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Prevalence of high LDL in US adults remains common, stable
The prevalence of high LDL in US adults has remained relatively stable in the past 12 years, from 37.2% in 1999-2000 to 37.8% in 2009-2010. However, efforts are needed to increase the awareness of high LDL, researchers reported.
Researchers analyzed data from the National Health and Nutrition Examination Surveys in 1999-2000 (n=1,659), 2001-2002 (n=1,897), 2003-2004 (n=1,698), 2005-2006 (n=1,692), 2007-2008 (n=2,044) and 2009-2010 (n=2,318) to determine trends in the prevalence, awareness, treatment and control of high LDL in US adults aged at least 20 years. NHANES participants completed questionnaires and underwent a medical exam and phlebotomy. In addition, they were asked whether a health care professional had told them their cholesterol was elevated, whether they had been prescribed lipid-lowering medication and whether they were taking their prescribed medication.
The researchers estimated that 80.8 million US adults had high LDL levels from 2007 to 2010.
Although levels remained stable from the 1999-2000 to 2009-2010 surveys (P=.687), the rate of adults with high LDL who were aware of their condition did not change since 2004. Awareness increased from 48.9% in 1999-2000 to 62.8% in 2003-2004, but decreased since then, with 61.5% of adults reporting awareness of their high LDL in 2009-2010 (P<.001).
Similarly, the rate of adults with high LDL who were being treated for their condition rose from 20.2% in 1999-2000 to 38.3% in 2003-2004, and increased slightly to 43% in 2009-2010 (P<.001). Treatment rates for those aware of their condition were 41.3% in 1999-2000, 72.6% in 2007-2008 and 70% in 2009-2010 (P<.001).
Control of high LDL ranged from 9.1% in 1999-2000 to 26.7% in 2005-2006 to 27.4% in 2009-2010 (P<.001). Control rates for those treated with lipid-lowering medication increased from 45% in 1999-2000 to 65.3% in 2005-2006, but decreased to 63.6% in 2009-2010 (P<.001). Adults with two or more risk factors for CHD or those in higher-risk categories were less likely to have their LDL under control compared with adults with one or no risk factors for CHD.
“Additional efforts are needed to prevent high LDL cholesterol and increase the awareness, treatment and control of high LDL cholesterol among US adults,” Paul Muntner, PhD, of the department of epidemiology at University of Alabama at Birmingham, and colleagues wrote.
Disclosure: The study was funded by Amgen. Two researchers are/were consultants for Amgen and one is employed by Amgen.
Perspective
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Why has LDL reduction not progressed in the last 10 years? There are several potential explanations. Although statins have been a tremendous breakthrough and will likely be considered from a historical perspective as the 'penicillin' of our generation, there has not been a new class of drugs approved for LDL since ezetimibe in 2003. Although ezetimibe is an effective LDL-lowering agent, there is controversy (unjustifiably so, in my opinion) regarding the clinical benefits of this drug due to a lack of data from a large outcome study. This controversy has also called into question the LDL-lowering hypothesis and the value of 'lower is better.' Therefore, the utilization of other drugs to go beyond statin therapy to lower LDL has stalled and probably is responsible for some of the lack of progress in further addressing LDL reduction in the United States.
Hopefully, if the IMPROVE-IT study demonstrates a clinical benefit with ezetimibe and/or the other novel agents for LDL reduction such as PCSK9 monoclonal antibodies become available, there will be a renewed effort to add to statins to improve LDL goal achievement.
Other issues also need to be considered, such as a lack of knowledge of the current guideline, health care disparities, cultural issues and the need for improved patient communication skills. Clinicians are very busy and often the patient needs better education or motivation to initiate and maintain statin therapy. The role of the 'health care team' needs to be better defined and implemented to improve patient outcomes. Therefore, it may not just be the need for more or better drugs to lower LDL, but improved utilization of existing drugs or lifestyle changes that will provide the solution for addressing the unmet needs in dyslipidemia management.
There also need to be improved efforts to educate both the clinician and the patient regarding the risk associated with LDL and the importance of genetic disorders such as familial hypercholesterolemia. There is a potential misconception that all elevations of LDL can be addressed solely by lifestyle intervention. Although physicians probably underestimate the benefits of lifestyle intervention, the patient frequently overestimates it. LDL reduction has been demonstrated to be a very effective strategy in the battle against CHD, but much more work lies ahead to improve upon existing therapies and also find the solutions to maximize patient education and motivation.