Unmet need for hypercholesterolemia care in 35 low- and middle-income countries: A cross-sectional study of nationally representative surveys

Abstract

Background As the prevalence of hypercholesterolemia is increasing in low- and middle-income countries (LMICs), detailed evidence is urgently needed to guide the response of health systems to this epidemic. This study sought to quantify unmet need for hypercholesterolemia care among adults in 35 LMICs. Methods and findings We pooled individual-level data from 129,040 respondents aged 15 years and older from 35 nationally representative surveys conducted between 2009 and 2018. Hypercholesterolemia care was quantified using cascade of care analyses in the pooled sample and by region, country income group, and country. Hypercholesterolemia was defined as (i) total cholesterol (TC) ≥240 mg/dL or self-reported lipid-lowering medication use and, alternatively, as (ii) low-density lipoprotein cholesterol (LDL-C) ≥160 mg/dL or self-reported lipid-lowering medication use. Stages of the care cascade for hypercholesterolemia were defined as follows: screened (prior to the survey), aware of diagnosis, treated (lifestyle advice and/or medication), and controlled (TC <200 mg/dL or LDL-C <130 mg/dL). We further estimated how age, sex, education, body mass index (BMI), current smoking, having diabetes, and having hypertension are associated with cascade progression using modified Poisson regression models with survey fixed effects. High TC prevalence was 7.1% (95% CI: 6.8% to 7.4%), and high LDL-C prevalence was 7.5% (95% CI: 7.1% to 7.9%). The cascade analysis showed that 43% (95% CI: 40% to 45%) of study participants with high TC and 47% (95% CI: 44% to 50%) with high LDL-C ever had their cholesterol measured prior to the survey. About 31% (95% CI: 29% to 33%) and 36% (95% CI: 33% to 38%) were aware of their diagnosis; 29% (95% CI: 28% to 31%) and 33% (95% CI: 31% to 36%) were treated; 7% (95% CI: 6% to 9%) and 19% (95% CI: 18% to 21%) were controlled. We found substantial heterogeneity in cascade performance across countries and higher performances in upper-middle-income countries and the Eastern Mediterranean, Europe, and Americas. Lipid screening was significantly associated with older age, female sex, higher education, higher BMI, comorbid diagnosis of diabetes, and comorbid diagnosis of hypertension. Awareness of diagnosis was significantly associated with older age, higher BMI, comorbid diagnosis of diabetes, and comorbid diagnosis of hypertension. Lastly, treatment of hypercholesterolemia was significantly associated with comorbid hypertension and diabetes, and control of lipid measures with comorbid diabetes. The main limitations of this study are a potential recall bias in self-reported information on received health services as well as diminished comparability due to varying survey years and varying lipid guideline application across country and clinical settings. Conclusions Cascade performance was poor across all stages, indicating large unmet need for hypercholesterolemia care in this sample of LMICs—calling for greater policy and research attention toward this cardiovascular disease (CVD) risk factor and highlighting opportunities for improved prevention of CVD.

National high prevalence, and low awareness, treatment and control of dyslipidaemia among people aged 15–69 years in Mongolia in 2019

“…The proportion of dyslipidaemia in Mongolia (58.6%) was higher than in China (> 18 years, 34.0%) 6 , lower than in Northern Ethiopia (≥ 20 years, 66.7%) 2 , lower than in Turkey (≥ 20 years, ≥ 79%) 8 , and Pakistan (≥ 20 years, 96%) 9 . The prevalence of high TC (26.9%) in this study was higher than in the 35 LMIC study (≥ 15 years, 7.1%) 5 , lower than in Northern Ethiopia (≥ 20 years, 30.8%) 2 , in Jordan (≥ 25 years, 44.3%) 7 , in Turkey (≥ 20 years, 43%) and Pakistan (≥ 20 years, 39.3%) 9 . Some of these prevalence differences may be attributed to the use of different cut-off points of lipid abnormality.…”

“…In 35 low- and middle-income countries (LMIC) (≥ 15 years), the prevalence of high TC was 7.1% and high LDL-C 7.5%, ≥ 31% of them were aware of their diagnosis, ≥ 29% were treated, and ≥ 7% were controlled 5 . In China (> 18 years), the prevalence of dyslipidaemia was 34.0% 6 , and 31.0% were aware, 19.5% in treatment and 8.9% were controlled 6 .…”

“…Factors associated with awareness of dyslipidaemia diagnosis include older age 5 , living in urban areas 11 , higher education 11 , higher BMI 5 , 11 , 17 , comorbid diagnosis of diabetes 5 , 11 , hypertension 5 , 11 , and CVD 11 . Factors associated with the treatment of dyslipidaemia or hypercholesterolemia include women 7 , comorbid hypertension, diabetes 5 , and CVD 11 .…”

“…Factors associated with awareness of dyslipidaemia diagnosis include older age 5 , living in urban areas 11 , higher education 11 , higher BMI 5 , 11 , 17 , comorbid diagnosis of diabetes 5 , 11 , hypertension 5 , 11 , and CVD 11 . Factors associated with the treatment of dyslipidaemia or hypercholesterolemia include women 7 , comorbid hypertension, diabetes 5 , and CVD 11 . Factors positively associated with control of dyslipidaemia include women 7 , urban residence 7 , obesity 7 , comorbid diabetes 5 , and CVD 11 , and overweight/obesity and physical inactivity were negatively associated with control of dyslipidaemia 11 .…”

“…Factors associated with the treatment of dyslipidaemia or hypercholesterolemia include women 7 , comorbid hypertension, diabetes 5 , and CVD 11 . Factors positively associated with control of dyslipidaemia include women 7 , urban residence 7 , obesity 7 , comorbid diabetes 5 , and CVD 11 , and overweight/obesity and physical inactivity were negatively associated with control of dyslipidaemia 11 . The aim of the study was to assess the prevalence, distribution, and correlates of dyslipidaemia among people aged 15 to 69 years in Mongolia.…”