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 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. Maja Marcus and colleagues use nationally-representative surveys conducted between 2009 and 2018 to investigate the unmet need for hypercholesterolemia care in 35 low- and middle-income countries. Author summary Why was this study done? The prevalence of hypercholesterolemia is increasing in low- and middle-income countries (LMICs). Evidence on how well health systems address this rising hypercholesterolemia burden is limited. Nationally representative studies analyzing care at the individual level across a larger number of LMICs are largely missing. What did the researchers do and find? We analyzed access to hypercholesterolemia care using pooled data from 35 nationally representative, individual-level surveys from LMICs. We found a prevalence of high total cholesterol (TC) of 7.1% (95% CI: 6.8% to 7.4%) and a high low-density lipoprotein cholesterol (LDL-C) prevalence of 7.5% (95% CI: 7.1% to 7.9%) in this set of countries. Using a cascade of care approach, we found that 43% (95% CI: 40% to 45%) of individuals 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. Using modified Poisson regression models, we found that access to care was significantly associated with a range of sociodemographic characteristics, such as high education and old age, as well as with the presentation of other cardiovascular disease (CVD) risk factors, such as comorbid diabetes or hypertension and a high body mass index. What do these findings mean? We found large unmet need for hypercholesterolemia care in this sample of LMICs. This calls for greater policy and research attention toward this CVD risk factor. High-performing countries, such as Sri Lanka, Costa Rica, Iran, and Morocco, may highlight policy opportunities for improved prevention of CVD. 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.