ABSTRACT:

Objective:

To analyze the prevalence of altered total cholesterol and fractions levels in the Brazilian population, according to biochemical data from the National Health Survey.

Methods:

A descriptive study, using data from the National Health Survey, collected between 2014 and 2015. Total cholesterol and fractions were analyzed and population prevalences of altered values according to socio-demographic variables were calculated. The cutoff points considered were: total cholesterol ≥ 200mg/dl; low-density lipoprotein LDL ≥ 130mg/dL and high-density lipoprotein HDL < 40mg/dL.

Results:

The prevalence of total cholesterol ≥200mg/dL in the population was 32.7%, and higher in women (35.1%). The prevalence of altered HDL was 31.8%, 22.0% in females and 42.8% in males. LDL ≥ 130mg/dL was found in 18.6% and was higher in women (19.9%). The population aged 45 years old and older and those with low levels of education presented a higher prevalence of altered cholesterol.

Conclusion:

Altered values of total cholesterol and fractions were frequent in the Brazilian population, especially among women, the elderly and people with low levels of education. These results may guide control and preventative actions such as healthy eating, physical activity and treatment, all of which aim to prevent coronary diseases.

Keywords:
Cholesterol; Cholesterol, HDL; Cholesterol, LDL; Cardiovascular diseases; Health surveys; Laboratory test

INTRODUCTION

Noncommunicable chronic diseases (NCDs) are the leading causes of morbidity and mortality worldwide. Among these diseases, cardiovascular diseases (CVD) stand out for their magnitude, and their association with disability and premature death¹1. World Health Organization. Global status report on noncommunicable diseases. [Internet]. 2014 [acessado em 5 dez. 2018]. Disponível em: Disponível em: http://apps.who.int/iris/bitstream/10665/148114/1/9789241564854_eng.pdf?ua=1
http://apps.who.int/iris/bitstream/10665... . In Brazil, about one third of deaths are due to CVD, and they are also the most significant cause of healthcare spending²2. Malta DC, Bernal RTI, Lima MG, Araújo SSC, Silva MMA, Freitas MIF, et al. Doenças crônicas não transmissíveis e a utilização de serviços de saúde: análise da Pesquisa Nacional de Saúde no Brasil. Rev Saúde Pública 2017; 51(Supl. 1): 1-10. http://dx.doi.org/10.1590/s1518-8787.2017051000090
http://dx.doi.org/10.1590/s1518-8787.201... .

Cholesterol is one of the most biologically important lipids. It is a precursor to steroid hormones, bile acids and vitamin D. As a component of cell membranes, cholesterol acts on its fluidity and metabolic regulation³3. Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune Neto A, et al. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017; 109(2 Supl. 1): 1-76. http://dx.doi.org/10.5935/abc.20170121
http://dx.doi.org/10.5935/abc.20170121... . Lipoproteins allow for lipid transport in the aqueous plasma and can be classified according to their density as a low-density lipoprotein (LDL) and a high-density lipoprotein (HDL)³3. Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune Neto A, et al. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017; 109(2 Supl. 1): 1-76. http://dx.doi.org/10.5935/abc.20170121
http://dx.doi.org/10.5935/abc.20170121... .

In the 1960s, studies in the Framingham Heart cohort showed evidence that elevated serum cholesterol values would increase the risk of myocardial infarction in subsequent years of the study⁴4. 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. http://dx.doi.org/10.7326/0003-4819-90-1-85
http://dx.doi.org/10.7326/0003-4819-90-1... . Later, other research confirmed associations between high cholesterol levels and increased risk for heart disease and stroke ⁵5. World Health Organization. Global Health Risks: Mortality and burden of disease attributable to selected major risks [Internet]. 2009 [acessado em 5 dez. 2018]. Disponível em: Disponível em: https://www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf
https://www.who.int/healthinfo/global_bu... ^,66. Xavier HT, Izar MC, Faria Neto JR, Assad MH, Rocha VZ, Sposito AC, et al. V Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose. Arq Bras Cardiol 2013; 101(4 Supl. 1): 1-20. http://dx.doi.org/10.5935/abc.2013S010
http://dx.doi.org/10.5935/abc.2013S010... .

The World Health Organization estimates point out that elevated serum cholesterol causes about 2.6million deaths and 29.7million years of life lost due to premature death and disability⁵5. World Health Organization. Global Health Risks: Mortality and burden of disease attributable to selected major risks [Internet]. 2009 [acessado em 5 dez. 2018]. Disponível em: Disponível em: https://www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf
https://www.who.int/healthinfo/global_bu... .

Clinical trials, meta-analyzes and clinical consensus demonstrate that dyslipidemia control is associated with important benefits in reducing cardiovascular events and mortality. The most well-known, the Adult Treatment Panel III(ATP III), in 2001, has guided countries in setting cutoff points and therapeutic targets for cholesterol levels depending on the risk of having a cardiovascular incident⁷7. 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): 2486-97. http://dx.doi.org/10.1001/jama.285.19.2486
http://dx.doi.org/10.1001/jama.285.19.24... .

Subsequent studies from different countries have developed guidelinesthat associate elevated cholesterol levels with higher risk not only of acute myocardial infarction, but also of peripheral arterial disease and stroke⁸8. Nayor M, Vasan RS. Recent Update to the Cholesterol Treatment Guidelines: A Comparison With International Guidelines. Circulation 2016; 133(18): 1795-806. https://doi.org/10.1161/CIRCULATIONAHA.116.021407
https://doi.org/10.1161/CIRCULATIONAHA.1... and point out that the best predictor of cardiac risk is the LDL⁸8. Nayor M, Vasan RS. Recent Update to the Cholesterol Treatment Guidelines: A Comparison With International Guidelines. Circulation 2016; 133(18): 1795-806. https://doi.org/10.1161/CIRCULATIONAHA.116.021407
https://doi.org/10.1161/CIRCULATIONAHA.1... .

Investigations indicate that there is a reduction in the CVD rate when plasma cholesterol is decreased, particularly LDL-cholesterol levels³3. Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune Neto A, et al. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017; 109(2 Supl. 1): 1-76. http://dx.doi.org/10.5935/abc.20170121
http://dx.doi.org/10.5935/abc.20170121... . Clinical trials with statins have shown that the greater the absolute reduction in LDL, the greater the reduction in CVD. However, there is still no consensus in the literature on the best LDL serum level needed to obtain the benefit ⁸8. Nayor M, Vasan RS. Recent Update to the Cholesterol Treatment Guidelines: A Comparison With International Guidelines. Circulation 2016; 133(18): 1795-806. https://doi.org/10.1161/CIRCULATIONAHA.116.021407
https://doi.org/10.1161/CIRCULATIONAHA.1... ^,99. Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 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(25): 2889-934. https://doi.org/10.1016/j.jacc.2013.11.002
https://doi.org/10.1016/j.jacc.2013.11.0... .

Despite the established evidence in the scientific literature regarding the association between cholesterol and coronary artery disease, population surveys that monitor the prevalence of cholesterol in Brazil are still scarce and mostly use self-reported data ¹⁰10. Pereira LPP, Sichieri PR, Segri NJ, Silva RMVG, Ferreira MG. Dislipidemia autorreferida na região Centro-Oeste do Brasil: prevalência e fatores associados. Ciênc Saúde Coletiva 2015; 20(6): 1815-24. https://doi.org/10.1590/1413-81232015206.16312014
https://doi.org/10.1590/1413-81232015206... ^,1111. Lotufo PA, Santos RD, Sposito AC, Bertolami M, Rocha-Faria Neto J, Izar MC, et al. Prevalência de Diagnóstico Médico de Colesterol Alto Autorreferido na População Brasileira: Análise da Pesquisa Nacional de Saúde, 2013. Arq Bras Cardiol 2017; 108(5): 411-6. http://dx.doi.org/10.5935/abc.20170055
http://dx.doi.org/10.5935/abc.20170055... . Theresults of the Brazilian Longitudinal Study of Adult Health (Estudo Longitudinal de Saúde do Adulto - ELSA Brazil), conducted among employees of federal universities around the country, showed a higher prevalence of altered LDL in men, black people, the elderly and people with low levels of education¹²12. Lotufo PA, Santos RD, Figueiredo RM, Pereira AC, Mill JG, Alvim SM, et al. Prevalence, awareness, treatment and control of high low-density lipoprotein cholesterol in Brazil: Baseline of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). J Clin Lipid 2016; 10(3): 568-76. https://doi.org/10.1016/j.jacl.2015.12.029
https://doi.org/10.1016/j.jacl.2015.12.0... .

In 2014 and 2015, the National Health Survey (Pesquisa Nacional de Saúde - PNS) collected biological material that included measurements of cholesterol and fractions ¹³13. Souza-Júnior PRB, Freitas MPS, Antonaci GA, Szwarcwald CL. Desenho da amostra da Pesquisa Nacional de Saúde 2013. Epidemiol Serv Saúde 2015; 24(2): 207-16. http://dx.doi.org/10.5123/S1679-49742015000200003
http://dx.doi.org/10.5123/S1679-49742015... ^,1414. Szwarcwald CL, Malta DC, Azevedo C, Souza Júnior PRB, Rozemberg LG. Exames laboratoriais da pesquisa nacional de saúde: Metodologia de amostragem, coleta, e análise dos dados. Rev Bras Epidemiol 2019. (no prelo)., enabling, for the first time, national analyzes on the distribution of altered cholesterol in the Brazilian population. Therefore, the aim of this study was to analyze the prevalence of altered total cholesterol levels and fractions in the Brazilian population, according to PNS biochemical data.

METHODS

The present study was a descriptive, epidemiological survey, and used data from PNS laboratory exams from 2014 to 2015. PNS is a national and home-based survey conducted by the Brazilian Institute of Geography and Statistics, in partnership with the Ministry of Health. It uses three-stage probabilistic samples, and interview records were obtained from 64,348 households. More methodological details can be read in other publications ¹³13. Souza-Júnior PRB, Freitas MPS, Antonaci GA, Szwarcwald CL. Desenho da amostra da Pesquisa Nacional de Saúde 2013. Epidemiol Serv Saúde 2015; 24(2): 207-16. http://dx.doi.org/10.5123/S1679-49742015000200003
http://dx.doi.org/10.5123/S1679-49742015... ^,1414. Szwarcwald CL, Malta DC, Azevedo C, Souza Júnior PRB, Rozemberg LG. Exames laboratoriais da pesquisa nacional de saúde: Metodologia de amostragem, coleta, e análise dos dados. Rev Bras Epidemiol 2019. (no prelo)..

The laboratory subsample consisted of 8,952 people, and 418 samples were excluded due to having enough material, hemolysis, sample loss and other reasons. Thus, there was a total of 8,534 exams for the current analysis. The study adopted post-stratification weights according to gender, age, education and region, aiming to establish estimates for the Brazilian adult population¹⁴14. Szwarcwald CL, Malta DC, Azevedo C, Souza Júnior PRB, Rozemberg LG. Exames laboratoriais da pesquisa nacional de saúde: Metodologia de amostragem, coleta, e análise dos dados. Rev Bras Epidemiol 2019. (no prelo)..

The research participants signed an informed consent form, and then peripheral blood was collected at any time of the day. It is also worth noting that the study followed the protocol that dispenses fasting for cholesterol measurement³3. Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune Neto A, et al. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017; 109(2 Supl. 1): 1-76. http://dx.doi.org/10.5935/abc.20170121
http://dx.doi.org/10.5935/abc.20170121... .

Total cholesterol (TC), LDL and HDL were collected in gel tubes. The next steps included waiting for 30minutes for clot retraction and then centrifuging and forwarding the samples, which were refrigerated at 2 to 8ºC. The temperature was controlled during each of the steps. These parameters were measured by an automated enzymatic/colorimetric method.

The prevalences for each category of TC levels and fractions were described by the following intervals:

The average of cholesterol levels and the TC/HDL ratio were calculated for the general population and according to age groups (18 to 29 years; 30 to 44 years; 45 to 59 years; 60 years or older).

Dichotomous analysis was performed (having altered cholesterol or not), and the population prevalence of altered TC and fractions were calculated, considering the following cutoff points: TC ≥ 200mg/dL; LDL ≥ 130mg/dL and HDL levels < 40mg/dL, in accordance with the clinical treatment parameters recommended by the ATPIII⁷7. 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): 2486-97. http://dx.doi.org/10.1001/jama.285.19.2486
http://dx.doi.org/10.1001/jama.285.19.24... . Prevalence was stratified by gender, age group (18-29 years; 30-44 years; 45-59 years; 60 years or older), education (0 to 8; 9 to 11, 12 years of schooling or more), race/color (white, dark-skinned black, light-skinned black and others) and regions of the country (North, Northeast, South, Southeast and Midwest).

To estimate differences between strata, Pearson’s χ² test was used. The data were analyzed using the Data Analysis and Statistical Software (Stata), version 14, based on the set of commands for analyzing data from surveys with a complex sample (survey).

The PNS was approved by the National Research Ethics Commission (Comissão Nacional de Ética em Pesquisa - CONEP) of the National Health Council (Conselho Nacional de Saúde - CNS), of the Ministry of Health. Adult participation in the research was voluntary and confidentiality of their information was guaranteed. Subjects selected for the research provided informed consent for all of the research procedures, including interviewing and blood and urine collection.

RESULTS

The mean TC in the population was 185mg/dL. It was 181.7mg/dL in males and 198.7mg/dL in females. The average was higher with the increase in age - in the age group 18 to 29 years, for example, it was 169.4mg/dL reaching higher averages between 45 and 59 years of age.

Regarding HDL, the population average was 46.5mg/dL - 43mg/dL for males and 49.6mg/dL for females. In general, in all age groups, the HDL values were similar, around 46.5mg/dL.

Regarding LDL, the population average was 104.7mg/dL - 102.9mg/dL in males and 106.2mg/dL in females. In the age group of 18-29 years, the average LDL was 93.1mg/dL. Higher values were observed between 40 and 59 years old (112.2mg/dL).

The TC/HDL ratio was high in the total population (4.3) in both men (4.6) and women (4.0). It was less than 4 only for the total population aged 18 to 29 years and women between 18 and 44 years old (Table 1).

TC values for the total population were: <160mg/dL (26.3%), ≥ 160 to <200mg/dL (41%), ≥200 to <220mg/dL (15.4%), ≥ 220 to <280 mg/dL (15.8%) and ≥ 280mg/dL (1.5%). ForHDL, the values were: <25mg / dL (2%), ≥ 25 to <30mg / dL (4.8%), ≥ 30 to <40mg/dL (25%), ≥ 40 to < 50mg/dL (33.2%) and ≥ 50mg/dL (35.1%). LDL values were: <100mg/dL (45.7%), ≥ 100 to <130mg/dL (35.7%), ≥ 130 to <160mg/dL (14.1%), ≥ 160 to <190mg/dL(3.8%) and ≥ 190mg/dL (0.7%). The TC/HDL ratio > 4 was found in 50% of the total population (Table 2).

The prevalence in the adult population of TC ≥ 200mg/dL was 32.7%, and was higher in women (35.1%). The prevalence of high cholesterol was higher among those aged over 45 years and lower among those with higher levels of education (p <0.001) (Table 3).

The prevalence of HDL lower than 40mg/dL in the adult population was 31.8%, and was approximately twice as high in males (42.8%) compared to females (22%). Altered HDL values were lower in the population with higher levels of education. Regarding the regions, altered HDL was less frequent in the Southern Region for the general population and in both genders (Table 4).

The prevalence of LDL ≥ 130mg/dL was 18.6%, higher in women (19.9%) and among participants aged 45 and over (p<0.001). Regarding education levels, it was more frequent in the range of zero to eight years of education for the total population (21.5%) and among women (24.9%) (p <0.001) (Table 5).

DISCUSSION

The collection of biological material performed in the PNS and the inclusion of cholesterol and fractions represent a major advance for Brazil. For the first time, this study traces the biochemical profile of clinical or preclinical conditions of TC, LDL, HDL and TC/HDL levels in the Brazilian population. Thus, PNS laboratory data may support the identification of cardiovascular risk in the population⁹9. Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 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(25): 2889-934. https://doi.org/10.1016/j.jacc.2013.11.002
https://doi.org/10.1016/j.jacc.2013.11.0... .

According to the results, over one third of the adult population had a high TC (above 200mg/dL). It was higher in women than in men, higher in the older population and lower in the population that had higher levels of education. HDL less than 40mg/dL affected one third of adults. The TC/HDL ratio ≥ 4 was also present in half of the Brazilian population. LDL above 130mg/dL reached one fifth of the adult population.

As in Brazil, population-based studies conducted in some countries have shown a high prevalence of dyslipidemia. In China, research with cut-off points based on Chinese guidelines considering LDL levels ≥ 130mg/dL and similar HDL levels for men and women found 33.5% TC, 0.6% LDL and 8.8% for altered HDL¹⁵15. Zhang FL, Xing YQ, Wu YH, Liu HY, Luo Y, Sun MS, et al. The prevalence, awareness, treatment and control of dyslipidemia in northeast China: a population-based cross-sectional survey. Lipids Health Dis 2017; 16(1): 61. http://dx.doi.org/10.1186/s12944-017-0453-2
http://dx.doi.org/10.1186/s12944-017-045... . In Turkey, using the ATP III⁷7. 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): 2486-97. http://dx.doi.org/10.1001/jama.285.19.2486
http://dx.doi.org/10.1001/jama.285.19.24... cutoff points, 43% of people had TC> 200mg/dL. The prevalence of elevated TC, LDL-cholesterol and triglyceride (TG) levels increased with age¹⁶16. Bayram F, Kocer D, Gundogan K, Kaya A, Demir O, Coskun R, et al. Prevalence of dyslipidemia and associated risk factores in Turkish adults. J Clin Lipidol. 2014; 8(2): 206-16. http://dx.doi.org/10.1016/j.jacl.2013.12.011
http://dx.doi.org/10.1016/j.jacl.2013.12... .

In Brazil, studies conducted in the state of São Paulo followed the ATP III⁷7. 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): 2486-97. http://dx.doi.org/10.1001/jama.285.19.2486
http://dx.doi.org/10.1001/jama.285.19.24... recommendations for defining the reference value the cutoff points for dyslipidemia. It was reported that dyslipidemia affected 61.9% of the population, especially those older than 40 years of age, in the city of Ribeirão Preto¹⁷17. De Moraes AS, Checchio MV, De 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. http://dx.doi.org/10.1590/S0004-27302013000900004
http://dx.doi.org/10.1590/S0004-27302013... . In São Paulo, desirable levels of TC were similar between women (64.7%) and men (64.9%). ForLDL, approximately 20% of men and women had levels between130 and 159mg/dL.Levelswere considered to be high (≥160mg/dL) in 11.8% of men and 13.6% of women. Desirable levels (40mg/dL) of ­HDL-cholesterol were found in 68% of women and 54.3% of men¹⁸18. De Fornés NS, Martins IS, Velásquez-Meléndez G, Latorre MRDO. Escores de Consumo alimentar e níveis lipêmicos em população de São Paulo, Brasil. Rev Saúde Pública 2002; 36(1): 12-8. http://dx.doi.org/10.1590/S0034-89102002000100003
http://dx.doi.org/10.1590/S0034-89102002... .

The biochemical data of the PNS differ from the self-reported data found in the Survey of Risk Factors and Protection for Chronic Diseases by Telephone Survey (Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico - Vigitel), which identified 22.6% of the adult population in Brazilian capital cities with high cholesterol¹⁹19. Brasil. Ministério da Saúde. Vigitel Brasil 2016. Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico [Internet]. Brasília: Ministério da Saúde; 2017 [acessado em 5 dez. 2018]. 160 p. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/vigitel_brasil_2016_fatores_risco.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... . In the PNS, using the self-reported questionnaire, the prevalence of high cholesterol was even lower (12.5%)¹¹11. Lotufo PA, Santos RD, Sposito AC, Bertolami M, Rocha-Faria Neto J, Izar MC, et al. Prevalência de Diagnóstico Médico de Colesterol Alto Autorreferido na População Brasileira: Análise da Pesquisa Nacional de Saúde, 2013. Arq Bras Cardiol 2017; 108(5): 411-6. http://dx.doi.org/10.5935/abc.20170055
http://dx.doi.org/10.5935/abc.20170055... . In addition, the PNS also measured the population who said they had never measured their cholesterol or TG (14.3%)¹¹11. Lotufo PA, Santos RD, Sposito AC, Bertolami M, Rocha-Faria Neto J, Izar MC, et al. Prevalência de Diagnóstico Médico de Colesterol Alto Autorreferido na População Brasileira: Análise da Pesquisa Nacional de Saúde, 2013. Arq Bras Cardiol 2017; 108(5): 411-6. http://dx.doi.org/10.5935/abc.20170055
http://dx.doi.org/10.5935/abc.20170055... . Therefore, the biochemical data described here identified higher prevalences, about one third of the population, which may partly reflect the lack of access to the tests¹¹11. Lotufo PA, Santos RD, Sposito AC, Bertolami M, Rocha-Faria Neto J, Izar MC, et al. Prevalência de Diagnóstico Médico de Colesterol Alto Autorreferido na População Brasileira: Análise da Pesquisa Nacional de Saúde, 2013. Arq Bras Cardiol 2017; 108(5): 411-6. http://dx.doi.org/10.5935/abc.20170055
http://dx.doi.org/10.5935/abc.20170055... .

Regarding gender, self-reported diagnostic estimates from the PNS coincide with laboratory test data presented in this study. The diagnosis was more frequent in women (15.1%) than in men (9.7%)¹¹11. Lotufo PA, Santos RD, Sposito AC, Bertolami M, Rocha-Faria Neto J, Izar MC, et al. Prevalência de Diagnóstico Médico de Colesterol Alto Autorreferido na População Brasileira: Análise da Pesquisa Nacional de Saúde, 2013. Arq Bras Cardiol 2017; 108(5): 411-6. http://dx.doi.org/10.5935/abc.20170055
http://dx.doi.org/10.5935/abc.20170055... . Similar results were also found in Vigitel, with higher prevalences among women (25.9%) than among men (18.8%)¹⁹19. Brasil. Ministério da Saúde. Vigitel Brasil 2016. Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico [Internet]. Brasília: Ministério da Saúde; 2017 [acessado em 5 dez. 2018]. 160 p. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/vigitel_brasil_2016_fatores_risco.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... .

The study found a higher prevalence among women, which is well documented in the literature ³3. Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune Neto A, et al. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017; 109(2 Supl. 1): 1-76. http://dx.doi.org/10.5935/abc.20170121
http://dx.doi.org/10.5935/abc.20170121... ^,2020. Phan BAP, Toth PP. Dyslipidemia in women: etiology and management. Int J Womens Health 2014; 6: 185-94. http://dx.doi.org/10.2147/IJWH.S38133
http://dx.doi.org/10.2147/IJWH.S38133... ^,2121. Edmunds E, Lip GYH. Cardiovascular risk in women: the cardiologist’s perspective. Q J Med 2000; 93(3): 135-45. https://doi.org/10.1093/qjmed/93.3.135
https://doi.org/10.1093/qjmed/93.3.135... . The high prevalence of dyslipidemia in women is described during menopause²⁰20. Phan BAP, Toth PP. Dyslipidemia in women: etiology and management. Int J Womens Health 2014; 6: 185-94. http://dx.doi.org/10.2147/IJWH.S38133
http://dx.doi.org/10.2147/IJWH.S38133... , pregnancy and the use of birth control pills, corticosteroids and anabolic steroids, probably due to the reduction in estrogen²¹21. Edmunds E, Lip GYH. Cardiovascular risk in women: the cardiologist’s perspective. Q J Med 2000; 93(3): 135-45. https://doi.org/10.1093/qjmed/93.3.135
https://doi.org/10.1093/qjmed/93.3.135... . Gestational hypertriglyceridemia occurs in order to meet increased maternal energy demands as a precursor to hormones for the placenta, and to provide cholesterol and fatty acids to the fetus³3. Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune Neto A, et al. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017; 109(2 Supl. 1): 1-76. http://dx.doi.org/10.5935/abc.20170121
http://dx.doi.org/10.5935/abc.20170121... .

The current study shows that TC and LDL are higher as age increases, with a slight decrease in the elderly population over 60 years of age. Lowering cholesterol in the elderly can be explained by loss of weight, improved eating habits, or comorbidities that may worsen food absorption²²22. Francisco PMSB, Segri NJ, Borim FSA, Malta DC. Prevalência simultânea de hipertensão e diabetes em idosos brasileiros: desigualdades individuais e contextuais. Ciênc Saúde Colet 2018; 23(11): 3829-40. http://dx.doi.org/10.1590/1413-812320182311.29662016
http://dx.doi.org/10.1590/1413-812320182... .

The Southern Region presented the lowest proportion of altered HDL, with no difference in relation to the regions for TC and LDL. PNS studies with self-reported data showed a high prevalence among residents of the South and Southeast macro-regions of the country, which could be explained in part by greater access to health services and diagnostic opportunities in these areas¹¹11. Lotufo PA, Santos RD, Sposito AC, Bertolami M, Rocha-Faria Neto J, Izar MC, et al. Prevalência de Diagnóstico Médico de Colesterol Alto Autorreferido na População Brasileira: Análise da Pesquisa Nacional de Saúde, 2013. Arq Bras Cardiol 2017; 108(5): 411-6. http://dx.doi.org/10.5935/abc.20170055
http://dx.doi.org/10.5935/abc.20170055... .

The study states that altered cholesterol is less frequent in the more educated population, which was also found in research with self-reported measures¹¹11. Lotufo PA, Santos RD, Sposito AC, Bertolami M, Rocha-Faria Neto J, Izar MC, et al. Prevalência de Diagnóstico Médico de Colesterol Alto Autorreferido na População Brasileira: Análise da Pesquisa Nacional de Saúde, 2013. Arq Bras Cardiol 2017; 108(5): 411-6. http://dx.doi.org/10.5935/abc.20170055
http://dx.doi.org/10.5935/abc.20170055... . Data from Vigitel indicate that the diagnosis of high cholesterol was more frequent in the low-educated population, ranging from 29 (zero to eight years of study) to 19.4% (12 years or more)¹⁹19. Brasil. Ministério da Saúde. Vigitel Brasil 2016. Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico [Internet]. Brasília: Ministério da Saúde; 2017 [acessado em 5 dez. 2018]. 160 p. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/vigitel_brasil_2016_fatores_risco.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... , which may be explained by the higher access to prevention, promotion and care practices in the population with higher levels of education and income²³23. 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 Saúde Pública 2017; 51(Supl. 1): 3s. http://dx.doi.org/10.1590/s1518-8787.2017051000074
http://dx.doi.org/10.1590/s1518-8787.201... .

It is worth noting that half of the adult population has a TC/HDL ratio greater than 4. Epidemiological studies, including Framingham, show that the TC/HDL ratio is inversely associated with the incidence of coronary atherosclerotic disease²⁴24. Leança CC, Passarelli M, Nakandakare ER, Quintão ECR. HDL: o yin-yang da doença cardiovascular. Arq Bras Endocrinol Metab 2010; 54(9): 777-84. http://dx.doi.org/10.1590/S0004-27302010000900002
http://dx.doi.org/10.1590/S0004-27302010... , in this regard high prevalence rates of a TC/HDL ratio greater than 4 suggest possible future cardiovascular events²⁴24. Leança CC, Passarelli M, Nakandakare ER, Quintão ECR. HDL: o yin-yang da doença cardiovascular. Arq Bras Endocrinol Metab 2010; 54(9): 777-84. http://dx.doi.org/10.1590/S0004-27302010000900002
http://dx.doi.org/10.1590/S0004-27302010... . Theratio, in this study, showed a high prevalence and therefore the importance of monitoring TC levels and fractions as a means of preventing cardiovascular disease³3. Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune Neto A, et al. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017; 109(2 Supl. 1): 1-76. http://dx.doi.org/10.5935/abc.20170121
http://dx.doi.org/10.5935/abc.20170121... . The 10% reduction in serum cholesterol in 40-year-old men was pertinent to a 50% decrease in cardiovascular disease over a five-year period and by 20% in 70-year-old men²⁵25. Kuwabara M, Motoki Y, Ichiura K, Fujii M, Inomata C, Sato H, et al. Association between toothbrushing and risk factors for cardiovascular disease: a large-scale, cross-sectional Japanese study. BMJ Open 2016; 6(1): e009870. http://doi.org/10.1136/bmjopen-2015-009870
http://doi.org/10.1136/bmjopen-2015-0098... ^,2626. Law MR, Wald NJ, Thompson SG. By how much and how quickly does reduction in serum cholesterol concentration lower risk of ischaemic heart disease? BMJ 1994; 308(6925): 367-72. https://dx.doi.org/10.1136%2Fbmj.308.6925.367
https://dx.doi.org/10.1136%2Fbmj.308.692... . Further studies showed a significant decrease in mortality from statin use⁸8. Nayor M, Vasan RS. Recent Update to the Cholesterol Treatment Guidelines: A Comparison With International Guidelines. Circulation 2016; 133(18): 1795-806. https://doi.org/10.1161/CIRCULATIONAHA.116.021407
https://doi.org/10.1161/CIRCULATIONAHA.1... .

Investigations reveal that, in addition to statin treatments, diet and regular physical activity can also contribute to cholesterol reduction in the elderly, as well as for all age groups ³3. Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune Neto A, et al. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017; 109(2 Supl. 1): 1-76. http://dx.doi.org/10.5935/abc.20170121
http://dx.doi.org/10.5935/abc.20170121... ^,99. Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 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(25): 2889-934. https://doi.org/10.1016/j.jacc.2013.11.002
https://doi.org/10.1016/j.jacc.2013.11.0... . Physical exercise plays an important role in preventing and controlling cardiovascular disease ³3. Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune Neto A, et al. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017; 109(2 Supl. 1): 1-76. http://dx.doi.org/10.5935/abc.20170121
http://dx.doi.org/10.5935/abc.20170121... ^,2727. Silva RC, Diniz MFHS, Alvim S, Vidigal PG, Fedeli LMG, Barreto SM. Atividade Física e Perfil Lipídico no Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil). Arq Bras Cardiol 2016; 107(1): 10-9. http://dx.doi.org/10.5935/abc.20160091
http://dx.doi.org/10.5935/abc.20160091... .

The data collected from the PNS also help in defining specific reference values for the Brazilian population and may influence new definitions of cardiovascular risk³3. Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune Neto A, et al. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017; 109(2 Supl. 1): 1-76. http://dx.doi.org/10.5935/abc.20170121
http://dx.doi.org/10.5935/abc.20170121... ^,88. Nayor M, Vasan RS. Recent Update to the Cholesterol Treatment Guidelines: A Comparison With International Guidelines. Circulation 2016; 133(18): 1795-806. https://doi.org/10.1161/CIRCULATIONAHA.116.021407
https://doi.org/10.1161/CIRCULATIONAHA.1... , which should be estimated based on the joint analysis of characteristics that increase the chance of an individual developing the condition, such as age, smoking, high blood pressure, diabetes, previous cardiovascular events, among others. Thus, future PNS studies could define and prioritize populations who are at risk for cardiovascular diseases and help support prevention, monitoring and treatment.

Among the limitations of the study are laboratory collection losses, however the use of sample weights allowed for adequate population estimates, and data generalization is relatively safe for national and macro-region projections ¹⁵15. Zhang FL, Xing YQ, Wu YH, Liu HY, Luo Y, Sun MS, et al. The prevalence, awareness, treatment and control of dyslipidemia in northeast China: a population-based cross-sectional survey. Lipids Health Dis 2017; 16(1): 61. http://dx.doi.org/10.1186/s12944-017-0453-2
http://dx.doi.org/10.1186/s12944-017-045... ^,1616. Bayram F, Kocer D, Gundogan K, Kaya A, Demir O, Coskun R, et al. Prevalence of dyslipidemia and associated risk factores in Turkish adults. J Clin Lipidol. 2014; 8(2): 206-16. http://dx.doi.org/10.1016/j.jacl.2013.12.011
http://dx.doi.org/10.1016/j.jacl.2013.12... . The cutoff points adopted were defined according to protocol³3. Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune Neto A, et al. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017; 109(2 Supl. 1): 1-76. http://dx.doi.org/10.5935/abc.20170121
http://dx.doi.org/10.5935/abc.20170121... and may vary according to the consensus review.

CONCLUSION

For the first time in Brazil, this study shows the prevalence of of altered serum TC, LDL and HDL levels points out that about one third of adults have cholesterol alterations. These results may guide control and preventative actions, such as healthy eating, physical activity and treatment of coronary diseases, which represent the leading cause of death in Brazil and worldwide. Furthermore, they can guide routine monitoring and pharmacological measures when indicated.

References

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