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Spanish perspective
TABLE
I
Recommendations of the Belgian m”~e”sus regarding fallowup of patianrs with hyperchokstemtaemia. and initiation of drug uwitment. -
Total sermn chalesteml < 2OLlmgldl(5.2 mm&l). No tratmen,. fcdlow-up after 5 years. serum cholesterol 2M!-250 mg/dl (5.2-6.5 mmaUl), with no peviwa cardiovawular events and less than two other risk facto~r.Dietaq iiiaaizi, f&wup sRci I ycx.
-Total
-Total
serum cholesterol 2CJ%250 mgldl 0.245 mmolll) pius two or more risk fxtorJ. Further investigalion of lowdensity lipoprotein, hjgh-dwsity lipopmwin, ape-lipupm.
teins. Dietary treatment. follow-up after 3 and 6 months. If cho?ssremlis > 250 m&it (6.5 mm&l) or low-density lipw protein > 150 mgIdl(3.9 mmoW. start drug therapy. -
Tatal serum cholesteml > 250 mgldl (6.5 mm&l). Stung recommendation an nutrition, fallow-up after 3 and 6 monLs. If no change. stat dmg therapy.
At present, average intake of fats, cholesterol, carbohydrates, proteins, and total kilocalories is above the levels recommended in the European consensus. While the polyunsaNrated:saNrated fat ratio has increased from 0.2 to 0.5, it still falls far short of the recommended ratio of 1. The recommendations of the Belgian consensus re-
garding follow-up shown in Table I.
and dmg treatment are as
J.A. Guti&rez and E. Ros Like other Mediterranean countries, Spain traditionally has a very low incidence of coronary heart disease. The incidence of coronary heart disease increased gradually through the 19709 hut appeared to stabilize in the 1980s. The current level is Itill low: 104/100,000 for men and 24/100,0(K) for women. Nevenbeless, concern is growing at the relatively high levels of plasma cholesterol seen throughout Spain. In the northeast. in Catalonia, data from the Monitoring Trends and Determinants in Cardiovascular Disease Study reveal cholesterol levels in adults of 200-240 mg/dl (5.2-6.2 mmoVl) - similar to those in the U.S.A. [I]. In Madrid, data from the
Study on Prevalence of Cardiovascular Risk Factors (EFCUM) show cholesterol levels of 198.8 mg/dl (5.1 mmol/l) for the adult population (177-225 mgId1 (4.6-5.8 mmoUl)) [2]. Of even greater concern are the high levels of plasma cholesterol found iii Spanish children. A meta-analysis of 21 studies during the 1980s. including nearly 20,000 children and adolescents [2], found a mean value of 173 mg!dl (4.5 mmoi/l) in Z&18year-old children. 10-15 mgl.ll (0.3-0.4 mmol/l) higher than those observed in the U.S. Lipid Research Clinics Program Prevalence Study. Data from the Study on Prevalence of Cardiovascular Risk Factors reveal a cholesterol level of 173.7 mg/dl (4.5 mmolIl) in Madrid’s children aged 5-12 years [2]. It is probable that the high cholesterol levels observed arc related to changes in eating habits in Spain. Over the last 30-40 years, meat consumption has doubled, the intake of milk and other dairy products has increased, and the consump tion of bread, vegetables, and vegetable oils has decreased. Throughout Spain, nearly 40% of dietary energy is derived from fat; approximately 13% is saturated fat, while about 50% is monounsaturated (olive oil). The Study on Prevalence of Cardiovascular Risk Factors showed an energy intake of 45.6% in the form of fats (saturated fatty acid: 15%; mono-unsaturated fatty acid: 21%; poly-unsaturated fatty acid: 9.6%; cholesterol: 473.8 mg/day) [2]. Salt intake is also high and appmximately half of Spanish adults arc tobacco smokers. Three sets of recommendations on cholesteml lowering have been published in Spain in the last 3 years [3, 4, 61. The recommendations of the Spanish Atherosclerosis Society 141 bmadly follow those of the Eumpcan Atheroxlemsis So& ety. The Society believes that the high consumption of mono-unsaturated fat in Spain may be an important reason for the low level of coronary heart disease, and has therefore, somewhat controversially, set recommended fat intake at relatively high levels (3.5-40% of dietary energy), but with a saturated fat intake below 10%. As with all the Spanish recommendations, the determinants for intervention are expressed in tew:, of iowdensity lipoprotein cholesterol. Belo- 150 mg/dl
(3.9 mmol/l) low-density lipoprotein, intervention is not recommended: above 185 mg/dI (4.8 mm&l), pbarmacoIogical therapy is advised. The Spanish Consensus for Cholesterol Contml [S] recommends the reduction of dietary fat to 3.5%.and to reduce saturated fat to 7-10% of calories. Opportunistic, rather than general screening is advised. Recommendations for intervention are similar to those of the European Consensus. R~~end~o~ have also been published for chikiren ~comme~ng a dietary fat intake of 30-35%. with IZ-i5% as mono~unsaturates [3]. If the cholesterol level remains > 225-250 mgldl (5.8-6.5 mmobl) and the low-density lipoprotein level :, 160 mg/dl(4. I mmobl) after dietary treatment, the Spanish recommendation is to introduce drug therapy from the age of 3 years (compared to US. recommendations of 10 years).
References
Dutch perspective A.EH. Stalenhwf C~&ovosnrlar disease accounts for 41% of mortality in fhe Dutch population, and, of this, is-
cbaemic heart disease accounts for 45%. Mortalitv because of coronary heart disease peaked & 1972, and has since decreased gradually in both men and women at a rate of about I .5% per year. Currently the rate of mortality because of coronary heart disease in The Netherlands is in the midrange for the industrialized countries, comparable to that in Germany,and Israel, and lower than that in the U.K. or Scandinavia. Only one in three of the Dutch population has an optimal serum cholesterol level of 193 mgldi (5.0 mmoYl)or bass.The prevalence of hypercholesterolaemia (defined as a plasma chotesterol level > 251 mg/dI (6.5 mmobl)) is about 15-16%, and appears to be increasing. There is also a marked increase in the number of individuals in the 50-59 year age group with levels > 309 mgjdl (8.0 mmobl) (Table I). A large national food consumption survey, undertaken in 1987-88. showed that 40% of diotary energy came from’fat, of whiih 15.8 energy % was saturated, 14.8 mono-tmsaturated, and 6.7 was polyunsaturated [I]. These figures are at variance with tbe. ~~n~tio~ of the Dntch Nationa Nutrition Council, of a total fat intake of 3035% and 10% saturated fat. The intake of saturated fats is mainly in the form of dairy products, particularly cheese and butter. There are differences in fat consumption according to sociwconomic class: the higher classes eat less meat and other saturated fats, but have a higher consumption of butter than the lower classes. A national ccusensus conference was held in 1987. and tbe consensus was revised in 1991 to take account of the inaction of new drugs, and to attempt to gain mote snppott from general practitioners. The consensus was pnblish~ in national journals [2-6]. The need for repeated measurements of serum cholesterol was emphasized. Genenit screening was not recommended, for the followq reasons: - Mean population cholesterol leve!s are already known to be above desirable levels, underlining the necessity for a population strategy. - The cho!este.wl sahte per se has 3 lnru pre&tive value in any given ~~vi~.
I
Recommendations of the Belgian m”~e”sus regarding fallowup of patianrs with hyperchokstemtaemia. and initiation of drug uwitment. -
Total sermn chalesteml < 2OLlmgldl(5.2 mm&l). No tratmen,. fcdlow-up after 5 years. serum cholesterol 2M!-250 mg/dl (5.2-6.5 mmaUl), with no peviwa cardiovawular events and less than two other risk facto~r.Dietaq iiiaaizi, f&wup sRci I ycx.
-Total
-Total
serum cholesterol 2CJ%250 mgldl 0.245 mmolll) pius two or more risk fxtorJ. Further investigalion of lowdensity lipoprotein, hjgh-dwsity lipopmwin, ape-lipupm.
teins. Dietary treatment. follow-up after 3 and 6 months. If cho?ssremlis > 250 m&it (6.5 mm&l) or low-density lipw protein > 150 mgIdl(3.9 mmoW. start drug therapy. -
Tatal serum cholesteml > 250 mgldl (6.5 mm&l). Stung recommendation an nutrition, fallow-up after 3 and 6 monLs. If no change. stat dmg therapy.
At present, average intake of fats, cholesterol, carbohydrates, proteins, and total kilocalories is above the levels recommended in the European consensus. While the polyunsaNrated:saNrated fat ratio has increased from 0.2 to 0.5, it still falls far short of the recommended ratio of 1. The recommendations of the Belgian consensus re-
garding follow-up shown in Table I.
and dmg treatment are as
J.A. Guti&rez and E. Ros Like other Mediterranean countries, Spain traditionally has a very low incidence of coronary heart disease. The incidence of coronary heart disease increased gradually through the 19709 hut appeared to stabilize in the 1980s. The current level is Itill low: 104/100,000 for men and 24/100,0(K) for women. Nevenbeless, concern is growing at the relatively high levels of plasma cholesterol seen throughout Spain. In the northeast. in Catalonia, data from the Monitoring Trends and Determinants in Cardiovascular Disease Study reveal cholesterol levels in adults of 200-240 mg/dl (5.2-6.2 mmoVl) - similar to those in the U.S.A. [I]. In Madrid, data from the
Study on Prevalence of Cardiovascular Risk Factors (EFCUM) show cholesterol levels of 198.8 mg/dl (5.1 mmol/l) for the adult population (177-225 mgId1 (4.6-5.8 mmoUl)) [2]. Of even greater concern are the high levels of plasma cholesterol found iii Spanish children. A meta-analysis of 21 studies during the 1980s. including nearly 20,000 children and adolescents [2], found a mean value of 173 mg!dl (4.5 mmoi/l) in Z&18year-old children. 10-15 mgl.ll (0.3-0.4 mmol/l) higher than those observed in the U.S. Lipid Research Clinics Program Prevalence Study. Data from the Study on Prevalence of Cardiovascular Risk Factors reveal a cholesterol level of 173.7 mg/dl (4.5 mmolIl) in Madrid’s children aged 5-12 years [2]. It is probable that the high cholesterol levels observed arc related to changes in eating habits in Spain. Over the last 30-40 years, meat consumption has doubled, the intake of milk and other dairy products has increased, and the consump tion of bread, vegetables, and vegetable oils has decreased. Throughout Spain, nearly 40% of dietary energy is derived from fat; approximately 13% is saturated fat, while about 50% is monounsaturated (olive oil). The Study on Prevalence of Cardiovascular Risk Factors showed an energy intake of 45.6% in the form of fats (saturated fatty acid: 15%; mono-unsaturated fatty acid: 21%; poly-unsaturated fatty acid: 9.6%; cholesterol: 473.8 mg/day) [2]. Salt intake is also high and appmximately half of Spanish adults arc tobacco smokers. Three sets of recommendations on cholesteml lowering have been published in Spain in the last 3 years [3, 4, 61. The recommendations of the Spanish Atherosclerosis Society 141 bmadly follow those of the Eumpcan Atheroxlemsis So& ety. The Society believes that the high consumption of mono-unsaturated fat in Spain may be an important reason for the low level of coronary heart disease, and has therefore, somewhat controversially, set recommended fat intake at relatively high levels (3.5-40% of dietary energy), but with a saturated fat intake below 10%. As with all the Spanish recommendations, the determinants for intervention are expressed in tew:, of iowdensity lipoprotein cholesterol. Belo- 150 mg/dl
(3.9 mmol/l) low-density lipoprotein, intervention is not recommended: above 185 mg/dI (4.8 mm&l), pbarmacoIogical therapy is advised. The Spanish Consensus for Cholesterol Contml [S] recommends the reduction of dietary fat to 3.5%.and to reduce saturated fat to 7-10% of calories. Opportunistic, rather than general screening is advised. Recommendations for intervention are similar to those of the European Consensus. R~~end~o~ have also been published for chikiren ~comme~ng a dietary fat intake of 30-35%. with IZ-i5% as mono~unsaturates [3]. If the cholesterol level remains > 225-250 mgldl (5.8-6.5 mmobl) and the low-density lipoprotein level :, 160 mg/dl(4. I mmobl) after dietary treatment, the Spanish recommendation is to introduce drug therapy from the age of 3 years (compared to US. recommendations of 10 years).
References
Dutch perspective A.EH. Stalenhwf C~&ovosnrlar disease accounts for 41% of mortality in fhe Dutch population, and, of this, is-
cbaemic heart disease accounts for 45%. Mortalitv because of coronary heart disease peaked & 1972, and has since decreased gradually in both men and women at a rate of about I .5% per year. Currently the rate of mortality because of coronary heart disease in The Netherlands is in the midrange for the industrialized countries, comparable to that in Germany,and Israel, and lower than that in the U.K. or Scandinavia. Only one in three of the Dutch population has an optimal serum cholesterol level of 193 mgldi (5.0 mmoYl)or bass.The prevalence of hypercholesterolaemia (defined as a plasma chotesterol level > 251 mg/dI (6.5 mmobl)) is about 15-16%, and appears to be increasing. There is also a marked increase in the number of individuals in the 50-59 year age group with levels > 309 mgjdl (8.0 mmobl) (Table I). A large national food consumption survey, undertaken in 1987-88. showed that 40% of diotary energy came from’fat, of whiih 15.8 energy % was saturated, 14.8 mono-tmsaturated, and 6.7 was polyunsaturated [I]. These figures are at variance with tbe. ~~n~tio~ of the Dntch Nationa Nutrition Council, of a total fat intake of 3035% and 10% saturated fat. The intake of saturated fats is mainly in the form of dairy products, particularly cheese and butter. There are differences in fat consumption according to sociwconomic class: the higher classes eat less meat and other saturated fats, but have a higher consumption of butter than the lower classes. A national ccusensus conference was held in 1987. and tbe consensus was revised in 1991 to take account of the inaction of new drugs, and to attempt to gain mote snppott from general practitioners. The consensus was pnblish~ in national journals [2-6]. The need for repeated measurements of serum cholesterol was emphasized. Genenit screening was not recommended, for the followq reasons: - Mean population cholesterol leve!s are already known to be above desirable levels, underlining the necessity for a population strategy. - The cho!este.wl sahte per se has 3 lnru pre&tive value in any given ~~vi~.