Cohort profile: Beijing Healthy Aging Cohort Study (BHACS).

The Beijing Healthy Aging Cohort Study (BHACS) was established to supplement the limited data of a large representative cohort of older people based on the general population and was designed to evaluate the prevalence, incidence, and natural history of cognitive decline, functional disability, and conventional vascular risk factors. The aim was to determine the evolution of these conditions by estimating the rates and determinants of progression and regression to adverse outcomes, including dementia, cardiovascular events, cancer, and all-cause death. It can therefore provide evidence to help policy makers develop better policies to promote healthy aging in China. BHACS consisted of three cohorts (BLSA, CCHS-Beijing, and BECHCS) in Beijing with a total population of 11 235 (6281 in urban and 4954 in rural areas) and an age range of 55 years or older (55-101 years) with a mean age of 70.35 ± 7.71 years (70.69 ± 7.62 years in urban and 69.92 ± 7.80 years in rural areas). BHACS-BLSA conducted the baseline survey in 2009 with a multistage stratification-random clustering procedure for people aged 55 years or older; BHACS-CCHS-Beijing conducted the baseline survey in 2013-2015 with a stratified multistage cluster random sampling method for people aged 55 years or older; and BHACS-BECHCS conducted the baseline survey in 2010-2014 with two-stage cluster random sampling method for people aged 60 years or older. Data were collected through questionnaires, physical measurements, and laboratory analyses. Topics covered by BHACS include a wide range of physical and mental health indicators, lifestyles and personal, family, and socio-economic determinants of health. There are no immediate plans to make the cohort data freely available to the public, but specific proposals for further collaboration are welcome. For further information and collaboration, please contact the corresponding author Yao He (e-mail: yhe301@x263.net).

Telecoupling between urban expansion and forest ecosystem service loss through cultivated land displacement: A case study of Zhejiang Province, China.

Urbanization can either directly occupy forests or indirectly lead to forest loss elsewhere through cultivated land displacement, resulting in further forest fragmentation and ecosystem service (ES) loss. However, the effects of urban expansion on forest area and ESs are unknown, and this is especially true for indirect effects. Taking Zhejiang Province, China, a typical deforested province, as an example, this study quantified the direct and indirect effects of urban expansion on forest area and five ESs (timber yield, water yield, carbon sequestration, soil conservation, and biodiversity) from 2000 to 2020, explored the relationship between forest structure (forest proportion, mean patch area, edge density, and mean euclidean nearest neighbor distance) change and ESs, and revealed the telecoupling of urban expansion and forest loss and cascade effects among urbanization, deforestation, forest structure, and ESs. The results indicated that the indirect forest loss (4.30%-6.15%) caused by cultivated land displacement due to urban expansion was larger than the direct forest loss (2.42%). Urban expansion has a greater negative impact on carbon sequestration (6.40%-8.20%), water yield (6.08%-7.78%), and biodiversity (5.79%-7.44%) than on timber yield (4.77%-6.17%) and soil conservation (4.43%-5.77%). The indirect forest ES loss was approximately 2.83-4.34 times greater than the direct forest ES loss. Most forest ESs showed a nonlinear significant positive correlation with changes in forest proportion and mean patch area and a significant nonlinear negative correlation with changes in edge density and mean Euclidean nearest neighbor distance (p < 0.05). There is telecoupling between urban expansion in one region and forest ES loss in other distant regions. This study contributes to guiding sustainable forest conservation and management globally.

A combination of Beers and STOPP criteria better detects potentially inappropriate medications use among older hospitalized patients with chronic diseases and polypharmacy: a multicenter cross-sectional study.

BACKGROUND: Research on potentially inappropriate medications (PIM) and medication-related problems (MRP) among the Chinese population with chronic diseases and polypharmacy is insufficient. OBJECTIVES: This study aimed to investigate the prevalence of PIM and MRP among older Chinese hospitalized patients with chronic diseases and polypharmacy and analyze the associated factors. METHODS: A retrospective cross-sectional study was conducted in five tertiary hospitals in Beijing. Patients aged ≥ 65 years with at least one chronic disease and taking at least five or more medications were included. Data were extracted from the hospitals' electronic medical record systems. PIM was evaluated according to the 2015 Beers criteria and the 2014 Screening Tool of Older Persons' Prescriptions (STOPP) criteria. MRPs were assessed and classified according to the Helper-Strand classification system. The prevalence of PIM and MRP and related factors were analyzed. RESULTS: A total of 852 cases were included. The prevalence of PIM was 85.3% and 59.7% based on the Beers criteria and the STOPP criteria. A total of 456 MRPs occurred in 247 patients. The most prevalent MRP categories were dosages that were too low and unnecessary medication therapies. Hyperpolypharmacy (taking ≥ 10 drugs) (odds ratio OR 3.736, 95% confidence interval CI 1.541-9.058, P = 0.004) and suffering from coronary heart disease (OR 2.620, 95%CI 1.090-6.297, P = 0.031) were the influencing factors of inappropriate prescribing (the presence of either PIM or MRP in a patient). CONCLUSION: PIM and MRP were prevalent in older patients with chronic disease and polypharmacy in Chinese hospitals. More interventions are urgently needed to reduce PIM use and improve the quality of drug therapies.

Combined homocysteine and apoE rs429358 and rs7412 polymorphism in association with serum lipid levels and cognition in Chinese community-dwelling older adults.

BACKGROUND: ApoE gene polymorphism and serum total homocysteine (tHcy) has been reportedly associated with cognition. In this study, we assessed the association of combined ApoE gene polymorphism and tHcy with cognition in Chinese elder adults. METHODS: A cross- sectional study was carried out by recruiting 1458 community-dwelling people aged 55+ and above in Beijing in 2009. All participants were interviewed using a standard questionnaire and underwent a physical examination. The mini-mental scale examination (MMSE) score was used in assessing cognitive function. Fasting venous blood samples were taken for ApoE rs429358, rs7412 genotyping, tHcy and other serum lipid measurements. RESULTS: Participants with high serum tHcy level showed a relatively lower orientation, attention abilities as well as the total MMSE score than the group with normal tHcy after adjusting confounding factors. ApoE rs429358 and rs7412 variants were observed to have the highest serum TC and TG level in the subjects with high serum tHcy level (p <  0.05). Cognition of the subjects was found to be significantly associated with high serum tHcy level and ApoE genetic polymorphism (p <  0.05). Independent of age, BMI, education levels, smoking and alcohol drinking, the worst cognitive ability were detected in the high serum tHcy level subjects with ApoE rs429358C/T and rs7412 C/T as compare with other groups, especially orientation function, memory and delayed recall ability and attention ability. CONCLUSION: High serum tHcy level in combination with ApoE rs429358 and rs7412 variants might be linked with serum lipid levels and cognition, particularly for orientation function and memory and delayed recall ability in old Chinese adults.

A frailty index based on routine laboratory data predicts increased risk of mortality in Chinese community-dwelling adults aged over 55 years: a five-year prospective study.

BACKGROUND: Frailty can be operationalized based on the accumulation of deficits using a frailty index (FI) and is associated with an increased risk of adverse health outcomes. Here, we aim to compare validity of a FI from laboratory data with that of the common clinical FI for prediction of mortality in adults aged 55 + years, also examine whether combined FI could improve identification of adults aged 55 + years at increased risk of death. METHODS: Data for this analysis were obtained from the Beijing Longitudinal Study of Aging that involved 1,257 community-dwelling Chinese people, aged 55 + years at baseline. The main outcome measure was 5-year mortality. An FI-self-report based on 30 self-reported health-related data was constructed. An FI-lab was developed using laboratory data, in addition to pulse, systolic and diastolic blood pressure, pulse pressure, body mass index (BMI) and waist. A combined FI comprised all items from each FI. Kaplan-Meier survival curve and Cox proportional hazards models were performed to evaluate the risk of each FI on death. The area under receiver operating characteristic(ROC) curves were used to compare the discriminative performance of each FI. RESULTS: Of 1257 participants, 155 died and 156 lost at the end of the 5-year follow-up. The mean FI-self-report score was 0.11 ± 0.10, the FI-lab score was 0.33 ± 0.14 and FI-combined score was 0.19 ± 0.09. Higher frailty level defined by each FI was associated with higher risk of death. After adjustment for age and sex, Cox proportional hazards models showed that the higher scores of frailty were associated with a higher risk of mortality for each FI, the hazard ratios for the FI-self-report and FI-lab and FI-combined were 1.04 (1.03 to 1.05) and 1.02 (1.01 to 1.03) and 1.05 (1.04 to 1.07), respectively. The areas under the ROC curve were 0.79 (0.77-0.82) for the FI-self-report, 0.77(0.75-0.80) for the FI-lab and 0.81(0.78-0.82) for FI-combined. CONCLUSIONS: A FI from laboratory data can stratify older adults at increased risk of death alone and in combination with FI based on self-report data. Assessment in clinical settings of creating an FI using routine collected laboratory data needs to be further developed.

Epilepsy centers in China: Current status and ways forward.

OBJECTIVE: China has the largest population of patients with epilepsy worldwide, which imposes a heavy burden on the public and health care systems. Several epidemiological surveys on epilepsy have been performed in China. Although these surveys grossly describe the prevalence and gap in treatment of epilepsy, the status of epilepsy centers is unclear. The number of epilepsy centers has increased substantially in recent decades. Therefore, a nationwide investigation of the scale and distribution, personnel, equipment, and epilepsy care capacity of each epilepsy center is of great value. METHODS: In 2017-2018, a multicenter cross-sectional survey was performed by the Commission on Standardized Development of Epilepsy Centers, China Association Against Epilepsy in 31 provinces, autonomous regions, and municipalities. The survey consisted of 74 questions divided into four sections: (1) overview, (2) personnel, (3) essential equipment and facilities, and (4) epilepsy care service capacity. The questions ranged from January 1, 2016 to December 31, 2016. The data were analyzed using descriptive statistics. RESULTS: There were 358 epilepsy centers for the 1.38 billion national population in 2016. Three quarters were in the eastern and western regions, and >90% were in tertiary hospitals. There were 9688 doctors engaged in epilepsy care, and 4.8% of doctors and electrophysiological physicians/technicians passed the national test for electroencephalography technical accreditation. A total of 9667 patients underwent resective surgeries in 2016. There were 888 vagus nerve stimulation procedures and 275 deep brain stimulation procedures. SIGNIFICANCE: This study is the first unique survey of epilepsy centers in China. Despite their rapid development, epilepsy centers cannot meet patients' needs at this stage. The results provide data-based evidence for the formulation of policies related to epilepsy service planning.

The link of depression, untreated hypertension, and diabetes with mortality in postmenopausal women: A cohort study.

OBJECTIVE: To explore the association of depression, as well as untreated hypertension or diabetes with all-cause death in community-based postmenopausal women in Beijing. METHODS: A cohort of 863 community-based postmenopausal women with no history of cardiovascular heart disease (CHD), stroke, cancer, or dementia was investigated on 20 July-28 September 2009 at baseline. Depression was diagnosed using the 30-item Center for Epidemiologic Studies Depression (CES-D) scale with CES-D ≥ 11. Meanwhile, data on health behavior, physical comorbidity, and social support at baseline were collected. These individuals were followed up from 20 July to 30 August 2014. All-cause mortality and cause of death were surveyed. RESULTS: After a median follow-up of 4.97 years, 120 subjects died of all-cause. Twenty-four died of stroke, 19 died of myocardial infarction, 21 died of cancer. The others died of aging, infection, and accident. Depression and untreated HP were significantly associated with all-cause mortality in Cox models after full adjustment for all of the potential confounders (Depression HR: 2.16, 95%CI: 1.35-3.46; Untreated hypertension HR: 1.84, 95%CI: 1.12-3.02). However, negative correlation of untreated diabetes on all-cause mortality was observed in this population (HR: 1.36, 95%CI: 0.75-2.49). When depression was co-existing with hypertension/diabetes, the HR for mortality elevated significantly (Depression co-existing with hypertension HR = 3.87, 95% CI: 2.07-7.23; Depression co-existing with diabetes HR = 5.02, 95% CI: 1.5-16.79). CONCLUSIONS: It is suggested we should take sufficient care of postmenopausal females with depression and control blood pressure and glucose more effectively. Abbreviations: HP: Hypertension; DM: Diabetes; TC: Cholesterol; TG: Triglyceride; BMI: Body-Mass Index; CES-D: Center for Epidemiologic Studies Depression; CDC: Centers for Disease Control and Prevention; HR: Hazard Ratio; CI: Confidence Interval; ADL: Activities of daily living scale.

Kidney dysfunction is associated with risk of cardiovascular events in middle-aged and elderly population with hypertension: A 5-year community-based cohort study in China
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AIM: To evaluate the association between kidney dysfunction and cardiovascular disease (CVD) events in a middle-aged and elderly population in China. MATERIALS AND METHODS: In July 2009, a baseline survey of health status was performed in adults aged 55 years and older from Beijing, China. Occurrence of CVD events and mortality in subjects free of CVD at baseline was recorded in a 5-year follow-up period until December 2014. The association of mild (eGFRCKD-EPI 45 - 59 mL/min/1.73m2) and moderate to severe (eGFRCKD-EPI < 45 mL/min/1.73m2) kidney dysfunction with adverse outcomes were analyzed with Cox regression analysis. RESULTS: A total of 1,257 subjects were included in the final analysis. The risk of CVD events in those with mild kidney dysfunction increased by 65% (HR: 1.65, 95% CI: 1.04 - 2.62) as compared to those with normal kidney function. Subjects with both hypertension and CKD experienced more significantly increased risk of CVD events (adjusted HR = 1.87, 95% CI 1.17 - 2.97) and stroke (adjusted HR = 2.24, 95% CI 1.24 - 4.04). Pulse pressure (PP) ≥ 60 mmHg was the strongest risk factor for stroke in patients with CKD, with the adjusted HR value of 1.98 (95% CI 1.08 - 3.64). CONCLUSION: Moderate to severe kidney dysfunction was an independent risk predictor of CVD events. Among subjects with hypertension or poorly controlled blood pressure level, the presence of CKD significantly increased the risks of CVD events and stroke.

Association of sleep duration with risk of all-cause mortality and poor quality of dying in oldest-old people: a community-based longitudinal study.

BACKGROUND: While sleep duration has been shown to be associated with health outcomes, few studies have been conducted among the oldest old. In addition, the impact of sleep duration on quality of dying is unknown. We aimed to evaluate how sleep duration affects all-cause mortality and quality of dying in people aged 80 + . METHODS: This community-based longitudinal study was performed by using data from 15,048 individuals aged ≥80 with information on sleep duration in the Chinese Longitudinal Healthy Longevity Survey. Cox and logistic regression models with penalized splines were applied to explore the shape of the association between sleep duration and all-cause mortality and poor quality of dying respectively and identify the interval of sleep duration resulting in the lowest risk of both. RESULTS: During a median follow-up of 3.1 years, 11,582 deaths including 4116 individuals who experienced poor quality of dying were recorded. Sleep duration showed a U-shaped association with all-cause mortality and sleeping about 8 h had the minimum risk of death; a J-shaped association was found between sleep duration and poor quality of dying. Compared with sleep duration of 7-9 h, the adjusted hazard ratio of total deaths was 1.08 (95% CI 1.03-1.13) for short duration (< 7 h) and 1.12 (95% CI 1.07-1.17) for long duration (> 9 h); the adjusted odds ratio of poor QOD was 1.10 (95% CI 1.01-1.21) for long duration, but this association was restricted to those with baseline unhealthy status (P-interaction = 0.04). CONCLUSIONS: Sleeping a little longer may be better for individuals over 80 years old, and sleep duration of 7-9 h per day is optimal for both survival and good quality of life near death.

Association of Lipids With Ischemic and Hemorrhagic Stroke: A Prospective Cohort Study Among 267 500 Chinese.

Background and Purpose- Previous results on the association between lipids and stroke were controversial. We investigated the association of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C ), high-density lipoprotein cholesterol (HDL-C), and triglyceride with stroke. Methods- Six cohort studies in China with 267 500 participants were included. Cox proportional hazards regression models and restricted cubic spline analyses were used to estimate hazard ratios and 95% CIs and explore linear and nonlinear relationships of lipids and stroke, respectively. Results- The median follow-up duration ranged from 6 to 19 years. During 2 295 881 person-years, 8072 people developed stroke. Multivariable adjusted hazard ratios (95% CIs) per 1 mmol/L increase in TC, LDL-C, triglyceride were 1.08 (1.05-1.11), 1.08 (1.04-1.11), 1.07 (1.05-1.09) for ischemic stroke, respectively. Compared with participants with TC 160-199.9 mg/dL, hazard ratios (95% CIs) were 1.43 (1.11-1.85) for hemorrhagic stroke in those with TC <120 mg/dL. Compared with participants with HDL-C 50 to 59.9 mg/dL, hazard ratios (95% CIs) were 1.23 (1.12-1.35), 1.13 (1.04-1.22) for ischemic stroke, and 1.28 (1.10-1.49), 1.17 (1.03-1.33) for hemorrhagic stroke in those with HDL-C <40 and 40 to 49.9 mg/dL, respectively. Restricted cubic spline analyses showed linear relationships of TC and LDL-C, and nonlinear relationships of HDL-C and triglyceride with ischemic stroke (all P<0.001). Hemorrhagic stroke showed linear relationships with TC and HDL-C (P=0.029 and <0.001 respectively), but no relationship with LDL-C and triglyceride (all P>0.05). Conclusions- TC, LDL-C, and triglyceride showed positive associations with ischemic stroke. The risk of hemorrhagic stroke was higher when TC was lower than 120 mg/dL. LDL-C and triglyceride showed no association with hemorrhagic stroke. The risks of ischemic and hemorrhagic stroke might be higher when HDL-C was lower than 50 mg/dL.

Metabolic syndrome and risks of carotid atherosclerosis and cardiovascular events in community-based older adults in China.

BACKGROUND AND OBJECTIVES: Previous studies on the importance of metabolic syndrome (MS) as a cardiovascular risk factor had not focused on older Chinese adults. The present study analyzed the association of MS with carotid atherosclerosis and the risk of cardiovascular events in Chinese adults. METHODS AND STUDY DESIGN: Data of a representative cohort study with 5-year follow-up were used. Community-dwelling people (n=1257) aged ≥55 years without cardiovascular disease (CVD) at baseline were followed up from 2009 to 2014. MS was defined based on the Chinese Diabetes Society criteria under the Chinese Medical Association. Multiple regression analyses were performed to examine the associations of MS with atherosclerosis and CVD events, with adjustment for confounding factors. RESULTS: In a multivariate logistic regression model with adjustment, MS was closely related to common carotid artery intima-media thickness (CCA-IMT) (1.62; 95% CI: 1.19-2.21) and carotid plaque presence (1.38; 95% CI: 1.01-1.89), but not with carotid artery stenosis. At the end of the 5-year follow- up, compared with subjects without MS, hazard ratios and 95% confidence intervals for the different risks in subjects with MS were 1.86 (1.02-3.29) for myocardial infarction (MI), 1.39 (1.01-2.05) for stroke, 1.52 (1.02- 2.37) for CVD death, and 1.13 (0.62-2.58) for total death, after adjusting for age, gender, smoking, drinking, physical activity, uric acid, high-sensitivity C-reactive protein, dietary factors and carotid atherosclerosis status. CONCLUSIONS: MS was significantly associated with IMT and the presence of carotid plaque and with positively increased risks of MI, stroke, and CVD mortality independent of CVD risk factors in older Chinese adults.

Influence of Age Ranges on Relationship of Complex Aortic Plaque With Cervicocephalic Atherosclerosis in Ischemic Stroke.

BACKGROUND: Complex aortic plaque is a potential cause of acute ischemic cerebrovascular disease, which needs timely identification. Also as a marker for systemic atherosclerosis, complex aortic plaque may be indicated by significant (≥50%) cervicocephalic atherosclerotic stenosis. We aimed at examining whether age ranges would influence their association to more accurately estimate the risk of having complex aortic plaque in acute ischemic cerebrovascular disease. METHODS: Aortic arch and cervicocephalic arteries were simultaneously evaluated using computed tomography angiography. Middle-aged (45-64 years) and old-aged (65-85 years) acute ischemic cerebrovascular disease patients were divided into 2 groups according to whether there was an aortic arch plaque with thickness of greater than or equal to 4 mm or associated ulcerations or mural thrombus. RESULTS: Old-aged patients (n = 107) had a higher prevalence of complex aortic plaque (67.3% versus 30.9%, P < .001) than those middle aged (n = 178). Among middle-aged patients, the presence of extracranial significant atherosclerotic stenosis (adjusted odd ratio = 2.89, 95% confidence interval: 1.42-5.86) rather than intracranial ones independently predicted complex aortic plaque. Regarding the extent of significant cervicocephalic atherosclerotic stenosis, the presence of multi-segment, bilateral, simultaneous extracranial and intracranial, and simultaneous anterior and posterior circulation ones were independent indicators for complex aortic plaque in the middle-aged subgroup (adjusted odd ratio = 2.42, 2.05, 2.26, 2.14, respectively). By contrast, no statistical correlation of complex aortic plaque and significant cervicocephalic atherosclerotic stenosis was found among old-aged patients. CONCLUSION: Considering the ranges of age was important to more precisely predict complex aortic plaque with significant cervicocephalic atherosclerotic stenosis in acute ischemic cerebrovascular disease.

Cognitive functioning transitions, health expectancies, and inequalities among elderly people in China: A nationwide longitudinal study.

OBJECTIVE: In China, cognitive impairment has become a huge challenge owing to the rapid aging process. We investigate cognitive health expectancy and potential factors leading to inequalities of cognitive health for Chinese older people. METHODS: The study included 19 943 participants aged 65 to 95 at the first observation in Chinese Longitudinal Healthy Longevity Survey collected during 2002-2014. Cognitive impairment was categorized into none, mild, and severe by the score of cMMSE. Multistate models based on continuous-time Markov process were applied to calculate cognitive health expectancies and estimate hazard ratio from no impairment to impairment for potential factors. RESULTS: Urban women and men aged 65 were expected to spend 31.18% and 19.82% of their remaining 17.46 and 15.45 years with cognitive impairment; meanwhile, rural women and men aged 65 were expected to spend 35.31% and 21.39% of their remaining 16.73 and 14.87 years with cognitive impairment. Women achieving lower educational attainment (HR1-6 years  = 0.78, 95% CI, 0.71-0.87; HR7+ years  = 0.59, 95% CI, 0.49-0.70) than men and rural residents having less access to medical service (HR = 0.79, 95% CI, 0.68-0.92) and doing less regular exercise (HR = 0.87, 95% CI, 0.80-0.96) than urban people caused the differences of cognitive health for genders and regions. CONCLUSIONS: Women and rural people experience less cognitive health expectancies compared with their counterparts, respectively. Chinese government should pay more attention to rural women and make efforts to reduce the inequalities of cognitive health by increasing opportunities of education for women and improving access to medical service and healthy lifestyle for rural people.

Body-mass index and all-cause mortality: individual-participant-data meta-analysis of 239 prospective studies in four continents.

BACKGROUND: Overweight and obesity are increasing worldwide. To help assess their relevance to mortality in different populations we conducted individual-participant data meta-analyses of prospective studies of body-mass index (BMI), limiting confounding and reverse causality by restricting analyses to never-smokers and excluding pre-existing disease and the first 5 years of follow-up. METHODS: Of 10 625 411 participants in Asia, Australia and New Zealand, Europe, and North America from 239 prospective studies (median follow-up 13·7 years, IQR 11·4-14·7), 3 951 455 people in 189 studies were never-smokers without chronic diseases at recruitment who survived 5 years, of whom 385 879 died. The primary analyses are of these deaths, and study, age, and sex adjusted hazard ratios (HRs), relative to BMI 22·5-<25·0 kg/m(2). FINDINGS: All-cause mortality was minimal at 20·0-25·0 kg/m(2) (HR 1·00, 95% CI 0·98-1·02 for BMI 20·0-<22·5 kg/m(2); 1·00, 0·99-1·01 for BMI 22·5-<25·0 kg/m(2)), and increased significantly both just below this range (1·13, 1·09-1·17 for BMI 18·5-<20·0 kg/m(2); 1·51, 1·43-1·59 for BMI 15·0-<18·5) and throughout the overweight range (1·07, 1·07-1·08 for BMI 25·0-<27·5 kg/m(2); 1·20, 1·18-1·22 for BMI 27·5-<30·0 kg/m(2)). The HR for obesity grade 1 (BMI 30·0-<35·0 kg/m(2)) was 1·45, 95% CI 1·41-1·48; the HR for obesity grade 2 (35·0-<40·0 kg/m(2)) was 1·94, 1·87-2·01; and the HR for obesity grade 3 (40·0-<60·0 kg/m(2)) was 2·76, 2·60-2·92. For BMI over 25·0 kg/m(2), mortality increased approximately log-linearly with BMI; the HR per 5 kg/m(2) units higher BMI was 1·39 (1·34-1·43) in Europe, 1·29 (1·26-1·32) in North America, 1·39 (1·34-1·44) in east Asia, and 1·31 (1·27-1·35) in Australia and New Zealand. This HR per 5 kg/m(2) units higher BMI (for BMI over 25 kg/m(2)) was greater in younger than older people (1·52, 95% CI 1·47-1·56, for BMI measured at 35-49 years vs 1·21, 1·17-1·25, for BMI measured at 70-89 years; pheterogeneity<0·0001), greater in men than women (1·51, 1·46-1·56, vs 1·30, 1·26-1·33; pheterogeneity<0·0001), but similar in studies with self-reported and measured BMI. INTERPRETATION: The associations of both overweight and obesity with higher all-cause mortality were broadly consistent in four continents. This finding supports strategies to combat the entire spectrum of excess adiposity in many populations. FUNDING: UK Medical Research Council, British Heart Foundation, National Institute for Health Research, US National Institutes of Health.

Cardiovascular and Cognitive Health Study in Middle-Aged and Elderly Residents of Beijing(CCHS-Beijing): Design and Rationale.

The Cardiovascular and Cognitive Health Study (CCHS-Beijing) is a population-based study of cardiovascular disease (CVD) and cognitive impairment in adults aged 55 and older in Beijing. The main aims of the study are to investigate the prevalence rates of CVD, asymptomatic atherosclerosis, and cognitive impairment, as well as validate the risk factors related to the onset and development of CVD, Alzheimer's disease (AD) and mild cognitive impairment (MCI). The study was designed to detect the traditional and new risk factors in this age group. Participants were recruited randomly from residential regions in the greater Beijing municipality area based on the average levels of development in Beijing, China in 2012 (based on socioeconomic, demographic, and geographical characteristics). Thorough physical and laboratory examination were performed at baseline (also the cross-sectional survey) to identify the risk factors such as hypertension, dyslipidemia, diabetes, as well as newly defined risk factors like elevated homocysteine, high sensitivity C-reactive protein, and urine micro-albumin. Subclinical disease of the cerebral vasculature included atherosclerosis of carotid arteries, intracranial arteries, and retinal vessels. Subclinical cardiac diseases included left ventricular enlargement, arrhythmias, chamber hypertrophy and myocardial ischemia. Blood pressure was documented using the ankle-arm method. In addition, neuropsychological assessments were performed for all subjects aged 65 and above. Baseline evaluation began during the period August 2013 to December 2014. Follow-up examination will occur in 5 years. The initial and recurrent CVD, AD and MCI events will be verified and validated during the follow-up period.

Metabolic Syndrome, Its Components, and Diabetes on 5-Year Risk of Recurrent Stroke among Mild-to-Moderate Ischemic Stroke Survivors: A Multiclinic Registry Study.

OBJECTIVES: The pieces of evidence regarding whether metabolic syndrome (MetS) is a better predictor than its individual components, especially diabetes, for recurrent stroke are limited. This study aimed to examine these associations. METHODS: A total of 1087 ischemic stroke patients were recruited consecutively from 2003 to 2004. They were followed up until the end of 2008. Baseline clinical and laboratory characteristics and new stroke event during follow-up were recorded. MetS was defined by the definition issued by the Chinese Medical Association/Chinese Diabetes Society. RESULTS: One hundred forty-three new stroke cases were recorded. After adjusting for baseline age, gender, education, marriage status, subtype stroke, length of index stroke to baseline assessment, history of cardiac diseases, smoking status, drinking status, clinics, aspirin treatment, and fibrinogen by Cox regression models, the risk of recurrent stroke was 43% higher in MetS patients than in non-MetS patients (hazard ratio [HR] = 1.43, 95% confidence interval [CI]: 1.01-2.01). The strength of this association is weaker than MetS individual components such as elevated glycemia (adjusted HR = 1.78, 95% CI: 1.26-2.52), elevated blood pressure (adjusted HR = 1.91, 95% CI: 1.11-3.30), or low high-density lipoprotein cholesterol (adjusted HR = 1.57, 95% CI: 1.08-2.51). Compared with the group with neither MetS nor diabetes, the adjusted risk of recurrent stroke was highest in the group with diabetes (HR = 2.77, 95% CI: 1.66-4.63), followed by those with both MetS and diabetes (HR = 1.91, 95% CI: 1.25-2.94). The risk of recurrent stroke in patients with MetS in the absence of diabetes was similar to those with neither. CONCLUSION: MetS is not superior to its individual components in predicting future recurrent stroke in patients who experience mild-to-moderate ischemic stroke.

Combined Effect of Hyperhomocysteinemia and Hypertension on the Presence of Early Carotid Artery Atherosclerosis.

BACKGROUND: To examine the individual effect of elevated homocysteine and its combined effect with hypertension on early carotid artery atherosclerosis (ECAS). METHODS: We recruited 1257 subjects from a community-based population in Beijing, China, aged 55 years and older. The definition of hyperhomocysteinemia was referred to as the presence of homocysteine concentrations greater than 15 µmol/L. Carotid intima-media thickness (CIMT), plaque, the sum of plaque thickness (plaque score, PS), and plaque location in common carotid artery were established by ultrasonography. The presence of increased CIMT (≥1.0 mm) and plaque was defined as ECAS. Age, sex, smoking, alcohol drinking, physical activity, total cholesterol, glucose, estimated glomerular filtration rate, hypoglycemic therapy, and lipid-lowering therapy were adjusted by logistic regression analysis. RESULTS: After adjustments for all potential confounders, the risks of presence of plaque, bilateral plaque, and high PS were significantly higher in the group with hyperhomocysteinemia as compared with reference group (the normal homocysteine and normotensive). The odds ratios (ORs) were 1.56 for presence of plaque (95% CI 1.05-2.33), 1.80 for bilateral plaque (95% CI 1.08-2.99), and 1.90 for high PS (95% CI 1.09-3.30), respectively. The group with both hyperhomocysteinemia and hypertension manifested the highest ORs of ECAS. The fully adjusted ORs were 1.67 for increased CIMT (95% CI 1.15-2.42), 2.48 for bilateral plaques (95% CI 1.54-3.99), and 2.69 for high PS (95% CI 1.61-4.47), correspondingly. CONCLUSIONS: Elevated homocysteine had a mild-to-moderate independent effect on ECAS. Combined with hypertension, hyperhomocysteinemia might increase the strength of the above-mentioned effects.

A comparison of risk factors for mortality from heart failure in Asian and non-Asian populations: an overview of individual participant data from 32 prospective cohorts from the Asia-Pacific Region.

BACKGROUND: Most of what is known regarding the epidemiology of mortality from heart failure (HF) comes from studies within Western populations with few data available from the Asia-Pacific region where the burden of heart failure is increasing. METHODS: Individual level data from 543694 (85% Asian; 36% female) participants from 32 cohorts in the Asia Pacific Cohort Studies Collaboration were included in the analysis. Adjusted hazard ratios (HR) and 95% confidence intervals (CI) for mortality from HF were estimated separately for Asians and non-Asians for a quintet of cardiovascular risk factors: systolic blood pressure, diabetes, body mass index, cigarette smoking and total cholesterol. All analyses were stratified by sex and study. RESULTS: During 3,793,229 person years of follow-up there were 614 HF deaths (80% Asian). The positive associations between elevated blood pressure, obesity, and cigarette smoking were consistent for Asians and non-Asians. There was evidence to indicate that diabetes was a weaker risk factor for death from HF for Asians compared with non-Asians: HR 1.26 (95% CI: 0.74-2.13) versus 3.04 (95% CI 1.76-5.25) respectively; p for interaction = 0.022. Additional adjustment for covariates did not materially change the overall associations. There was no good evidence to indicate that total cholesterol was a risk factor for HF mortality in either population. CONCLUSIONS: Most traditional cardiovascular risk factors including elevated blood pressure, obesity and cigarette smoking appear to operate similarly to increase the risk of death from HF in Asians and non-Asians populations alike.

[Association of serum high-density lipoprotein cholesterol level and risk of recurrent ischemic stroke].

OBJECTIVE: To observe the association between high-density lipoprotein cholesterol (HDL-C) level and rate of ischemic stroke recurrence. METHODS: A total of 1 059 patients with ischemic stroke were enrolled from 5 community health centers and underwent baseline surveys during the period of January 2003 to December 2006. After baseline surveys, patients were followed up every 6 months until December 31, 2008. The new stroke events were recorded as the primary study endpoint. The association between HDL-C, HDL-C/TC and ischemic stroke recurrence was analyzed by Cox regression analysis. RESULTS: The proportions of stroke patients with high ( ≥ 1.55 mmol/L), moderate (1.04-1.54 mmol/L) and low (<1.04 mmol/L) HDL-C levels were 15.58% (165/1 059) , 54.58% (578/1 059) and 29.84% (316/1 059) respectively. During a mean of (3.21 ± 1.04) years follow-up, recurrent ischemic stroke was recorded in 137 patients. Compared with HDL-C ≥ 1.40 mmol/L group, multivariate Cox regression analysis showed that stroke recurrence rates of patients with HDL-C ≤ 1.00 mmol/L and ranged from 1.01 to 1.19 mmol/L increased by 0.944 (HR = 1.944, 95%CI:1.033-3.659, P = 0.039) and 1.027 (HR = 2.027, 95%CI:1.116-3.682, P = 0.020)fold , respectively. Recurrence rates increased 1.237 (HR = 2.237, 95%CI:1.208-4.144, P = 0.010) fold in patients with HDL-C/TC ≤ 0.19 mmol/L compared to patients with HDL-C/TC ≥ 0.28 mmol/L. CONCLUSION: The risk of ischemic stroke recurrence increases with decreasing HDL-C level or HDL-C/TC ratio.