Journal Information
Vol. 32. Issue 12.
Pages 987-996 (December 2013)
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Vol. 32. Issue 12.
Pages 987-996 (December 2013)
Original Article
Open Access
Characterization of lipid profile in primary health care users in Portugal
Caracterização do perfil lipídico nos utentes dos cuidados de saúde primários em Portugal
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Nuno Cortez-Diasa,b,c,
Corresponding author
cortezdias@yahoo.com

Corresponding author.
, Susana Robalo Martinsa,c, Adriana Belod, Manuela Fiúzaa,c, em nome dos Investigadores do Estudo VALSIM
a Serviço de Cardiologia, Hospital de Santa Maria, Centro Hospitalar de Lisboa Norte, Lisboa, Portugal
b Programa de Formação Médica Avançada da Fundação Calouste Gulbenkian, Fundação Champalimaud, Ministério da Saúde e Fundação para a Ciência e Tecnologia, Lisboa, Portugal
c Centro de Cardiologia da Universidade de Lisboa, Clínica Universitária de Cardiologia da Universidade de Lisboa, Lisboa, Portugal
d Centro Nacional de Colecção de Dados em Cardiologia, Sociedade Portuguesa de Cardiologia, Lisboa, Portugal
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Tables (7)
Table 1. Serum total cholesterol by gender and age-group.
Table 2. LDL-cholesterol levels by gender and age-group.
Table 3. Triglyceride levels by gender and age-group.
Table 4. HDL-cholesterol levels by gender and age-group.
Table 5. Lipid profile of the study population adjusted for gender, age and region of residence.
Table 6. Lipid profile of male population by age-group.
Table 7. Lipid profile of female population by age-group.
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Abstract
Aim

To characterize the distribution of total cholesterol (TC), LDL cholesterol (LDL-C), HDL cholesterol (HDL-C) and triglycerides in primary health care users.

Methods

We performed a cross-sectional study in a primary care setting, involving 719 general practitioners based on stratified distribution proportional to the population density of each region of Portugal. The first two adult patients scheduled for an appointment on a given day were invited to participate. A questionnaire was applied to assess sociodemographic, clinical and laboratory data, including lipid profile.

Results

The study included 16856 individuals (mean age 58.1±15.1 years; 61.6% women). Data on TC, LDL-C, HDL-C and triglycerides was available in 95.9% (n=16159), 59.1% (n=9956), 95.4% (n=16074) and 97.9% (n=16494) of the population, respectively. Hypercholesterolemia (TC ≥200 mg/dl) was detected in 47% and 38.4% had high levels of LDL-C (≥130 mg/dl). Hypertriglyceridemia (≥200 mg/dl) and low HDL-C (<40 mg/dl) were less prevalent, affecting roughly 13% of the population. Dyslipidemia was more common in midle-aged men and in post-menopausal women. Of the population aged over 40, 54.1% met eligibility criteria for lipid-lowering therapy and 44.7% were medicated with statins, but only 16.0% of these had TC ≤175 mg/dl.

Conclusions

Dyslipidemia is highly prevalent in primary health care users in Portugal. It is particularly common in middle-aged men and post-menopausal women, who should be considered target groups for preventive public health measures.

Keywords:
Hypercholesterolemia
Dislipidemia
Hypertriglyceridemia
Prevalence
Resumo
Objetivo

Caracterizar a distribuição dos níveis de colesterol total (CT), colesterol LDL (C-LDL), colesterol HDL (C-HDL) e triglicéridos nos utentes dos cuidados de saúde primários em Portugal.

Métodos

Estudo transversal envolvendo 719 médicos de família, segundo distribuição estratificada e proporcional à densidade populacional de cada região. Os primeiros dois utentes adultos de cada dia de consulta foram convidados a participar independentemente do motivo de consulta. Foi utilizado um inquérito para recolha de dados sociodemográficos, clínicos e laboratoriais, incluindo o perfil lipídico avaliado nos 12 meses precedentes.

Resultados

Foram avaliados 16.856 indivíduos (61,6% do sexo feminino, 58 ± 15 anos), dispondo-se da determinação de CT, C-LDL, C-HDL e triglicéridos em 95,9% (N = 16.159), 59,1% (N = 9.956), 95,4% (N = 16.074) e 97,9% (N = 16.494), respetivamente. Detetou-se hipercolesterolemia (≥ 200 mg/dl) em 47% e níveis aumentados de C-LDL (≥ 130 mg/dl) em 38,4%. A hipertrigliceridemia (≥ 200 mg/dl) e o C-HDL diminuído (< 40 mg/dl) foram menos prevalentes, afetando 13% da população. A dislipidemia foi mais frequente nos homens entre os 30-60 anos e nas mulheres pós-menopausa. Considerando a população com idade ≥ 40 anos, 54,1% dos indivíduos cumpriam critérios de elegibilidade para terapêutica hipolipidemiante e 44,7% estavam medicados com estatinas (mas apenas 16,0% desses apresentavam CT ≤ 175 mg/dl).

Conclusões A prevalência de dislipidemia é elevada entre os utentes adultos dos cuidados de saúde primários em Portugal. Além disso, é particularmente frequente nos homens entre os 30-60 anos e nas mulheres após a menopausa, que deverão constituir grupos-alvo nas estratégias preventivas de saúde pública.

Palavras-chave:
Hipercolesterolemia
Dislipidemia
Hipertrigliceridemia
Prevalência
List of abbreviations
CVD

cardiovascular disease

HDL-C

HDL cholesterol

LDL-C

LDL cholesterol

TC

total cholesterol

TG

triglycerides

Full Text
Introduction

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide and a major problem in Portugal, in terms of coronary artery disease and even more of stroke, the incidence of which is among the highest in the world.1,2 Furthermore, the incidence of CVD is increasing in developed and developing countries, the result of changes in lifestyles and increased prevalence of cardiovascular risk factors.3,4

Dyslipidemia is an important risk factor for CVD, since cholesterol is a central component of atheromatous plaques. The link between cholesterol levels and coronary and cerebrovascular disease has been clearly demonstrated.5,6 It is estimated that hypercholesterolemia is implicated in 56% of cases of coronary disease and 18% of cerebrovascular disease.7,8 At the same time, lowering levels of total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) with HMG-coenzyme A reductase inhibitors (statins) has been shown to reduce the incidence of CVD in primary prevention9–11 and the risk of recurrence in secondary prevention.12,13 The beneficial effect of lipid-lowering therapy on mortality rates means that assessment of global cardiovascular risk is now of fundamental importance.

Major medical societies have repeatedly reviewed optimum cholesterol levels for the general population and for those at increased risk, and have successively reduced the threshold for a diagnosis of hypercholesterolemia.14–16 It is now recognized that other changes in lipid profile also predispose to premature CVD. Atherogenic dyslipidemia is defined as a combination of high levels of triglycerides (TG), apolipoprotein B and small LDL particles, together with low levels of high-density lipoprotein cholesterol (HDL-C). It is also often associated with other cardiovascular risk factors in the form of metabolic syndrome.

The prevalence of dyslipidemia in Portugal has been investigated in various epidemiological studies at regional17–19 and national level,20,21 and estimated in a systematic review.22–24 However, these studies present considerable differences in diagnostic criteria, methodologies, target populations and method of assessing lipid levels. This makes the present analysis of lipid profile in adult primary health care users in Portugal of particular importance.

The aim of the present study was to characterize the distribution of TC, LDL-C, HDL-C and TG and to estimate the prevalence of dyslipidemia in primary health care users in Portugal. A second objective was to determine the prevalence of lipid-lowering therapy and to assess the level of control of lipid profile in those under such therapy.

Methods

The VALSIM study was a cross-sectional observational study of adult primary care users in Portugal.25 It involved 719 general practitioners, based on stratified and proportional distribution by district and region of mainland Portugal, Madeira and the Azores. The study was carried out between April 2006 and November 2007.

The first two adult patients scheduled for an appointment on a given day who met the study criteria were invited to participate, irrespective of the reason for the consultation and of the presence of cardiovascular risk factors. The inclusion criterion was the existence of laboratory test results for fasting glucose, HDL-C and TG performed in the previous year; the exclusion criterion was the presence of clinical conditions that could affect a diagnosis of metabolic syndrome, such as thyroid dysfunction. After informed consent was obtained, a questionnaire was applied to characterize sociodemographic, anthropometric, clinical (personal history, current medication, diet and physical activity) and laboratory data. Coronary artery disease was considered present when this diagnosis had been made by the attending physician, with no requirement for exams confirming the diagnosis and no distinction being made as to the clinical setting involved (angina, acute coronary syndrome or myocardial infarction). Stroke was considered present when this diagnosis had been made by the attending physician, with no requirement for exams confirming the diagnosis and no distinction being made as to the type (ischemic or hemorrhagic). Diabetes was defined as the presence of fasting glucose ≥126 mg/dl or below this level under therapy with oral antidiabetics or insulin.

The 10-year risk of cardiovascular death was estimated in the population aged over 40 by application of the SCORE system, using the charts for countries with low CVD risk.26 Individuals aged under 40 were not included in the analysis, while the risk for those aged over 65 was estimated by applying the charts for age 65. Patients with a history of coronary artery disease, stroke, diabetes or severe hyper-cholesterolemia (TC ≥320 mg/dl or LDL-C ≥240 mg/dl) were assumed to be at high baseline cardiovascular risk. Of the remaining patients, those with an estimated 10-year risk of cardiovascular death of ≥5% after stratification were also considered at high cardiovascular risk.

To enable comparison with previous studies in the Portuguese population, the prevalence of hypercholesterolemia was determined using different definitions: (1) serum TC ≥200 mg/dl; (2) TC ≥200 mg/dl or below this level under lipid-lowering therapy; and (3) different cut-offs according to estimated 10-year risk of cardiovascular death. In the latter case, hypercholesterolemia was considered present in individuals at low cardiovascular risk with TC ≥190 mg/dl (5 mmol/l), in those at high cardiovascular risk (due to previous history or after stratification) with TC ≥175 mg/dl (4.5 mmol/l), and in all those taking lipid-lowering drugs, irrespective of their estimated cardiovascular risk.

Patients with high cardiovascular risk and TC ≥175 mg/dl (4.5 mmol/l) were considered eligible for lipid-lowering therapy, as were those already under such therapy.

Statistical analysis

Categorical variables were analyzed to determine absolute and relative frequencies, with 95% confidence intervals. Prevalence rates were adjusted for gender and age by the total probability theorem, taking into account the demographic composition of the adult population resident in Portugal, by district and region, in 2000 (2001 Census, National Institute of Statistics [INE]). Categorical variables were compared using the chi-square test. Numerical variables were analyzed based on the number of observations, means, standard deviation, medians, and analysis of variance by Levene's test. Numerical variables with a normal distribution (as assessed by the Kolmogorov-Smirnov test) were compared using the Student's t test, and those with a non-normal distribution were compared using Kruskal-Wallis non-parametric tests. The statistical analysis was performed using SPSS, a level of significance of 5% being used in comparative analyses (p<0.05).

ResultsStudy population

The VALSIM study assessed 16 856 individuals, of whom 61.6% were women, with a mean age of 58±15 years. Data on serum TC, LDL-C, HDL-C and TG were available in 95.9% (n=16159), 59.1% (n=9956), 95.4% (n=16074) and 97.9% (n=16494), respectively.

Of the individuals assessed, 14 251 were aged ≥40 years (male [M]: 5573; female [F]: 8678). Of this population, 29.5% (M: 34.4%; F: 25.4%) met at least one criterion for high cardiovascular risk based on previous history: 8.2% (M: 9.5%; F: 7.2%) had coronary artery disease, 3.3% (M: 3.7%; F: 2.8%) a history of cerebrovascular disease, 22.1% (M: 25.3%; F: 19.4%) diabetes, and 1.5% (M: 1.8%; F: 1.2%) severe hypercholesterolemia (TC ≥320 mg/dl or LDL-C ≥240 mg/dl). A further 3.7% (M: 6.9%; F: 0.8%) were placed in the high-risk group after stratification (estimated 10-year risk ≥5%).

Serum lipid levels

Mean TC in the study population was 206±41 mg/dl, and 200±40 mg/dl adjusted for gender and age, with no difference between the sexes (M: 200±42 mg/dl; F: 200±38 mg/dl). Mean LDL-C was 126±37 mg/dl, and 122±36 mg/dl adjusted for gender and age (M: 123±37 mg/dl; F: 120±35 mg/dl). TC and LDL-C levels increased and then decreased with age (Tables 1 and 2). Up to the fifth decade of life, TC and LDL-C levels were higher in men, while in older individuals they were higher in women (Table 3).

Table 1.

Serum total cholesterol by gender and age-group.

Gender and age-group  Cholesterol (mean ± SD)  Percentile
      10  15  25  50  75  85  90  95 
Men  6163  204±42  141  154  163  177  200  230  246  259  277 
18–29  240  182±39  123  136  144  159  180  201  222  232  246 
30–39  449  201±41  143  154  162  174  199  226  240  256  273 
40–49  792  213±45  146  160  168  184  210  240  260  271  294 
50–59  1348  211±44  146  159  169  181  207  237  255  265  288 
60–69  1648  205±41  142  156  165  179  202  230  247  259  276 
70–79  1346  198±40  138  151  159  173  195  220  239  248  264 
≥80  317  195±40  134  148  157  169  191  218  235  249  265 
Women  9889  207±40  148  160  168  180  203  230  246  258  277 
18–29  521  183±37  132  141  149  160  179  204  215  224  246 
30–39  824  189±35  136  148  155  168  187  208  224  232  250 
40–49  1406  200±36  145  156  164  176  198  221  238  247  260 
50–59  2146  213±39  156  167  175  187  210  237  251  265  283 
60–69  2527  212±40  153  165  173  185  210  235  252  263  281 
70–79  1982  210±40  151  163  172  183  207  233  250  263  282 
≥80  449  209±41  152  163  170  183  206  232  251  261  283 
Total  16 159  206±41  145  158  166  179  202  230  246  258  277 
Table 2.

LDL-cholesterol levels by gender and age-group.

Gender and age-group  LDL cholesterol (mean ± SD)  Percentile
      10  15  25  50  75  85  90  95 
Men  3807  126±38  68  81  90  100  124  149  164  174  190 
18–29  134  110±34  62  73  78  88  106  128  143  160  177 
30–39  271  124±36  71  85  88  98  121  148  164  171  189 
40–49  487  130±40  70  80  90  103  130  155  170  184  196 
50–59  822  132±39  74  85  94  106  128  155  169  183  201 
60–69  1019  127±38  68  82  93  101  126  150  164  174  186 
70–79  852  121±35  67  79  87  98  120  141  157  166  180 
≥80  210  120±36  55  72  86  100  118  145  157  168  182 
Women  6085  126±37  71  82  90  101  124  148  162  173  190 
18–29  294  103±29  60  68  75  84  100  121  131  137  157 
30–39  456  114±35  64  73  79  91  110  133  149  156  178 
40–49  841  120±34  67  79  86  97  119  142  155  164  178 
50–59  1326  131±37  74  86  94  107  129  154  169  179  196 
60–69  1624  131±36  76  87  96  107  129  152  166  178  192 
70–79  1271  127±36  72  86  94  103  125  148  162  174  190 
≥80  255  129±41  70  81  90  101  123  150  172  181  200 
Total  9956  126±37  70  81  90  101  124  149  162  173  190 
Table 3.

Triglyceride levels by gender and age-group.

Gender and age-group  Triglycerides (mean ± SD)  Percentile
      10  15  25  50  75  85  90  95 
Men  6.304  146±94  58  68  76  91  125  176  209  240  296 
18–29  245  120±78  43  53  61  72  98  143  165  201  282 
30–39  459  153±106  57  67  76  90  124  180  224  259  337 
40–49  816  169±120  61  73  82  96  136  200  258  299  374 
50–59  1388  157±105  62  74  83  96  137  188  218  250  326 
60–69  1676  147±88  61  72  78  93  129  178  208  237  278 
70–79  1374  128±66  54  64  70  82  113  157  187  207  241 
≥80  323  126±60  59  64  69  87  111  150  180  197  235 
Women  10 078  127±70  54  63  70  82  112  153  181  204  248 
18–29  530  102±83  45  54  59  69  90  121  140  154  182 
30–39  830  109±58  44  52  59  71  98  134  158  180  217 
40–49  1434  117±66  47  56  61  73  102  142  168  192  245 
50–59  2189  129±69  54  63  70  82  113  155  185  210  259 
60–69  2579  135±75  60  69  76  89  119  161  190  215  263 
70–79  2026  134±65  62  72  79  91  119  162  189  213  250 
≥80  457  128±56  64  72  80  90  117  153  172  193  224 
Total  16 494  134±80  55  65  72  85  117  161  192  217  268 

Mean TG adjusted for gender and age was 132±81 mg/dl, and was significantly higher in men (M: 146±96 mg/dl vs. F: 119±69 mg/dl; p<0.001). TG also increased and then decreased with age, and was higher in men of all age-groups (Table 4); furthermore, the highest mean values were seen at an earlier age in men.

Table 4.

HDL-cholesterol levels by gender and age-group.

Gender and age-group  HDL-cholesterol (mean ± SD)  Percentile
      10  15  25  50  75  85  90  95 
Men  6161  51±18  33  36  38  42  48  57  63  68  76 
18–29  237  51±15  32  35  37  42  49  58  61  65  70 
30–39  448  50±16  32  36  37  40  47  55  60  65  75 
40–49  794  50±16  32  35  36  40  47  56  61  68  74 
50–59  1369  51±16  33  36  38  42  48  57  62  66  74 
60–69  1635  52±18  33  37  39  42  49  58  64  68  76 
70–79  1347  52±19  33  36  39  42  49  58  65  69  78 
≥80  309  53±22  32  36  38  42  49  59  65  70  78 
Women  9801  57±18  37  40  43  47  55  65  70  75  83 
18–29  500  60±16  38  42  45  50  58  67  72  79  86 
30–39  795  59±18  37  41  44  48  57  66  72  78  84 
40–49  1382  58±18  37  41  44  47  56  65  70  76  84 
50–59  2132  57±18  37  40  42  47  55  65  70  75  84 
60–69  2529  56±17  37  40  42  47  54  63  69  74  81 
70–79  1986  58±20  37  40  42  47  55  65  71  76  84 
≥80  447  57±16  37  41  43  47  55  66  73  78  86 
Total  16 074  55±18  35  38  41  45  52  62  68  73  81 

Mean HDL-C adjusted for gender and age was 55±17 mg/dl, and was significantly lower in men (M: 51±17 mg/dl vs. F: 58±18 mg/dl; p<0.001), but did not vary significantly with age (Table 6).

Prevalence of dyslipidemia

The estimated prevalence of hypercholesterolemia in primary health care users was 47.0% (unadjusted: 53.2%), based on a TC cut-off of 200 mg/dl; 57.9% (unadjusted: 64.4%) presented TC ≥190 mg/dl, and 11.4% (unadjusted: 13.4%) had TC ≥250 mg/dl. Overall prevalence was similar in both sexes (Table 5), but varied significantly with age, tending to be higher in middle-aged men, but in older age-groups women tended to predominate (Figure 1, Table 6). Elevated LDL-C (≥130 mg/dl) was found in 38.4% of the population, with a similar proportion in both sexes.

Table 5.

Lipid profile of the study population adjusted for gender, age and region of residence.

Variable  Men  Women  Total 
Total cholesterol
<200 mg/dl  53.1%  52.9%  53.0% 
200–239 mg/dl  30.1%  31.9%  31.0% 
≥240 mg/dl  16.9%  15.2%  16.0% 
≥200 mg/dl  46.9%  47.1%  47.0% 
LDL cholesterol
<100 mg/dl  26.3%  28.7%  27.6% 
100–129 mg/dl  33.0%  35.0%  34.0% 
130–159 mg/dl  24.2%  23.5%  23.8% 
160–189 mg/dl  11.4%  8.6%  10.0% 
≥190 mg/dl  5.0%  4.2%  4.6% 
≥130 mg/dl  40.7%  36.3%  38.4% 
Triglycerides
<150 mg/dl  65.8%  76.8%  71.6% 
150–199 mg/dl  17.5%  14.2%  15.8% 
200–499 mg/dl  15.5%  8.7%  12.0% 
≥500 mg/dl  1.2%  0.2%  0.7% 
≥200 mg/dl  16.7%  9.0%  12.7% 
HDL cholesterol
≥60 mg/dl  20.2%  40.6%  30.9% 
40–59 mg/dl  60.9%  52.2%  56.3% 
<40 mg/dl  18.9%  7.2%  12.8% 
Figure 1.

Prevalence of hypercholesterolemia (≥200 mg/dl) by gender and age.

(0.14MB).
Table 6.

Lipid profile of male population by age-group.

Variable  Age-group
  18–29  30–39  40–49  50–59  60–69  70–79  ≥80  Total 
Total cholesterol
<200 mg/dl  72.1%  50.6%  39.0%  42.8%  46.2%  54.9%  58.4%  53.1% 
200–239 mg/dl  21.3%  34.1%  35.5%  33.5%  34.6%  30.3%  28.7%  30.1% 
≥240 mg/dl  6.7%  15.4%  25.5%  23.7%  19.2%  14.8%  12.9%  16.9% 
LDL cholesterol
<100 mg/dl  40.3%  27.3%  22.4%  17.8%  22.0%  25.9%  24.3%  26.3% 
100–129 mg/dl  35.1%  29.5%  26.1%  34.5%  32.2%  36.2%  38.6%  33.0% 
130–159 mg/dl  14.2%  26.2%  30.4%  25.9%  27.4%  24.2%  23.3%  24.2% 
160–189 mg/dl  8.2%  12.5%  14.2%  13.5%  14.1%  10.1%  11.4%  11.4% 
≥190 mg/dl  2.2%  4.4%  7.0%  8.3%  4.3%  3.6%  2.4%  5.0% 
Triglycerides
<150 mg/dl  77.1%  63.8%  57.7%  58.1%  61.4%  71.1%  73.7%  65.8% 
150–199 mg/dl  13.1%  15.0%  17.3%  21.2%  21.1%  17.0%  17.0%  17.5% 
200–499 mg/dl  9.8%  19.2%  22.3%  19.4%  16.7%  11.5%  9.3%  15.5% 
≥500 mg/dl  0.0%  2.0%  2.7%  1.4%  0.8%  0.4%  0.0%  1.2% 
HDL cholesterol
≥60 mg/dl  21.9%  17.4%  18.1%  19.6%  21.7%  22.9%  23.0%  20.2% 
40–59 mg/dl  59.5%  60.9%  58.1%  60.9%  61.8%  60.2%  58.9%  60.9% 
<40 mg/dl  18.6%  21.7%  23.8%  19.4%  16.6%  16.9%  18.1%  18.9% 

Hypertriglyceridemia (≥200 mg/dl) was detected in 12.7% and low HDL-C (<40 mg/dl) in 12.8%; both were more common in men (OR: 1.43; 95% CI 1.37–1.48; p<0.001 and OR: 1.59; 95% CI 1.55–1.63; p<0.001, respectively) (Table 5).

The prevalence of lipid disorders increased and then decreased with age (Figures 1–3), the highest prevalences being found in the fourth decade of life in men (Table 6), and one or two decades later in women (Table 7).

Figure 2.

Prevalence of hypertriglyceridemia (≥200 mg/dl) by gender and age.

(0.12MB).
Figure 3.

Prevalence of low HDL cholesterol (<40 mg/dl) by gender and age.

(0.12MB).
Table 7.

Lipid profile of female population by age-group.

Variable  Age-group
  18–29  30–39  40–49  50–59  60–69  70–79  ≥80  Total 
Total cholesterol
<200 mg/dl  72.4%  64.2%  52.4%  39.3%  39.3%  42.6%  43.9%  52.9% 
200–239 mg/dl  21.7%  28.0%  33.4%  38.3%  38.9%  36.8%  35.9%  31.9% 
≥240 mg/dl  6.0%  7.8%  14.2%  22.4%  21.8%  20.6%  20.3%  15.2% 
LDL cholesterol
<150 mg/dl  88.3%  81.7%  78.9%  72.1%  68.8%  67.8%  73.3%  76.8% 
150–199 mg/dl  9.2%  11.6%  12.3%  16.1%  17.9%  19.8%  18.6%  14.2% 
200–499 mg/dl  2.3%  6.6%  8.6%  11.5%  12.9%  11.9%  7.9%  8.7% 
≥500 mg/dl  0.2%  0.1%  0.2%  0.2%  0.4%  0.4%  0.2%  0.2% 
Triglycerides
<100 mg/dl  46.6%  36.4%  27.6%  18.5%  17.9%  20.1%  22.0%  28.7% 
100–129 mg/dl  35.7%  34.9%  34.5%  32.3%  33.4%  36.2%  34.9%  35.0% 
130–159 mg/dl  13.9%  19.7%  26.4%  28.2%  29.3%  27.0%  23.9%  23.5% 
160–189 mg/dl  2.7%  5.9%  8.7%  13.7%  13.9%  11.4%  12.5%  8.6% 
≥190 mg/dl  1.0%  3.1%  2.9%  7.3%  5.6%  5.3%  6.7%  4.2% 
HDL cholesterol
≥60 mg/dl  46.8%  42.5%  38.7%  35.8%  34.4%  36.1%  36.7%  40.6% 
40–59 mg/dl  47.4%  50.3%  54.1%  55.3%  56.9%  55.0%  55.9%  52.2% 
<40 mg/dl  5.8%  7.2%  7.2%  8.9%  8.6%  8.9%  7.4%  7.2% 

When hypercholesterolemia was defined as TC ≥200 mg/dl or below this threshold under lipid-lowering therapy, its prevalence rose to 63.7% (unadjusted 73.5%), with no significant difference between the sexes (M: 63.9%; F: 63.4%).

When account was taken of both 10-year risk of cardiovascular death and TC levels, the prevalence of hypercholesterolemia in the study population reached 82.2% (M: 83.1%; F: 81.4%; p<0.001).

Lipid-lowering therapy

Of the population aged ≥40 years, 54.1% met eligibility criteria for lipid-lowering therapy (M: 57.8%; F: 50.8%); this finding was significantly more common in men (OR: 1.45; 95% CI 1.31–1.61; p<0.001) and increased with age (Figure 4).

Figure 4.

Eligibility for lipid-lowering therapy.

(0.15MB).

In this patient subgroup, 44.7% were medicated with statins (M: 45.4%; F: 44.0%), and of those with indication for lipid-lowering therapy, 77.7% were receiving treatment, with a higher proportion of women (M: 73.6%; F: 81.4%). However, of those medicated with statins, only 16.0% had controlled TC (≤175 mg/dl) – M: 18.6%; F: 13.8% – and only 12.8% had controlled levels of both TC (≤175 mg/dl) and LDL-C (<100 mg/dl) – M: 15.1%; F: 10.8%.

Discussion

The present study shows that there is a high prevalence of dyslipidemia among adult primary health care users in Portugal. Hypercholesterolemia was detected in 47% of the study population (based on a TC cut-off of 200 mg/dl), and 38.4% had LDL-C ≥130 mg/dl. Elevated TG (≥200 mg/dl) and low HDL-C (<40 mg/dl) were less prevalent, affecting under 13% of the population.

The prevalence of CVD has progressively increased, initially in developed countries and more recently in developing countries, in parallel with changes in lifestyle and increases in body weight. The prevalence of obesity has also risen in the last ten years in Portugal,27,28 and is now estimated at 16.8% of men and 21.8% of women.29 The adverse epidemiological impact of cardiovascular risk factors would probably be even greater were it not for the implementation of preventive measures designed to improve their control. For example, improved detection and treatment of hypertension has led to a progressive reduction in mean blood pressure values worldwide over the last 30 years.30 However, the effect of various interventions designed to improve lipid profile has probably been more limited; despite the availability and widespread use of powerful lipid-lowering drugs, mean TC levels have remained virtually unchanged worldwide over the same period.31 It is thus particularly important to assess a population's lipid profile and the extent of control of dyslipidemia.

Mean TC adjusted for gender and age in our population of adult primary health care users (200±40 mg/dl) is similar to that observed in developed countries of western Europe, North America and south-east Asia (M: 203 mg [196–208 mg]; F: 202 mg [195–210 mg]).30 Although overall mean TC levels are similar in both sexes, there are significant differences with age. TC, LDL-C and TG increase with age, reaching maximum values in men aged 40–49 and in women aged 50–59, the differences being more marked in younger age-groups, and with significantly higher levels in men. The differences between the sexes tend to disappear or reverse in older individuals, with slightly higher levels in women. These changes in lipid profile with age have also been reported in other studies.32

The prevalence of dyslipidemia in Portugal has been investigated in various epidemiological studies at regional17–19 and national level20,21 and estimated in a systematic review.22–24 Seventy-one percent of these studies used a TC cut-off of ≥200 mg/dl as the criterion of hypercholesterolemia and reported an estimated prevalence ranging between 47% and 75%.22–24 The 2001 BECEL epidemiological study, aimed at characterizing lipid profile in the Portuguese population, included 1500 individuals aged 18–96 years.22–24 Hypercholesterolemia (defined as TC ≥190 mg/dl) was found in 68.5% (95% CI 66.4–70.5); 23.4% had TC ≥240 mg/dl, and 71% presented LDL-C ≥115 mg/dl. The ALTO-MAR study (2001) included 16.763 individuals, of whom 23.4% presented TC ≥240 mg/dl and 21.8% ≥250 mg/dl.22–24 Comparison between these studies is hindered by the use of different definitions of dyslipidemia, the result of the varying diagnostic cut-offs used in international guidelines.

The VALSIM study was based on the NCEP ATP III recommendations15 and the results presented in this article are based on these cut-offs. However, to facilitate comparison with epidemiological studies using different definitions, we also estimated prevalence based on other commonly used cut-offs. Our results suggest a lower prevalence of dyslipidemia among primary health care users in Portugal: 47% had TC ≥200 mg/dl and 16% had ≥240 mg/dl. These values are in line with estimated prevalences of hypercholesterolemia in other southern European countries, including Spain, where it is estimated that 20% of adults present TC >250 mg/dl and 50% present ≥200 mg/dl.33,34

Our study also indicates that 44.7% of primary health care users aged over 40 are being treated with statins, which is reflected in increased expenditure on lipid-lowering drugs in Portugal. According to a study by Teixeira et al.,35 the number of daily doses per 1000 population rose from 10.21 in 1995 to 67.93 in 2004. There was thus an annual mean increase of 34.5% in the use of statins during that period, and expenditure on lipid-lowering drugs accounted for 5% of outpatient medication costs (123 million euros) in 2003.

The finding of such a high prevalence and poor control of hypercholesterolemia points to the need for public health measures, particularly promotion of a healthy diet, to complement pharmacological treatment in high-risk groups.

Study limitations

The present study was performed in a primary health care setting, as this is a reliable way of recruiting a large sample of individuals that is representative of a country's different regions. However, caution is required in extrapolating the results to the overall population, since important differences may exist between the population followed in primary health care and others. Furthermore, while the method of selection (the first two patients on any given day) is intended to be random, it may be affected by inequalities in access to health services.

Given the size of the study, laboratory tests were not performed by a single central laboratory. Nevertheless, laboratories in Portugal undergo certification and quality control, which minimizes variation in references values and makes comparison of results acceptable.

Ten-year risk of cardiovascular death was only calculated for those aged over 40, with no upper age limit; for the purposes of the study, individuals aged over 65 were assessed using the formula applicable to those aged 65. This method may have underestimated the actual cardiovascular risk in older individuals, but does not compromise the overall interpretation of the results.

When assessing the prevalence of lipid-lowering therapy, all patients taking such medication were considered eligible for the therapy; the study did not set out to assess the appropriateness of any decision to institute lipid-lowering therapy on the part of attending physicians.

Conclusions

Dyslipidemia is highly prevalent in primary health care users in Portugal, with elevated TC levels (≥200 mg/dl) in 47%. The study's results contribute to the epidemiological characterization of cardiovascular risk in the Portuguese population, which is essential for the planning of appropriate preventive public health measures. In addition, the study updates estimates of prevalence reported by previous studies and provides data on prevalences by gender and age and using different diagnostic cut-offs.

Conflicts of interest

The authors have no conflicts of interest to declare.

References
[1]
M. Correia, M.R. Silva, I. Matos, et al.
Prospective community-based study of stroke in Northern Portugal: incidence and case fatality in rural and urban populations.
[2]
A.F. Goncalves, S.M. Cardoso.
The prevalence of cerebrovascular stroke in Coimbra.
Acta Med Port, 10 (1997), pp. 543-550
[3]
P. de Sá, J.A. Dias, J.M. Miguel.
The evolution of mortality from ischemic heart disease and cerebrovascular diseases in Portugal in the decade of the 80s.
Acta Med Port, 7 (1994), pp. 71-81
[4]
M. Mirzaei, A.S. Truswell, K. Arnett, et al.
Cerebrovascular disease in 48 countries: secular trends in mortality.
J Neurol Neurosurg Psychiatry, 83 (2012), pp. 138-145
[5]
J. Stamler, M.L. Daviglus, D.B. Garside, et al.
Relationship of baseline serum cholesterol levels in 3 large cohorts of younger men to long-term coronary, cardiovascular, and all-cause mortality and to longevity.
JAMA, 284 (2000), pp. 311-318
[6]
M.J. Pencina, R.B. d’Agostino Sr., M.G. Larson, et al.
Predicting the 30-year risk of cardiovascular disease: the Framingham heart study.
Circulation, 119 (2009), pp. 3078-3084
[7]
M. Gouveia, M. Borges, J. Costa, et al.
Burden of disease from hypercholesterolemia in Portugal.
Rev Port Cardiol, 23 (2004), pp. 255-270
[8]
M. Gouveia, M. Borges, J. Costa, et al.
Costs of illness due to hypercholesterolemia in Portugal.
Rev Port Cardiol, 23 (2004), pp. 1037-1054
[9]
A.M. Gotto Jr., E. Whitney, E.A. Stein, et al.
Relation between baseline and on-treatment lipid parameters and first acute major coronary events in the Air Force/Texas Coronary Atherosclerosis Prevention Study (AFCAPS/TexCAPS).
Circulation, 101 (2000), pp. 477-484
[10]
J. Shepherd, S.M. Cobbe, I. Ford, West of Scotland Coronary Prevention Study Group, et al.
Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia.
N Engl J Med, 333 (1995), pp. 1301-1307
[11]
B. Dahlof, P.S. Sever, N.R. Poulter, et al.
Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial.
[12]
C. Baigent, A. Keech, P.M. Kearney, et al.
Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins.
[13]
R. de Caterina, M. Scarano, R. Marfisi, et al.
Cholesterol-lowering interventions and stroke: insights from a meta-analysis of randomized controlled trials.
J Am Coll Cardiol, 55 (2010), pp. 198-211
[14]
A.L. Catapano, Z. Reiner, B.G. de Backer, et al.
ESC/EAS Guidelines for the management of dyslipidaemias The Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS).
Atherosclerosis, 217 (2011), pp. 3-46
[15]
National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III), 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) final report.
Circulation, 106 (2002), pp. 3143-3421
[16]
J. Genest, J. Frohlich, G. Fodor, et al.
Recommendations for the management of dyslipidemia and the prevention of cardiovascular disease: Summary of the 2003 update.
CMAJ, 169 (2003), pp. 921-924
[17]
L. Nunes, J. Pipa, C. Nascimento, et al.
Prevalence of several cardiovascular risk factors in a population in the municipality of Viseu.
Rev Port Cardiol, 16 (1997), pp. 703-707
[18]
V. Schneider, J. Cruz, D. Lopes, et al.
The prevalence of the principal cardiovascular risk factors in the population of the Azores.
Rev Port Cardiol, 14 (1995), pp. 1019-1027
[19]
P. von Hafe, C. Lopes, M.J. Maciel, et al.
The clustering of cardiovascular risk factors in the urban population of Porto.
Acta Med Port, 11 (1998), pp. 1059-1064
[20]
L.M. Santiago.
Incidence and prevalence of hypercholesterolemia in Portugal.
Rev Port Cardiol, 22 (2003), pp. 1283-1284
[21]
R.P. dos Reis, H.P. dos Reis.
Cardiovascular risk factors in the list of patients of a general practitioner.
Rev Port Cardiol, 9 (1990), pp. 607-612
[22]
J. Costa, M. Borges, E. Oliveira, et al.
Incidence and prevalence of hypercholesterolemia in Portugal: a systematic review. Part I.
Rev Port Cardiol, 22 (2003), pp. 569-577
[23]
J. Costa, M. Borges, E. Oliveira.
Incidence and prevalence of hypercholesterolemia in Portugal: a systemic review. Part II.
Rev Port Cardiol, 22 (2003), pp. 683-702
[24]
J. Costa, M. Borges, E. Oliveira, et al.
Incidence and prevalence of hypercholesterolemia in Portugal: a systematic review. Part III.
Rev Port Cardiol, 22 (2003), pp. 829-836
[25]
M. Fiuza, N. Cortez-Dias, S. Martins, et al.
Metabolic syndrome in Portugal: prevalence and implications for cardiovascular risk – results from the VALSIM Study.
Rev Port Cardiol, 27 (2008), pp. 1495-1529
[26]
R.M. Conroy, K. Pyorala, A.P. Fitzgerald, et al.
Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project.
Eur Heart J, 24 (2003), pp. 987-1003
[27]
I. do Carmo, O. dos Santos, J. Camolas, et al.
Overweight and obesity in Portugal: national prevalence in 2003–2005.
[28]
H.F. Carreira, M.F. Pereira, A.F. Azevedo, et al.
Trends of BMI and prevalence of overweight and obesity in Portugal (1995–2005): a systematic review.
Public Health Nutr, 15 (2012), pp. 972-981
[29]
L.B. Sardinha, D.A. Santos, A.M. Silva, et al.
Prevalence of overweight, obesity, and abdominal obesity in a representative sample of Portuguese adults.
[30]
G.F. Danaei, M.M. Finucane, J. Lin, et al.
National, regional, and global trends in systolic blood pressure since 1980: systematic analysis of health examination surveys and epidemiological studies with 786 country-years and 5.4 million participants.
[31]
F.F. Farzadfar, M.M. Finucane, G. Danaei, et al.
National, regional, and global trends in serum total cholesterol since 1980: systematic analysis of health examination surveys and epidemiological studies with 321 country-years and 3.0 million participants.
[32]
C.D. Gardner, M.A. Winkleby, S.P. Fortmann.
Population frequency distribution of non-high-density lipoprotein cholesterol (Third National Health and Nutrition Examination Survey [NHANES III], 1988–1994).
Am J Cardiol, 86 (2000), pp. 299-304
[33]
M.J. Medrano, E. Cerrato, R. Boix, et al.
Cardiovascular risk factors in Spanish population: metaanalysis of cross-sectional studies.
Med Clin (Barc), 124 (2005), pp. 606-612
[34]
O.F. Vegazo, J.R. Banegas, F. Civeira, et al.
Prevalence of dyslipidemia in outpatients of the Spanish health service: the HISPALIPID Study.
Med Clin (Barc), 127 (2006), pp. 331-334
[35]
I.J. Teixeira, A. Escoval, M. Schiappa.
Lipid-lowering drugs: use and expenditure in Portugal (1995–2004).
Rev Port Cardiol, 26 (2007), pp. 475-493

Please cite this article as: Cortez-Dias N, Robalo Martins S, Belo A, Fiúza M, em nome dos Investigadores do Estudo VALSIM. Caracterização do perfil lipídico nos utentes dos cuidados de saúde primários em Portugal. Rev Port Cardiol. 2013;32:987–996.

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