This statement summarizes the third USPSTF recommendations for screening for lipid disorders and the supporting scientific evidence, and it updates the 1995 recommendations contained in the Guide to Clinical Preventive Services, second edition.¹ Explanations of the ratings and of the strength of overall evidence are given in Appendix A and Appendix B, respectively. The complete information upon which this statement is based, including evidence tables and references, is available in the accompanying article, Screening for Lipid Disorders² and in the Systematic Evidence Review³ on this topic. Screening for lipid disorders in children and adolescents will be addressed in a separate statement.

This article originally appeared in the American Journal of Preventive Medicine. Select for copyright, source, and reprint information.

• TC and HDL-C can be measured on nonfasting or fasting samples.
  Abnormal results should be confirmed by a repeated sample on a separate occasion, and the average of both results should be used for risk assessment. Although measuring both TC and HDL-C is more sensitive and specific for assessing coronary heart disease risk, TC alone is an acceptable screening test if available laboratory services cannot provide reliable measurements of HDL. In conjunction with HDL-C, low-density lipoprotein cholesterol (LDL-C) and TC provide comparable information, but measuring LDL-C requires a fasting sample and is more expensive. In patients with elevated risk on screening results, lipoprotein analysis, including fasting triglycerides, may provide information that is useful in choosing optimal treatments.
• Screening is recommended for men aged 20 to 35 years and for women aged 20 to 45 years in the presence of any of the following:
  • Diabetes.
  • A family history of cardiovascular disease before age 50 years in male relatives or age 60 years in female relatives.
  • A family history suggestive of familial hyper-lipidemia.
  • Multiple coronary heart disease risk factors (e.g., tobacco use, hypertension).
• The optimal interval for screening is uncertain.
  On the basis of other guidelines and expert opinion, reasonable options include every 5 years, shorter intervals for people who have lipid levels close to those warranting therapy, and longer intervals for low-risk people who have had low or repeatedly normal lipid levels.
• An age to stop screening is not established.
  Screening may be appropriate in older people who have never been screened, but repeated screening is less important in older people because lipid levels are less likely to increase after age 65 years.
• Treatment decisions should take into account overall risk of heart disease rather than lipid levels alone.
  Overall risk assessment should include the presence and severity of the following risk factors: age, gender, diabetes, elevated blood pressure, family history (in younger adults), and smoking. Tools that incorporate specific information on multiple risk factors provide more accurate estimation of cardiovascular risk than categorizations based on counting the numbers of risk factors.^4,5
• Treatment choices should take into account costs and patient preferences.
  Drug therapy is usually more effective than diet alone, but choice of treatment should consider overall risk, costs of treatment, and patient preferences. Guidelines for treating high cholesterol are available from the National Cholesterol Education Program of the National Institutes of Health (6). Although diet therapy is an appropriate initial therapy for most patients, a minority achieve substantial reductions in lipid levels from diet alone; drugs are frequently needed to achieve therapeutic goals, especially for high-risk people. Lipid-lowering treatments should be accompanied by interventions addressing all modifiable risk factors for heart disease, including smoking cessation, treatment of blood pressure, diabetes, and obesity, as well as promotion of a healthy diet and regular physical activity. Long-term adherence to therapies should be emphasized.
• All patients, regardless of lipid levels, should be offered counseling about the benefits of a diet low in saturated fat and high in fruits and vegetables, regular physical activity, avoiding tobacco use, and maintaining a healthy weight.

The clearest benefit of lipid screening is identifying individuals whose near-term risk of coronary heart disease is sufficiently high to justify drug therapy or other intensive lifestyle interventions to lower cholesterol. Screening men older than age 35 years and women older than age 45 years will identify nearly all individuals whose risk of coronary heart disease is as high as that of the subjects in the existing primary prevention trials. In a population with a 1% risk of coronary heart disease per year, drug treatment of 67 people for 5 years is required to prevent one coronary heart disease event. Most younger people have a substantially lower risk, unless they have other important risk factors for coronary heart disease or familial hyperlipidemia.

The primary goal of screening younger people is to promote lifestyle changes, which may provide long-term benefits later in life. The average effect of diet interventions is small, however, and screening is not necessary to advise young adults about the benefits of a healthy diet and regular exercise. Although universal screening may detect some patients with familial hyperlipidemia earlier than selective screening, whether this will lead to important reductions in coronary events is not known.

Routine measurement of nonfasting TC and HDL every 5 years is recommended by the National Cholesterol Education Program's Adult Treatment Panel II (ATP II), sponsored by the National Institutes of Health,⁶ and endorsed by the American Heart Association⁷ and the American College of Obstetricians and Gynecologists.⁸ The American College of Physicians and American Academy of Family Physicians suggest periodic cholesterol measurement in men aged 35 to 65 years and in women aged 45 to 65 years.^9,10,11 In 1994, the Canadian Task Force on Preventive Health Care recommended selective case-finding in men aged 30 to 59 years, rather than routine screening.¹² The ATP II and the Canadian Task Force recommendations are currently being updated.

Members of the U.S. Preventive Services Task Force are: Alfred O. Berg, M.D., M.P.H., Chair, USPSTF (Professor and Chair, Department of Family Medicine, University of Washington, Seattle, WA); Janet D. Allan, Ph.D., R.N., C.S., Vice-chair, USPSTF (Dean and Professor, School of Nursing, University of Texas Health Science Center, San Antonio, TX); Paul S. Frame, M.D. (Tri-County Family Medicine, Cohocton, NY, and Clinical Professor of Family Medicine, University of Rochester, Rochester, NY); Charles J. Homer, M.D., M.P.H. (Executive Director, National Initiative for Children's Healthcare Quality, Boston, MA); Tracy A. Lieu, M.D., M.P.H. (Associate Professor, Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, Boston, MA); Cynthia D. Mulrow, M.D., M.Sc. (Professor of Medicine, University of Texas Health Science Center, Audie L. Murphy Memorial Veterans Hospital, San Antonio, TX); C. Tracy Orleans, Ph.D. (Senior Scientist, The Robert Wood Johnson Foundation, Princeton, NJ); Jeffrey F. Peipert, M.D., M.P.H. (Director of Research, Women and Infants' Hospital, Providence, RI); Nola J. Pender, Ph.D., R.N. (Professor and Associate Dean for Research, School of Nursing, University of Michigan, Ann Arbor, MI); Harold C. Sox, Jr., M.D. (Professor and Chair, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH); Steven M. Teutsch, M.D., M.P.H. (Senior Director, Outcomes Research and Management, Merck & Company, Inc., West Point, PA); Carolyn Westhoff, M.D., M.Sc. (Associate Professor of Obstetrics, Gynecology and Public Health, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY); and Steven H. Woolf, M.D., M.P.H. (Professor of Family Medicine, Department of Family Practice, Medical College of Virginia, Fairfax, VA).

The USPSTF grades its recommendations according to one of five classifications (A, B, C, D, or I), reflecting the strength of evidence and magnitude of net benefit (benefits minus harms).

A. The USPSTF strongly recommends that clinicians routinely provide [the service] to eligible patients. (The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.)

B. The USPSTF recommends that clinicians routinely provide [the service] to eligible patients. (The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms.)

C. The USPSTF makes no recommendation for or against routine provision of [the service]. (The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.)

D. The USPSTF recommends against routinely providing [the service] to asymptomatic patients. (The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits.)

I. The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. (Evidence that [the service] is effective is lacking, of poor quality, or conflicting and that the balance of benefits and harms cannot be determined.)

The USPSTF grades the quality of the overall evidence for a service on a 3-point scale (good, fair, or poor).

Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.

Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies; generalizability to routine practice; or indirect nature of the evidence on health outcomes.

Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.