Heart disease is the leading cause of death in the United States (Murphy, et. al., 2018). Blood lipid levels are fundamental measures included in NHANES that can be used for cardiovascular risk assessment. The goals the NHANES blood lipid measurements include: 1) monitoring the prevalence and trends in major cardiovascular conditions and overall risk factors in the U.S.; 2) evaluating prevention and treatment programs targeting cardiovascular disease in the U.S.; and 3) monitoring the status of hyperlipidemia.
In 2018, new Blood Cholesterol Guidelines were released, by the American College of Cardiology and American Heart Association Task Force on Clinical Practice Guidelines, which aim to reduce the risk of atherosclerotic cardiovascular disease through cholesterol management (Grundy, et. al., 2018). The blood lipids measurements in NHANES include total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoproteins cholesterol (LDL-C), and triglycerides. The present file provides data on total cholesterol. Data on LDL-C and triglycerides are provided in Cholesterol – Low – Density Lipoprotein and Triglycerides (TRIGLY_J) file, and HDL-C data are provided in Cholesterol - High - Density Lipoprotein (HDL_J).
Examined participants aged 6 years and older were eligible.
Total Cholesterol
The laboratory method used to measure total cholesterol is an enzymatic assay. In this enzymatic assay, esterified cholesterol is converted to cholesterol by cholesterol esterase. The resulting cholesterol is then acted upon by cholesterol oxidase to produce cholest-4-en-3-one and hydrogen peroxide. The hydrogen peroxide then reacts with 4-aminophenazone in the presence of peroxidase to produce a colored product that is measured at 505 nm (secondary wavelength = 700 nm). The final step is known as the Trinder reaction. This method is a single reagent, endpoint reaction that is specific for cholesterol.
Cholesterol, a steroid molecule with a hydroxyl group in the C3 position, is synthesized in many types of tissue, but mainly in the liver and intestinal wall. About 75 percent of cholesterol is newly synthesized, with the remainder originating from dietary intake. Cholesterol measurement is performed to screen for atherosclerotic risk and in the diagnosis and treatment of disorders involving elevated cholesterol as well as lipid and lipoprotein metabolic disorders.
Refer to the Laboratory Method Files section for a detailed description of the laboratory methods used.
Serum total cholesterol levels were directly measured. Please see below the Data Processing and Editing section for more details. For laboratory methods used for low-density lipoproteins cholesterol (LDL-C), and triglycerides and HDL-C, please refer to the accompanying documentation: TRIGLY_J and HDL_J.
There were no changes to the lab method, lab equipment, or lab site for this component in the NHANES 2017-2018 cycle.
Total Cholesterol (Frozen) Laboratory Procedure Manual (February 2020)
Serum specimens were processed, stored, and shipped to the University of Minnesota, Minneapolis, MN for analysis.
Detailed instructions on specimen collection and processing are discussed in the NHANES Laboratory Procedures Manual (LPM). Vials are stored under appropriate frozen (–30°C) conditions until they are shipped to University of Minnesota for testing.
The NHANES quality assurance and quality control (QA/QC) protocols meet the 1988 Clinical Laboratory Improvement Act mandates. Detailed QA/QC instructions are discussed in the NHANES LPM.
Mobile Examination Centers (MECs)
Laboratory team performance is monitored using several techniques. NCHS and contract consultants use a structured competency assessment evaluation during visits to evaluate both the quality of the laboratory work and the quality control procedures. Each laboratory staff member is observed for equipment operation, specimen collection and preparation; testing procedures and constructive feedback are given to each staff member. Formal retraining sessions are conducted annually to ensure that required skill levels were maintained.
Analytical Laboratories
NHANES uses several methods to monitor the quality of the analyses performed by the contract laboratories. In the MEC, these methods include performing blind split specimens collected on “dry run” sessions. In addition, contract laboratories randomly perform repeat testing on 2% of all specimens.
NCHS developed and distributed a quality control protocol for all CDC and contract laboratories, which outlined the use of Westgard rules (Westgard et al., 1981) when running NHANES specimens. Progress reports containing any problems encountered during shipping or receipt of specimens, summary statistics for each control pool, QC graphs, instrument calibration, reagents, and any special considerations are submitted to NCHS quarterly. The reports are reviewed for trends or shifts in the data. The laboratories are required to explain any identified areas of concern.
The data were reviewed. Incomplete data or improbable values were sent to the performing laboratory for confirmation.
One derived variable was created in this data file. The variable was created using the following formula:
LBDTCSI
The total cholesterol in mg/dL (LBXTC) was converted to mmol/L (LBDTCSI) by multiplying by 0.02586.
Refer to the 2017-2018 Laboratory Data Overview for general information on NHANES laboratory data.
There are over 800 laboratory tests performed on NHANES participants. However, not all participants provided biospecimens or enough volume for all the tests to be performed. The specimen availability can also vary by age or other population characteristics. For example, in 2017-2018, approximately 80% of children aged 1-17 years who were examined in the MEC provided a blood specimen through phlebotomy, while 95% of examined adults age 18 and older provided a blood specimen. Analysts should evaluate the extent of missing data in the dataset related to the outcome of interest as well as any predictor variables used in the analyses to determine whether additional re-weighting for item non-response is necessary.
Please refer to the NHANES Analytic Guidelines and the on-line NHANES Tutorial for further details on the use of sample weights and other analytic issues.
Demographic and Other Related Variables
The analysis of NHANES laboratory data must be conducted using the appropriate survey design and demographic variables. The NHANES 2017-2018 Demographics File contains demographic data, health indicators, and other related information collected during household interviews as well as the sample design variables. The recommended procedure for variance estimation requires use of stratum and PSU variables (SDMVSTRA and SDMVPSU, respectively) in the demographic data file.
The Fasting Questionnaire File includes auxiliary information, such as fasting status, length of fast, and the time of venipuncture.
The laboratory data file can be linked to other NHANES data file using the unique survey participant identifier (i.e., SEQN).
Detection Limits
The detection limits were constant for this analyte in the data set.
The lower limit of detection (LLOD, in mg/dL) for total cholesterol:
|
Variable Name |
Analyte Description |
LLOD |
|
LBXTC |
Serum Total cholesterol (Frozen) |
4 |
| Code or Value | Value Description | Count | Cumulative | Skip to Item |
|---|---|---|---|---|
| 76 to 446 | Range of Values | 6738 | 6738 | |
| . | Missing | 697 | 7435 |
| Code or Value | Value Description | Count | Cumulative | Skip to Item |
|---|---|---|---|---|
| 1.97 to 11.53 | Range of Values | 6738 | 6738 | |
| . | Missing | 697 | 7435 |