ATHEROSCLEROSIS SUPPLEMENTS Atherosclerosis Supplements 20 (2015) 1 5 www.elsevier.com/locate/atherosclerosis Think Again About Cholesterol Survey Alberico L. Catapano a, *, Olov Wiklund b, on behalf of the European Atherosclerosis Society a Department of Pharmacological and Biomolecular Sciences, University of Milan, IRCCS Multimedica, Milan, b Sahlgrenska Academy, University of Gothenburg, Abstract Cardiovascular disease (CVD) is still the main cause of death in Europe. Elevated plasma cholesterol, specifically low-density lipoprotein cholesterol (LDL-C), is the main causative risk factor for CVD, most prominently associated with coronary heart disease. A widespread disinformation about cholesterol and CVD is one factor underlying a poor compliance to lipid-lowering therapy. To investigate how cholesterol, CVD and cholesterol reduction is perceived in the population, a survey was commissioned by the European Atherosclerosis Society (EAS). Nearly half of people above 25 years of age are most worried about cancer (45%), compared to just over one in four who are worried about heart disease (27%). A majority believe being overweight (72%), blood pressure (70%) and smoking (67%) most affect heart health, far more than note cholesterol (59%) and family history (39%). The majority of adults recognize that high LDL (or bad ) cholesterol should be a health priority for everyone, including those younger than 40 and those who are not overweight. However, 1 in 4 (25%) incorrectly believe that it does not need to be a concern until someone shows signs or symptoms. Although 89% of adults surveyed agreed it is important for people to know whether or not they have high LDL-C, an overwhelming 92% did not know their LDL-C levels or had never had their cholesterol levels tested. A high 63% had never heard of familial hypercholesterolemia: France had the lowest level of awareness (41%) to with a high 80%, and the association of the disease with high levels of LDL-C is quite poor (only ), with only at 22% versus a high in Spain of 54%. A large part of the people participating in the survey were quite uncertain about the modality of transmission for familial hypercholesterolemia in the family. All in all, this survey highlights the need for more information among citizens for the role of cholesterol in determining CVD. 2015 Elsevier Ireland Ltd. All rights reserved. Keywords: Cholesterol; hypercholesterolemia; familial; low-density lipoprotein; high-density lipoprotein Introduction Cardiovascular disease (CVD) is still the main cause of death in Europe. Recently published statistics show that more than of deaths among men and about 50% among women are caused by CVD [1]. On the other hand, the mortality from all cancer forms is attributed to of all deaths in men and 19% among women. Among the CVDs, coronary heart disease is the most prominent with about 20% of all deaths. Thus, coronary heart disease is about as common a cause of death as all cancer forms accumulated. Elevated plasma cholesterol, specifically low-density lipoprotein cholesterol (LDL-C), is the main causative risk factor for CVD, most prominently associated with coronary heart disease. The causative relation between cholesterol and CVD has been shown in animal models, in genetic studies, * Corresponding author. Professor Alberico L. Catapano, Department of Pharmacological and Biomolecular Sciences, University of Milan, Via Balzaretti, 9, 20133 Milan,. Tel.: +39 02 5031 8302; fax: +39 02 5031 8386. E-mail address: alberico.catapano@unimi.it (A.L. Catapano). in epidemiological studies [2,3] and in recent decades in a large number of intervention trials [4 7]. Although the scientific evidence is overwhelming, the discussion about the relation between cholesterol and CVD and the benefit from cholesterol lowering is ongoing in the media, driven by poor knowledge about cholesterol. A widespread disinformation about cholesterol and CVD is one factor underlying a poor compliance to lipid-lowering therapy. Even among patients with very high risk or in secondary prevention the compliance to cholesterol lowering therapy is poor [8 10], leaving patients without possible protection against CVD [11]. To investigate how cholesterol, CVD and cholesterol reduction is perceived in the population a survey was commissioned by the European Atherosclerosis Society (EAS). The objectives of the survey were to: Identify adults concern and knowledge about heart health and high cholesterol, on both a personal and a public health level. Uncover areas of misconception of the definition, risk factors, symptoms, and consequences of high LDL-C. Determine adults awareness of familial hyper cholesterolemia. 1567-5688 2015 Elsevier Ireland Ltd. All rights reserved.
2 A.L. Catapano et al. / Atherosclerosis Supplements 20 (2015) 1 5 Table 1 Demographics of the participants in the Think About Cholesterol Survey UK France Spain Norway n 12,142 1,051 1,033 1,006 1,006 1,036 1,001 1,000 1001 1000 1000 1001 1007 Gender Male 49% 49% 47% 49% 46% 49% 49% 49% 4 50% 49% 4 4 Female 51% 51% 53% 51% 54% 51% 51% 51% 52% 50% 51% 52% 52% Age 25 34 1 19% 17% 16% 16% 1 1 17% 16% 20% 19% 1 15% 35 44 19% 1 19% 16% 20% 25% 19% 1 19% 21% 1 17% 19% 45 54 20% 21% 20% 22% 22% 22% 20% 21% 21% 19% 19% 19% 17% 55 64 17% 17% 1 1 16% 17% 1 1 1 17% 17% 19% 17% 65+ 25% 27% 27% 17% 25% 25% 27% 23% 2 2 33% Mean 50.9 51.0 50.8 51.2 51.0 48.0 50.8 51.0 51.5 49.5 51.4 51.4 53.0 Median 51 51 52 53 51 47 52 52 51 48 52 53 54 Survey methodology The survey was conducted online between 25 th of August and the 9 th of September, 2015, among 12,142 adults, 25 years of age and older. The survey was conducted in eleven European countries (,,, France,,,, Norway, Spain,, and the UK) and in. Sample size in each country was approximately 1,000 (Table 1). The survey was conducted online on behalf of the EAS by Harris Poll, a leading global provider of information and analytics. Respondents to the survey were selected among those who agree to participate in Harris Poll surveys. The study was sponsored by Sanofi and Regeneron Pharmaceuticals Inc. Results and discussion Awareness of CVD and cholesterol The results revealed nearly half of people above 25 years of age are most worried about cancer (45%), compared to just over one in four who are worried about heart disease (27%) (Fig. 1). This is in contrast with the published update [1] on causes of death in Europe, showing that CVD causes 40 50% of all deaths while cancer is the cause of death in 25%. A majority believe being overweight (72%), blood pressure (70%) and smoking (67%) most affect heart health, far more than note cholesterol (59%) and family history (39%) (Fig. 3). Only realize that Europe is the region where high cholesterol is most common, 46% mistakenly believe it is North America (Fig. 2). Nearly two-thirds (66%) of respondents do not know LDL-C is the bad type of cholesterol and more than half (54%) do not know having low levels of LDL-C is good for long-term health. The knowledge of cholesterol and CVD evidently can be dramatically improved and this should be a challenge for the medical society. The demand seems to be present since more than four in five (84%) agree that high LDL-C is something that everyone should be very concerned about. Knowledge about cholesterol and causes of high cholesterol The majority of adults recognize that high LDL (or bad ) cholesterol should be a health priority for everyone, including those younger than 40 and those who are not overweight. That said, one in four (25%) incorrectly believe that it does not need to be a concern until someone shows signs or symptoms, and an overwhelming majority (92%) is unaware Diseases or Health Conditions Personally Most Worried About Cancer 45% CVD (NET) Heart Disease Stroke Worried About UK 23% Dementia Heart disease Stroke 27% 27% CVD NET: 37% France 27% 25% 1 17% 39% 22% Spain 43% 25% Diabetes HIV/AIDS Ebola Hepatitis 6% 5% 19% 44% 34% 24% 16% 44% 3 23% Norway 41% 41% 49% 34% None 21% 13% 15% Figure 1. Disease or health conditions that survey participants were personally most worried about. Multiple selections were allowed.
A.L. Catapano et al. / Atherosclerosis Supplements 20 (2015) 1 5 3 Geographic Region Where High Cholesterol is Most Common Europe 1% 1% 2% 3% 17% 46% UK 2 France North America Europe 23% South America Spain 22% Africa 33% South East Asia Not sure Norway 46% Figure 2. Opinion among participants in which geographic region high cholesterol is most common. Factors that have the Greatest Impact on LDL Cholesterol Levels Weight Diet Cigarette smoking High alcohol intake High blood pressure Family history of heart disease (genetics) Exercise Age Diabetes Medications Gender (male/female) Not sure 2% 13% 1 25% 23% 52% 52% UK France Spain Norway Family History of Heart Disease 44% 17% 34% 42% 24% 13% Figure 3. Survey participants opinion on factors that have the greatest impact on LDL cholesterol levels. Multiple selections were allowed. that women have a higher risk of high bad cholesterol than do men. The majority of adults surveyed (82%) are aware that certain factors (such as diet or weight, etc.) have the greatest impact on LDL-C levels. However, only 52% recognize diet as the major contributor to high cholesterol (Fig. 3), and about one in two adults surveyed make a mistaken connection with the effects of aging and believe incorrectly that high bad cholesterol is a natural consequence of getting older. More than two in five (44%) also incorrectly believe that there are noticeable symptoms associated with bad cholesterol when it reaches high levels (Fig. 4). The survey strongly suggests that improved awareness and knowledge about cholesterol and disease should be a major effort in order to improve cardiovascular health. Very few know their cholesterol levels Although 89% of adults surveyed agreed it is important for people to know whether or not they have high LDL-C, an overwhelming 92% did not know their LDL-C levels or had never had their cholesterol levels tested (Fig. 5). Thus, there is a long gap between knowledge about the risk of high cholesterol and taking action to reduce that risk. The results show that cholesterol testing should be made more easily available for everybody. Lack of correct information More than half of those surveyed feel there is a lack of clear information available on how people should manage their LDL-C (57%). Adults over 40 should aim to keep their LDL-C under 2.5 3.0 mmol/l; however, 59% were unsure of the appropriate target levels. The public discussion about the role of different diets and the differences between guidelines may have given a feeling of poor information and insecurity how to find correct information. There is room for improvement using scientifically based information tools. The public is asking for information and a majority believes that managing high LDL-C with diet is important (89%), but they are lacking correct information.
4 A.L. Catapano et al. / Atherosclerosis Supplements 20 (2015) 1 5 Symptoms of High LDL Cholesterol None - there are no symptoms ated with high LDL (or ''bad'') holesterol Not Sure Fatigue Weight eg tgain UK Fran e 20% ty breathing 15% 37% Chest pain 14% Spain Dementia 4% Coughing 3% 45% 3% Norway 41% Not sure 22% 49% 34% 3 Figure 4. Survey participants opinion on symptoms associated with high LDL cholesterol. Multiple selections were allowed. Most Recent Cholesterol Levels LDL cholesterol HDL cholesterol Total cholesterol 7% 10% Mean: 3.5 Median: 3 Mean: 2.3 Median: 2 Mean: 5.2 Median: 5 61% 62% 59% Figure 5. Survey participants self-reported cholesterol levels. Entered a number Not sure/don't recall I have never had my cholesterol levels tested Familial hypercholesterolemia (FH) If we analyze the data regarding the questions related to FH, surprisingly 63% have never heard of it: France had the lowest level of awareness (41%) to with a high 80%, and the association of the disease with high levels of LDL-C is quite poor (only ), with only at 22% vs a high in Spain of 54%. Consequently a large part of the people participating in the survey were quite uncertain about the modality of FH transmission in the offspring with 61% not sure about the likelihood of a child of someone with FH inheriting the condition. All in all, the knowledge about FH appears to be rather poor and there is a clear need to better promote understanding of the disease. However, this cannot be without proper campaigns to the public and, likewise, to physicians led by scientific societies. Limitations The survey was not performed on a random population sample but rather on adults agreeing to participate in online surveys. This should be considered in the interpretation of the results. However, the results give a good general impression of the general awareness of the adult population about the issues raised in the survey, and may be a basis for further discussions and also for future initiatives to improve awareness. Trends for differences between countries were observed; the design of the study and data about specific differences between nations are presented as supplementary material and will be further exploited in subsequent publications. Conclusion The survey indicates that the public is aware of cholesterol as a risk factor and the importance of this risk factor for cardiovascular health. However, there are a number of misconceptions that may interfere with possibilities to reduce heart disease in the population. Although awareness may be high, action is taken by a minority. Improvement in knowledge, in available correct information, and access to blood testing are key factors to improve cardiovascular health by reducing plasma cholesterol.
A.L. Catapano et al. / Atherosclerosis Supplements 20 (2015) 1 5 5 A complete presentation of the results of the survey is available on Atherosclerosis Supplements as supplementary information. Source of funding and authorship The supplement was financially supported by Sanofi and Regeneron Pharmaceuticals Inc. The authors meet the criteria for authorship as recommended by the International Committee of Medical Journal Editors (ICMJE), and were fully responsible for all content development and editorial decisions. Conflict of interest None declared. Appendix A. Supplementary data Supplementary data related to this article can be found at: http://dx.doi.org/10.1016/s1567-5688(15)30011-8 References 1. Townsend N, Nichols M, Scarborough P, Rayner M. Cardiovascular disease in Europe - epidemiological update 2015. Eur Heart J 2015;36(40):2696 705. 2. Emerging Risk Factors C, Di Angelantonio E, Gao P, Pennells L, Kaptoge S, Caslake M, et al. Lipid-related markers and cardiovascular disease prediction. JAMA 2012;307(23):2499 506. 3. Prospective Studies C, Lewington S, Whitlock G, Clarke R, Sherliker P, Emberson J, et al. Blood cholesterol and vascular mortality by age, sex, and blood pressure: a meta-analysis of individual data from 61 prospective studies with 55,000 vascular deaths. Lancet 2007;370(9602):1829 39. 4. Cholesterol Treatment Trialists (CTT) Collaboration, Baigent C, Blackwell L, Emberson J, Holland LE, Reith C, et al. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170,000 participants in 26 randomised trials. Lancet 2010;376(9753):1670 81. 5. Cholesterol Treatment Trialists (CTT) Collaboration, Fulcher J, O Connell R, Voysey M, Emberson J, Blackwell L, et al. Efficacy and safety of LDL-lowering therapy among men and women: metaanalysis of individual data from 174,000 participants in 27 randomised trials. Lancet 2015;385(9976):1397 405. 6. Cholesterol Treatment Trialists (CTT) Collaboration, Kearney PM, Blackwell L, Collins R, Keech A, Simes J, et al. Efficacy of cholesterollowering therapy in 18,686 people with diabetes in 14 randomised trials of statins: a meta-analysis. Lancet 2008;371(9607):117 25. 7. Cholesterol Treatment Trialists (CTT) Collaboration, Mihaylova B, Emberson J, Blackwell L, Keech A, Simes J, et al. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials. Lancet 2012;380(9841):581 90. 8. Annual report SWEDEHEART 2012. Scand Cardiovasc J 2014;48 Suppl 63:2 133. 9. Kotseva K, Wood D, De Bacquer D, De Backer G, Ryden L, Jennings C, et al. EUROASPIRE IV: A European Society of Cardiology survey on the lifestyle, risk factor and therapeutic management of coronary patients from 24 European countries. Eur J Prev Cardiol 2015 pii: 2047487315569401. [Epub ahead of print] 10. Siggaard-Andersen N, Freiberg JJ, Nordestgaard BG. Only a fraction of patients with ischaemic diseases or diabetes are treated to recommended target values for plasma lipids. Dan Med J 2012;59(7):A4470. 11. Hamood H, Hamood R, Green MS, Almog R. Effect of adherence to evidence-based therapy after acute myocardial infarction on all-cause mortality. Pharmacoepidemiol Drug Saf 2015;24(10):1093 104.