Time trends of cardiovascular disease risk factors in China

Yangpin Li, MD, PhD, Frank Hu, 16 Jan 2014

Fueled by rapid urbanization and changes in dietary and lifestyle choices, cardiovascular and other chronic diseases have emerged as a critical public health issue in China. The prevalence of hypertension in 2010 reached 33.5% (an estimated 330 million hypertensive patients), and the awareness and control rates are extremely low. Type 2 diabetes is an increasing epidemic in China with more than 100 million people affected. Although the Chinese population has a lower BMI than the global average level, abdominal obesity has become especially common in Chinese adults. Despite tobacco control efforts, the prevalence of smoking in China remains at a high level and domestic production of cigarette continue to rise. With unprecedented growth in urbanization, work and transportation-related physical activity levels have declined sharply, accelerating the epidemics of obesity and chronic diseases, which not only affect health and quality of life, but also have economical and social consequences.

Cardiovascular disease is the leading cause of death in China, accounting for 37.8% of all deaths in 20101. Unhealthy diets, high blood pressure, tobacco smoking, high fasting glucose, physical inactivity and low physical activity, alcohol use, high body mass index (BMI) and high cholesterol contribute to the majority of the cardiovascular deaths in China1. Most of these risk factors are preventable and could be modified by improving diet and exercise. Exploring the time trends of these risk factors can provide scientific information and evidence for developing strategies to reduce cardiovascular morbidity and mortality.

Dietary risk factors

China has experienced a dramatic shift from its tradition dietary pattern to a Western dietary pattern in recent decades. According to the annual report of National Bureau of Statistic of China2, the annual consumption of whole grains (unprocessed grains) of rural household per capita decreased from 266 kg in 1993 to 171 kg in 2011; similar trend was found in the urban population. Meanwhile, the annual consumption of meat, egg, fish and dairy products increased from 18.7 kg to 36.8 kg in rural areas and from 46 kg to 74 kg in urban areas from 1993 to 2011. Compared to other countries, such as Germany, Finland, South Korea, India, dietary changes have been the most drastic in China, which is rapidly adopting a Western, animal-based diet12.

High blood pressure

High blood pressure is the second leading contributor to cardiovascular disease mortality in China1. As shown in Figure 1, the prevalence of hypertension has been increasing steadily and substantially in the past several decades. The prevalence of hypertension was 5.11% in 1959 based on the first national survey of hypertension but the definition was not clearly recorded3. The prevalence increased to 7.73% in 1979 among people aged 15 years or above. From 1991, after the new definition of hypertension was applied, the prevalence of hypertension reached 13.6% among people aged 15 years or above5. In 2002, the prevalence of hypertension was 17.7% and 18.8% among population aged over 15 and over 18 years, respectively9, 13.

It increased to 33.5% or an estimated 330 million in 2010.11 The prevalence of hypertension in Chinese adults was comparable to that in the US14. Based on the same definition, the overall prevalence of hypertension among U.S. adults aged over 18 years in 2003−2010 was 30.4% 11, 14. However, the awareness rate was much lower in the Chinese population (24%) 13 as compared to that in the U.S. adult population (61%)14. The treatment rate among those affected individuals who were aware of their condition was similar in China (78%) and in the U.S. (74%). However, the control rate was much lower in China. Among those with hypertension, an estimated of 46% Americans had their hypertension controlled14, compared with only 25% of people with hypertension in China13

Figure 1: Time trend of prevalence of hypertension in 19593, 19793, 19915, 20029 and 201011

Tobacco smoking

Despite tobacco control efforts, the prevalence of smoking in China remains at a high level. In 2010, 28.1% of adults (52.9% of men and 2.4% of women) or an estimated 301 million were current smokers in China, making China the largest consumer of tobacco products in the world15. At the same time, second hand smoking is highly common in China15-17. In 2010, an estimated 740 million non-smokers were exposed to second hand smoking in China, based on the estimation of 2010 China Global Adults Smoking Survey (GATS) carried out by the Chinese Center for Disease Control and Prevention16.

China is also the world’s largest tobacco manufacturer. China produces about 2.66 million tons of tobacco leaves each year, accounting for one-third of the world’s tobacco production per year18. In 1952, China produced around 133 million cigarettes per year, which increased steadily to 1,649 million cigarettes in 1990 and remained flat for around 10 years, and then increased steadily again to 2,516 million cigarettes in 2012 (Figure 2). The fraction of deaths attributable to tobacco use increased from 12.8% in 1990 to 16.4% in 2010 in China1

Figure 2: Time trend of domestic production of cigarettes in China (Data sources: National Bureau of Statistics of China)

High fasting glucose and diabetes

Type 2 diabetes is a growing epidemic in China, characterised by a rapid rate of increase over a short period of time as well as onset at a relatively young age and low body mass index19. Type 2 diabetes in China was rare in the 1980s4, with an estimated prevalence of 0.67%. In subsequent national surveys conducted in 19946, 2000-20017 and 2007-20088, the prevalence of diabetes was 2.5%, 5.5% and 9.7%, respectively (Figure 3). The estimated number of adult diabetic patients was 92.4 million in 20088, making China the country with the largest number of diabetic patients in the world.

In 2010-2011, the China Non-Communicable Disease Surveillance Group applied the 2010 American Diabetes Association diagnostic criteria by further including haemoglobin A1c≥6.5%, in addition to elevated fasting glucose, to a large national survey. This resulted in an estimation of overall prevalence of diabetes of 11.6% among Chinese adults 18 years or older10. This prevalence is similar to that in the US adults (11.3%)20 and much higher than the average prevalence worldwide (8.3%)21. Similar to hypertension, the awareness, treatment and control rates of diabetes are very low in China. In 2010, the proportion of diabetes patients who were aware of their condition was 30.1%, and only 25.8% of diabetic patients received treatment for the disease, and only 39.7% of those treated had adequate glycaemic control10.

Figure 3: Prevalence of type 2 diabetes in China estimated at 19804, 19946, 2000-20017, 2007-20088 and 2010-201110

Physical inactivity and low physical activity

Rapid urbanisation, major shifts in types of employment and the growing use of new technologies have caused a steep decline in physical activity in China. The primary means of transportation have changed from walking and bicycling to driving. Meanwhile, China has seen a dramatic increase in sedentary lifestyles such as TV watching and computer use.

The bicycle was the most commonly used form of transportation in China in the 1970s and the rates of bicycle use continued to increase in the following 2-3 decades. By 1983, 37% of people commuted by bicycles compared to 19.5% by mass transit. In 1988, 57.1% of people commuted by bicycles compared to 37% by mass transit22. In the 1990s, the ownership of bicycles in Chinese households reached the peak. On average, each rural family owned 1.5 bicycles and each family in urban areas had 2 bicycles in the middle of the 1990s. After that, the ownership of bicycles in Chinese household dropped substantially. In 2011, the bicycle ownership was only 77 bicycles per 100 households in rural areas. While bicycle ownership decreased, car ownership in urban areas and motorcycle ownership in rural areas have experienced a shape increase. In 2011, around 61% of rural households owned a motorcycle and 19% of urban households owned a car.

At the same time, TV ownership has increased from 38 sets per 1000 persons in 1985 to 135 sets per 100 households in urban areas in 2011 (112 sets per 100 rural households). Mobile phone ownership increased more rapidly than TV ownership in both rural and urban areas. In 2011, almost every family had more than one mobile phone. Another indicator of sedentary activity is increasing computer ownership. In 2011, the computer ownership was 82 sets per 100 households in urban areas and 18 sets per 100 households in rural areas.

Alcohol use

Alcohol-related disorders were among the ten most common causes of years lived with disability (YLDs) and cardiovascular mortality in China in 20101. Although light to moderate alcohol consumption is associated with a reduced risk of cardiovascular morbidity and mortality, consumption of larger amounts of alcohol is associated with higher risks for stroke incidence and mortality 23.

Based on the WHO data, per capita alcohol consumption for Chinese aged 15 years and older was 1.03 litters in 1970, and rose to 5.17 litters in 1996, kept relatively stable afterwards, with 5.91 litters in 200524. According to the China Bureau of Statistics, the average annual liquor consumption was 6.5 kg in rural areas and 9.7 kg in urban areas in 1993. In the following two decades, alcohol consumption has been increasing in rural areas but decreasing in urban areas, leading to much higher consumption levels among rural than urban residents. In 2011, the average annual liquor consumption was 10.2 kg in rural and 6.8 kg in urban. There is a large gender difference in alcohol consuming patterns. Around 40% men regularly drink at least once per week, while less than 5% women drink alcohol regularly; this pattern did not change significantly between 1991 and 2009.

Data on heavy drinking and alcohol-related disorders are limited in China. According to the 2002 China National Nutrition and Health survey, the prevalence of heavy drinking (men >25g/day, women >15g/day) in Chinese adults was around 4.7 % (8.4% for male and 0.8% for female) 25. The prevalence of heavy drinking among alcohol consumers was 39.6% in urban areas and 54.7% in rural areas. The 45-59 years old age group had the highest prevalence of heavy drinking25. In 2004-2008, the prevalence of heavy drinking among regular alcohol consumers was 37% when heavy drinking was defined as > 60 g/day of alcohol for men on a weekly basis26.

High cholesterol and dyslipidaemia

Rapid transition to the Western dietary pattern with an animal-based diet in China has led to a rapid increase in serum cholesterol levels27. In 1982-1984, the prevalence of borderline high or high total cholesterol ( ³ 5.28 mmol/L) was 17.6% in men and 19.2% in women, which increased to 24% in men and 27.1% in women in 1992-1994. The prevalence increased to 33.1% in men and 33.8% in women in 199828, and then kept relatively stable afterwards, which was 31.3% in men and 31.7% in women in 2007-200829. The awareness, treatment, and control of borderline high or high total cholesterol were 11.0%, 5.1%, and 2.8%, respectively, in 2007-200829.

Besides high cholesterol, high triglyceride and low high-density lipoprotein (HDL) were also common in the Chinese population. Low HDL (≤0.91 mmol/L) was reported in 7.4% adults (9.3% of men and 5.4% of women) in 2002 China National Nutrition and Health Survey9. In the 2007-2008 China National Diabetes and Metabolic Disorders Study, low HDL (defined as HDL<1.04 mmol/L) was observed in 22.3% of Chinese adults (27.1% of men and 17.5% of women)29. Hypertriglyceridemia (defined as plasma triglyceride ≥1.7 mmol/L) was observed in 11.9% of adults in 2002 (14.5% of men and 9.9% of women) 9.

High body mass index (BMI) and obesity

The Chinese population has a relatively low BMI. The BMI of men and women in China was 0.9 kg/m2 and 1.2 kg/m2 lower than the global average in 200830. Despite a steady increase in BMI in the past decades, China remains among the bottom 30% of countries with the lowest male and female mean BMI among the 199 countries and territories that joined the WHO Global Burden of Disease (GBD) project30. However, compared to Caucasian populations, Chinese people tend to develop diabetes and other chronic diseases at a relatively low BMI levels 31: That is why the cut-off points of overweight and obesity have been defined at lower BMI levels for Chinese adults (24 kg/m2 for overweight and 28 kg/m2 for obesity)32.

Applying the Chinese BMI criteria, the prevalence of overweight and obesity was 13.6% in males in 1989 based on the data from the China Nutrition and Health Survey (Figure 4), which kept increasing rapidly from 1989 to 2009, and resulted in a prevalence of 39.6% in 2009. Among women, the prevalence of overweight and obesity was 17.6% in 1989, which rapidly increased to 40.5% in 2004 and kept flat afterwards (Figure 4).

Figure 4: Time trend of overweight and obesity

 Waist circumference (WC), a maker of central or abdominal obesity, has been increasing steeply in Chinese population. The prevalence of abdominal obesity (WC³85 cm for men and ³80 cm for women) increased from 17.7% to 48.4% among men and from 28.8% to 53.5% among women (Figure 5).

Figure 5: Proportion of waist circumference distribution

An alarming trend of a dramatic increase in obesity has been observed in children. According to the age-sex-specific BMI percentile criteria for Chinese children and adolescent, the prevalence of overweight and obesity of children and adolescents aged 7-18 years was 1.24%, 4.98%, 8.83%, 11.7% and 14.6%, respectively, in 1985, 1995, 2000, 2005 and 201033. In 1985, the prevalence of overweight and obesity was 1.34%, 1.55%, 0.47% and 1.6% in boys and girls in urban areas, and boys and girls in rural areas, respectively. The corresponding prevalence of overweight and obesity of children and adolescents was 23.2%, 12.7%, 13.8% and 8.6%, respectively, in 201033.

Summary

China has experienced a dramatic shift from its tradition dietary pattern to a Western dietary pattern in recent decades. The prevalence of hypertension in 2010 was 33.5% (an estimated 330 million hypertensive patients), and the awareness and control rates are extremely low. Despite tobacco control efforts, the prevalence of smoking in China remains at a high level and domestic production of cigarette continue to rise. Type 2 diabetes is an increasing epidemic in China with more than 100 million people affected. Rapid transition to the Western dietary pattern with an animal-based diet in China has led to a large increase in serum cholesterol levels. Although the Chinese population has a lower BMI than the global average level, the prevalence of overweight and obesity is increasing rapidly in both adults and children, and abdominal obesity is especially common in Chinese adults.

Compelling evidence indicates that the current chronic disease epidemic is largely driven by changes in diet and lifestyle in China. Over the past several decades, traditional patterns of eating have been replaced with a Western diet high in animal products, processed carbohydrates, and sugar-sweetened beverages.

At the same time, overall physical activity levels have decreased considerably due to rapid urbanisation and industrialisation. China’s limited chronic care infrastructure makes it ill-equipped to deal with an epidemic of chronic disease. Population-based intervention studies demonstrate the efficacy of preventive strategies to reduce disease burden. However, translating these findings into practice requires changes in health systems and public policies.34 To achieve the goals of improving health for all people, chronic disease prevention needs to be a national public policy imperative. Its great potential to cut medical costs and reduce widespread health and social inequalities in China cannot be realised without full involvement of all stakeholders. These include the government, healthcare, education, industry, urban planners, the media, the food production and service sectors, NGOs, communities, and individuals. Prevention is certainly beyond the scope of any one ministry or government agency.

Clearly, prevention of chronic diseases should be elevated to a top priority for national public policy because it can cut medical costs, improve quality of life, and reduce widespread health and social and inequalities in China.

Acknowledgement

Much of the data presented in this article were based on the China Statistic Yearbook 1996 to 2012 and the China Health and Nutrition Survey (CHNS). We thank the National Bureau of Statistics of China, National Institute of Nutrition and Food Safety, China Center for Disease Control and Prevention, Carolina Population Center (5 R24 HD050924), the University of North Carolina at Chapel Hill, the NIH (R01-HD30880, DK056350, R24 HD050924, and R01-HD38700) and the Fogarty International Center for financial support for the CHNS data collection and analysis files from 1989 to 2011 surveys, and the China-Japan Friendship Hospital, Ministry of Health for support for CHNS 2009.

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Authors

Yangpin Li, MD, PhD

Research Scientist, Department of Nutrition, Harvard T.H. Chan School of Public Health

Yanping Li received her medical degree from Tianjin Medical School in China, a Master of Science from the Chinese Academy of Preventive Medicine in 2000, and PhD in 2008 from Wageningen University, the Netherlands.

Her research interests include: (1) Trends of lifestyle factors and their association with obesity and other chronic diseases among the Chinese population; (2) Fetal programming of chronic diseases and its interaction with lifestyle factors in adulthood; (3) Genes and environmental interactions in relation to the risk of obesity and diabetes; and (4) Restless legs syndrome and other sleep disorders among Americans.

Frank Hu

Professor of Nutrition and Epidemiology, Harvard School of Public Health; Professor of Medicine, Harvard Medical School

Frank Hu is Professor of Nutrition and Epidemiology at Harvard School of Public Health and Professor of Medicine, Harvard Medical School and Channing Division of Network Medicine, Brigham and Women’s Hospital. He is Co-director of the Program in Obesity Epidemiology and Prevention at Harvard. He also serves as Director of the Harvard Transdisciplinary Research in Energetics and Cancer (TREC) Center and Epidemiology and Genetics Core of Boston Nutrition and Obesity Research Center (BNORC).

Mr Hu's research is mainly focused on nutritional and lifestyle epidemiology and prevention of obesity and type 2 diabetes as well as gene-environment interactions. His research group has conducted detailed examinations of the relationships between dietary and lifestyle factors (especially sugar-sweetened beverages, dietary patterns, and diet quality) and risk of obesity, diabetes, and cardiovascular disease. These findings have contributed to current public health recommendations for chronic disease prevention. Mr Hu is also collaborating with researchers from China and India in obesity and diabetes epidemiologic and randomized intervention studies. He has published more than 500 original papers and reviews and a textbook on Obesity Epidemiology (Oxford University Press 2008).

Mr Hu is the recipient of the Kelly West Award for Outstanding Achievement in Epidemiology by American Diabetes Association in 2010.  He has served on the Institute of Medicine (IOM) Committee on Preventing the Global Epidemic of Cardiovascular Disease, and is a member of the Obesity Guideline Expert Panel at NIH.

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