The expanding burden of cardiometabolic risk in China: the China Health and Nutrition Survey

Weight status changes from childhood to adulthood were associated with cardiometabolic outcomes in adulthood

AIM

Few studies have assessed the association between weight changes from childhood to adulthood and cardiometabolic factors in adulthood. The aim of this study was to explore the relationships between weight changes from childhood to adulthood and cardiometabolic factors in adulthood using national Chinese data.

METHODS

We included 649 participants from the China Health and Nutrition Survey from 1989 to 2009 and divided them into four groups by their body mass index from 6 to 37 years of age. They were selected using multistage random cluster sampling from 15 areas with large variations in economic and social development. Poisson regression models assessed associations between weight status changes and cardiometabolic outcomes in adulthood.

RESULTS

The risk of multiple abnormal cardiometabolic outcomes in adulthood was increased in the 126 subjects with normal weight in childhood but overweight or obesity in adulthood and the 28 with obesity at both ages, compared to the 462 with normal weight at both ages. There was insufficient evidence to demonstrate that the 33 who had weight issues as children, but not as adults, had an increased risk.

CONCLUSION

Being overweight or obese in both childhood and adulthood or during adulthood only increased the risk of abnormal cardiometabolic outcomes in adulthood. Larger studies need to investigate whether weight problems in childhood, but not adulthood, increase the risk.

A Bayesian network analysis of the probabilistic relationships between metabolically healthy obesity and cardiovascular disease risk under new diagnostic criteria

BACKGROUND

The relationship between metabolically healthy obesity (MHO) and cardiovascular disease (CVD) risk remains debated. The critical point may be the lack of consensus on MHO's definition and diagnostic criteria.

OBJECTIVE

This study aimed to investigate the association of MHO status with arteriosclerosis-CVD (ASCVD) risk in Chinese under new diagnostic criteria.

METHODS

Participants aged 35-79 in the 2009 China Health and Nutrition Survey cohort were included. The 10-year ASCVD risk was predicted by the prediction for ASCVD risk in China, and participants with a predicted risk of ⩾ 10% were classified into the high-risk group. The Bayesian network (BN) models were constructed to characterize the multivariable probabilistic connections between metabolically obesity phenotypes and ASCVD risk.

RESULTS

The 10-year ASCVD risk score and the proportion of individuals at ASCVD high risk were significantly different between metabolically obesity phenotypes (P< 0.001). BN reasoning results showed that MHO individuals were not significantly associated with a 10-year ASCVD risk. Among metabolically unhealthy individuals, the conditional probability of high ASCVD risk increased with the Body Mass Index (BMI), with the conditional probability of high ASCVD risk was 24.63% (95% CI: 22.81-26.55%), 32.97% (95% CI: 30.75-35.27%) and 40.2% (95% CI: 36.64-43.86%) for metabolically unhealthy normal weight (MUNW), metabolically healthy overweight weight (MHOW), and metabolically unhealthy obesity (MUO) group, respectively. Subgroup analysis showed that MHO individuals were at increased risk of CVD compared with metabolically healthy normal weight (MHNW) individuals only in females.

CONCLUSION

These results showed that there was no significant increase in ASCVD risk of MHO phenotype based on the new diagnostic criteria, suggesting that MHO is in a relatively healthy state.

Combined impact of elevated C-reactive protein levels and dyslipidemia on stroke: a CHNS prospective cohort study

Background

The objective of this study was to examine whether the combination of elevated levels of C-reactive protein (CRP) and dyslipidemia increased the risk of stroke among middle-aged and older adult individuals in China.

Methods

This study utilized longitudinal data from the China Health and Nutrition Survey (CHNS) collected in 2009, 2015, and 2018. A total of 8,023 participants aged ≥40 years (3,595 males and 4,428 females) were included. The Generalized Estimating Equation (GEE) method was employed to examine the association between inflammation, dyslipidemia, their combined effects, and stroke in the Chinese population.

Results

A total of 174 stroke events occurred during follow-up. Compared with those with normal CRP levels (CRP ≤ 3 mg/L), the adjusted ORs and 95%CI were 2.13 (1.25, 3.64) for the female with elevated CRP level. Compared with those with non-dyslipidemia, the adjusted ORs and 95%CI were 1.56 (1.03, 2.37) for the individuals with high LDL cholesterol, 1.93 (1.12, 3.33) for the male with high LDL cholesterol. Compared with those with normal CRP levels and non-dyslipidemia, the adjusted ORs and 95%CI were 1.74 (1.08, 2.78) for the individuals with elevated CRP levels and dyslipidemia, 2.41 (1.29, 4.49) for the male with elevated CRP levels and dyslipidemia. People with the coexistence of elevated CRP levels and dyslipidemia had the highest risk of stroke among male.

Conclusion

In females, higher levels of inflammation are associated with an increased incidence of stroke. In males, individuals with dyslipidemia characterized by high LDL cholesterol levels are more susceptible to stroke. In the general population, the joint effect of inflammation and dyslipidemia predisposes individuals to a higher risk of stroke, particularly among males.

Dietary inflammatory potential and the risk of nonfatal cardiovascular diseases in the China Health and Nutrition Survey

BACKGROUND

To our knowledge, no evidence exists to link dietary inflammatory potential to cardiovascular disease (CVD) in China. Furthermore, the precise mechanisms underlying the link between a pro-inflammatory diet and CVD remain incompletely understood.

OBJECTIVE

We aimed to investigate the relationship between dietary inflammatory potential and nonfatal CVD in the Chinese population and to explore the mediating role of insulin resistance.

METHODS

A total of 4822 adults who participated in the China Health and Nutrition Survey (CHNS) were included in this analysis. The dietary inflammatory index (DII) was used to assess dietary inflammatory potential. Cox proportional hazards models and restricted cubic spline were applied to assess the longitudinal associations. The triglyceride-glucose (TyG) index was calculated to measure insulin resistance. Mediation analysis using a two-stage regression method for survival data was employed to explore the mediating effects of the TyG index on the association between DII score and nonfatal CVD.

RESULTS

During a median follow-up of 18 y, 234 incident cases of nonfatal CVD, including 136 strokes and 114 myocardial infarctions (MIs), were observed. For each standard deviation of the DII score, nonfatal CVD incidence increased by 15% (hazard ratio [HR]: 1.15, 95% confidence interval [CI]: 1.01-1.31), and stroke incidence increased by 22% (HR = 1.22, 95% CI: 1.03-1.45). DII score displayed a linear association with nonfatal CVD and stroke (P for nonlinearity = 0.250 and 0.238, respectively). No significant association was found between the DII score and MI. Mediation analyses showed that the TyG index mediated 5.90% and 9.35% of the total association between DII score and nonfatal CVD and stroke, respectively.

CONCLUSIONS

This study provides evidence that dietary inflammatory potential is positively associated with nonfatal CVD and stroke in Chinese adults, and the association was partly mediated by insulin resistance.

Evaluating eight indicators for identifying metabolic syndrome in Chinese and American adolescents

BACKGROUND

Early intervention and diagnosis of Metabolic Syndrome (MetS) are crucial for preventing adult cardiovascular disease. However, the optimal indicator for identifying MetS in adolescent remains controversial.

METHODS

In total,1408 Chinese adolescents and 3550 American adolescents aged 12-17 years were included. MetS was defined according to the modified version for adolescents based on Adult Treatment Panel III (NCEP-ATP III) criteria. Areas under the curve (AUC) and corresponding 95% confidence interval (95% CI) of 8 anthropometric/metabolic indexes, such as waist circumference (WC), body mass index (BMI), a body shape index (ABSI), waist triglyceride index (WTI), were calculated to illustrate their ability to differentiate MetS. Sensitivity analysis using the other MetS criteria was performed.

RESULTS

Under the modified NCEP-ATP III criteria, WTI had the best discriminating ability in overall adolescents, with AUC of 0.922 (95% CI: 0.900-0.945) in Chinese and 0.959 (95% CI: 0.949-0.969) in American. In contrast, ABSI had the lowest AUCs. Results of sensitivity analysis were generally consistent for the whole Chinese and American population, with the AUC for WC being the highest under some criteria, but it was not statistically different from that of WTI.

CONCLUSIONS

WTI had relatively high discriminatory power for MetS detection in Chinese and American adolescents, but the performance of ABSI was poor.

IMPACT

While many studies have compared the discriminatory power of some anthropometric indicators for MetS, there are few focused on pediatrics. The current study is the first to compare the discriminating ability of anthropometric/metabolic indicators (WC, BMI, TMI, ABSI, WHtR, VAI, WTI, and TyG) for MetS in adolescents. WTI remains the optimal indicator in screening for MetS in adolescents. WC was also a simple and reliable indicator when screening for MetS in adolescents, but the performance of ABSI was poor. This study provides a theoretical basis for the early identification of MetS in adolescents by adopting effective indicators.

The association between alcohol consumption and blood lipids in Chinese children and adolescent: findings from the China Health and Nutrition Survey

BACKGROUND

Alcohol consumption by children and adolescents is receiving increasing attention. It may cause dyslipidemia, a risk factor for cardiovascular disease. However, the association between alcohol consumption and blood lipids in children and adolescents is unclear, and so we aimed to characterize this association.

METHODS

Data from the China Health and Nutrition Survey were extracted from children and adolescents aged 7-18 years for whom information was available on alcohol consumption. The population was divided into drinking and nondrinking groups. The χ2, Student's t, or Mann-Whitney U test was used to compare groups. Univariate and multivariate linear regression and propensity score matching (PSM) analysis were used to identify the association between alcohol consumption and blood lipids.

RESULTS

This study included 408 children and adolescents with 35 drinkers and 373 nondrinkers. The drinkers had significantly lower values of total cholesterol (TC) (3.8 mmol/L for nondrinkers versus 3.5 mmol/L for drinkers, p = 0.002) and high-density lipoprotein cholesterol (HDL-C) (1.3 mmol/L for nondrinkers versus 1.2 mmol/L for drinkers, p = 0.007), but not for low-density lipoprotein cholesterol (LDL-C) (2.1 mmol/L for nondrinkers versus 2.0 mmol/L for drinkers, p = 0.092) or triglyceride (TG) (0.9 mmol/L for nondrinkers versus 0.8 mmol/L for drinkers, p = 0.21). The univariate and multivariate analyses led to the same conclusions. After PSM there was still a significant negative association between alcohol consumption and TC or HDL-C.

CONCLUSION

Alcohol consumption in children and adolescents exhibited significant negative associated with TC and HDL-C, but not with LDL-C or TG. These findings need to be confirmed in future prospective research, and the health effects of blood lipid changes caused by drinking in children and adolescents need to be clarified.

Utility of waist-to-height ratio, waist circumference and body mass index in predicting clustered cardiometabolic risk factors and subclinical vascular phenotypes in children and adolescents: A pooled analysis of individual data from 14 countries

AIMS

The clinical utility of waist-to-height ratio (WHtR) in predicting cardiometabolic risk factors (CMRFs) and subclinical markers of cardiovascular disease remains controversial. We aimed to compare the utility of WHtR with waist circumference (WC) and body mass index (BMI) in identifying children and adolescents (youths) at risk for cardiometabolic outcomes, including clustered CMRFs, high carotid intima-media thickness (cIMT), and arterial stiffness (assessed as high pulse wave velocity, PWV).

METHODS

We analyzed data from 34,224 youths (51.0 % boys, aged 6-18 years) with CMRFs, 5004 (49.5 % boys, aged 6-18 years) with cIMT measurement, and 3100 (56.4 % boys, aged 6-17 years) with PWV measurement from 20 pediatric samples across 14 countries.

RESULTS

WHtR, WC, and BMI z-scores had similar performance in discriminating youths with ≥3 CMRFs, with the area under the curve (AUC) (95 % confidence interval, CI)) ranging from 0.77 (0.75-0.78) to 0.78 (0.76-0.80) using the modified National Cholesterol Education Program (NCEP) definition, and from 0.77 (0.74-0.79) to 0.77 (0.74-0.80) using the International Diabetes Federation (IDF) definition. Similarly, all three measures showed similar performance in discriminating youths with subclinical vascular outcomes, with AUC (95 % CI) ranging from 0.67 (0.64-0.71) to 0.70 (0.66-0.73) for high cIMT (≥P95 values) and from 0.60 (0.58-0.66) to 0.62 (0.58-0.66) for high PWV (≥P95 values).

CONCLUSIONS

Our findings suggest that WHtR, WC, and BMI are equally effective in identifying at-risk youths across diverse pediatric populations worldwide. Given its simplicity and ease of use, WHtR could be a preferable option for quickly screening youths with increased cardiometabolic risk in clinical settings.

Associations of dietary iron intake with cardiovascular disease risk and dyslipidemia among Chinese adults

BACKGROUND

Whether iron intake can affect cardiovascular disease (CVD) and dyslipidemia is controversial. However, few studies have focused on reducing the risk of CVD in people at risk for dyslipidemia. This study explored the linear relationship and possible nonlinear relationship between CVD and dyslipidemia.

METHODS

Dietary data were obtained from the China Health and Nutrition Survey between 2004 and 2015. The survey included 8173 participants older than 18 years. CVD risk was estimated by the Framingham risk score (FRS). Logistic regression analysis was used to determine whether iron intake affects CVD incidence and lipid profiles. The nonlinear association was tested with restricted cubic splines (RCSs).

RESULTS

For males, higher total iron intake [the fifth quintile (Q) vs. Q1 odds ratio (OR): 0.335, 95% confidence interval (CI): 0.248-0.453], heme iron intake (OR: 0.679, 95% CI: 0.492-0.937) and non-heme iron intake (OR: 0.362, 95% CI: 0.266-0.492) reduced CVD incidence. Heme iron intake increased high low-density lipoprotein cholesterol (LDL-C) (OR: 1.786, 95% CI: 1.226-2.602), high total cholesterol (TC) (OR: 2.404, 95% CI: 1.575-3.669), high triglyceride (TG) (OR: 1.895, 95% CI: 1.423-2.523), and low apolipoprotein A1/apolipoprotein B (ApoA-1/ApoB) risk (OR: 1.514, 95% CI: 1.178-1.945). Moderate non-heme iron intake reduced high-density lipoprotein cholesterol (HDL-C) incidence (Q5 vs. Q1 OR: 0.704, 95% CI: 0.507-0.979). For females, higher total iron intake (Q5 vs. Q1 OR: 0.362, 95% CI: 0.266-0.492) and non-heme iron intake (OR: 0.347, 95% CI: 0.154-0.781) reduced CVD incidence. Heme iron intake increased high LDL-C (OR: 1.587, 95% CI: 1.160-2.170) and high TC incidence (OR: 1.655, 95% CI: 1.187-2.309).

CONCLUSIONS

Men, especially those at risk of developing dyslipidemia, should consume non-heme rather than heme iron to reduce CVD incidence. For women, increased heme iron intake did not reduce CVD incidence. Therefore, women should minimize their heme iron intake to prevent dyslipidemia.

Correlations between China's socioeconomic status, disease burdens, and pharmaceuticals and personal care product levels in wastewater

The presence of pharmaceutical and personal care products (PPCPs) in domestic wastewater can potentially indicate socioeconomic status and disease burdens. However, current knowledge is limited to the correlation between specific pharmaceuticals and diseases. This study aims to explore the associations between socioeconomic status, disease burdens, and PPCP levels in domestic wastewater at a national level. Samples from 171 wastewater influents across China were used to measure PPCPs, and the per capita consumption of PPCPs was calculated. Results showed that the 31 targeted PPCPs were widely present in wastewater with varying occurrence characteristics. The mean consumption levels of different PPCPs varied greatly, ranging from 0.03 to 110723.15 µg/d/capita. While there were no significant regional differences in the overall pattern of PPCP consumption, 22 PPCPs showed regional variations between Northern China and Southern China. PPCPs with similar usage purposes exhibited similar distribution patterns. Disease burden (70.1%) was the main factor affecting most PPCP consumption compared to socioeconomic factors (26.4%). Through correlation analyses, specific types of PPCPs were identified that were highly associated with socioeconomic status and disease burdens, such as hypertension-bezafibrate, brucellosis-quinolones, sulfonamides, hepatitis-triclosan, triclocarban, socioeconomic development-fluoxetine, and people's living standards-gemfibrozil. Despite some uncertainties, this study provides valuable insights into the relationship between PPCPs in domestic wastewater and socioeconomic status and human health.

Mid-arm muscle circumference and triceps skinfold thickness associated with cardiometabolic disease in Chinese residents: A prospective cohort study

BACKGROUND AND AIMS

The association of cardiometabolic disease (CMD) with body muscle and fat mass remains unclear. Mid-arm muscle circumference (MAMC) and triceps skinfold (TSF) thickness are easily obtained measuring methods for these two body compositions. This study aimed to investigate the association of CMD with MAMC and TSF thickness among Chinese residents.

METHODS

A total of 9440 eligible participants from the China Health and Nutrition Survey were included in the analysis. Associations of CMD prevalence with MAMC and TSF thickness were estimated using logistic regression models. Multivariable COX proportional-hazards regression models were used to estimate the effect of baseline MAMC and TSF thickness on subsequent CMD.

RESULTS

Positive associations of CMD prevalence with MAMC (odds ratio [OR] = 1.169, 95% confidence interval [CI] 1.110-1.232, P < 0.001) and TSF thickness (OR = 1.313, 95%CI 1.240-1.390, P < 0.001) were observed in the cross-sectional analysis. In the longitudinal study, a 1-SD increase in MAMC was associated with a 13.6% increased risk of CMD incidence (hazard ratio [HR] = 1.136, 95%CI 1.073-1.204, P < 0.001), and a 1-SD increase in TSF thickness had a 17.6% increased risk of CMD incidence (HR = 1.176, 95%CI 1.084-1.276, P < 0.001). For the CMD components, both MAMC and TSF thickness contributed to increased incidences of hypertension (HR = 1.163, 95%CI 1.097-1.233, P < 0.001 in MAMC; HR = 1.218, 95%CI 1.110-1.336, P < 0.001 in TSF thickness) and diabetes mellitus (HR = 1.166, 95%CI 1.028-1.323, P = 0.017 in MAMC; HR = 1.352, 95%CI 1.098-1.664, P = 0.004 in TSF thickness).

CONCLUSIONS

Individuals with higher MAMC and TSF thickness had an increased incidence of CMD, mainly hypertension and diabetes mellitus. This study revealed a seemingly counterintuitive association between body muscle mass and metabolic homeostasis. Although the potential mechanisms require further exploration, the impact of body muscle mass on metabolic health cannot be ignored.

Physiological Dysregulation Proceeds and Predicts Health Outcomes Similarly in Chinese and Western Populations

BACKGROUND

A decade ago, we proposed an index of physiological dysregulation based on Mahalanobis distance (DM) that measures how far from the norm an individual biomarker profile is. While extensive validation has been performed, focus was mostly on Western populations with little comparison to developing countries, particularly at a physiological system level. The degree to which the approach would work in other sociocultural contexts and the similarity of dysregulation signatures across diverse populations are still open questions.

METHODS

Using 2 data sets from China and 3 from Western countries (United States, United Kingdom, and Italy), we calculated DM globally and per physiological system. We assessed pairwise correlations among systems, difference with age, prediction of mortality and age-related diseases, and sensitivity to interchanging data sets with one another as the reference in DM calculation.

RESULTS

Overall, results were comparable across all data sets. Different physiological systems showed distinct dysregulation processes. Association with age was moderate and often nonlinear, similarly for all populations. Mahalanobis distance predicted most health outcomes, although differently by physiological system. Using a Chinese population as the reference when calculating DM for Western populations, or vice versa, led to similar associations with health outcomes, with a few exceptions.

CONCLUSIONS

While small differences were noticeable, they did not systematically emerge between Chinese and Western populations, but rather diffusively across all data sets. These findings suggest that DM presents similar properties, notwithstanding sociocultural backgrounds, and that it is equally effective in capturing the loss of homeostasis that occurs during aging in diverse industrial human populations.

There was a similar U-shaped nonlinear association between waist-to-height ratio and the risk of new-onset hypertension: findings from the CHNS

Background

The association between waist-to-height ratio (WHtR) with hypertension has not been adequately explained, so in this study we sought to clarify the predictive role of WHtR on the incidence of hypertension as well as the potential nonlinear associations in the general population.

Methods

In this large prospective cohort study, a total of 4,458 individuals from the China Health and Nutrition Survey (CHNS) were included in the analysis. Multivariate Cox regression analyses, subgroup analyses, receiver operator characteristic (ROC) and restricted cubic spline (RCS) analyses were used to examine the association of WHtR with the risk of new-onset hypertension.

Results

Hypertension occurred in 32.8% of participants during the maximum six-year follow-up period. Compared with the group with lower WHtR, the group with higher WHtR had a higher incidence of hypertension (p < 0.001). Multivariate Cox regression analysis showed that the risk of hypertension was 1.45 times higher in the high WHtR group than in the low WHtR group, and that the risk of hypertension increased by 30.4% for every 0.1 unit increase in WHtR (p < 0.001). Subgroup analyses also validated the stratified associations between WHtR and the risk of new-onset hypertension in most subgroups (p < 0.05). ROC analyses also revealed that WHtR was superior to body mass index in predicting new-onset hypertension (AUC: 0.626 vs. 0.607, p = 0.009). Further RCS analysis detected a nonlinear association between WHtR and risk of new-onset hypertension (P for nonlinearity <0.001).

Conclusion

WHtR was nonlinearly associated with the risk of new-onset hypertension in the general population.

Establishing international optimal cut-offs of waist-to-height ratio for predicting cardiometabolic risk in children and adolescents aged 6-18 years

BACKGROUND

Waist-to-height ratio (WHtR) has been proposed as a simple and effective screening tool for assessing central obesity and cardiometabolic risk in both adult and pediatric populations. However, evidence suggests that the use of a uniform WHtR cut-off of 0.50 may not be universally optimal for pediatric populations globally. We aimed to determine the optimal cut-offs of WHtR in children and adolescents with increased cardiometabolic risk across different countries worldwide.

METHODS

We used ten population-based cross-sectional data on 24,605 children and adolescents aged 6-18 years from Brazil, China, Greece, Iran, Italy, Korea, South Africa, Spain, the UK, and the USA for establishing optimal WHtR cut-offs. We performed an external independent test (9,619 children and adolescents aged 6-18 years who came from other six countries) to validate the optimal WHtR cut-offs based on the predicting performance for at least two or three cardiometabolic risk factors.

RESULTS

Based on receiver operator characteristic curve analyses of various WHtR cut-offs to discriminate those with ≥ 2 cardiometabolic risk factors, the relatively optimal percentile cut-offs of WHtR in the normal weight subsample population in each country did not always coincide with a single fixed percentile, but varied from the 75th to 95th percentiles across the ten countries. However, these relatively optimal percentile values tended to cluster irrespective of sex, metabolic syndrome (MetS) criteria used, and WC measurement position. In general, using ≥ 2 cardiometabolic risk factors as the predictive outcome, the relatively optimal WHtR cut-off was around 0.50 in European and the US youths but was lower, around 0.46, in Asian, African, and South American youths. Secondary analyses that directly tested WHtR values ranging from 0.42 to 0.56 at 0.01 increments largely confirmed the results of the main analyses. In addition, the proposed cut-offs of 0.50 and 0.46 for two specific pediatric populations, respectively, showed a good performance in predicting ≥ 2 or ≥ 3 cardiometabolic risk factors in external independent test populations from six countries (Brazil, China, Germany, Italy, Korea, and the USA).

CONCLUSIONS

The proposed international WHtR cut-offs are easy and useful to identify central obesity and cardiometabolic risk in children and adolescents globally, thus allowing international comparison across populations.

L-shaped association between dietary coenzyme Q10 intake and high-sensitivity C-reactive protein in Chinese adults: a national cross-sectional study

Background: Chronic inflammation contributes to the occurrence and progression of many diseases. Most previous clinical studies have explored the effect of high-dose CoQ10 supplements on inflammation. Food is another important source of CoQ10, but the relationship between the intake of CoQ10 from dietary sources and inflammation was unknown. We aimed to explore the dose-response association between the intake of dietary-derived CoQ10 and inflammation-related biomarkers. Methods: Seven thousand nine hundred and fifty-three Chinese adults from the China Health and Nutrition Survey (CHNS) were the subjects of this cross-sectional investigation. Dietary CoQ10 intake was assessed using dietary information from three days. High-sensitivity C-reactive protein (hsCRP) and white blood cell count (WBC) were assessed using fasting venous blood. Results: In an adjusted linear regression model, CoQ10 consumption from dietary sources was inversely associated with hsCRP, with effect sizes in each group: Q2 (β = -0.85 mg L-1, 95% CI: -1.43 to -0.28 mg L-1, P = 0.004), Q3 (β = -0.70 mg L-1, 95% CI: -1.28 to -0.12 mg L-1, P = 0.017), and Q4 (β = -0.79 mg L-1, 95% CI: -1.39 to -0.19 mg L-1, P = 0.010). Moreover, restricted cubic splines (RCS) revealed a non-linear L-shaped association between dietary-derived CoQ10 consumption and hsCRP (Pnonlinear < 0.001). According to subgroup analyses, these relationships were more significant in males, or >45 years old (Ptrend < 0.05). Nevertheless, no significant relationship was found between dietary-derived CoQ10 intake and WBC. Conclusions: These findings suggested a significant negative association between dietary-derived CoQ10 and hsCRP levels.

Associations between the inflammatory potential of diets with adherence to plant-based dietary patterns and the risk of new-onset cardiometabolic diseases in Chinese adults: findings from a nation-wide prospective cohort study

Aims: convincing evidence is still limited for the validation of associations between the inflammatory potential of diets, based on the dietary inflammatory index (DII), and cardiometabolic outcomes. We aimed to investigate the associations between the DII with adherence to plant-based dietary patterns and the risk of new-onset cardiometabolic diseases (CMDs), including stroke, type 2 diabetes mellitus (T2DM) and myocardial infarction (MI). Methods: adults (N = 14 652) from the China Health and Nutrition Survey (1997-2015) were included in the current analysis. Dietary intake data were collected using a combination of 3 day consecutive 24 h dietary recalls and the food weighing method. The DII was calculated with established and validated methods. CMDs were identified using validated self-reported questionnaires. The Cox proportional hazard regression model was used for statistical analysis. Results: during a mean follow-up of 10 years, a total of 404 new-onset stroke, 1051 new-onset T2DM and 280 new-onset MI cases were identified. Lower PDI, hPDI, ERD, WISH and PHDI scores and higher uPDI scores were associated with higher DII scores (all P-trend < 0. 0001). A pro-inflammatory diet, as reflected by relatively higher DII scores, was positively associated with an increased risk of stroke (Q5 vs. Q1: HR = 1.90; 95% CI: 1.26-2.88; P-trend = 0.0006), T2DM (Q5 vs. Q1: HR = 2.08; 95% CI: 1.61-2.69; P-trend < 0.0001) and MI (Q5 vs. Q1: HR = 1.70; 95% CI: 1.04-2.76; P-trend = 0.0114) in the entire cohort. Sex and BMI significantly modified the association between the DII and the risk of T2DM, and sex significantly modified the association between the DII and the risk of MI. Conclusions: lower adherence to healthy and sustainable plant-based dietary patterns and higher adherence to unhealthy plant-based dietary patterns were associated with higher DII scores. With the use of the DII, we reported long-term positive associations between a pro-inflammatory diet and an increased risk of new-onset stroke, T2DM and MI in Chinese adults who were free from CMDs and cancer at the baseline. These findings provided evidence for the validation of associations between the DII and cardiometabolic health, and contributed to the current literature suggesting careful evaluations of whether the DII should be incorporated into dietary guidelines and utilized as an effective tool for improving the diet quality and CMD prevention in the Chinese population.

BMI at different childhood age periods associated with cardiometabolic disorders in young adulthood

OBJECTIVE

The aim of this study was to investigate when the association between childhood obesity and adult cardiometabolic disorders starts to be operative.

METHODS

The study cohort included 811 participants who had data on blood pressure, lipid profile, fasting blood glucose, fasting insulin, or alanine aminotransferase in adulthood and had at least one measurement of BMI in childhood.

RESULTS

Childhood BMI z score was significantly associated with increased risks of ≥1 cardiometabolic disorders, ≥2 cardiometabolic disorders, and elevated blood pressure in adulthood for age groups of 6 to 9 years, 10 to 12 years, 13 to 15 years, and 16 to 18 years, after adjustment for covariates. For low high-density lipoprotein cholesterol, significant associations were observed for age groups of 10 to 12 years, 13 to 15 years, and 16 to 18 years. For elevated triglyceride and elevated alanine aminotransferase, significant associations were observed for age groups of 13 to 15 years and 16 to 18 years. For insulin resistance, significant associations were observed for age groups of 10 to 12 years and 16 to 18 years. For elevated total cholesterol, elevated low-density lipoprotein cholesterol, or elevated fasting blood glucose, no association was observed in any age group.

CONCLUSIONS

The association between childhood BMI and adult cardiometabolic disorders begins to be operative from early life. These results support universal screening of childhood obesity starting at an early age.

Association between Diet Quality and Stroke among Chinese Adults: Results from China Health and Nutrition Survey 2011

The low-burden Diet Quality Questionnaire (DQQ) is a standardized tool to collect indicators of dietary adequacy as well as indicators of the protection of health against noncommunicable diseases (NCDs) within the framework of the global diet quality project. Stroke is the leading cause of the cardiovascular disease burden in China, with poor diet being one of the major risk factors. In this study, we aimed to understand the association of several indicators of diet quality derived from the DQQ with stroke among Chinese adults and, further, to examine the gender differences using the 2011 wave of the China Health and Nutrition Survey. Multivariable logistic regression was used to examine the associations of the NCD-Protect score, NCD-Risk score, and global dietary recommendations score (GDR) score with stroke. There were 192 stroke cases (121 in men and 71 in women) of 12,051 adults. The continuous NCD-Risk score was positively associated with stroke in women (odds ratio (OR) = 1.52, 95% confidence interval (CI): 1.13-2.06). When compared with women with an NCD-Risk score of 0 points, those with an NCD-Risk score ≥2 points had a higher risk of stroke (OR = 2.71, 95% CI: 1.35-5.43). In addition, compared with women with a GDR score ≤0, those with a GDR score ≥2 points had lower odds of stroke (OR = 0.42, 95% CI: 0.22-0.77). Poor diet quality, as reflected by the NCD-Risk score, was associated with an increased risk of stroke in Chinese women, but not in men. Our findings provided evidence that an optimal diet quality could be conducive to preventing stroke for Chinese women and suggested a diverse diet characterized by the limited consumption of unhealthy foods, such as red meat, processed meat, sweets, soft drinks (sodas), and packaged ultra-processed salty snacks.

U-shaped association of serum uric acid with cardiovascular disease risk scores and the modifying role of sex among Chinese adults

BACKGROUND AND AIMS

Serum uric acid (SUA) is involved in the development of cardiovascular disease (CVD). However, information on the dose-response relationship between SUA and CVD is limited in the Chinese population. This study aimed to investigate the potential nonlinear dose-response association of SUA with CVD risk in a Chinese population and to explore the effect of sex on these associations.

METHODS AND RESULTS

Cross-sectional data, from 6252 Chinese adults aged 30-74 years who participated in the China Health and Nutrition Survey 2009, were stratified by SUA deciles. The 10-year risk of CVD was determined using the Framingham risk score. A restricted cubic spline (RCS) was incorporated into the logistic models to assess the nonlinear relationship between SUA and CVD. Among the participants, 65%, 20%, and 15% had low, moderate, and high 10-year CVD risks, respectively. Compared with the reference SUA strata of 225 to <249 μmol/L, CVD risk was significantly increased at SUA ≥294 μmol/L, with adjusted ORs ranging from 2.39 (1.33-4.33) to 4.25 (2.37-7.65). An increasingly higher nonsignificant CVD risk was found at SUA <225 μmol/L and showed a nonlinear U-shaped association. In the fitted RCS model, an approximate U-shaped association between SUA and CVD risk scores was found in women, but this significant nonlinear relationship was not found in men.

CONCLUSION

This study showed that both lower and higher SUA levels were associated with a higher 10-year CVD risk among Chinese adults, forming a U-shaped relationship, and this pattern was particularly pronounced for women.

The Association between Plant-Based Diet Indices and Metabolic Syndrome in Chinese Adults: Longitudinal Analyses from the China Health and Nutrition Survey

Objectives: To investigate the association between a plant-based diet and metabolic syndrome (MetS) among Chinese adults. Methods: Based on the data from the 2004–2015 China Health and Nutrition Survey and the corresponding edition of China Food Composition, we calculated the healthy plant-based diet indices (hPDI) and unhealthy plant-based diet indices (uPDI). The Cox proportional hazards regression model was used to estimate the hazard ratios (HRs) with 95% confidence intervals (CIs) for MetS. Mediation analysis was further conducted to explore the mediator role of Body Mass Index (BMI) in the association between hPDI and MetS. Results: We included 10,013 participants, and over a median follow-up of 5 years, 961 patients (9.60%) developed MetS. Compared to those in the lowest quintile of hPDI score, we found that those in the highest quintile of hPDI score had a 28% lower ([HR]: 0.72, 95% CI 0.56–0.93, Ptrend = 0.021) risk of developing MetS and had a 20% lower (hazard ratio [HR]: 0.80, 95% CI 0.70–0.92, Ptrend = 0.004) risk of developing abdominal obesity. No significant associations were observed between uPDI and the MetS, but those in the highest quintile of uPDI score had a 36% higher (hazard ratio [HR]: 1.36, 95% CI 1.20–1.64, Ptrend < 0.001) risk of developing abdominal obesity, compared to those in the lowest quintile of uPDI score. In exploratory analysis, we observed that BMI at baseline mediated 27.8% of the association between hPDI and incident MetS, and BMI at baseline mediated 29.7% of the association between hPDI and abdominal obesity. Conclusion: The current findings reveal a possible causal relationship between a healthy plant-based diet and a reduced risk of MetS, especially abdominal obesity. It is observed that BMI may mediate the relationship between hPDI score and MetS. Controlling early dietary patterns and BMI may help reduce the risk of MetS.

Association of hemoglobin A1c with the incidence of hypertension: A large prospective study

Background

Although hemoglobin A1c (HbA1c) is closely related to diabetes, its relationship with the incidence of hypertension is still unknown, so we aimed to evaluate the relationship between HbA1c and the incidence of hypertension in the general population.

Method

In this large prospective cohort study with a median follow-up of 2 years, we included 4,074 participants from the China Health and Nutrition Survey (CHNS). Multivariate COX regression, subgroup analysis, receiver operator characteristic (ROC) curve and restricted cubic spline (RCS) were used to evaluate the relationship between HbA1c and incidental hypertension.

Results

Compared with participants without incident hypertension, participants with incident hypertension had higher levels of HbA1c (P < 0.05). In univariate COX regression analysis, HbA1c was associated with the risk of hypertension (HR: 1.161, 95% CI: 1.105-1.221, P < 0.001). In multivariate COX regression analysis adjusted for confounding variables, HbA1c was still closely related to the risk of hypertension (HR: 1.102, 95% CI: 1.006-1.206, P = 0.037). And subgroup analysis showed that the relationship between HbA1c and hypertension remained significant in female, lower than high school and non-obese subgroups (P < 0.05). ROC curve also showed that HbA1c could predict the risk of hypertension (AUC = 0.583, 95% CI: 0.568-0.598, P < 0.001). Further RCS analysis showed that HbA1c was positively correlated with the risk of hypertension (P for nonlinearity = 0.642).

Conclusion

HbA1c was linearly and positively associated with the incidence of hypertension.

Associations between body mass index in different childhood age periods and hyperuricemia in young adulthood: the China Health and Nutrition Survey cohort study

BACKGROUND

Few studies have evaluated the specific age period in childhood when the association of body mass index with adult hyperuricemia begins to be operative. This study aimed to examine the associations between body mass index in different childhood age periods and the risk of adult hyperuricemia in China.

METHODS

The study cohort from the China Health and Nutrition Survey included 676 participants who were aged ≥ 18 years and had data on uric acid in 2009 with at least one measurement of body mass index in childhood surveys before 2009. There were 357, 365, 358, 427, and 432 observations in childhood age groups of ≤ 5 years, 6-9 years, 10-12 years, 13-15 years, and 16-18 years, respectively. Body mass index Z score was calculated based on 2000 Center for Disease Control and Prevention growth charts for the United States.

RESULTS

Childhood body mass index Z scores measured at age ≤ 5 years, 6-9 years, 10-12 years, and 13-15 years had no statistical association with adult uric acid. In comparison, childhood body mass index Z scores measured at age 16-18 years were significantly associated with adult uric acid (β = 11.539, P = 0.007), and the strength of association was stronger in girls (β = 18.565, P = 0.002) than in boys (β = 9.209, P = 0.087). In addition, childhood body mass index Z scores measured at age 16-18 years were significantly associated with an increased risk of adult hyperuricemia (odds ratio = 1.323, 95% confidence interval = 1.003-1.746, P = 0.048), but not for other age groups.

CONCLUSION

The association between childhood body mass index and young adulthood hyperuricemia was influenced by childhood age.

Exploring the environment-nutrition-obesity effects associated with food consumption in different groups in China

Unsustainable diet is one of the main reasons for the nutrition-health-environment trilemma. However, information on environment-nutrition-obesity effects associated with food consumption is still limited. This study analyzes these diet-related impacts of different groups classified by various socio-economic attributes: location, gender, age, income, education, and occupation. We applied the samples in China Health and Nutrition Survey and divided them into advantaged group and dis-advantaged group according to the probability of access to more nutritious food. Results show that the advantaged groups had higher and more rapidly increasing dietary and nutrition quality than their counterpart during 1997-2011. On the contrary, the non-advantaged group' body mass index increased faster. Meanwhile, the high-income group as well as government and professional & technological workers have passed the criterion for overweight. The environmental footprints, i.e., nitrogen, phosphorus, carbon, and water footprints, of high-income group were higher 89%, 70%, 98%, and 41% than low-income group, respectively. Notably, food consumption sustainability of each group has declined, and the non-advantaged groups' is much more sustainable. We concluded that inequality existed and tends to expand in food consumption and its related impacts of different socio-economic groups. A reformed responsibility allocation system is needed during dietary transition for better environmental management. Strategies to improve dietary quality for advantaged group focus on improving the types of high-quality protein foods, such as milk and seafood, while the non-advantaged group can choose to increase the types of high-quality but relatively cheap foods like vegetables and fruits considering the availability and living cost.

Inverse Association between Dietary Diversity Score Calculated from the Diet Quality Questionnaire and Psychological Stress in Chinese Adults: A Prospective Study from China Health and Nutrition Survey

Specific nutrients or dietary patterns influence an individual’s psychological stress. As a major aspect of a healthy diet, the influence of dietary diversity on psychological stress remains uncertain. Within these contexts, we aimed to examine the association between the dietary diversity score and psychological stress, using prospective data from the China Health and Nutrition Survey (CHNS). We included 7434 adult participants, with complete dietary information, in the 2011 wave, and followed-up with perceived stress scale (PSS-14) in the 2015 wave. The dietary intake of foods was coded into 29 food groups, using the DQQ for China, and the dietary diversity scores were obtained, using DQQ, by calculating the number of food groups consumed during one 24-h dietary recall. The univariate analysis, and logistic regression model were used to examine the relationship between psychological stress and diet diversity. Approximately half of the participants (4204, 56.55%) perceived a higher level of stress (PSS-14 total score > 25). Dietary diversity was lower in the higher-stress group (p for trend <0.0001). Unconditional multivariate logistic regression demonstrated that participants with higher daily dietary diversity were less likely to experience higher-level psychological stress, compared with participants with lower daily dietary diversity (ORs range: 0.480−0.809). Dietary diversity was found to be inversely associated with psychological stress, in this prospective analysis of a national population. Further studies are required to figure out the mechanism and effectiveness of dietary diversity on psychological stress.

Gender differences in the associations of circulating erythrocytes and hemoglobin with hypertension risk

OBJECTIVE

Studies on associations of erythrocytes parameters with hypertension risk are scarce. We aimed to examine associations of the erythrocytes parameters with the hypertension risk and potential effect modification by gender using data from the China Health and Nutrition Survey.

METHODS

A total of 5419 eligible participants (2468 men, 45.5%) without hypertension at baseline in 2009 were included and followed for a median of 6.1 years. Parameters of erythrocytes and hemoglobin were measured at baseline. Multivariable Cox proportional hazards models were used to estimate the hazard ratio for the associations between these parameters and hypertension risk. Data were collected from 2009 to 2015 and analyzed in 2021.

RESULTS

A total of 1178 incident cases of hypertension were identified during the follow-up. In women, erythrocytes and hemoglobin were positively associated with risk of hypertension, yielding the highest hazard ratio in the third quartile of 1.59 (95% confidence interval, 1.28-1.97, P trend < 0.001) for erythrocytes and in the fourth quartile of 1.64 (95% confidence interval, 1.23-2.17, P trend < 0.001) for hemoglobin compared with their first quartile, respectively. In addition, quartiles of erythrocytes and hemoglobin were not associated with risk of hypertension in men ( P trend > 0.050).

CONCLUSION

Erythrocytes and hemoglobin were associated with an increased risk of hypertension in women, but not in men. Our findings suggest that special attention for the prevention of hypertension should be given to those women with the moderate to high level of circulating erythrocytes and higher level of hemoglobin.

Modifiable factors of 20-year blood pressure trajectories among normotensives and their associations with hypertension : a prospective study

Little is known about the impact of modifiable risk factors on blood pressure (BP) trajectories and their associations with hypertension (HTN). We aimed to identify BP trajectories in normotensive Chinese adults and explore their influencing factors and associations with HTN. We used data from 3436 adults with at least four BP measurements between 1989 and 2018 in the China Health and Nutrition Survey, an ongoing cohort study. We measured BP using mercury sphygmomanometers with appropriate cuff sizes in all surveys. We used group-based trajectory modelling to identify BP trajectories between 1989 and 2009 and multiple logistic and Cox regression models to analyse their influencing factors and associations with HTN in 2011-2018. We identified five systolic blood pressure (SBP) trajectories, 'Low-increasing (LI)', 'Low-stable (LS)', 'Moderate-increasing (MI)', 'High-stable (HS)' and 'Moderate-decreasing (MD)', and four diastolic blood pressure (DBP) trajectories classified as 'Low-increasing (LI)', 'Moderate-stable (MS)', 'Low-stable (LS)' and 'High-increasing (HI)'. People with higher physical activity (PA) levels and lower waist circumferences (WC) were less likely to be in the SBP LI, MI, HS and MD groups (P < 0·05). People with higher fruit and vegetable intakes, lower WCs and salt intakes and higher PA levels were less likely to be in the DBP LI, MS and HI groups (P < 0·05). Participants in the SBP HS group (hazard ratio (HR) 2·01) or the DBP LI, MS and HI groups (HR 1·38, 1·40, 1·71, respectively) had higher risks of HTN (P < 0·05). This study suggests that BP monitoring is necessary to prevent HTN in the Chinese population.

Long-term drinking behavior change patterns and its association with hyperuricemia in chinese adults: evidence from China Health and Nutrition Survey

Background

We aimed to explore the association between long-term drinking behavior change patterns with hyperuricemia (HUA) in Chinese community adults.

Methods

This study was designed as a community-based unbalanced cohort study involving 4127 adults aged between 18 ~ 75 years, derived from the China Health and Nutrition Survey (CHNS) in 1997 and 2009. Drinking behavior change patterns were categorized into: never drinking, change to drinking, quitting drinking, and continued drinking. The alcoholism, type, and frequency of drinking were further categorized. We applied logistic regression models to explore the associations between drinking behavior change patterns and HUA.

Results

The average age of the participants was 54.6 (± 11.3) years and 47.8% were male. The overall prevalence of HUA was 15.5%. Drinking behavior change patterns of quitting (aOR 1.8; 95% CI 1.1 ~ 2.8) and continued drinking (aOR 2.0; 95% CI 1.3 ~ 3.0) were positively associated with high risks of HUA in the male participants. Early drinking behaviors such as liquor intake (aOR 1.8; 95% CI 1.4 ~ 2.5) and high consumption or frequency showed a positive correlation with HUA. Of note, heavy alcoholism (aOR 2.0; 95% CI 1.4 ~ 2.8) and daily drinking (aOR 2.5; 95% CI 1.7 ~ 3.6) had the highest risks of HUA. Furthermore, in the male participants, the association between early total alcohol intake and HUA was more pronounced at 18 standard drinks intake, with a stable increasing trend. In contrast, no statistical correlation was observed between the drinking behaviors and HUA in the female participants.

Conclusions

Drinking behavior change patterns of quitting and continued drinking are strongly associated with increased risks of HUA in males. The risks emanated from early drinking behaviors such as liquor drinking, high drinking frequency, and alcohol consumption. Although quitting drinking was associated with lower HUA risks compared to continued drinking, it still presented an undeniable risk for HUA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13637-4.

Association Between Serum Aminotransferases and Risk of New-Onset Cardiometabolic Disease in a Healthy Chinese Population: A Cohort Study

Purpose

This study aimed to investigate the association between serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), and incident metabolic disease in a cohort of community-based older Chinese people.

Patients and Methods

Five thousand healthy Gaohang residents who attended community health checks at the Shanghai East Hospital in 2013 were recruited. Biological, biochemical, and lifestyle variables were collected. The cohort was followed for new-onset metabolic disease in 2014 and 2017, with a final study population of 3,123 (63%) after follow-up. The study outcome included type-2 diabetes mellitus and metabolic syndrome.

Results

Baseline AST and ALT were associated with incident type-2 diabetes mellitus (HR 1.019, 95% CI 1.006-1.032, p = 0.003 and HR 1.016, 95% CI 1.008-1.025, p < 0.001 respectively). These associations persisted after adjusting for traditional risk factors including age, sex, income, waist circumference, systolic blood pressure, diastolic blood pressure, HbA1c, triglyceride, cholesterol, HDL and eGFR. Baseline AST and ALT were associated with incident metabolic syndrome in the crude analysis (HR 0.980, 95% CI 0.965-0.996, p = 0.012 and HR 0.992, 95% CI 0.988-0.997, p = 0.001, respectively). However, the association between AST and ALT with metabolic syndrome was non-significant after adjusting for biochemical parameters such as the lipid profile.

Conclusion

This study demonstrated that serum AST and ALT are associated with new-onset type-2 diabetes mellitus, independent of traditional risk factors, in a cohort of older Chinese people. These findings may contribute to disease risk stratification and management in type-2 diabetes.

Alcohol consumption and its association with chronic kidney disease: Evidence from a 12-year China health and Nutrition Survey

BACKGROUND AND AIMS

Alcohol consumption is a major threat to global health. The aim of the present study was to explore the association between alcohol consumption and chronic kidney disease (CKD) in a Chinese population.

METHODS AND RESULTS

A total of 4664 participants, aged ≥18 years, who participated in a baseline alcohol survey in 1997 and were followed up in 2009 of the China Health and Nutrition Survey (CHNS), were recruited in the current study. Data on alcohol consumption was obtained using standardized questionnaires, with CKD (defined as eGFR <60 mL/min/1.73 m²) as the outcome. The results showed that 37.3% of the participants had consumed alcohol at the baseline. Current drinkers were mainly men, with at least senior high school education, and a history of smoking. In the 2009 survey, 14.5% of the participants had CKD. Association analyses revealed that alcohol drinkers had a lower likelihood of CKD than non-drinkers (11.0% vs. 16.6%, aOR: 0.76, 95%CI: 0.58-1.00), after adjusting potential covariates. Restricted cubic splines revealed that the relationship between alcohol consumption and CKD prevalence was U-shaped. The probability of CKD significantly increased when alcohol consumption exceeded 18 standard drinks per week (aOR: 1.66, 95%CI: 1.00-2.76). Approximately one-fourth of participants changed their drinking patterns during the 12-year follow-up, and male drinkers with persistent drinking patterns had the lowest prevalence of CKD (aOR: 0.48, 95% CI: 0.31-0.73).

CONCLUSION

Alcohol consumption showed a U-shaped association with CKD. Moderate drinkers exhibited a lower disease prevalence compared with non-drinkers and heavy drinkers. Further studies should be conducted to explore the mechanisms underlying this protective effect. However, non-drinkers should not start drinking alcohol even with this protective effect.

Benchmarking the driver acceleration impact on vehicle energy consumption and CO2 emissions

The study proposes a methodology for quantifying the impact of real-world heterogeneous driving behavior on vehicle energy consumption, linking instantaneous acceleration heterogeneity and CO₂ emissions. Data recorded from 20 different drivers under real driving are benchmarked against the Worldwide Harmonized Light Vehicle Test Cycle (WLTC), first by correlating the speed cycle with individual driver behavior and then by quantifying the CO₂ emissions and consumption. The vehicle-Independent Driving Style metric (IDS) is used to quantify acceleration dynamicity, introducing driving style stochasticity by means of probability distribution functions. Results show that the WLTC cycle assumes a relatively smooth acceleration style compared to the observed ones. The method successfully associates acceleration dynamicity to CO₂ emissions. We observe a 5% difference in the CO₂ emissions between the most favourable and the least favourable case. The intra-driver variance reached 3%, while the inter-driver variance is below 2%. The approach can be used for quantifying the driving style induced emissions divergence.

Dietary Copper and Selenium Intakes and the Risk of Type 2 Diabetes Mellitus: Findings from the China Health and Nutrition Survey

The long-term associations between dietary copper (Cu) and selenium (Se) intakes and type 2 diabetes mellitus (T2DM) risk are unclear. We aimed to examine the prospective associations between dietary Cu and Se intakes and T2DM risk in Chinese adults. A total of 14,711 adults from the China Health and Nutrition Survey (1997–2015) were included. Nutrient intakes were assessed by 3 consecutive 24 h recalls and food-weighing methods. T2DM was identified by a validated questionnaire and laboratory examination. Cox regression models were used for statistical analysis. A total of 1040 T2DM cases were diagnosed during 147,142 person-years of follow-up. In fully adjusted models, dietary Cu or Se intake was not associated with T2DM risk. Dietary Se intake significantly modified the association between dietary Cu intake and T2DM risk, and dietary Cu intake was positively associated with T2DM risk when Se intake was lower than the median (p-interaction = 0.0292). There were no significant effect modifications on the associations by age, sex, BMI, or region. Although dietary Cu or Se intake was not independently associated with T2DM risk in Chinese adults free from cardiometabolic diseases and cancer at the baseline, there was a significant interaction between dietary Cu and Se intakes on T2DM risk.

Inverse Association Between Variety of Proteins With Appropriate Quantity From Different Food Sources and New-Onset Hypertension

The relationships of the variety and quantity of different sources of dietary proteins with hypertension remain uncertain. We aimed to investigate associations between the variety and quantity of proteins intake from 8 major food sources and new-onset hypertension among 12 177 participants from the China Health and Nutrition Survey. Dietary intake was measured by 3 consecutive 24-hour dietary recalls combined with a household food inventory. The variety score of protein sources was defined as the number of protein sources consumed at the appropriate level, accounting for types and quantity of proteins. New-onset hypertension was defined as systolic blood pressure ≥140 mm Hg and diastolic blood pressure ≥90 mm Hg, or physician-diagnosed hypertension or receiving antihypertensive treatment, during the follow-up. During a median follow-up of 6.1 years, there were U-shaped associations of percentages energy from total, unprocessed or processed red meat-derived, whole grain-derived, and poultry-derived proteins with new-onset hypertension; an reverse J-shaped association of fish-derived protein with new-onset hypertension; L-shaped associations of eggs-derived and legumes-derived proteins with new-onset hypertension; and an reverse L-shaped association of refined grain-derived protein with new-onset hypertension (all P values for nonlinearity <0.001). That is, for each protein, there is a window of consumption (appropriate level) where the risk of hypertension is lower. Moreover, a significantly lower risk of new-onset hypertension was found in those with higher variety score of protein sources (per score increment, hazard ratio, 0.74 [95% CI, 0.72-0.76]). In summary, there was an inverse association between the variety of proteins with appropriate quantity from different food sources and new-onset hypertension.

Effect Modification of Hyperuricemia, Cardiovascular Risk, and Age on Chronic Kidney Disease in China: A Cross-Sectional Study Based on the China Health and Nutrition Survey Cohort

Introduction

The question of whether the increased burden of chronic kidney disease (CKD) is caused by the interaction of hyperuricemia and cardiovascular disease (CVD) risk factors or is accelerated by aging remains unresolved. The purpose of this study is to better understand the effect modification of hyperuricemia, cardiovascular risk, and age on CKD among the Chinese population.

Methods

This cross-sectional study of 8243 participants was derived from the China Health and Nutrition Survey (CHNS) in 2009. Inclusion criteria included age ≥18 years, non-pregnancy, and no history of high-protein diet prior to blood test. Demographics, comorbidities, health-related behaviors, and serum biomarkers were collected. Interaction association of hyperuricemia, CVD risk and age with CKD were analyzed using Logistic regression.

Results

CKD was detected in 359 (27.2%, 95% CI 24.8∼29.7%) of 1321 participants with hyperuricemia and 680 (9.8%, 95% CI 9.1∼10.5%) of 6,922 participants without hyperuricemia, and these patterns remained significant after controlling for age, gender, and Framingham risk score (adjusted odds ratio [aOR] 3.82, 95% CI 3.20∼4.57). We found a negative multiplicative interaction between hyperuricemia and CVD risk on CKD. The aOR in low-CVD risk groups was 5.51 (95% CI 4.03∼7.52), followed by medium-CVD risk groups (aOR: 3.64, 95% CI 2.61∼5.09) and high-CVD risk groups (aOR: 2.89, 95% CI 2.12∼3.96). CVD risk was less associated with CKD in hyperuricemia group (aOR: 0.92, 95% CI 0.68∼1.22) than in non-hyperuricemia group (aOR: 1.43, 95% CI 1.21∼1.70). Furthermore, hyperuricemia and age had a significant additive effect on CKD, with a synergy index of 2.26 (95% CI 1.45∼3.52). Coexisting with older age and hyperuricemia, the likelihood of developing CKD was higher than the sum of the two alone.

Conclusion

The link between hyperuricemia and CKD begins at a young age and becomes stronger in the low CVD risk group. For young adults, early detection of hyperuricemia, routine CVD risk assessment, and timely intervention of modifiable factors are warranted.

A Bayesian Network Analysis of the Probabilistic Relationships Between Various Obesity Phenotypes and Cardiovascular Disease Risk in Chinese Adults: Chinese Population-Based Observational Study

BACKGROUND

Cardiovascular disease (CVD) risk among individuals with different BMI levels might depend on their metabolic health. The extent to which metabolic health status and BMI affect CVD risk, either directly or through a mediator, in the Chinese population remains unclear.

OBJECTIVE

In this study, the Bayesian network (BN) perspective is adopted to characterize the multivariable probabilistic connections between CVD risk and metabolic health and obesity status and identify potential factors that influence these relationships among Chinese adults.

METHODS

The study population comprised 6276 Chinese adults aged 30 to 74 years who participated in the China Health and Nutrition Survey 2009. BMI was used to categorize participants as normal weight, overweight, or obese, and metabolic health was defined by the Adult Treatment Panel-3 criteria. Participants were categorized into 6 phenotypes according to their metabolic health and BMI categorization. The 10-year risk of CVD was determined using the Framingham Risk Score. BN modeling was used to identify the network structure of the variables and compute the conditional probability of CVD risk for the different metabolic obesity phenotypes with the given structure.

RESULTS

Of 6276 participants, 64.67% (n=4059), 20.37% (n=1279), and 14.95% (n=938) had a low, moderate, and high 10-year CVD risk. An averaged BN with a stable network structure was constructed by learning 300 bootstrapped networks from the data. Using BN reasoning, the conditional probability of high CVD risk increased as age progressed. The conditional probability of high CVD risk was 0.43% (95% CI 0.2%-0.87%) for the 30 to 40 years age group, 2.25% (95% CI 1.75%-2.88%) for the 40 to 50 years age group, 16.13% (95% CI 14.86%-17.5%) for the 50 to 60 years age group, and 52.02% (95% CI 47.62%-56.38%) for those aged ≥70 years. When metabolic health and BMI categories were instantiated to their different statuses, the conditional probability of high CVD risk increased from 7.01% (95% CI 6.27%-7.83%) for participants who were metabolically healthy normal weight to 10.47% (95% CI 7.63%-14.18%) for their metabolically healthy obese (MHO) counterparts and up to 21.74% and 34.48% among participants who were metabolically unhealthy normal weight and metabolically unhealthy obese (MUO), respectively. Sex was a significant modifier of the conditional probability distribution of metabolic obesity phenotypes and high CVD risk, with a conditional probability of high CVD risk of only 2.02% and 22.7% among MHO and MUO women, respectively, compared with 21.92% and 48.21% for their male MHO and MUO counterparts, respectively.

CONCLUSIONS

BN modeling was applied to investigate the relationship between CVD risk and metabolic health and obesity phenotypes in Chinese adults. The results suggest that both metabolic health and obesity status are important for CVD prevention; closer attention should be paid to BMI and metabolic status changes over time.

A doubly robust method to handle missing multilevel outcome data with application to the China Health and Nutrition Survey

Missing data are common in longitudinal cohort studies and can lead to bias, particularly in studies with informative missingness. Many common methods for handling informatively missing data in survey samples require correctly specifying a model for missingness. Although doubly robust methods exist to provide unbiased regression coefficients in the presence of missing outcome data, these methods do not account for correlation due to clustering inherent in longitudinal or cluster-sampled studies. In this work, we developed a doubly robust method to estimate the regression of an outcome on a predictor in the presence of missing multilevel data on the outcome, which results in consistent estimation of regression coefficients assuming correct specification of either (1) the probability of missingness or (2) the outcome model. This method involves specification of separate hierarchical models for missingness and for the outcome, conditional on observed auxiliary variables and cluster-specific random effects, to account for correlation among observations. We showed this proposed estimator is doubly robust and derived its asymptotic distribution, conducted simulation studies to compare the method to an existing doubly robust method developed for independent data, and applied the method to data from the China Health and Nutrition Survey, an ongoing multilevel longitudinal cohort study.

Gender differences in the relationships between housework and metabolic markers: a longitudinal cohort study in China

Background

Metabolic syndrome has become a major health threat throughout the world, but there are few studies that focus on the effects of housework on human metabolism. This study explores the association between housework and metabolic markers and examines whether there are gender differences in the relationship of housework intensity on these markers.

Methods

We obtained data for 2,624 participants from the China Health and Nutrition Survey and used binary logistic regression to analyze the association between housework and metabolic markers (triglycerides, high- and low-density lipoprotein cholesterol, hemoglobin, blood glucose, cholesterol, and blood pressure).

Results

We observed no association between housework and metabolic markers for men. However, we find that women who engaged in housework had a higher risk of triglycerides than those who did not (OR=1.16, 95% CI: 1.16, 4.25). Compared with low-intensity, we also find that women who performed moderate- and high-housework intensity had a higher risk of triglycerides (moderate-intensity: OR=1.78, 95% CI: 1.14, 2.78; high-intensity: OR=1.91, 95% CI: 1.22, 2.98), MetS (OR=1.54, 95% CI: 0.98, 2.43; OR=1.68, 95% CI: 1.07, 2.66), pre-hypertension (OR=1.68, 95% CI: 1.08, 2.62; OR=1.63, 95% CI: 1.04, 2.55), and obesity (OR=1.65, 95% CI: 1.01, 2.70; OR=1.66, 95% CI: 1.01, 2.72).

Conclusion

In women, we find that housework is positively associated with the metabolic markers, triglycerides, MetS, and pre-hypertension. However, we did not find evidence that this relationship exists in men, f or any biomarkers we considered. One possible explanation is that people who engage in high-intensity housework are more stressed and sleep less, which could be a mechanism by which housework becomes associated with metabolic disease.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12566-6.

Mediating Effect of Body Mass Index and Dyslipidemia on the Relation of Uric Acid and Type 2 Diabetes: Results From China Health and Retirement Longitudinal Study

Objective

This study assessed temporal relationships of serum uric acid (SUA) with blood glucose and determine the mediating effects of body mass index (BMI) and dyslipidemia on the relation of SUA and risk of type 2 diabetes.

Methods

Participants aged ≥ 45 years were participated in 2011 and followed up until 2015. Cox proportional hazards regression with a robust variance estimator was performed to explore the association of SUA with the risk of diabetes, and crosslagged path analysis was introduced to examine the temporal relationships between SUA and blood glucose. A mediation analysis was finally used to identify the mediating effect of BMI and dyslipidemia on the relation of SUA and the future risk of diabetes.

Results

A total of 9,020 participants were included with an average age of 58.59 years at baseline in 2011, and 53.6% of them were women. Linear dose–response relationship was identified by restricted spline cubic analysis between baseline SUA and follow-up blood glucose (the non-linear trend for fasting plasma glucose (FPG): β2 = −0.71, p = 0.52; for HbA1c: β2 = 0.05, p = 0.07; for risk of diabetes: β2 = 0.12, p = 0.39). Additionally, compared with the lowest quartiles of SUA, the adjusted risk ratios of diabetes were 1.00 (95% CI: 0.82–1.23), 1.08 (95% CI: 0.89–1.31), and 1.37 (95% CI: 1.11–1.96) for quartile 2–4 (p-trend &lt; 0.01), respectively. Further additional adjustments for BMI or dyslipidemia, these ratios were not statistically significant. In addition, a unidirectional relationship from baseline SUA to follow-up FPG (ρ1 = 0.24, p = 0.03) was further confirmed using crosslagged path analysis. After stratifying by genders, the above results were only significant in the women subgroup, and we thus conducted a mediation analysis in women and found that the BMI and dyslipidemia partially mediated the effect of SUA on diabetes with a 23.05 and 18.82% mediating effect, respectively.

Conclusions

These findings provide strong evidence that hyperuricemia preceded diabetes, and the effect of baseline SUA on follow-up type 2 diabetes was more pronounced among middle-aged and elderly Chinese women, especially in postmenopausal women, and this effect is partly mediated by BMI and dyslipidemia at baseline.

Association between life-course cigarette smoking and metabolic syndrome: a discovery-replication strategy

BACKGROUND

The relation between cigarette smoking and metabolic syndrome (MetS) remains unclear, and previous studies focusing on MetS are limited in sample size. We investigated the association between life-course smoking and MetS with independent discovery and replication samples.

METHODS

Preliminary analysis utilized data from an annual cross-sectional survey of 15,222 participants aged ≥ 60 years in Tianjin, China. Suggestive associations were followed-up in 8565 adults from the China Health and Nutrition Survey. MetS was identified according to the criteria of the Chinese Diabetes Society in 2013. Life-course smoking was assessed by a comprehensive smoking index (CSI), based on information on smoking intensity, duration, and time since cessation across life-course, collected through standard questionnaires. Participants were divided into four groups: non-smokers; and the tertiles of CSI in ever smokers. Multivariable logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between life-course smoking and MetS.

RESULTS

In the discovery sample, ORs of MetS were 2.01 (95%CI: 1.64-2.47) and 1.76 (95%CI: 1.44-2.16) for smokers in the highest and second tertile of CSI compared with never smokers. Potential interaction was shown for age, with increased ORs for MetS associated with smoking limited to individuals who aged < 70 years (P_interaction = 0.015). We were able to replicate the association between cigarette smoking and MetS in an independent adult sample (second tertile vs. never: OR = 1.30, 95%CI: 1.04-1.63). The interaction of smoking with age was also replicated.

CONCLUSIONS

Life-course cigarette smoking is associated with an increased odds of MetS, especially among individuals who aged < 70 years.

Life-course blood pressure trajectories and incident diabetes: A longitudinal cohort in a Chinese population

BACKGROUND

Blood pressure levels are correlated with diabetes among middle-aged or older adults. However, longitudinal trajectories of blood pressure during young adulthood and their impact on diabetes have been insufficiently studied.

METHODS

The longitudinal cohort consisted of 4,625 adults who had blood pressure and body mass index (BMI) repeatedly measured five to nine times during 18-60 years of age. Distinct systolic blood pressure (SBP) trajectories were identified by a group-based trajectory model. Logistic regression analyses were used to investigate the association between trajectory patterns or quartiles of area under the curve values of SBP trajectories and incident diabetes, respectively.

RESULTS

Four distinct trajectory groups were identified for SBP: normotensive-stable (n = 761, 16.5%), prehypertension-stable (n = 2,381, 51.5%), stage I hypertension-increasing (n = 1,231, 26.6%), and stage II hypertension-increasing (n = 251, 5.4%). Compared with subjects who remained at SBP <120 mmHg in the normotensive-stable group, individuals in the prehypertension-stable trajectory exhibited a normal SBP range (<140 mmHg), and they still had a significantly higher risk of diabetes (adjusted OR = 1.82, p = 0.029). Individuals had a greater risk of diabetes in the stage I hypertension-increasing group (adjusted OR = 2.31, p = 0.006) and the highest risk in the stage II hypertension-increasing group (adjusted OR = 3.91, p < 0.001) relative to the normotensive-stable group. Furthermore, compared with the first quartile, adjusted ORs (95% CIs) of the fourth quartile of SBP incremental and total AUC were 2.50 (1.61-3.97) and 1.82 (1.15-2.94), respectively.

CONCLUSIONS

Long-term SBP trajectory is a significant predictor for incident diabetes, which is independent of baseline SBP and body weight, attaching importance to maintaining optimal blood pressure levels and controlling changing slopes of SBP for preventing diabetes.

Does self-perceived income priority matter? The association between income inequality and allostatic load in China

There is a scarcity of evidence about the association between income inequality and allostatic load (AL) across diverse population, which is critical to identify the downstream biological pathway of the inequality-health linkage. This study aimed to determine the association of income inequality with AL, and assess whether there are differences in such association between people with different perception of income priority. We utilized data from the 2006 and 2009 wave of China Health and Nutrition Survey (CHNS). Multilevel linear regression analyses were conducted to examine the association between AL score and community Gini coefficient. Additionally, to investigate whether the association of income inequality and AL score would vary among individuals with different perception of income priority, a cross-level interaction term for Gini coefficient and self-perceived income priority was applied. Both the cross-sectional analysis in 2009 (coefficient = 0.081, p = .016) and the time-lagged analysis (0.106, 0.008) suggested that community-level Gini coefficient was positively associated with AL. Similar result was only found among individuals from low median income communities in subsample analysis. Additionally, the cross-level interaction between Gini coefficient and self-perceived income priority was significantly associated with AL among respondents from low-median income communities. There is a positive association between income inequality and AL among Chinese adults, with individual who perceived income as a higher priority in their life suffering more from income inequality. This study contributes to the increasing efforts and new perspective to understand the inner mechanism of both the detrimental effect of income inequality and the accumulation of AL.

Dietary patterns in association with the risk of elevated blood pressure, lipid profile and fasting plasma glucose among adults in Jiangsu Province of China

BACKGROUND AND AIMS

This study aimed to identify unique dietary patterns, and to examine the correlation of dietary patterns with elevated blood pressure, lipid profile and fasting plasma glucose (FPG) among adults in Jiangsu Province of China.

METHODS AND RESULTS

4951 individuals were selected in this cross-sectional study from nutrition and health survey in Jiangsu Province in 2014. Factor analysis was used to identify the dietary patterns. Higher quartile of the cereals-seafood-dairy dietary pattern was inversely associated with high low-density lipoprotein cholesterol (LDL) (composed to Q1, OR = 0.834, 95% CI: 0.700∼0.993, P < 0.05) and FPG (composed to Q1, OR = 0.725, 95% CI: 0.609-0.862, P < 0.05), while higher quartile of the traditional Jiangsu dietary pattern was positively associated with low high-density lipoprotein cholesterol (HDL) (composed to Q1, OR = 1.395, 95% CI: 1.067∼1.825, P < 0.05) and high systolic blood pressure (SBP) (composed to Q1, OR = 1.238, 95% CI: 1.020∼1.503, P < 0.05). Higher scores of the refined food-oriented dietary pattern was inversely related to high triglycerides (TG) (composed to Q1, OR = 0.665, 95% CI: 0.551∼0.802, P < 0.05), but was positively related to high TC (composed to Q1, OR = 2.179, 95% CI: 1.817∼2.614), high LDL (composed to Q1, OR = 2.431, 95% CI: 2.037∼2.902, P < 0.05) and elevated FPG (composed to Q1, OR = 1.734, 95% CI: 1.458∼2.061, P < 0.05).

CONCLUSION

Different structure of dietary patterns do affect the blood pressure, lipid profile and fasting plasma glucose among adults in Jiangsu Province, China.

The Effect of China's Compulsory Education Reforms on Physiological Health in Adulthood: A Natural Experiment

Lower education is related to higher biological risks for physiological health, but it remains unclear whether the risks can be reduced through policies aimed at increasing years of education. We utilized China's compulsory education reforms as a unique natural experiment, which stipulates that primary and lower secondary education is mandatory and free for all school-age children. Using a regression discontinuity design (RDD), we assessed the effect of the reform eligibility on biomarkers. The reforms resulted in an increase in years of education for those from communities with the middle 1/3 per capita income (PCI) (β = 2.44, 95% CI = 0.23 - 4.64). Reform eligibility had no impact on allostatic risks for the total sample (β = 0.065, 95% CI = -0.70 - 0.83) and for those from communities with the lowest (β = 0.35, 95% CI = -0.77 - 1.47) or highest third of PCI (β = 0.68, 95% CI = -0.64 - 2.00), while it reduced the metabolic risk (β = -0.14, 95% CI = -0.26 - -0.015) and total allostatic load (β = -1.58, 95% CI = -3.00 - -0.16) among those from communities with the middle third PCI. The results were confirmed by sensitivity analyses of different placebo cutoff points and bandwidths. The reforms led to better physiological health to some extent, but the effect only manifested in people from communities with a moderate community PCI, and had little impact on affluent or disadvantaged groups. Our findings stressed that the institutional context and respondents' socioeconomic environment must be taken into account when assessing the health impact of China's compulsory education reforms.

The Association between Trajectories of Anthropometric Variables and Risk of Diabetes among Prediabetic Chinese

In order to explore the association between trajectories of body mass index (BMI) and mid-upper arm circumference (MUAC) and diabetes and to assess the effectiveness of the models to predict diabetes among Chinese prediabetic people, we conducted this study. Using a national longitudinal study, 1529 cases were involved for analyzing the association between diabetes and BMI trajectories or MUAC trajectories. Growth mixture modeling was conducted among the prediabetic Chinese population to explore the trajectories of BMI and MUAC, and logistic regression was applied to evaluate the association between these trajectories and the risk of diabetes. The receiver operating characteristic curve (ROC) and the area under the curve (AUC) were applied to assess the feasibility of prediction. BMI and MUAC were categorized into 4-class trajectories, respectively. Statistically significant associations were observed between diabetes in certain BMI and MUAC trajectories. The AUC for trajectories of BMI and MUAC to predict diabetes was 0.752 (95% CI: 0.690-0.814). A simple cross-validation using logistic regression indicated an acceptable efficiency of the prediction. Diabetes prevention programs should emphasize the significance of body weight control and maintaining skeletal muscle mass and resistance training should be recommended for prediabetes.

'Trend in premature mortality from four major NCDs in Nanjing, China, 2007-2018'

BACKGROUND

This study aims to analyze the trends of premature mortality caused from four major non-communicable diseases (NCDs), namely cardiovascular disease (CVD), cancer, chronic respiratory diseases, and diabetes in Nanjing between 2007 and 2018 and project the ability to achieve the "Healthy China 2030" reduction target.

METHODS

Mortality data of four major NCDs for the period 2007-2018 were extracted from the Death Information Registration and Management System of Chinese Center for Disease Control and Prevention. Population data for Nanjing were provided by the Nanjing Bureau of Public Security. The premature mortality was calculated using the life table method. Joinpoint regression model was used to estimate the average annual percent changes (AAPC) in mortality trends.

RESULTS

From 2007 to 2018, the premature mortality from four major NCDs combined in Nanjing decreased from 15.5 to 9.5%, with the AAPC value at - 4.3% (95% CI [- 5.2% to - 3.4%]). Overall, it can potentially achieve the target, with a relative reduction 28.6%. The premature mortality from cancer, CVD, chronic respiratory diseases and diabetes all decreased, with AAPC values at - 4.2, - 5.0%, - 5.9% and - 1.6% respectively. A relative reduction of 40.6 and 41.2% in females and in rural areas, but only 21.0 and 12.8% in males and in urban areas were projected.

CONCLUSION

An integrated approach should be taken focusing on the modifiable risk factors across different sectors and disciplines in Nanjing. The prevention and treatment of cancers, diabetes, male and rural areas NCDs should be enhanced.

Distinct Prognostic Role of Serum Uric Acid Levels for Predicting All-Cause Mortality Among Chinese Adults Aged 45~75 Years With and Without Diabetes

Introduction

The current study sought to explore the effect of baseline serum uric acid (SUA) on the risk of all-cause mortality among Chinese adults aged 45~75 years and to determine its interaction relationship with diabetes.

Methods

The study was designed as a community-based cohort of 4467 adults aged between 45~75 years included in a 6-years follow-up period from 2009 to 2015 years by the China Health and Nutrition Survey (CHNS). Baseline SUA levels were grouped into quartiles and its association on all-cause mortality was explored using multivariate Cox proportional hazards models. Stratified analyses were performed to explore the associations of SUA quartiles with all-cause mortality among diabetic and non-diabetic individuals.

Results

A total of 141 deaths (5.3 per 1000 person-years) were recorded During a follow-up of 26431 person-years. Out of the 141 deaths, 28 deaths (10.1 per 1000 person-years) were reported in the diabetic groups and 113 deaths (4.8 per 1000 person-years) were recorded in the non-diabetic group. An increased risk of all-cause mortality was observed for participants in the first and fourth quartiles compared with the second SUA quartile, (Q1 SUA: aHR=2.1, 95% CI 1.1~4.1; Q4 SUA: aHR=2.1, 95% CI 1.1~4.0). Stratification of participants by diabetes status showed a U-shaped association for non-diabetic individuals. Whereas, declined eGFR, rather than SUA, was an independent risk factor for all-cause mortality in diabetic individuals (aHR=0.7, 95% CI 0.6~1.0).

Conclusion

Our study proved that the prognostic role of SUA for predicting all-cause death might be regulated by diabetes. Both low and high SUA levels were associated with increased mortality, supporting a U-shaped association only in non-diabetic individuals. Whereas, renal dysfunction rather than SUA was an independent risk factor for all-cause mortality. Further studies should be conducted to determine the SUA levels at which intervention should be conducted and explore target follow-up strategies to prevent progression leading to poor prognosis.

The geriatric nutritional risk index mediated the relationship between serum uric acid and hypertension: a mediation analysis

Background

The elevated serum uric acid (SUA) is associated with an increased risk of hypertension and nutritional status. Malnutrition might modify the association of SUA with hypertension. Therefore, the aims of this study were to examine the mediation effect of malnutrition on the association of SUA with the risk of hypertension in Chinese population.

Methods

The study was based on the China Health and Nutrition Survey in 2009. Participants aged ≥ 60 years with complete analyzed data were eligible. The Geriatric Nutritional Risk Index (GNRI) was calculated by serum albumin (ALB) and BMI. Participants were identified as hypertension if systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg or receiving antihypertensive drug.

Results

There were 2371 participants included in the final analysis. In total, there was a significant mediation effect of the GNRI on the relationship between SUA level with hypertension (P < 0.001; OR: 1.096; and 95 % CI: 1.048–1.146). And the proportion mediated was 17.77 %. The results stratified by sex were consistent with those of total population. The significant mediation effects of the GNRI were found in the 60–69 years and 70–79 years groups (P = 0.002 and 0.032; OR: 1.099 and 1.075; and 95 % CI: 1.036–1.165 and 1.006–1.148, respectively) but not in the 80–99 years group (P = 0.303). The proportions mediated were16.22 % and 18.36 %, respectively.

Conclusions

The GNRI can mediate and account for approximately 17.77 % of the relationship between SUA level and the risk of hypertension. And this mediation effect was fully observed in both males and females, especially in the 60–79 years population.

The curse of modernization? Western fast food and Chinese children's weight

The income-adjusted price of fast food in China is five times more than in the United States, yet we show that the introduction of Western fast-food restaurants to China still leads to significant weight gain in children. Using the community-year-level presence of Western fast-food outlets, difference-in-differences estimations find a 4.8-percentage-point increase in the prevalence of overweight/obese children after controlling for child and year fixed effects. The effect decreases at a distance of 3-4 km from a fast-food restaurant, and we find no further weight gain 2 years after the restaurant's introduction. The underweight rate is not affected by fast-food introduction. The increase in fat share of energy intake serves as the channel for weight gain. Children in high-income families, younger than 11 years, and girls are more affected than other Chinese children.

Nutrition transition and chronic diseases in China (1990-2019): industrially processed and animal calories rather than nutrients and total calories as potential determinants of the health impact

OBJECTIVE

To extend analyses of nutrition transition in developed countries to China within the framework of the 3Vs rule considering degree of processing starting with plant/animal calorie ratio (Rule 1), industrially processed foods (IPFs, Rule 2), and food diversity through nutrient intakes (Rule 3).

DESIGN

Total and main food group (n 13) calorie intakes, percentages of animal and IPF calories, adequacy of the Dietary Reference Intake (DRI) and prevalence of chronic diseases were retrieved from scientific literature and international databases.

SETTING

China, 1990–2019.

PARTICIPANTS

Overall population.

RESULTS

The total calorie intake decreased by 9 % over 30 years while the prevalence of chronic diseases substantially increased. Percentages of IPFs (Rule 1) and animal (Rule 2) calorie intake shifted from 9 to 30 % and 2 to 30 %, respectively. Meanwhile, the overall DRI adequacy (Rule 3) did not improve, with calcium and retinol deficiencies in 2019, and, although remaining above DRI, iron, copper, magnesium, and vitamins E, C and B1–B9 intakes regularly decreased. Notably, the prevalence of obesity increased five-fold, paralleling the exponential increase in IPF calorie intake. Both sources of calories were highly correlated with prevalence of main chronic diseases.

CONCLUSIONS

Despite a slight decreased of total calorie consumption and small variations of adequacy with DRI, the farther the Chinese population moved away from the 3Vs rule during the 1990–2019 period, the more the prevalence of chronic diseases increased. Further analyses on foods’ transitions will be better assessed when advocating sources/quality of calories (Rules 1/2), rather than only nutrient composition (Rule 3).

Development and internal validation of a multivariable prediction model for 6-year risk of stroke: a cohort study in middle-aged and elderly Chinese population

OBJECTIVE

To develop and internally validate a prediction model for 6-year risk of stroke and its primary subtypes in middle-aged and elderly Chinese population.

DESIGN

This is a retrospective cohort study from a prospectively collected database.

PARTICIPANTS

We included a total 3124 adults aged 45-80 years, free of stroke or myocardial infarction at baseline in the 2009-2015 cohort of China Health and Nutrition Survey.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcome of the prediction model was stroke. Investigated predictors were: age, gender, body mass index (BMI), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), total cholesterol (TC), hypertension (HBP), drinking status, smoking status, diabetes and site. Stepwise multiple Cox regression was applied to identify independent predictors. A nomogram was constructed to predict 6-year risk of stroke based on the multiple analysis results. Bootstraps with 1000 resamples were applied to both C-index and calibration curve.

RESULT

The overall incidence of overall stroke was 2.98%. Age, gender, HBP and TC were found as significant risk predictors for overall stroke; age, gender, HBP and LDL-C were found as significant risk predictors for ischaemic stroke; age, gender, HBP, BMI and HDL-C were found as significant risk predictors for haemorrhagic stroke. The nomogram was constructed using significant variables included in the model, with a C-index of 0.74 (95% CI: 0.72 to 0.76), 0.74 (95% CI: 0.71 to 0.77), and 0.81 (95% CI: 0.78 to 0.84) for overall stroke, ischaemic stroke, and haemorrhagic stroke model, respectively. The calibration curves demonstrated the good agreements between predicted and observed 6-year risk probability.

CONCLUSION

Our nomogram could be convenient, easy to use and effective prognoses for predicting 6-year risk of stroke in middle-aged and elderly Chinese population.

Short sleep duration increases the risk of hyperuricemia among Chinese adults: findings from the China Health and Nutrition Survey

STUDY OBJECTIVES

Hyperuricemia is a growing public health problem with its increasing prevalence. Few studies have investigated the association between sleep duration and hyperuricemia. The objective of this study is to explore whether short sleep duration is an independent risk factor of hyperuricemia in Chinese adults.

METHODS

The data we analyzed was extracted from the 2009 wave of the China Health and Nutrition Survey. The population we analyzed included 8289 participants aged 18 years or older with sleep of 5-10 h per 24 h. We categorized the population into three groups by sleep duration: 5-6 h (short sleeper),7-8 h (regular sleeper), and 9-10 h (long sleeper). Hyperuricemia was defined as serum uric acid ≥7 mg/dL in men and ≥6 mg/dL in women.

RESULTS

Among the three groups, 9.8% were short sleepers, 68.4% were regular sleepers and 21.8% were long sleepers. The prevalences of hyperuricemia were 19.5%,15.2% and 15.5% respectively. The risks of hyperuricemia in regular and long sleep groups were lower than short sleep group, and the association remained after adjusting for indexes including age, gender, chronic kidney disease, hypertension, diabetes mellitus, high low-density lipoprotein cholesterol (LDL-c), and obesity. In subgroup analysis, we found the association was still observed in participants without hypertension, diabetes mellitus or obesity.

CONCLUSIONS

Our findings suggest that short sleep duration is associated with higher risk of hyperuricemia independently of cardiometabolic risk factors, especially in individuals without traditional hyperuricemia risk factors.