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Summary Background In China, depressive disorders have been estimated to be the second leading cause of years lived with disability. However, nationally representative epidemiological data for depressive disorders, in particular use of mental health services by adults with these disorders, are unavailable in China. The present study, part of the China Mental Health Survey, 2012–15, aims to describe the socioeconomic characteristics and the use of mental health services in people with depressive disorders in China. Methods The China Mental Health Survey was a cross-sectional epidemiological survey of mental disorders in a multistage clustered-area probability sample of adults of Chinese nationality (≥18 years) from 157 nationwide representative population-based disease surveillance points in 31 provinces across China. Trained investigators interviewed the participants with the Composite International Diagnostic Interview 3.0 to ascertain the presence of lifetime and 12-month depressive disorders according to DSM-IV criteria, including major depressive disorder, dysthymic disorder, and depressive disorder not otherwise specified. Participants with 12-month depressive disorders were asked whether they received any treatment for their emotional problems during the past 12 months and, if so, the specific types of treatment providers. The Sheehan Disability Scale (SDS) was used to assess impairments associated with 12-month depressive symptoms. Data-quality control procedures included logic check by computers, sequential recording check, and phone-call check by the quality controllers, and reinterview check by the psychiatrists. Data were weighted according to the age–sex–residence distribution data from China's 2010 census population survey to adjust for differential probabilities of selection and differential response, as well as to post-stratify the sample to match the population distribution. Findings 28 140 respondents (12 537 [44·6%] men and 15 603 [55·4%] women) completed the survey between July 22, 2013, and March 5, 2015. Ethnicity data (Han or non-Han) were collected for only a subsample. Prevalence of any depressive disorders was higher in women than men (lifetime prevalence odds ratio [OR] 1·44 [95% CI 1·20–1·72] and 12-month prevalence OR 1·41 [1·12–1·78]), in unemployed people than employed people (lifetime OR 2·38 [95% CI 1·68–3·38] and 12-month OR 2·80 [95% CI 1·88–4·18]), and in people who were separated, widowed, or divorced compared with those who were married or cohabiting (lifetime OR 1·87 [95% CI 1·39–2·51] and 12-month OR 1·85 [95% CI 1·40–2·46]). Overall, 574 (weighted % 75·9%) of 744 people with 12-month depressive disorders had role impairment of any SDS domain: 439 (83·6%) of 534 respondents with major depressive disorder, 207 (79·8%) of 254 respondents with dysthymic disorder, and 122 (59·9%) of 189 respondents with depressive disorder not otherwise specified. Only an estimated 84 (weighted % 9·5%) of 1007 participants with 12-month depressive disorders were treated in any treatment sector: 38 (3·6%) in speciality mental health, 20 (1·5%) in general medical, two (0·3%) in human services, and 21 (2·7%) in complementary and alternative medicine. Only 12 (0·5%) of 1007 participants with depressive disorders were treated adequately. Interpretation Depressive disorders in China were more prevalent in women than men, unemployed people than employed, and those who were separated, widowed, or divorced than people who were married or cohabiting. Most people with depressive disorders reported social impairment. Treatment rates were very low, and few people received adequate treatment. National programmes are needed to remove barriers to availability, accessibility, and acceptability of care for depression in China. Funding National Health Commission and Ministry of Science and Technology of People's Republic of China. Translation For the Chinese translation of the abstract see Supplementary Materials section.

What is already known about this topic? Breast cancer is the most common cancer in women in China and around the world. By 2019, 121 countries have instituted a national screening program as a secondary prevention measure for breast cancer. What is added by this report? Breast cancer screening rates in China were 18.9% in women aged 20 years and above, and 25.7% in women aged 35–64 years in 2015. The screening rate for women aged 20 years and above was significantly higher in urban areas than in rural areas (24.6% vs. 15.0%), and in the eastern region than in the central and western regions (24.0% vs. 15.1% and 15.3%). What are the implications for public health practice? Continued efforts should be made to strengthen national and local policy initiatives and financial support for population-based, organized screening programs for breast cancer. Health education and accessibility of screening services to women across the country should be strengthened, especially for women aged 50 years and above.

What is already known about this topic? Hypertension has become a major public health problem worldwide because of its high prevalence and various complications, and it ranks the most important risk factor for cardiovascular diseases (CVDs). What is added by this report? The prevalence, awareness, treatment, and control of hypertension in the labor force population in 2015 in China were 21.4%, 26.1%, 19.6%, and 6.3%, respectively. Hypertension prevalence in the labor force population remains high and the control of hypertension is still very low. What are the implications for public health practice? Effective public health strategies targeting the labor force population, especially older adults, males, and overweight and obese participants are needed for hypertension prevention and control.

What is already known on this topic? Hypertension is a major public health concern in China, and hypertensive patients have elevated heart rates (HR), which can synergize with higher blood pressure to promote adverse health outcomes. What is added by this report? The risk of increased HR was statistically significant but relatively lower in subjects with treated and controlled hypertension. This lower impact might be modified by sex, marital status, smoking, and physical activity. What are the implications for public health practice? To mitigate the substantial burden of increased HR among hypertensive patients, improving blood pressure control and promoting healthy lifestyles should be prioritized.

What is already known on this topic? Alcohol use is attributed to more than 200 diseases and injury conditions. Recent conventional and genetic evidence is beginning to counter the benefit of moderate drinking. The prevalence of current alcohol use was 35.7% in 2007 among the Chinese population aged 18–69 years, but comparable estimations on a provincial-level has not been reported in China. What is added by this report? The prevalence of current alcohol use in the preceding year was 41.3% among the Chinese population aged 18 years and above in 2015. The prevalence of current alcohol use and the average level of daily pure alcohol intake among drinkers showed clustered and diversified geographic distribution across provinces. What are the implications for public health practice? Given diversified demographics and geographic characteristics of the current alcohol drinking population, the alcohol control policies and intervention strategies should be adopted at a provincial level to reduce alcohol-related mortality and disability.

What is already known about this topic? Excessive salt intake is an important risk factor for hypertension and cardiovascular diseases (CVDs). The amount of salt intake of Chinese is one of the highest all over the world. At a national level, the awareness of maximum daily salt intake recommended by the “Dietary Guidelines of Chinese residents” had not been reported. What is added by this report? This is the first nationally representative study about awareness of maximum daily salt intake in China. In 2015, the awareness rate of maximum daily salt intake and behavior rate of salt reduction among Chinese adults aged 18 years old and above was 6.1% and 37.3%, respectively. The awareness rate of maximum daily salt intake and behavior rate of salt reduction was low among adult residents in China. What are the implications for public health practice? To increase the behavior rate of salt reduction in China, awareness of the maximum daily salt intake needs to be strengthened to Chinese residents, especially in rural areas or for people with low education levels and low incomes.

What is already known about this topic? Cervical cancer is the fourth most common cancer of women around the world. Age-adjusted incidence and mortality rates of cervical cancer were 11.78 and 3.29 per 100,000, respectively, in China in 2015. What is added by this report? Cervical cancer screening rates were 25.7% for women aged 20–64 years old and 31.4% for women aged 35–64 years old in China in 2015. Screening rates were lower in rural areas than in urban areas and varied across provinces. What are the implications for public health practice? Efforts should be made to continue to strengthen national and local policy initiatives, financial support, health education, and accessibility to women in rural areas for cervical cancer screening coverage.

Summary Background In China, mean body-mass index (BMI) and obesity in adults have increased steadily since the early 1980s. However, to our knowledge, there has been no reliable assessment of recent trends, nationally, regionally, or in certain population subgroups. To address this evidence gap, we present detailed analyses of relevant data from six consecutive nationally representative health surveys done between 2004 and 2018. We aimed to examine the long-term and recent trends in mean BMI and prevalence of obesity among Chinese adults, with specific emphasis on changes before and after 2010 (when various national non-communicable disease prevention programmes were initiated), assess how these trends might vary by sex, age, urban–rural locality, and socioeconomic status, and estimate the number of people who were obese in 2018 compared with 2004. Methods We used data from the China Chronic Disease and Risk Factors Surveillance programme, which was established in 2004 with the aim to provide periodic nationwide data on the prevalence of major chronic diseases and the associated behavioural and metabolic risk factors in the general population. Between 2004 and 2018 six nationally representative surveys were done. 776 571 individuals were invited and 746 020 (96·1%) participated, including 33 051 in 2004, 51 050 in 2007, 98 174 in 2010, 189 115 in 2013, 189 754 in 2015, and 184 876 in 2018. After exclusions, 645 223 participants aged 18–69 years remained for the present analyses. The mean BMI and prevalence of obesity (BMI ≥30 kg/m2) were calculated and time trends compared by sex, age, urban–rural locality, geographical region, and socioeconomic status. Findings Standardised mean BMI levels rose from 22·7 kg/m2 (95% CI 22·5–22·9) in 2004 to 24·4 kg/m2 (24·3–24·6) in 2018 and obesity prevalence from 3·1% (2·5–3·7) to 8·1% (7·6–8·7). Between 2010 and 2018, mean BMI rose by 0·09 kg/m2 annually (0·06–0·11), which was half of that reported during 2004–10 (0·17 kg/m2, 95% CI 0·12–0·22). Similarly, the annual increase in obesity prevalence was somewhat smaller after 2010 than before 2010 (6·0% annual relative increase, 95% CI 4·4–7·6 vs 8·7% annual relative increase, 4·9–12·8; p=0·13). Since 2010, the rise in mean BMI and obesity prevalence has slowed down substantially in urban men and women, and moderately in rural men, but continued steadily in rural women. By 2018, mean BMI was higher in rural than urban women (24·3 kg/m2 vs 23·9 kg/m2; p=0·0045), but remained lower in rural than urban men (24·5 kg/m2 vs 25·1 kg/m2; p=0·0007). Across all six surveys, mean BMI was persistently lower in women with higher levels of education compared with women with lower levels of education, but the inverse was true among men. Overall, an estimated 85 million adults (95% CI 70 million–100 million; 48 million men [95% CI 39 million–57 million] and 37 million women [31 million–43 million]) aged 18–69 years in China were obese in 2018, which was three times as many as in 2004. Interpretation In China, the rise in mean BMI among the adult population appears to have slowed down over the past decade. However, we found divergent trends by sex, geographical area, and socioeconomic status, highlighting the need for a more targeted approach to prevent further increases in obesity in the Chinese general population. Funding China National Key Research and Development Program, China National Key Project of Public Health Program, and Youth Scientific Research Foundation of the National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention.

Background: In China, depressive disorders have been estimated to be the second leading cause of years lived with disability (YLDs). However, nationally representative epidemiological data for depressive disorders, in particular depressed adults’ mental health services use, are still unavailable in China. The present study is a part of the Chinese National Mental Health Survey (CMHS), 2012–15, which reported the prevalence, treatment, and associated disability of depressive disorders in the Chinese general population. Methods: The CMHS recruited a representative sample of 28140 Chinese residents (≥ 18 years) by using multistage proportional-to-population-size sampling method. Trained investigators interviewed participants with the Composite International Diagnostic Interview 3.0 to ascertain the presence of lifetime and 12-month depressive disorders according to DSM-IV criteria, including major depressive disorder (MDD), dysthymic disorder (DD), and depressive disorder not otherwise specified (DD-NOS). Participants with 12-month depressive disorders were asked whether they ever received any 12-month treatment for their emotional problems and the specific types of treatment providers. The Quick Inventory of Depressive Symptomatology and Sheehan Disability Scale (SDS) were used to evaluate the severity of and role impairments associated with 12-month depressive symptoms. Findings: The weighted lifetime and 12-month prevalence rates of any depressive disorder were 6.8% (95%CI: 5.8-7.8%) and 3.6% (95%CI: 3.0-4.2%), respectively; the corresponding figures were 3.4% (95%CI: 2.0-3.9%) and 2.1% (95%CI: 1.8-2.4%) for MDD, 1.4% (95%CI: 1.1-1.7%) and 1.0% (95%CI: 0.8-1.3%) for DD, and 3.2% (95%CI: 2.6-3.9%) and 1.4% (95%CI: 1.1-1.7%) for DD-NOS. Overall, 77.2% of persons with 12-month depressive disorders had role impairment of any SDS domain: 82.2% for MDD, 81.5% for DD, and 64.6% for DD-NOS. Depressed participants reported an average of 41.0 days out of role in the past year due to depression; the corresponding figures were 49.7 days for MDD, 54.9 days for DD, and 12.2 days for DD-NOS. In total, 88.9% of individuals with 12-month depressive disorders had clinically significant depressive symptoms: 93.7% for MDD, 91.7% for DD, and 77.5% for DD-NOS. MDD and DD had similar proportions of “severe” or “very severe” depressive symptoms (43.0% and 42.1%), which were higher than DD-NOS (13.9%). 9.5% of participants with 12-month depressive disorders were treated in any treatment sector: 3.6% in the specialty mental health (SMH), 1.5% in the general medical (GM), 0.3% in the human services (HS), and 3.3% in the complementary-alternative medical (CAM) sector. Respondents with MDD and DYS had the highest proportion of seeking treatment in SMH sector (4.7% and 3.0%) while those with DD-NOS had the highest proportion of seeking treatment in CAM sector (most treatments were Traditional Chinese Medicine) (3.3%). Only 0.5% of participants with depressive disorders were treated adequately. Rates of treatment adequacy of MDD and DYS in SMH sector were 9.2% and 2.4%, respectively. Both rates in GM sector were 0%. Interpretation: Compared to western countries, our data show a relatively low prevalence of depressive disorders in China. Nevertheless, their associated role impairments, symptom severities, and disabilities are severe. Importantly, the treatment rates are rather low, let alone adequate treatment. Nationwide programs aiming at removing barriers in availability, accessibility, and acceptability to mental healthcare are needed in China. Funding: The study was funded by the Special Research Project for Non-profit Public Service of the Chinese Ministry of Health (grant number 201202022), the National Twelfth Five-Year Plan for Science and Technology Support of the Chinese Ministry of Science and Technology (grant numbers 2012BAI01B01 & 2015BAI13B00) and the National Key R&D Program of China (grant numbers 2017YFC0907800, 2017YFC0907801). Declaration of Interests: The authors have no conflicts of interest to declare Ethical Approval: The study protocol of CMHS was approved by the Ethics Committee of the Sixth Hospital of Peking University (No.: IMH-IRB-2013-13-1).

Background: Physical inactivity is an essential health-related behaviour and a significant risk factor for chronic non-communicable diseases. Temporal trends in physical inactivity in Chinese adults are unclear. Method: Four nationally representative cross-sectional surveys were conducted in 31 provinces in China between 2010 and 2018. Using a multi-stage, stratified, cluster-randomized sampling method, 669 919 Chinese adults were selected to participate in the surveys, and 645 903 adults were included in the analyses. Domain-specific (work-, transport-, and recreation-) moderate- to vigorous-intensity physical activity (MVPA) was measured using the Global Physical Activity Questionnaire. Physical activity was defined as not doing at least 150 minutes of moderate-intensity, 75 minutes of vigorous-intensity PA per week, or any equivalent combination of the two. Temporal changes in physical inactivity and no domain-specific PA were analyzed using linear regression methods. All analysis was accounted for the complex sampling design. Findings: From 2010 to 2018, the prevalence of physical inactivity among Chinese adults increased from 17·9% (95%CI, 16·3-19·5) to 22·3% (95%CI, 20·9-23·8) (Ptrend

Background: Recent studies have shown an increase in the prevalence of hyperuricemia (HUA) worldwide. However, representative national data suggesting national trends of HUA in China are lacking. Methods: Using a multi-stage, stratified, cluster-randomized sampling design, two cross-sectional surveys (representative of national and provincial information) were conducted in 31 provinces (autonomous regions and municipalities) in mainland China, with 166,861 Chinese adults in 2015–16 and 168,351 in 2018–19. Serum uric acid (SUA) levels of all participants were measured after a >10-hour overnight fast. HUA was defined when SUA was >420 μmol/L. Prevalence estimates were weighted to represent the total population considering the complex sampling design. Multivariable logistic regression models estimated factors associated with HUA. Findings: The overall HUA prevalence in the Chinese adult population was 11.1% (95% CI, 10.3–11.8%) in 2015–16 and 14.0% (95% CI, 13.1-14.8%) in 2018–19; an alarming rise was observed in the three years. HUA was more common in men with 19.3% (95% CI, 17.9–20.7%) in 2015–16 and 24.4% (95% CI, 23.0–25.8%) in 2018–19. The HUA prevalence also escalated from 2.8% (95% CI, 2.5-3.0%) in 2015–16 to 3.6% (95% CI, 3.2–4.0%) in 2018–19 in women. Various risk factors, including urban culture, settlement in the East, Zhuang descent, high education, heavy or frequent beer drinking, high red meat intake, physical inactivity, high BMI, central obesity, hypertension, hyperlipidemia, and low eGFR, were significantly associated with HUA. Interpretation: The estimated HUA prevalence among Chinese adults was 14.0% in 2018–19; significant escalating trends were observed between 2015 and 2019. Therefore, HUA is a public health problem in China. Funding: Chinese Central Government and National Key R&D Program of China. Declaration of Interest: We declare no competing interests. Ethical Approval: The ethical review committee of the Chinese Center for Disease Control and Prevention (China CDC) approved the 2015 CCDRFS (approval number 201519- A) and that of the National Center for Chronic and Noncommunicable Disease Control and Prevention, China CDC approved the 2018 CCDRFS (approval number 201819).

Background: Cardiovascular disease is the leading cause of death in China. Objectives: We aimed to evaluate the levels of cardiovascular health among Chinese adults and to understand the geographic patterns based on a nationally and provincially representative survey. Methods: In 2015, a total of 74,771 respondents aged ≥ 20 years with no history of cardiovascular disease were randomly sampled from 298 counties/districts of 31 provinces in mainland China and were interviewed. Seven metrics, including smoking, body mass index, physical activity, diet, total cholesterol, blood pressure, and fasting glucose, were determined. Ideal cardiovascular health was defined as the simultaneous presence of all metrics at the ideal level. A score ranging from 0 to 14 was calculated as the sum of all seven metrics for each province. Scores for four health behaviors and four health factors were also calculated. Results: The age-adjusted prevalence of ideal cardiovascular health was only 1.13% among Chinese adults above 20 years old in 2015 (0.50% among men and 1.77% among women; 1.63% among urban residents and 0.68% among rural residents). The age-adjusted prevalence varied greatly across provinces, ranging from 0.05% in Qinghai to 2.97% in Heilongjiang. Ideal diet (7.4%) was the least common among seven cardiovascular health metrics and ideal blood pressure (32.2%) was the second least one. We also saw significant heterogeneity among provinces in age-adjusted cardiovascular health score, health behavior score, and health factors score. In all provinces, women had higher scores than men for cardiovascular health, health behaviors and health factors. Differences in cardiovascular health and health behavior scores between urban and rural areas were associated with levels of socio-economic development. Conclusions: Strategies for addressing poor cardiovascular health require geographic targeting and localized consideration.

Introduction Periodic population surveys of smoking behavior can inform development of effective tobacco control strategies. We investigated smoking patterns, cessation, and knowledge about smoking hazards in China. Methods A nationally representative cross-sectional survey recruited 176 318 people aged ≥18 years across 31 provinces of China in 2013–2014, using multi-stage stratified cluster sampling methods. The smoking patterns, cessation, and knowledge about smoking hazards were analyzed, overall and in population subgroups, adjusting for sample selection weight and post-stratification factors. Results Among men, 60.7% were ever-smokers, with proportions of regular, occasional and former smokers being 46.3%, 5.5%, and 8.8% respectively. Among women, only 2.8% had ever smoked. The prevalence of ever smoking in men was higher in rural than urban areas (63.2% vs. 57.6%) and varied from 39.5% to 67.4% across 31 provinces. Among male regular smokers, the mean daily number of cigarettes smoked was 17.8, with mean age at first starting to smoke daily being 20.1 years. Among current smokers, one-third (32.6% men, 32.1% women) had tried to quit before and 36.8% (36.8% men, 35.5% women) intended to quit in the future. Of the Chinese adults, 75.9% recognized that smoking was hazardous, with the proportions believing that smoking could cause lung cancer, heart attack or stroke being 67.0%, 33.2%, and 29.5%, respectively and with 26.0% reporting that smoking could cause all these conditions. Conclusion Among Chinese adults, the smoking prevalence remained high in men but was low in women. In both men and women, knowledge about smoking hazards was poor. Implications This study showed that tobacco smoking remained highly prevalent among adult men in China in 2013–2014. Moreover, men born in recent decades were more likely to start smoking at younger ages and to smoke more cigarettes than those born in previous generations. There was a large regional variation in male smoking prevalence, with the least economically developed regions having higher prevalence. In contrast, few women in China smoked, especially among those born in recent decades. The contrasting smoking patterns in men and women is likely to result in an increasingly large gender disparity in life expectancy in the coming decades.

Hypertension has been the most important risk factor for disease burden in China. We aimed to conduct the first national spatial analysis of hypertension status, awareness, treatment and control in China.Choropleth maps were used to examine the spatial patterning of hypertension, awareness, treatment and control in a nationally and provincially representative sample of 174 389 adults from the 2013 to 2014 China Chronic Disease and Risk Factors Surveillance. Multilevel regressions were used to analyze each outcome across provinces, counties, towns and villages/residential committees and to test the proportion of area-level variances explained by known risk factors.Hypertension prevalence was highest in the north (e.g. Liaoning = 37.7%) and lowest in the south (e.g. Hainan = 17.9%). Among participants found to have hypertension, awareness was generally low, especially in the south (e.g. Guizhou = 18.0%). Receipt of treatment among those who were aware of their hypertension status was above 70% in all provinces except for Tibet (37.7%) and Guizhou (54.5%). Control of hypertension among those receiving treatment (SBP 140 and DBP 90 mmHg) was generally low, especially in northeastern and southwestern provinces. Adjustment for demographic, socioeconomic and behavioral factors, weight status, healthcare use and urbanization of residence accounted for 57.7% of variation between provinces in hypertension status, 48.5% in awareness, 47.6% in treatment and 18.0% in control.Hypertension is spatially patterned in China and there is an unmet need at each step from diagnosis to receiving treatment and achieving controlled hypertension. Geographically targeted strategies are required to enhance hypertension prevention and management in China.

ObjectivesTo examine the relationship between sleep duration and hypertension of migrant workers aged 18–59 years in China.DesignPopulation-based cross-sectional study using a complex survey sampling design.ParticipantsThere were 43 655 subjects in our analysis, after excluding people with missing information for key exposure and outcome variables and abnormal values for sleep duration (≤2 or ≥17 hours).Primary outcome measureHypertension was defined as systolic blood pressure (BP) ≥140 mm Hg and/or diastolic BP ≥90 mm Hg, or self-reported history of hypertension diagnosis in hospitals at the township (community) level or above and use of hypertensive medicine in the last 2 weeks.ResultsOf 43 655 subjects, 15.6% (95% CI 15.1% to 16.1%) of migrant workers had hypertension. The prevalence of hypertension decreased with the increased sleep duration, both in males and females. Logistic regression models, using 7–8 hours sleep/day as the reference, showed a greater odds for hypertension among men and women who reported interaction=0.096). Further stratified by age and migration time, it revealed that among adults less than 45 years old, those sleeping 9 or more hours had adjusted odds for hypertension of 0.82 (95% CI 0.72 to 0.93, pinteraction=0.020),while there was no evidence of an association between sleep duration and hypertension among adults aged 45–59 years. Among adults whose migration time was less than 4.5 years, those sleeping 9 or more hours had adjusted odds for hypertension of 0.80 (95% CI 0.68 to 0.94, pinteraction=0.097).ConclusionThe association between sleep duration and hypertension varies by age. Short sleep duration (

Aims: To evaluate the independence of the effect of 2-hour post-load plasma glucose (2hPG), fasting plasma glucose (FPG) and glycated hemoglobin (HbA1c) on cardiovascular disease (CVD) after adjusting for each other and non-glycemic factors. Methods: We analyzed data from a nationally representative sample of 174,329 Chinese adults from a survey conducted in 2013–2014. The associations of glycemic measures with the risk of CVD were examined and compared by using logistic regression analyses. Results: After adjusting for non-glycemic factors, the odds ratio for one standard-deviation increase of 2hPG, FPG and HbA1c was 1.08 (95% confidence interval [CI]: 1.05–1.11), 1.02 (95% CI: 0.99–1.06) and 1.05 (95% CI: 1.02–1.07), respectively. The odds ratio for 2hPG (1.10, 95% CI: 1.05–1.16) remained statistically significant after FPG and HbA1c were added to the models, whereas the odds ratios for FPG and HbA1c became statistically insignificant after 2hPG was adjusted for. The results remained consistent across various scenarios. Conclusions: 2hPG showed an effect on cardiovascular risk which was independent from FPG and HbA1c, whereas whether the effects of FPG and HbA1c were independent from 2hPG was open to question. This finding calls for more research on how to better use FPG and HbA1c in diagnosing diabetes.

Background Cardiovascular disease is the leading cause of death in China. The aim of this study was to evaluate the levels of cardiovascular health among Chinese adults and to understand the geographic pattern of cardiovascular health. Methods In 2015, a total of 74,726 respondents aged ≥ 20 years with no history of cardiovascular disease were randomly sampled from 298 counties/districts of 31 provinces in mainland China and were interviewed. Seven metrics, including smoking, body mass index, physical activity, diet, total cholesterol, blood pressure, and fasting glucose, were determined. Ideal cardiovascular health was defined as the simultaneous presence of all metrics at the ideal level. A score ranging from 0 to 14 was calculated as the sum of all seven metrics for each province. Scores for cardiovascular health behaviors (smoking, body mass index, physical activity and diet) and those for cardiovascular health factors (smoking, total cholesterol, blood pressure, and fasting glucose) were also calculated. Findings The mean age was 44.4 ± 15.9 years, and 49.3% were women. The age-sex-standardized prevalence of ideal cardiovascular health was universally poor, ranging from 0.02% [95% confidence interval (CI): 0%, 0.05%] in Tibet to 2.76% (95% CI: 0.45%, 5.07%) in Heilongjiang. Ideal diet (7.1%) was the least common factor of the seven metrics in each province and varied considerably across provinces. Other component metrics of ideal cardiovascular health were also spatially patterned. In all provinces, women had higher scores than men for cardiovascular health, health behaviors and health factors. Differences in cardiovascular health and health behavior scores between urban and rural areas were associated with levels of socio-economic development. Interpretation Strategies for addressing poor cardiovascular health require geographic targeting and localized consideration. Funding This research was supported by National Key R&D Program, the Shenzhen Strategic Emerging Industry Development Special Fund, and the Fund of "Sanming" Project of Medicine in Shenzhen.

Previous studies have shown increasing prevalence of diabetes in China, which now has the world's largest diabetes epidemic.To estimate the recent prevalence and to investigate the ethnic variation of diabetes and prediabetes in the Chinese adult population.A nationally representative cross-sectional survey in 2013 in mainland China, which consisted of 170 287 participants.Fasting plasma glucose and hemoglobin A1c levels were measured for all participants. A 2-hour oral glucose tolerance test was conducted for all participants without diagnosed diabetes.Primary outcomes were total diabetes and prediabetes defined according to the 2010 American Diabetes Association criteria. Awareness and treatment were also evaluated. Hemoglobin A1c concentration of less than 7.0% among treated diabetes patients was considered adequate glycemic control. Minority ethnic groups in China with at least 1000 participants (Tibetan, Zhuang, Manchu, Uyghur, and Muslim) were compared with Han participants.Among the Chinese adult population, the estimated standardized prevalence of total diagnosed and undiagnosed diabetes was 10.9% (95% CI, 10.4%-11.5%); that of diagnosed diabetes, 4.0% (95% CI, 3.6%-4.3%); and that of prediabetes, 35.7% (95% CI, 34.1%-37.4%). Among persons with diabetes, 36.5% (95% CI, 34.3%-38.6%) were aware of their diagnosis and 32.2% (95% CI, 30.1%-34.2%) were treated; 49.2% (95% CI, 46.9%-51.5%) of patients treated had adequate glycemic control. Tibetan and Muslim Chinese had significantly lower crude prevalence of diabetes than Han participants (14.7% [95% CI, 14.6%-14.9%] for Han, 4.3% [95% CI, 3.5%-5.0%] for Tibetan, and 10.6% [95% CI, 9.3%-11.9%] for Muslim; P .001 for Tibetan and Muslim compared with Han). In the multivariable logistic models, the adjusted odds ratios compared with Han participants were 0.42 (95% CI, 0.35-0.50) for diabetes and 0.77 (95% CI, 0.71-0.84) for prediabetes for Tibetan Chinese and 0.73 (95% CI, 0.63-0.85) for diabetes and 0.78 (95% CI, 0.71-0.86) for prediabetes in Muslim Chinese.Among adults in China, the estimated overall prevalence of diabetes was 10.9%, and that for prediabetes was 35.7%. Differences from previous estimates for 2010 may be due to an alternate method of measuring hemoglobin A1c.

Elevated serum total cholesterol and low-density lipoprotein cholesterol (LDL-C) levels are established risk factors for cardiovascular diseases, a leading cause of death in China. We sought to assess the latest levels of serum lipids, prevalence of dyslipidemia and achievement of LDL-C lowering targets among Chinese adults.Data was obtained from a national representative survey recruited 163,641 adults aged18years in mainland China between 2013 and 2014. Fasting serum total cholesterol (TC), LDL-C, high-density lipoprotein cholesterol (HDL-C), and triglycerides (TG) were measured by standard methods. Multiple logistic regression was preformed to estimate potential risk factors for dyslipidemias. Proportion of residents not achieve the therapeutic goals for LDL-C by atherosclerotic cardiovascular diseases (ASCVD) risk stratification were evaluated.Nationally, the population-weighted means of TC, HDL-C, and LDL-C, and median of TG were 4.70, 1.35, 2.88, and 1.49mmol/L, respectively. The prevalence of high TC, high LDL-C, low HDL-C and high TG was 6.9%, 8.1%, 20.4% and 13.8%. Among individuals with high ASCVD risk, 74.5% had uncontrolled LDL-C levels (2.6mmol/L) and 5.5% of them were treated. For very-high-risk individuals, 93.2% didn't achieve their LDL-lowering goals (1.8mmol/L) and 14.5% of them were treated.Chinese adults currently experienced a high prevalence of abnormal serum lipid levels, more common in urban adults or those with obesity or central obesity. A significant proportion of people with high or very high ASCVD risk didn't meet LDL-C targets. Improvements in achievement of lipid-level targets and of LDL-lowering therapy rates based on ASCVD risk stratification were necessary.

Background and Purpose— Despite previous investigations, substantial uncertainty remains about the relation between body mass index (BMI) and stroke, especially in populations with a relatively low BMI but a high stroke rate. Methods— A nationally representative prospective study of mortality included 212 000 Chinese men 40 to 79 years old without known cardiovascular disease in 1990 to 1991 who were followed up for 10 years. Standardized hazard ratios were calculated for stroke mortality by baseline systolic blood pressure (SBP) and BMI. Results— Mean SBP and BMI were 124 mm Hg and 21.7 kg/m 2 , respectively. During 10 years of follow-up, 5766 stroke deaths were recorded. There were strong, positive relations between BMI and SBP and between SBP and stroke mortality, with a 3-mm Hg higher baseline SBP associated with a 5.6% (95% CI, 5.3% to 6.0%; P 25 kg/m 2 ( P 2 , and among them, BMI was not associated with stroke mortality despite its strong association with BP (which continued to a BMI 2 ). The relation with BMI was similar for ischemic and hemorrhagic stroke but appeared to be steeper among lifelong nonsmokers than among current smokers ( P =0.01 for difference between slopes) despite similarly positive relations between BMI and SBP and between SBP and stroke risk in both smoking categories. Conclusions— High BMI was strongly associated with increased stroke mortality only among men who were overweight or obese.

Background Hypertension is a major cause of cardiovascular disease. Periodic nationwide surveys are essential for monitoring secular trend of hypertension and its control in population. We assessed prevalence of hypertension and related awareness, treatment and control rates in Chinese adults in 2013-14. Methods A nationally representative survey recruited 174 621 adults aged>18 years from 31 provinces in mainland China between 2013 and 2014. Population-weighted prevalence of hypertension and related rates of awareness, treatment and control were calculated and compared by age, sex, region and other factors of interest. Results Overall, 27.8% of Chinese adults were hypertensive, with the adjusted prevalence higher in men than in women and increasing steeply with rising age. Of those with hypertension, 31.9% were previously diagnosed, of those diagnosed, 82.9% were treated, and of those treated, 34.6% had their blood pressure properly controlled, resulting in an overall control rates of 9.7% among those with hypertension. Despite similar prevalence, the awareness, treatment and control were much better in urban areas than in rural areas. Among hypertensive individuals, older age, higher levels of education or household income tended to be associated with better awareness, treatment and control rates. During 2013-14, 292 million adults in China had hypertension, representing an absolute increase of 139 million individuals since year 2002. Conclusions Among Chinese adults, more than one forth had hypertension and the prevalence has increased significantly during recent decades. Despite huge efforts, the levels of awareness, treatment and control rates of hypertension remain extremely low, foreshadowing substantial unnecessary disease burden.

Several epidemiological studies have reported on the association between body mass index (BMI) and risk of esophageal cancer, but these were mostly in Western populations where many are overweight or obese. There is little direct evidence about the relationship in China where the mean BMI is relatively low and the disease rate is high. We examined the data from a populationbased prospective study of 220,000 Chinese men aged 40–79 without a previous history of cancer (mean BMI 21.7 kg/m 2 ), which included 1,082 esophageal cancer deaths during 10 years of follow-up. Adjusted hazard ratios for death from esophageal cancer by baseline BMI category were calculated using Cox proportional hazards models. Even among men with good self-assessed health and BMI 18.5 kg/m 2 , there was a strong inverse association between BMI and death from esophageal cancer, with each 5 kg/ m 2 higher BMI associated with 25% (95%CI: 11–36%) lower esophageal cancer mortality. This inverse association persisted when analysis was restricted to men who had never smoked or when the first 5 years of follow-up were excluded. The strength of the relationship was consistent with the pooled estimate for squamous cell carcinoma of the esophagus in a meta-analysis of prospective studies (31% lower relative risk per 5 kg/m 2 higher BMI; 95% CI: 25–37%), but contrasted with that for adenocarcinoma which showed a positive association with BMI. Together, these data provide reliable evidence that in many populations low BMI is associated with an increased risk of squamous cell carcinoma of the esophagus. ' 2007 Wiley-Liss, Inc.

Good public-health decisionmaking is dependent on reliable and timely statistics on births and deaths (including the medical causes of death). All high-income countries, without exception, have national civil registration systems that record these events and generate regular, frequent, and timely vital statistics. By contrast, these statistics are not available in many low-income and lower-middle-income countries, even though it is in such settings that premature mortality is most severe and the need for robust evidence to back decisionmaking most critical. Civil registration also has a range of benefits for individuals in terms of legal status, and the protection of economic, social, and human rights. However, over the past 30 years, the global health and development community has failed to provide the needed technical and financial support to countries to develop civil registration systems. There is no single blueprint for establishing and maintaining such systems and ensuring the availability of sound vital statistics. Each country faces a different set of challenges, and strategies must be tailored accordingly. There are steps that can be taken, however, and we propose an approach that couples the application of methods to generate better vital statistics in the short term with capacity-building for comprehensive civil registration systems in the long run.

Objectives - To examine the modification of temperature-mortality association by factors at the individual and community levels. Design and methods - This study investigated this issue using a national database comprising daily data of 66 Chinese communities for 2006–2011. A ‘threshold-natural cubic spline’ distributed lag non-linear model was utilised to estimate the mortality effects of daily mean temperature, and then examined the modification of the relationship by individual factors (age, sex, education level, place of death and cause of death) using a meta-analysis approach and community-level factors (annual temperature, population density, sex ratio, percentage of older population, health access, household income and latitude) using a meta-regression method. Results - We found significant effects of high and low temperatures on mortality in China. The pooled excess mortality risk was 1.04% (95% CI 0.90% to 1.18%) for a 1°C temperature decrease below the minimum mortality temperature (MMT), and 3.44% (95% CI 3.00% to 3.88%) for a 1°C temperature increase above MMT. At the individual level, age and place of death were found to be significant modifiers of cold effect, while age, sex, place of death, cause of death and education level were effect modifiers of heat effect. At the community level, communities with lower socioeconomic status and higher annual temperature were generally more vulnerable to the mortality effects of high and low temperatures. Conclusions - This study identifies susceptibility based on both individual-level and community-level effect modifiers; more attention should be given to these vulnerable individuals and communities to reduce adverse health effects of extreme temperatures.