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The congruence of many types of scientific evidence has led to general agreement in the medical community of the need to lower blood cholesterol to reduce the incidence of CHD. In 1985, the NCEP, a consortium of practitioners, public health professionals, voluntary health organizations, and government agencies, began a collaborative effort of professional and public education.

In 1988, the Adult Treatment Panel of NCEP delineated guidelines for the detection, evaluation, and treatment of high blood cholesterol in adults. Treatment of individuals at risk cannot proceed, of course, until their cholesterol levels have been defined. Accordingly, NCEP advises adults: “Know your cholesterol number.”

The second report of the Adult Treatment Panel II, released in 1993, updated recommendations for cholesterol management in adults. This report is similar to the first in outline, and it continues to identify LDL as the primary target of cholesterol lowering therapy. However, the report contains three new features that distinguish it from the first. These include:

• Increased emphasis on CHD risk status as a guide to type and intensity of cholesterol-lowering therapy.
  - Identification of the patient with existing CHD or other atherosclerotic diseases as being at highest risk, and establishment of lower targets for LDL-cholesterol for these patients.
  - Addition of age to the list of major CHD risk factors, defined as >45 years in men and >55 years in women.
  - Recommendation of delaying the use of drug therapy in most young adult men (<35 years) and premenopausal women with LDL-cholesterol levels in the range of 160-220 mg/dL who are otherwise at low risk for CHD in the near future.
  - Enhanced recognition that high-risk post-menopausal women, and high-risk elderly patients who are otherwise in good health, are candidates for cholesterol-lowering therapy.
• More attention to HDL as a CHD risk factor.
  - Addition of HDL-cholesterol to initial cholesterol testing.
  - Designation of high HDL-cholesterol as a “negative” CHD risk factor.
  - Consideration of HDL-cholesterol levels in the choice of drug therapy
• Increased emphasis on weight loss and physical activity as components of the dietary therapy of high blood cholesterol.

The second new emphasis, more attention to HDL as a CHD risk factor, has important implications for cholesterol screening. Increasing scientific evidence indicates that a low HDL-cholesterol is a major risk factor for CHD. The purpose of HDL testing is to identify individuals who may have either a low or an elevated HDL-cholesterol, in order to improve initial CHD risk assessment and to guide later therapy. If the HDL test is available, it should be added to initial total cholesterol testing, providing that accuracy is assured. Although practical circumstances may dictate that cholesterol screening be carried out without the HDL-cholesterol measurement, ATP II recommendations should be kept in mind, and screenees should be reminded of the importance of obtaining an HDL test in the future.

The NCEP advocates a dual strategy for lowering cholesterol levels in the general population. The first is the public health strategy, which encourages the general public to modify life habits with the aim of reducing CHD risk factors, including high blood cholesterol. This approach makes use of public education, governmental policy, and food industry actions to foster healthful changes in habits. The second approach is the clinical strategy, which attempts to identify high-risk individuals in the clinical setting. It is primarily a case-finding approach and is based on the premise that a large portion of the general population periodically passes through the clinical setting where the opportunity for appropriate cholesterol testing exists. Cholesterol screening outside the medical setting serves both the public health and clinical approaches. It assists in increasing the general public’s awareness of the dangers of high blood cholesterol, while at the same time it facilitates the finding of new cases.

The NCEP guidelines, as well as the availability of portable chemistry analyzers that make cholesterol measurement rapid, affordable, relatively painless, and readily available, initially led to widespread screening outside the physician’s office and enthusiastic public responses. Hospitals, nursing homes, health fairs, supermarkets, exercise clubs, and many nonmedical sites have provided screening for blood cholesterol. In addition, public screening has also become commercialized, with profit-oriented organizations selling these services. Recently, public screening activities appear to have declined, but there still exists a need to provide updated guidance on this subject.

In October 1988, the NHLBI sponsored a Workshop on Public Screening for High Blood Cholesterol to review and evaluate data from public cholesterol screenings and make recommendations for quality control, recruitment, referral, and education. Data were presented from NHLBI supported community heart disease prevention demonstration projects, the Model Systems for Cholesterol Screening Program, and scientists working in the field. The workshop proposed objectives for public screening and made recommendations for achieving these objectives. This document updates the workshop guidelines in light of recent developments, including the recommendations of ATP II.

CENTENTS

SUMMARY/RECOMMENDATIONS

Recommendations

INTRODUCTION/BACKGROUND

Objectives for Public Cholesterol Screening

RESEARCH FINDINGS AND RECOMMENDATIONS

Recruitment of Screening Participants
Analyzer Operation and Quality Control
Education of Participants
Staff Training
Screening Environment
Referral and Followup
Other Issues
Cholesterol Testing in Children and Adolescents
Home Testing
Direct LDL-Cholesterol

APPENDIX 1. RISK FACTOR QUESTIONNAIRE

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