Poly(phenylalanine) and poly(3,4-dihydroxy-L-phenylalanine): Promising biomedical materials for building stimuli-responsive nanocarriers.

Cancer is a serious threat to human health because of its high annual mortality rate. It has attracted significant attention in healthcare, and identifying effective strategies for the treatment and relief of cancer pain requires urgency. Drug delivery systems (DDSs) offer the advantages of excellent efficacy, low cost, and low toxicity for targeting drugs to tumor sites. In recent decades, copolymer carriers based on poly(phenylalanine) (PPhe) and poly(3,4-dihydroxy-L-phenylalanine) (PDopa) have been extensively investigated owing to their good biocompatibility, biodegradability, and controllable stimulus responsiveness, which have resulted in DDSs with loading and targeted delivery capabilities. In this review, we introduce the synthesis of PPhe and PDopa, highlighting the latest proposed synthetic routes and comparing the differences in drug delivery between PPhe and PDopa. Subsequently, we summarize the various applications of PPhe and PDopa in nanoscale-targeted DDSs, providing a comprehensive analysis of the drug release behavior based on different stimulus-responsive carriers using these two materials. In the end, we discuss the challenges and prospects of polypeptide-based DDSs in the field of cancer therapy, aiming to promote their further development to meet the growing demands for treatment.

Association of high-density lipoprotein cholesterol with all-cause and cause-specific mortality in a Chinese population of 3.3 million adults: a prospective cohort study.

Background: High-density lipoprotein cholesterol (HDL-C) has been inversely associated with cardiovascular disease (CVD) risk, but recent evidence suggests that extremely high levels of HDL-C are paradoxically related to increased CVD incidence and mortality. This study aimed to comprehensively examine the associations of HDL-C with all-cause and cause-specific mortality in a Chinese population. Methods: The China Health Evaluation And risk Reduction through nationwide Teamwork (ChinaHEART) project included 3,397,547 participants aged 35-75 years with a median follow-up of 3.9 years. Baseline HDL-C levels were measured, and mortality data was ascertained from the National Mortality Surveillance System and Vital Registration of Chinese Center for Disease Control and Prevention. Findings: This study found U-shaped associations of HDL-C with all-cause, cardiovascular and cancer mortality. When compared with the groups with the lowest risk, the adjusted hazard ratios (95% CIs) for HDL-C <30 mg/dL was 1.23 (1.17-1.29), 1.33 (1.23-1.45) and 1.18 (1.09-1.28) for all-cause, CVD and cancer mortality, respectively. For HDL-C >90 mg/dL, the corresponding HR (95% CIs) was 1.10 (1.05-1.15), 1.09 (1.01-1.18) and 1.11 (1.03-1.19). Similar U-shaped patterns were also found in associations of HDL-C with ischemic heart disease, ischemic stroke, and liver cancer. About 3.25% of all-cause mortality could be attributed to abnormal levels of HDL-C. The major contributor to mortality was ischemic heart disease (16.06 deaths per 100,000 persons, 95% UI: 10.30-22.67) for HDL-C <40 mg/dL and esophageal cancer (2.29 deaths per 100,000 persons, 95% UI: 0.57-4.77) for HDL-C >70 mg/dL. Interpretation: Both low and high HDL-C were associated with increased mortality risk. We recommended 50-79 mg/dL as the optimal range of HDL-C among Chinese adults. Individuals with dyslipidemia might benefit from proper management of both low and high HDL-C. Funding: The CAMS Innovation Fund for Medical Science (2021-1-I2M-011), the National High Level Hospital Clinical Research Funding (2022-GSP-GG-4), the Ministry of Finance of China and National Health Commission of China, and the 111 Project from the Ministry of Education of China (B16005), the Program for Guangdong Introducing Innovative and Enterpreneurial Teams (2019ZT08Y481), Sanming Project of Medicine in Shenzhen (SZSM201811096), the Young Talent Program of the Academician Fund, Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen (YS-2022-006) and Guangdong Basic and Applied Basic Research Foundation (2023A1515010076 & 2021A1515220173).

Bio-Inspired Drug Delivery Systems: From Synthetic Polypeptide Vesicles to Outer Membrane Vesicles.

Nanomedicine is a broad field that focuses on the development of nanocarriers to deliver specific drugs to targeted sites. A synthetic polypeptide is a kind of biomaterial composed of repeating amino acid units that are linked by peptide bonds. The multiplied amphiphilicity segment of the polypeptide could assemble to form polypeptide vesicles (PVs) under suitable conditions. Different from polypeptide vesicles, outer membrane vesicles (OMVs) are spherical buds of the outer membrane filled with periplasmic content, which commonly originate from Gram-negative bacteria. Owing to their biodegradability and excellent biocompatibility, both PVs and OMVs have been utilized as carriers in delivering drugs. In this review, we discuss the recent drug delivery research based on PVs and OMVs. These related topics are presented: (1) a brief introduction to the production methods for PVs and OMVs; (2) a thorough explanation of PV- and OMV-related applications in drug delivery including the vesicle design and biological assessment; (3) finally, we conclude with a discussion on perspectives and future challenges related to the drug delivery systems of PVs and OMVs.

Trends in smoking prevalence in urban and rural China, 2007 to 2018: Findings from 5 consecutive nationally representative cross-sectional surveys.

BACKGROUND: Tobacco smoking is a leading cause of premature death in China, especially among adult men. Since the implementation of the Framework Convention on Tobacco Control in 2005, nationwide tobacco control has been strengthened, but its long-term impact on smoking prevalence is unclear. METHODS AND FINDINGS: Five nationally representative surveys of the China Chronic Disease and Risk Factor Surveillance (CCDRFS) were conducted in 2007, 2010, 2013, 2015, and 2018. A total of 624,568 adults (278,605 men and 345,963 women) aged 18 to 69 years were randomly selected from 31 provinces (or equivalent) in China. Temporal changes in smoking prevalence and patterns (e.g., percentages of those smoking manufactured cigarettes, amount smoked, and age at smoking initiation) were analyzed, overall and by sex, urban or rural residence, year of birth, education and occupation, using linear regression methods. Among men, the standardized prevalence of current smoking decreased from 58.4% (95% confidence interval [CI]: 56.1 to 60.7) to 50.8% (95% CI: 49.1 to 52.5, p < 0.001) between 2007 and 2018, with annual decrease more pronounced in urban (55.7% [95% CI: 51.2 to 60.3] to 46.3% [95% CI: 43.7 to 49.0], p < 0.001) than rural men (59.9% [95% CI: 57.5 to 62.4] to 54.6% [95% CI: 52.6 to 56.6], p = 0.05) and in those born before than after 1980. Among rural men born after 1990, however, the prevalence increased from 40.2% [95% CI: 34.0 to 46.4] to 52.1% ([95% CI: 45.7 to 58.5], p = 0.007), with the increase taking place mainly before 2015. Among women, smoking prevalence remained extremely low at around 2% during 2007 to 2018. No significant changes of current smoking prevalence (53.9% to 50.8%, p = 0.22) were observed in male patients with at least 1 of major chronic diseases (e.g., hypertension, diabetes, myocardial infarction, stroke, chronic obstructive pulmonary disease (COPD)). In 2018, 25.6% of adults aged ≥18 years smoked, translating into an estimated 282 million smokers (271 million men and 11 million women) in China. Across 31 provinces, smoking prevalence varied greatly. The 3 provinces (Yunnan, Guizhou, and Hunan) with highest per capita tobacco production had highest smoking prevalence in men (68.0%, 63.4%, and 61.5%, respectively), while lowest prevalence was observed in Shanghai (34.8%). Since the children and teenage groups were not included in the surveys, we could not assess the smoking trends among youths. Furthermore, since the smoking behavior was self-reported, the smoking prevalence could be underestimated due to reporting bias. CONCLUSIONS: In this study, we observed that the smoking prevalence has decreased steadily in recent decades in China, but there were diverging trends between urban and rural areas, especially among men born after 1980. Future tobacco control strategies should target rural young men, regions with high tobacco production, and patients suffering from chronic diseases.

Cardiovascular risk factors in China: a nationwide population-based cohort study.

BACKGROUND: It is estimated that 4 million deaths are due to cardiovascular diseases each year in China. Comprehensive understanding about modifiable risk factors and how the risk differs across regions is needed to inform public health policies. We aimed to examine the geographical profile of cardiovascular disease risk across China. METHODS: In this study, we analysed data from a nationwide, population-based screening project, which covered 152 rural counties and 100 urban districts from 31 provinces in China. Between Sept 1, 2015, and Nov 30, 2019, standardised measurements were taken from participants aged 35-75 years who had lived in the region for at least 6 of the preceding 12 months to collect information on blood pressure, blood lipids, blood glucose, physical activity, tobacco smoking, alcohol use, overweight or obesity, and intake frequencies of fruits, vegetables, whole grains, legumes, and red meat. Individuals with a high risk of cardiovascular disease were identified according to medical history and WHO risk prediction charts. FINDINGS: 983 476 individuals were included in this study. Among the participants included, 10·3% (95% CI 10·2-10·3) had a high cardiovascular disease risk after standardising age and sex, with a range of 3·1-24·9% across counties or districts. Among the seven regions in mainland China, the prevalence of high risk of cardiovascular disease was relatively high in northeast China (12·6% [12·4-12·8]) and north China (11·4% [11·3-11·6]), whereas it was low in south China (8·0% [7·8-8·2]). The geographical profiles of the 12 major cardiovascular disease risk factors were different. We found that the regions with high cardiovascular disease risk were facing challenges such as obesity and high blood pressure (north China) and consumption of unhealthy non-staple food (low intake of fruits and vegetables or high intake of red meat; northeast China). By contrast, south China-the region with the lowest cardiovascular disease risk-had the highest prevalence of unhealthy staple food (low intake of whole grains and beans), abnormal metabolism (glucose and lipid), and low physical activity in the country. INTERPRETATION: Risk for cardiovascular diseases varies geographically, and the major contributing risk factors are different across regions in China. Hence, geographically targeted interventions are needed to mitigate the risk and reduce the burden in such a vast country. FUNDING: Ministry of Science and Technology, Ministry of Finance, and National Health Commission of China.

Hemodynamic characteristics in preeclampsia women during cesarean delivery after spinal anesthesia with ropivacaine.

BACKGROUND: Very few studies have been published on the hemodynamic changes associated with spinal anesthesia induced with ropivacaine during cesarean deliveries in preeclamptic women. AIM: To record and analyze hemodynamic data in women with preeclampsia undergoing cesarean delivery after spinal anesthesia induced with ropivacaine. METHODS: Ten eligible women with preeclampsia were enrolled in this prospective observational study. Spinal anesthesia was performed with 2.4 mL of 0.5% ropivacaine. Hemodynamic changes were then analyzed at multiple time points. The hemodynamic responses to vasopressor interventions and uterotonic agents, as well as maternal and neonatal outcomes were also recorded. RESULTS: Stable hemodynamic trends were observed in this study. Cardiac output (CO) and stroke volume increased mildly during surgery. In contrast, mean arterial pressure and systemic vascular resistance showed a moderate decrease from induction until the end of surgery. Central venous pressure dramatically increased after delivery. Oxytocin administration was associated with the most significant hemodynamic fluctuations during surgery, namely, an increase in CO and heart rate. Phenylephrine intervention was only required in three patients, and caused an increase in mean arterial pressure and systemic vascular resistance along with a decrease in heart rate, stroke volume, and CO. No maternal and neonatal complications were observed during this study, except transient episodes of hypotension. CONCLUSION: Spinal anesthesia for caesarian delivery with ropivacaine in women with preeclampsia is linked to modest hemodynamic changes of no clinical significance in this study. Careful cardiovascular monitoring is still recommended, particularly after the delivery of the fetus or the use of oxytocin.

Geographical variations in cardiovascular health in China: A nationwide population-based survey of 74,726 adults.

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.

Prevalence of Smoking and Knowledge About the Hazards of Smoking Among 170 000 Chinese Adults, 2013-2014.

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.

The influence of diet and behaviour on metabolic syndrome and the prevalence of metabolic syndrome according to different definitions in west China.

BACKGROUND AND OBJECTIVES: This study investigated the updated prevalence of metabolic syndrome among adults in West China and the influence of diet and behaviour on metabolic syndrome. METHODS AND STUDY DESIGN: A cross-sectional survey was conducted from 2013-2014, and multi-stage stratified clustering sampling was applied in 12 counties of Sichuan province. Data regarding metabolic syndrome and style risk factors were collected through interviewer-administered questionnaires, and physical measurements were recorded following a standardized protocol. Logistic regression models were used to explore the association between metabolic syndrome and its risk factors. RESULTS: A total of 7,131 adults participated. The prevalence of metabolic syndrome was 16.9% and 23.8% according to the International Diabetes Federation criteria and the consensus definition, respectively. The International Diabetes Federation criteria failed to identify 28.8% of the participants identified by the consensus definition. The odds ratios (ORs) of suffering from Metabolic syndrome in people eating pork every week compared with at lower frequencies, people eating more than 100 g of red meat/day, people with more sedentary behaviour per day, and people consuming at least 20 cigarettes/day were 1.76 (1.09-2.84), 1.28 (1.01- 1.62), 1.03 (0.99-1.07), and 1.46 (1.12-1.92), respectively, according to the consensus definition, and 1.51 (1.09- 2.10), 1.4 (1.14-1.72), 1.07 (1.02-1.13), and 1.5 (1.16-1.94), respectively, based on the International Diabetes Federation criteria. CONCLUSIONS: The International Diabetes Federation criteria were less sensitive in identifying metabolic syndrome than the consensus definition. More sedentary behaviour, smoking >=20 cigarettes per day, and a higher frequency of pork intake increased the risk of metabolic syndrome in this study.

Public knowledge of cardiovascular disease and response to acute cardiac events in three cities in China and India.

OBJECTIVE: To inform interventions targeted towards reducing mortality from acute myocardial infarction (AMI) and sudden cardiac arrest in three megacities in China and India, a baseline assessment of public knowledge, attitudes and practices was performed. METHODS: A household survey, supplemented by focus group and individual interviews, was used to assess public understanding of cardiovascular disease (CVD) risk factors, AMI symptoms, cardiopulmonary resuscitation (CPR) and automated external defibrillators (AEDs). Additionally, information was collected on emergency service utilisation and associated barriers to care. RESULTS: 5456 household surveys were completed. Hypertension was most commonly recognised among CVD risk factors in Beijing and Shanghai (68% and 67%, respectively), while behavioural risk factors were most commonly identified in Bangalore (smoking 91%; excessive alcohol consumption 64%). Chest pain/discomfort was reported by at least 60% of respondents in all cities as a symptom of AMI, but 21% of individuals in Bangalore could not name a single symptom. In Beijing, Shanghai and Bangalore, 26%, 15% and 3% of respondents were trained in CPR, respectively. Less than one-quarter of participants in all cities recognised an AED. Finally, emergency service utilisation rates were low, and many individuals expressed concern about the quality of prehospital care. CONCLUSIONS: Overall, we found low to modest knowledge of CVD risk factors and AMI symptoms, infrequent CPR training and little understanding of AEDs. Interventions will need to focus on basic principles of CVD and its complications in order for patients to receive timely and appropriate care for acute cardiac events.

Geographical Inequality in Tobacco Control in China: Multilevel Evidence From 98†058 Participants.

Background: We investigated the spatial patterning and correlates of tobacco smoking, exposure to secondhand smoke, smoking in public places, workplace smoking prohibition, pro- and counter-tobacco advertisements in mainland China. Methods: Choropleth maps and multilevel models were used to assess geographical variation and correlates of the aforementioned outcome variables for 98 058 participants across 31 provinces of China in 2010. Results: Current tobacco smoking prevalence was higher in the central provinces for men and in the north eastern provinces and Tibet for women. Secondhand smoke was higher for both genders in Qinghai and Hunan provinces. Workplace tobacco restrictions was higher in the north and east, whereas smoking in public places was more common in the west, central, and far northeast. Protobacco advertising was observed in public places more often by men (18.5%) than women (13.1%). Men (35.5%) were also more likely to sight counter-tobacco advertising in public places than women (30.1%). Awareness of workplace tobacco restrictions was more common in affluent urban areas. Lower awareness of workplace tobacco restrictions was in less affluent urban and rural areas. Sightings of tobacco smoking in public places was highest in restaurants (80.4% for men, 75.0% for women) and also commonly reported in less affluent urban and rural areas. Exposure to secondhand smoke was lower among women (but not men) where workplace tobacco restrictions was more common and higher regardless of gender in areas where smoking in public places was more commonly observed. Conclusions: Geographical and gender-sensitive targeting of tobacco prevention and control initiatives are warranted. Implications: This study demonstrates spatial patterning of China's 300 million smokers across the country that are different for men and women. Many of the factors that influence tobacco use, such as pro- and counter-advertising, also vary geographically. Workplace smoking restrictions are more commonly reported among individuals with higher educational attainment, but this not does appear to translate into reduced exposure to secondhand smoke. There is a need to intervene in other contexts, especially in restaurants and on public transport. Geographically targeted and gender-sensitive policy is required to advance effective tobacco control and prevention of noncommunicable diseases across all of China.

Can China achieve a one-third reduction in premature mortality from non-communicable diseases by 2030?

BACKGROUND: The United Nation's Sustainable Development Goals for 2030 include reducing premature mortality from non-communicable diseases (NCDs) by one third. To assess the feasibility of this goal in China, we projected premature mortality in 2030 of NCDs under different risk factor reduction scenarios. METHODS: We used China results from the Global Burden of Disease Study 2013 as empirical data for projections. Deaths between 1990 and 2013 for cardiovascular disease (CVD), diabetes, chronic respiratory disease, cancer, and other NCDs were extracted, along with population numbers. We disaggregated deaths into parts attributable and unattributable to high systolic blood pressure (SBP), smoking, high body mass index (BMI), high total cholesterol, physical inactivity, and high fasting glucose. Risk factor exposure and deaths by NCD category were projected to 2030. Eight simulated scenarios were also constructed to explore how premature mortality will be affected if the World Health Organization's targets for risk factors reduction are achieved by 2030. RESULTS: If current trends for each risk factor continued to 2030, the total premature deaths from NCDs would increase from 3.11 million to 3.52 million, but the premature mortality rate would decrease by 13.1%. In the combined scenario in which all risk factor reduction targets are achieved, nearly one million deaths among persons 30 to 70 years old due to NCDs would be avoided, and the one-third reduction goal would be achieved for all NCDs combined. More specifically, the goal would be achieved for CVD and chronic respiratory diseases, but not for cancer and diabetes. Reduction in the prevalence of high SBP, smoking, and high BMI played an important role in achieving the goals. CONCLUSIONS: Reaching the goal of a one-third reduction in premature mortality from NCDs is possible by 2030 if certain targets for risk factor intervention are reached, but more efforts are required to achieve risk factor reduction.

National incidence of traumatic fractures in China: a retrospective survey of 512 187 individuals.

BACKGROUND: Traumatic fractures place a substantial burden on health-care systems worldwide. Although detailed information about incidence, distribution, and risk factors for traumatic fractures is vital for planning and prevention, in China, national data are unavailable. We aimed to do an up-to-date national survey on the population-weighted incidence of traumatic fractures in China. METHODS: The China National Fracture Study (CNFS) was a retrospective epidemiological study that recruited a nationally representative sample from eight provinces, 24 urban cities, and 24 rural counties in China using stratified random sampling and the probability proportional to size method. All eligible household members who had lived in their current residence for 6 months or longer were personally interviewed by trained research teams about traumatic fractures of the trunk, arms, or legs (not including the skull, sternum, and ribs) that had occurred in 2014. Telephone surveys were used for participants who were non-contactable after repeated visits. Fracture cases were verified by clinical records, medical history, and radiographs by orthopaedic surgeons and radiologists. We estimated incidence rates for traumatic fractures for the overall population and for subgroups by age and sex, as well as by demographic factors such as ethnic origin, occupation, geographical region, and residency category. We also studied potential associations between fractures and various factors of interest, such as age, ethnic origin, education, smoking, alcohol drinking, sleep time per day, and history of previous fracture. Data were weighted during statistical analysis to ascertain the national incidence rate. This study is registered with the Chinese Clinical Trial Registry, number ChiCTR-EPR-15005878. FINDINGS: Between Jan 19, 2015, and May 16, 2015, 535 836 individuals were selected and invited to participate in the study. Questionnaires from 23 649 (4%) individuals were excluded due to missing items, insufficient responses, or logical errors. Following exclusions, 512 187 (96%) individuals participated in the CNFS, consisting of 259 649 (51%) boys and men and 252 538 (49%) girls and women. Of these individuals, 1763 individuals had experienced traumatic fractures during 2014 (n=1833). The population-weighted incidence rate of traumatic fractures of the trunk, arms, or legs was 3·21 (95% CI 2·83-3·59) per 1000 population in 2014 (3·65, 3·12-4·18 in men and 2·75, 2·46-3·04 in women). For all ages, sleeping less than 7 h per day was identified as a risk factor for traumatic fractures. We identified previous fracture history as a risk factor for adults aged 15 years and older. Alcohol consumption incurred a risk effect for men aged 15 years and older and women aged 15-64 years. INTERPRETATION: Our results provide detailed information about fracture incidence, distribution, and risk factors, which can now be used as an up-to-date clinical evidence base for national health-care planning and preventive efforts in China and elsewhere. Specific public health policies that focus on decreasing alcohol consumption, prohibiting drunk driving, promoting smoking cessation, and encouraging individuals to obtain sufficient sleep and maintain a healthy bodyweight should be urgently implemented to help reduce the risk of traumatic fractures. FUNDING: The Hebei Province Medical Science Special Major Projects Research Fund.

Prevalence, Incidence, and Mortality of Stroke in China: Results from a Nationwide Population-Based Survey of 480 687 Adults.

BACKGROUND: China bears the biggest stroke burden in the world. However, little is known about the current prevalence, incidence, and mortality of stroke at the national level, and the trend in the past 30 years. METHODS: In 2013, a nationally representative door-to-door survey was conducted in 155 urban and rural centers in 31 provinces in China, totaling 480 687 adults aged ≥20 years. All stroke survivors were considered as prevalent stroke cases at the prevalent time (August 31, 2013). First-ever strokes that occurred during 1 year preceding the survey point-prevalent time were considered as incident cases. According to computed tomography/MRI/autopsy findings, strokes were categorized into ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and stroke of undetermined type. RESULTS: Of 480 687 participants, 7672 were diagnosed with a prevalent stroke (1596.0/100 000 people) and 1643 with incident strokes (345.1/100 000 person-years). The age-standardized prevalence, incidence, and mortality rates were 1114.8/100 000 people, 246.8 and 114.8/100 000 person-years, respectively. Pathological type of stroke was documented by computed tomography/MRI brain scanning in 90% of prevalent and 83% of incident stroke cases. Among incident and prevalent strokes, ischemic stroke constituted 69.6% and 77.8%, intracerebral hemorrhage 23.8% and 15.8%, subarachnoid hemorrhage 4.4% and 4.4%, and undetermined type 2.1% and 2.0%, respectively. Age-specific stroke prevalence in men aged ≥40 years was significantly greater than the prevalence in women (P<0.001). The most prevalent risk factors among stroke survivors were hypertension (88%), smoking (48%), and alcohol use (44%). Stroke prevalence estimates in 2013 were statistically greater than those reported in China 3 decades ago, especially among rural residents (P=0.017). The highest annual incidence and mortality of stroke was in Northeast (365 and 159/100 000 person-years), then Central areas (326 and 154/100 000 person-years), and the lowest incidence was in Southwest China (154/100 000 person-years), and the lowest mortality was in South China (65/100 000 person-years) (P<0.002). CONCLUSIONS: Stroke burden in China has increased over the past 30 years, and remains particularly high in rural areas. There is a north-to-south gradient in stroke in China, with the greatest stroke burden observed in the northern and central regions.

Prevalence and patterns of tobacco smoking among Chinese adult men and women: findings of the 2010 national smoking survey.

BACKGROUND: China consumes about 40% of the world's cigarettes, predominantly by men, following a large increase in recent decades. We assess sex-specific prevalence and changing patterns of smoking in Chinese adults in the current decade. METHODS: A nationally representative survey of smoking was conducted in 2010 among 100 000 Chinese adults aged ≥18 years, using a multistage stratified cluster sampling method. Information on smoking frequency, type, amount, age started and quitting was collected. Sex-specific standardised prevalence and means were analysed and compared with estimates in the 1996 national survey. RESULTS: In Chinese men aged ≥18, 62.4% were ever-smokers in 2010, including 54.0% current smokers and 8.4% ex-smokers. The smoking prevalence was higher in rural than in urban men (63.9% vs 58.4%). In younger men, the age to start smoking was earlier and exclusive cigarette use was much higher. Among current smokers, only 17.3% intended to quit. Compared with a similar survey in 1996 among adults aged 30-69, more smokers had quit in 2010 than in 1996 (11.0% vs 4.2%), but the number of cigarettes smoked per current smoker was higher (17.9 vs 15.2). In Chinese women, only 3.4% ever smoked and there has been a large intergenerational decrease in smoking uptake rates. In 2010, there were 318 million current smokers in China, consuming an estimated 1740 billion cigarettes. CONCLUSIONS: The prevalence of smoking remained extremely high in men, but low and falling in Chinese women. Tobacco smoking remains an important public health issue in China, and stronger and more efficient tobacco control is urgently needed.

The cardiometabolic risk profile of Chinese adults with diabetes: A nationwide cross-sectional survey.

AIMS: We aimed to estimate the cardiometabolic risk profile of Chinese adults with diabetes. METHODS: We conducted a nationally representative survey of 98,658 noninstitutionalized Chinese adults aged ≥18years using a complex, multistage, probability sampling design in 2010. Diabetes was defined in 12,607 participants according to the 2010 American Diabetes Association criteria. All estimates were weighted to represent the overall Chinese adults with diabetes. RESULTS: Among Chinese adults with diabetes, the weighted prevalence estimates were 47.5% (95% confidence interval (CI): 46.4%-48.7%) for low fruit and vegetable intake, 20.3% (19.3%-21.2%) for low physical activity, 27.2% (26.2%-28.3%) for current smoking, 10.9% (10.3%-11.7%) for obesity, 52.2% (51.0%-53.3%) for systolic blood pressure (BP) ≥140mmHg, 46.8% (45.6%-47.9%) for low-density lipoprotein (LDL) cholesterol ≥100mg/dL, 36.4% (35.3%-37.5%) for hemoglobin A1c (HbA1c) ≥7.0% (53mmol/mol), and 69.5% (68.4%-70.6%) for metabolic syndrome. Proportions of Chinese patients with diabetes with 0, 1, 2, 3, and 4 cardiometabolic risk factors including current smoking, systolic BP ≥140mmHg, LDL cholesterol ≥100mg/dL, and HbA1c≥7.0% (53mmol/mol) were 13.4% (12.6%-14.2%), 32.9% (31.8%-33.9%), 35.0% (33.9%-36.1%), 16.2% (15.4%-17.0%), and 2.6% (2.3%-3.0%), respectively. CONCLUSIONS: Cardiometabolic risk factors were highly prevalent among Chinese with diabetes. Effective interventions should be taken.

Clustering of cardiovascular behavioral risk factors and blood pressure among people diagnosed with hypertension: a nationally representative survey in China.

This study aimed to examine association between the number of behavioral risk factors and blood pressure (BP) level among a nationally representative sample of Chinese people diagnosed with hypertension. A total of 31,694 respondents aged 18+ years with diagnosed hypertension were extracted from the 2013-2014 China Chronic Disease and Risk Factor Surveillance. BP of each respondent was classified into six levels according to criteria in 2007 Guidelines for the Management of Arterial Hypertension. Information for smoking, alcohol drinking, fruit and vegetables consumption, physical inactivity, and overweight and obesity were obtained. The average number of risk factors was determined by BP level to explore potential risk factor clustering. Ten generalized proportional odds models were used to examine association between clustering of behavioral risk factors and BP level. A clear gradient between the number of behavioral risk factors and BP level was observed for men and women (P < 0.05 for both genders). BP level for men and women was much likely to upgrade as number of risk factors accumulated (P < 0.01 for 10 models). Behavioral modifications may decrease BP, and combinations of two or more behavioral interventions could potentially result in even better BP management among people diagnosed with hypertension.

Diabetes-related metabolic risk factors in internal migrant workers in China: a national surveillance study.

BACKGROUND: Little is known about the cardiometabolic health of internal migrant workers in China. We aimed to examine the prevalence of diabetes-related cardiometabolic risk factors in this large, but little-studied population. METHODS: We did this national surveillance study within the Chinese Center for Disease Control and Prevention's National Disease Surveillance Point System, which includes a nationally representative sample of 170 study sites in all 31 provinces, autonomous regions, and municipalities in mainland China. We used a stratified multistage cluster sampling design to select a nationally representative sample of 48,704 Chinese internal migrant workers aged 18-59 years in 2012. We defined migrant workers as individuals whose residence at the time of the study differed from their permanent residence in the government household registration system. Medical history, information about lifestyle risk factors, and clinical measurements were collected from study participants at workplaces or local health centres by trained staff. Overnight fasting blood samples were collected in the morning and oral glucose tolerance tests were done in accordance with a standard protocol. All calculations were weighted to represent the overall Chinese migrant worker population aged 18-59 years by assigning each participant a weight coefficient. Weight coefficients were derived from the 2012 China population census data for migrant population according to the distributions of industry sector, age, and sex. FINDINGS: Among Chinese migrant workers aged 18-59 years, the weighted prevalence estimates were 26·8% (95% CI 26·4-27·3) for overweight, 4·7% (4·5-5·0) for obesity, 29·4% (28·9-29·9) for central obesity, 30·5% (30·0-31·0) for prediabetes, 5·1% (4·9-5·3) for diabetes, 16·3% (15·9-16·7) for hypertension, 34·5% (34·0-35·0) for dyslipidaemia, and 18·6% (18·2-19·0) for metabolic syndrome. 9·0% (8·7-9·3) of Chinese migrant workers had none of the following cardiometabolic risk factors, including current cigarette smoking, low fruit and vegetable intake, low physical activity, obesity or central obesity, diabetes, hypertension, and dyslipidaemia, 26·7% (26·2-27·2) had one, 30·2% (29·7-30·7) had two, 19·6% (19·1-20·0) had three, 9·9% (9·6-10·3) had four, 3·7% (3·5-3·9) had five, 0·8% (0·8-0·9) had six, and 0·1% (0·1-0·1) had seven. The proportions of individuals with three or more risk factors were 44·6% (43·9-45·3) in men and 20·2% (19·6-20·9) in women. Most metabolic risk factors were significantly less prevalent in migrant workers than in the general population in China (all p<0·001), although in women, the proportion with central obesity was similar (p=0·50), and in men, the proportion with metabolic syndrome was similar (p=0·07), and overweight (p<0·0001), obesity (p=0·0008), and central obesity (p<0·0001) were more prevalent in male migrant workers. INTERPRETATION: Compared with the general population in China, most cardiometabolic risk factors were less prevalent in migrant workers. However, overweight, obesity and central obesity were more prevalent in male migrant workers than among men in the general population. Cardiometabolic risk profiles for migrant workers are not optimal and effective national interventions that can reach this special population are needed. FUNDING: Chinese Ministry of Finance, Ministry of Health, and Ministry of Science and Technology.

Cause-specific mortality for 240 causes in China during 1990-2013: a systematic subnational analysis for the Global Burden of Disease Study 2013.

BACKGROUND: China has experienced a remarkable epidemiological and demographic transition during the past three decades. Far less is known about this transition at the subnational level. Timely and accurate assessment of the provincial burden of disease is needed for evidence-based priority setting at the local level in China. METHODS: Following the methods of the Global Burden of Disease Study 2013 (GBD 2013), we have systematically analysed all available demographic and epidemiological data sources for China at the provincial level. We developed methods to aggregate county-level surveillance data to inform provincial-level analysis, and we used local data to develop specific garbage code redistribution procedures for China. We assessed levels of and trends in all-cause mortality, causes of death, and years of life lost (YLL) in all 33 province-level administrative units in mainland China, all of which we refer to as provinces, for the years between 1990 and 2013. FINDINGS: All provinces in mainland China have made substantial strides to improve life expectancy at birth between 1990 and 2013. Increases ranged from 4.0 years in Hebei province to 14.2 years in Tibet. Improvements in female life expectancy exceeded those in male life expectancy in all provinces except Shanghai, Macao, and Hong Kong. We saw significant heterogeneity among provinces in life expectancy at birth and probability of death at ages 0-14, 15-49, and 50-74 years. Such heterogeneity is also present in cause of death structures between sexes and provinces. From 1990 to 2013, leading causes of YLLs changed substantially. In 1990, 16 of 33 provinces had lower respiratory infections or preterm birth complications as the leading causes of YLLs. 15 provinces had cerebrovascular disease and two (Hong Kong and Macao) had ischaemic heart disease. By 2013, 27 provinces had cerebrovascular disease as the leading cause, five had ischaemic heart disease, and one had lung cancer (Hong Kong). Road injuries have become a top ten cause of death in all provinces in mainland China. The most common non-communicable diseases, including ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and cancers (liver, stomach, and lung), contributed much more to YLLs in 2013 compared with 1990. INTERPRETATION: Rapid transitions are occurring across China, but the leading health problems and the challenges imposed on the health system by epidemiological and demographic change differ between groups of Chinese provinces. Localised health policies need to be implemented to tackle the diverse challenges faced by local health-care systems. FUNDING: China National Science & Technology Pillar Program 2013 (2013BAI04B02) and Bill & Melinda Gates Foundation.