Hyperlipidemia: The Population Health Perspective

High blood cholesterol is a major risk factor for heart disease. Heart disease is the leading cause of death in the United States. Nearly 100 million American adults have total blood cholesterol values of 200 mg/dL and higher; and 34.5 million American adults have levels of 240 or above. As a result, public health agencies have attempted to reduce the prevalence of hyperlipidemia through screening and by increasing public awareness of high cholesterol and strategies for reducing it. According to the Centers for Disease Control, 74.6 percent of adults aged 18 years and older had their blood cholesterol checked within the preceding 5 years in 2008 (age adjusted to the year 2000 standard population). A national health objectives of Healthy People 2020 is to increase to 82.1% the proportion of adults who have been screened for high blood cholesterol within the preceding 5 years.

This module will review the national standards of screening, diagnosis, and management of hyperlipidemia and allow you to explore socio-cultural aspects of this chronic condition.

African Americans have the highest overall death rates of coronary heart disease, and have an earlier age of onset of CHD as compared to whites. Some of the reasons for these dramatic health disparities are the high prevalence and suboptimal control of coronary risk factors, lack of access to optimal care, community mistrust of the medical system, and institutional racism. Hypertension, hyperlipidemia, diabetes mellitus, left ventricular hypertrophy, obesity, cigarette smoking, physical inactivity, and multiple CHD risk factors all occur more frequently in African Americans as compared to whites. (Heart Disease 2001; Ann Intern Med 1997)

Latinos are now the largest minority group in the United States. Despite a less favorable cardiovascular risk profile among Latinos (greater prevalence of hyperlipidemia, more obesity, central obesity, and lower HDL-cholesterol and higher triglyceride levels), CHD and cardiovascular disease mortality are approximately 20 percent lower among adult Latinos than among whites in the United States. Even though Latinos appear to have lower than expected mortality from CHD and CVD, the proportion of total deaths due to these two diseases is similar to that for whites in the United States and one cannot conclude that Latinos are protected from CHD or that they should be treated less aggressively than other groups. It is important to remember that Latinos are a heterogeneous group (ex. Puerto Ricans, Dominicans, Mexicans, Chileans, Venezuelans), and most of the data is based on Mexican Americans. (J Am Coll Cardiol 1997; JAMA 1993)

Another heterogenous group is Native Americans. Indian Health Service studies indicate that CVD mortality rates vary among different Native American communities and appear to be increasing. CVD is now the leading cause of death in Native Americans (CDC 2013). The CHD incidence rates among Native American men and women are higher than whites and are associated with higher mortality rates. The significant independent predictors of CVD in Native American women were hyperlipidemia, age, obesity, LDL, albuminuria, triglycerides, and hypertension. (Circulation 1999; Am J Epidemiology 1995)

Information on Asian-Americans (the fastest growing racial/ethnic group in the US) and Pacific Islanders is extremely limited. A prospective study is currently ongoing in Hawaii focusing on Japanese-American men. South Asians are a rapidly growing group within the United States. There is a higher CHD risk in this population, which may be related in part to a higher prevalence of the metabolic syndrome, insulin resistance, and hyperlipidemia. Efforts to reduce cholesterol and other CHD risk factors in this group with South Asian Indian ancestry appear to be extremely important. (Ann Epidemiol 1997; Metabolism 1998; Palaniappan et al 2010)

“Assuring quality health care for all persons requires that physicians understand how each patient’s socio-cultural background affects his or her health beliefs and behaviors.”
– J. Emilio Carrillo, MD, MPH; et al. (Annals of Internal Medicine 1999)

A competent physician today must face the challenge of caring for multicultural patients who speak various languages, have wide ranging socioeconomic status, different levels of acculturation, and unique ways of understanding illness and health care. The rates of patient satisfaction and adherence with medical regimens are closely related to the effectiveness of communication and the physician–patient relationship. Acquiring effective listening skills will allow you to improve clinical diagnosis and management, promote culturally responsive health education, avoid unnecessary medical testing, and lead to better understanding between you and your patients.