Elsevier

The Lancet

Volume 377, Issue 9765, 12–18 February 2011, Pages 578-586
The Lancet

Articles
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

https://doi.org/10.1016/S0140-6736(10)62038-7Get rights and content

Summary

Background

Data for trends in serum cholesterol are needed to understand the effects of its dietary, lifestyle, and pharmacological determinants; set intervention priorities; and evaluate national programmes. Previous analyses of trends in serum cholesterol were limited to a few countries, with no consistent and comparable global analysis. We estimated worldwide trends in population mean serum total cholesterol.

Methods

We estimated trends and their uncertainties in mean serum total cholesterol for adults 25 years and older in 199 countries and territories. We obtained data from published and unpublished health examination surveys and epidemiological studies (321 country-years and 3·0 million participants). For each sex, we used a Bayesian hierarchical model to estimate mean total cholesterol by age, country, and year, accounting for whether a study was nationally representative.

Findings

In 2008, age-standardised mean total cholesterol worldwide was 4·64 mmol/L (95% uncertainty interval 4·51–4·76) for men and 4·76 mmol/L (4·62–4·91) for women. Globally, mean total cholesterol changed little between 1980 and 2008, falling by less than 0·1 mmol/L per decade in men and women. Total cholesterol fell in the high-income region consisting of Australasia, North America, and western Europe, and in central and eastern Europe; the regional declines were about 0·2 mmol/L per decade for both sexes, with posterior probabilities of these being true declines 0·99 or greater. Mean total cholesterol increased in east and southeast Asia and Pacific by 0·08 mmol/L per decade (−0·06 to 0·22, posterior probability=0·86) in men and 0·09 mmol/L per decade (−0·07 to 0·26, posterior probability=0·86) in women. Despite converging trends, serum total cholesterol in 2008 was highest in the high-income region consisting of Australasia, North America, and western Europe; the regional mean was 5·24 mmol/L (5·08–5·39) for men and 5·23 mmol/L (5·03–5·43) for women. It was lowest in sub-Saharan Africa at 4·08 mmol/L (3·82–4·34) for men and 4·27 mmol/L (3·99–4·56) for women.

Interpretation

Nutritional policies and pharmacological interventions should be used to accelerate improvements in total cholesterol in regions with decline and to curb or prevent the rise in Asian populations and elsewhere. Population-based surveillance of cholesterol needs to be improved in low-income and middle-income countries.

Funding

Bill & Melinda Gates Foundation and WHO.

Introduction

Raised serum total cholesterol is an important cardiovascular risk factor, which causes an estimated 4·4 million deaths every year worldwide.1, 2, 3, 4 Variations in diet, especially consumption of animal-based versus plant-based fats, adiposity, and use of drugs to lower cholesterol have led to differences in serum cholesterol concentrations across populations and over time.5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19

Reliable population-based data for cholesterol trends are needed to assess the effects of diet, adiposity, and statin use; guide priority setting; and evaluate programmes. Investigators of the MONICA Project and other studies have analysed trends in serum cholesterol in specific communities and recorded changes as large as 0·7 mmol/L per decade.5, 9, 10, 18, 20, 21, 22, 23, 24, 25 Less is known about national trends, in high-income or developing countries.5, 17, 19, 26, 27, 28 Previous comparative cross-population analyses5, 8, 16, 18, 29 were based on a small number of data sources, used data that might not have been population based, did not explicitly address missing data for whole countries or for older ages, combined data from nationally representative surveys with subnational and community studies without distinguishing them, and did not quantify uncertainty. Our aim was to estimate trends in cholesterol by country, and to systematically quantify uncertainty.

Section snippets

Study design

We estimated 1980–2008 trends in mean serum total cholesterol and their uncertainties, by sex, for 199 countries and territories in 21 subregions of the Global Burden of Diseases, Injuries, and Risk Factors study, which are grouped into seven merged regions (webappendix p 16). Although LDL cholesterol, ratio of total to HDL cholesterol, and specific apolipoproteins might be better indicators of cardiovascular risk,1, 4, 30 our primary analysis was based on total cholesterol because our search

Results

Our analysis included 321 country-years of data for serum total cholesterol with 3·0 million participants (figure 1). 166 country-years were from 24 high-income countries and 155 from 66 low-income and middle-income countries, showing the global gap in lipids surveillance, even relative to blood pressure and BMI.31, 33 High-income Asia-Pacific, North America, and western Europe had the most data per country (webappendix pp 39–41). Japan had 20 years of national data since 1980, and the USA had

Discussion

Findings from our systematic analysis of worldwide serum total cholesterol have shown that the global average changed little between 1980 and 2008. This apparent lack of change stems from opposite trends in Australasia, North America, and Europe, where serum total cholesterol decreased from high concentrations, and in east and southeast Asia and Pacific, where it rose from low concentrations. Such polarised trends are arguably the most salient feature of this risk factor, especially relative to

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