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Prevalence of Cholesterol Treatment Eligibility and Medication Use Among Adults — United States, 2005–2012

Carla Mercado, PhD1; Ariadne K. DeSimone2,3; Erika Odom, PhD1; Cathleen Gillespie, MS1; Carma Ayala, PhD1; Fleetwood Loustalot, PhD1

A high blood level of low-density lipoprotein cholesterol (LDL-C) remains a major risk factor for atherosclerotic cardiovascular disease (ASCVD) (1), although data from 2005 through 2012 has shown a decline in high cholesterol (total and LDL cholesterol) along with an increase in the use of cholesterol-lowering medications (2–4). The most recent national guidelines (published in 2013) from the American College of Cardiology and the American Heart Association (ACC/AHA) expand previous recommendations for reducing cholesterol to include lifestyle modifications and medication use as part of complete cholesterol management and to lower risk for ASCVD (5–8). Because changes in cholesterol treatment guidelines might magnify existing disparities in care and medication use, it is important to describe persons currently eligible for treatment and medication use, particularly as more providers implement the 2013 ACC/AHA guidelines. To understand baseline estimates of U.S. adults on or eligible for cholesterol treatment, as well as to identify sex and racial/ethnic disparities, CDC analyzed data from the 2005–2012 National Health and Nutrition Examination Surveys (NHANES). Because the 2013 ACC/AHA guidelines focus on initiation or continuation of cholesterol treatment, adults meeting the guidelines' eligibility criteria as well as adults who were currently taking cholesterol-lowering medication were assessed as a group. Overall, 36.7% of U.S. adults or 78.1 million persons aged ≥21 years were on or eligible for cholesterol treatment. Within this group, 55.5% were currently taking cholesterol-lowering medication, and 46.6% reported making lifestyle modifications, such as exercising, dietary changes, or controlling their weight, to lower cholesterol; 37.1% reported making lifestyle modifications and taking medication, and 35.5% reported doing neither. Among adults on or eligible for cholesterol-lowering medication, the proportion taking cholesterol-lowering medication was higher for women than men and for non-Hispanic whites (whites) than Mexican-Americans and non-Hispanic blacks (blacks). Further efforts by clinicians and public health practitioners are needed to implement complementary and targeted patient education and disease management programs to reduce sex and racial/ethnic disparities among adults eligible for treatment of cholesterol.

NHANES is an ongoing national survey using a complex, multistage, probability sampling design to measure the health and nutritional status of the noninstitutionalized U.S. population.* Detailed physical examinations, including laboratory measures and interviews, were conducted. Data from four 2-year cycles (2005–2012) were analyzed. Exam response rates ranged from 70% to 77% for 22,281 participants aged ≥21 years. Participants were excluded from the analyses if they were pregnant (n = 491) or missing a fasting laboratory specimen (n = 13,155), or if treatment eligibility could not be determined (n = 273). When using survey analyses to address the complex sampling design, fasting sample weights were used to account for missing fasting laboratory measures. The final study sample included 8,644 participants. Serum LDL-C levels were calculated based on the Friedewald method (9) using the measured values of total cholesterol, triglycerides, and high-density lipoprotein cholesterol (HDL-C). Adults who were currently taking any cholesterol-lowering medication, or who met eligibility criteria for medication based on the 2013 ACC/AHA guidelines, were defined as meeting current eligibility guidelines for cholesterol treatment.

Current cholesterol-lowering medication use was self-reported from the medical history interview or transcribed from medication bottles recorded in the prescription medication interview. As outlined by the 2013 ACC/AHA guidelines, persons who should initiate or continue cholesterol-lowering medication included four groups: 1) persons with clinical ASCVD (self-reported history of coronary heart disease, myocardial infarction, stable or unstable angina, or stroke); 2) persons with LDL-C ≥190 mg/dL; 3) persons aged 40–75 years with diabetes, LDL-C 70–189 mg/dL, and without clinical ASCVD; and 4) persons aged 40–75 years without clinical ASCVD or diabetes, with LDL-C 70–189 mg/dL, and estimated 10-year ASCVD risk from Pooled Cohort Equation§ ≥7.5% (5,6). Lifestyle modifications were based on affirmative responses when asked whether a "doctor or health professional ever told you to (increase exercise, eat fewer high fat or high cholesterol foods, or control weight to) lower your cholesterol" and self-report that the participant is "now following this advice." Because lifestyle modification questions were not asked for NHANES cycle 2011–2012, estimates for all lifestyle modifications apply to NHANES cycles 2005–2010. All other estimates apply to NHANES cycles 2005–2012.

Analyses were performed using fasting sample weights and adjusted variance estimates to account for complex sampling. Pearson's chi-square test was used to determine significant differences (p<0.05) across sex and racial/ethnic groups. Population counts were estimated using population totals provided from NHANES and averaging the population during the time coinciding with the four NHANES cycles.

Overall, 36.7% of U.S. adults or 78.1 million persons aged ≥21 years were on or eligible for cholesterol treatment, among whom 55.5% were taking cholesterol-lowering medication, and 46.6% reported making lifestyle modifications to lower cholesterol. There were significant differences in the percentage of men (40.8%) and women (32.9%; p≤0.001) on or eligible for treatment as well as among racial/ethnic groups (24.2% for Mexican-Americans, 38.4% for whites, and 39.5% for blacks; p<0.001) (Table 1). Among persons on or eligible for treatment, there were significant differences in the proportion taking cholesterol-lowering medication between men and women (52.9% versus 58.6%; p = 0.010) and racial/ethnic groups (58.0% for whites, 47.1% for Mexican-Americans, and 46.0% for blacks; p<0.001). Significant differences in the proportion of participants on or eligible for cholesterol-lowering medication were also found among subgroups of age, poverty-to-income ratio, body mass index (BMI), and presence of diabetes or hypertension.

Prevalence of cholesterol-lowering medication use among adults eligible for treatment varied within sex and racial/ethnic subgroups, with the lowest prevalence (5.7%) among blacks who did not have a routine place for health care and the highest prevalence among persons who reported making lifestyle modifications (approximately 80% for a majority of subgroups) (Table 2). Among adults on or eligible for treatment, prevalence of cholesterol-lowering medication use (p≤0.001) and making lifestyle modifications (p = 0.001) was higher for those with lower LDL-C levels (Figure).

Discussion

During 2005–2012, based on the 2013 ACC/AHA guidelines, approximately 37% of U.S. adults were on or eligible for cholesterol-lowering medication. Eligibility for and use of cholesterol-lowering medication differed by sex and race/ethnicity across various sociodemographic and health-related factors. Among adults who were eligible for treatment, disparities in the proportion taking cholesterol-lowering medication existed among categories of sex, racial/ethnicity, age, poverty-to-income ratio, BMI, and presence of diabetes or hypertension. This report is one of the first to examine sex and racial/ethnic differences in medication use in a nationally representative sample of adults who are eligible for treatment.

Similar to those of previous reports (7,10), these results indicate that approximately half of treatment-eligible adults were taking cholesterol-lowering medication according to the newly released 2013 ACC/AHA guidelines. Furthermore, lower percentages of treatment-eligible Mexican-Americans and blacks were taking cholesterol-lowering medication compared with whites. A majority of persons who reported making lifestyle modifications were also taking cholesterol-lowering medication. Lifestyle modifications, including engaging in regular physical activity, adhering to a heart-healthy diet, and maintaining a healthy weight, are well-known primary and critical components of health promotion and ASCVD risk reduction when implemented before and in combination with cholesterol-lowering medication (5,8). In alignment with incentives offered to health providers in the use of electronic medical records to improve patient care and to promote equitable and high-quality care, clinicians and public health practitioners can use sociodemographic data within their electronic health records to characterize the populations within their practices who are eligible for cholesterol treatment and implement targeted screening, patient education, and disease management programs. In addition, the 2013 ACC/AHA guidelines propose that clinicians monitor therapeutic response to cholesterol-lowering medications and reinforce adherence to both lifestyle regimens and medication at regular intervals (5). Finally, stakeholders should implement evidence-based interventions from the Guide to Community Preventive Services to improve screening and management of cholesterol.**

The findings in this report are subject to at least five limitations. First, the proportion of adults eligible for treatment might be underestimated, because older adults in nursing homes or other institutions, who are more likely to be eligible for cholesterol treatment, are not included in NHANES. Second, estimates for lifestyle modifications only represent data from 2005–2010. Third, although NHANES data collection is standardized, self-reported data are subject to recall bias. Fourth, adults taking cholesterol-lowering medications were considered to be receiving treatment aligned with the 2013 ACC/AHA guidelines, potentially overestimating prevalence of eligibility and treatment use. Fifth, persons taking medication included any type of cholesterol-lowering medication and not only statin therapy as recommended by the 2013 ACC/AHA guidelines. However, based solely on the prescription medication file, approximately 88% of persons taking any cholesterol-lowering medication were taking statins.

Cholesterol treatment for the reduction of ASCVD risk is promoted widely in the United States, including activities such as Healthy People 2020 (11) and the Million Hearts initiative (12). CDC-funded state programs use public health strategies for cardiovascular disease and risk factor management outlined in the Million Hearts initiative, including strategies related to improving clinical management of cholesterol. For example, CDC supports Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN)†† programs in 20 states and two tribal organizations, and State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity, and Associated Risk Factors and Promote School Health§§ grants in all 50 states and the District of Columbia. These include and provide healthy behavior support for populations at risk and provide comprehensive and effective management of primary cardiovascular disease risk factors. Coordinated community and clinical programs are needed to better identify all persons now eligible for cholesterol treatment.

1Divison of Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, CDC; 2Emory University School of Medicine, Atlanta, Georgia; 3Rollins School of Public Health, Emory University, Atlanta, Georgia.

Corresponding author: Carla Mercado, cmercado@cdc.gov, 770-488-8075.

References

  1. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation 2015;131:e29–322.
  2. Kuklina EV, Carroll MD, Shaw KM, Hirsch R. Trends in high LDL cholesterol, cholesterol-lowering medication use, and dietary saturated-fat intake: United States, 1976–2010. NCHS data brief, no 117. Hyattsville, MD: National Center for Health Statistics, US Department of Health and Human Services, CDC; 2013. Available at http://www.cdc.gov/nchs/data/databriefs/db117.pdf.
  3. Carroll MD, Fryar CD, Kit BK. Total and high-density lipoprotein cholesterol in adults: United States, 2011–2014. NCHS data brief, no 226. Hyattsville, MD: National Center for Health Statistics, US Department of Health and Human Services, CDC; 2015. Available at http://www.cdc.gov/nchs/data/databriefs/db226.pdf.
  4. Gu Q, Paulose-Ram R, Burt VL, Kit BK. Prescription cholesterol-lowering medication use in adults aged 40 and over: United States, 2003–2012. NCHS data brief, no 177. Hyattsville, MD: National Center for Health Statistics, US Department of Health and Human Services, CDC; 2014. Available at http://www.cdc.gov/nchs/data/databriefs/db177.pdf.
  5. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:2889–934.
  6. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. J Am Coll Cardiol 2014;63:2935–59.
  7. Pencina MJ, Navar-Boggan AM, D'Agostino RB Sr, et al. Application of new cholesterol guidelines to a population-based sample. N Engl J Med 2014;370:1422–31.
  8. Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:2960–84.
  9. 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.
  10. Sarpong EM, Zuvekas SH. Trends in statin therapy among adults (age ≥ 18), United States, 2000 to 2011. Statistical brief #458. Rockville, MD: Agency for Healthcare Research and Quality; 2014. Available at http://meps.ahrq.gov/mepsweb/data_files/publications/st458/stat458.pdf.
  11. US Department of Health and Human Services. Healthy people 2020: heart disease and stroke. Washington DC: US Department of Health and Human Services; 2013. Available at http://www.healthypeople.gov/2020/topics-objectives/topic/heart-disease-and-stroke.
  12. Frieden TR, Berwick DM. The "Million Hearts" initiative—preventing heart attacks and strokes. N Engl J Med 2011;365:e27.

* Additional information available at http://www.cdc.gov/nchs/nhanes.htm.

Cholesterol-lowering medication considered from medication bottles included bile acid sequestrants, cholesterol absorption inhibitors, HMG-CoA reductase inhibitors (statins), fibric acid derivatives, or combinations/others.

§ Race- and sex-specific equations considering age, total cholesterol, HDL-C, systolic blood pressure, hypertension medication use, smoking status, and diabetes status to calculate 10-year ASCVD risk.

Additional information available at http://www.cdc.gov/nchs/nhanes/response_rates_cps.htm.

** Additional information available at http://www.thecommunityguide.org/cvd/ROPC.html.

†† Additional information available at http://www.cdc.gov/wisewoman.

§§ Additional information available at http://www.cdc.gov/dhdsp/programs/spha/index.htm.


Summary

What is already known on this topic?

A high blood level of low-density lipoprotein cholesterol (LDL-C) is a major risk factor for the development of atherosclerotic cardiovascular disease (ASCVD). Lifestyle modification, when implemented before and in combination with cholesterol-lowering medication, is a critical component of health promotion and ASCVD risk reduction.

What is added by this report?

During 2005–2012, among the estimated 78 million U.S. adults aged ≥21 years eligible for treatment, 55.5% were taking cholesterol-lowering medication and 46.6% reported making lifestyle modifications at baseline. Differences in medication use exist among sex and racial/ethnic groups.

What are the implications for public health practice?

Further efforts by clinicians and public health practitioners are needed to implement complementary and targeted patient education and disease management programs to reduce sex and racial/ethnic disparities among adults eligible for treatment of cholesterol.


TABLE 1. Prevalence of treatment eligibility* among adults aged ≥21 years, and cholesterol-lowering medication use among adults on or eligible for treatment, by selected characteristics — National Health and Nutrition Examination Survey, United States, 2005–2012

Characteristic

All

Treatment-eligible

Prevalence of treatment eligibility*

Taking cholesterol-lowering medication

Sample size

% (95% CI)

No. in population (millions)

p-value§

% (95% CI)

p-value§

Total

3,737

36.7 (35.0–38.4)

78.1

55.5 (53.6–57.5)

Sex

Men

2,051

40.8 (38.5–43.1)

41.7

<0.001

52.9 (50.4–55.5)

0.010

Women

1,686

32.9 (30.8–35.1)

36.4

58.6 (55.3–61.7)

Age group (yrs)

21–39

120

4.0 (3.2–4.9)

3.0

<0.001

41.3 (30.7–52.7)

<0.001

40–64

1,850

44.4 (41.8–47.0)

43.9

51.4 (48.3–54.4)

≥65

1,767

80.7 (78.6–82.7)

30.3

62.7 (60.0–65.4)

Race/Ethnicity

Mexican-American

507

24.2 (20.7–28.0)

7.5

<0.001

47.1 (42.7–51.5)

<0.001

Non-Hispanic White

1,804

38.4 (36.1–40.8)

56.3

58.0 (55.4–60.6)

Non-Hispanic Black

844

39.5 (36.8–42.3)

9.4

46.0 (41.8–50.3)

Poverty-to-income ratio

<100%

668

34.7 (31.4–38.1)

9.3

0.025

46.5 (40.5–52.7)

0.026

100%–299%

1,510

38.8 (36.2–41.5)

30.6

54.4 (50.8–57.9)

300%–499%

629

33.0 (30.4–35.8)

17.5

57.8 (52.7–62.7)

≥500%

609

36.7 (32.9–40.7)

20.5

58.9 (53.3–64.4)

Education (persons aged ≥25 yrs)

<High school diploma

1,214

47.1 (44.3–49.9)

17.8

<0.001

54.7 (51.1–58.3)

0.802

High school diploma

942

46.1 (42.9–49.4)

21.3

56.0 (52.3–59.7)

Some college

899

37.4 (34.4–40.6)

20.7

54.4 (50.0–58.8)

≥College degree

668

32.0 (29.0–35.2)

18.3

57.2 (51.1–63.1)

BMI categories**

Normal

760

25.4 (23.1–27.8)

15.8

<0.001

52.6 (47.4–57.7)

0.008

Overweight

1,233

36.8 (34.4–39.2)

26.5

52.3 (48.6–56.0)

Obese

1,649

46.7 (44.2–49.3)

35.0

59.6 (56.5–62.5)

Diabetes††

Yes

1,423

88.3 (85.8–90.4)

24.5

<0.001

63.1 (60.0–66.2)

<0.001

No

2,309

28.9 (27.2–30.6)

53.6

52.0 (49.5–54.5)

Hypertension§§

Yes

2,411

69.5 (66.9–72.0)

39.8

<0.001

63.2 (60.9–65.5)

<0.001

No

1,296

18.6 (17.2–20.2)

38.3

39.8 (36.0–43.8)

Abbreviations: ASCVD = atherosclerotic cardiovascular disease; BMI = body mass index; CI = confidence interval; LDL-C = low-density lipoprotein cholesterol.

* Currently taking cholesterol-lowering medication or eligible for cholesterol treatment based on the 2013 American College of Cardiology and the American Heart Association guidelines. Eligibility for cholesterol treatment include persons 1) with clinical ASCVD, 2) with LDL-C ≥190 mg/dL, 3) aged 40–75 years with diabetes, LDL-C 70–189 mg/dL, and without clinical ASCVD, or 4) aged 40–75 years without clinical ASCVD or diabetes with LDL-C 70–189 mg/dL and estimated 10-year ASCVD risk ≥7.5%. (Additional information available at https://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a and https://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437741.48606.98).

On the basis of 1) responding "yes" to the following questions, "To lower your blood cholesterol, have you ever been told by a doctor or other health professional to take prescribed medicine?" and "Are you now following this advice to take prescribed medicine?" or 2) cholesterol-lowering medication was identified in the prescription medication questionnaire.

§ p-value based on Pearson's chi-square test.

Ratio of family income to poverty is based on U.S. Department of Health and Human Services poverty guidelines. Additional information available at http://wwwn.cdc.gov/Nchs/Nhanes/2011-2012/DEMO_G.htm#Analytic_Notes.

** BMI categories: normal (18.5 –<25 kg/m2), overweight (25 –<30 kg/m2), obese (≥30 kg/m2).

†† Fasting glucose ≥126 mg/dL, A1C ≥6.5, responded yes to the question "Other than pregnancy, have you ever been told by a doctor that you have diabetes?," or taking medication for diabetes.

§§ Systolic blood pressure ≥140 mmHg, diastolic blood pressure ≥90 mmHg, or taking blood pressure-lowering medication.


TABLE 2. Prevalence of cholesterol-lowering medication use* among adults aged ≥21 years who are on or eligible for treatment, by sex and race/ethnicity — National Health and Nutrition Examination Survey, United States, 2005–2012

Characteristic

Cholesterol-lowering medication use among treatment-eligible adults

Sex

Race/ethnicity

Men

Women

p-value§

Mexican-American

Non-Hispanic white

Non-Hispanic black

p-value§

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

Age group (yrs)

21–39

44.1 (27.9–61.6)

38.2 (16.2–66.4)

0.665

48.7 (21.5–76.0)

37.5 (18.9–56.1)

58.4 (34.6–82.2)

0.262

40–64

47.5 (43.5–51.4)

56.9 (51.4–62.4)

0.012

42.2 (36.5–47.9)

55.0 (50.7–59.3)

41.2 (35.3–47.1)

<0.001

≥65

63.4 (59.0–67.9)

62.1 (58.8–65.4)

0.637

58.4 (47.3–69.6)

63.0 (59.7–66.3)

55.6 (49.4–61.9)

0.059

Poverty-to-income ratio**

<100%

38.4 (29.3–47.6)

52.5 (45.5–59.5)

0.004

45.5 (37.3–53.8)

47.9 (35.4–60.5)

44.1 (33.3–54.8)

0.719

100%–299%

49.9 (45.8–54.0)

58.6 (53.4–63.8)

0.010

46.5 (37.4–55.7)

56.9 (51.7–62.1)

45.2 (39.6–50.9)

0.001

300%–499%

59.0 (52.3–65.6)

56.2 (48.9–63.4)

0.540

60.8 (44.8–76.8)

58.0 (51.0–65.1)

53.5 (41.4–65.6)

0.625

≥500%

54.5 (46.6–62.4)

67.7 (59.6–75.8)

0.026

38.9 (24.5–53.3)

60.6 (53.3–67.9)

46.0 (30.9–61.1)

0.016

Education (persons aged ≥25 yrs)

<High school diploma

52.0 (47.1–56.8)

57.5 (52.2–62.8)

0.161

43.9 (37.6–50.2)

62.4 (56.1–68.7)

43.7 (35.8–51.6)

<0.001

High school diploma

47.3 (42.5–52.2)

64.0 (59.1–69.0)

<0.001

53.0 (36.2–69.8)

57.9 (52.6–63.2)

45.6 (35.8–55.3)

0.017

Some college

52.2 (44.6–59.8)

57.0 (50.6–63.4)

0.368

50.8 (31.8–69.7)

55.2 (49.3–61.0)

47.6 (39.6–55.5)

0.171

≥College degree

58.7 (51.7–65.6)

54.7 (44.8–64.6)

0.428

55.4 (36.0–74.8)

58.5 (51.2–65.7)

48.7 (35.7–61.7)

0.213

BMI categories††

Normal

47.1 (40.1–54.2)

58.6 (52.1–65.0)

0.011

41.4 (31.9–51.0)

53.6 (45.8–61.3)

35.8 (25.5–46.1)

0.003

Overweight

48.5 (43.7–53.3)

58.0 (52.6–63.3)

0.010

46.4 (37.6–55.1)

54.9 (50.5–59.4)

39.7 (31.3–48.1)

<0.001

Obese

59.7 (56.0–63.4)

59.4 (54.8–64.0)

0.917

49.8 (42.4–57.2)

62.7 (58.4–66.9)

52.7 (47.0–58.4)

<0.001

Diabetes§§

Yes

65.0 (61.2–68.8)

61.2 (55.7–66.8)

0.316

53.5 (47.5–59.5)

65.8 (60.8–70.8)

58.7 (53.0–64.5)

0.002

No

47.8 (44.5–51.2)

57.2 (53.1–61.3)

0.002

39.8 (31.5–48.1)

55.1 (52.1–58.0)

36.4 (30.6–42.3)

<0.001

Hypertension¶¶

Yes

69.7 (66.5–72.9)

65.1 (61.2–69.0)

0.072

60.7 (53.7–67.7)

68.8 (65.6–72.1)

58.6 (53.6–63.6)

<0.001

No

29.9 (25.8–34.0)

47.1 (41.6–52.6)

<0.001

29.6 (21.9–37.3)

41.0 (36.3–45.7)

15.9 (10.3–21.6)

<0.001

History of ASCVD***

Yes

71.3 (65.6–76.9)

53.4 (48.4–58.4)

<0.001

49.2 (37.7–60.7)

66.1 (60.5–71.7)

51.1 (43.0–59.2)

<0.001

No

46.4 (43.5–49.3)

60.3 (56.8–63.8)

<0.001

46.2 (41.8–50.6)

54.8 (51.7–58.0)

44.2 (39.4–48.9)

<0.001

Health care coverage†††

Yes

56.8 (54.0–59.6)

61.6 (58.3–65.0)

0.041

55.5 (48.9–62.0)

60.4 (57.8–63.1)

49.5 (45.8–53.3)

<0.001

No

26.0 (18.9–33.2)

34.0 (26.5–41.5)

0.148

32.2 (19.9–44.5)

31.5 (20.4–42.7)

27.1 (16.9–37.3)

0.748

Health care coverage types§§§

Medicare

59.2 (51.3–67.2)

60.1 (50.6–69.6)

0.859

59.4 (50.6–68.2)

60.0 (50.7–69.3)

53.7 (42.9–64.4)

0.516

Private

55.8 (52.1–59.4)

61.7 (57.4–65.9)

0.049

49.7 (41.5–57.9)

59.8 (56.7–63.0)

46.8 (41.4–52.2)

<0.001

Public

59.4 (53.1–65.8)

62.6 (56.3–68.9)

0.412

63.1 (46.0–80.3)

63.6 (55.5–71.8)

52.3 (46.0–58.5)

0.067

Routine place for health care¶¶¶

Yes

56.4 (53.7–59.0)

60.0 (56.9–63.2)

0.103

54.3 (48.7–59.9)

59.8 (57.2–62.4)

49.0 (44.6–53.4)

<0.001

No

15.7 (7.0–24.4)

26.8 (16.0–37.7)

0.083

17.9 (5.6–30.3)

24.0 (13.2–34.8)

5.7 (3.4–8.0)

0.044


TABLE 2. (Continued) Prevalence of cholesterol-lowering medication use* among adults aged ≥21 years who are on or eligible for treatment, by sex and race/ethnicity — National Health and Nutrition Examination Survey, United States, 2005–2012

Characteristic

Cholesterol-lowering medication use among treatment-eligible adults

Sex

Race/ethnicity

Men

Women

p-value§

Mexican-American

Non-Hispanic white

Non-Hispanic black

p-value§

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

No. of times received health care in past yr****

0

7.6 (2.5–12.7)

17.4 (4.5–30.3)

0.047

12.4 (4.1–20.8)

11.6 (0.2–23.1)

6.6 (3.7–9.5)

0.638

1

34.2 (26.1–42.4)

44.1 (33.7–54.6)

0.102

28.4 (14.6–42.3)

43.1 (31.3–54.9)

19.2 (6.7–31.7)

0.002

≥2

62.1 (59.2–64.9)

62.6 (59.8–65.4)

0.805

60.9 (54.5–67.2)

63.3 (60.8–65.8)

54.5 (49.2–59.8)

0.002

Aware of high cholesterol††††

75.1 (71.9–78.4)

78.5 (75.5–81.6)

0.147

75.5 (68.5–82.6)

77.7 (74.8–80.7)

71.1 (67.5–74.8)

0.025

Lifestyle modifications§§§§

79.7 (76.1–83.3)

79.2 (74.8–83.6)

0.867

81.1 (73.6–88.5)

80.1 (76.1–84.1)

72.1 (65.7–78.5)

0.040

Exercising

81.8 (77.6–86.0)

82.9 (77.7–88.0)

0.733

81.5 (74.2–88.9)

83.0 (78.0–88.0)

77.5 (71.2–83.8)

0.012

Diet changes

80.4 (77.1–83.8)

78.9 (74.5–83.3)

0.596

82.3 (72.6–92.0)

80.6 (76.8–84.4)

70.4 (63.8–76.9)

0.076

Weight control

80.5 (75.9–85.2)

83.4 (78.8–87.9)

0.403

83.0 (75.0–90.9)

82.6 (77.6–87.6)

73.9 (67.0–80.9)

0.195

Abbreviations: ASCVD = atherosclerotic cardiovascular disease; BMI = body mass index; CI = confidence interval; LDL-C = low-density lipoprotein cholesterol.

* On the basis of 1) responding "yes" to the following questions, "To lower your blood cholesterol, have you ever been told by a doctor or other health professional to take prescribed medicine?" and "Are you now following this advice to take prescribed medicine?" or 2) cholesterol-lowering medication was identified in the prescription medication questionnaire.

Currently taking cholesterol-lowering medication or eligible for cholesterol treatment based on the 2013 American College of Cardiology and the American Heart Association guidelines. Eligibility for cholesterol treatment include persons 1) with clinical ASCVD, 2) with LDL-C ≥190 mg/dL, 3) aged 40–75 years with diabetes, LDL-C 70–189 mg/dL, and without clinical ASCVD, or 4) aged 40–75 years without clinical ASCVD or diabetes with LDL-C 70–189 mg/dL and estimated 10-year ASCVD risk ≥7.5%. (Additional information available at https://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a and https://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437741.48606.98).

§ p-value based on Pearson's chi-square test.

Estimates statistically unstable with relative standard error ≥30%. These estimates should be interpreted with caution.

** Ratio of family income to poverty is based on U.S. Department of Health and Human Services poverty guidelines. Additional information available at http://wwwn.cdc.gov/Nchs/Nhanes/2011-2012/DEMO_G.htm#Analytic_Notes.

†† BMI categories: normal (18.5 –<25 kg/m2), overweight (25 –<30 kg/m2), obese (≥30 kg/m2).

§§ Fasting glucose ≥126 mg/dL, A1C ≥6.5, responded yes to the question "Other than pregnancy, have you ever been told by a doctor that you have diabetes?" or taking medication for diabetes.

¶¶ Systolic blood pressure ≥140 mmHg, diastolic blood pressure ≥90 mmHg, or taking blood pressure-lowering medication.

*** Self-reported history of coronary heart disease, myocardial infarction, stable or unstable angina, or stroke.

††† Participants were asked, "Are you covered by health insurance or some other health care plan?"

§§§ Health care coverage type reported were Medicare, private insurance, public health insurance (Medicaid, Children's Health Insurance Program, state- or government-sponsored health plan, or military health plan), or more than one type.

¶¶¶ On the basis of response to the question, "Is there a place that you usually go when sick or need advice about health?"

**** On the basis of response to the question, "During the past 12 months, how many times have you seen a doctor or other health care professional about your health, not including being hospitalized overnight?"

†††† On the basis of response to the question, "Have you ever been told by a doctor or other health professional that your blood cholesterol level was high?"

§§§§ Each lifestyle modification (exercising, diet changes [less dietary fat], and weight control) was determined by answering "yes" to the following questions, "To lower your blood cholesterol, have you ever been told by a doctor to (increase exercise, eat fewer high fat or high cholesterol foods, or control weight)?" and "Are you now following this advice to (increase exercise, eat fewer high fat or high cholesterol foods, or control weight)?" Questions were not asked in the 2011–2012 National Health and Nutrition Examination Survey cycle, and estimates represent cycles 2005–2010.


FIGURE. Number* and percentage of adults aged ≥21 years who are on or eligible for cholesterol-lowering treatment, distribution of LDL-C§ levels, and percentage taking cholesterol-lowering medication, making lifestyle modifications,** or both — National Health and Nutrition Examination Survey, United States, 2005–2012

The figure above is a flow chart showing the number and percentage of adults aged 21 years or older who are on or eligible for cholesterol-lowering treatment, the distribution of low-density lipoprotein cholesterol levels, and the percentage taking cholesterol-lowering medication, making lifestyle modifications, or both, in the United States during 2005-2012.

Abbreviations: ASCVD = atherosclerotic cardiovascular disease; LDL-C = low-density lipoprotein cholesterol; NHANES = National Health and Nutrition Examination Survey.

* Weighted population count was estimated using Current Population Surveys averaging the population across the four NHANES cycles (2005–2006, 2007–2008, 2009–2010, and 2011–2012).

Currently taking cholesterol-lowering medication or eligible for cholesterol treatment based on the 2013 American College of Cardiology and the American Heart Association guidelines. Eligibility for cholesterol treatment include persons 1) with clinical ASCVD, 2) with LDL-C ≥190 mg/dL, 3) aged 40–75 years with diabetes, LDL-C 70–189 mg/dL, and without clinical ASCVD, or 4) aged 40–75 years without clinical ASCVD or diabetes with LDL-C 70–189 mg/dL and estimated 10-year ASCVD risk ≥7.5%. (Additional information available at https://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a and https://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437741.48606.98).

§ Serum LDL-C levels calculated based on Friedewald method (http://www.clinchem.org/content/18/6/499.full.pdf) using measured values of total cholesterol, triglycerides, and high-density lipoprotein cholesterol.

On the basis of 1) responding "yes" to the following questions, "To lower your blood cholesterol, have you ever been told by a doctor or other health professional to take prescribed medicine?" and "Are you now following this advice to take prescribed medicine?" or 2) cholesterol-lowering medication was identified in the prescription medication questionnaire.

** Each lifestyle modification (exercising, diet changes [less dietary fat], and weight control) was determined by answering yes to the following questions, "To lower your blood cholesterol, have you ever been told by a doctor or other health professional to (increase exercise, eat fewer high fat or high cholesterol foods, or control weight)?" and "Are you now following this advice to (increase exercise, eat fewer high fat or high cholesterol foods, or control weight)?" Questions were not asked in the 2011–2012 NHANES cycle, and estimates represent cycles 2005–2010.

Alternate Text: The figure above is a flow chart showing the number and percentage of adults aged 21 years or older who are on or eligible for cholesterol-lowering treatment, the distribution of low-density lipoprotein cholesterol levels, and the percentage taking cholesterol-lowering medication, making lifestyle modifications, or both, in the United States during 2005-2012.



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