CHAPTER TWO

LITERATURE REVIEW
2.0 Introduction
2.1 Theoretical review
High blood cholesterol is a leading risk factor in the development of atherosclerosis and
coronary heart disease (CHD). The risks associated with high blood cholesterol can be
reduced by screening and early intervention. Current clinical practice guidelines provide
evidenced-based standards for detection, treatment, and control of high blood
cholesterol. Healthy People 2020 monitors national progress related to screening and
controlling high blood cholesterol through the National Health Interview Survey and the
National Health and Nutrition Examination Survey (NHANES). State-level estimates of
self-reported cholesterol screening and high blood cholesterol prevalence are available
using Behavioral Risk Factor Surveillance System (BRFSS) data. To assess recent trends
in the percentage of adults aged ≥18 years who had been screened for high blood
cholesterol during the preceding 5 years, and the percentage among those who had
been screened within the previous 5 years and who were ever told they had high blood
cholesterol, CDC analyzed BRFSS data from 2005, 2007, and 2009.

The results of that analysis showed that the percentage of adults reporting having been
screened for high blood cholesterol within the preceding 5 years increased overall from
72.7% in 2005 to 76.0% in 2009. In addition, the percentage who had ever been told
they had high cholesterol increased from 33.2% to 35.0%. Both self-reported screening
and high cholesterol varied by state and sociodemographic subgroup. To reach the
Healthy People 2020 target for cholesterol screening, public health practitioners should
emphasize the importance of screening, especially among adults, men, Hispanics, and
persons with lower levels of education.

Cholesterol is a major risk factor for cardiovascular disease. In 2003, the percentage of
adults who had their cholesterol screened during the preceding 5 years was 73.1%.
Among those who had a cholesterol screening, 31.1% reported ever being told they
 had high cholesterol. The prevalence of cholesterol screening has been reported as
higher among the elderly, women, whites, and blacks.

2.2 Conceptual Framework

Mechanisms by which Effectiveness of current

cholesterol contributes interventions for managing
 Lipids cholesterol-related disorders
 Lipoproteins
 Statins
 plasma cholesterol
 Exercising
concentration
 Eating a healthy diet
 recommend medication

DIET & Life Style Best practice for

managing cholesterol
 low-density lipoprotein z
CHOLESTEROL  Lifestyle changes
 prevent the formation of
 Reducing the amount of
plaque
saturated fat
Life Style  losing weight
 Smoking  regular aerobic exercise
 Overweight and Extraneous variable
obesity (demographic data)

 Gender
 Age
 Wealth status
 Habits of eating
2.3 related studies

The effectiveness of statins (3-hydroxy-3-methyl-glutaryl coenzyme A reductase

inhibitors) in treating hyperlipidemia and preventing cardiovascular events is well
documented.1,2 In 2001, the National Cholesterol Education Program (NCEP) published
the Third Adult Treatment Panel (ATP-III) guidelines, which recommend therapeutic
lifestyle changes and drug treatment with statins for patients with high low-density
lipoprotein cholesterol (LDL-C).

Several studies indicate that LDL-C levels are declining among US adults.4-6 while this
may be partially due to diet, a significant role for statins is suggested by increased use
of lipid-lowering therapy during the 1990s.5 However, few data are available on trends
in statin use among US adults with high LDL-C. Previous reports have relied on self-
report of lipid-lowering therapy, including medications other than statins, or analysis of
population-level pharmacy databases.5,7 Furthermore, patient-level data on statin use
since publication of the ATP-III guidelines are limited. The main goal of the current
study was to document trends in statin use among US adults during the period from
before to after publication of the ATP-III guidelines in 2001. Additionally, the impact of
these trends of statin use on LDL-C levels and control rates was determined. Finally, we
identified subgroups, defined by demo graphic and behavioral characteristics, with
suboptimal statin use in the period after publication of the ATP-III guidelines. To
achieve these goals, we analyzed data from the population-based National Health and
Nutrition Examination Survey (NHANES) 1999–2000, 2001–2002, and 2003–2004.

Substantial epidemiologic evidence suggests a negative linear correlation between of

high-density lipoprotein cholesterol (HDL-C) levels and the incidence of coronary heart
disease (CHD); an inverse relationship between HDL-C and cardiovascular disease was
not well established until the Framingham study in the 1970s, which identified HDL-C as
a powerful risk factor inversely associated with the incidence of CHD. High-density
lipoprotein (HDL) is positively associated with a decreased risk of coronary heart
disease (CHD). As defined by the United States National Cholesterol Education Program
Adult Treatment Panel III guidelines, an HDL-C level of 60 mg/dL or greater is a
negative (protective) risk factor. On the other hand, a high-risk HDL-C level is described
as one that is less than 40 mg/dL

The major apolipoproteins of HDL are apolipoprotein (apo) A-I and apo A-II, the alpha-
lipoproteins. Elevated concentrations of apo A-I and apo A-II are called hyper
alphalipoproteinemia (HALP), which is associated with lower risk CHD. Conversely, hypo
alpha lipo proteinemia increases the risk of CHD. The levels at which HDL-C confers
benefit or risk are not discrete, and the cut points are somewhat arbitrary, especially
considering that HDL-C levels are, on average, higher in United States women
compared with men. Hyper alpha 11 lipo proteinemia (HALP) is caused by a variety of
genetic and environmental factors. Among these, plasma cholesteryl ester transfer
protein (CETP) deficiency is the most important and frequent cause of HALP in Asian
populations. CETP facilitates the transfer of cholesteryl ester (CE) from a high-density
lipoprotein (HDL) to apolipoprotein (apo) B-containing lipoproteins, and is a key protein
in the reverse cholesterol transport system.

However, environmental factors also have a significant impact on HDL-C. Smoking and
obesity are the most significant risk factors associated with a lower HDL-C. Besides
these factors, genetic variants also have an impact on HDL-C. Certain genes play an
essential role in the synthesis and metabolism of serum lipids. One of these genes is the
lipoprotein lipase (LPL) gene, whose variant (Rs 328) has been associated with HDL-C
and triglyceride. LPL rs328 GG and CG genotypes were found to be significantly related
to a higher HDL-C and triglyceride. Randomized controlled clinical trials have
demonstrated that interventions to raise HDL-C levels are associated with reduced CHD
events. Exercise is one of the lifestyle integrations that have been recommended for
improving lipid fractions such as HDL cholesterol.

Several studies have shown that aerobic exercise is associated with higher HDL-C.
Among them is Dr. Satoru Kodama (Ochanomizu University, Tokyo, Japan) and
colleagues, who showed that aerobic training resulted in a 2.53-mg/dL increase in HDL-
C levels, so, by rough estimates, it could result in a 5.1% and 7.6% reduction in
cardiovascular disease risk in men and women, respectively. The most important
element of an exercise program is the duration per session. Aerobic exercise has also
been associated with a better prognosis of cardiovascular disease. Based on a previous
study, intermittent exercise programs were associated with significantly improvements
in lipid profiles following eight weeks of training in obese children. The effects of
exercise behavior on the predicted CVD risks were found to vary depending on different
factors. Badminton, an indoor intermittent exercise most popular in Asia, has been
shown to improve the maximum power output of regular practitioners, so it should be
considered as a strategy for improving the health and well-being of untrained females
who are currently not meeting the physical activity guidelines.

Outdoor exercises have been linked to air pollution and associated health issues. The
respiratory physiology of exercise suggests that athletes and other exercisers may
experience magnified exposure to ambient air pollution in outdoor exercises, hence
should avoid exercising by the road side, as ozone (O3) is particularly damaging to
athletes. As badminton is an indoor sport, playing it might reduce the harmful health
effects associated with air pollution. For instance, in sedentary United Kingdom females,
badminton significantly lowered some cardiovascular health markers, including the
mean arterial pressure, systolic and diastolic blood pressure, and resting heart rate.

The findings from another study revealed that playing badminton can reduce all-cause
mortality by 47% and CVD mortality risk by 59%. Both aerobic exercise and badminton
have positive effects on health. Several investigations have been made regarding HDL-C
and aerobic exercise [16]. The results show that HDL-C levels compared to other lipid
fractions are more sensitive to aerobic exercise. As far as research on HDL-C and
exercise is concerned, hardly any has been done with regards to badminton exercise
[3,19]. Because of this, we investigated the association between badminton, aerobic
exercise, and HDL-C among adult Taiwanese.
The National Health and Nutrition Examination Survey 2005–2006 reported mean
intakes of 278 mg cholesterol/day in the USA, whereas adult females averaged 237
compared to 358 mg cholesterol/day for adult males.7 As the pervasive public health
programmes are focusing on nutrition education, shifting from red meat to poultry, the
general population is increasingly concerned about cholesterol intake. The trends in
compliance with the dietary recommendations of the Swiss Society for Nutrition in the
Geneva population were assessed for the period from 1999 to 2009 using 10 cross-
sectional, population-based surveys, and found that the percentage of participants with
a cholesterol intake of ≤ 300 mg/day increased from 40.8% in 1999 to 43.6% in 2009
for men and from 57.8% to 61.4% in women, although the quality of the Swiss diet did
not improve over the study period.

By contrast, few studies longitudinally reported that mean daily cholesterol intake and
the proportion of people with a greater intake than the recommended amount
increased in adults of both Taiwanese and Chinese origin. On the contrary, food sources
of cholesterol may be undergoing great changes with the modifications in lifestyle and
dietary habits worldwide. China has experienced extremely rapid economic growth over
the past three decades, which induced the epidemic of a Western lifestyle. However,
the dietary cholesterol intake status in Chinese in recent years is rarely reported. Taken
together, the longitudinal studies targeted on the trends and food group patterns of
dietary cholesterol intake in China are required. By use of longitudinal data from the
China Health and Nutrition Survey (CHNS), the aims of the present study were to
examine the trends in dietary cholesterol intake and its food sources in Chinese adults
younger than 60 years between 1991 and 2011, and to investigate the differences in
dietary cholesterol intake across demographic factors.
2.4 Research Gap

The Literature review in this study is very researchable findings that published more
manuscript and research papers. The gap of this study is there no other studies
conducted about Impact of Cholesterol among Adult at Badar-Qasim hospital in Bossaso
Puntland Somalia.