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High prevalence of low HDL cholesterol concentrations and mixed

VIEWS: 10 PAGES: 10

									       High prevalence of low HDL cholesterol concentrations
       and mixed hyperlipidemia in a Mexican nationwide survey
                      Carlos A. Aguilar-Salinas,1,* Gustavo Olaiz,† Victoria Valles,* Juan Manuel Ríos Torres,*
                      Francisco J. Gómez Pérez,* Juan A. Rull,* Rosalba Rojas,† Aurora Franco,† and Jaime Sepulveda†
                      Departamento de Endocrinología y Metabolismo de Lípidos,* del Instituto Nacional de Ciencias Médicas y
                      Nutrición, Vasco de Quiroga 15, Mexico City 14000, Mexico; and Instituto Nacional de Salud Publica,†
                      Cuernavaca, Morelos, Mexico



Abstract The prevalence of lipid abnormalities revealed in a             During the past decade, a vast amount of evidence has
survey done in 417 Mexican cities is described. Information           confirmed the critical role played by the dyslipidemias in
was obtained on 15,607 subjects, aged 20 to 69 years. In this re-     the pathogenesis of atherosclerosis (8–12). Multiple
port, only samples obtained after a 9- to 12-h fast were in-
cluded (2,256 cases: 953 men and 1,303 women). The popula-
                                                                      studies have shown that modification of the plasma lipid
tion is representative of Mexican urban adults. Mean lipid            concentrations is a useful approach in decreasing cardiovas-
concentrations were: cholesterol, 4.80 mmol/l; triglycerides,         cular mortality (13–15). Several studies have demonstrated
2.39 mmol/l; HDL cholesterol, 1.00 mmol/l; and LDL choles-            that the prevalence of some forms of the dyslipidemias is
terol, 3.06 mmol/l. The most prevalent abnormality was HDL            high in Mexico (16); the 1988 National Seroe-pidemiologic
cholesterol below 0.9 mmol/l (46.2% for men and 28.7% for             Survey showed that the prevalence of hypercholester-
women). Hypertriglyceridemia ( 2.26 mmol/l) was the second
most prevalent abnormality (24.3%). Severe hypertriglyceri-
                                                                      olemia found in northern Mexico is similar to that reported
demia ( 11.2 mmol/l) was observed in 0.42% of the popula-             in the United States (17). Smaller studies also have suggested
tion. Increased LDL cholesterol ( 4.21 mmol/l) was observed           that hypertriglyceridemia and hypoalphalipoproteinemia
in 11.2% of the sample. Half of the hypertriglyceridemic sub-         are frequent risk factors in Mexican adults (18, 19). On the
jects had a mixed dyslipidemia or low HDL cholesterol. More           basis of the age distribution of the Mexican population,
than 50% of the low HDL cholesterol cases were not related to         composed mainly of those 30 years old and younger, it is
hypertriglyceridemia. Insulin resistance was found in 59% of
them.      In conclusion, the prevalence of hypoalphalipopro-
                                                                      very likely that the prevalence of the lipid abnormalities
teinemia and other forms of dyslipidemia in Mexican adults is         will be even greater in the next few decades. Periodic
very high and it is among the highest previously reported             studies of the prevalence of the main coronary risk factors
worldwide. —Aguilar-Salinas, C. A., G. Olaiz, V. Valles, J. M.        will help to predict the trends on cardiovascular mortality
Ríos Torres, F. J. Gómez Pérez, J. A. Rull, R. Rojas, A. Franco,      for upcoming years and will help in designing preventive
and J. Sepulveda. High prevalence of low HDL cholesterol con-         strategies to cope with this health problem.
centrations and mixed hyperlipidemia in a Mexican nationwide
survey. J. Lipid Res. 2001. 42: 1298–1307.
                                                                         In the period 1992–1993, the Ministry of Health of
                                                                      Mexico conducted the National Survey of Chronic Dis-
                                                                      eases to estimate the prevalence of obesity, type 2 diabetes,
Supplementary key words diabetes • obesity • hypertension • choles-
terol • Mexico • insulin resistance • hypertriglyceridemia            renal pathology, hypertension, and dyslipidemia. The ob-
                                                                      jective of this article is to describe the prevalence, by age
                                                                      and gender, of the lipid abnormalities revealed in the sur-
   The chronic-degenerative disorders have become a grow-             vey. The results are presented using an epidemiological
ing health problem in Mexico. Coronary heart disease and              and a clinically oriented approach.
diabetes are the first and fourth leading causes of death in
Mexico, followed by stroke as the fifth leading cause (1).                           MATERIALS AND METHODS
The interaction between genetic and environmental factors
explains the increasing magnitude of the phenomenon.                  Population sample
Several authors have demonstrated that the Mexican popu-                 This is a cross-sectional study that includes individuals from
                                                                      cities with more than 2,500 people. A multistage sampling proce-
lation has a genetic predisposition to the metabolic syn-
drome type 2 diabetes and several primary forms of dyslipi-
demias (2–4). A high-fat, high-carbohydrate, calories-rich
diet; tobacco use; alcohol consumption; and the sedentary               Abbreviations: apoA-I, apolioprotein A-I; BMI, body mass index;
                                                                      HOMA, homeostasis model.
lifestyle of a large proportion of the population are among             1 To whom correspondence should be addressed.

the recognized environmental factors (5–7).                               e-mail: caguilarsalinas@yahoo.com



1298      Journal of Lipid Research Volume 42, 2001
dure was used. The country was divided into four regions: north-           Definitions
ern, central, and southern, composed of 10 states each, and the                Three different cutpoints were used to analyze the prevalence
metropolitan area of Mexico City (including the remaining two              of hypertriglyceridemia, based on the different existing consen-
states). A random sample of Basic Geographical Statistical Units           sus recommendations. The selected cutpoints were 1.58, 2, and
was obtained in each state from a database recently generated by              2.2 mmol/l (21 –23). A cholesterol 6.3 mmol/l was consid-
the Instituto Nacional de Geografía y Estadística and after the            ered to be hypercholesterolemia. HDL cholesterol concentration
general sampling frame was constructed by the Health Ministry.             was considered to be abnormal if it was 0.9 mmol/l. Mixed
Neighborhood blocks were randomly selected and all adults                  hyperlipidemia was defined as cholesterol 5.2 mmol/l plus
(aged 20 to 69 years) in all households of the selected blocks             triglycerides 2.26 mmol/l. Severe hyperlipidemia was defined
were surveyed (with the exception of those living in militar y, reli-      as cholesterol 7.8 mmol/l and/or triglycerides 5.6 mmol/l.
gious, and health and other institutions). A total of 417 cities           Normotriglyceridemic hypoalphalipoproteinemia was defi ned as
were studied. The sample was representative of the Mexican ur-             HDL cholesterol 0.9 mmol/l and triglycerides 2.26 mmol/l.
ban population, which in 1990 constituted 71% of the total popu-           Isolated hypertriglyceridemia was defined as an increased tri-
lation (20). A target of 4,731 individuals and 2,030 households per        glyceride concentration and a cholesterol 5.2 mmol/l. These
region was estimated using the household as the sampling unit              cutpoints were based on the 1992 recommendations of the Euro-
and using the average of 2.33 adults per household (according to           pean Atherosclerosis Society (24). Overweight was defined as
the 1990 National Census). The sample size was considered suffi -           BMI 25–30 kg/m2 for males and females. Obesity was defined as
cient to detect risk factors at the regional level, that have at least a   BMI 30 kg/m2. Individuals were diagnosed as diabetics if they
prevalence of 4% with a relative error of estimation of 0.289 and a        had a previous diagnosis of diabetes or had a fasting blood glu-
nonresponse rate of 30%. Information was obtained on 15,607 in-            cose value 7 mmol/l (126 mg/dl) and no previous history of
dividuals; the response rate was 82.5%. The study was conducted            diabetes. Hypertension was diagnosed when the subject’s systolic
in accordance with the Helsinki Declaration of Human Studies.              pressure was 140 mm Hg and/or diastolic pressure was 90 mm
                                                                           Hg and/or the subject currently used an antihypertensive medi-
Personal interview
                                                                           cation. Blood pressure was measured twice in two different visits
   A general structured interview was conducted. A previously              if the initial measurement was 120/80. Ischemic heart disease
standardized questionnaire was used to obtain information on               was considered if there was a history of myocardial infarction.
demographic and socioeconomic aspects, family health history,              Homeostasis model (HOMA) scores were used for assessing in-
personal medical history, and lifestyle factors, such as smoking.          sulin sensitivity. Subjects with a value above 2.4 were considered
In the same visit, anthropometric and blood pressure measure-              insulin resistant. This cutpoint represents the 90th percentile of
ments were obtained. Systolic (1st-phase) and diastolic (5th-              the general population in this survey; similar cutpoints had been
phase) blood pressures were measured to the nearest even digit             used in previous reports (25).
with a sphygmomanometer while the subject was in the supine
position after a 5-min rest. Participants removed their shoes and          Statistical analysis
upper garments. Height was measured to the nearest 0.5 cm.
                                                                              The data were codified and captured under ASCII fixed format.
Body weight was measured on a daily calibrated balance and re-
                                                                           The database was validated through recognition of missing values,
corded to the nearest 0.1 kg. Body mass index (BMI) was calcu-
                                                                           outliers, and inconsistencies among variables. Descriptive analysis
lated as weight (kg), divided by height (m 2), and was used as an
                                                                           included the estimation of mean values and standard deviations
index of overall adiposity. The equipment was regularly cali-
                                                                           for continuous variables. These values were rounded to the nearest
brated using reference samples provided by the manufacturer.
                                                                           integer or first decimal. Prevalence and frequencies are expressed
Methods                                                                    in term of percentage. The ANOVA test was applied to compare
                                                                           differences among the subgroups of the population. Categorical
   Blood samples were obtained from 77.6% of the population
                                                                           variables were compared by the chi square statistic with Yates’ Cor-
(n     14,682). This report includes the results from 2,256 sub-
                                                                           rection for Continuity or the Fisher Exact Test when appropriate.
jects who had a 9- to 12-h fasting period, required for a complete
                                                                           All the statistical analysis was conducted in SPSS for Windows.
lipid profile (15.3% of the population). These cases were ran-
domly distributed among the population; no bias was detected
for regional or socioeconomic status in this subset of cases. All
                                                                                                      RESULTS
analytical measurements were done at the Departamento de Endo-
crinología and Metabolismo of the Instituto Nacional de Ciencias
                                                                             The study included 2,256 subjects (953 men and 1,303
Médicas y Nutrición “Salvador Zubirán.” The sampling proce-
dure was standardized during a 28-week training course. The
                                                                           women). Most subjects were younger than 40 years old;
subjects were sampled at their homes; they remained seated for             the age distribution is representative of Mexican adults
5 min before blood was drawn.                                              (Table 1 and Table 2). Mean lipid concentrations were
   Plasma glucose was analyzed by the glucose-oxidase method               cholesterol, 4.8 mmol/l (182.7 mg/dl); triglycerides,
(Boehringer-Mannheim). Plasma concentrations of total choles-              2.3 mmol/l (213.4 mg/dl); HDL cholesterol, 1.0 mmol/l
terol and triglycerides were determined by enzymatic methods               (38.3 mg/dl); and LDL cholesterol, 3.0 mmol/l (116.4 mg/
(Boehringer-Mannheim). HDL cholesterol was measured after                  dl). The distribution by percentiles, stratified by age and
precipitation of VLDL and LDL by the phosphotungstate                      gender, of the cholesterol, triglycerides, LDL cholesterol,
method (Boehringer-Mannheim); LDL cholesterol was mea-
                                                                           and HDL cholesterol concentrations is shown in Table 1.
sured by beta quantification. Intra-assay CV values for total cho-
lesterol, triglycerides, and HDL cholesterol were 3%, 5%, and 5%,          Prevalence of isolated lipid abnormalities
respectively. Insulin was analyzed by ELISA in the ES-33 system
(Boehringer-Mannheim). The cross-reactivity with proinsulin for              The prevalence of hypertriglyceridemia, hypercholes-
this assay was 40%. Our laboratory followed standardization pro-           terolemia, and hypoalphalipoproteinemia is shown in
cedures according to the recommendation of the World Health                Table 2. The data are stratified by age and gender. The
Organization, including the use of external control sera.                  most common abnormality was a low HDL cholesterol


                                                                     Aguilar-Salinas et al. Prevalence of dyslipidemias in Mexico        1299
             TABLE 1.   Distribution of cholesterol, triglycerides, HDL, and LDL cholesterol concentrations in urban Mexican adults

                                                                                    Percentiles

                                            Both Genders                                  Males                              Females
                                             (n 2,256)                               (n     953)                           (n 1,303)

Age Group (Years)                  10            50           90           10              50        90           10           50      90

Cholesterol (mmol/l)
  Total                           3.4           4.6           6.0          3.5             4.7       6.1          3.4         4.5      5.9
  20–29                           3.2           4.2           5.4          3.3             4.3       5.6          3.2         4.1      5.3
  30–39                           3.5           4.7           6.1          3.7             4.8       6.4          3.4         4.6      5.9
  40–49                           3.7           4.8           6.2          3.8             4.9       6.6          3.6         4.7      6.0
  50–59                           4.0           5.2           6.4          3.8             5.1       6.4          4.1         5.2      6.5
  60–69                           4.0           5.1           6.5          3.8             4.8       6.6          4.0         5.3      6.5
LDL cholesterol (mmol/l)
  Total                           1.9           2.8           4.2          1.9             2.9       4.3          1.9         2.8      4.1
  20–29                           1.8           2.6           3.7          1.8             2.7       3.9          1.7         2.5      3.6
  30–39                           2.0           3.0           4.2          2.0             3.0       4.4          1.9         2.9      4.1
  40–49                           2.0           3.0           4.4          2.1             3.0       4.6          1.9         3.0      4.2
  50–59                           2.2           3.4           4.7          2.1             3.4       4.7          2.4         3.4      4.7
  60–69                           2.3           3.3           4.6          2.3             3.1       4.5          2.3         3.5      4.6
HDL cholesterol (mmol/l)
  Total                           0.6           0.9           1.4          0.6             0.9       1.3          0.7         1.0      1.5
  20–29                           0.7           1.0           1.4          0.6             0.9       1.3          0.7         1.1      1.5
  30–39                           0.6           0.9           1.4          0.6             0.8       1.3          0.7         1.0      1.4
  40–49                           0.6           0.9           1.3          0.6             0.9       1.2          0.7         1.0      1.4
  50–59                           0.6           0.9           1.4          0.6             0.8       1.1          0.7         1.1      1.5
  60–69                           0.7           1.0           1.5          0.6             1.0       1.4          0.7         1.1      1.6
Triglycerides (mmol/l)
  Total                           0.7           1.5           3.3          0.8             1.7       4.0          0.7         1.4      2.8
  20–29                           0.6           1.2           2.5          0.7             1.3       3.1          0.6         1.1      2.2
  30–39                           0.8           1.6           3.4          0.9             1.9       4.8          0.8         1.4      2.8
  40–49                           0.9           1.8           3.5          1.0             2.0       4.2          0.8         1.7      3.0
  50–59                           1.1           1.9           4.0          1.3             2.2       4.3          1.0         1.8      3.5
  60–69                           1.0           2.2           4.2          0.9             2.1       3.7          1.0         1.7      4.5




concentration (46.2% for men, 28.7% for women, and                       population (Table 3). The prevalence was significantly
36% for both genders). The second most common abnor-                     higher in men compared with women (20.9% vs. 7.2%, re-
mality was hypertriglyceridemia. Several cutpoints, based                spectively, P 0.01). In men, the prevalence at ages 20 to
on the current available consensus, were used. Even with                 29 was almost as high as that observed in women ages 50
the less strict criteria, more than 10% of the subjects aged             to 59 (13.1% vs. 15%, respectively). After age 60, its preva-
20 to 29 years had this abnormality; this defect was more                lence decreased, suggesting a survival effect.
frequent in men. Severe hypertriglyceridemia [ 11.2
mmol/l (1000 mg/dl)] was found in 0.5% of men, 0.16%                     Normotriglyceridemic hypoalphalipoproteinemia
of women, and in 0.4% of both genders. Increased LDL                        This profile was among the most common forms of dys-
cholesterol concentrations ( 160 mg/dl) were observed                    lipidemias in the population reported here (18.6% of
in 12.7% of men, 10.3% of women, and 11.2% of both                       general population). The prevalence was higher in men
genders. As expected, the prevalence of hypercholester-                  than in women (22% vs. 16%, respectively, P 0.05). The
olemia was higher in older individuals and in men.                       prevalence found in young men (23.1%) was similar to
                                                                         that observed in men aged 50 to 59 (26.5%). A survival ef-
Prevalence of lipid phenotypes                                           fect was found in women older than 50 years (Table 4).
   The lipid abnormalities could be due to multiple etiolo-              Several etiologies may be present in this group. Tobacco
gies and are associated with different cardiovascular risk               was used by 31.2% of these subjects. Insulin resistance, as-
factors. This statement is especially true for hypertriglycer-           sessed by a HOMA value above 2.4, was found in 59% of
idemia. Thus, the crude description of the prevalence of                 this group. Thirty-six percent had a BMI between 25 and
the isolated lipid abnormalities is a gross estimation of the            30 kg/m2, and 20.9% had a value higher than 30 kg/m2.
lipid related cardiovascular risk of a population. A more                Less than 1% had a BMI lower than 18 kg/m2.
precise description is obtained when the lipid abnormali-
ties are grouped as lipid phenotypes. The prevalence of the              Mixed hyperlipidemias
most relevant lipid phenotypes is shown in Tables 3–7.                     The simultaneous elevation of cholesterol and triglycer-
                                                                         ide concentrations was observed in 12.6% of the general
Hypertriglyceridemia/hypoalphalipoproteinemia                            population (Table 3). Close to 20% of subjects over 50
   This atherogenic profile, usually seen in the insulin re-              years old had a mixed dyslipidemia. This abnormality was
sistance syndrome, was observed in 12.9% of the general                  more frequent in men than in women (16.8% vs. 9.6%, re-


1300      Journal of Lipid Research Volume 42, 2001
                  TABLE 2.     Prevalence of lipid abnormalities in men, women, and both genders in general population

                                    Triglycerides                  Cholesterol                       HDL C                            LDL C

                             1.68          2         2.26   5.2       6.31       7.89    0.9      0.9–1.18    1.18       2.6     2.6–3.3   3.4–4.2         4.2

Both genders (n 2,256)
  20–29 (n 888)            26.8        18.9         14.0    13.9       2.5       0.2    43.6        26.5     30.0       49.0      31.6        15.5      3.9
  30–39 (n 594)            45.9        33.4         27.3    29.7       7.7       1.0    53.2        20.5     26.3       31.4      35.9        20.4     12.3
  40–49 (n 382)            55.6        41.8         30.1    33.2       9.5       0.8    52.5        23.7     23.7       29.0      34.0        24.7     12.3
  50–59 (n 245)            60.5        46.9         38.3    48.2      13.5       1.2    53.5        23.7     22.9       18.5      28.0        33.7     19.8
  60–69 (n 147)            55.2        43.4         35.9    45.2      13.7       2.7    39.0        26.7     34.2       20.8      29.9        31.3     18.1
    Totals                 42.3        31.3         24.3    27.1       7.0       0.8    48.4        24.1     27.5       35.8      32.6        21.4     10.2
Men (n 953)
  20–29 (n 390)            32.4        23.9         19.5    17.4       3.1       0.5    52.5        26.4     21.1       41.7      34.4        18.6      5.2
  30–39 (n 239)            59.8        46.2         46.5    36.7      11.4       1.7    63.3        19.0     17.7       25.2      38.0        19.7     17.1
  40–49 (n 162)            61.4        48.7         36.7    37.5      11.3       1.3    63.1        22.5     14.4       23.6      38.2        22.9     15.3
  50–59 (n 98)             67.0        54.6         44.3    46.9      11.2       2.0    73.5        22.4      4.1       24.7      22.7        33.0     19.6
  60–69 (n 64)             61.3        51.6         40.3    36.5      12.7       3.2    46.0        27.0     27.0       25.8      38.7        21.0     14.5
    Totals                 49.7        38.8         31.9    30.0       8.1       1.3    58.8        23.5     17.7       31.7      35.0        21.3     12.0
Women (n 1,303)
  20–29 (n 498)            22.5        14.9          9.8    11.1       2.0       0.0    36.6        26.5     36.8       54.6      29.4        13.1      2.9
  30–39 (n 355)            36.4        24.6         17.6    25.0       5.2       0.6    46.3        21.6     32.2       35.7      34.5        20.9      9.0
  40–49 (n 220)            51.4        36.7         25.2    30.1       8.2       0.5    44.7        24.7     30.6       32.9      31.0        25.9     10.2
  50–59 (n 147)            56.2        41.8         34.2    49.0      15.0       0.7    40.1        24.5     35.4       14.4      31.5        34.2     19.9
  60–69 (n 83)             50.6        37.3         32.5    51.8      14.5       2.4    33.7        26.5     39.8       17.1      23.2        39.0     20.7
    Totals                 36.8        25.8         18.8    25.0       6.2       0.5    40.8        24.6     34.5       38.8      30.9        21.4      8.8




spectively, P   0.01), especially at ages 50 to 59. This de-                 and 240 mg/dl); women above age 50 composed the group
fect was also common in young men (8.1%).                                    in which this abnormality was most common ( 41%).

Severe dyslipidemias                                                         Effects of diabetes on the prevalence
   Extreme elevations of triglycerides (5.6 mmol/l or 500                    of lipid abnormalities
mg/dl) were the most common form of severe dyslipidemia                        One hundred ninety-three patients with diabetes were
(Table 3). This abnormality was observed in 2.9% of the                      included. Due to the sample size, the results were strati-
general population. On the other hand, extreme choles-                       fied only by age. As shown in Table 5, isolated hypertri-
terol elevations ( 7.8 mmol/l or 300 mg/dl) with normal                      glyceridemia (54.9%), isolated hypercholesterolemia
triglycerides levels were found in only 0.29% of the cases.                  (42.5%), and mixed dyslipidemias (31%) were the most
The prevalence of severe hypertriglyceridemia was higher in
men than in women (5.5% vs. 1.4%, respectively). Remark-                         TABLE 3. Prevalence of several abnormal lipid patterns in men,
ably, 3.1% of men aged 20 to 29 years had this defect.                                 women, and both genders in general population

Isolated hypertriglyceridemia                                                                    Hypertriglyceridemia/     Mixed                 Severe
                                                                                               Hypoalphalipoproteinemia Dyslipidemias         Dyslipidemias
   Small differences in the diagnostic criteria had a large
impact on the prevalence of this abnormality (Table 4). A                    Both genders (n 5 2,256)
                                                                               20–29                   7.6                      5.1                  1.5
0.5 mmol/l (50 mg/dl) difference (from 1.6 to 2.2 mmol/l)                      30–39                  15.8                     14.4                  3.8
resulted in a 100% increase in the prevalence, from 15.8%                      40–49                  15.9                     16.9                  2.6
to 31.8%. Even by using the least strict criteria, the preva-                  50–59                  19.1                     23.7                  4.8
                                                                               60–69                  15.6                     21.3                  7.4
lence of this lipid profile was high, ranging from 10.2% in                       Totals               12.98                    12.6                  3.1
the youngest subjects to 26% in the oldest group. This ab-                   Men (n 953)
normality was more common in men than in women                                 20–29                  13.1                      8.1                  3.1
                                                                               30–39                  29.7                     23.7                  8.4
(21.3% vs. 12.1%, respectively). More than 30% of men                          40–49                  26.5                     20.1                  5.6
older than 50 years old had a fasting triglyceride concen-                     50–59                  25.5                     27.6                  8.2
tration above 2.2 mmol/l (200 mg/dl).                                          60–69                  14.1                     19.4                  4.7
                                                                                 Totals               20.9                     16.8                  5.5
Isolated hypercholesterolemia                                                Women (n 1,303)
                                                                               20–29                   3.4                      2.8                  0.4
   Cases with increased cholesterol concentration and tri-                     30–39                   6.5                      8.1                  0.8
glycerides below 2.2 mmol/l were included in this category                     40–49                   8.2                     14.6                  0.5
(Table 4). Isolated hypercholesterolemia was found in                          50–59                  15.0                     21.2                  2.7
                                                                               60–69                  16.9                     22.9                  9.6
18.7% of the population. The vast majority of cases had a                        Totals                7.2                      9.6                  1.4
cholesterol concentration between 5.2 and 6.3 mmol/l
(200 and 240 mg/dl); only 3.5% of all individuals had con-                        Concentrations are expressed in mmol/l. Hypertriglyceridemia/
                                                                             Hypoalphalipoproteinemia     triglycerides 2.26  HDL cholesterol
centrations above this range. Close to 10% of the youngest                     0.9. Mixed Dyslipidemias triglycerides 2.26 Cholesterol 6.31.
group had cholesterol between 5.2 and 6.3 mmol/l (200                        Severe Dyslipidemias triglycerides 5.6 and/or Cholesterol 7.89.


                                                                    Aguilar-Salinas et al. Prevalence of dyslipidemias in Mexico                       1301
               TABLE 4.    Prevalence of several abnormal lipid patterns in men, women, and both genders in general population

                                              Hypertriglyceridemia                                        Hypercholesterolemia
                                                Cholesterol 5.2                                             Triglycerides 2.26                 HDL-Cholesterol 0.9
                                                                                                                                                   Triglycerides
                                       1.68                2                  2.26                5.2                6.31                 7.89           2.26

Both genders (n 2,256)
  20–29                               21.6               14.9             10.2                 9.9                  1.2                   0.1              20.4
  30–39                               34.8               23.2             18.02               20.5                  2.8                   0.4              19.6
  40–49                               44.2               29.0             19.5                23.1                  6.8                   0.3              17.5
  50–59                               50.0               34.1             27.7                39.3                  8.6                   0.6              15.1
  60–69                               45.0               35.0             42.5                36.5                  3.2                   0                11.5
    Totals                            31.8               21.7             15.8                18.7                  3.29                  0.29             18.6
Men (n 953)
  20–29                               24.8               17.8             13.7                11.4                  1.3                   0.3              23.1
  30–39                               48.0               33.1             27.7                21.9                  2.9                   0.7              20.1
  40–49                               50.5               36.4             26.3                27.0                  8.0                   0                21.6
  50–59                               54.9               37.3             31.4                35.2                  5.6                   1.9              26.5
  60–69                               52.5               45.0             32.5                27.0                  2.7                   0                17.2
    Totals                            38.0               27.3             21.3                19.1                  3.2                   0.5              22.0
Women (n 1,303)
  20–29                               19.3               12.8              7.8                 8.8                  1.1                   0                18.5
  30–39                               27.2               17.5             12.5                19.9                  2.8                   0.4              19.4
  40–49                               40.1               24.3             15.1                20.9                  6.1                   0.6              14.5
  50–59                               46.7               32.0             25.3                41.7                 10.4                   0                 7.5
  60–69                               37.5               25.0             20.0                42.9                  3.6                   0                 7.2
    Totals                            27.6               17.9             12.1                18.6                  3.4                   0.2              16.1

    Concentrations are expressed in mmol/l.




prevalent abnormal lipid profiles in the patient with dia-                            Effects of overweight and obesity on
betes. This disorder increased the likelihood of having al-                          the prevalence of lipid abnormalities
most every class of lipid abnormality. The risk was statistically                       Four hundred fifty-two obese individuals (BMI 30
significant for mixed dyslipidemias (OR 3.1), severe dyslipi-                         kg/m2) and 787 overweight individuals (BMI 25 – 30 kg/
demias (OR 4.7), isolated hypertriglyceridemia (OR 6.4),                             m2) were included in the analysis. Due to the sample
and isolated hypercholesterolemia (OR 5.7). The combina-                             size, the results were stratified only by age. As shown in
tion hypertriglyceridemia/hypoalphalipoproteinemia was                               Table 6, the prevalence of abnormal lipid profiles was
found in 26% of the diabetic population. Severe hypertri-                            very similar between obese and overweight subjects.
glyceridemia was found in 10.8%. Normotriglyceridemic                                Hypertriglyceridemia (35.4% and 32.5%, respectively) and
hypoalphalipoproteinemia was found in 7.6% of cases.                                 mixed dyslipidemias (18% and 18.1%, respectively) were



                   TABLE 5.     Prevalence of several abnormal lipid patterns in both genders with type 2 diabetes (n                      193)

                                        Hypertriglyceridemia/                             Mixed                                     Severe
Both Genders                           Hypoalphalipoproteinemia                        Dyslipidemias                             Dyslipidemias

20–29                                              25.0                                    45.4                                      33.0
30–39                                              29.6                                    25.9                                      14.8
40–49                                              24.0                                    26.0                                      10.0
50–59                                              30.5                                    36.2                                       8.4
60–69                                              20.8                                    29.7                                      16.6
  Totals                                           26.0                                    31.08                                     13.3
  Odds ratio (95% CI)                         2.35 (0.5–3.3)                          3.12 (1.1–4.3)                           4.79 (1.08–7.7)
                                          Hypertriglyceridemia                                          Hypercholesterolemia
                                            Cholesterol 5.2                                               Triglycerides 2.26                     HDL-Cholesterol 0.9
                                                                                                                                                      Triglycerides
                               1.58                  2                 2.26                 5.2                   6.31             7.89                     2.26

20–29                        100                  100                100                   45.4                  9.09              0                     0
30–39                         55.0                 51.8               44.4                 29.6                 18.5               3.7                   7.4
40–49                         76.0                 58.0               50.0                 42.0                  8.0               0                    14.0
50–59                         75.0                 67.2               60.3                 45.7                 20.3               0                     5.08
60–69                         74.0                 61.7               48.9                 45.8                 22.9               8.3                   6.2
  Totals                      74.09                63.2               54.9                 42.5                 16.9               2.5                   7.6
  Odds ratio (95% CI)    6.13 (1.4–8.5)       6.19 (1.5–8.4)     6.48 (1.5–8.8)       3.23 (0.8–4.3)       5.77 (1.3–8.9)      0.85 (0–2.1)          0.35 (0–1.5)

    Concentrations are expressed in mmol/l. Hypertriglyceridemia/Hypoalphalipoproteinemia triglycerides 2.26  HDL cholesterol 0.9.
Mixed Dyslipidemias triglycerides 2.26 Cholesterol 6.31. Severe Dyslipidemias triglycerides 5.6 and/or Cholesterol 7.89. Odds ratios
were estimated using the general population as reference.


1302      Journal of Lipid Research Volume 42, 2001
               TABLE 6.      Prevalence of several abnormal lipid patterns in obese (n          452) and overweight (n         787) subjects

                      Hypertriglyceridemia/                                     Mixed                                                         Severe
                    Hypoalphalipoproteinemia                                 Dyslipidemias                                                 Dyslipidemias

Both Genders    Obese                   Overweight                  Obese                 Overweight                              Obese                 Overweight

20–29            27.1                       8.4                      16.8                     5.5                                  3.9                     2.1
30–39            19.1                      22.6                      14.1                    21.7                                  5.2                     5.9
40–49            19.0                      18.8                      15.7                    21.1                                  0.8                     3.1
50–59            24.1                      25.7                      28.9                    26.8                                  3.6                     6.1
60–69            25.0                      20.0                      15.6                    31.6                                 12.5                     6.6
  Totals         21.0                      17.7                      18.0                    18.1                                  3.9                     4.3
                                                  Obese                                                                 Overweight

                    Hypertriglyceridemia                    Hypercholesterolemia                Hypertriglyceridemia                 Hypercholesterolemia
                      Cholesterol 5.2                         Triglycerides 2.26                  Cholesterol 5.2                      Triglycerides 2.26

                  1.58           2          2.26           5.2        6.31         7.89       1.58         2            2.26         5.2         6.31        7.89

20–29            56.4          43.5        34.6           26.7        5.9          0         34.0       23.1           16.5       14.0           2.9         4.2
30–39            56.2          38.3        30.3           29.5       10.4          1.7       58.2       44.0           37.7       35.5          10.5         0.8
40–49            63.0          47.8        34.4           30.5        9.9          0.8       62.1       45.5           33.3       35.8          10.2         0.6
50–59            63.4          54.8        43.9           56.0       15.6          1.2       61.8       49.4           45.3       45.3          12.3         0
60–69            56.2          40.6        37.5           42.8       12.5          3.1       68.3       56.6           51.6       41.6          15.0         1.6
  Totals         59.4          45.2        35.4           35.5       10.4          1.1       53.0       39.7           32.5       31.1           8.7         0.64
                         HDL Cholesterol 0.9
                          Triglycerides 2.26

                Obese                   Overweight

20–29            22.7                      25.7
30–39            23.4                      21.0
40–49            21.4                      15.7
50–59            10.8                      10.3
60–69             6.2                      10.0
  Totals         19.2                      19.2

    Concentrations are expressed in mmol/l. Hypertriglyceridemia/Hypoalphalipoproteinemia triglycerides 2.26  HDL cholesterol                                 0.9.
Mixed Dyslipidemias triglycerides 2.26 Cholesterol 6.31. Severe Dyslipidemias triglycerides 5.6 and/or Cholesterol 7.89.


the most prevalent abnormal lipid profiles in these sub-                        triglycerides above 2.26 mmol (200 mg/dl). In some sub-
jects. Obesity increased the prevalence of almost every ab-                    sets of the population the problem was even worse. Preva-
normal lipid profile; however, none of the odds ratios were                     lence was higher in men, especially when they were older
statistically significant. The combination hypertriglyceri-                     than age 50. Hypercholesterolemia was significantly less
demia/hypoalphalipoproteinemia was found in nearly 20%                         common compared with the two aforementioned abnor-
of the subjects. Severe hypertriglyceridemia was found in a                    malities. Moreover, the majority of these subjects had cho-
percent similar to that observed in the general population.                    lesterol concentrations between 5.2 and 6.3 mmol/l
Decreased HDL cholesterol, not related to hypertriglyceri-                     (200–240 mg/dl); only 10% of the population had a cho-
demia, was found in 19% of cases.                                              lesterol level high enough to consider the subject at risk
                                                                               due only by its presence.
Effects of hypertension on the prevalence                                         Dyslipidemias are caused by the interaction of genetic
of lipid abnormalities                                                         and environmental factors. As shown in Table 8, the prev-
   Four hundred ninety-two hypertensive subjects were                          alence of the lipid abnormalities reported here is similar
included in the analysis. As shown in Table 7, the preva-                      to that observed in Turkish (26) and other Asian popula-
lence of the abnormal lipid profiles was higher in the                          tions, including Bangladeshi and Pakistani populations
hypertensive subjects compared with the general popu-                          (27). Like Mexican adults, Turks have a high incidence of
lation; however, none of the odds ratios was statistically                     coronary heart disease (estimated by the Turkish Ministry
significant. Hypertriglyceridemia (36.5%) and mixed                             of Health to cause 37% of deaths), although the mean
dyslipidemias (21.2%) were the abnormalities most fre-                         cholesterol and LDL cholesterol concentrations are re-
quently observed in this subset of the population.                             markably lower compared with ethnic groups with high
                                                                               rates of cardiovascular mortality. These populations have
                                                                               one of the highest prevalences of low HDL cholesterol
                          DISCUSSION                                           worldwide (53% of males and 26% of women). Genetic
                                                                               factors seem to be part of the explanation of this abnor-
   These data clearly demonstrate that some forms of dys-                      mality, since HDL cholesterol levels remain low in Turks
lipidemias are very common in Mexican adults. Close to                         living in different environments. Mexican American women
50% had hypoalphalipoproteinemia ( 0.9 mmol/l, 35                              had significantly lower HDL cholesterol levels than did
mg/dl) and almost a third of the population had fasting                        white US females in the NHANES III report (1.39% vs.


                                                                        Aguilar-Salinas et al. Prevalence of dyslipidemias in Mexico                        1303
                      TABLE 7.      Prevalence of several abnormal lipid patterns in both genders with hypertension (n                  492)

                             Hypertriglyceridemia/                                      Mixed                                 Severe
Both genders                Hypoalphalipoproteinemia                                 Dyslipidemias                         Dyslipidemia

20–29                               11.2                                                  8.4                                 3.7
30–39                               25.7                                                 21.9                                 4.7
40–49                               19.8                                                 22.8                                 5.6
50–59                               28.1                                                 27.08                                3.1
60–69                               21.7                                                 28.5                                10.2
  Totals                            21.1                                                 21.2                                 5.2
  Odds ratio (95% CI)         1.78 (0.3–2.2)                                        1.8 (0.3–2.3)                        1.7 (0.1–2.7)
                                                      Hypertriglyceridemia                                             Hypercholesterolemia
                                                        Cholesterol 5.2                                                  Triglycerides 2.26

                                     1.58                            2                    2.26              5.2                  6.31                   7.89

20–29                               38.3                         25.2                    19.6              18.6                3.7                      0
30–39                               55.2                         42.8                    37.1              42.8               13.5                      1.9
40–49                               66.6                         50.4                    36.1              43.8               10.4                      1.9
50–59                               65.6                         58.3                    48.9              47.9               15.6                      0
60–69                               63.6                         50.6                    44.1              53.2               18.1                      2.5
  Totals                            57.3                         44.8                    36.5              40.4               11.8                      1.2
  Odds ratio (95% CI)          2.87 (0.8–3.5)               2.92 (0.8–3.5)          3.06 (0.9–3.8)    2.94 (0.8–3.6)      3.8 (1–5.4)            4.17 (0.3–12.8)
                          HDL Cholesterol 0.9
                            Triglycerides 2.26
20–29                               21.4
30–39                               15.2
40–49                               16.9
50–59                                8.3
60–69                               10.2
  Totals                            14.8
  Odds ratio (95% CI)         0.76 (0.1–0.99)

    Concentrations are expressed in mmol/l. Hypertriglyceridemia/Hypoalphalipoproteinemia triglycerides 2.26  HDL cholesterol 0.9.
Mixed Dyslipidemias triglycerides 2.26 Cholesterol 6.31. Severe Dyslipidemias triglycerides 5.6 and/or Cholesterol 7.89. Odds ratios
were estimated using the general population as reference.



1.47% mmol/l, respectively). These observations suggest                              in subjects with similar genetic backgrounds living in dif-
that the genetic factors causing low HDL cholesterol levels                          ferent environments. Compared with Mexican Americans,
may be common to both ethnic groups. Genetic similari-                               Mexican adults had significantly lower HDL cholesterol
ties between Mexican and Turkish populations have been                               concentrations (18). These observations suggest that envi-
described in other disorders, such as Behcet’s Syndrome                              ronmental factors may also be part of the explanation for
[based on the high frequency of HLA-B5 found in both                                 the high frequency of hypoalphalipoproteinemia ob-
populations (28)]. Recently, increased hepatic lipase activ-                         served in Mexico. Remarkable differences exist between
ity has been described as a possible cause of low HDL cho-                           Mexican and Mexican American adults regarding nutri-
lesterol in Turkish men (29). This abnormality remains to                            ent intakes. The proportion of calories obtained from car-
be studied in our population.                                                        bohydrates is significantly higher in Mexicans than in
   One approach to analyzing the influence of environ-                                Mexican Americans (51.6% vs. 45.8%, respectively) (30).
mental factors is to assess the prevalence of dyslipidemias                          Even English-speaking Mexican American women eat



               TABLE 8.    Comparison of serum lipid levels among Mexican, Mexican American, Turkish, and several other populations

                                                   Cholesterol                    Triglycerides               HDL Cholesterol                    LDL Cholesterol

                                               M                 F            M                   F          M               F                  M               F

Turks in Central Black Sea (50)             4.2              4.5             1.2              1.05          0.88           1.08                2.69            2.87
Turks in Istanbul (26)                      5.2              4.6             1.6              1.01          0.98           1.16                3.52            3.03
Turks in Germany (51)                       4.9              4.5             1.52             0.99          0.98           1.19                3.21            2.89
Germans in Germany (51)                     5.6              5.4             1.34             0.99          1.21           1.55                3.72            3.41
Urban Mexican adultsa                       4.9              4.7             2.7              2.08          0.94           1.08                3.19            3.05
Mexican-Americans (52)                      5.4              5.4             1.65             1.24          1.16           1.39                3.02            3.02
Whites Americans (52)                       5.4              5.4             1.58             1.18          1.16           1.47                3.52            3.39
Chinese (53)                                5.5              5.4             1.22             1.00          1.24           1.42                3.57            3.52
Finns (54)                                  5.6              5.6             1.26             1.00          1.16           1.42                3.80            3.70

    Data are expressed as mean concentrations (mmol/l). Reference sources are shown between parenthesis.
    a This study.




1304      Journal of Lipid Research Volume 42, 2001
greater amounts of fat (mainly saturated fat) and lower           we present the results not only showing the prevalence of
amounts carbohydrates and fiber than Mexican American              isolated lipid abnormalities. We believe that a more clini-
women born in Mexico (31). The high consumption of                cally oriented approach, the classification by lipid pheno-
simple carbohydrates may contribute to the high preva-            types, gives a better picture of the lipid-related athero-
lence of hypertrigliceridemia and low HDL cholesterol             genic risk of the population. This is especially true for the
(32). Also, high consumption of saturated fats raises             study of hypertriglyceridemia, an abnormality caused by
apoA-I concentration (and HDL cholesterol) by increas-            either atherogenic or nonatherogenic disorders (39, 40).
ing production rate and decreasing fractional catabolic           This approach has been successfully used in the PROCAM
rate without altering apoA-I mRNA levels (33). However,           study, a prospective study done with 4,559 men in Ger-
if hypertriglyceridemia results from the change in the di-        many (41). This study shows that the cardiovascular risk of
etary habits, the increase of HDL cholesterol may be              hypertriglyceridemic subjects is strongly influenced by the
blunted. These data suggest dietary factors contribute to         concurrent cholesterol and HDL cholesterol levels.
the high prevalence of hypoalphalipoproteinemia and hy-           Whereas the cardiovascular event rate of the subjects with
pertriglyceridemia revealed in this report.                       high triglycerides and normal cholesterol ( 5.2 mmol/l)
   We propose that the very high prevalence of low HDL            was the same as that of normolipidemic controls, the risk
cholesterol in urban Mexican adults results from two              was at least two times higher in cases with mixed dyslipi-
groups of abnormalities. Low HDL cholesterol is ex-               demia. This observation has important implications to our
plained in close to 50% of the cases by the coexistence of        results. Of the 30% of subjects with a triglyceride level
hypertriglyceridemia. An inverse relationship exists be-          above 2.2 mmol, only half of them have a mixed dyslipi-
tween fasting triglycerides and HDL cholesterol concen-           demia or low HDL cholesterol. Consequently, the crude
trations. In these cases, HDL cholesterol is normalized as        analysis of the high prevalence hypertriglyceridemia will
triglycerides return to normal. The other 50% of cases            overestimate the cardiovascular risk of our population.
(isolated low HDL cholesterol) may result from the coex-          This approach has two additional advantages. First, it al-
istence of insulin resistance (34), malnutrition, low-fat         lows also to discriminate that hypercholesterolemia was
content diet (35), tobacco use, and/or genetic factors to         explained by the plasma accumulation of LDL in three of
be identified. Not every one of these mechanisms is associ-        every four cases; in close to 25%, the correct diagnosis was
ated with an increased cardiovascular risk. However, in this      a mixed dyslipidemia instead of isolated hypercholester-
population, insulin resistance, excess body fat, and/or to-       olemia. Second, as previously described, it shows that close
bacco use seems to be present in close to 60% of the subjects.    to 50% of the low HDL cholesterol cases are not related to
   The distribution of the lipid concentrations reported          a fasting triglyceride concentration above 2.2 mmol/l. In
here is remarkably different from that of Mexican Ameri-          both instances, this differentiation is important on the basis
cans living in the US. Almost every percentile value of the       of its diagnostic and therapeutic implications (42, 43).
cholesterol distribution is 0.5 mmol/l ( 20 mg/dl) lower             The prevalence of some of the lipid profiles deserves
in the population reported here. Prevalence of hypercho-          additional comments. First, almost every abnormal lipid
lesterolemia ( 6.3 mmol/l, 240 mg/dl) in Mexican                  profile was more common in males. Second, using the re-
adults was lower than that observed in Mexican Americans          sults of the PROCAM study as a reference (44), some ma-
in the NHANES II and III reports (10% vs. 16.6% and               jor differences were found in our population. The preva-
16.9%, respectively); Mexican Americans had the lowest            lence of mixed dyslipidemias is remarkably higher in this
prevalence of hypercholesterolemia of the race groups in-         report, especially in women. In the PROCAM study, the
cluded in those reports (36). Hypercholesterolemia was            prevalence observed in 50-year-old men and women was
twice as frequent in US white males compared with Mexi-           16.1% and 3.8%, respectively. As shown in Table 3, in our
can males included in this study. These observations sug-         population, at age 50, 27.6% of men and 21.2% of women
gest that genetic factors may protect the Mexican popula-         had this abnormal lipid profile. These data suggest that
tion against hypercholesterolemia, but, still, environmental      the most common causes of mixed dyslipidemias, such as
factors, such as the growing consumption of dietary choles-       type 2 diabetes and familial combined hyperlipidemia
terol and saturated fat, could increase the prevalence of hy-     (44, 45), are common abnormalities in Mexico (46). An-
percholesterolemia in urban Mexico in the near future. As         other major difference is found in the prevalence of se-
the environmental conditions of urban Mexicans get closer         vere dyslipidemias. In that report, the most common form
to the prevailing conditions confronted by Mexican Ameri-         of severe dyslipidemia was cholesterol above 7.8 mmol
cans, the prevalence of hypercholesterolemia may increase.        (300 mg/dl). In contrast, in our population, severe hyper-
   Our data are in accordance with previous reports in            triglyceridemia was several times more common than se-
Mexican populations (17, 19, 37, 38). The prevalence of           vere hypercholesterolemia. Almost 3% of the adults had
hypercholesterolemia ( 6.3 mmol/l, 240 mg/dl) re-                 triglyceride levels that could put them at risk of having
ported here was almost identical to that reported in the          acute pancreatitis. These data suggest that some actions
1988 National Seroepidemiologic Survey (10% vs. 10.6%,            (including decreasing consumption of simple carbohy-
respectively), composed of 33,558 samples randomly ob-            drates and alcohol) are required in a large number of
tained in adults older than 20 years (17). Unfortunately,         Mexican adults to prevent a rising prevalence of pancre-
triglycerides and HDL cholesterol concentrations were             atitis (47). Finally, the prevalence of some of the athero-
not included in that survey. In contrast to other reports,        genic lipid profiles shown in Table 3 was remarkably high in


                                                            Aguilar-Salinas et al. Prevalence of dyslipidemias in Mexico   1305
the younger subjects. Close to 7% had hypertriglyceridemia/                   6. Esparza, J., C. Fox, I. T. Harper, P. H. Bennett, L. O. Schulz, M. E.
hypoalphalipoproteinemia, 10% had hypercholester-                                Valencia, and E. Ravussin. 2000. Daily energy expenditure in
                                                                                 Mexican and USA Pima Indians: low physical activity as a possible
olemia, and 20% had isolated low HDL cholesterol levels.                         cause of obesity. Int. J. Obes. Relat. Metab. Disord. 24: 55–59.
These data suggest that as these individuals get older, the                   7. Munoz de Chavez, M., A. Chavez-Villasana, M. Chavez-Muñoz, and
prevalence of atherogenic lipid profiles will be even                             I. Eichin-Vuskovic. 2000. Sale of street food in Latin America. The
                                                                                 Mexican case: joy or jeopardy? World Rev. Nutr. Diet. 86: 138–154.
greater. Taken together these observations suggest that                       8. Stamler, J., D. Wentworth, and J. Neaton. 1986. Is the relationship
the prevalence of the atherogenic lipid profiles is differ-                       between serum cholesterol and risk of death from coronary heart
ent in Mexican adults compared with Caucasian popula-                            disease continuous and graded? Findings on the 356,222 primary
                                                                                 screens of the Multiple Risk Factor Intervention Trial (MRFIT). J.
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fective preventive programs are urgently needed in Mexico,                    9. Rose, G., and M. Shipley. 1986. Plasma cholesterol and death from
especially for young males.                                                      coronary disease: 10 year results of the Whitehall study. Br. Med. J.
                                                                                 29: 306.
   Finally, the impact of diabetes, obesity, and arterial hy-                10. Gotto, A. M. 1998. Risk factor modification: rationale for manage-
pertension on the prevalence of several lipid abnormali-                         ment of dyslipidemia. Am. J. Med. 104: 6S–8S.
ties was assessed. As expected, these disorders were associ-                 11. Castelli, W. P. 1984. Epidemiology of coronary heart disease. The
                                                                                 Framingham Study. Am. J. Med. 7: 4.
ated with an increased likelihood of having several forms
                                                                             12. Grundy, S. M., R. Pasternak, P. Greenland, S. Smith, and V. Fuster.
of atherogenic lipid profiles (48). The most common ab-                           1999. Assessment of cardiovascular risk by use of multiple risk fac-
normalities found in patients with type 2 diabetes were                          tor assessment equations. Circulation. 100: 1481–1492.
isolated hypertriglyceridemia, followed by moderated hy-                     13. Fager, G., and O. Wiklung. 1997. Cholesterol reduction and clini-
                                                                                 cal benefit. Are there limits to our expectations? Arterioscler.
percholesterolemia and mixed hyperlipidemia. The same                            Thromb. Vasc. Biol. 17: 3527–3533.
trend was observed for obesity and arterial hypertension,                    14. Miettinen, T., K. Pyöralä, A. Olsson, T. Musliner, T. Cook, O.
but the magnitude of the risk was lower with these two fac-                      Faergeman, K. Berg, T. Pedersen, and J. Kjelshus for the Scandina-
                                                                                 vian Simvastatin Study Group. 1997. Cholesterol lowering therapy
tors. Interestingly, the prevalence of lipid abnormalities                       in women and elderly patients with myocardial infarction or an-
was similar in overweight subjects compared with obese in-                       gina pectoris. Circulation. 96: 4211–4218.
dividuals, suggesting that the lipid comorbidities appear                    15. Shepherd, J., S. M. Cobbe, I. Ford, C. G. Isles, A. R. Lorimer, P. W.
                                                                                 MacFarlane, J. H. McKillop, and C. J. Packard. 1995. Prevention of
early in the development of excessive fat accumulation.                          coronary heart disease with pravastatin in men with hypercholes-
   In conclusion, our data show that the prevalence of hy-                       terolemia. N. Engl. J. Med. 333: 1301.
poalphalipoproteinemia and other forms of dyslipidemia                       16. Quibrera, I. R., H. G. Hernández, and C. G. Aradillas. 1994. Preva-
                                                                                 lencia de diabetes, intolerancia a la glucosa, hiperlipidemia y fac-
is very high in Mexican adults and it is among the highest                       tores de riesgo en función de nivel socioeconómico. Rev. Invest.
previously reported worldwide. Genetic and environmen-                           Clin. 44: 321–328.
tal factors may contribute to the explanation of the high                    17. Posadas-Romero, C., R. Tapia-Conyer, I. Lerman-Garber, J. Zamora-
prevalence reported here. Preventive programs are ur-                            González, G. Cardoso-Saldaña, B. Salvatierra-Izaba, and J. Sepúlveda-
                                                                                 Amor. 1995. Cholesterol levels and prevalence of hypercholester-
gently needed in Mexico for decreasing the prevalence of                         olemia in a Mexican adult population. Atherosclerosis. 118: 275–284.
several forms of dyslipidemia. We believe that these pro-                    18. Stern, M. P., C. Gonzalez-Villalpando, B. Mitchell, E. Villalpando,
grams must consider decreasing the prevalence of obesity                         S. Haffner, and H. Hazuda. 1992. Genetic and environmental de-
                                                                                 terminants of type II diabetes in Mexico City and San Antonio.
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toward the general population and physicians will be re-                     19. Fanghanel-Salmon, G., L. Sanchez-Reyes, S. Arellano-Montaño, E.
quired. However, it would be worst to wait and treat mil-                        Valdes-Liaz, J. Chavira-Lopez, and R. A. Rascon-Pacheco. 1997.
                                                                                 The prevalence of risk factors for coronary disease in workers of
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                                                                       Aguilar-Salinas et al. Prevalence of dyslipidemias in Mexico                1307

								
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