Low Cholesterol, Mortality, and Quality of
Life in Old Age During a 39-Year Follow-Up
Timo E. Strandberg, MD, PHD,* Arto Strandberg, MD,* Kirsi Rantanen, MD,†
Veikko V. Salomaa, MD, PHD,‡ Kaisu Pitkälä, MD, PHD,* Tatu A. Miettinen, MD, PHD*
We assessed the impact of serum cholesterol level in early midlife on total mortality during
up to 39 years of follow-up and on the quality of life (QoL) in old age.
Total effects of low serum cholesterol on health have been in dispute, especially in elderly
persons, and there are few data on the long-term effects of low cholesterol on QoL.
The cohort consisted of 3,277 healthy businessmen age 30 to 45 years at baseline (1960s). In
addition to baseline, serum cholesterol values were available for part of the cohort in 1974,
1986, and 2000. The QoL was assessed in 80.9% of survivors (n ? 1,820, mean age 73 years)
with a RAND-36 (SF-36) QoL questionnaire in 2000. Mortality up to 2002 (n ? 1,173) was
retrieved from national registers.
Cholesterol was clearly reduced in survivors during follow-up, except in the lowest baseline
serum cholesterol group. Baseline cholesterol predicted 39-year total mortality in a graded
manner (p ? 0.0001), and a value ?5.0 mmol/l was associated with a 25% reduction in total
mortality. In old age, the physical component summary score of RAND-36 was significantly
(p ? 0.02) higher (better) in the lowest baseline cholesterol group; no difference was found
in the mental component summary score (p ? 0.51).
CONCLUSIONS Low serum cholesterol level in midlife predicted not only better survival but also better
physical function and QoL in old age, without adversely affecting mental QoL.
Cardiol 2004;44:1002–8) © 2004 by the American College of Cardiology Foundation
(J Am Coll
The research behind the current goals of hypolipidemic
therapy is extensive (1,2), and the cardiovascular benefits of
cholesterol lowering for five to seven years have been
repeatedly demonstrated (2). Still, there have been contro-
versies regarding the truly long-term prognostic value of low
cholesterol on total mortality, especially in older individuals
See page 1009
(3–5). Also the long-term effects of low (or lowered)
cholesterol on mental functioning and quality of life (QoL)
have been in dispute (6,7). Because there are now efficient
drugs to bring cholesterol to low levels, we still need
long-term data to show that low cholesterol is not harmful.
We present the results on a large group of men who were
initially healthy, age 30 to 45 years, and whose baseline
cholesterol was related not only to total mortality during up
to 39 years of follow-up but also to health-related QoL in
old age. It should be noted that our study essentially reflects
the association of naturally (or lowered by secular changes)
low cholesterol levels with mortality because the effects of
cholesterol-lowering drugs are largely restricted to the last
years of follow-up.
Baseline examinations in 1968 to 1973 and follow-up
examinations in 1974 and 1985. The study population and
examinations have been described in detail (8–11), and a
flow chart of examinations pertaining to cholesterol is
shown in Figure 1. The follow-up data are comprehensive at
baseline and at the end, whereas the three in-between
evaluations include only part of the population.
A total of 3,490 initially healthy men, mostly business
executives born in 1919 to 1934, participated in voluntary
health check-ups from 1964 to 1973 (median 1968) at the
Institution of Occupational Health in Helsinki, Finland. At
that time occupational health care was not customary in
Finnish companies. The health check-up procedures in-
cluded clinical examinations and laboratory tests. Ergometry
was performed, but data were not entered into the database
and are thus not available for analysis. Only one baseline
measurement of serum cholesterol is available, and between
baseline and the 2000 survey only mortality data were
collected systematically from all participants. The first
scientific approach (8) was performed in 1974, when the
men consented to an evaluation in which electrocardio-
graphic findings were correlated to risk factors (including
cholesterol) and coronary heart disease. The men were also
evaluated with mailed questionnaires and laboratory exam-
From the *Department of Medicine, Geriatric Clinic, and †Department of
Neurology, University of Helsinki, Helsinki, Finland; and ‡KTL-National Public
Health Institute, Helsinki, Finland. The Päivikki and Sakari Sohlberg Foundation,
the Helsinki University Central Hospital, and the Finnish Foundation for Cardio-
vascular Research have provided financial support. Dr. Strandberg is a senior research
fellow of the Academy of Finland (Grant 48613). All authors have cooperated with
companies marketing cholesterol-lowering drugs.
Manuscript received December 9, 2003; revised manuscript received April 21,
2004, accepted April 27, 2004.
Journal of the American College of Cardiology
© 2004 by the American College of Cardiology Foundation
Published by Elsevier Inc.
Vol. 44, No. 5, 2004
of younger men to long-term coronary, cardiovascular, and all-cause
mortality and to longevity. JAMA 2000;284:311–8.
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cardiovascular disease in Finland since the early 1970s: a success story.
J Nutr Health Aging 2001;5:150–4.
22. Pedersen TR, Wilhelmsen L, Faergeman O, et al. Follow-up
study of patients randomized in the Scandinavian Simvastatin
Survival Study (4S) of cholesterol lowering. Am J Cardiol 2000;
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SJ, Miettinen TA. Cardiovascular morbidity and multifactorial pri-
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1008Strandberg et al.
Cholesterol, Mortality, and Quality of Life
JACC Vol. 44, No. 5, 2004
September 1, 2004:1002–8