Genetic and healthy lifestyle factors in relation to the incidence and prognosis of severe liver disease in the Chinese population.

BACKGROUND: Severe liver disease (SLD), including cirrhosis and liver cancer, constitutes a major disease burden in China. We aimed to examine the association of genetic and healthy lifestyle factors with the incidence and prognosis of SLD. METHODS: The study population included 504,009 participants from the prospective China Kadoorie Biobank aged 30-79 years. The individuals were from 10 diverse areas in China without a history of cancer or liver disease at baseline. Cox regression was used to estimate adjusted hazard ratios (HRs) for incident SLD and death after SLD diagnosis associated with healthy lifestyle factors (smoking, alcohol, physical activity, and central adiposity). Additionally, the contribution of genetic risk for hepatitis B virus (HBV, assessed by genetic variants in major histocompatibility complex, class II, DP/DQ [ HLA - DP / DQ ] genes) was also estimated. RESULTS: Compared with those with 0-1 healthy lifestyle factor, participants with 2, 3, and 4 factors had 12% (HR 0.88 [95% confidence interval [CI] 0.85, 0.92]), 26% (HR 0.74 [95%CI: 0.69, 0.79]), and 44% (HR 0.56 [95%CI: 0.48, 0.65]) lower risks of SLD, respectively. Inverse associations were observed among participants with both low and high genetic risks (HR per 1-point increase 0.83 [95%CI: 0.74, 0.94] and 0.91 [95%CI: 0.82, 1.02], respectively; Pinteraction = 0.51), although with a non-significant trend among those with a high genetic risk. Inverse associations were also observed between healthy lifestyle factors and liver biomarkers regardless of the genetic risk. Despite the limited power, healthy lifestyle factors were associated with a lower risk of death after incident SLD among participants with a low genetic risk (HR 0.59 [95%CI: 0.37, 0.96]). CONCLUSIONS: Lifestyle modification may be beneficial in terms of lowering the risk of SLD regardless of the genetic risk. Moreover, it is also important for improving the prognosis of SLD in individuals with a low genetic risk. Future studies are warranted to examine the impact of healthy lifestyles on SLD prognosis, particularly among individuals with a high genetic risk.

Heterogeneity in the diagnosis and prognosis of ischemic stroke subtypes: 9-year follow-up of 22,000 cases in Chinese adults.

BACKGROUND: Reliable classification of ischemic stroke (IS) etiological subtypes is required in research and clinical practice, but the predictive properties of these subtypes in population studies with incomplete investigations are poorly understood. AIMS: To compare the prognosis of etiologically classified IS subtypes and use machine learning (ML) to classify incompletely investigated IS cases. METHODS: In a 9-year follow-up of a prospective study of 512,726 Chinese adults, 22,216 incident IS cases, confirmed by clinical adjudication of medical records, were assigned subtypes using a modified Causative Classification System for Ischemic Stroke (CCS) (large artery atherosclerosis (LAA), small artery occlusion (SAO), cardioaortic embolism (CE), or undetermined etiology) and classified by CCS as "evident," "probable," or "possible" IS cases. For incompletely investigated IS cases where CCS yielded an undetermined etiology, an ML model was developed to predict IS subtypes from baseline risk factors and screening for cardioaortic sources of embolism. The 5-year risks of subsequent stroke and all-cause mortality (measured using cumulative incidence functions and 1 minus Kaplan-Meier estimates, respectively) for the ML-predicted IS subtypes were compared with etiologically classified IS subtypes. RESULTS: Among 7443 IS subtypes with evident or probable etiology, 66% had SAO, 32% had LAA, and 2% had CE, but proportions of SAO-to-LAA cases varied by regions in China. CE had the highest rates of subsequent stroke and mortality (43.5% and 40.7%), followed by LAA (43.2% and 17.4%) and SAO (38.1% and 11.1%), respectively. ML provided classifications for cases with undetermined etiology and incomplete clinical data (24% of all IS cases; n = 5276), with area under the curves (AUC) of 0.99 (0.99-1.00) for CE, 0.67 (0.64-0.70) for LAA, and 0.70 (0.67-0.73) for SAO for unseen cases. ML-predicted IS subtypes yielded comparable subsequent stroke and all-cause mortality rates to the etiologically classified IS subtypes. CONCLUSION: This study highlighted substantial heterogeneity in prognosis of IS subtypes and utility of ML approaches for classification of IS cases with incomplete clinical investigations.

Association between Fish Consumption and Risk of Chronic Obstructive Pulmonary Disease among Chinese Men and Women: an 11-Year Population-Based Cohort Study.

BACKGROUND: Epidemiological evidence on the relation between fish consumption and chronic obstructive pulmonary disease (COPD) is limited, especially among Chinese. OBJECTIVES: The aim was to explore the prospective association between fish consumption and COPD among a large population-based Chinese cohort. METHODS: The China Kadoorie Biobank recruited over 0.5 million participants from 10 geographically diverse regions across China from 2004 to 2008. Consumption frequency of fish at baseline was assessed by a validated food-frequency questionnaire. A total of 169,188 men and 252,238 women who had no prior COPD or other major chronic diseases at baseline were included in our analyses. Cox proportional hazard models were used to estimate HRs and 95% CIs for fish consumption categories in relation to incident COPD. RESULTS: During a median follow-up of 11.1 y, 11,292 incident COPD cases were documented. Fish consumption was inversely associated with COPD risk among women, with a 17% reduction in risk for participants who consumed fish ≥4 d/wk compared with nonconsumption (HR: 0.83; 95% CI: 0.70, 0.99; P-trend = 0.017), whereas we did not observe such a dose-response relation among men (HR: 0.89; 95% CI: 0.76, 1.05; P-trend = 0.373). The joint analysis showed that COPD risk was 38% and 48% lower in men and women who consumed fish ≥4 d/wk and had a healthy lifestyle [having ≥4 of the following healthy lifestyle factors: not smoking currently; never or rarely drinking alcohol; adequate physical activity; BMI (kg/m2): 18.5-23.9; normal waist circumference; reasonable diet], compared with participants with fish consumption <4 d/wk and an unhealthy lifestyle (≤1 factors). CONCLUSIONS: Higher fish consumption was associated with lower COPD risk among Chinese women but not men. This association was independent of lifestyle factors. Eating adequate fish with an overall healthy lifestyle might help lower the risk of COPD.

Healthy lifestyle and life expectancy at age 30 years in the Chinese population: an observational study.

BACKGROUND: The improvement of life expectancy is one of the aims of the Healthy China 2030 blueprint. We aimed to investigate the extent to which healthy lifestyles are associated with life expectancy in Chinese adults. METHODS: We used the prospective China Kadoorie Biobank (CKB) study to examine the relative risk of mortality associated with individual and combined lifestyle factors (never smoking or quitting not for illness, no excessive alcohol use, being physically active, healthy eating habits, and healthy body shape). Participants with coronary heart disease, stroke, cancer, or missing values for body-mass index were excluded. For analysis of chronic respiratory diseases, participants with chronic obstructive pulmonary disease or asthma were excluded. We estimated the national prevalence of lifestyle factors using data from the China Nutrition and Health Surveillance (CNHS; 2015) and derived mortality rates from the Global Burden of Diseases, Injuries, and Risk Factors Study (2015). All three data sources were combined to estimate the life expectancy of individuals at age 30 years following different levels of lifestyle factors by using the life table method. The cause-specific decomposition of the life expectancy differences was analysed using Arriaga's method. FINDINGS: After the exclusion of CKB participants with coronary heart disease, stroke, cancer, or missing BMI data at baseline, 487 209 were included in the primary analysis. Participants with COPD or asthma at baseline were additionally excluded for chronic respiratory disease-related analysis, leaving 451 233 participants with data available for analysis. Data from 171 127 adults aged 30-84 years from the CNHS 2015 were used to estimate the sex-specific and age-specific prevalence of lifestyle-related factors. There were 42 496 deaths documented over a median follow-up of 11·1 years (IQR 10·2-12·1) in CKB. The adjusted hazard ratios (aHRs) of participants adopting five versus 0-1 low-risk factors was 0·38 (95% CI 0·34-0·43) for all-cause mortality, aHR 0·37 (0·30-0·46) for cardiovascular disease mortality, aHR 0·47 (0·39-0·56) for cancer mortality, and aHR 0·30 (0·14-0·64) for chronic respiratory disease mortality. The life expectancy at age 30 years for individuals with 0-1 low-risk factors was on average 41·7 years (95% CI 41·5-42·0) for men and 47·3 years (46·6-48·0) for women. For individuals with all five low-risk factors, the life expectancy at age 30 was 50·5 years (95% CI 48·5-52·4) for men and 55·4 years (53·5-57·4) for women; meaning a difference of 8·8 years (95% CI 6·8-10·7) for men and 8·1 years (6·5-9·9) for women. The estimated extended life expectancy for men and women was mainly attributable to reduced death from cardiovascular disease (2·4 years [27% of the total extended life expectancy] for men and 3·7 years [46%] for women), cancer (2·6 years [30%] for men and 0·9 years [11%] for women), and chronic respiratory disease (0·6 years [7%] for men and 1·2 years [15%] for women). INTERPRETATION: Our findings suggest that increasing the adoption of these five healthy lifestyle factors through public health interventions could be associated with substantial gains in life expectancy in the Chinese population. FUNDING: National Natural Science Foundation of China, National Key Research and Development Program of China, Kadoorie Charitable Foundation, UK Wellcome Trust.

Conventional and genetic risk factors for chronic Hepatitis B virus infection in a community-based study of 0.5 million Chinese adults.

Despite universal vaccination of newborns, the prevalence of chronic hepatitis virus B (HBV) infection and the associated disease burden remain high among adults in China. We investigated risk factors for chronic HBV infection in a community-based study of 512,726 individuals aged 30-79 years recruited from ten diverse areas during 2004-2008. Multivariable logistic regression was used to estimate odds ratios (ORs) of hepatitis B surface antigen (HBsAg) positivity recorded at baseline by sociodemographic and lifestyle factors, and medical history. In a random subset (n = 69,898) we further assessed the association of 18 single nucleotide polymorphisms (SNPs) previously shown to be associated with HBsAg positivity and development of chronic liver disease (CLD) (1600 cases). Several factors showed strong associations with HBsAg positivity, particularly younger age (< 40 vs. ≥ 60 years: OR 1.48, 95% CI 1.32-1.66), male sex (1.40, 1.34-1.46) and urban residency (1.55, 1.47-1.62). Of the 18 SNPs selected, 17 were associated with HBsAg positivity, and 14 with CLD, with SNPs near HLA-DPB1 were most strongly associated with both outcomes. In Chinese adults a range of genetic and non-genetic factors were associated with chronic HBV infection and CLD, which can inform targeted screening to help prevent disease progression.

Association of Red Meat Consumption, Metabolic Markers, and Risk of Cardiovascular Diseases.

Objective: The metabolic mechanism of harmful effects of red meat on the cardiovascular system is still unclear. The objective of the present study is to investigate the associations of self-reported red meat consumption with plasma metabolic markers, and of these markers with the risk of cardiovascular diseases (CVD). Methods: Plasma samples of 4,778 participants (3,401 CVD cases and 1,377 controls) aged 30-79 selected from a nested case-control study based on the China Kadoorie Biobank were analyzed by using targeted nuclear magnetic resonance to quantify 225 metabolites or derived traits. Linear regression was conducted to evaluate the effects of self-reported red meat consumption on metabolic markers, which were further compared with the effects of these markers on CVD risk assessed by logistic regression. Results: Out of 225 metabolites, 46 were associated with red meat consumption. Positive associations were observed for intermediate-density lipoprotein (IDL), small high-density lipoprotein (HDL), and all sizes of low-density lipoprotein (LDL). Cholesterols, phospholipids, and apolipoproteins within various lipoproteins, as well as fatty acids, total choline, and total phosphoglycerides, were also positively associated with red meat consumption. Meanwhile, 29 out of 46 markers were associated with CVD risk. In general, the associations of metabolic markers with red meat consumption and of metabolic markers with CVD risk showed consistent direction. Conclusions: In the Chinese population, red meat consumption is associated with several metabolic markers, which may partially explain the harmful effect of red meat consumption on CVD.

Dairy consumption and risks of total and site-specific cancers in Chinese adults: an 11-year prospective study of 0.5 million people.

BACKGROUND: Previous studies of primarily Western populations have reported contrasting associations of dairy consumption with certain cancers, including a positive association with prostate cancer and inverse associations with colorectal and premenopausal breast cancers. However, there are limited data from China where cancer rates and levels of dairy consumption differ importantly from those in Western populations. METHODS: The prospective China Kadoorie Biobank study recruited ~0.5 million adults from ten diverse (five urban, five rural) areas across China during 2004-2008. Consumption frequency of major food groups, including dairy products, was collected at baseline and subsequent resurveys, using a validated interviewer-administered laptop-based food frequency questionnaire. To quantify the linear association of dairy intake and cancer risk and to account for regression dilution bias, the mean usual consumption amount for each baseline group was estimated via combining the consumption level at both baseline and the second resurvey. During a mean follow-up of 10.8 (SD 2.0) years, 29,277 incident cancer cases were recorded among the 510,146 participants who were free of cancer at baseline. Cox regression analyses for incident cancers associated with usual dairy intake were stratified by age-at-risk, sex and region and adjusted for cancer family history, education, income, alcohol intake, smoking, physical activity, soy and fresh fruit intake, and body mass index. RESULTS: Overall, 20.4% of participants reported consuming dairy products (mainly milk) regularly (i.e. ≥1 day/week), with the estimated mean consumption of 80.8 g/day among regular consumers and of 37.9 g/day among all participants. There were significant positive associations of dairy consumption with risks of total and certain site-specific cancers, with adjusted HRs per 50 g/day usual consumption being 1.07 (95% CI 1.04-1.10), 1.12 (1.02-1.22), 1.19 (1.01-1.41) and 1.17 (1.07-1.29) for total cancer, liver cancer (n = 3191), female breast cancer (n = 2582) and lymphoma (n=915), respectively. However, the association with lymphoma was not statistically significant after correcting for multiple testing. No significant associations were observed for colorectal cancer (n = 3350, 1.08 [1.00-1.17]) or other site-specific cancers. CONCLUSION: Among Chinese adults who had relatively lower dairy consumption than Western populations, higher dairy intake was associated with higher risks of liver cancer, female breast cancer and, possibly, lymphoma.

The Prospective Associations of Lipid Metabolism-Related Dietary Patterns with the Risk of Diabetes in Chinese Adults.

BACKGROUND: This study aimed to identify lipid metabolism-related dietary patterns with reduced rank regression (RRR) among Chinese adults and examine their associations with incident diabetes. METHODS: We derived lipid metabolism-related dietary patterns using an RRR with 21 food groups as predictors as well as total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides, body mass index (BMI), and waist circumference from the responses of 17,318 participants from the second resurvey of the China Kadoorie Biobank (CKB). The dietary scores were calculated for the entire cohort. We followed up 479,207 participants for diabetes incidence from the baseline and used multivariable Cox regression models to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs). RESULTS: Two lipid metabolism-related dietary patterns were extracted. The dietary pattern-characterized by high intakes of fish, poultry, and other staples as well as fresh fruit and vegetables-was correlated with a higher BMI, waist circumference, and LDL cholesterol. Participants in the highest quintile (Q5) had a 44% increased risk of diabetes incidence when compared with those in the lowest quintile (Q1) (HR = 1.44; 95% CI: 1.31-1.59). CONCLUSIONS: A dietary pattern characterized by high intakes of both animal and plant foods was related to obesity and dyslipidemia and could increase the risk of diabetes incidence.

Diagnostic accuracy of major stroke types in Chinese adults: A clinical adjudication study involving 40,000 stroke cases.

Background: Widespread use of brain imaging in suspected stroke cases in Chinese adults has prompted the need for clinical adjudication studies of stroke types. We conducted a clinical adjudication study to assess the reporting and diagnostic accuracy of major stroke types. Methods: The prospective China Kadoorie Biobank recruited >512,000 adults (mean age 52 years, 59% women) from 10 urban and rural areas in China during 2004-2008, and recorded 45,859 first-ever incident stroke cases during an 11-year follow-up. Medical records were retrieved in ∼85%, and clinical details were recorded using a handheld computer for specialist physician adjudicators who applied conventional WHO clinical criteria for diagnosis of stroke. The positive predictive value (PPV) for reported and adjudicated stroke cases was examined for major stroke types (ischaemic stroke [IS], intracerebral haemorrhage [ICH], subarachnoid haemorrhage [SAH]), calendar year, area, and hospital type. Findings: Of 38,823 cases with retrieved medical records, the PPV for reported strokes was 91%. Among 29,952 adjudicated cases, the PPV for adjudicated cases was 81%, with higher PPV for ICH (n = 3391; 98%) and SAH (364; 98%) than for IS (20,473; 79%). Of 5504 cases with a verified IS diagnosis that was refuted on adjudication, 3763 (68%) had silent lacunar infarcts (LACI). The proportion of cases with silent LACI increased from 7.1% in 2004-2008 to 18.2% in 2016-2017. If cases with silent LACI were classified as IS, as advocated by new International Classification of Diseases (ICD-11) diagnostic criteria for stroke involving imaging and clinical rather than clinical criteria alone, the PPV increased to 93%. Interpretation: While the overall reporting and diagnostic accuracy of stroke types in Chinese adults is high, the recent implementation of new diagnostic criteria for IS has important implications for contemporary clinical practice and research on stroke in Chinese populations. Funding: Kadoorie Charitable Foundation, Hong Kong, China, UK Wellcome Trust (212946/Z/18/Z, 202922/Z/16/Z, 104085/Z/14/Z, 088158/Z/09/Z), Chinese National Natural Science Foundation (91843302), and the National Key Research and Development Program of China (2016YFC0900500, 2016YFC0900501, 2016YFC0900504, 2016YFC1303904). British Heart Foundation, and UK Medical Research Council, and Cancer Research UK.

Natural history of silent lacunar infarction: 10-year follow-up of a community-based prospective study of 0.5 million Chinese adults.

BACKGROUND: Widespread use of brain imaging in China has resulted in an increased prevalence of silent lacunar infarct (LACI) in addition to symptomatic LACI, but their clinical relevance is not fully understood. METHODS: We compared the 5-year risks of recurrent stroke and all-cause mortality for silent LACI vs symptomatic LACI in a prospective study of 489,597 Chinese adults with no history of stroke or ischemic heart disease at baseline. Data on recurrent stroke and all-cause mortality were obtained by linkage with local stroke and mortality registries and health insurance records for all hospital admissions. FINDINGS: Among 12,150 cases with an adjudicated diagnosis of first-ever LACI, 4,134 (34%) had silent LACI and 8,016 (66%) had symptomatic LACI. All cases had brain imaging, but only 33% of silent LACI and 40% of symptomatic LACI cases had brain magnetic resonance imaging (MRI). The standardized event rates for silent LACI were 2-fold greater in urban than rural areas, but the ratios of silent LACI vs symptomatic LACI were similar in all areas. Cases with silent LACI vs symptomatic LACI had comparable 5-year risks of recurrent stroke (38% vs 43%) and all-cause mortality (11% vs 14%), respectively. For both silent and symptomatic LACI cases, most cases of recurrent stroke had non-LACI (70% vs 72%). While the relative risks of recurrent stroke did not differ by age, sex and area, the absolute risks of all-cause mortality varied by sex, age and area. INTERPRETATION: The prognosis of cases with silent LACI was comparable with symptomatic LACI, and the results highlight the need for further randomized trials assessing the efficacy and safety of established treatments for ischemic stroke in cases with silent LACI. FUNDING: Wellcome Trust (212946/Z/18/Z, 202922/Z/16/Z, 104085/Z/14/Z, 088158/Z/09/Z) and National Key Research and Development Program of China (2016YFC0900500, 2016YFC0900501, 2016YFC0900504, 2016YFC1303904) and National Natural Science Foundation of China (91843302); UK Medical Research Council (MC_UU_00017/1,MC_UU_12026/2 MC_U137686851), Cancer Research UK (C16077/A29186; C500/A16896) and British Heart Foundation (CH/1996001/9454). ZH was supported West China Hospital, Sichuan University (ZYGD18009 and 2016YFC1300505) for a visiting scholarship to the University of Oxford, UK, during 2018-19.

Association of CETP Gene Variants With Risk for Vascular and Nonvascular Diseases Among Chinese Adults.

Importance: Increasing levels of high-density lipoprotein (HDL) cholesterol through pharmacologic inhibition of cholesteryl ester transfer protein (CETP) is a potentially important strategy for prevention and treatment of cardiovascular disease (CVD). Objective: To use genetic variants in the CETP gene to assess potential risks and benefits of lifelong lower CETP activity on CVD and other outcomes. Design, Setting, and Participants: This prospective biobank study included 151 217 individuals aged 30 to 79 years who were enrolled from 5 urban and 5 rural areas of China from June 25, 2004, through July 15, 2008. All participants had baseline genotype data, 17 854 of whom had lipid measurements and 4657 of whom had lipoprotein particle measurements. Median follow-up of 9.2 years (interquartile range, 8.2-10.1 years) was completed January 1, 2016, through linkage to health insurance records and death and disease registries. Exposures: Five CETP variants, including an East Asian loss-of-function variant (rs2303790), combined in a genetic score weighted to associations with HDL cholesterol levels. Main Outcomes and Measures: Baseline levels of lipids and lipoprotein particles, cardiovascular risk factors, incidence of carotid plaque and predefined major vascular and nonvascular diseases, and a phenome-wide range of diseases. Results: Among the 151 217 individuals included in this study (58.4% women and 41.6% men), the mean (SD) age was 52.3 (10.9) years. Overall, the mean (SD) low-density lipoprotein (LDL) cholesterol level was 91 (27) mg/dL; HDL cholesterol level, 48 (12) mg/dL. CETP variants were strongly associated with higher concentrations of HDL cholesterol (eg, 6.1 [SE, 0.4] mg/dL per rs2303790-G allele; P = 9.4 × 10-47) but were not associated with lower LDL cholesterol levels. Within HDL particles, cholesterol esters were increased and triglycerides reduced, whereas within very low-density lipoprotein particles, cholesterol esters were reduced and triglycerides increased. When scaled to 10-mg/dL higher levels of HDL cholesterol, the CETP genetic score was not associated with occlusive CVD (18 550 events; odds ratio [OR], 0.98; 95% CI, 0.91-1.06), major coronary events (5767 events; OR, 1.08; 95% CI, 0.95-1.22), myocardial infarction (3118 events; OR, 1.14; 95% CI, 0.97-1.35), ischemic stroke (13 759 events; OR, 0.94; 95% CI, 0.86-1.02), intracerebral hemorrhage (6532 events; OR, 0.94; 95% CI, 0.83-1.06), or other vascular diseases or carotid plaque. Similarly, rs2303790 was not associated with any vascular diseases or plaque. No associations with nonvascular diseases were found other than an increased risk for eye diseases with rs2303790 (4090 events; OR, 1.43; 95% CI, 1.13-1.80; P = .003). Conclusions and Relevance: CETP variants were associated with altered HDL metabolism but did not lower LDL cholesterol levels and had no significant association with risk for CVD. These results suggest that in the absence of reduced LDL cholesterol levels, increasing HDL cholesterol levels by inhibition of CETP may not confer significant benefits for CVD.

Fresh fruit consumption in relation to incident diabetes and diabetic vascular complications: A 7-y prospective study of 0.5 million Chinese adults.

BACKGROUND: Despite the well-recognised health benefits of fresh fruit consumption, substantial uncertainties remain about its potential effects on incident diabetes and, among those with diabetes, on risks of death and major vascular complications. METHODS AND FINDINGS: Between June 2004 and July 2008, the nationwide China Kadoorie Biobank study recruited 0.5 million adults aged 30-79 (mean 51) y from ten diverse localities across China. During ~7 y of follow-up, 9,504 new diabetes cases were recorded among 482,591 participants without prevalent (previously diagnosed or screen-detected) diabetes at baseline, with an overall incidence rate of 2.8 per 1,000 person-years. Among 30,300 (5.9%) participants who had diabetes at baseline, 3,389 deaths occurred (overall mortality rate 16.5 per 1,000), along with 9,746 cases of macrovascular disease and 1,345 cases of microvascular disease. Cox regression yielded adjusted hazard ratios (HRs) associating each disease outcome with self-reported fresh fruit consumption, adjusting for potential confounders such as age, sex, region, socio-economic status, other lifestyle factors, body mass index, and family history of diabetes. Overall, 18.8% of participants reported consuming fresh fruit daily, and 6.4% never/rarely (non-consumers), with the proportion of non-consumers about three times higher in individuals with previously diagnosed diabetes (18.9%) than in those with screen-detected diabetes (6.7%) or no diabetes (6.0%). Among those without diabetes at baseline, higher fruit consumption was associated with significantly lower risk of developing diabetes (adjusted HR = 0.88 [95% CI 0.83-0.93] for daily versus non-consumers, p < 0.001, corresponding to a 0.2% difference in 5-y absolute risk), with a clear dose-response relationship. Among those with baseline diabetes, higher fruit consumption was associated with lower risks of all-cause mortality (adjusted HR = 0.83 [95% CI 0.74-0.93] per 100 g/d) and microvascular (0.72 [0.61-0.87]) and macrovascular (0.87 [0.82-0.93]) complications (p < 0.001), with similar HRs in individuals with previously diagnosed and screen-detected diabetes; estimated differences in 5-y absolute risk between daily and non-consumers were 1.9%, 1.1%, and 5.4%, respectively. The main limitation of this study was that, owing to its observational nature, we could not fully exclude the effects of residual confounding. CONCLUSION: In this large epidemiological study in Chinese adults, higher fresh fruit consumption was associated with significantly lower risk of diabetes and, among diabetic individuals, lower risks of death and development of major vascular complications.

Burden of carotid artery atherosclerosis in Chinese adults: Implications for future risk of cardiovascular diseases.

Background Population-based studies of ultrasound measures of carotid atherosclerosis are informative about future risks of cardiovascular disease. Design Cross-sectional studies of carotid artery atherosclerosis in 24,822 Chinese adults from the China Kadoorie Biobank and 2579 Europeans from the UK Biobank. Methods Mean intima-media thickness of the common carotid arteries and presence of carotid artery plaque were examined in the China Kadoorie Biobank study. The carotid intima-media thickness (cIMT) findings in Chinese (mean age 59 years) were compared with a European population (mean age 62 years). Results Overall, the mean cIMT in Chinese was 0.70 mm (SD 0.16) and increased with age by 0.08 mm (SE 0.008) per 10-years older age. About 31% of the Chinese had carotid plaques and the prevalence varied 10-fold with age (6% at 40-49 to 63% at 70-89 years) and four-fold by region (range, 14%-57%). After adjustment for age, sex and region, plaque prevalence was higher in smokers than in non-smokers (36% vs. 28%) and two-fold higher in individuals with systolic blood pressure ≥160 mmHg than those with systolic blood pressure <120 mmHg (44% vs. 22%) in the China Kadoorie Biobank study. Mean cIMT was similar in the younger Chinese and European adults, but increased more steeply with age in the Chinese ( p = 0.002). Conclusions About one-third of Chinese adults had carotid plaques. The rate of progression of carotid atherosclerosis with age was more extreme in the Chinese compared with the European population, highlighting the need for more intensive strategies for cardiovascular disease prevention in China.

Regional variations in the prevalence and misdiagnosis of air flow obstruction in China: baseline results from a prospective cohort of the China Kadoorie Biobank (CKB).

BACKGROUND: Despite the great burden of chronic respiratory diseases in China, few large multicentre, spirometry-based studies have examined its prevalence, rate of underdiagnosis regionally or the relevance of socioeconomic and lifestyle factors. METHODS: We analysed data from 512 891 adults in the China Kadoorie Biobank, recruited from 10 diverse regions of China during 2004-2008. Air flow obstruction (AFO) was defined by the lower limit of normal criteria based on spirometry-measured lung function. The prevalence of AFO was analysed by region, age, socioeconomic status, body mass index (BMI) and smoking history and compared with the prevalence of self-reported physician-diagnosed chronic bronchitis or emphysema (CB/E) and its symptoms. FINDINGS: The prevalence of AFO was 7.3% in men (range 2.5-18.2%) and 6.4% in women (1.5-18.5%). Higher prevalence of AFO was associated with older age (p<0.0001), lower income (p<0.0001), poor education (p<0.001), living in rural regions (p<0.001), those who started smoking before the age of 20 years (p<0.001) and low BMI (p<0.001). Compared with self-reported diagnosis of CB/E, 88.8% of AFO was underdiagnosed; underdiagnosis proportion was highest in 30-39-year olds (96.7%) compared with the 70+ age group (81.1%), in women (90.7%), in urban areas (89.4%), in people earning 5K-10 K ¥ monthly (90.3%) and in those with middle or high school education (92.6%). INTERPRETATION: In China, the burden of AFO based on spirometry was high and significantly greater than that estimated based on self-reported physician-diagnosed CB/E, especially in rural areas, reflecting major issues with diagnosis of AFO that will impact disease treatment and management.