Prevlene of Coronry Hert Disese Risk Ftors n Sreening for High Cholesterol Levels Among Young Aults, Unite Sttes, 1999 2006 Elen V. Kuklin, MD, PhD Pul W. Yoon, SD, MPH Nor L. Keenn, PhD Division for Hert Disese n Stroke Prevention, Ntionl Center for Chroni Disese Prevention n Helth Promotion, Centers for Disese Control n Prevention, Atlnt, Georgi ABSTRACT PURPOSE Previous stuies hve reporte low rtes of sreening for high holesterol levels mong young ults in the Unite Sttes. Although reommentions for sreening young ults without risk ftors for oronry hert isese (CHD) iffer, ll guielines reommen sreening ults with CHD, CHD equivlents, or 1 or more CHD risk ftors. This stuy exmine ntionl prevlene of CHD risk ftors n ompline with the holesterol sreening guielines mong young ults. METHODS Ntionl estimtes were otine using results for 2,587 young ults (men ge 20 to 35 yers; women ge 20 to 45 yers) from the 1999 2006 Ntionl Helth n Nutrition Exmintion Surveys. We efine high low-ensity lipoprotein holesterol (LDL-C) s levels higher thn the gol speifi for eh CHD risk tegory outline in the Ntionl Cholesterol Eution Progrm Ault Tretment Pnel III guielines. RESULTS Aout 59% of young ults h CHD or CHD equivlents, or 1 or more of the following CHD risk ftors: fmily history of erly CHD, smoking, hypertension, or oesity. In our stuy, the overll sreening rte in this popultion ws less thn 50%. Moreover, no signifint ifferene in sreening rtes etween young ults with no risk ftors n their ounterprts with 1 or more risk ftors ws foun even fter justment for soioemogrphi n helth re ftors. Approximtely 65% of young ults with CHD or CHD equivlents, 26% of young ults with 2 or more risk ftors, 12% of young ults with 1 risk ftor, n 7% with no risk ftor h high level of LDL-C. CONCLUSIONS CHD risk ftors re ommon in young ults ut o not pper to lter sreening rtes. Improvement of risk ssessment n mngement for riovsulr isese mong young ults is wrrnte. Ann Fm Me 2010;8:327-333. oi:10.1370/fm.1137. Confl its of interest: none reporte CORRESPONDING AUTHOR Elen V. Kuklin, MD, PhD Division for Hert Disese n Stroke Prevention Centers for Disese Control n Prevention 4770 Bufor Hwy, NE, Milstop K-47 Atlnt, GA 30341 ekuklin@.gov INTRODUCTION An norml lipi profi le is highly ommon ut moifi le risk ftor for oronry hert isese (CHD), leing use of mortlity in the Unite Sttes. The importne of sreening for ientifi tion n linil mngement of yslipiemi is reognize y severl professionl ssoitions n puli helth orgniztions. 1,2 The Ntionl Cholesterol Eution Progrm Ault Tretment Pnel III (NCEP ATP III), enorse y the Amerin Hert Assoition n the Ntionl Hert, Lung, n Bloo Institute, reommens universl sreening for high holesterol levels eginning t ge 20 yers. 2 The US Preventive Servies Tsk Fore (USPSTF) votes trgete holesterol sreening pproh for young ults (men ge 20 to 35 yers n women ge 20 to 327
45 yers). The USPSTF reommens sreening young ults with CHD, CHD equivlents (other forms of therosleroti vsulr isese, ietes, or CHD risk of 20% or greter within 10 yers), or 1 or more CHD risk ftors (high loo pressure, smoking, fmily history, n oesity). 1 There re no speifi USPSTF reommentions for persons who o not hve CHD risk ftors. Thus lthough sreening guielines vry, there is greement onerning the nee to sreen young ults who re t inrese risk of CHD. Previous reports se on the Behviorl Risk Ftor Surveillne System t inite low sreening rte mong young ults. In 2003 only out 60% of US ults ge 20 to 44 yers h h their holesterol levels heke in the preeing 5 yers, ompre with 85% n 89% of ults ge 45 to 64 yers n 65 yers n oler, respetively. 3 Although the use of rug therpy to tret high levels of low-ensity lipoprotein holesterol (LDL-C) my e inite in smll proportion of young ults, therpeuti lifestyle hnges woul e suffi ient to mnge high LDL-C mong most young ults. 2 Dt on ompline with holesterol-sreening guielines mong young ults n the prevlene of high LDL-C re sre, however. This stuy, whih relie on t for 1999 to 2006 from the Ntionl Helth n Nutrition Exmintion Survey (NHANES) of young ults (men ge 20 to 35 yers n women ge 20 to 45 yers), h 3 ojetives to etermine: (1) the proportion of persons with CHD, CHD equivlents, or CHD risk ftors; (2) rtes of the self-reporte sreening for high holesterol levels tht h een performe efore the stuy; n (3) the prevlene of high LDL-C levels tht h een ssesse y fsting lipi testing uring the NHANES. METHODS Stuy Prtiipnts NHANES is ontinuous survey of the helth n nutritionl sttus of the US ivilin, noninstitutionlize popultion; prtiipnts re selete through omplex, multistge proility esign. 4 Eh yer, pproximtely 6,000 prtiipnts re selete to prtiipte in the stuy. Persons who gree to prtiipte re fi rst interviewe in their homes out their helth, isese history, n iet. interviewe prtiipnts re invite to lol Moile Exm Center for ministrtion of itionl questionnires, physil exmintions, n lortory tests. NHANES t re relese in 2-yer inrements; the present nlysis ws onute with t from the 4 most reent stuy yles: 1999-2000, 2001-2002, 2003-2004, n 2005-2006. The overll response rtes for omplete exmintions mong ll sreene prtiipnts for the stuy yles were 76% (9,282 of 12,160), 80% (10,477 of 13,156), 76% (9,643 of 12,761), n 77% (9,950 of 12,862), respetively. In this stuy, to inrese the smple size n nlyti options, t from the 4 stuy yles were omine into 1 t set. Among 39,352 prtiipnts invite to the Moile Exm Center, 13,875 were rnomly selete to fst 8 or more hours (up to 24 hours) for lortory testing. As i the other susmples, the fsting susmple hs its own esignte weight, whih tkes into ount the omplex survey esign, survey nonresponse, n poststrtifi tion in representing the US ivilin, noninstitutionlize ensus popultion. After exlusion of 10,663 prtiipnts ge younger thn 20 yers, men 35 yers or oler, or women 45 yers or oler, our stuy smple onsiste of 3,212 prtiipnts. Women who h positive urine pregnny test or who reporte tht they were pregnnt (n = 462), s well s prtiipnts with missing lipi profi le t or loo pressure t (n = 163), were exlue, leving n nlytil smple of 2,587 prtiipnts. Assessment of CHD Risk Ftors Prtiipnts with self-reporte history of CHD (ngin or myoril infrtion) were ientifi e s prtiipnts with CHD. Those prtiipnts with selfreporte stroke or ietes n those with fsting loo gluose levels of 126 mg/l or higher were ientifi e s prtiipnts with CHD equivlents. We exmine the following 4 CHD risk ftors tht oring to the USPSTF guielines shoul e use to etermine the eligiility for holesterol sreening in young ults: (1) igrette smoking (self-reporte smoking every y or some ys); (2) hypertension (the verge of 3 loo pressure mesurements from the NHANES physil exmintion t or exeeing 140/90 mm Hg, or self-reporte urrent use of ntihypertensive meition); (3) fmily history of premture CHD (ngin or myoril infrtion) in fi rstegree reltive younger thn 50 yers; n (4) oesity ( oy mss inex of 30 or greter tht ws lulte s weight in kilogrms ivie y the squre of the height in meters). Assessment n Definition of Sreening Sttus The holesterol sreening rtes were estimte se on the self-reporte sreening tht took ple efore our stuy. Prtiipnts were ske whether they h ever h their loo holesterol levels heke n how long it h een sine their lst holesterol test. Sreening ws ihotomize s either (1) never sreene or sreene 5 or more yers go or (2) sreene within the lst 5 yers. 328
Lipi Mesurements n Definition of High LDL-C Levels We tegorize LDL-C levels se on the ATP III risk tegories n gols for therpeuti lifestyle hnges n rug therpy (Tle 1), n we efi ne high LDL-C levels s levels ove the gol for eh risk tegory. The group of prtiipnts with high LDL-C levels inlue those who were eligile for therpeuti lifestyle hnge n rug therpy. Detils on the lssifi tion of the stuy prtiipnts into the 3 ATP III risk tegories (high, intermeite, n low) re pulishe elsewhere. 5 For ll lipi nlyses, frozen venous serum smples were shippe on ry ie to the Lipoprotein Anlytil Lortory t the Johns Hopkins University Hospitl, Bltimore, Mryln. 6 Methos for etermining totl holesterol, high-ensity lipoprotein holesterol (HDL-C), n triglyerie levels for 1999-2006 NHANES surveys hve een esrie elsewhere. 5 LDL-C vlues were lulte from mesure vlues of totl holesterol, triglyeries, n HDL-C oring to the Frieewl lultion. lipi mesurements were stnrize through the Centers for Disese Control n Prevention Ntionl Hert, Lung, n Bloo Institute Lipi Stnriztion Progrm. 7 Assessment n Definition of Soioemogrphi Chrteristis Informtion on re/ethniity, helth insurne overge, eution, inome, n helth re visits ws otine y using struture questionnire. Re/ ethniity ws tegorize s non-hispni white, non- Hispni lk, Mexin Amerin, n others. The others group inlue multiple re n other Hispni. Beuse the smple ws esigne to provie estimtes for non-hispni white, non-hispni lk, n Mexin Amerin popultions of the Unite Sttes, we inlue the others group in the nlysis ut i not report estimtes for this group euse of its smll smple size, heterogeneity, n nonrepresenttive nture. Prtiipnts were lssifi e s insure if they reporte hving privte insurne, Meii, or Civilin Helth n Meil Progrm of the Uniforme Servies (CHAMPUS)/Veterns Affirs insurne. The CHD RISK FACTORS AND CHOLESTEROL SCREENING Tle 1. LDL-C Gol n Cut Point Levels for Therpeuti Lifestyle Chnges n Drug Therpy y Risk Ctegory, NCEP ATP III Risk Ctegory High: CHD or CHD equivlent (10-y risk >20%) Intermeite: 2 risk ftors (10-y risk 20%) e Gol mg/l Initite Therpeuti Lifestyle Chnges mg/l Drug Therpy mg/l <100 100 100 (<100: onsier rug options) <130 130 130: 10-y risk 10%-20% (100-129: onsier rug options) 160: 10-y risk <10% Low: 1 risk ftor f <160 160 190 (160-189: LDL-lowering rug optionl) CHD = oronry hert isese; LDL-C = low-ensity lipoprotein holesterol; NCEP ATP III = Ntionl Cholesterol Eution Progrm Ault Tretment Pnel III. Persons t high risk or moertely high risk who hve lifestyle-relte risk ftors (eg, oesity, physil intivity, elevte triglyerie level, low HDL-C level, or metoli synrome) re nites for therpeuti lifestyle hnges to moify these risk ftors regrless of LDL-C level. LDL-C lowering rug therpy, when given, shoul e suffiient to reue LDL-C levels 30%-40%. CHD inlues history of myoril infrtion, unstle ngin, stle ngin, oronry rtery proeures (ngioplsty or ypss surgery), or eviene of linilly signifint myoril ishemi. CHD equivlents inlue linil mnifesttions of nonoronry forms of therosleroti isese (peripherl rteril isese, ominl orti neurysm, n roti rtery isese, suh s trnsient ishemi ttks or stroke of roti origin or >50% ostrution of roti rtery), ietes, n 2 risk ftors with 10-yer risk for hr CHD >20%. e CHD risk ftors inlue igrette smoking, hypertension (loo pressure 140/90 mm Hg or tking ntihypertensive meition), low high-ensity lipoprotein holesterol (<40 mg/l), fmily history of premture CHD (CHD in mle first-egree reltive ge <55 yers; CHD in femle first-egree reltive ge <65 yers), n ge (men 45 yers; women 55 yers). Eletroni 10-yer risk lultors re ville t http://www.nhli. nih.gov/guielines/holesterol. f Almost ll persons with 1 risk ftor hve 10-yer risk <10%; thus, 10-yer risk ssessment is unneessry. poverty inex rtio (totl fmily inome ivie y the poverty threshol inex juste for fmily size, omposition, n lotion t yer of interview) ws tegorize numerilly oring to the following esriptions: low (1 or less: fmily inome is less thn or equl to the poverty threshol inex), meium (2 to 3: fmily inome is 2 to 3 times s high s the poverty threshol inex); n high (more thn 3: fmily inome is more thn 3 times s high s the poverty threshol inex). Helth re ess ws ssesse y responses to the question, During the pst 12 months, how mny times hve you seen otor or other helth re professionl out your helth t otor's offi e, lini, hospitl emergeny room, t home or some other ple? Prtiipnts responses were groupe into 4 tegories: 0, 1, 2 to 3, n 4 or more times. Dt Anlysis Estimte popultion prevlene n stnr errors were lulte using SUDAAN sttistil softwre to ount for nonresponse n the omplex smpling esign. 8 The signifi ne of ifferene in prevlene ws ssesse y χ 2 test. 8 Ajustment for multiple omprisons ws me using the Bonferroni metho. 9 Orthogonl polynomil oeffi ients tht re lulte reursively oring to the metho of Fisher n Ytes were use for testing liner trens. 8 329
Beuse the prevlene of sreening ws less thn 50%, Cox regression ws use to lulte prevlene proportion rtios n their 95% onfi ene intervls (CIs) to exmine the ssoition etween sreening n the preitors. Although Cox regression is use to estimte the umultive iniene rtio for longituinl t, it lso n e use to estimte the prevlene proportion rtio for ross-setionl t when risk perio is onstnt (eh oservtion hs equl follow-up time). 10 RESULTS Tle 2 shows the istriution of soioemogrphi hrteristis n risk tegories in the popultion of interest. Aout 82% of the popultion h t lest high shool eution, 85% h n inome ove the poverty level, 73% h meil insurne, n 78% h esse helth re uring the lst 12 months. Aout 60% of the popultion h 1 or more CHD risk ftors. A higher proportion of women h meil insurne (79% vs 65%, P <.05) n reeive helth re 1 or more times uring the lst 12 months (87% vs 65%, P <.05) when ompre with men. The prevlene of risk ftors n NCEP ATP III risk tegories ws similr mong women n men, exept for oesity (31% vs 24%, respetively, P <.05). Tle 3 isplys the rte of holesterol sreening y risk tegories. Although the rte of sreening for high holesterol levels mong persons without CHD Tle 2. Soioemogrphi Chrteristis n CHD Risk Ftors for Men Age 20 to 35 Yers n Women Age 20 to 45 Yers, NHANES, 1999 2006 Chrteristi Totl No. Men Women Chrteristi Totl No. Men Women Sex Mle 1,041 38.8 (1.1) 100 Femle 1,546 61.2 (1.1) 100 Re/ethniity Non-Hispni 1,110 65.6 (1.7) 62.3 (2.3) 67.7 (1.7) white Non-Hispni 587 12.6 (1.1) 11.5 (1.4) 13.3 (1.2) lk Mexin- 651 10.5 (1.0) 13.5 (1.3) 8.6 (0.9) Amerin Other 239 11.3 (1.4) 12.7 (1.9) 10.4 (1.4) Eution Less thn high 657 18.2 (1.1) 20.9 (1.7) 16.6 (1.3) shool High shool 633 25.7 (1.3) 29.6 (2.0) 23.2 (1.4) More thn high 1,294 56.0 (1.6) 49.5 (1.8) 60.2 (2.0) shool Poverty inex 1 475 15.0 (0.9) 13.7 (1.1) 15.8 (1.2) 2-3 1,007 39.4 (1.4) 43.5 (2.1) 36.7 (1.4) 3 921 45.7 (1.5) 42.8 (2) 47.4 (1.5) Meil insurne Yes 1,746 73.1 (1.2) 64.8 (1.8) 78.4 (1.3) No 841 26.9 (1.2) 35.2 (1.8) 21.6 (1.3) Times reeive helth re uring lst 12 mo 0 626 21.7 (0.9) 35 (1.5) 13.3 (1.0) 1 576 22.1 (0.8) 25.6 (1.3) 20 (1.1) 2-3 1,086 44.2 (1.1) 32.8 (1.5) 51.4 (1.3) 4 299 12.0 (0.7) 6.6 (0.9) 15.4 (1.0) CHD or CHD 126 4.6 (0.4) 2.7 (0.6) 5.9 (0.7) equivlent Risk ftors High loo 286 10.9 (0.7) 11.2 (1.2) 10.6 (0.9) pressure e Smoking f 557 24.1 (1.0) 26.9 (1.4) 22.3 (1.3) Fmily history f 356 15.9 (0.8) 13.8 (1.3) 17.2 (1.1) Oesity g 791 28.3 (1.0) 23.6 (1.4) 31.3 (1.3) 2 436 17.9 (1.1) 17.6 (1.4) 18.0 (1.3) 1 965 37.3 (1.0) 39.6 (1.7) 35.9 (1.4) 0 1,060 40.2 (1.1) 40.1 (1.8) 40.3 (1.3) NCEP ATP III risk tegories High h 131 4.8 (0.5) 3.0 (0.5) 6.0 (0.7) Intermeite i 300 13.1 (0.9) 17.7 (1.5) 10.1 (0.9) Low j 2,156 82.1 (1.1) 79.3 (1.6) 83.9 (1.1) Currently tking lipi-lowering meitions 36 1.7 (0.3) NA k 2.3 (0.5) CHAMPUS = Civilin Helth n Meil Progrm of the Uniforme Servies; CHD = oronry hert isese; NA = not ville; NCEP ATP III = Ntionl Cholesterol Eution Progrm Ault Tretment Pnel III; NHANES = Ntionl Helth n Nutrition Exmintion Survey; SE = stnr error. Clulte s totl fmily inome/poverty threshol inex juste for fmily size, omposition, n lotion t yer of interview: low ( 1: fmily inome less thn or equl to poverty threshol inex); meium (2-3: fmily inome 2 to 3 times s high s poverty threshol inex); n high (>3: fmily inome >3 times s high s poverty threshol inex). Hving privte insurne, Meii, or CHAMPUS/Veterns Affirs insurne. Assesse y responses to the question, During the pst 12 months, how mny times hve you seen otor or other helth re professionl out your helth t otor s offie, lini, hospitl emergeny room, t home or some other ple? Self-reporte oronry hert isese, ngin, myoril infrtion, stroke, or ietes (self-reporte or fsting loo gluose 126 mg/l). e Systoli loo pressure >140 mm Hg, istoli loo pressure >90 mm Hg, or reporting presription meition for hypertension. f Self-reporte. g Boy mss inex 30 kg/m 2 (weight in kilogrms ivie y the squre of height in meters). h CHD or CHD equivlent or 2 mjor CHD risk ftors n 10-yer Frminghm risk >20%. i Two or more mjor CHD risk ftors n 10-yer Frminghm risk 20%. j One or no mjor CHD risk ftor. k Reltive SE 30%, estimte is unrelile. 330
or CHD equivlent ws higher mong women thn mong men (49%-53% vs 30%-38%, respetively), no signifi nt ifferene in sreening for holesterol ws oserve mong persons with 1 or 2 or more risk ftors for CHD ompre with persons with no risk ftors in oth sexes. The rte of sreening for high holesterol levels mong persons with CHD or CHD equivlent ws less thn 70% ut ws signifi ntly higher thn the sreening rte for persons with no risk ftors. Ajustment for soioemogrphi hrteristis in multivrite Cox regression moels h only smll effet on sreening rtes y numer of CHD risk ftors regrless of sex. Tle 4 shows the prevlene of high LDL-C levels. Prevlene inrese with the numer of the CHD risk ftors; 6.7% of persons with no risk ftors h high LDL-C levels ompre with 25.9% of those with 2 or more risk ftors. The highest prevlene of high LDL-C levels (65.1%) ws foun mong persons with CHD or CHD equivlent. The prevlene of high LDL-C levels mong young ults without CHD risk ftors ws 10.1% n 4.6% for men n women, respetively. Similr to the holesterol sreening, justment for soioemogrphi hrteristis in Tle 3. Sreening y Numer of Risk Ftors Among Men Age 20 to 35 Yers n Women Age 20 to 45 Yers (N = 2,587), NHANES, 1999 2006 Risk Ftor Sreening Sreening Risk Rtio (95% CI) CHD or CHD equivlent 67.7 (5.7) 1.5 (1.1-2.2) 2 47.4 (3.0) 1.2 (1.0-1.4) 1 45.1 (2.3) 1.2 (1.0-1.4) 0 41.8 (1.8) Referent Men 20-35 y CHD or CHD equivlent 63.6 (10.9) 2.40 (1.40-4.13) 2 37.9 (4.8) 1.30 (0.87-1.94) 1 35.9 (2.7) 1.36 (1.01-1.84) 0 30.0 (2.4) Referent Women 20-45 y CHD or CHD equivlent 68.9 (6.6) 1.32 (0.89-1.96) 2 53.4 (3.9) 1.12 (0.90-1.39) 1 51.6 (2.8) 1.10 (0.90-1.34) 0 49.3 (2.2) Referent CHD = oronry hert isese; CI = onfiene intervl; NHANES = Ntionl Helth n Nutrition Exmintion Survey; SE = stnr error. High loo pressure, smoking, fmily history, n oesity. Self-reporte holesterol sreening within the lst 5 yers. N = 2,402 ue to missing t. Eh moel ws juste for re/ethniity, eution, poverty sttus, meil insurne sttus, n helth re ess uring lst 12 months, n ge (ontinuous). Self-reporte oronry hert isese, ngin, myoril infrtion, stroke, or ietes (self-reporte or fsting loo gluose 126 mg/l). multivrite Cox regression moels h only smll effet on prevlene of high LDL-C levels y numer of CHD risk ftors regrless of sex. DISCUSSION Aoring to 1999-2006 NHANES t, pproximtely 65% of young ults with CHD or CHD equivlent, 26% of young ults with 2 or more risk ftors, 12% of young ults with 1 risk ftor, n 7% with no CHD risk ftors h high LDL-C level. Sreening, however, for high loo holesterol levels in young ults, exept for persons with CHD or CHD equivlent, ws low: out 50% for women n less thn 40% for men. The ge n sex isprities in the use of preventive servies hve een reporte efore. For exmple, the sreening rte inreses s funtion of ge t the popultion level, 11 n younger men re signifi ntly less likely thn younger women to reeive ertin preventive servies. 12 In our stuy, no signifi nt ifferene ws foun in sreening rtes Tle 4. Prevlene n Stnr Errors of High LDL-C Levels y Numer of Risk Ftors Among Men Age 20 to 35 Yers n Women Age 20 to 45 Yers (N = 2,587), NHANES, 1999 2006 Risk Ftors High LDL-C High LDL-C, Risk Rtio (95% CI) CHD or CHD equivlent 65.1 (4.2) 12.8 (8.8;18.5) 2 25.9 (2.6) 4.0 (2.7;5.9) 1 12.5 (1.3) 1.8 (1.3;2.6) 0 6.7 (0.8) e Referent Men 20-35 y CHD or CHD equivlent 55.1 (10.1) 5.6 (1.6;11.9) 2 27.5 (3.8) 2.8 (1.5;5.1) 1 13.9 (1.9) 1.2 (0.7-2.1) 0 10.1 (1.7) e Referent Women 20-45 y CHD or CHD equivlent 68 (4.9) 21.1 (13.4;33.3) 2 24.9 (3.1) 5.7 (3.5;9.2) 1 11.6 (1.8) 2.6 (1.5; 4.4) 0 4.6 (0.8) e Referent CHD = oronry hert isese; CI = onfiene intervl; LDL-C = low-ensity lipoprotein holesterol; NHANES = Ntionl Helth n Nutrition Exmintion Survey. Risk ftors: high loo pressure, smoking, fmily history, n oesity. LDL-C 100, 130, n 160 mg/l for high, intermeite, n low NCEP ATP III risk tegories, respetively. N = 2,402 ue to missing t. Eh moel ws juste for re/ethniity, eution, poverty sttus, meil insurne sttus, n helth re ess uring lst 12 months, n ge (ontinuous). Self-reporte oronry hert isese, ngin, myoril infrtion, stroke, or ietes (self-reporte or fsting loo gluose 126 mg/l). e Liner tren ross risk tegories ssesse y lulting orthogonl polynomil oeffiients oring to the metho of Fisher n Ytes; P vlue for liner trens <.001. 331
etween young ults with no risk ftors n their ounterprts with 1 or more risk ftors even fter justment for soioemogrphi n helth re ftors. Beuse the severity of theroslerosis in young ults inreses with the numer of risk ftors, 13-15 the low sreening rtes, prtiulrly mong young persons with 2 or more risk ftors, re of onern. A teneny for more multory re visits hs een propose s ftor explining higher sreening rtes mong young women thn mong young men. 12 The effi ieny of popultion-se pprohes in the prevention of CHD is not well stuie. 16 The Amerin Hert Assoition (AHA) supports puli sreenings tht meet eptle riteri for reruitment, reliility of mesurement of holesterol levels, pproprite eutionl informtion, properly trine stff n referrl. The AHA reognize tht smll-sle sreening t work sites, shools, hurhes, ommunity enters, or neighorhoo linis hve potentil for ientifying highrisk iniviuls. The AHA sttes, however, tht the integrtion of ommunity sreening progrms into the meil re system is importnt to ensure test results interprettion n follow-up y the physiin responsile for the ptient s re. 17 Future stuies re neee to ientify how holesterol sreening mong young ults n e improve in primry re settings. In our stuy, out 59% of young ults s efi ne y NCEP sreening guielines (men ge 20 to 35 yers n women ge 20 to 45 yers) h CHD, CHD equivlent, or 1 or more of the following risk ftors: fmily history of erly CHD, smoking, hypertension, or oesity. Our results lso support the nee to improve ssessment n mngement of riovsulr isese risk ftors mong young ults. Beuse therpeuti lifestyle hnges re inite more often thn is rug therpy for young ults, linil mngement of risk ftors in this group my e hllenging. Helth re liniins pereive limite time, lk of skills, inequte reimursement, n iffi ulties in ptient herene to lifestyle hnges s rriers to effetive ounseling. 18 These onerns notwithstning, preventive efforts fouse on eresing the numer of CHD risk ftors my e essentil for preventing CHD lter in life n reuing the uren of CHD t the ntionl level. Inee, s hs een shown y results from NHANES III mong white, non-hispni persons ge 35 to 74 yers, only smll proportion of CHD events (out 10%) our mong persons with isolte risk ftors n LDL-C levels t whih rug therpy is not inite. 19 Thus, the Amerin Meil Assoition (AMA) promotes ounseling on helth ehvior in linil prtie y voting full insurne overge for ounseling for smoking n niotine epenene, lohol onsumption, helthy iet, n physil tivity mong ults. 20 Menwhile, the AMA suggests inorporting routine tht requires miniml time, reinfores the importne of the key helth ehviors, n refers ptients to ommunity resoures s neessry. 20 As with linil ounseling, not ll ommunity-se lifestyle interventions hve een foun to e effetive in the prevention of CHD, ut some interventions show promising results. 21 For exmple, in stuy y Roux n ollegues, 22 ommunity-se interventions to promote physil tivity ppere to sustntilly reue iniene of CHD over lifetime (140 to 476 ses per 100,000 persons). Comprehensive nlysis of the ville prevention strtegies might serve s fountion for improving urrent n future prevention efforts in young ults. Results reporte in this stuy shoul e interprete with the following limittions in min. First, mislssifi tion is is possile in our stuy. The NHANES question on fmily history of hert ttk or ngin sks out fi rst-egree reltives younger thn 50 yers regrless of sex inste of using 55 yers for men n 65 yers for women, ges propose y the NCEP ATP III. Thus, some prtiipnts my e inppropritely ple in the low-risk rther thn in the intermeite- or high-risk tegory. Seon, the proportion of prtiipnts with CHD or CHD equivlent my e unerestimte in our stuy euse of lk of t on peripherl vsulr isese, symptomti roti rtery isese, n ominl orti neurysm. Our stuy, however, fouse on young ults for whom the prevlene of these onitions is known to e low. 23 Finlly, lthough the olletion n exmintion of lortory t were stnrize, self-reporte t from interviews n questionnires my e sujet to misunerstning n rell is. The fi nings in this stuy suggest pproximtely two-thirs of ll young ults hve 1 or more riovsulr risk ftors. Among young ults, we foun tht the prevlene of high holesterol levels inrese with the numer of CHD risk ftors, ut the holesterol sreening rte ws less thn 50% regrless of risk sttus. Our results inite tht improvement of risk ssessment n mngement for riovsulr isese mong young ults through eviene-se linil n puli helth interventions is wrrnte. To evelop n implement these interventions suessfully, omprehensive nlysis of the urrently ville prevention strtegies is neee. To re or post ommentries in response to this rtile, see it online t http://www.nnfmme.org/gi/ontent/full/8/4/327. Key wors: Coronry hert isese; hyperlipiemi; helth promotion; mss sreening 332
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