ARTICLE • Ciênc. Saúde Colet. 26 (02) 12 Feb 2021Feb 2021 • https://doi.org/10.1590/1413-81232021262.37102020   copy

Factors associated with high LDL-Cholesterol in the Brazilian adult population: National Health Survey

Ana Carolina Micheletti Gomide Nogueira de Sá Ísis Eloah Machado Regina Tomie Ivata Bernal Deborah Carvalho Malta About the authors

Abstract

The study analyzed factors associated with high LDL-Cholesterol in Brazilian population. This is a cross-sectional study with laboratory data from 8,534 individuals collected in National Health Survey were analyzed. The prevalence levels of LDL-Cholesterol <130 and ≥ 130 mg/dL were calculated. The outcome variable was high LDL-Cholesterol (≥ 130 mg/dL) and explanatory variables were sociodemographic, anthropometric, lifestyle, chronic diseases and self-rated health. To Poisson regression was used and estimated prevalence ratios (PR) with 95% confidence levels (CI) to verify associations. The prevalence of high LDL-Cholesterol was 18.58%. In the final multivariate model were associated with the outcome: 30 to 44 years (PR 1.99; CI 1.58-2.54), 45 to 59 years (PR 2.89; CI 2.29-3.64), 60 years or more (PR 2.90; CI 2.29-3.68), living in the Northeast Region (PR 1.16; CI 1.02 - 1.32), overweight (PR 1.32; CI 1.15-1.51), obesity (PR 1.41; CI 1.19-1.65) or anemia (PR 0.66; CI 0.54-0.80). The LDL-Cholesterol was associated with aging, overweight, obesity, live in the Northeast and anemia. The monitoring of LDL levels is relevant, due to the increased risk with age, and can guide the adopting healthy lifestyles and diagnosis in places with lower access.

Key words:
Cholesterol; LDL; Dyslipidemias; Health surveys; Risk factors; Laboratory test

Introduction

The Brazilian and global adult population is exposed to the conditions of illness resulting from high cholesterol levels. Evidence that elevated serum cholesterol levels increased the risk of acute myocardial infarction (AMI)11 Kannel WB, Castelli WP, Gordon T. Cholesterol in the prediction of atherosclerotic disease. New perspectives based on the Framingham study. Ann Intern Med 1979; 90(1):85-91. was presented in the 1960s. Since then, research has confirmed an association between high cholesterol levels, not only with the risk of AMI but also with peripheral arterial diseases and strokes22 Nayor M, Vasan RS. Recent Update to th Cholesterol Treatment Guidelines: A Comparison With International Guidelines. Circulation 2016; 133(18):1795-1806..

Abnormal concentrations of lipids, or lipoproteins, circulating in the bloodstream, especially cholesterol and triglycerides (TG), are defined as dyslipidemia, which develops with or without repercussions on the vascular territory and is associated with other clinical manifestations that may increase the risk of cardiovascular diseases33 Diaz MN, Frei B, Vita JA, Keaney Junior JF. Antioxidants and atherosclerotic heart disease. N Engl J Med 1997; 37(6):408-416.,44 Coelho VG, Caetano LF, Liberatori Júnior RDR, Cordeiro JA, Souza DRS. Perfil Lipídico e Fatores de Risco para Doenças Cardiovasculares em Estudantes de Medicina. Arq Bras Cardiol 2005; 85(1):57-62.. Dyslipidemia can be the result of genetic abnormalities, underlying diseases, or environmental factors55 Durrington P. Dyslipidaemia. Lancet 2003; 362(9385):717-731..

Elevated low-density-lipoprotein cholesterol (LDL-cholesterol) levels mainly contribute to atherosclerotic cardiovascular diseases (CVD)66 Cholesterol Treatment Trialists' (CTT) Collaboration. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170,000 participants in 26 randomised trials. Lancet 2010; 376(9753):1670-1681.,77 Cholesterol Treatment Trialists' (CTT) Collaboration. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials. Lancet 2012; 380(9841):581-590.. Lipoproteins are responsible for the transport and solubilization of lipids. They consist of lipids and proteins called Apolipoproteins (Apo). One of the lipoproteins classes is rich in cholesterol and includes low-density-lipoproteins (LDL), which is the primary cholesterol carrier in the circulation to peripheral tissues88 Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune A Neto, Bertolami A, Pereira AC, Lottenberg AM, Sposito AC, Chagas ACP, Casella A Filho, Simão AF, Alencar AC Filho, Caramelli B, Magalhães CC, Negrão CE, Ferreira CEDS, Scherr C, Feio CMA, Kovacs C, Araújo DB, Magnoni D, Calderaro D, Gualandro DM, Mello EP Junior, Alexandre ERG, Sato EI, Moriguchi EH, Rached FH, Santos FCD, Cesena FHY, Fonseca FAH, Fonseca HARD, Xavier HT, Mota ICP, Giuliano ICB, Issa JS, Diament J, Pesquero JB, Santos JED, Faria JR Neto, Melo JX Filho, Kato JT, Torres KP, Bertolami MC, Assad MHV, Miname MH, Scartezini M, Forti NA, Coelho OR, Maranhão RC, Santos RDD Filho, Alves RJ, Cassani RL, Betti RTB, Carvalho T, Martinez TLDR, Giraldez VZR, Salgado W Filho. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017; 109(2 Supl. 1):1-76.. LDL is directly related to the pathogenesis of atherosclerosis, which is the basis of most cardiovascular events99 Ribeiro AL, Ducan BB, Bramt LCC, Lotudo PA, Mill JG, Barreto SM. Cardiovascular Health in Brazil: Trends and Perspectives. Circulation 2016; 133(4):422-433.. Thus, this lipoprotein is identified as the best predictor of cardiac risk22 Nayor M, Vasan RS. Recent Update to th Cholesterol Treatment Guidelines: A Comparison With International Guidelines. Circulation 2016; 133(18):1795-1806. and has been a therapeutic target to reduce CVD risks1010 Upadhyay RK. Emerging risk biomarkers in cardiovascular diseases and disorders. J Lipids 2015; 2015:971453..

The latest report from the World Health Organization (WHO) in 2009 showed that increased serum cholesterol levels caused 2.6 million deaths and 29.7 million years of life lost due to premature death and disabilities1111 World Health Organization (WHO). Global Health Risks: Mortality and burden of disease attributable to selected major risks. Geneva: WHO; 2009.. Specifically, for the risks attributed to increased LDL-cholesterol, in 2017, estimates pointed to the occurrence of 4.3 million global deaths, corresponding to 7.7% of all deaths and 94.9 million years of Disability-Adjusted Life Years (DALYs) lost1212 Mattiuzzi C, Sanchis-Gomar F, Lippi G. Worldwide burden of LDL cholesterol: Implications in cardiovascular disease. Nutr Metab Cardiovasc Dis 2020; 30(2):241-244.,1313 Institute for Health Metrics and Evaluation (IHME). GBD Compare Data Visualization. Seattle: IHME; 2017.. In Brazil, the significant burden of death and disability attributed to high LDL-cholesterol is also evident. A total of 99,315 deaths (7.36% of the total deaths) and the loss of 2,335,294.99 DALYs were estimated in 2017 alone1313 Institute for Health Metrics and Evaluation (IHME). GBD Compare Data Visualization. Seattle: IHME; 2017..

This scenario shows the importance of public policies aimed at controlling modifiable factors such as dyslipidemia. Especially as a strategy to reduce morbimortality due to CVD, considered the main cause of death worldwide99 Ribeiro AL, Ducan BB, Bramt LCC, Lotudo PA, Mill JG, Barreto SM. Cardiovascular Health in Brazil: Trends and Perspectives. Circulation 2016; 133(4):422-433.,1414 Zhong Z, Liu J, Li B, Li C, Liu Z, Yang M, Zhong W, Zhao P. Serum lipid profiles in patients with acute myocardial infarction in Hakka population in Southern China. Lipids Health Dis 2017; 16(1):246.

15 Bayram F, Kocer D, Gundogan K, Kaya A, Demir O, Coskun R, Sabuncu T, Karaman A, Cesur M, Rizzo M. Prevalence of dyslipidemia and associated risk factors in Turkish adults. J Clin Lipidol 2014; 8(2):206-216.

16 Opoku S, Gan Y, Fu W, Chen D, Addo-Yobo E, Trofimovitch D, Yue W, Yan F, Wang Z, Lu Z. Prevalence and risk factors for dyslipidemia among adults in rural and urban China: findings from the China National Stroke Screening and prevention project (CNSSPP). BMC Public Health 2019; 19:1500.

17 Musunuru K. Atherogenic Dyslipidemia: Cardiovascular Risk and Dietary Intervention. Lipids 2010; 45(10):907-914.-1818 Knight BS, Sunn N, Pennell CE, Adamson SL, Lye SJ. Developmental regulation of cardiovascular function is dependent on both genotype and environment. Am J Physiol Heart Circ Physiol 2009; 297(6):H2234-2241.. From this perspective, knowledge of dyslipidemia by the analysis of the lipid profile is essential, since it aims to identify isolated or combined changes55 Durrington P. Dyslipidaemia. Lancet 2003; 362(9385):717-731.,1515 Bayram F, Kocer D, Gundogan K, Kaya A, Demir O, Coskun R, Sabuncu T, Karaman A, Cesur M, Rizzo M. Prevalence of dyslipidemia and associated risk factors in Turkish adults. J Clin Lipidol 2014; 8(2):206-216. of total cholesterol (TC) levels, TG, LDL-cholesterol fraction, and high-density-lipoprotein (HDL-cholesterol) cholesterol fraction1414 Zhong Z, Liu J, Li B, Li C, Liu Z, Yang M, Zhong W, Zhao P. Serum lipid profiles in patients with acute myocardial infarction in Hakka population in Southern China. Lipids Health Dis 2017; 16(1):246.. Factors associated with dyslipidemia are sociodemographic factors, such as gender, age1515 Bayram F, Kocer D, Gundogan K, Kaya A, Demir O, Coskun R, Sabuncu T, Karaman A, Cesur M, Rizzo M. Prevalence of dyslipidemia and associated risk factors in Turkish adults. J Clin Lipidol 2014; 8(2):206-216.,1919 Pereira LPP, Sichieri PR, Segri NJ, Silva RMVG, Ferreira MG. Dislipidemia autorreferida na região Centro-Oeste do Brasil: prevalência e fatores associados. Cien Saude Colet 2015; 20(6):1815-1824.

20 Wang S, Xu L, Joanas JB, You QS, Wang YX, Yang H. Prevalence and associated factors of dyslipidemia in the adult Chinese population. PLoS One 2011; 6(3):e17326.-2121 Moraes SA, Checchio MV, Freitas ICM. Dislipidemia e fatores associados em adultos residentes em Ribeirão Preto, SP. Resultados do Projeto EPIDCV. Arq Bras Endocrinol Metab 2013; 57(9):691-701., schooling2222 Qi L, Ding X, Tang W, Li Q, Mao D, Wang Y. Prevalence and Risk Factors Associated with Dyslipidemia in Chongqing, China. Int J Environ Res Public Health 2015; 12(10):13455-13465., place of residence1515 Bayram F, Kocer D, Gundogan K, Kaya A, Demir O, Coskun R, Sabuncu T, Karaman A, Cesur M, Rizzo M. Prevalence of dyslipidemia and associated risk factors in Turkish adults. J Clin Lipidol 2014; 8(2):206-216.,1919 Pereira LPP, Sichieri PR, Segri NJ, Silva RMVG, Ferreira MG. Dislipidemia autorreferida na região Centro-Oeste do Brasil: prevalência e fatores associados. Cien Saude Colet 2015; 20(6):1815-1824.,2020 Wang S, Xu L, Joanas JB, You QS, Wang YX, Yang H. Prevalence and associated factors of dyslipidemia in the adult Chinese population. PLoS One 2011; 6(3):e17326., lifestyles1919 Pereira LPP, Sichieri PR, Segri NJ, Silva RMVG, Ferreira MG. Dislipidemia autorreferida na região Centro-Oeste do Brasil: prevalência e fatores associados. Cien Saude Colet 2015; 20(6):1815-1824.

20 Wang S, Xu L, Joanas JB, You QS, Wang YX, Yang H. Prevalence and associated factors of dyslipidemia in the adult Chinese population. PLoS One 2011; 6(3):e17326.-2121 Moraes SA, Checchio MV, Freitas ICM. Dislipidemia e fatores associados em adultos residentes em Ribeirão Preto, SP. Resultados do Projeto EPIDCV. Arq Bras Endocrinol Metab 2013; 57(9):691-701., overweight, obesity1515 Bayram F, Kocer D, Gundogan K, Kaya A, Demir O, Coskun R, Sabuncu T, Karaman A, Cesur M, Rizzo M. Prevalence of dyslipidemia and associated risk factors in Turkish adults. J Clin Lipidol 2014; 8(2):206-216.,1616 Opoku S, Gan Y, Fu W, Chen D, Addo-Yobo E, Trofimovitch D, Yue W, Yan F, Wang Z, Lu Z. Prevalence and risk factors for dyslipidemia among adults in rural and urban China: findings from the China National Stroke Screening and prevention project (CNSSPP). BMC Public Health 2019; 19:1500.,1919 Pereira LPP, Sichieri PR, Segri NJ, Silva RMVG, Ferreira MG. Dislipidemia autorreferida na região Centro-Oeste do Brasil: prevalência e fatores associados. Cien Saude Colet 2015; 20(6):1815-1824.,2020 Wang S, Xu L, Joanas JB, You QS, Wang YX, Yang H. Prevalence and associated factors of dyslipidemia in the adult Chinese population. PLoS One 2011; 6(3):e17326., chronic diseases, such as hypertension and diabetes1515 Bayram F, Kocer D, Gundogan K, Kaya A, Demir O, Coskun R, Sabuncu T, Karaman A, Cesur M, Rizzo M. Prevalence of dyslipidemia and associated risk factors in Turkish adults. J Clin Lipidol 2014; 8(2):206-216.,2020 Wang S, Xu L, Joanas JB, You QS, Wang YX, Yang H. Prevalence and associated factors of dyslipidemia in the adult Chinese population. PLoS One 2011; 6(3):e17326., and poor self-rated health1919 Pereira LPP, Sichieri PR, Segri NJ, Silva RMVG, Ferreira MG. Dislipidemia autorreferida na região Centro-Oeste do Brasil: prevalência e fatores associados. Cien Saude Colet 2015; 20(6):1815-1824..

In Brazil, epidemiological surveys monitoring the prevalence of dyslipidemia are scarce and mostly use self-reported data1919 Pereira LPP, Sichieri PR, Segri NJ, Silva RMVG, Ferreira MG. Dislipidemia autorreferida na região Centro-Oeste do Brasil: prevalência e fatores associados. Cien Saude Colet 2015; 20(6):1815-1824.,2323 Lotufo PA, Santos RD, Sposito AC, Bertolami M, Rocha-Faria J Neto, Izar MC, Szwarcwald C, Prado RR, Stoppa SR, Malta DC, Bensenor IM. Prevalência de Diagnóstico Médico de Colesterol Alto Autorreferido na População Brasileira: Análise da Pesquisa Nacional de Saúde, 2013. Arq Bras Cardiol 2017; 108(5):411-416.. In this context, aiming at monitoring the risk indicators for NCDs, the National Health Survey (PNS) collected biological material that included measurements of cholesterol and fractions2424 Souza-Júnior PRB, Freitas MPS, Antonaci GA, Szwarcwald CL. Desenho da amostra da Pesquisa Nacional de Saúde 2013. Epidemiol Serv Saúde 2015; 24(2):207-216.

25 Szwarcwald CL, Malta DC, Azevedo C, Souza-Júnior PRB, Rosenfeld LG. Exames laboratoriais da pesquisa nacional de saúde: Metodologia de amostragem, coleta, e análise dos dados. Rev Bras Epidemiol 2019; 22(Supl. 2):1-9.-2626 Malta DC, Szwarcwald CL, Machado IE, Pereira CA, Figueiredo AW, Sá ACMGN, Velasquez-Melendez G, Santos FM, Souza-Júnior PRB, Stopa SR, Rosenfeld LG. Prevalência de colesterol total e frações alterados na população adulta brasileira: Pesquisa Nacional de Saúde. Rev Bras Epidemiol 2019; 22(Supl. 2):1-13. and allowed to monitor dyslipidemia in the Brazilian population through laboratory tests2626 Malta DC, Szwarcwald CL, Machado IE, Pereira CA, Figueiredo AW, Sá ACMGN, Velasquez-Melendez G, Santos FM, Souza-Júnior PRB, Stopa SR, Rosenfeld LG. Prevalência de colesterol total e frações alterados na população adulta brasileira: Pesquisa Nacional de Saúde. Rev Bras Epidemiol 2019; 22(Supl. 2):1-13..

Thus, considering the relevance above of the negative repercussions on health caused by increased LDL-cholesterol levels and that, in clinical practice, these circulating molecular structures have been so important2727 Ridker PM. LDL cholesterol: controversies and future therapeutic directions. Lancet 2014; 384(9943):607-617., it is necessary to conduct studies investigate factors associated with increased LDL-cholesterol in Brazil.

In this sense, this study innovated by making unprecedented analyses of factors associated with high LDL-cholesterol in Brazilian adults through laboratory tests of the broadest health survey in Brazil: the PNS2828 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde 2013: percepção do estado de saúde, estilos de vida e doenças crônicas: Brasil, Grandes Regiões e Unidades da Federação. Rio de Janeiro: IBGE; 2014.. Furthermore, the research advances by bringing novelty concerning relevant information on the population diagnosis of increased LDL-cholesterol and its associated factors in the face of public health challenges for detecting cardiovascular risk and prevention of CVD. Also, this work supports actions to prevent dyslipidemia and improve the health situation of the Brazilian population.

Thus, this study aimed to analyze the factors associated with the distribution of high LDL-cholesterol in the Brazilian adult population.

Methods

This is a cross-sectional study that employed the PNS laboratory tests’ database between 2014 and 2015. PNS is a nationwide and home-based survey conducted by the Brazilian Institute of Geography and Statistics (IBGE), in partnership with the Ministry of Health (MS). The research used a probabilistic sample in three stages in which interview records were obtained from 64,348 households2424 Souza-Júnior PRB, Freitas MPS, Antonaci GA, Szwarcwald CL. Desenho da amostra da Pesquisa Nacional de Saúde 2013. Epidemiol Serv Saúde 2015; 24(2):207-216.,2525 Szwarcwald CL, Malta DC, Azevedo C, Souza-Júnior PRB, Rosenfeld LG. Exames laboratoriais da pesquisa nacional de saúde: Metodologia de amostragem, coleta, e análise dos dados. Rev Bras Epidemiol 2019; 22(Supl. 2):1-9., and the collection of biological material was planned in a subsample of 25% of surveyed census tracts2424 Souza-Júnior PRB, Freitas MPS, Antonaci GA, Szwarcwald CL. Desenho da amostra da Pesquisa Nacional de Saúde 2013. Epidemiol Serv Saúde 2015; 24(2):207-216.

25 Szwarcwald CL, Malta DC, Azevedo C, Souza-Júnior PRB, Rosenfeld LG. Exames laboratoriais da pesquisa nacional de saúde: Metodologia de amostragem, coleta, e análise dos dados. Rev Bras Epidemiol 2019; 22(Supl. 2):1-9.-2626 Malta DC, Szwarcwald CL, Machado IE, Pereira CA, Figueiredo AW, Sá ACMGN, Velasquez-Melendez G, Santos FM, Souza-Júnior PRB, Stopa SR, Rosenfeld LG. Prevalência de colesterol total e frações alterados na população adulta brasileira: Pesquisa Nacional de Saúde. Rev Bras Epidemiol 2019; 22(Supl. 2):1-13. to conduct the PNS laboratory tests.

PNS laboratory analyses were selected from a subsample consisting of 8,952 individuals. A total of 418 samples were excluded due to insufficient material, hemolysis, and sample loss. Altogether, 8,534 blood samples from the selected individuals were chosen for this analysis. Due to losses and aiming to reduce representation bias, the study adopted post-stratification weightings by gender, age, schooling, and region, to establish estimates for the Brazilian adult population2525 Szwarcwald CL, Malta DC, Azevedo C, Souza-Júnior PRB, Rosenfeld LG. Exames laboratoriais da pesquisa nacional de saúde: Metodologia de amostragem, coleta, e análise dos dados. Rev Bras Epidemiol 2019; 22(Supl. 2):1-9.. Peripheral blood was collected at any time of the day2626 Malta DC, Szwarcwald CL, Machado IE, Pereira CA, Figueiredo AW, Sá ACMGN, Velasquez-Melendez G, Santos FM, Souza-Júnior PRB, Stopa SR, Rosenfeld LG. Prevalência de colesterol total e frações alterados na população adulta brasileira: Pesquisa Nacional de Saúde. Rev Bras Epidemiol 2019; 22(Supl. 2):1-13., and the study followed the protocol that dispenses with fasting for cholesterol measurement88 Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune A Neto, Bertolami A, Pereira AC, Lottenberg AM, Sposito AC, Chagas ACP, Casella A Filho, Simão AF, Alencar AC Filho, Caramelli B, Magalhães CC, Negrão CE, Ferreira CEDS, Scherr C, Feio CMA, Kovacs C, Araújo DB, Magnoni D, Calderaro D, Gualandro DM, Mello EP Junior, Alexandre ERG, Sato EI, Moriguchi EH, Rached FH, Santos FCD, Cesena FHY, Fonseca FAH, Fonseca HARD, Xavier HT, Mota ICP, Giuliano ICB, Issa JS, Diament J, Pesquero JB, Santos JED, Faria JR Neto, Melo JX Filho, Kato JT, Torres KP, Bertolami MC, Assad MHV, Miname MH, Scartezini M, Forti NA, Coelho OR, Maranhão RC, Santos RDD Filho, Alves RJ, Cassani RL, Betti RTB, Carvalho T, Martinez TLDR, Giraldez VZR, Salgado W Filho. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017; 109(2 Supl. 1):1-76.. LDL-cholesterol samples were collected in gel tubes. Clot retraction lasted 30 minutes, after which samples were centrifuged and sent under refrigeration at 2-8ºC and temperature control throughout the steps. This parameter was measured by an automated enzymatic-colorimetric method2626 Malta DC, Szwarcwald CL, Machado IE, Pereira CA, Figueiredo AW, Sá ACMGN, Velasquez-Melendez G, Santos FM, Souza-Júnior PRB, Stopa SR, Rosenfeld LG. Prevalência de colesterol total e frações alterados na população adulta brasileira: Pesquisa Nacional de Saúde. Rev Bras Epidemiol 2019; 22(Supl. 2):1-13.. Further methodological details and PNS laboratory collections are available in other publications2424 Souza-Júnior PRB, Freitas MPS, Antonaci GA, Szwarcwald CL. Desenho da amostra da Pesquisa Nacional de Saúde 2013. Epidemiol Serv Saúde 2015; 24(2):207-216.

25 Szwarcwald CL, Malta DC, Azevedo C, Souza-Júnior PRB, Rosenfeld LG. Exames laboratoriais da pesquisa nacional de saúde: Metodologia de amostragem, coleta, e análise dos dados. Rev Bras Epidemiol 2019; 22(Supl. 2):1-9.-2626 Malta DC, Szwarcwald CL, Machado IE, Pereira CA, Figueiredo AW, Sá ACMGN, Velasquez-Melendez G, Santos FM, Souza-Júnior PRB, Stopa SR, Rosenfeld LG. Prevalência de colesterol total e frações alterados na população adulta brasileira: Pesquisa Nacional de Saúde. Rev Bras Epidemiol 2019; 22(Supl. 2):1-13..

This study included variables related to the LDL-cholesterol fraction (measured in laboratory tests), sociodemographic, lifestyles, and chronic diseases2929 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde 2013: Manual de Entrevista. Rio de Janeiro: IBGE; 2013.. The outcome variable was having high LDL-cholesterol or not. Thus, a dichotomous analysis was performed, defined by the LDL cutoff point ≥ 130 mg/dL, as recommended by the National Cholesterol Education Program (NCEP-ATPIII)3030 Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). JAMA 2001; 285(19):2486-2497.. The explanatory variables were:

  1. a) Sociodemographic: gender (male and female); age (adults over 18 years old); education (categorized as illiterate and incomplete elementary school, complete elementary and incomplete high school, complete high school and over); skin color (white and others that corresponded to yellow and indigenous; black and brown); Brazilian regions (North, Northeast, Southeast, South, and Midwest).

  2. b) Anthropometric: Body Mass Index (BMI) calculated from weight and height measurements in the PNS2828 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde 2013: percepção do estado de saúde, estilos de vida e doenças crônicas: Brasil, Grandes Regiões e Unidades da Federação. Rio de Janeiro: IBGE; 2014.. BMI was classified according to the World Health Organization (WHO), as normal/underweight (BMI < 25 kg/m2), overweight (BMI between 25 and 29 kg/m2) and obesity (BMI ≥ 30kg/m2)3131 World Health Organization (WHO). Obesity: preventing and managing the global epidemic. Geneva: WHO; 2000..

  3. c) Lifestyle: consumption of fatty red meat. The following question was asked for constructing this indicator: “When you eat red meat, do you usually remove the excess visible fat or eat it with fat?” Answers were categorized as “yes” and “no” for reporting consumption of fatty red meat; the consumption of alcoholic beverages was assessed by the questions: “How many days a week do you usually drink alcohol?”; “In general, on the day you drink, how many doses of alcohol do you drink?” (one dose of alcoholic beverage is equivalent to one can of beer, one glass of wine or one dose of cachaça, whiskey, or any other distilled alcoholic beverage). The construction of this indicator was based on alcohol abuse and frequent consumption. Thus, we used the concept of “heavy drinking” proposed by the CDC3232 Centers for Disease Control and Prevention (CDC). Fact Sheets - Preventing Excessive Alcohol Use. Atlanta: CDC; 2020.. This study classified consumption into no consumption (never or less than once a week), light/moderate (1-7 weekly doses for women and 1-14 weekly doses for men3232 Centers for Disease Control and Prevention (CDC). Fact Sheets - Preventing Excessive Alcohol Use. Atlanta: CDC; 2020.) and abuse (weekly intake equal or higher than eight doses for women and 15 for men3232 Centers for Disease Control and Prevention (CDC). Fact Sheets - Preventing Excessive Alcohol Use. Atlanta: CDC; 2020.). Tobacco use indicator was built with the following question: “Do you currently smoke any tobacco product?” with answer options “Yes, daily”; “Yes, less than daily”; “I don’t currently smoke”. Those who answered positively to the question were considered smokers.

  4. d) Chronic noncommunicable diseases (NCDs): kidney failure. This indicator was calculated using PNS laboratory test data. The glomerular filtration rate (GFR) was less than 60 mL/min/1.73 m2 in the blood test, and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation3333 Kidney Disease Improving Global Outcomes. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int Suppl 2013; 3(1):1-150. was used for the calculation. In this study, ethnicity adjustment was not used as recommended by most methods3333 Kidney Disease Improving Global Outcomes. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int Suppl 2013; 3(1):1-150.. We used the value of glycated hemoglobin ≥ 6.5%3434 World Health Organization (WHO). Use of glycated haemoglobin (HbA1c) in the diagnosis of diabetes mellitus. Genebra: WHO; 2011.,3535 American Diabetes Association. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2018. Diabetes Care 2018; 41 (Supl. 1):S13-S27. dosed by a blood test in the PNS and the self-reported diagnosis of the disease for the construction of the diabetes variable, considering the positive answer to the question: “Has any doctor ever diagnosed you with diabetes?” (Categorized as “yes” or “no”). Regarding arterial hypertension, the self-reported diagnosis for the disease was used to make this indicator, assessed by the questions: “Has any doctor ever diagnosed you with arterial hypertension - high blood pressure? (Categorized as “yes” or “no”); “In the past two weeks, have you taken any medications because of arterial hypertension (high blood pressure)?” (Categorized as “yes” or “no”). Blood pressure measurements measured in the PNS were also used, where arterial hypertension was defined as systolic pressure ≥ 140 and diastolic pressure ≥ 90 mmHg, according to the criteria of the Seventh Brazilian Guideline on Hypertension3636 Malachias MVB, Souza WKSB, Plavnik FL, Rodrigues CIS, Brandão AA, Neves MFT, Bortolotto LA, Franco RJS, Poli-de-Figueiredo CE, Jardim PCBV, Amodeo C, Barbosa ECD, Koch V, Gomes MAM, Paula RB, Póvoa RMS, Colombo FC, Ferreira Filho S, Miranda RD, Machado CA, Nobre F, Nogueira AR, Mion Júnior D, Kaiser S, Forjaz CLM, Almeida FA, Martim JFV, Sass N, Drager LF, Muxfeldt E, Bodanese LC, Feitosa AD, Malta D, Fuchs S, Magalhães ME, Oigman W, Moreira Filho O, Pierin AMG, Feitosa GS, Bortolotto MRFL, Magalhães LBNC, Silva ACS, Ribeiro JM, Borelli FAO, Gus M, Passarelli Júnior O, Toledo JY, Salles GF, Martins LC, Jardim TSV, Guimarães ICB, Antonello IC, Lima Júnior E, Matsudo V, Silva GV, Costa LS, Alessi A, Scala LCN, Coelho EB, Souza D, Lopes HF, Gowdak MMG, Cordeiro Júnior AC, Torloni MR, Klein MRST, Nogueira PK, Lotaif LAD, Rosito GBA, Moreno Júnior H. 7ª Diretriz Brasileira de Hipertensão Arterial: Capítulo 2 - Diagnóstico e Classificação. Arq. Bras. Cardiol. 2016; 107(3 Supl. 3):1-83..

  5. e) Self-rated health: for the construction of this indicator, we used the question: “In general, how do you rate your health?” Categorized as “very good”/“good”, “fair” and “very poor”/“poor”.

Sociodemographic, gender, age, schooling, skin color, and region variables were also evaluated as possible confounding factors.

The descriptive analysis of the explanatory variables and the prevalence of LDL-cholesterol < 130 mg/dL (optimal threshold)3131 World Health Organization (WHO). Obesity: preventing and managing the global epidemic. Geneva: WHO; 2000. and ≥130 mg/dL (high threshold) were presented in proportions (%) with 95% confidence intervals (95% CI). Regarding the associated factors concerning the outcome, the analysis considered the causal determination blocks proposed by the theoretical model of Bergmann et al.3737 Bergmann MLA, Bergmann GG, Halpern R, Rech RR, Constanzi CB, Alli LR. Colesterol Total e Fatores Associados: Estudo de Base Escolar no Sul do Brasil. Arq Bras Cardiol 2011; 97(1):17-25. and other studies1515 Bayram F, Kocer D, Gundogan K, Kaya A, Demir O, Coskun R, Sabuncu T, Karaman A, Cesur M, Rizzo M. Prevalence of dyslipidemia and associated risk factors in Turkish adults. J Clin Lipidol 2014; 8(2):206-216.,1616 Opoku S, Gan Y, Fu W, Chen D, Addo-Yobo E, Trofimovitch D, Yue W, Yan F, Wang Z, Lu Z. Prevalence and risk factors for dyslipidemia among adults in rural and urban China: findings from the China National Stroke Screening and prevention project (CNSSPP). BMC Public Health 2019; 19:1500.,1919 Pereira LPP, Sichieri PR, Segri NJ, Silva RMVG, Ferreira MG. Dislipidemia autorreferida na região Centro-Oeste do Brasil: prevalência e fatores associados. Cien Saude Colet 2015; 20(6):1815-1824.

20 Wang S, Xu L, Joanas JB, You QS, Wang YX, Yang H. Prevalence and associated factors of dyslipidemia in the adult Chinese population. PLoS One 2011; 6(3):e17326.-2121 Moraes SA, Checchio MV, Freitas ICM. Dislipidemia e fatores associados em adultos residentes em Ribeirão Preto, SP. Resultados do Projeto EPIDCV. Arq Bras Endocrinol Metab 2013; 57(9):691-701.. The choice of the theoretical model3737 Bergmann MLA, Bergmann GG, Halpern R, Rech RR, Constanzi CB, Alli LR. Colesterol Total e Fatores Associados: Estudo de Base Escolar no Sul do Brasil. Arq Bras Cardiol 2011; 97(1):17-25. is justified because it is a national study in which the authors built the model, but other research with adults1515 Bayram F, Kocer D, Gundogan K, Kaya A, Demir O, Coskun R, Sabuncu T, Karaman A, Cesur M, Rizzo M. Prevalence of dyslipidemia and associated risk factors in Turkish adults. J Clin Lipidol 2014; 8(2):206-216.,1919 Pereira LPP, Sichieri PR, Segri NJ, Silva RMVG, Ferreira MG. Dislipidemia autorreferida na região Centro-Oeste do Brasil: prevalência e fatores associados. Cien Saude Colet 2015; 20(6):1815-1824.

20 Wang S, Xu L, Joanas JB, You QS, Wang YX, Yang H. Prevalence and associated factors of dyslipidemia in the adult Chinese population. PLoS One 2011; 6(3):e17326.-2121 Moraes SA, Checchio MV, Freitas ICM. Dislipidemia e fatores associados em adultos residentes em Ribeirão Preto, SP. Resultados do Projeto EPIDCV. Arq Bras Endocrinol Metab 2013; 57(9):691-701. that investigated all the variables present in this study were also considered.

Each of the explanatory variables’ entry occurred according to the hierarchical theoretical model, which considered five blocks of causal determination (Figure 1).

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Figure 1
Hierarchical theoretical model of factors associated with high LDL-cholesterol.

Association analyses were examined using the prevalence ratios (PR) and respective 95% CI and were calculated using the Poisson regression model with robust variance. PRs above 1 indicated a risk factor, and PRs below 1 indicated a protective factor.

Three regression models were built. In model 1, bivariate analyses between the outcome variable and each explanatory variable were considered, and the estimated crude PR (PRcru) was estimated. In model 2, the analysis adjusted for gender, schooling, skin color, and the region was performed, and the adjusted PR (PRadj) was calculated; the age variable was excluded, as it pointed out that, using this adjustment, some variables accepted by the scientific community as factors associated with dyslipidemia1919 Pereira LPP, Sichieri PR, Segri NJ, Silva RMVG, Ferreira MG. Dislipidemia autorreferida na região Centro-Oeste do Brasil: prevalência e fatores associados. Cien Saude Colet 2015; 20(6):1815-1824.

20 Wang S, Xu L, Joanas JB, You QS, Wang YX, Yang H. Prevalence and associated factors of dyslipidemia in the adult Chinese population. PLoS One 2011; 6(3):e17326.

21 Moraes SA, Checchio MV, Freitas ICM. Dislipidemia e fatores associados em adultos residentes em Ribeirão Preto, SP. Resultados do Projeto EPIDCV. Arq Bras Endocrinol Metab 2013; 57(9):691-701.-2222 Qi L, Ding X, Tang W, Li Q, Mao D, Wang Y. Prevalence and Risk Factors Associated with Dyslipidemia in Chongqing, China. Int J Environ Res Public Health 2015; 12(10):13455-13465. lost their statistical significance. In model 3 (final model), a multivariate analysis adjusted for all explanatory variables was performed, and variables with p < 0.20 in bivariate analyses were selected and included in the model. In this analysis, the PRadj b were estimated, and the explanatory variables that presented a value of p ≤ 0.05 were considered as factors associated with high LDL-cholesterol. Confounding variables were tested considering aspects of the literature88 Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune A Neto, Bertolami A, Pereira AC, Lottenberg AM, Sposito AC, Chagas ACP, Casella A Filho, Simão AF, Alencar AC Filho, Caramelli B, Magalhães CC, Negrão CE, Ferreira CEDS, Scherr C, Feio CMA, Kovacs C, Araújo DB, Magnoni D, Calderaro D, Gualandro DM, Mello EP Junior, Alexandre ERG, Sato EI, Moriguchi EH, Rached FH, Santos FCD, Cesena FHY, Fonseca FAH, Fonseca HARD, Xavier HT, Mota ICP, Giuliano ICB, Issa JS, Diament J, Pesquero JB, Santos JED, Faria JR Neto, Melo JX Filho, Kato JT, Torres KP, Bertolami MC, Assad MHV, Miname MH, Scartezini M, Forti NA, Coelho OR, Maranhão RC, Santos RDD Filho, Alves RJ, Cassani RL, Betti RTB, Carvalho T, Martinez TLDR, Giraldez VZR, Salgado W Filho. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017; 109(2 Supl. 1):1-76.,1515 Bayram F, Kocer D, Gundogan K, Kaya A, Demir O, Coskun R, Sabuncu T, Karaman A, Cesur M, Rizzo M. Prevalence of dyslipidemia and associated risk factors in Turkish adults. J Clin Lipidol 2014; 8(2):206-216.,1616 Opoku S, Gan Y, Fu W, Chen D, Addo-Yobo E, Trofimovitch D, Yue W, Yan F, Wang Z, Lu Z. Prevalence and risk factors for dyslipidemia among adults in rural and urban China: findings from the China National Stroke Screening and prevention project (CNSSPP). BMC Public Health 2019; 19:1500.,1919 Pereira LPP, Sichieri PR, Segri NJ, Silva RMVG, Ferreira MG. Dislipidemia autorreferida na região Centro-Oeste do Brasil: prevalência e fatores associados. Cien Saude Colet 2015; 20(6):1815-1824.

20 Wang S, Xu L, Joanas JB, You QS, Wang YX, Yang H. Prevalence and associated factors of dyslipidemia in the adult Chinese population. PLoS One 2011; 6(3):e17326.-2121 Moraes SA, Checchio MV, Freitas ICM. Dislipidemia e fatores associados em adultos residentes em Ribeirão Preto, SP. Resultados do Projeto EPIDCV. Arq Bras Endocrinol Metab 2013; 57(9):691-701.,3838 Liu HH, Li JJ. Aging and dyslipidemia: a review of potential mechanisms. Ageing Res Rev 2015; 19:43-52.

39 Vekic J, Zeljkovic A, Stefanovic A, Jelic-Ivanovic Z, Spasojevic-Kalimanovska V. Obesity and dyslipidemia. Metabolism 2019; 92:71-81.

40 Naoum FA. Alterações do perfil lipídico nas anemias. Rev Bras Hematol Hemoter 2005; 27(3):223-226.

41 Mikolasevic I, Žutelija M, Mavrinac V, Orlic L. Dyslipidemia in patients with chronic kidney disease: etiology and management. Int J Nephorol Renovasc Dis 2017; 10:35-45.-4242 Schofield JD, Liu Y, Rao-Balakrishna P, Malik RA, Soran H. Dyslipidemia. Diabetes Ther 2016; 7(2):203-219..

For all analyses, the sample structure and post-stratification weightings were considered. Data were analyzed using the Data Analysis and Statistical Software (Stata), version 14, using commands for analyzing data from surveys with a complex sample (survey).

The laboratory database and PNS questionnaires are available on the PNS website of the Oswaldo Cruz Foundation (www.pns.fiocruz.br). The PNS was approved by the National Research Ethics Commission (CONEP) of the National Health Council (CNS), MS, under N° 328.159, of June 26, 2013. Adult participation in the research was voluntary, and information confidentiality was guaranteed. The selected individuals signed the Informed Consent Form and were instructed on receiving the report containing the results of the examinations2828 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde 2013: percepção do estado de saúde, estilos de vida e doenças crônicas: Brasil, Grandes Regiões e Unidades da Federação. Rio de Janeiro: IBGE; 2014..

Results

The prevalence of increased LDL-cholesterol was 18.58% in the adult population and was higher in individuals aged 30 and over (17.55%), reaching approximately 25% in those aged 60 years and over, the less educated, such as the illiterate and with incomplete elementary education (21.53%), those overweight (21.10%), obesity (23.30%), arterial hypertension (23.27%), diabetes (24.72%) and those who self-rating their health as very poor/poor (24.24%) and fair (22.05%). Anemic individuals had a lower prevalence of increased LDL-cholesterol (13.29%) (Table 1).

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Table 1
Prevalence of LDL-cholesterol optimal (< 130 mg/dL) and increased (≥ 130 mg/dL) thresholds, and 95% CI in adults (≥ 18 years), according to sociodemographic, anthropometric, lifestyle, chronic noncommunicable diseases, and self-rated health. National Health Survey, Brazil, 2014-2015.

In Table 2, the factors associated with increased LDL-cholesterol were analyzed. The results presented show that the magnitude of the associations varied according to the factors analyzed.

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Table 2
Factors associated with high LDL-cholesterol (≥ 130 mg / dL) in adults ≥ 18 years old, crude (regression model 1) and adjusted (regression model 2) prevalence and their respective 95% CI, according to the variables selected. National Health Survey, Brazil, 2014-2015.

In the bivariate analysis (model 1), the protective factors were schooling, complete elementary and incomplete high school (PRb = 0.78; 95% CI 0.66-0.93); complete high school and more (PRb = 0.77; 95% CI 0.68-0.88); black and brown skin color (PRb = 0.87; 95% CI 0.77-0.97) and anemia (PRb = 0.69; 95% CI 0.56-0.83). Risk factors were: female gender (PRb = 1.16; 95% CI 1.03-1.30); age, 30-44 years (PRb = 1.99; 95% CI 1.60-2.49), 45-59 years (PRb = 2.90; 95% CI 2.34-3.59), 60 years and over (PRb = 2.78; 95% CI 2.24-3.46); regions: Northeast (PRb = 1.22; 95% CI 1.08-1.38) and South (PRb = 1.23; 95% CI 1.05-1.45); overweight (PRb = 1.53; 95% CI 1.34-1.75) and obesity (PRb = 1.69; 95% CI 1.45-1.96); arterial hypertension (PRb = 1.34; 95% CI 1.18-1.51), kidney failure (PRb = 1.24; 95% CI 1.01-1.51) and diabetes (PRb = 1.38; 95% CI 1.18-1.61); self-rated fair (PRb = 1.33; 95% CI 1.18-1.50) and very poor/poor health (PRb = 1.47; 95% CI 1.22-1.76). The other variables such as consumption of fatty red meat (p = 0.433), light/moderate alcoholic beverage consumption (p = 0.501) and alcohol abuse (p = 0.154), and tobacco use (p = 0.218) were not significant.

In model 2, in the analysis adjusted for gender, schooling, skin color, and region, all associations found in model 1 were maintained, except for kidney failure (PRadj a = 1.11; 95% CI 0.91-1.37) and South region (PRadj a = 1,21; CI95% 0,94 - 1,33), which lost statistical significance.

Table 3 shows model 3. In the multivariate regression analysis, some of the variables lost statistical significance when analyzed together and were not included in the final model. The factors associated with increased LDL-cholesterol were anemia, protective concerning the outcome (PRadj b = 0.66; 95% CI 0.54-0.80); and among the risk factors, the following remained: increasing age 30-44 years PRadj b = 1.99 (95% CI 1.58-2.54), 45-59 years PRadj b = 2.89 (95% CI 2.29-3.64), 60 years and over PRadj b = 2.90 (95% CI 2.29-3.68), Northeast region (PRadj b = 1.16; 95% CI 1.02-1.32), overweight (PRadj b = 1.32; 95% CI 1.15-1.51), and obesity (PRadj b = 1.41; 95% CI 1.19-1.65).

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Table 3
Factors associated with high LDL-cholesterol (≥ 130 mg/dL) in adults ≥ 18 years old, adjusted prevalence ratio (regression model 3) and their respective 95% CI, according to the selected variables. National Health Survey, Brazil, 2014-2015.

Discussion

LDL-cholesterol measured by laboratory analysis in the PNS was elevated in one-fifth of the Brazilian adult population. In model 2, factors associated with increased LDL-cholesterol were female, age group above 30 years, schooling, black and brown skin color, Northeast region, altered BMI, arterial hypertension, diabetes, and anemia. In the final model, the factors associated with the outcome were age over 30, overweight and obesity, living in the Northeast, and anemia. In this study, the factors associated with increased LDL-cholesterol are in agreement with the literature1515 Bayram F, Kocer D, Gundogan K, Kaya A, Demir O, Coskun R, Sabuncu T, Karaman A, Cesur M, Rizzo M. Prevalence of dyslipidemia and associated risk factors in Turkish adults. J Clin Lipidol 2014; 8(2):206-216.,1919 Pereira LPP, Sichieri PR, Segri NJ, Silva RMVG, Ferreira MG. Dislipidemia autorreferida na região Centro-Oeste do Brasil: prevalência e fatores associados. Cien Saude Colet 2015; 20(6):1815-1824.

20 Wang S, Xu L, Joanas JB, You QS, Wang YX, Yang H. Prevalence and associated factors of dyslipidemia in the adult Chinese population. PLoS One 2011; 6(3):e17326.-2121 Moraes SA, Checchio MV, Freitas ICM. Dislipidemia e fatores associados em adultos residentes em Ribeirão Preto, SP. Resultados do Projeto EPIDCV. Arq Bras Endocrinol Metab 2013; 57(9):691-701.,3737 Bergmann MLA, Bergmann GG, Halpern R, Rech RR, Constanzi CB, Alli LR. Colesterol Total e Fatores Associados: Estudo de Base Escolar no Sul do Brasil. Arq Bras Cardiol 2011; 97(1):17-25..

This study’s limitations were the impossibility of attesting a causal relationship and the possibility of reverse causality. On the one hand, we were unable to attest to the causal relationship between the variables examined due to the study’s cross-sectional nature. Because the outcome and its causes are analyzed in a single moment, the associations described here may result from lifestyle changes and other changes regarding treatment. On the other hand, it is worth mentioning the possibility of reverse causality between the NCDs studied here and high LDL-cholesterol. Thus, these results should be interpreted with caution. However, to control this bias, the methodological analyses were carried out critically, and we attempted to control this situation using a multivariate model, following the hierarchy of causal determination blocks based on the scientific literature1515 Bayram F, Kocer D, Gundogan K, Kaya A, Demir O, Coskun R, Sabuncu T, Karaman A, Cesur M, Rizzo M. Prevalence of dyslipidemia and associated risk factors in Turkish adults. J Clin Lipidol 2014; 8(2):206-216.,1616 Opoku S, Gan Y, Fu W, Chen D, Addo-Yobo E, Trofimovitch D, Yue W, Yan F, Wang Z, Lu Z. Prevalence and risk factors for dyslipidemia among adults in rural and urban China: findings from the China National Stroke Screening and prevention project (CNSSPP). BMC Public Health 2019; 19:1500.,1919 Pereira LPP, Sichieri PR, Segri NJ, Silva RMVG, Ferreira MG. Dislipidemia autorreferida na região Centro-Oeste do Brasil: prevalência e fatores associados. Cien Saude Colet 2015; 20(6):1815-1824.

20 Wang S, Xu L, Joanas JB, You QS, Wang YX, Yang H. Prevalence and associated factors of dyslipidemia in the adult Chinese population. PLoS One 2011; 6(3):e17326.

21 Moraes SA, Checchio MV, Freitas ICM. Dislipidemia e fatores associados em adultos residentes em Ribeirão Preto, SP. Resultados do Projeto EPIDCV. Arq Bras Endocrinol Metab 2013; 57(9):691-701.-2222 Qi L, Ding X, Tang W, Li Q, Mao D, Wang Y. Prevalence and Risk Factors Associated with Dyslipidemia in Chongqing, China. Int J Environ Res Public Health 2015; 12(10):13455-13465.,3737 Bergmann MLA, Bergmann GG, Halpern R, Rech RR, Constanzi CB, Alli LR. Colesterol Total e Fatores Associados: Estudo de Base Escolar no Sul do Brasil. Arq Bras Cardiol 2011; 97(1):17-25..

High LDL-cholesterol in adults over 30 years of age identified in this research can be explained by the lipid changes resulting from the gradual aging process, as likelihood increases with age. Aging mechanisms affect tissues and organs, resulting in changes in the hepatic endothelium, increased insulin resistance, decreased androgen in men and hormones in women resulting from menopause and post-climacteric phase3838 Liu HH, Li JJ. Aging and dyslipidemia: a review of potential mechanisms. Ageing Res Rev 2015; 19:43-52.. Similar results were also found in other studies in Brazil2323 Lotufo PA, Santos RD, Sposito AC, Bertolami M, Rocha-Faria J Neto, Izar MC, Szwarcwald C, Prado RR, Stoppa SR, Malta DC, Bensenor IM. Prevalência de Diagnóstico Médico de Colesterol Alto Autorreferido na População Brasileira: Análise da Pesquisa Nacional de Saúde, 2013. Arq Bras Cardiol 2017; 108(5):411-416.,4343 Brasil. Ministério da Saúde (MS). Vigitel Brasil 2014: vigilância dos fatores de risco e proteção para as doenças crônicas por inquérito telefônico. Brasília: MS; 2015. and other countries, such as China4444 Zhang M, Deng Q, Wang L, Huang Z, Zhou M, Li Y, Zhao Z, Zhang Y, Wang L. Prevalence of dyslipidemia and achievement of low-density lipoprotein cholesterol targets in Chinese adults: A nationally representative survey of 163,641 adults. Int J Cardiol 2018; 260:196-203. and the U.S.4545 Tóth PP, Potter D, Ming EE. Prevalence of lipid abnormalities in the United States: the National Health and Nutrition Examination Survey 2003-2006. J Clin Lipidol 2012; 6(4):325-330..

The population with altered BMI had a higher prevalence of increased LDL-cholesterol, and these data confirm that overweight and obesity, especially abdominal adiposity, contribute to the occurrence of dyslipidemia3939 Vekic J, Zeljkovic A, Stefanovic A, Jelic-Ivanovic Z, Spasojevic-Kalimanovska V. Obesity and dyslipidemia. Metabolism 2019; 92:71-81.. Insulin resistance is the most common metabolic disorder in obesity. It is related to increased cholesterol because of elevated levels of free fatty acids (FFA), which culminates in reducing the degradation of ApoB100, which is the main component of very-low-density lipoproteins (VLDL) and greater hepatic secretion of VLDL. As a result, TG increase (their excess is secreted as VLDL), leading to hypertriglyceridemia. Also, VLDL metabolizes into small, dense LDL-cholesterol particles, generating its accumulation3939 Vekic J, Zeljkovic A, Stefanovic A, Jelic-Ivanovic Z, Spasojevic-Kalimanovska V. Obesity and dyslipidemia. Metabolism 2019; 92:71-81..

Living in the Northeast Region was a risk factor for increased LDL-cholesterol. A possible explanation for this would be the care gaps evidenced by the lower prevalence of medical visits reported in the last 12 months, which contributes to underdiagnosis and late treatment, especially in the Northeast and North regions, when compared to other regions4646 Stopa SR, Malta DC, Monteiro CN, Szwarcwald CL, Goldbaum M, Cesar CLG. Acesso e uso de serviços de saúde pela população brasileira, Pesquisa Nacional de Saúde 2013. Rev Saude Publica 2017; 51 (Supl. 1):3s.. Another hypothesis is the increase in risk factors, such as obesity, which has shown a growing trend in the last 11 years4747 Malta DC, Silva AG, Tonaco LAB, Freitas MIF, Velasquez-Melendez G. Tendência temporal da prevalência de obesidade mórbida na população adulta brasileira entre os anos de 2006 e 2017. Cad Saude Publica 2019; 35(9):e00223518.. While PNS data show improvements and advances in access and use of health services, regional gaps are still observed in the country4646 Stopa SR, Malta DC, Monteiro CN, Szwarcwald CL, Goldbaum M, Cesar CLG. Acesso e uso de serviços de saúde pela população brasileira, Pesquisa Nacional de Saúde 2013. Rev Saude Publica 2017; 51 (Supl. 1):3s.. All explanations lack empirical and theoretical evidence and must be further investigated.

Individuals with anemia had a lower prevalence of high LDL-cholesterol. Low plasma cholesterol values are described in several types of acquired and hereditary anemias (megaloblastic, iron deficiency, aplastic, associated with liver disease, hereditary spherocytosis, sickle cell, and thalassemia)4040 Naoum FA. Alterações do perfil lipídico nas anemias. Rev Bras Hematol Hemoter 2005; 27(3):223-226., which is due to the greater use of plasma cholesterol, determined by the renewal of erythrocyte lipids in cases of lower survival or increased hemolysis and the more significant dilution of serum cholesterol due to the increase in plasma volume secondary to low hematocrit and hemoglobin values4040 Naoum FA. Alterações do perfil lipídico nas anemias. Rev Bras Hematol Hemoter 2005; 27(3):223-226.. In sickle cell anemia and thalassemia, the hepatic dysfunction reduces endogenous cholesterol production and increases the lipid profile changes in patients with low TC, LDL, and HDL levels4040 Naoum FA. Alterações do perfil lipídico nas anemias. Rev Bras Hematol Hemoter 2005; 27(3):223-226..

The female gender was a risk factor in the bivariate and adjusted analyses. The difference between gender and the prevalence of dyslipidemia is not well established in the literature1919 Pereira LPP, Sichieri PR, Segri NJ, Silva RMVG, Ferreira MG. Dislipidemia autorreferida na região Centro-Oeste do Brasil: prevalência e fatores associados. Cien Saude Colet 2015; 20(6):1815-1824.. However, the high prevalence of dyslipidemia in women during menopause4848 Phan BA, Toth PP. Dyslipidemia in women: etiology and management. Int J Womens Health 2014; 6:185-194. and post-climacteric phase88 Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune A Neto, Bertolami A, Pereira AC, Lottenberg AM, Sposito AC, Chagas ACP, Casella A Filho, Simão AF, Alencar AC Filho, Caramelli B, Magalhães CC, Negrão CE, Ferreira CEDS, Scherr C, Feio CMA, Kovacs C, Araújo DB, Magnoni D, Calderaro D, Gualandro DM, Mello EP Junior, Alexandre ERG, Sato EI, Moriguchi EH, Rached FH, Santos FCD, Cesena FHY, Fonseca FAH, Fonseca HARD, Xavier HT, Mota ICP, Giuliano ICB, Issa JS, Diament J, Pesquero JB, Santos JED, Faria JR Neto, Melo JX Filho, Kato JT, Torres KP, Bertolami MC, Assad MHV, Miname MH, Scartezini M, Forti NA, Coelho OR, Maranhão RC, Santos RDD Filho, Alves RJ, Cassani RL, Betti RTB, Carvalho T, Martinez TLDR, Giraldez VZR, Salgado W Filho. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017; 109(2 Supl. 1):1-76. has been documented, probably due to the loss of hormonal protection in these life stages4949 Edmunds E, Lip GYH. Cardiovascular risk in women: the cardiologist perspective. Q J Med 2000; 93(3):135-145..

Black and brown skin color was a protective factor in the bivariate and adjusted analyses, in agreement with the ELSA-Brasil study results and other research conducted in the U.S.5050 Frank AT, Zhao B, Jose PO, Azar KM, Fortmann SP, Palaniappan LP. Racial/ethnic differences in dyslipidemia patterns. Circulation 2014; 129(5):570-579.,5151 McIntosh MS, Kumar V, Kalynych C, Lott M, Hsi A, Chang JL, Lerman R. Racial Differences in Blood Lipids Lead to Underestimation of Cardiovascular Risk in Black Women in a Nested observational Study. Glob Adv Health Med 2013; 2(2):76-79., which indicated a lower prevalence of dyslipidemia among blacks5252 Santos RD, Bensenor IM, Pereira AC, Lotufo PA. Dyslipidemia according to gender and race: The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). J Clin Lipidol 2016; 10(6):1362-1368.. A possible reason for this finding can be that socioeconomic status, dietary pattern, and other environmental factors vary widely by ethnicity5151 McIntosh MS, Kumar V, Kalynych C, Lott M, Hsi A, Chang JL, Lerman R. Racial Differences in Blood Lipids Lead to Underestimation of Cardiovascular Risk in Black Women in a Nested observational Study. Glob Adv Health Med 2013; 2(2):76-79.. However, additional research is required to explore the theme in Brazil further.

As for education, the bivariate and adjusted analyses showed that individuals with less education had a higher prevalence of increased LDL-cholesterol. We emphasize that cardiovascular risk factors are more prevalent among individuals with low socioeconomic status, including schooling, which may be due to higher access to health services and promotion practices in a highly-educated population5353 Malta DC, Bernal RTI, Lima MG, Araújo SSC, Silva MMAD, Freitas MIF, Barros MBA. Doenças crônicas não transmissíveis e a utilização de serviços de saúde: análise da Pesquisa Nacional de Saúde no Brasil. Rev Saude Publica 2017; 51 (Supl. 1):4s..

Diseases such as high blood pressure and diabetes were risk factors for LDL-cholesterol but lost statistical significance in the final model due to age adjustment. It is noteworthy that these variables are more frequent among older adults, which could justify these results. It is also worth noting that the NCDs studied here are associated with higher LDL levels due to the pathophysiological mechanisms of these diseases88 Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune A Neto, Bertolami A, Pereira AC, Lottenberg AM, Sposito AC, Chagas ACP, Casella A Filho, Simão AF, Alencar AC Filho, Caramelli B, Magalhães CC, Negrão CE, Ferreira CEDS, Scherr C, Feio CMA, Kovacs C, Araújo DB, Magnoni D, Calderaro D, Gualandro DM, Mello EP Junior, Alexandre ERG, Sato EI, Moriguchi EH, Rached FH, Santos FCD, Cesena FHY, Fonseca FAH, Fonseca HARD, Xavier HT, Mota ICP, Giuliano ICB, Issa JS, Diament J, Pesquero JB, Santos JED, Faria JR Neto, Melo JX Filho, Kato JT, Torres KP, Bertolami MC, Assad MHV, Miname MH, Scartezini M, Forti NA, Coelho OR, Maranhão RC, Santos RDD Filho, Alves RJ, Cassani RL, Betti RTB, Carvalho T, Martinez TLDR, Giraldez VZR, Salgado W Filho. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017; 109(2 Supl. 1):1-76.,4141 Mikolasevic I, Žutelija M, Mavrinac V, Orlic L. Dyslipidemia in patients with chronic kidney disease: etiology and management. Int J Nephorol Renovasc Dis 2017; 10:35-45.,4242 Schofield JD, Liu Y, Rao-Balakrishna P, Malik RA, Soran H. Dyslipidemia. Diabetes Ther 2016; 7(2):203-219..

The relationship between NCDs and dyslipidemia is documented, as is that these diseases are at increased risk for atherosclerotic CVD88 Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune A Neto, Bertolami A, Pereira AC, Lottenberg AM, Sposito AC, Chagas ACP, Casella A Filho, Simão AF, Alencar AC Filho, Caramelli B, Magalhães CC, Negrão CE, Ferreira CEDS, Scherr C, Feio CMA, Kovacs C, Araújo DB, Magnoni D, Calderaro D, Gualandro DM, Mello EP Junior, Alexandre ERG, Sato EI, Moriguchi EH, Rached FH, Santos FCD, Cesena FHY, Fonseca FAH, Fonseca HARD, Xavier HT, Mota ICP, Giuliano ICB, Issa JS, Diament J, Pesquero JB, Santos JED, Faria JR Neto, Melo JX Filho, Kato JT, Torres KP, Bertolami MC, Assad MHV, Miname MH, Scartezini M, Forti NA, Coelho OR, Maranhão RC, Santos RDD Filho, Alves RJ, Cassani RL, Betti RTB, Carvalho T, Martinez TLDR, Giraldez VZR, Salgado W Filho. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017; 109(2 Supl. 1):1-76.,4141 Mikolasevic I, Žutelija M, Mavrinac V, Orlic L. Dyslipidemia in patients with chronic kidney disease: etiology and management. Int J Nephorol Renovasc Dis 2017; 10:35-45.,4242 Schofield JD, Liu Y, Rao-Balakrishna P, Malik RA, Soran H. Dyslipidemia. Diabetes Ther 2016; 7(2):203-219.. In kidney failure, lipoprotein metabolism changes occur due to inadequate enzyme activity and metabolic pathways that result in dyslipidemia4141 Mikolasevic I, Žutelija M, Mavrinac V, Orlic L. Dyslipidemia in patients with chronic kidney disease: etiology and management. Int J Nephorol Renovasc Dis 2017; 10:35-45.. Dyslipidemia is a common metabolic abnormality in diabetes due to factors such as insulin deficiency or resistance, adipocytokines, and hyperglycemia, which, when chronic, results in a more significant accumulation of dense LDL particles4242 Schofield JD, Liu Y, Rao-Balakrishna P, Malik RA, Soran H. Dyslipidemia. Diabetes Ther 2016; 7(2):203-219.. In hypertension, aggression to the vascular endothelium causes endothelial dysfunction, culminating in increased permeability of plasma lipoproteins, favoring the retention of LDL particles88 Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune A Neto, Bertolami A, Pereira AC, Lottenberg AM, Sposito AC, Chagas ACP, Casella A Filho, Simão AF, Alencar AC Filho, Caramelli B, Magalhães CC, Negrão CE, Ferreira CEDS, Scherr C, Feio CMA, Kovacs C, Araújo DB, Magnoni D, Calderaro D, Gualandro DM, Mello EP Junior, Alexandre ERG, Sato EI, Moriguchi EH, Rached FH, Santos FCD, Cesena FHY, Fonseca FAH, Fonseca HARD, Xavier HT, Mota ICP, Giuliano ICB, Issa JS, Diament J, Pesquero JB, Santos JED, Faria JR Neto, Melo JX Filho, Kato JT, Torres KP, Bertolami MC, Assad MHV, Miname MH, Scartezini M, Forti NA, Coelho OR, Maranhão RC, Santos RDD Filho, Alves RJ, Cassani RL, Betti RTB, Carvalho T, Martinez TLDR, Giraldez VZR, Salgado W Filho. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017; 109(2 Supl. 1):1-76..

In the lifestyle block, none of the variables remained in models 2 and 3. However, the evidence for the importance of dietary patterns and adopting a healthy lifestyle as control and prevention measures for dyslipidemia is well established88 Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune A Neto, Bertolami A, Pereira AC, Lottenberg AM, Sposito AC, Chagas ACP, Casella A Filho, Simão AF, Alencar AC Filho, Caramelli B, Magalhães CC, Negrão CE, Ferreira CEDS, Scherr C, Feio CMA, Kovacs C, Araújo DB, Magnoni D, Calderaro D, Gualandro DM, Mello EP Junior, Alexandre ERG, Sato EI, Moriguchi EH, Rached FH, Santos FCD, Cesena FHY, Fonseca FAH, Fonseca HARD, Xavier HT, Mota ICP, Giuliano ICB, Issa JS, Diament J, Pesquero JB, Santos JED, Faria JR Neto, Melo JX Filho, Kato JT, Torres KP, Bertolami MC, Assad MHV, Miname MH, Scartezini M, Forti NA, Coelho OR, Maranhão RC, Santos RDD Filho, Alves RJ, Cassani RL, Betti RTB, Carvalho T, Martinez TLDR, Giraldez VZR, Salgado W Filho. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017; 109(2 Supl. 1):1-76.,5454 Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, Braun LT, de Ferranti S, Faiella-Tommasino J, Forman DE, Goldberg R, Heidenreich PA, Hlatky MA, Jones DW, Lloyd-Jones D, Lopez-Pajares N, Ndumele CE, Orringer CE, Peralta CA, Saseen JJ, Smith SC Jr, Sperling L, Virani SS, Yeboah J. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinic Practice Guidelines. J Am Coll Cardiol 2019; 73(24):3168-3209.,5555 Mach F, Baigent C, Catapano AL, Koskinas KC, Casula M, Badimon L, Chapman MJ, De Backer GG, Delgado V, Ference BA, Graham IM, Halliday A, Landmesser U, Mihaylova B, Pedersen TR, Riccardi G, Richter DJ, Sabatine MS, Taskinen MR, Tokgozoglu L, Wiklund O, ESC Scientific Document Group. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J 2020; 41(1):111-188.. It is recommended to reduce sugars and include lean meats, fruits, grains, and vegetables in the diet88 Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune A Neto, Bertolami A, Pereira AC, Lottenberg AM, Sposito AC, Chagas ACP, Casella A Filho, Simão AF, Alencar AC Filho, Caramelli B, Magalhães CC, Negrão CE, Ferreira CEDS, Scherr C, Feio CMA, Kovacs C, Araújo DB, Magnoni D, Calderaro D, Gualandro DM, Mello EP Junior, Alexandre ERG, Sato EI, Moriguchi EH, Rached FH, Santos FCD, Cesena FHY, Fonseca FAH, Fonseca HARD, Xavier HT, Mota ICP, Giuliano ICB, Issa JS, Diament J, Pesquero JB, Santos JED, Faria JR Neto, Melo JX Filho, Kato JT, Torres KP, Bertolami MC, Assad MHV, Miname MH, Scartezini M, Forti NA, Coelho OR, Maranhão RC, Santos RDD Filho, Alves RJ, Cassani RL, Betti RTB, Carvalho T, Martinez TLDR, Giraldez VZR, Salgado W Filho. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017; 109(2 Supl. 1):1-76.. Physical exercise reduces cardiovascular morbimortality by improving HDL functioning, increasing resistance to LDL oxidation, and increasing the flow of cholesterol88 Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune A Neto, Bertolami A, Pereira AC, Lottenberg AM, Sposito AC, Chagas ACP, Casella A Filho, Simão AF, Alencar AC Filho, Caramelli B, Magalhães CC, Negrão CE, Ferreira CEDS, Scherr C, Feio CMA, Kovacs C, Araújo DB, Magnoni D, Calderaro D, Gualandro DM, Mello EP Junior, Alexandre ERG, Sato EI, Moriguchi EH, Rached FH, Santos FCD, Cesena FHY, Fonseca FAH, Fonseca HARD, Xavier HT, Mota ICP, Giuliano ICB, Issa JS, Diament J, Pesquero JB, Santos JED, Faria JR Neto, Melo JX Filho, Kato JT, Torres KP, Bertolami MC, Assad MHV, Miname MH, Scartezini M, Forti NA, Coelho OR, Maranhão RC, Santos RDD Filho, Alves RJ, Cassani RL, Betti RTB, Carvalho T, Martinez TLDR, Giraldez VZR, Salgado W Filho. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017; 109(2 Supl. 1):1-76.. The consumption of alcoholic beverages is not recommended for individuals with hypertriglyceridemia due to the combination of ethanol and saturated fatty acids, potentiating the increase in TG88 Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune A Neto, Bertolami A, Pereira AC, Lottenberg AM, Sposito AC, Chagas ACP, Casella A Filho, Simão AF, Alencar AC Filho, Caramelli B, Magalhães CC, Negrão CE, Ferreira CEDS, Scherr C, Feio CMA, Kovacs C, Araújo DB, Magnoni D, Calderaro D, Gualandro DM, Mello EP Junior, Alexandre ERG, Sato EI, Moriguchi EH, Rached FH, Santos FCD, Cesena FHY, Fonseca FAH, Fonseca HARD, Xavier HT, Mota ICP, Giuliano ICB, Issa JS, Diament J, Pesquero JB, Santos JED, Faria JR Neto, Melo JX Filho, Kato JT, Torres KP, Bertolami MC, Assad MHV, Miname MH, Scartezini M, Forti NA, Coelho OR, Maranhão RC, Santos RDD Filho, Alves RJ, Cassani RL, Betti RTB, Carvalho T, Martinez TLDR, Giraldez VZR, Salgado W Filho. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017; 109(2 Supl. 1):1-76. levels.

On the other hand, moderate alcohol consumption (acceptable consumption ≤ 10g/day - 1 unit) increases HDL’s plasma concentration, curbs LDL concentrations, and is associated with reduced CVD risk5555 Mach F, Baigent C, Catapano AL, Koskinas KC, Casula M, Badimon L, Chapman MJ, De Backer GG, Delgado V, Ference BA, Graham IM, Halliday A, Landmesser U, Mihaylova B, Pedersen TR, Riccardi G, Richter DJ, Sabatine MS, Taskinen MR, Tokgozoglu L, Wiklund O, ESC Scientific Document Group. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J 2020; 41(1):111-188.. Concerning tobacco use, smoking harms the arterial endothelium and increases the levels of TC and LDL, decreasing HDL. Thus, smoking cessation is beneficial at any life stage88 Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune A Neto, Bertolami A, Pereira AC, Lottenberg AM, Sposito AC, Chagas ACP, Casella A Filho, Simão AF, Alencar AC Filho, Caramelli B, Magalhães CC, Negrão CE, Ferreira CEDS, Scherr C, Feio CMA, Kovacs C, Araújo DB, Magnoni D, Calderaro D, Gualandro DM, Mello EP Junior, Alexandre ERG, Sato EI, Moriguchi EH, Rached FH, Santos FCD, Cesena FHY, Fonseca FAH, Fonseca HARD, Xavier HT, Mota ICP, Giuliano ICB, Issa JS, Diament J, Pesquero JB, Santos JED, Faria JR Neto, Melo JX Filho, Kato JT, Torres KP, Bertolami MC, Assad MHV, Miname MH, Scartezini M, Forti NA, Coelho OR, Maranhão RC, Santos RDD Filho, Alves RJ, Cassani RL, Betti RTB, Carvalho T, Martinez TLDR, Giraldez VZR, Salgado W Filho. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017; 109(2 Supl. 1):1-76.,5555 Mach F, Baigent C, Catapano AL, Koskinas KC, Casula M, Badimon L, Chapman MJ, De Backer GG, Delgado V, Ference BA, Graham IM, Halliday A, Landmesser U, Mihaylova B, Pedersen TR, Riccardi G, Richter DJ, Sabatine MS, Taskinen MR, Tokgozoglu L, Wiklund O, ESC Scientific Document Group. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J 2020; 41(1):111-188..

The data from this study also point to the relevance of self-rated health. This variable is a predictor of morbimortality22 Nayor M, Vasan RS. Recent Update to th Cholesterol Treatment Guidelines: A Comparison With International Guidelines. Circulation 2016; 133(18):1795-1806. and, thus, should be studied. The results presented here were similar to the PNS data survey, which showed a strong association between self-assessment and dyslipidemia for those who had a poor self-rated health status1919 Pereira LPP, Sichieri PR, Segri NJ, Silva RMVG, Ferreira MG. Dislipidemia autorreferida na região Centro-Oeste do Brasil: prevalência e fatores associados. Cien Saude Colet 2015; 20(6):1815-1824..

High LDL-cholesterol in the Brazilian population is associated with aging, overweight, obesity, living in the Northeast, and anemia. These data reinforce the importance of monitoring the lipid profile in adults - due to elevated LDL levels, because of aging and changes in BMI - and the diagnosis in places with lower access by the Brazilian population. Also, Brazil has regional, cultural, and socioeconomic differences. Thus, it is essential to know these characteristics to identify and address health inequities. Moreover, this study reinforces the importance of actions for the control and prevention of dyslipidemia, such as adopting measures of healthy lifestyles, which include diet and maintenance of BMI within the recommended levels in Brazilian adults.

Acknowledgments

We are grateful to the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), for the Doctoral scholarship received by author ACMGNS, the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), for the Research Productivity scholarship received by author DCM, and the Health Surveillance Secretariat of the Ministry of Health.

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Publication Dates

  • Publication in this collection
    12 Feb 2021
  • Date of issue
    Feb 2021

History

  • Received
    02 Oct 2020
  • Accepted
    02 Oct 2020
  • Published
    04 Oct 2020
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