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Marcus ME, Ebert C, Geldsetzer P, et al. Unmet need for hypercholesterolemia care in 35 low- and middle-income countries: A cross-sectional study of nationally representative surveys. PLoS Med. 2021;18(10):e1003841doi: 10.1371/journal.pmed.1003841.
Marcus, M. E., Ebert, C., Geldsetzer, P., Theilmann, M., Bicaba, B. W., Andall-Brereton, G., Bovet, P., Farzadfar, F., Singh Gurung, M., Houehanou, C., Malekpour, M. R., Martins, J. S., Moghaddam, S. S., Mohammadi, E., Norov, B., Quesnel-Crooks, S., Wong-McClure, R., Davies, J. I., Hlatky, M. A., Atun, R., Bärnighausen, T. W., Jaacks, L. M., Manne-Goehler, J., & Vollmer, S. (2021). Unmet need for hypercholesterolemia care in 35 low- and middle-income countries: A cross-sectional study of nationally representative surveys. PLoS medicine, 18(10), e1003841. https://doi.org/10.1371/journal.pmed.1003841
Marcus, Maja E, et al. "Unmet need for hypercholesterolemia care in 35 low- and middle-income countries: A cross-sectional study of nationally representative surveys." PLoS medicine vol. 18,10 (2021): e1003841. doi: https://doi.org/10.1371/journal.pmed.1003841
Marcus ME, Ebert C, Geldsetzer P, Theilmann M, Bicaba BW, Andall-Brereton G, Bovet P, Farzadfar F, Singh Gurung M, Houehanou C, Malekpour MR, Martins JS, Moghaddam SS, Mohammadi E, Norov B, Quesnel-Crooks S, Wong-McClure R, Davies JI, Hlatky MA, Atun R, Bärnighausen TW, Jaacks LM, Manne-Goehler J, Vollmer S. Unmet need for hypercholesterolemia care in 35 low- and middle-income countries: A cross-sectional study of nationally representative surveys. PLoS Med. 2021 Oct 25;18(10):e1003841. doi: 10.1371/journal.pmed.1003841. eCollection 2021 Oct. PMID: 34695124; PMCID: PMC8575312.
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PLoS Med. 2021 Oct 25;18(10):e1003841. doi: 10.1371/journal.pmed.1003841. eCollection 2021 Oct.

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

PLoS medicine

Maja E Marcus, Cara Ebert, Pascal Geldsetzer, Michaela Theilmann, Brice Wilfried Bicaba, Glennis Andall-Brereton, Pascal Bovet, Farshad Farzadfar, Mongal Singh Gurung, Corine Houehanou, Mohammad-Reza Malekpour, Joao S Martins, Sahar Saeedi Moghaddam, Esmaeil Mohammadi, Bolormaa Norov, Sarah Quesnel-Crooks, Roy Wong-McClure, Justine I Davies, Mark A Hlatky, Rifat Atun, Till W Bärnighausen, Lindsay M Jaacks, Jennifer Manne-Goehler, Sebastian Vollmer

Affiliations

  1. Department of Economics & Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany.
  2. RWI-Leibniz Institute for Economic Research, Essen (Berlin Office), Germany.
  3. Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California, United States of America.
  4. Heidelberg Institute of Global Health, Heidelberg University and University Hospital, Heidelberg, Germany.
  5. Ministry of Health, Ouagadougou, Burkina Faso.
  6. Caribbean Public Health Agency, Port of Spain, Trinidad and Tobago.
  7. Ministry of Health, Victoria, Seychelles.
  8. University Centre for General Medicine and Public Health (Unisanté), Lausanne, Switzerland.
  9. Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.
  10. Health Research and Epidemiology Unit, Ministry of Health, Thimphu, Bhutan.
  11. Laboratory of Epidemiology of Chronic and Neurological Diseases, Faculty of Health Sciences, University of Abomey-Calavi, Abomey-Calavi, Benin.
  12. Faculty of Medicine and Health Sciences, Universidade Nacional Timor Lorosa'e, Dili, Timor-Leste.
  13. Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.
  14. National Center for Public Health, Ulaanbaatar, Mongolia.
  15. Office of Epidemiology and Surveillance, Caja Costarricense de Seguro Social, San Jose, Costa Rica.
  16. Institute for Applied Health Sciences, University of Birmingham, Birmingham, United Kingdom.
  17. MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, University of Witwatersrand, Johannesburg, South Africa.
  18. Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa.
  19. Department of Medicine, Stanford University, Stanford, California, United States of America.
  20. Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America.
  21. Africa Health Research Institute, Somkhele, South Africa.
  22. Global Academy of Agriculture and Food Security, University of Edinburgh, Edinburgh, United Kingdom.
  23. Public Health Foundation of India, New Delhi, Delhi NCR, India.
  24. Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America.

PMID: 34695124 PMCID: PMC8575312 DOI: 10.1371/journal.pmed.1003841

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.

Conflict of interest statement

The authors have declared that no competing interests exist.

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