Serum lipids and lipoproteins in Chinese men and women.

Abstract

Because of rapid change in lifestyle risk factors, cardiovascular disease has become the leading cause of death in China. We sought to estimate the national levels of serum lipids and lipoproteins among the Chinese adult population.
We conducted a cross-sectional study in a nationally representative sample of 46 239 adults aged ≥20 years. Fasting serum total, high-density lipoprotein, and low-density lipoprotein cholesterol and triglycerides were measured by standard methods. The age-standardized estimates of total, high-density lipoprotein, and low-density lipoprotein cholesterol and triglycerides were 4.72 (95% confidence interval, 4.70-4.73), 1.30 (1.29-1.30), 2.68 (2.67-2.70), and 1.57 (1.55-1.58) mmol/L, respectively, in the Chinese adult population. In addition, 22.5% (21.8-23.3%) or 220.4 million (212.1-228.8) Chinese adults had borderline high total cholesterol (5.18-6.21 mmol/L), and 9.0% (8.5-9.5%) or 88.1 million (83.4-92.8) had high total cholesterol (≥6.22 mmol/L). The population estimates for borderline high (3.37-4.13 mmol/L), high (4.14-4.91 mmol/L), and very high (≥4.92 mmol/L) low-density lipoprotein cholesterol were 13.9% (13.3-14.5%) or 133.5 million (127.0-140.1), 3.5% (3.3-3.8%) or 33.8 million (31.2-36.5), and 3.0% (2.8-3.3%) or 29.0 million (26.3-31.8) persons, respectively. In addition, 22.3% (21.6-23.1%) or 214.9 million (207.0-222.8) persons had low high-density lipoprotein cholesterol (<1.04 mmol/L). The awareness, treatment, and control of borderline high or high total cholesterol were 11.0%, 5.1%, and 2.8%, respectively, in the Chinese adult population.
Serum total and low-density lipoprotein cholesterol levels were high and increasing in the Chinese population. Without effective intervention, atherosclerotic cardiovascular diseases may soar in the near future in China.

Full text

Page 1

Shan and Jiang He
Lixiang Lin, Li Chen, Xiaohui Guo, Zhigang Zhao, Qiang Li, Zhiguang Zhou, Guangliang
Juming Lu, Zhongyan Shan, Jie Liu, Haoming Tian, Qiuhe Ji, Dalong Zhu, Jiapu Ge,
Wenying Yang, Jianzhong Xiao, Zhaojun Yang, Linong Ji, Weiping Jia, Jianping Weng,
Serum Lipids and Lipoproteins in Chinese Men and Women
1524-4539
Copyright © 2012 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online ISSN:
Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX 72514
published online April 9, 2012
Circulation

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Serum Lipids and Lipoproteins in Chinese Men and Women

Running title: Yang et al.; Serum lipids and lipoproteins in China

Wenying Yang, MD1; Jianzhong Xiao, MD, PhD1; ZhaojunYang, MD1; Linong Ji, MD2;
Weiping Jia, MD3; Jianping Weng, MD4; Juming Lu, MD5; Zhongyan Shan, MD6; Jie Liu, MD7;
Haoming Tian, MD8; Qiuhe Ji, MD9; Dalong Zhu, MD10; Jiapu Ge, MD11; Lixiang Lin, MD12;
Li Chen, MD13; Xiaohui Guo, MD14; Zhigang Zhao, MD15; Qiang Li, MD16;
Zhiguang Zhou, MD17, Guangliang Shan, MD, PhD18; Jiang He, MD, PhD19 on behalf of the
China National Diabetes and Metabolic Disorders Study Investigators*

1China-Japan Friendship Hospital; 2Peking Univ Peoples’ Hospital, Beijing; 3Shanghai Jiaotong Univ
Affiliated Sixth People's Hospital, Shanghai; 4Sun Yat-sen Univ Third Hospital, Guangzhou; 5Chinese
PLA General Hospital, Beijing; 6The First Affiliated Hospital, Chinese Medical Univ, Liaoling; 7Shanxi
Province People’s Hospital, Shanxi; 8West China Hospital, Sichuan Univ, Sichuan; 9Xijing Hospital,
Fourth Military Medical Univ, Shaanxi; 10The Affiliated Drum Tower Hospital of Nanjing Univ Medical
School, Jiangsu; 11Xinjiang Uygur Autonomous Region’s Hospital, Xinjiang; 12Fujian Provincial
Hospital, Fujiang; 13Qilu Hospital, Qilu Hospital of Shandong Univ, Shandong; 14Peking Univ First
Hospital, Beijing; 15Henan Province People’s Hospital, Henan; 16The Second Affiliated Hospital of
Harbin Medical Univ, Heilongjiang; 17Xiangya Second Hospital, Hunan; 18Peking Union Medical
College, Beijing, China; 19Tulane Univ School of Public Health & Tropical Medicine, New Orleans, LA
*See appendix for list of the China National Diabetes & Metabolic Disorders Study group


Correspondence:
Wenying Yang, MD
Department of Endocrinology
China-Japan Friendship Hospital
Beijing, China, 100029
Tel: 86-10- 8420-5719
Fax: 86-10-84205716
E-mail: ywy_1010@yahoo.com.cn
Journal Subject Code: [8] Epidemiology
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Abstract:

Background - Due to rapid change in lifestyle risk factors, cardiovascular disease has become
the leading cause of death in China. We aimed to estimate the national levels of serum lipids and
lipoproteins among the Chinese adult population.
Methods and Results - We conducted a cross-sectional study in a nationally representative
sample of 46,239 adults aged ?20 years. Fasting serum total, high-density lipoprotein (HDL),
and low-density lipoprotein (LDL) cholesterol and triglycerides were measured using standard
methods. The age-standardized estimates of total, HDL and LDL cholesterol, and triglycerides
were 4.72 (95% confidence interval 4.70-4.73), 1.30 (1.29-1.30), 2.68 (2.67-2.70), and 1.57
(1.55-1.58) mmol/L, respectively, in the Chinese adult population. In addition, 22.5% (21.8-
23.3) or 220.4 million (212.1-228.8) Chinese adults had borderline high total cholesterol (5.18-
6.21 mmol/L) while 9.0% (8.5-9.5) or 88.1 million (83.4-92.8) had high total cholesterol (?6.22
mmol/L). The population estimates for borderline high (3.37-4.13 mmol/L), high (4.14-4.91
mmol/L) and very high (?4.92 mmol/L) LDL-cholesterol were 13.9% (13.3-14.5) or 133.5
million (127.0-140.1), 3.5% (3.3-3.8) or 33.8 million (31.2-36.5), and 3.0 (2.8-3.3) or 29.0
million (26.3-31.8) persons, respectively. In addition, 22.3% (21.6-23.1) or 214.9 million (207.0-
222.8) persons had low HDL-cholesterol (<1.04 mmol/L). The awareness, treatment, and control
of borderline high or high total cholesterol were 11.0%, 5.1%, and 2.8%, respectively, in the
Chinese adult population.
Conclusions - Serum total and LDL cholesterol levels were high and increasing in the Chinese
population. Without effective intervention, atherosclerotic cardiovascular diseases may soar in
the near future in China.
Key words: lipids; lipoproteins; China; cross-sectional studies; prevalence
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With rapid economic development and resulting adverse changes in lifestyle (such as a high
intake of dietary saturated fat and increased physical inactivity), cardiovascular diseases have
become the leading cause of death in China.1,2 For example, it was estimated that 43.8% of
deaths in Chinese adults aged 40 years or older were attributable to heart disease and stroke
during 1991 to 2000 in a national prospective cohort study.2 Elevated serum lipids are one of the
most important modifiable risk factors for cardiovascular disease in western 3,4, as well as in
Asian 5,6, populations. The Global Burden of Metabolic Risk Factors of Chronic Diseases
Collaborating Group reported that mean total cholesterol declined in Australasia, North America,
and Europe between 1980 and 2008, but increased in east and southeast Asia and Pacific
regions.7 These estimates, however, are modeled based on serum total cholesterol data mostly
from small regional studies. National data on serum lipids and lipoproteins are scarce, especially
in developing countries.
The objectives of the present study are: (1) to provide current and reliable data on
population levels of serum lipids and lipoproteins in the general adult population in China; (2) to
estimate the prevalence, awareness, treatment, and control of hypercholesterolemia in the
Chinese population; and (3) to examine the association between metabolic risk factors and levels
of serum lipids and lipoproteins in the Chinese population.

Methods
Study Population
The China National Diabetes and Metabolic Disorders Study was conducted from June 2007 to
May 2008. The details of the study population and methods have been published elsewhere.8 In
brief, we used a multiple-stage stratified sampling method to select a nationally representative
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sample of the general population aged ?20 years in China (Figure 1, Supplemental Figure).
The sampling process was stratified by geographic regions, urbanization, and economic
development status. The first 2-stages of sampling to select provinces from geographic regions
and to select cities and counties from provinces were not random. The next stages to select city
districts from cities and rural townships from counties, as well as to select street districts from
city districts and rural villages from townships, were random. This multi-stage stratified
sampling process resulted in an oversampling of urban residents. In total, 152 urban street
districts and 112 rural villages were selected. The final stage of sampling was stratified by the
gender and age distribution based on China Population Data from 2006.9 Only persons who had
lived in their current residence for ?5 years were eligible to participate. All individuals
permanently living in county seats and larger urban settings (i.e., prefectural-level cities,
provincial-level cities, and municipalities) were considered urban residents while individuals
living in townships and villages were considered rural residents.
A total of 54,240 individuals were selected and invited to participate in the study. Of them, a
total of 47,325 persons (18,976 men and 28,349 women) completed the study. The overall
response rate was 87.3%: 81.0% men and 92.0% women; 88.1% in urban areas and 82.7% in
rural areas. After excluding 538 persons with missing demographic information and 1,030 who
lacked lipids data, 45,757 adults were included in the final analysis.
Institutional review boards or ethics committees at all participating institutes approved
the study protocol. Written informed consent was obtained from each participant before data
collection.
Data collection
Data collection was conducted in examination centers at local health stations or community
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clinics in the participants' residential area. During the clinic visits, trained research staff
administered a standard questionnaire to collect information on demographic characteristics,
personal and family medical history, and lifestyle risk factors.10 The interview included
questions related to the diagnosis and treatment of hypercholesterolemia or hypertriglyceridemia.
Cigarette smoking was defined as having smoked at least 100 cigarettes in one’s lifetime. Those
who smoked tobacco products at the time of the survey were classified as current smokers. The
amount and type of alcohol consumed during the past year was collected, and alcohol drinking
was defined as consuming alcohol at least once per week. Regular leisure-time physical activity
was defined as participation in 30 or more minutes of moderate or vigorous activity per day at
least 3 days per week. Socioeconomic status, education, occupation, and income were also
recorded. The economic development of provinces or municipalities was defined based on the
gross domestic product per capita in 2006. Blood pressure, body weight, height, and waist
circumference were measured using standard methods.10 Body-mass index was calculated as
weight in kilograms divided by the square of height in meters.
Blood samples were drawn by venipuncture after at least 10 hours of overnight fasting to
measure serum total, HDL and LDL cholesterol, triglycerides, and plasma glucose. Blood
specimens were processed at the field center and shipped by air to the central laboratories in each
province. Serum cholesterol and triglycerides were assessed enzymatically with commercially
available reagents at the clinical biochemical laboratories in each province. All clinical
laboratories in this study successfully completed a standardization and certification program.
All study investigators and staff members successfully completed a training program that
oriented them to both the aims of the study and to the specific tools and methodologies
employed. At the training sessions, interviewers were given detailed instructions on
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administration of the study questionnaire. Clinical staff members were trained to obtain blood
pressure, anthropometry measurements, and blood specimens according to a standard protocol.10
Statistical analysis
All statistical analyses were conducted using SUDAAN software (version 10; Research Triangle
Institute, Research Triangle Park, NC). All estimates were weighted to represent the total
Chinese adult population aged ?20 years, based on Chinese population data from 2008, and the
study sampling scheme, and considered several features of the survey, including oversampling
for female and urban residents, non-response, economic development, and other demographic or
geographic differences between the sample and the total population. Standard errors were
estimated by a technique appropriate to the complex survey design. All p-values were 2-tailed
and not adjusted for multiple testing.
Mean levels of total, HDL, and LDL cholesterol and triglycerides were estimated for the
overall population and by urbanization (urban and rural) for men and women after age-
standardization to the population distribution in China in 2008.11 Next, age-specific mean levels
were determined for men and women. Serum total, HDL, and LDL cholesterol levels were
classified based on the Third Report of the Expert Panel on Detection, Evaluation, and Treatment
of High Blood Cholesterol in Adults (ATP III).12 The prevalence estimates of total, HDL, and
LDL cholesterol categories were calculated for the overall population and by gender using the
direct method according to the population distribution in China in 2008.11 Estimated numbers of
individuals by cholesterol categories were calculated using subgroup-specific prevalence by age,
gender, geographic region, urbanization, economic development, and population size in China in
2008.

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Results
Table 1 shows the demographic and clinical characteristics of study participants by dyslipidemia
status in urban and rural areas.
Mean lipid and lipoprotein levels
The age and gender-standardised mean levels of total, HDL, and LDL cholesterol and
triglycerides were 4.72, 1.30, 2.68, and 1.57 mmol/L, respectively, in the general Chinese
population aged ?20 years (Table 2). Overall, the age-standardized mean levels of HDL-
cholesterol were slightly higher in women than in men, while the mean level of triglycerides was
higher in men than in women. In addition, age-standardized mean levels of total and LDL
cholesterol and triglycerides were significantly higher in residents living in urban compared to in
rural China (all p<0.0001). This is true for both men and women. In general, HDL and LDL
cholesterol levels increased continuously over the entire age range in both men and women.
Triglyceride levels increased with age until 49 years in men and 69 years in women and then
decreased.
Prevalence of dyslipidemia
The age-standardised prevalence of borderline high total cholesterol (5.18–6.21 mmol/L) and
high total cholesterol (?6.22 mmol/L) was 22.5% and 9.0%, respectively (Table 3). This
represents 220 million Chinese adults aged ?20 years with borderline high total cholesterol and
88 million persons with high total cholesterol. The prevalence of borderline high and high total
cholesterol increased with age in both men and women (Figure 2, upper panels). In addition, the
prevalence of borderline high (25.1% vs. 20.5% for men, p<0.0001; and 24.4% vs. 20.7% for
women, p=0.0003) and high total cholesterol (10.2% vs. 7.5% for men, p=0.0001; and 10.0% vs.
8.7% for women, p=0.06) was more common in urban residents compared to rural residents
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(Figure 3, upper panels).
The age-standardized prevalence of borderline high (3.37-4.13 mmol/L), high (4.14-4.91
mmol/L) and very high (?4.92 mmol/L) LDL-cholesterol was 13.9%, 3.5%, and 3.0%,
respectively, which represents 134, 34, and 29 million persons, respectively, in the general adult
Chinese population aged ?20 years (Table 3). The prevalence of borderline high and high LDL-
cholesterol increased with age (Figure 2, lower panels). In addition, the prevalence of borderline
high (16.7% vs. 10.9% for men, p<0.0001; and 16.8% vs. 12.0% for women, p<0.0001), high
(4.8% vs. 2.4% for men, p<0.0001; and 4.8% vs. 2.4% for women, p<0.0001), and very high
(4.4% vs. 1.9% for men, p<0.0001 and 3.5% vs. 2.5% for women, p=0.01) LDL-cholesterol was
higher in urban residents compared to rural residents for both men and women (Figure 3, middle
panels).
The age-standardized prevalence of low HDL-cholesterol (<1.04 mmol/L) was 22.3% in
the general adult population aged ?20 years in China, which represents 215 million persons
(Table 3). The age-standardized prevalence of low HDL-cholesterol was higher in urban
(28.7%) than in rural (25.7%) men, p=0.01. In contrast, it was higher in rural (19.1%) than in
urban (15.7%) women, p=0.0002 (Figure 3, lower panels).
Awareness, treatment and control of hypercholesterolemia
Among all participants who had borderline high total cholesterol (?5.18 mmol/L) or who
reported using cholesterol-lowering medications, the proportion of those who were aware of
their condition was 12.8% in men and 9.3% in women, the proportion of those who were treated
was 6.1% in men and 4.1% in women, and the proportion of those who had a total cholesterol
concentration <5.18 mmol/L was 3.3% in men and 2.2% in women. In addition, the proportion
of those being treated who had a total cholesterol <5.18 mmol/L was 52.1% in men and 55.4% in
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women. Among those with high total cholesterol (?6.22 mmol/L) or who reported using
cholesterol-lowering medications, the proportions of awareness, treatment, and control (total
cholesterol concentration <6.22 mmol/L) in men and women were 27.6% and 20.7%, 21.4% and
14.0%, and 18.3% and 11.2%, respectively. In addition, the proportion of those being treated
who had a total cholesterol <6.22 mmol/L was 88.1% in men and 78.4% in women. The
proportions of awareness, treatment, and control of high total cholesterol were higher in urban
residents compared to rural residents, although the difference in the control of borderline high
total cholesterol was not statistically significant (Figure 4, upper panels).
Among men and women who had borderline high LDL-cholesterol (?3.37 mmol/L) or
who reported using cholesterol-lowering medications, 16.6% and 12.8% were aware of their
condition, 9.6% and 6.4% were treated, and 6.6% and 4.1% had an LDL-cholesterol <3.37
mmol/L, respectively. In addition, the proportion of those being treated who had an LDL-
cholesterol <3.37 mmol/L was 73.9% in men and 61.3% in women. Among those with high or
very high LDL-cholesterol (?4.14 mmol/L) or who reported using cholesterol-lowering
medications, the proportions of awareness, treatment, and control (LDL-cholesterol <4.14
mmol/L) were 36.1% and 29.1%, 28.8% and 20.7%, and 25.3% and 16.8% in men and women,
respectively. In addition, the proportion of those being treated who had an LDL-cholesterol
<4.14 mmol/L was 93.0% in men and 76.1% in women. The proportions of awareness,
treatment, and control of high LDL-cholesterol were not statistically different between urban and
rural residents, except that urban residents had a higher awareness of borderline high-LDL
(Figure 4, lower panels).
Metabolic factors and lipid and lipoprotein levels
There were strong, positive, and significant associations between body-mass index, waist
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circumference, blood pressure, fasting plasma glucose, and 2-hr postload glucose with serum
total and LDL cholesterol and triglycerides in both men and women (Table 4). Body mass index
and waist circumference were inversely associated with HDL-cholesterol in both men and
women but fasting and 2-hr postload glucose levels were inversely associated with HDL only in
men.
Discussion
Our study indicates that mean levels of total and LDL cholesterol and triglycerides are much
higher than previously reported in the general Chinese adult population.13–16 Furthermore, our
study suggests that 31.5% of the Chinese general population aged ?20 years, or 308 million
persons, have borderline high or high total cholesterol, while 20.4%, or 196 million persons have
a borderline high, high, or very high level of LDL-cholesterol. Among those who have elevated
total or LDL cholesterol, the proportions of patients who are aware, treated and controlled are
very low. The current study documents a large and increasing burden of high serum total and
LDL cholesterol in the Chinese general population.
Several previous epidemiological studies reported serum lipid levels in Chinese
populations.13–16 The PRC-USA Collaborative Study included 8,975 rural and urban residents
aged 35–54 years from Beijing and Guangzhou, while the InterASIA Study included a nationally
representative sample of 15,540 Chinese adults aged 35–74 years.15 The 2002 China National
Nutrition and Health Survey (NNHS) measured serum lipids in a nationally representative
sample of 49,252 Chinese aged ?18 years and provided the best comparison data for our study.16
Overall mean serum total cholesterol was 3.81 mmol/L (3.81 in men and 3.82 in women), HDL-
cholesterol was 1.30 mmol/L (1.26 in men and 1.33 in women), and triglycerides was 1.10
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mmol/L (1.13 for men and 1.05 for women) in NNHS participants. Our study, which was
conducted only 5?6 years later, documented a 23.9% (or 0.91 mmol/L) increase in total
cholesterol and a 42.7% (or 0.47 mmol/L) increase in triglycerides. These increases are very
dramatic and deserve further investigation. These increases are unlikely due to changes in
laboratory measurement methods, because HDL-holesterol levels, which are influenced little by
dietary changes, were identical in the two studies. The differences in sampling methods cannot
explain the entire increase in serum lipid levels either. The 2002 NNHS oversampled rural
Chinese populations, and the final lipid estimates were not weighted by the sampling scheme and
the Chinese general population distribution. However, the mean levels of serum total cholesterol
and triglycerides are significantly higher in both rural and urban residents in our study than those
in the 2002 NNHS. Therefore, the observed rapid increase in serum total cholesterol and
triglycerides is most likely real and could continue without effective intervention.
These study findings have important public health implications. Traditionally, mortality
from atherosclerotic cardiovascular diseases has been infrequent in China and is estimated to be
only about one-tenth of that in Western populations.17 Although cardiovascular diseases have
rapidly increased recently, coronary heart disease mortality remained low. For example,
coronary heart disease mortality (85.5/105 person-years) was only one-third of stroke mortality
(276.9/105 person-years) in the Chinese population.2 A low serum total cholesterol level related
to a low habitual dietary intake of fat and cholesterol was considered the main underlying reason
for the low atherosclerotic cardiovascular mortality in China.17 The current study noted a
relatively high mean level of serum cholesterol but a low rate of hypercholesterolemia control.
Clinical trials have documented that a 10% difference in serum cholesterol was associated with
about 15% difference in risk of coronary heart disease.18 Without a national emphasis on
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prevention and control of hypercholesterolemia, atherosclerotic cardiovascular diseases will soar
in the near future in China, which will add extra pressure to an already overburdened healthcare
system.
In contrast to the experience of the Chinese population, serum cholesterol levels have
declined in most populations in the world during the past several decades.7,19–21 For example,
the Global Burden of Metabolic Risk Factors of Chronic Diseases Collaborating Group
estimated that total cholesterol declined about 0.2 mmol/L per decade for both sexes in the
Australasia, North America, and Europe.7 In the US, the mean level of total cholesterol declined
from 5.75 mmol/L to 5.26 mmol/L between 1960–1962 and 1999–2002.20 Additionally, the
mean level of LDL-cholesterol declined from 3.57 mmol/L to 2.97 mmol/L between 1976–1980
and 2005–2006. 21 The rapid increase in serum lipid levels in the Chinese population is
troublesome given the global trend of reduction of serum lipids. Economic growth and
associated changes in lifestyle and diet might contribute to the increase in serum lipid levels in
the Chinese population. For example, the mean level of serum cholesterol was much higher in
the regions with faster economic growth, such as Shanghai and Beijing, in our study and
others.22,23 The proven approaches for lipid reduction in western populations, including national
and local cholesterol education programs; use of financial and regulatory mechanisms to
encourage healthy lifestyle, including healthy diets; wide-spread use of statins and other lipid-
lowering drugs; and population-based surveillance of serum cholesterol, can be applied to the
Chinese populations for the prevention and control of high serum lipids.
Among individuals with elevated total and LDL cholesterol, the proportion of those who
were aware, treated or controlled for their condition was much lower than in western
populations24 and should be a reason for great concern. To improve the awareness, treatment,
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and control of hypercholesterolemia, a comprehensive intervention approach targeting both
population and individual levels should be applied.12,25 The government and health
policymakers can play an important role though healthcare system reform to provide coverage
for routine cholesterol screening and make lipid-lowering medications affordable or
reduce/eliminate drug copayments.
Our study indicated that obesity is an important determinant of serum lipid levels. These
findings are consistent with previous reports.26–28 Furthermore, our study indicates that lifestyle
factors, such as cigarette smoking, alcohol consumption, and physical activity, are related to
serum lipids. Lifestyle modification should be an important approach for the primary prevention
of hypercholesterolemia in communities.12,28–30
Our study was conducted in a large representative sample of the Chinese adult population
in which a high response rate was achieved. Standard protocols and instruments along with strict
training processes for data collection and a vigorous quality assurance program were employed
to ensure the data we collected was of high quality. For all these reasons, this study provides the
most reliable and up-to-date information on lipids and lipoproteins in the adult population in
China. Our study, however, also has several limitations. For instance, women were
overrepresented in our study. The inclusion criteria of current residence for 5 years or longer
make a large number of male migrant workers ineligible for this study. In addition, the response
rate was lower in men than women. We took these issues into account when calculating
statistical weights. However, if the lipid values of migrants to urban settings differ from those of
non-migrants in the same age group, the overall lipid levels in rural males are most likely to be
underestimated. Dietary intake and work-related physical activity were not assessed in our study,
so their effect on serum lipids cannot be examined. Furthermore, we could not classify the study
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participants into ATP III risk categories due to the lack of necessary information.
This large national survey of serum lipids and lipoproteins indicated that the mean serum total
and LDL cholesterol and triglyceride levels were high and increasing in the Chinese population.
Furthermore, the awareness, treatment and control rates of hypercholesterolemia were low.
Without effective intervention, atherosclerotic cardiovascular diseases are projected to soar in
the near future in China. These study findings argue for a public health priority shift to more
focus on the prevention and control of chronic diseases, such as hyperlipidemia and associated
atherosclerotic cardiovascular diseases in China.

Acknowledgements: All authors contributed to study design and data collection. Ms. C Chen
analyzed the data under supervision of Drs. W Yang and J He. Drs. W Yang and J He wrote the
first draft of the manuscript. All authors revised the report and approved the final version of the
manuscript for publication.

Funding Sources: This study was supported by the Chinese Medical Association Foundation
and Chinese Diabetes Society. The sponsor of the study had no role in study design, data
collection, data analysis, data interpretation, or writing of the report. The authors had final
responsibility for the decision to submit for publication.

Conflict of Interest Disclosures: None

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Klag MJ, Whelton PK. Major causes of death among men and women in China. N Engl J Med.
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3. Stamler J, Daviglus ML, Garside DB, Dyer AR, Greenland P, Neaton JD. Relationship of
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