Prevalence and factors associated with self-reported diagnosis of high cholesterol in the Brazilian adult population: National Health Survey 2019

Ana Carolina Micheletti Gomide Nogueira de Sá Crizian Saar Gomes Alexandra Dias Moreira Gustavo Velasquez-Melendez Deborah Carvalho Malta About the authors

Abstract

Objective:

To estimate the prevalence of self-reported high cholesterol diagnosis and to analyze the factors associated with the prevalence in the Brazilian adult population.

Methods:

Cross-sectional study, using data from the 2019 National Health Survey. The diagnosis of high cholesterol was self-reported. Poisson regression models yielded prevalence ratios (PR) and 95% confidence intervals (95%CI).

Results:

In the 88,531 adults, the prevalence of high cholesterol was 14.6%. Positively associated: female sex (PR = 1.44; 95%CI 1.40;1.52), age ≥ 60 years (PR = 3.80; 95%CI 3.06;4.71), health insurance (PR = 1.33; 95%CI 1.24;1.42), poor or very poor self-rated health (PR = 1.75; 95%CI 1.60;1.90), hypertension (PR = 1.78; 95%CI 1.68;-1.89), diabetes (RP = 1.54; 95%CI 1.45;1.65), renal failure (PR = 1.33; 95%CI 1.15;1.53), obesity (PR = 1.27; 95%CI 1.18;1.36), former smoker (PR = 1.13; 95%CI 1.07;1.20), alcohol abuse (PR = 1.11; 95%CI 1.01;1.21), physically active during leisure time (PR = 1.22; 95%CI 1.15;1.30).

Conclusion:

High cholesterol was associated with sociodemographic characteristics, health condition and lifestyle.

Keywords:
Dyslipidemia; Hypercholesterolemia; Cholesterol; Health Surveys; Risk Factors; Cross-Sectional Studies

Study contributions

Main results

In Brazil, 14.6% of adults reported having high cholesterol, and were factors associated being sex female, ageing, socioeconomic status, worst self-assessment of health, chronic diseases, overweight/obesity, race/ Black/Brown skin color, behavioral habits and lifestyles.

Implications for services

The results of this study can provide support for health promotion public policies, for the development of clinical protocols within the scope of the Brazilian National Health System (SUS), and for supporting actions related to the prevention and reduction of dyslipidemia and cardiovascular diseases.

Perspectives

The high prevalence of self-reported high cholesterol in the Brazilian adult population, identified in the 2019 National Health Survey, implies that monitoring dyslipidemia is crucial for the prevention of cardiovascular diseases in the country.

Introdution

Dyslipidemia is characterized by abnormal concentrations of lipid circulating in the bloodstream, such as total cholesterol, triglycerides, low density lipoprotein (LDL), or high-density lipoprotein (HDL).11. Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune A Neto, et al. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017 Jul;109(2 Supl 1):1-76. doi: 10.5935/abc.20170121.
https://doi.org/10.5935/abc.20170121...

Elevations in the levels of total cholesterol, triglycerides, and mainly LDL, increase the risks of cardiovascular and cerebrovascular diseases.22. Kopin L, Lowenstein C. Dyslipidemia. Ann Intern Med 2017;167(11):ITC81-ITC96. doi: 10.7326/AITC201712050.
https://doi.org/10.7326/AITC201712050...
According to the last report on high levels of serum cholesterol issued by the World Health Organization (WHO), published in 2009, it caused 2.6 million deaths (4.5% of the total) and 29.7 million disability adjusted life years (DALYs) throughout the world.33. World Health Organization (WHO). Global Health Risks: mortality and burden of disease attributable to selected major risks. WHO: Geneva; 2009. In middle-income countries it was responsible for 1.3 million deaths (5.2% of the total), and 14 million DALYs (2.5% of the total).33. World Health Organization (WHO). Global Health Risks: mortality and burden of disease attributable to selected major risks. WHO: Geneva; 2009. Worldwide, high levels of LDL caused, in 2019, 4,396,983 deaths (7.8% of the total) and 98,618,020 DALYs (3.9% of the total)44. Institute for Health Metrics and Evaluation. GBD Compare Data Visualization. Seattle: IHME; 2019. and, in Brazil, 99,375 deaths (7.0% of the total) and 2,363,140 DALYs (3.6% of the total).44. Institute for Health Metrics and Evaluation. GBD Compare Data Visualization. Seattle: IHME; 2019.

Globally, adult populations are exposed to illnesses and health problems, due to high levels of total cholesterol and fractions,55. Sá ACMGN, Machado ÍE, Bernal RTI, Malta DC. Factors associated with high LDL-Cholesterol in the Brazilian adult population: National Health Survey. Cien Saude Colet 2021;26(2):541-553. doi: 10.1590/1413-81232021262.37102020.
https://doi.org/10.1590/1413-81232021262...
as a consequence of unhealthy lifestyles, chronic diseases or genetic factors.11. Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune A Neto, et al. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017 Jul;109(2 Supl 1):1-76. doi: 10.5935/abc.20170121.
https://doi.org/10.5935/abc.20170121...

Regarding the factors associated to dyslipidemia, the literature documents sociodemographic characteristics,55. Sá ACMGN, Machado ÍE, Bernal RTI, Malta DC. Factors associated with high LDL-Cholesterol in the Brazilian adult population: National Health Survey. Cien Saude Colet 2021;26(2):541-553. doi: 10.1590/1413-81232021262.37102020.
https://doi.org/10.1590/1413-81232021262...

6. 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. doi: 10.1590/S0004-27302013000900004.
https://doi.org/10.1590/S0004-2730201300...

7. 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. doi: 10.1590/1413-81232015206.16312014.
https://doi.org/10.1590/1413-81232015206...
-88. 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. doi: 10.1371/journal.pone.0017326.
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inadequate lifestyles,66. 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. doi: 10.1590/S0004-27302013000900004.
https://doi.org/10.1590/S0004-2730201300...

7. 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. doi: 10.1590/1413-81232015206.16312014.
https://doi.org/10.1590/1413-81232015206...
-88. 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. doi: 10.1371/journal.pone.0017326.
https://doi.org/10.1371/journal.pone.001...
altered body mass index (BMI),55. Sá ACMGN, Machado ÍE, Bernal RTI, Malta DC. Factors associated with high LDL-Cholesterol in the Brazilian adult population: National Health Survey. Cien Saude Colet 2021;26(2):541-553. doi: 10.1590/1413-81232021262.37102020.
https://doi.org/10.1590/1413-81232021262...
,77. 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. doi: 10.1590/1413-81232015206.16312014.
https://doi.org/10.1590/1413-81232015206...
,88. 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. doi: 10.1371/journal.pone.0017326.
https://doi.org/10.1371/journal.pone.001...
,99. Bayram F, Kocer D, Gundogan K, Kaya A, Demir O, Coskun R, et al. Prevalence of dyslipidemia and associated risk factors in Turkish adults. J Clin Lipidol 2014;8(2):206-216. doi: 10.1016/j.jacl.2013.12.011.
https://doi.org/10.1016/j.jacl.2013.12.0...
noncommunicable chronic diseases (NCDs), 55. Sá ACMGN, Machado ÍE, Bernal RTI, Malta DC. Factors associated with high LDL-Cholesterol in the Brazilian adult population: National Health Survey. Cien Saude Colet 2021;26(2):541-553. doi: 10.1590/1413-81232021262.37102020.
https://doi.org/10.1590/1413-81232021262...
,77. 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. doi: 10.1590/1413-81232015206.16312014.
https://doi.org/10.1590/1413-81232015206...

8. 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. doi: 10.1371/journal.pone.0017326.
https://doi.org/10.1371/journal.pone.001...
-99. Bayram F, Kocer D, Gundogan K, Kaya A, Demir O, Coskun R, et al. Prevalence of dyslipidemia and associated risk factors in Turkish adults. J Clin Lipidol 2014;8(2):206-216. doi: 10.1016/j.jacl.2013.12.011.
https://doi.org/10.1016/j.jacl.2013.12.0...
and poor self-rated health status.77. 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. doi: 10.1590/1413-81232015206.16312014.
https://doi.org/10.1590/1413-81232015206...

Considering the negative impacts of dyslipidemia on cardiovascular health, this study takes a step forward by identifying, for the first time, the prevalence of self-reported diagnosis of high cholesterol and its associated factors in the adult population, using data from the National Health Survey (Pesquisa Nacional de Saúde - PNS), 2019 edition. The last PNS that collected self-reported data was conducted in 201377. 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. doi: 10.1590/1413-81232015206.16312014.
https://doi.org/10.1590/1413-81232015206...
,1010. Lotufo PA, Santos RD, Sposito AC, Bertolami M, Rocha-Faria J Neto, Izar MC, et al. Self-Reported High-Cholesterol Prevalence in the Brazilian Population: analysis of the 2013 National Health Survey. Arq Bras Cardiol 2017 May;108(5):411-416. doi: 10.5935/abc.20170055.
https://doi.org/10.5935/abc.20170055...
and the prevalence of high cholesterol in the Brazilian adult population was 12.5%.1010. Lotufo PA, Santos RD, Sposito AC, Bertolami M, Rocha-Faria J Neto, Izar MC, et al. Self-Reported High-Cholesterol Prevalence in the Brazilian Population: analysis of the 2013 National Health Survey. Arq Bras Cardiol 2017 May;108(5):411-416. doi: 10.5935/abc.20170055.
https://doi.org/10.5935/abc.20170055...
Furthermore, in view of the higher prevalence of dyslipidemia due to alterations in the lipid profile according to the 2014 and 2015 PNS’s laboratory tests database (32.7% high total cholesterol,1111. Malta DC, Szwarcwald CL, Machado ÍE, Pereira CA, Figueiredo AW, Sá ACMGN, et al. Prevalence of altered total cholesterol and fractions in the Brazilian adult population: National Health Survey. Rev Bras Epidemiol 2019 Oct 7;22(Suppl 02):E190005.SUPL.2. doi: 10.1590/1980-549720190005.supl.2.
https://doi.org/10.1590/1980-54972019000...
18.6% high LDL55. Sá ACMGN, Machado ÍE, Bernal RTI, Malta DC. Factors associated with high LDL-Cholesterol in the Brazilian adult population: National Health Survey. Cien Saude Colet 2021;26(2):541-553. doi: 10.1590/1413-81232021262.37102020.
https://doi.org/10.1590/1413-81232021262...
,1111. Malta DC, Szwarcwald CL, Machado ÍE, Pereira CA, Figueiredo AW, Sá ACMGN, et al. Prevalence of altered total cholesterol and fractions in the Brazilian adult population: National Health Survey. Rev Bras Epidemiol 2019 Oct 7;22(Suppl 02):E190005.SUPL.2. doi: 10.1590/1980-549720190005.supl.2.
https://doi.org/10.1590/1980-54972019000...
and 31.8% low HDL55. Sá ACMGN, Machado ÍE, Bernal RTI, Malta DC. Factors associated with high LDL-Cholesterol in the Brazilian adult population: National Health Survey. Cien Saude Colet 2021;26(2):541-553. doi: 10.1590/1413-81232021262.37102020.
https://doi.org/10.1590/1413-81232021262...
,1111. Malta DC, Szwarcwald CL, Machado ÍE, Pereira CA, Figueiredo AW, Sá ACMGN, et al. Prevalence of altered total cholesterol and fractions in the Brazilian adult population: National Health Survey. Rev Bras Epidemiol 2019 Oct 7;22(Suppl 02):E190005.SUPL.2. doi: 10.1590/1980-549720190005.supl.2.
https://doi.org/10.1590/1980-54972019000...
, it is important to understand the present scenario of this condition in the country. The results can contribute to supporting public policies and control measures and, as a result, to the prevention of dyslipidemia.

Thus, the objective of this study was to estimate the prevalence of self-reported high cholesterol diagnosis and to analyze the factors associated with its prevalence in the Brazilian adult population.

Methods

Study design

This was a cross-sectional study that used data from the 2019 PNS, which was conducted between August 2019 and March 2020.

Context

The PNS is a national-level, population-based household health survey conducted by the Brazilian Institute of Geography and Statistics (IBGE), in partnership with the Ministry of Health. The PNS uses a probability sample design and three-stage stratification: censor tracts, households and residents,1212. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. Pesquisa Nacional de Saúde 2019: histórico, métodos e perspectivas. Epidemiol Serv Saúde 2020;29(5):e2020315. doi: 10.1590/S167949742020000500004.
https://doi.org/10.1590/S167949742020000...
with the last two being selected by simple random sampling.1212. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. Pesquisa Nacional de Saúde 2019: histórico, métodos e perspectivas. Epidemiol Serv Saúde 2020;29(5):e2020315. doi: 10.1590/S167949742020000500004.
https://doi.org/10.1590/S167949742020000...
,1313. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde 2019: percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal. Brasil e grandes regiões [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística, 2020 [acesso 16 jun. 2021]. 113 p. Disponível em: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101764.pdf
https://biblioteca.ibge.gov.br/visualiza...
In the 2019 PNS edition, in the third stage of selection, one resident from each household was randomly selected among those aged 15 years and older, based on a list of household residents obtained at the time of the interview.1212. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. Pesquisa Nacional de Saúde 2019: histórico, métodos e perspectivas. Epidemiol Serv Saúde 2020;29(5):e2020315. doi: 10.1590/S167949742020000500004.
https://doi.org/10.1590/S167949742020000...
,1313. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde 2019: percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal. Brasil e grandes regiões [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística, 2020 [acesso 16 jun. 2021]. 113 p. Disponível em: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101764.pdf
https://biblioteca.ibge.gov.br/visualiza...

However, the following were excluded from the PNS: barracks, military bases, prisons, indigenous communities, lodgings, campsites, farming settlements, quilombola communities, waterborne vessels, convents and monasteries, hospitals and long-stay institutions for the elderly, children or adolescents. Further details on the methodological procedures are described in previous publications.1212. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. Pesquisa Nacional de Saúde 2019: histórico, métodos e perspectivas. Epidemiol Serv Saúde 2020;29(5):e2020315. doi: 10.1590/S167949742020000500004.
https://doi.org/10.1590/S167949742020000...
,1313. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde 2019: percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal. Brasil e grandes regiões [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística, 2020 [acesso 16 jun. 2021]. 113 p. Disponível em: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101764.pdf
https://biblioteca.ibge.gov.br/visualiza...

Due to PNS’s complex sampling design, sample weighting for households and selected residents were defined. The final weighting is the product of the inverse of the selection probabilities at each stage of the sampling plan, aiming to correct losses and to make adjustments to the population totals.1212. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. Pesquisa Nacional de Saúde 2019: histórico, métodos e perspectivas. Epidemiol Serv Saúde 2020;29(5):e2020315. doi: 10.1590/S167949742020000500004.
https://doi.org/10.1590/S167949742020000...
,1313. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde 2019: percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal. Brasil e grandes regiões [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística, 2020 [acesso 16 jun. 2021]. 113 p. Disponível em: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101764.pdf
https://biblioteca.ibge.gov.br/visualiza...

Participants

For the present study, data from selected residents1212. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. Pesquisa Nacional de Saúde 2019: histórico, métodos e perspectivas. Epidemiol Serv Saúde 2020;29(5):e2020315. doi: 10.1590/S167949742020000500004.
https://doi.org/10.1590/S167949742020000...
aged ≥ 18 years were used.

Data source

The 2019 PNS data which were used and its database and questionnaires are open access and were obtained through the PNS repository, available from https://www.pns.icict.fiocruz.br/.

The PNS questionnaire is divided in modules, containing information about place of residence, all the residents, and the resident selected for the interview.1212. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. Pesquisa Nacional de Saúde 2019: histórico, métodos e perspectivas. Epidemiol Serv Saúde 2020;29(5):e2020315. doi: 10.1590/S167949742020000500004.
https://doi.org/10.1590/S167949742020000...
,1313. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde 2019: percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal. Brasil e grandes regiões [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística, 2020 [acesso 16 jun. 2021]. 113 p. Disponível em: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101764.pdf
https://biblioteca.ibge.gov.br/visualiza...
In this study, questions from the following modules were used: Identification; Residents’ characteristics (C); Level of education (D); Health insurance coverage (I); Self-perceived health (N); Lifestyle (P); and Chronic diseases (Q).1212. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. Pesquisa Nacional de Saúde 2019: histórico, métodos e perspectivas. Epidemiol Serv Saúde 2020;29(5):e2020315. doi: 10.1590/S167949742020000500004.
https://doi.org/10.1590/S167949742020000...
,1313. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde 2019: percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal. Brasil e grandes regiões [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística, 2020 [acesso 16 jun. 2021]. 113 p. Disponível em: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101764.pdf
https://biblioteca.ibge.gov.br/visualiza...

Variables

The outcome variable was the self-reported diagnosis of high cholesterol, evaluated by the following question: Has any doctor ever told you that you have high cholesterol? A diagnosis of high cholesterol was considered the answer “yes”.

Explanatory variables included:

  1. Sociodemographic characteristics: sex (male; female); age group in years (18 to 24; 25 to 39; 40 to 59; ≥ 60); level of education (no schooling and incomplete primary education; complete primary education and incomplete secondary education; complete secondary education and incomplete higher education; complete higher education); race/skin color [White; Brown; Black; and others (corresponding to Yellow and Indigenous)]; region (North; Northeast; Southeast; South; Midwest); health insurance coverage (yes; no) - based on the questions on the identification module and the C, D, and I modules, and the questionnaire.

  2. Self-perceived health: self-rated health (very good/good; fair; poor/very poor); self-reported diagnosis of hypertension (yes; no); self-reported diagnosis of diabetes (yes; no); self-reported diagnosis of renal failure (yes; no); nutritional status (low weigth/eutrophic, classified by the body mass index [BMI] < 25 kg/m2); overweight (BMI around 25 to 29 kg/m2); obesity (BMI ≥ 30kg/m2).1414. World Health Organization (WHO). Obesity: preventing and managing the global epidemic. Report of a WHO consultation. WHO: Geneve; 2000. Disponível em: https://apps.who.int/iris/handle/10665/42330?locale-attribute=pt&.

  3. Lifestyle: smoking (non-smoker; former smoker; smoker); abusive consumption of alcoholic beverages (yes - consumption of five or more drinks on a single occasion; no);1313. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde 2019: percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal. Brasil e grandes regiões [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística, 2020 [acesso 16 jun. 2021]. 113 p. Disponível em: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101764.pdf
    https://biblioteca.ibge.gov.br/visualiza...
    recommended consumption of fruits and vegetables (yes - consumption of such foods at least 25 times a week, with a minimum consumption of five fruits, including fruit juice, or five vegetables; no);1515. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Guia alimentar para a população brasileira [Internet]. 2. ed. Brasília: Ministério da Saúde; 2014 [acesso 16 jun. 2021]. 156 p. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/guia_alimentar_populacao_brasileira_2ed.pdf
    https://bvsms.saude.gov.br/bvs/publicaco...
    consumption of ultra-processed foods (yes - reported consumption of five or more groups of ultra-processed foods on the previous day; no);1313. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde 2019: percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal. Brasil e grandes regiões [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística, 2020 [acesso 16 jun. 2021]. 113 p. Disponível em: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101764.pdf
    https://biblioteca.ibge.gov.br/visualiza...
    sufficient leisure time physical activity (yes - the following was considered as active: spending 150 minutes per week on activities of light or moderate intensity, or 75 minutes a week on vigorous-intensity activities, regardless of the number of days; no).1616. World Health Organization (WHO). Global recommendations on physical activity for health. Geneva: World Health Organization; 2010.

For the individuals who reported a diagnosis of high cholesterol, the following aspects were also investigated: age at first diagnosis of high cholesterol (mean age of first diagnosis) and recommendations from the health professional regarding high cholesterol: keeping a healthy diet (yes; no); maintaining adequate weight (yes; no); maintaining regular physical activity (yes; no); use of medication (yes; no); not smoking (yes; no); regular follow-ups with a health professional (yes; no).

Further details on the construction of variables for this study and the calculation methods are presented in the Supplementary material 1.

Statistical analysis

In the descriptive analyses, prevalences were estimated, presented as proportions (%) and with 95% confidence intervals (95%CI). The completeness of the variables was also analyzed descriptively to identify incomplete data (completeness was above 99% for all variables).

To verify the associations between the outcome and the explanatory variables, the prevalence ratio (PR) was used as a measure of association, obtained by Poisson regression models with robust variance. The theoretical model of the study by Sá et al.55. Sá ACMGN, Machado ÍE, Bernal RTI, Malta DC. Factors associated with high LDL-Cholesterol in the Brazilian adult population: National Health Survey. Cien Saude Colet 2021;26(2):541-553. doi: 10.1590/1413-81232021262.37102020.
https://doi.org/10.1590/1413-81232021262...
was considered. Bivariate analyzes were performed to obtain the crude PRs (cPR) and 95%CI. A multivariable analysis was performed, including variables with p-value < 0.20 in the crude analyses, to calculate the adjusted PRs (aPR) and 95%CI. The forward method was used to select the variables. In the final model, variables with p-value < 0.05 were considered as associated factors. Confounding variables were tested considering aspects in the literature.55. Sá ACMGN, Machado ÍE, Bernal RTI, Malta DC. Factors associated with high LDL-Cholesterol in the Brazilian adult population: National Health Survey. Cien Saude Colet 2021;26(2):541-553. doi: 10.1590/1413-81232021262.37102020.
https://doi.org/10.1590/1413-81232021262...

6. 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. doi: 10.1590/S0004-27302013000900004.
https://doi.org/10.1590/S0004-2730201300...

7. 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. doi: 10.1590/1413-81232015206.16312014.
https://doi.org/10.1590/1413-81232015206...

8. 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. doi: 10.1371/journal.pone.0017326.
https://doi.org/10.1371/journal.pone.001...
-99. Bayram F, Kocer D, Gundogan K, Kaya A, Demir O, Coskun R, et al. Prevalence of dyslipidemia and associated risk factors in Turkish adults. J Clin Lipidol 2014;8(2):206-216. doi: 10.1016/j.jacl.2013.12.011.
https://doi.org/10.1016/j.jacl.2013.12.0...

The analyses were performed by means of the Software for Statistics and Data Science (Stata), version 14, using the survey module for complex samples, which incorporates post-stratification weights.

Ethical aspects

The 2019 PNS followed all the ethical principles for the conduct of research involving human subjects and was approved by the National Research Ethics Committee of the Ministry of Health, Opinion No. 3,529,376. All participants who were interviewed provided free and informed consent and agreed to participate in the study; confidentiality of their information was guaranteed.

Results

The 2019 PNS anticipated sample was 108,525 households and the final sample consists of 94,114 households. For the analyses in this study, the total is 88,531 individuals age ≥ 18 years.

The prevalence of self-reported medical diagnosis of high cholesterol was 14.6% (95%CI 14.1;15.0). The mean age at the time of first medical diagnosis of high cholesterol was 45.9 years (95%CI 45.4;46.4; standard deviation = 16.5). Individuals with high cholesterol reported receiving recommendations from health professionals for maintaining a healthy diet (94.1%) and adequate weight (88.3%); and regular physical activity (87.9%); and for using cholesterol medication (74.2%), not smoking (60.7%), and having regular follow-ups with a health professional (74.0%) (Table 1).

Table 1
Characteristics of adult Brazilians with self-reported diagnosis of high cholesterol, 2019 National Health Survey, Brazil

The prevalence of high cholesterol was higher in: females (17.6%; 95%CI 17.0;18.3), the elderly (27.2%; 95%CI 26.2;28.3), inhabitans from the Southeast region (15.8; 95%CI 14.9;16.7), individuals who have health insurance (18.3%; 95%CI 17.4;19.2), those who self-rated their health as poor or very poor (31.3%; 95%CI 29.1;33.6), individuals with hypertension (30.9%; 95%CI 29.9;32.0), diabetes (39.2%; 95%CI 37.2;41.2), renal failure (33.7%; 95%CI 29.3;38.4), and obesity (19.7%; 95%CI 18.7;20.7), former smokers (19.5%; 95%CI 18.6;20.4); and for those who consumed fruits and vegetables as recommended (18.2%; 95%CI 17.0;19.5). On the other hand, the lowest prevalence of high cholesterol was present in individuals with intermediate education (complete elementary school and incomplete secondary school, 11.0%; 95%CI 10.1;12.0), of Black race/skin color (13.0%; 95%CI 11.9;14.2), who consumed alcoholic beverages abusively (10.6%; 95%CI 9.7;11.6), who consumed five or more groups of ultra-processed foods (9.8%; 95%CI 8.9;10.7), and who were physically active during leisure time (14.0%; 95%CI 13.2;14.8) (Table 2).

Table 2
Prevalence, crude prevalence ratios and 95% confidence intervals for self-reported diagnosis of high cholesterol among Brazilian adults, according to sociodemographic characteristics, clinical conditions and lifestyle, 2019 National Health Survey, Brazil

In the final multivariate model, it was found that being female (aPR = 1.44; 95%CI 1.40;1.52), people with advanced age (25 to 39 years: aPR = 1.67; 95%CI 1.33;2.08; 40 to 59 years: aPR = 3.33; 95%CI 2.70;4.11; ≥ 60: aPR = 3.80; 95%CI 3.06;4.71), having health insurance (aPR = 1.33; 95%CI 1.24;1.42), self-rated health as fair (aPR = 1.40; 95%CI 1.32;1.50) and poor or very poor (PR = 1.75; 95%CI 1.60;1.90), having hypertension (PR = 1.78; 95%CI 1.68;1.89), diabetes (aPR = 1.54; 95%CI 1.45;1.65 ) and renal failure (aPR = 1.33; 95%CI 1.15;1.53), being overweight (aPR = 1.26; 95%CI 1.20;1.33), obese (aPR = 1.27; 95%CI 1.18;1.36), a former smoker (aPR = 1.13; 95%CI 1.07;1.20), drinking alcoholic beverages in excess (aPR = 1.11; 95%CI 1.01;1.21), and being physically active during leisure time (aPR = 1.22; 95%CI 1.15;1.30) were associated with higher prevalence of high cholesterol. Having an intermediate level of education (complete elementary school and incomplete secondary school, aPR = 0.89; 95%CI 0.81;0.98), being of Brown race/skin color (aPR = 0.91; 95%CI 0.86;0.97) and Black (aPR = 0.84; 95%CI 0.77;0.93), and a smoker (aPR = 0.88; 95%CI 0.80;0.97) were associated with lower prevalence of high cholesterol (Table 3).

Table 3
Prevalence ratios and 95% confidence intervals, from the final multivariable Poisson regression model, for factors associated with self-reported diagnosis of high cholesterol among Brazilian adults (n = 87,669), 2019 National Health Survey, Brazil

Discussion

One out of seven adult Brazilians reported a diagnosis of high cholesterol, as per the 2019 PNS data. Prevalence was positively associated with: being female; advanced age; having health insurance; fair, poor or very poor self-rated health; having hypertension, diabetes, renal failure; being overweight or obese; being a former smoker; abusive alcohol consumption; and being physically active during leisure time. They were inversely associated with having completed elementary and secondary education, being of Black and Brown race/skin color, and being a smoker.

Among the limitations of this study are those inherent to cross-sectional studies: the inability to determine causality; the associations presented were analyzed at a single point in time and can be influenced by changes in lifestyle and treatment; some results can be subject to survival bias, such as the difference in terms of associations in relation to sex; and possible reverse causality between NCDs, lifestyle and dyslipidemia variables. Another limitation is the fact that the survey collected self-referred information, being subject to information and diagnosis classification biases, which may lead to underreporting or underestimation.77. 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. doi: 10.1590/1413-81232015206.16312014.
https://doi.org/10.1590/1413-81232015206...
Even though clinical laboratory measurements are more accurate, population studies on dyslipidemia with laboratory test data are scarce in Brazil due to high costs.77. 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. doi: 10.1590/1413-81232015206.16312014.
https://doi.org/10.1590/1413-81232015206...
,1111. Malta DC, Szwarcwald CL, Machado ÍE, Pereira CA, Figueiredo AW, Sá ACMGN, et al. Prevalence of altered total cholesterol and fractions in the Brazilian adult population: National Health Survey. Rev Bras Epidemiol 2019 Oct 7;22(Suppl 02):E190005.SUPL.2. doi: 10.1590/1980-549720190005.supl.2.
https://doi.org/10.1590/1980-54972019000...
Studies using self-reported information are important for monitoring the prevalence of high cholesterol,77. 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. doi: 10.1590/1413-81232015206.16312014.
https://doi.org/10.1590/1413-81232015206...
as they are a faster and more inexpensive way to obtain data.1010. Lotufo PA, Santos RD, Sposito AC, Bertolami M, Rocha-Faria J Neto, Izar MC, et al. Self-Reported High-Cholesterol Prevalence in the Brazilian Population: analysis of the 2013 National Health Survey. Arq Bras Cardiol 2017 May;108(5):411-416. doi: 10.5935/abc.20170055.
https://doi.org/10.5935/abc.20170055...
Furthermore, the study was conducted with a representative sample of the population and the generalizations of estimates are relatively safe.

In adults, the mean age at the time of first diagnosis was approximately 46 years. In the 2013 PNS, the mean age was 46.7 years.1010. Lotufo PA, Santos RD, Sposito AC, Bertolami M, Rocha-Faria J Neto, Izar MC, et al. Self-Reported High-Cholesterol Prevalence in the Brazilian Population: analysis of the 2013 National Health Survey. Arq Bras Cardiol 2017 May;108(5):411-416. doi: 10.5935/abc.20170055.
https://doi.org/10.5935/abc.20170055...
In the present study, there was high prevalence of recommendations from health professionals to adults with high cholesterol in terms of adopting healthy behaviors and health care such as medication use and monitoring. Similar results were found in the 2013 PNS.1010. Lotufo PA, Santos RD, Sposito AC, Bertolami M, Rocha-Faria J Neto, Izar MC, et al. Self-Reported High-Cholesterol Prevalence in the Brazilian Population: analysis of the 2013 National Health Survey. Arq Bras Cardiol 2017 May;108(5):411-416. doi: 10.5935/abc.20170055.
https://doi.org/10.5935/abc.20170055...
Literature establishes the importance of adopting a healthy diet, maintaining an adequate BMI, as well as regular physical activity in order to prevent and control dyslipidemia.11. Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune A Neto, et al. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017 Jul;109(2 Supl 1):1-76. doi: 10.5935/abc.20170121.
https://doi.org/10.5935/abc.20170121...
In addition, those individuals also benefit from treatment with hypolipidemic agents, as the reduction in total cholesterol, mainly LDL, decreases morbidity and mortality resulting from cardiovascular diseases.11. Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune A Neto, et al. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017 Jul;109(2 Supl 1):1-76. doi: 10.5935/abc.20170121.
https://doi.org/10.5935/abc.20170121...

The prevalence of high cholesterol found in the 2019 PNS was higher than in the 2013 PNS (12.5%; 95%CI 12.1;13.0).1010. Lotufo PA, Santos RD, Sposito AC, Bertolami M, Rocha-Faria J Neto, Izar MC, et al. Self-Reported High-Cholesterol Prevalence in the Brazilian Population: analysis of the 2013 National Health Survey. Arq Bras Cardiol 2017 May;108(5):411-416. doi: 10.5935/abc.20170055.
https://doi.org/10.5935/abc.20170055...
Studies in Brazil,55. Sá ACMGN, Machado ÍE, Bernal RTI, Malta DC. Factors associated with high LDL-Cholesterol in the Brazilian adult population: National Health Survey. Cien Saude Colet 2021;26(2):541-553. doi: 10.1590/1413-81232021262.37102020.
https://doi.org/10.1590/1413-81232021262...
,1010. Lotufo PA, Santos RD, Sposito AC, Bertolami M, Rocha-Faria J Neto, Izar MC, et al. Self-Reported High-Cholesterol Prevalence in the Brazilian Population: analysis of the 2013 National Health Survey. Arq Bras Cardiol 2017 May;108(5):411-416. doi: 10.5935/abc.20170055.
https://doi.org/10.5935/abc.20170055...
,1111. Malta DC, Szwarcwald CL, Machado ÍE, Pereira CA, Figueiredo AW, Sá ACMGN, et al. Prevalence of altered total cholesterol and fractions in the Brazilian adult population: National Health Survey. Rev Bras Epidemiol 2019 Oct 7;22(Suppl 02):E190005.SUPL.2. doi: 10.1590/1980-549720190005.supl.2.
https://doi.org/10.1590/1980-54972019000...
Turkey,99. Bayram F, Kocer D, Gundogan K, Kaya A, Demir O, Coskun R, et al. Prevalence of dyslipidemia and associated risk factors in Turkish adults. J Clin Lipidol 2014;8(2):206-216. doi: 10.1016/j.jacl.2013.12.011.
https://doi.org/10.1016/j.jacl.2013.12.0...
the United States,1717. 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 Jul-Aug;6(4):325-30. doi: 10.1016/j.jacl.2012.05.002.
https://doi.org/10.1016/j.jacl.2012.05.0...
and China1818. Opoku S, Gan Y, Fu W, Chen D, Addo-Yobo E, Trofimovitch D, et al. 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. doi: 10.1186/s12889-019-7827-5.
https://doi.org/10.1186/s12889-019-7827-...
identified higher laboratory prevalence of dyslipidemias55. Sá ACMGN, Machado ÍE, Bernal RTI, Malta DC. Factors associated with high LDL-Cholesterol in the Brazilian adult population: National Health Survey. Cien Saude Colet 2021;26(2):541-553. doi: 10.1590/1413-81232021262.37102020.
https://doi.org/10.1590/1413-81232021262...
,1010. Lotufo PA, Santos RD, Sposito AC, Bertolami M, Rocha-Faria J Neto, Izar MC, et al. Self-Reported High-Cholesterol Prevalence in the Brazilian Population: analysis of the 2013 National Health Survey. Arq Bras Cardiol 2017 May;108(5):411-416. doi: 10.5935/abc.20170055.
https://doi.org/10.5935/abc.20170055...
,1111. Malta DC, Szwarcwald CL, Machado ÍE, Pereira CA, Figueiredo AW, Sá ACMGN, et al. Prevalence of altered total cholesterol and fractions in the Brazilian adult population: National Health Survey. Rev Bras Epidemiol 2019 Oct 7;22(Suppl 02):E190005.SUPL.2. doi: 10.1590/1980-549720190005.supl.2.
https://doi.org/10.1590/1980-54972019000...
,1717. 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 Jul-Aug;6(4):325-30. doi: 10.1016/j.jacl.2012.05.002.
https://doi.org/10.1016/j.jacl.2012.05.0...
,1818. Opoku S, Gan Y, Fu W, Chen D, Addo-Yobo E, Trofimovitch D, et al. 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. doi: 10.1186/s12889-019-7827-5.
https://doi.org/10.1186/s12889-019-7827-...
than those found in this study.

The increase of dyslipidemia between the 20131010. Lotufo PA, Santos RD, Sposito AC, Bertolami M, Rocha-Faria J Neto, Izar MC, et al. Self-Reported High-Cholesterol Prevalence in the Brazilian Population: analysis of the 2013 National Health Survey. Arq Bras Cardiol 2017 May;108(5):411-416. doi: 10.5935/abc.20170055.
https://doi.org/10.5935/abc.20170055...
and 2019 editions of the PNS may be a consequence of greater detection, as a result of improvements and the expansion of access to as well as of use of health services in the country,1919. 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). doi: 10.1590/S1518-8787.2017051000074.
https://doi.org/10.1590/S1518-8787.20170...
but it may also be related to the increase in overweight, obesity and the consumption of ultra-processed foods.2020. Malta DC, Silva AGD, Tonaco LAB, Freitas MIF, Velasquez-Melendez G. Time trends in morbid obesity prevalence in the Brazilian adult population from 2006 to 2017. Cad Saude Publica 2019 Sep 16;35(9):e00223518. doi: 10.1590/0102-311X00223518.
https://doi.org/10.1590/0102-311X0022351...
The difference between self-reported and laboratory data may suggest underestimation of diagnosis in the population studied.2121. Fontanelli MM, Nogueira LR, Garcez MR, Sales CH, Corrente JE, César CLG, et al. Validity of self-reported high cholesterol in the city of São Paulo, Brazil, and factors associated with this information's sensitivity. Cad Saude Publica 2018 29;34(12):e00034718. doi: 10.1590/0102-311X00034718.
https://doi.org/10.1590/0102-311X0003471...
In this context, monitoring dyslipidemia in the country77. 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. doi: 10.1590/1413-81232015206.16312014.
https://doi.org/10.1590/1413-81232015206...
is crucial for the prevention of cardiovascular diseases, which are the main cause of mortality in Brazil.44. Institute for Health Metrics and Evaluation. GBD Compare Data Visualization. Seattle: IHME; 2019.

This study is in line with other investigations that identified a higher prevalence of dyslipidemia in women.55. Sá ACMGN, Machado ÍE, Bernal RTI, Malta DC. Factors associated with high LDL-Cholesterol in the Brazilian adult population: National Health Survey. Cien Saude Colet 2021;26(2):541-553. doi: 10.1590/1413-81232021262.37102020.
https://doi.org/10.1590/1413-81232021262...
,88. 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. doi: 10.1371/journal.pone.0017326.
https://doi.org/10.1371/journal.pone.001...
,1010. Lotufo PA, Santos RD, Sposito AC, Bertolami M, Rocha-Faria J Neto, Izar MC, et al. Self-Reported High-Cholesterol Prevalence in the Brazilian Population: analysis of the 2013 National Health Survey. Arq Bras Cardiol 2017 May;108(5):411-416. doi: 10.5935/abc.20170055.
https://doi.org/10.5935/abc.20170055...
,1818. Opoku S, Gan Y, Fu W, Chen D, Addo-Yobo E, Trofimovitch D, et al. 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. doi: 10.1186/s12889-019-7827-5.
https://doi.org/10.1186/s12889-019-7827-...
Dyslipidemia is highly prevalent among women,2222. Phan BA, Toth PP. Dyslipidemia in women: etiology and management. Int J Womens Health 2014 Feb 7;6:185-94. doi: 10.2147/IJWH.S38133.
https://doi.org/10.2147/IJWH.S38133...
with higher occurrence with increasing age, during pregnancy, menopause and post-menopause due to hormonal changes.2222. Phan BA, Toth PP. Dyslipidemia in women: etiology and management. Int J Womens Health 2014 Feb 7;6:185-94. doi: 10.2147/IJWH.S38133.
https://doi.org/10.2147/IJWH.S38133...
With advancing age, the increase in levels of triglycerides, total cholesterol, LDL, and reduction of HDL is accentuated.2222. Phan BA, Toth PP. Dyslipidemia in women: etiology and management. Int J Womens Health 2014 Feb 7;6:185-94. doi: 10.2147/IJWH.S38133.
https://doi.org/10.2147/IJWH.S38133...
As people age, changes in the lipid profile place women at greater risk of cardiovascular diseases.2222. Phan BA, Toth PP. Dyslipidemia in women: etiology and management. Int J Womens Health 2014 Feb 7;6:185-94. doi: 10.2147/IJWH.S38133.
https://doi.org/10.2147/IJWH.S38133...
In Brazil, data from the 2013 PNS showed a positive association in women, with or without chronic diseases, when compared to men, regarding greater use of health services and number of doctor visits in the last 12 months,2323. Malta DC, Bernal RTI, Lima MG, Araújo SSC de, Silva MMA da, Freitas MI de F, et al. Noncommunicable diseases and the use of health services: analysis of the National Health Survey in Brazil. Rev Saude Publica 2017 Jun 1;51(suppl 1). doi: 10.1590/S1518-8787.2017051000090.
https://doi.org/10.1590/S1518-8787.20170...
favoring diagnosis and treatment in this group.

As in other studies, this investigation identified a positive association between age and the diagnosis of high cholesterol.55. Sá ACMGN, Machado ÍE, Bernal RTI, Malta DC. Factors associated with high LDL-Cholesterol in the Brazilian adult population: National Health Survey. Cien Saude Colet 2021;26(2):541-553. doi: 10.1590/1413-81232021262.37102020.
https://doi.org/10.1590/1413-81232021262...

6. 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. doi: 10.1590/S0004-27302013000900004.
https://doi.org/10.1590/S0004-2730201300...
-77. 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. doi: 10.1590/1413-81232015206.16312014.
https://doi.org/10.1590/1413-81232015206...
,99. Bayram F, Kocer D, Gundogan K, Kaya A, Demir O, Coskun R, et al. Prevalence of dyslipidemia and associated risk factors in Turkish adults. J Clin Lipidol 2014;8(2):206-216. doi: 10.1016/j.jacl.2013.12.011.
https://doi.org/10.1016/j.jacl.2013.12.0...
Dyslipidemias are more prevalent with increasing age2424. Liu HH, Li JJ. Aging and dyslipidemia: a review of potential mechanisms. Ageing Res Rev 2015 Jan;19:43-52. doi: 10.1016/j.arr.2014.12.001.
https://doi.org/10.1016/j.arr.2014.12.00...
due to ageing of the main organs of homeostasis, resulting in changes in the hepatic endothelium, in increased insulin resistance and hormonal changes, such as the decrease in estrogen and progesterone in women and androgen in men throughout life, leading to repercussions on the lipid profile.2424. Liu HH, Li JJ. Aging and dyslipidemia: a review of potential mechanisms. Ageing Res Rev 2015 Jan;19:43-52. doi: 10.1016/j.arr.2014.12.001.
https://doi.org/10.1016/j.arr.2014.12.00...
Another possible explanation for this finding is the fact that, in Brazil, elderly people use healthcare services more frequently, which contributes to the diagnosis.1919. 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). doi: 10.1590/S1518-8787.2017051000074.
https://doi.org/10.1590/S1518-8787.20170...

There was lower prevalence of high cholesterol in people with an intermediate level of education. Studies with the laboratory PNS data55. Sá ACMGN, Machado ÍE, Bernal RTI, Malta DC. Factors associated with high LDL-Cholesterol in the Brazilian adult population: National Health Survey. Cien Saude Colet 2021;26(2):541-553. doi: 10.1590/1413-81232021262.37102020.
https://doi.org/10.1590/1413-81232021262...
showed that high levels of total cholesterol and LDL are less frequent in more educated adults and the prevalence was lower in individuals with average schooling compared with those with a lower level of education.55. Sá ACMGN, Machado ÍE, Bernal RTI, Malta DC. Factors associated with high LDL-Cholesterol in the Brazilian adult population: National Health Survey. Cien Saude Colet 2021;26(2):541-553. doi: 10.1590/1413-81232021262.37102020.
https://doi.org/10.1590/1413-81232021262...
,1111. Malta DC, Szwarcwald CL, Machado ÍE, Pereira CA, Figueiredo AW, Sá ACMGN, et al. Prevalence of altered total cholesterol and fractions in the Brazilian adult population: National Health Survey. Rev Bras Epidemiol 2019 Oct 7;22(Suppl 02):E190005.SUPL.2. doi: 10.1590/1980-549720190005.supl.2.
https://doi.org/10.1590/1980-54972019000...
The prevalence of lipid profile changes for total cholesterol, according to years of study, were: 37.1% (zero to eight years), 28.6% (nine to 11 years) and 30.4% (over 12 years);1111. Malta DC, Szwarcwald CL, Machado ÍE, Pereira CA, Figueiredo AW, Sá ACMGN, et al. Prevalence of altered total cholesterol and fractions in the Brazilian adult population: National Health Survey. Rev Bras Epidemiol 2019 Oct 7;22(Suppl 02):E190005.SUPL.2. doi: 10.1590/1980-549720190005.supl.2.
https://doi.org/10.1590/1980-54972019000...
and for LDL: 21.5% (zero to eight years), 16.8% (nine to 11 years) and 16.7% (over 12 years).55. Sá ACMGN, Machado ÍE, Bernal RTI, Malta DC. Factors associated with high LDL-Cholesterol in the Brazilian adult population: National Health Survey. Cien Saude Colet 2021;26(2):541-553. doi: 10.1590/1413-81232021262.37102020.
https://doi.org/10.1590/1413-81232021262...
,1111. Malta DC, Szwarcwald CL, Machado ÍE, Pereira CA, Figueiredo AW, Sá ACMGN, et al. Prevalence of altered total cholesterol and fractions in the Brazilian adult population: National Health Survey. Rev Bras Epidemiol 2019 Oct 7;22(Suppl 02):E190005.SUPL.2. doi: 10.1590/1980-549720190005.supl.2.
https://doi.org/10.1590/1980-54972019000...
Possible explanations for the occurrence of these findings are: higher demand for healthcare due to a greater understanding of the disease and the inherent risks,1919. 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). doi: 10.1590/S1518-8787.2017051000074.
https://doi.org/10.1590/S1518-8787.20170...
as well as the adoption of further practices in terms of preventive actions, health promotion and healthcare.1111. Malta DC, Szwarcwald CL, Machado ÍE, Pereira CA, Figueiredo AW, Sá ACMGN, et al. Prevalence of altered total cholesterol and fractions in the Brazilian adult population: National Health Survey. Rev Bras Epidemiol 2019 Oct 7;22(Suppl 02):E190005.SUPL.2. doi: 10.1590/1980-549720190005.supl.2.
https://doi.org/10.1590/1980-54972019000...
,1919. 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). doi: 10.1590/S1518-8787.2017051000074.
https://doi.org/10.1590/S1518-8787.20170...
,2525. Psaltopoulou T, Hatzis G, Papageorgiou N, Androulakis E, Briasoulis A, Tousoulis D. Socioeconomic status and risk factors for cardiovascular disease: impact of dietary mediators. Hellenic J Cardiol 2017 Jan-Feb;58(1):32-42. doi: 10.1016/j.hjc.2017.01.022.
https://doi.org/10.1016/j.hjc.2017.01.02...

Regarding race/skin color, the data from this study were similar to population-based investigations in Brazil,55. Sá ACMGN, Machado ÍE, Bernal RTI, Malta DC. Factors associated with high LDL-Cholesterol in the Brazilian adult population: National Health Survey. Cien Saude Colet 2021;26(2):541-553. doi: 10.1590/1413-81232021262.37102020.
https://doi.org/10.1590/1413-81232021262...
,2626. 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 Nov-Dec;10(6):1362-1368. doi: 10.1016/j.jacl.2016.08.008.
https://doi.org/10.1016/j.jacl.2016.08.0...
in which lower prevalence of dyslipidemia was found among those of Black and Brown race/skin color. There is little information on the lipid profile of admixed populations, but it is known that there are differences between ethnicities.2626. 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 Nov-Dec;10(6):1362-1368. doi: 10.1016/j.jacl.2016.08.008.
https://doi.org/10.1016/j.jacl.2016.08.0...
In Blacks, a lower prevalence of high levels of LDL and triglycerides is documented in comparison with Whites; however, people of Brown race/skin color have lipid concentrations close to that of Whites.2626. 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 Nov-Dec;10(6):1362-1368. doi: 10.1016/j.jacl.2016.08.008.
https://doi.org/10.1016/j.jacl.2016.08.0...
Black people have lipid patterns associated with a lower risk of cardiovascular diseases.2626. 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 Nov-Dec;10(6):1362-1368. doi: 10.1016/j.jacl.2016.08.008.
https://doi.org/10.1016/j.jacl.2016.08.0...
Given the lack of information on this topic in admixed populations such as in Brazil, and the differences in the lipid profiles,2626. 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 Nov-Dec;10(6):1362-1368. doi: 10.1016/j.jacl.2016.08.008.
https://doi.org/10.1016/j.jacl.2016.08.0...
further studies are needed to elucidate the potential differences in the country.

Some socioeconomic proxy variables are related to cardiovascular risk factors.2525. Psaltopoulou T, Hatzis G, Papageorgiou N, Androulakis E, Briasoulis A, Tousoulis D. Socioeconomic status and risk factors for cardiovascular disease: impact of dietary mediators. Hellenic J Cardiol 2017 Jan-Feb;58(1):32-42. doi: 10.1016/j.hjc.2017.01.022.
https://doi.org/10.1016/j.hjc.2017.01.02...
People who use health insurances generally have a higher income, which enables access to services and diagnosis.2323. Malta DC, Bernal RTI, Lima MG, Araújo SSC de, Silva MMA da, Freitas MI de F, et al. Noncommunicable diseases and the use of health services: analysis of the National Health Survey in Brazil. Rev Saude Publica 2017 Jun 1;51(suppl 1). doi: 10.1590/S1518-8787.2017051000090.
https://doi.org/10.1590/S1518-8787.20170...
Having access to a health insurance may have contributed to the higher number of diagnoses, given that a higher prevalence of health service use was observed, in Brazil, in people with NCDs and who have health insurance plans.2323. Malta DC, Bernal RTI, Lima MG, Araújo SSC de, Silva MMA da, Freitas MI de F, et al. Noncommunicable diseases and the use of health services: analysis of the National Health Survey in Brazil. Rev Saude Publica 2017 Jun 1;51(suppl 1). doi: 10.1590/S1518-8787.2017051000090.
https://doi.org/10.1590/S1518-8787.20170...
In addition, dyslipidemias are highly prevalent in developing countries, and individuals in higher socioeconomic strata are at increased risk of developing NCDs.2727. Espírito Santo LR, Faria TO, Silva CSO, Xavier LA, Reis VC, Mota GA, et al. Socioeconomic status and education level are associated with dyslipidemia in adults not taking lipid-lowering medication: a population-based study. Int Health 2019 Nov 6:ihz089. doi: 10.1093/inthealth/ihz089.
https://doi.org/10.1093/inthealth/ihz089...
This is due to higher rates of obesity and overweight in such countries,2525. Psaltopoulou T, Hatzis G, Papageorgiou N, Androulakis E, Briasoulis A, Tousoulis D. Socioeconomic status and risk factors for cardiovascular disease: impact of dietary mediators. Hellenic J Cardiol 2017 Jan-Feb;58(1):32-42. doi: 10.1016/j.hjc.2017.01.022.
https://doi.org/10.1016/j.hjc.2017.01.02...
which contribute to the occurrence of dyslipidemias.66. 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. doi: 10.1590/S0004-27302013000900004.
https://doi.org/10.1590/S0004-2730201300...
,2727. Espírito Santo LR, Faria TO, Silva CSO, Xavier LA, Reis VC, Mota GA, et al. Socioeconomic status and education level are associated with dyslipidemia in adults not taking lipid-lowering medication: a population-based study. Int Health 2019 Nov 6:ihz089. doi: 10.1093/inthealth/ihz089.
https://doi.org/10.1093/inthealth/ihz089...
,2828. Vekic J, Zeljkovic A, Stefanovic A, Jelic-Ivanovic Z, Spasojevic-Kalimanovska V. Obesity and dyslipidemia. Metabolism 2019; 92:71-81. doi: 10.1016/j.metabol.2018.11.005.
https://doi.org/10.1016/j.metabol.2018.1...

The positive associations found between obesity and overweight and a diagnosis of high cholesterol are in line with other studies.55. Sá ACMGN, Machado ÍE, Bernal RTI, Malta DC. Factors associated with high LDL-Cholesterol in the Brazilian adult population: National Health Survey. Cien Saude Colet 2021;26(2):541-553. doi: 10.1590/1413-81232021262.37102020.
https://doi.org/10.1590/1413-81232021262...
,77. 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. doi: 10.1590/1413-81232015206.16312014.
https://doi.org/10.1590/1413-81232015206...

8. 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. doi: 10.1371/journal.pone.0017326.
https://doi.org/10.1371/journal.pone.001...
-99. Bayram F, Kocer D, Gundogan K, Kaya A, Demir O, Coskun R, et al. Prevalence of dyslipidemia and associated risk factors in Turkish adults. J Clin Lipidol 2014;8(2):206-216. doi: 10.1016/j.jacl.2013.12.011.
https://doi.org/10.1016/j.jacl.2013.12.0...
,1818. Opoku S, Gan Y, Fu W, Chen D, Addo-Yobo E, Trofimovitch D, et al. 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. doi: 10.1186/s12889-019-7827-5.
https://doi.org/10.1186/s12889-019-7827-...
In overweight and obesity, the occurrence of insulin resistance is related to increased cholesterol levels.2828. Vekic J, Zeljkovic A, Stefanovic A, Jelic-Ivanovic Z, Spasojevic-Kalimanovska V. Obesity and dyslipidemia. Metabolism 2019; 92:71-81. doi: 10.1016/j.metabol.2018.11.005.
https://doi.org/10.1016/j.metabol.2018.1...
This is due to the elevations of free fatty acid concentrations, with increased hepatic secretion of very low density lipoproteins (VLDL), with consequent metabolization of VLDL to LDL particles (small and dense) that accumulate in the vasculature, in addition to elevations of triglycerides.2828. Vekic J, Zeljkovic A, Stefanovic A, Jelic-Ivanovic Z, Spasojevic-Kalimanovska V. Obesity and dyslipidemia. Metabolism 2019; 92:71-81. doi: 10.1016/j.metabol.2018.11.005.
https://doi.org/10.1016/j.metabol.2018.1...

The NCDs studied herein (hypertension, diabetes and renal failure) are associated with dyslipidemias.11. Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune A Neto, et al. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017 Jul;109(2 Supl 1):1-76. doi: 10.5935/abc.20170121.
https://doi.org/10.5935/abc.20170121...
,2929. Bianchi S, Baronti A, Cominotto R, Bigazzi R. Le alterazioni del metabolismo lipidico nella malattia renale cronica [Lipid metabolism abnormalities in Chronic Kidney Disease]. G Ital Nefrol 2016;33(S68).,3030. Schofield JD, Liu Y, Rao-Balakrishna P, Malik RA, Soran H. Diabetes Dyslipidemia. Diabetes Ther 2016 Jun;7(2):203-219. In arterial hypertension, atherosclerosis affects the elasticity of the arteries, with increased blood pressure and endothelial dysfunction, increasing vascular permeability to lipoproteins, favoring the accumulation, oxidation and immunogenicity of LDL.11. Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune A Neto, et al. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017 Jul;109(2 Supl 1):1-76. doi: 10.5935/abc.20170121.
https://doi.org/10.5935/abc.20170121...
People with renal failure present changes in the lipid profile due to abnormalities in lipoprotein metabolism and, as the renal function deteriorates, triglycerides and LDL concentrations increase and HDL concentrations decrease.2929. Bianchi S, Baronti A, Cominotto R, Bigazzi R. Le alterazioni del metabolismo lipidico nella malattia renale cronica [Lipid metabolism abnormalities in Chronic Kidney Disease]. G Ital Nefrol 2016;33(S68). Dyslipidemias can be secondary to diabetes,11. Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune A Neto, et al. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017 Jul;109(2 Supl 1):1-76. doi: 10.5935/abc.20170121.
https://doi.org/10.5935/abc.20170121...
mainly due to insulin resistance, resulting in retention of dense LDL particles and the presence of low HDL, which is a common abnormality in people with diabetes.3030. Schofield JD, Liu Y, Rao-Balakrishna P, Malik RA, Soran H. Diabetes Dyslipidemia. Diabetes Ther 2016 Jun;7(2):203-219.

This study showed a positive association between worse self-rated health status and the diagnosis of high cholesterol. This data is relevant, since self-rated health status is an important predictor of mortality and morbidity.77. 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. doi: 10.1590/1413-81232015206.16312014.
https://doi.org/10.1590/1413-81232015206...
The findings in this study are consistent with other studies that identified an association between fair, poor or very poor self-rated health and dyslipidemia.55. Sá ACMGN, Machado ÍE, Bernal RTI, Malta DC. Factors associated with high LDL-Cholesterol in the Brazilian adult population: National Health Survey. Cien Saude Colet 2021;26(2):541-553. doi: 10.1590/1413-81232021262.37102020.
https://doi.org/10.1590/1413-81232021262...
,77. 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. doi: 10.1590/1413-81232015206.16312014.
https://doi.org/10.1590/1413-81232015206...
Possible explanations are the perception of the disease in terms of its consequences and functional changes.77. 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. doi: 10.1590/1413-81232015206.16312014.
https://doi.org/10.1590/1413-81232015206...

The positive associations between engaging in physical activities and being a former smoker, and the negative association between being a smoker and the diagnosis of high cholesterol may be consequences of changes in lifestyle and treatment. It can also be a possible effect of reverse causality, suggesting that adults with high cholesterol adhered to those changes as a result of the diagnosis. Evidence suggests that physical activity increases HDL, reduces VLDL and triglycerides and increases resistance to LDL oxidation.11. Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune A Neto, et al. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017 Jul;109(2 Supl 1):1-76. doi: 10.5935/abc.20170121.
https://doi.org/10.5935/abc.20170121...
Smoking results in endothelial dysfunction and promotes atherosclerosis; smoking causes an increase in total cholesterol and LDL levels, and a decrease in HDL, with smoking cessation being beneficial at any stage of life.11. Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune A Neto, et al. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017 Jul;109(2 Supl 1):1-76. doi: 10.5935/abc.20170121.
https://doi.org/10.5935/abc.20170121...
Additionally, the positive association between alcohol abuse and high cholesterol diagnosis, identified in this study, is worrying, since the combination of abusive use of alcohol and saturated fatty acids can increase elevations in triglycerides; thus, reducing the consumption of alcoholic beverages is recommended.11. Faludi AA, Izar MCO, Saraiva JFK, Chacra APM, Bianco HT, Afiune A Neto, et al. Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arq Bras Cardiol 2017 Jul;109(2 Supl 1):1-76. doi: 10.5935/abc.20170121.
https://doi.org/10.5935/abc.20170121...

The prevalence of self-reported dyslipidemia was high among adult Brazilians. The factors associated with the diagnosis of high cholesterol were: being female, ageing, higher socioeconomic status, worse self-rated health status, worse self-assessment of health status, having hypertension, diabetes and having renal failure, overweight and obesity, being a former smoker and a smoker, being physically active during leisure time, and being of Black and Brown race/skin color, besides alcohol abuse. This study can provide support in relation to health promotion public policies, the development of clinical protocols in the scope of the Brazilian National Health System, and support for actions to prevent and decrease the rates of dyslipidemia and cardiovascular diseases.

Acknowledgment

We would like to thank the Coordination for the Improvement of Higher Education Personnel (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES) for the PhD scholarship received by Sá ACMGN; the Brazilian National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico - CNPq) for the Research Productivity grant received by Malta DC.

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  • Funding

    This study received financial support from Fundo Nacional de Saúde, from the Secretaria de Vigilância em Saúde, Brazilian Ministry of Education, TED 66/2018.

Supplementary Material 1


Variable construction and calculation methods, 2019 National Health Survey, Brazil

Publication Dates

  • Publication in this collection
    29 June 2022
  • Date of issue
    2022

History

  • Received
    22 Apr 2021
  • Accepted
    26 July 2021
Secretaria de Vigilância em Saúde - Ministério da Saúde do Brasil Brasília - Distrito Federal - Brazil
E-mail: leilapgarcia@gmail.com