) screening, 2) being told a level, and 3) remembering that level. Of all respondents, 63% reported being screened; of those screened, 76% reported being told their levels; and of those told their levels, 60% knew their levels. Although these findings suggest some success in each step, cholesterol awareness requires success in all three steps combined. Because persons may know their cholesterol levels does not necessarily indicate they will take actions to reduce their cholesterol levels; however, it is an important step in the process of cholesterol reduction. Persons who are aware of their cholesterol levels are more likely to initiate steps to reduce their blood cholesterol levels (8).

Factors that may be associated with variations in cholesterol screening and awareness by state include differences in 1) perceptions (among both health-care providers and the public) about the risk for CHD and about the effectiveness of cholesterol reduction, 2) the availability and quality of health care, and 3) the socioeconomic resources within communities.

Despite the relatively low level of cholesterol awareness, in recent years, substantial progress has been made in increasing cholesterol screening and awareness. For example, previous studies have indicated the proportion of U.S. adults who knew their cholesterol levels increased substantially from 1986 through 1990 (9,10). Public and private program efforts to increase awareness of both health-care providers and the public have included mass media campaigns, cholesterol screenings, and educational seminars. In addition, to increase identification and treatment of high blood cholesterol, the NCEP mailed guidelines to approximately 150,000 primary-care physicians in the United States. However, to contribute to further reductions in CHD morbidity and mortality, this report suggests that additional efforts are needed to increase cholesterol screening and awareness among young adults, minorities, and persons with less than a high school education.


  1. Office of Medical Application Research, National Institutes of Health. Lowering blood cholesterol to prevent heart disease. JAMA 1985;253:2080-6.

  2. Lipid Research Clinics Program. The Lipid Research Clinics Coronary Primary Prevention trial results. II. The relationship of reduction in incidence of coronary heart disease to cholesterol lowering. JAMA 1984;251:365-74.

  3. National Cholesterol Education Program. Report of the Expert Panel on Population Strategies for Blood Cholesterol Reduction. Washington, DC: US Department of Health and Human Services, 1990; NIH publication no. 90-3046.

  4. Remington PL, Smith MY, Williamson DF, et al. Design, characteristics, and usefulness of state-based behavioral risk factor surveillance: 1981-87. Public Health Rep 1988;103:366-75.

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

  6. Stamler J, Wentworth D, Newton J. Is relationship between serum cholesterol and risk of premature death from coronary heart disease continuous and graded?: findings in 356,222 primary screenees of the Multiple Risk Factor Intervention Trial (MRFIT). JAMA 1986;256:2823-8.

  7. Sempos C, Fulwood R, Haines C, et al. The prevalence of high blood cholesterol levels among adults in the United States. JAMA 1989;262:45-52.

  8. Havas S, Koumjian L, Reisman J, Hsu L, Wozenski S. Results of the Massachusetts model systems for blood cholesterol screening project. JAMA 1991;266:375-81.

  9. Schucker B, Wittes JT, Santanello NC, et al. Changes in cholesterol awareness and action. Results from two national physician and public surveys. Arch Intern Med 1991;151:666-73.

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

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