Association between frequency of dairy product consumption and hypertension: a cross-sectional study in Zhejiang Province, China.

BACKGROUND: Hypertension, a well-known risk factor, contributes to millions of deaths from cardiovascular and renal diseases worldwide. However, evidence on the association between frequency of dairy product consumption and hypertension is inconsistent. METHODS: The data for the present study are from the Tongxiang baseline dataset of the China Kadoorie Biobank prospective study. A total of 53,916 participants aged 30-79 years were included in the final analysis. Multivariable logistic regression was utilized to evaluate the association of dairy product consumption with hypertension, and multiple linear regression was conducted to assess the association of dairy product consumption with systolic and diastolic blood pressure. RESULTS: Of the 53,916 participants, 2.6% reported consuming dairy products weekly, and 44.4% had prevalent hypertension. After adjusting for socio-demographic status, lifestyle factors, BMI, waist circumference, sleep duration and snoring, when compared with participants who never consumed dairy products, the odds ratios (95% CI) for hypertension among those consuming dairy products less than once per week, and ≥ 1 time per week were 0.85 (0.77-0.95) and 0.74 (0.65-0.84), respectively. The corresponding odds ratios (95% CI) for men were 0.85 (0.71-1.02) and 0.75 (0.61-0.92), respectively (Ptrend = 0.001), and for women were 0.88 (0.76-1.01) and 0.77 (0.65-0.91), respectively. (Ptrend < 0.001). CONCLUSIONS: In this large epidemiological study, higher frequency of dairy product consumption is associated with significantly lower odds of hypertension among Chinese adults.

The Effects of Chronic Disease Management in Primary Health Care: Evidence from Rural China.

Health systems globally face increasing morbidity and mortality from chronic diseases, yet many - especially in low- and middle-income countries - lack strong chronic disease management in primary health care (PHC). We provide evidence on China's efforts to promote PHC management using unique five-year panel data in a rural county, including health care utilization from medical claims and health outcomes from biomarkers. Utilizing plausibly exogenous variation in management intensity generated by administrative and geographic boundaries, we compare hypertension/diabetes patients in villages within two kilometers distance but managed by different townships. Results show that, compared to patients in townships with median management intensity, patients in high-intensity townships have 4.8% more PHC visits, 5.2% fewer specialist visits, 11.7% lower likelihood of having an inpatient admission, and 3.6% lower medical spending. They also tend to have better medication adherence and better control of blood pressure. The resource savings from avoided inpatient admissions substantially outweigh the costs of the program.

The Impact of Catastrophic Medical Insurance in China: A five-year patient-level panel study.

Background: In an effort to provide greater financial protection from the risk of large medical expenditures, China has gradually added catastrophic medical insurance (CMI) to the various basic insurance schemes. Tongxiang, a rural county in Zhejiang province, China, has had CMI since 2000 for their employee insurance scheme, and since 2014 for their resident insurance scheme. Methods: Compiling and analysing patient-level panel data over five years, we use a difference-in-difference approach to study the effect of the 2014 introduction of CMI for resident insurance beneficiaries in Tongxiang. In our study design, resident insurance beneficiaries are the treatment group, while employee insurance beneficiaries are the control group. Findings: We find that availability of CMI significantly increases medical expenditures among resident insurance beneficiaries, including for both inpatient and outpatient spending. Despite the greater financial protection, out-of-pocket expenditures increased, in part because patients accessed treatment more often at higher-level hospitals. Interpretation: Better financial coverage for catastrophic medical expenditures led to greater access and expenditures, not only for inpatient admissions-the category that most often leads to catastrophic expenditures-but for outpatient visits as well. These patterns of expenditure change with CMI may reflect both enhanced access to a patient's preferred site of care as well as the influence of incentives encouraging more care under fee-for-service payment. Funding: Stanford University's Freeman Spogli Institute for International Studies' Policy Implementation Lab and a Shorenstein Asia Pacific Research Center faculty research award provided funding for this project. Chinese translation of the abstract (Appendix 1).

Association between frequency of spicy food consumption and hypertension: a cross-sectional study in Zhejiang Province, China.

BACKGROUND: Hypertension is a known risk factor for multiple chronic diseases. Existing literature on the association between frequency of spicy food consumption and hypertension shows mixed findings. METHODS: The analyses are based on the Tongxiang baseline dataset of the China Kadoorie Biobank prospective study, including data from electronic questionnaires, physical measurements and blood sample collection. A total of 53,916 participants aged 30-79 years were included in the final analysis. Multivariable logistic regression was used to estimate the association of spicy food consumption with hypertension, and multiple linear regression was performed to explore the association of spicy food consumption with systolic and diastolic blood pressure. RESULTS: Of the 53,916 participants, 23,921 had prevalent hypertension. 12.3% of participants reported consuming spicy food weekly. Among female participants, after adjusting for socio-demographic status, lifestyle factors, BMI, waist circumference, sleep duration and snoring, when compared with females who never consumed spicy food, the odds ratios (95% CI) for hypertension were 1.02 (0.96-1.08), 0.90 (0.79-1.01), and 0.88 (0.78-0.99), respectively, for females who consumed spicy food less than once weekly, 1-2 times weekly, and ≥ 3 times weekly (Ptrend = 0.04). The corresponding odds ratios for males were 1.02 (0.95-1.09), 1.07 (0.95-1.20), and 0.91 (0.81-1.01), respectively (Ptrend = 0.39). Among current alcohol drinkers, compared to participants who never consumed spicy food, the odds ratio (95% CI) for hypertension among participants consuming spicy food daily was 0.98 (0.80-1.20). The corresponding figure for non-current drinkers was 0.72 (0.62-0.84). The association was stronger among non-current alcohol drinkers than among current drinkers (Pheterogeneity = 0.02). CONCLUSIONS: Frequency of spicy food consumption is inversely associated with hypertension in females, but not in males.

Association of daytime napping in relation to risk of diabetes: evidence from a prospective study in Zhejiang, China.

BACKGROUND: Diabetes was a major risk factor for numerous chronic diseases. However, the associations between daytime napping and diabetes in the existing literature is still inconsistent. METHODS: The analysis included 53,916 participants aged 30-79 years of the China Kadoorie Biobank prospective study from Tongxiang. Incident diabetes were identified through linkage with incident diabetes surveillance systems, health insurance system, and death registries. Cox regressions were used to estimate the associations of daytime napping with diabetes. RESULTS: 5.11% of participants reported habitual daytime napping. During 488,233 person-years (median 9.4 years) of follow-up, 3333 incident diabetes, including 1249 males and 2084 females, were documented. After adjusting for socio-demographic status, behavioral lifestyle, BMI, waist circumference and snoring, as comparison with those without daytime napping, the hazard ratios for risk of diabetes were 1.39 (95% CI 1.21-1.59). The corresponding figures for males and females were 1.45 (95% CI 1.20-1.74) and 1.30 (95% CI 1.05-1.59), respectively. The corresponding figures for postmenopausal and premenopausal females were 1.41 (95% CI 1.08-1.80) and 1.13 (95% CI 0.78-1.59), respectively. CONCLUSIONS: Habitual daytime napping is positively associated with risk of diabetes in adults, except premenopausal females.

Awareness, current use of electronic cigarettes and associated smoking factors in Zhejiang Chinese adolescents.

OBJECTIVES: The present study aims at examining the prevalence of awareness and current use of electronic cigarettes (e-cigarettes) among middle and high school students from Zhejiang, China. Smoking-related factors associated with e-cigarettes use will also be explored. METHODS: This cross-sectional study was based on 2017 Zhejiang Youth Risk Behavior Survey. A total of 24,157 adolescents were recruited and relevant data of e-cigarettes and smoking-related factors were collected via a self-reported questionnaire. Logistic regression models were used to examine the association between e-cigarettes current use and the smoking-related factors. Odds ratios (ORs) and their 95% confidence intervals (CIs) were reported. RESULTS: Overall, 70.61% of middle and high school students reported hearing of e-cigarettes, while only 2.15% reported using e-cigarettes in the past month. Among smoking-related factors, cigarette smoking (ever and current), use of other tobacco products, second hand smoke exposure and previous attempts to quit smoking were significantly associated with higher current e-cigarettes use in adolescents. CONCLUSIONS: These results presented high awareness of e-cigarettes while relatively low use in Chinese adolescents. Smoking-related factors were significantly associated with increased e-cigarettes use.

Direct medical cost of diabetes in rural China using electronic insurance claims data and diabetes management data.

AIMS/INTRODUCTION: To evaluate the annual direct medical cost attributable to type 2 diabetes mellitus according to socioeconomic factors, medical conditions and complications categories. MATERIALS AND METHODS: We created uniquely detailed data from merging datasets of the local diabetes management system and the social security system in Tongxiang, China. We calculated the type 2 diabetes mellitus-related total cost and out-of-pocket cost for inpatient admissions and outpatient visits, and compared the cost for patients with or without complications by different healthcare items. RESULTS: A total of 16,675 patients were eligible for analysis. The type 2 diabetes mellitus-related cost accounted for 40.6% of the overall cost. The cost per patient was estimated to be a median of 1,067 Chinese Yuan, 7,114 Chinese Yuan and 969 Chinese Yuan for inpatient and outpatient cost, respectively. The median total cost for hospital-based care was 3.69-fold higher than that for primary care. The median cost of patients with complications was 3.46-fold higher than that of those without complications. The median cost for a patient with only macrovascular, only microvascular or both macrovascular and microvascular complications were 3.13-, 3.79- and 10.95-fold higher than that of patients without complications. Pharmaceutical expenditure accounted for 51.8 and 79.7% of the total cost for patients with or without complications, respectively. CONCLUSIONS: Although the type 2 diabetes mellitus-related cost per patient was relatively low, it accounted for a great proportion of the overall cost. Complications obviously aggravated the economic burden of type 2 diabetes mellitus. Proper management and the prevention of diabetes and its complications are urgently required to curtail the economic burden.

How do type 2 diabetes mellitus (T2DM)-related complications and socioeconomic factors impact direct medical costs? A cross-sectional study in rural Southeast China.

OBJECTIVE: To evaluate type 2 diabetes mellitus (T2DM)-related direct medical costs by complication type and complication number, and to assess the impacts of complications as well as socioeconomic factors on direct medical costs. DESIGN: A cross-sectional study using data from the region's diabetes management system, social security system and death registry system, 2015. SETTING: Tongxiang, China. PARTICIPANTS: Individuals diagnosed with T2DM in the local diabetes management system, and who had 2015 insurance claims in the social security system. Patients younger than 35 years and patients whose insurance type changed in the year 2015 were excluded. MAIN OUTCOME MEASURES: The mean of direct medical costs by complication type and number, and the percentage increase of direct medical costs relative to a reference group, considering complications and socioeconomic factors. RESULTS: A total of 19 015 eligible individuals were identified. The total cost of patients with one complication was US$1399 at mean, compared with US$248 for patients without complications. The mean total cost for patients with 2 and 3+ complications was US$1705 and US$2994, respectively. After adjustment for socioeconomic confounders, patients with one complication had, respectively, 83.55% and 38.46% greater total costs for inpatient and outpatient services than did patients without complications. The presence of multiple complications was associated with a significant 44.55% adjusted increase in total outpatient costs, when compared with one complication. Acute complications, diabetic foot, stroke, ischaemic heart disease and diabetic nephropathy were the highest cost complications. Gender, age, education level, insurance type, T2DM duration and mortality were significantly associated with increased expenditures of T2DM. CONCLUSIONS: Complications significantly aggravated expenditures on T2DM. Specific kinds of complications and the presence of multiple complications are correlated with much higher expenditures. Proper management and the prevention of related complications are urgently needed to reduce the growing economic burden of diabetes.

Age at natural menopause and risk of diabetes in adult women: Findings from the China Kadoorie Biobank study in the Zhejiang area.

AIMS/INTRODUCTION: There has been considerable professional debate on the association between age at menopause and diabetes risk, while the findings are controversial. The present study explored the association between late menopause and the prevalence of diabetes in the Chinese population. MATERIAL AND METHODS: The data were part of the baseline survey of China Kadoorie Biobank from Zhejiang Province. A total of 17,076 postmenopausal women were included in the present study. Logistic regression models were used to calculate the adjusted odds ratios and their 95% confidence intervals. RESULTS: Of the participating women, 1,288 (7.54%) had type 2 diabetes. In comparison with those with menopause at 46-52 years, women with menopause at a later age (≥53 years) were 1.21-fold (95% confidence interval 1.03-1.43) more likely to have diabetes. CONCLUSIONS: The present findings suggested that later age at menopause was associated with an increased prevalence of diabetes.

Menopause Characteristics, Total Reproductive Years, and Risk of Cardiovascular Disease Among Chinese Women.

BACKGROUND: Previous studies, mostly of Western women, have reported inconsistent findings on the association of menopause characteristics (status, age, and time since menopause) and total reproductive years with risk of cardiovascular disease (CVD). METHODS AND RESULTS: The China Kadoorie Biobank recruited 302 632 women in 2004 to 2008 from 10 regions across China. During 9-year follow-up, 19 393 incident cases of stroke, 18 611 of ischemic heart disease, and 4978 CVD deaths occurred. Cox regression yielded adjusted hazard ratios relating each menopause characteristic and total reproductive years to CVD risk. Among 274 233 women with no prior CVD at baseline, 134 010 were naturally postmenopausal women (mean [SD] age at menopause of 48.6 [4.0] years and total reproductive years 32.7 [4.4]). Compared with premenopausal women, naturally peri- or postmenopausal women were at a higher risk of either fatal or nonfatal CVD. Among women who had had menopause, inverse associations were observed between age at menopause and risks of CVD mortality, incident ischemic heart disease, stroke, and subtypes of stroke, with 1.5% higher risk of CVD death (P<0.001), 0.7% for incident ischemic heart disease (P=0.002), and 0.5% for incident stroke (P=0.02) for every 1 year lower age at menopause. Compared with women who had menopause at age 48 to 50 years, lower age at menopause (ie, <43 years) was associated with 14% higher risk of CVD death and 6% higher risks of both incident ischemic heart disease and stroke. Higher risks of both fatal and nonfatal CVD were also found in women with 5 to 10, 10 to 15, 15 to 20, or >20 years since menopause compared with <5 years since menopause. Total reproductive years were inversely associated with risks of both fatal and nonfatal CVD, with 1.4% lower risk of CVD death per additional reproductive year (P<0.001). CONCLUSIONS: Women with younger age at menopause, longer time since menopause, or fewer total reproductive years had a higher risk of CVD.

The association between sleep duration, snoring and prevalent type 2 diabetes mellitus with regard to gender and menopausal status: the CKB study in Zhejiang rural area, China.

AIMS: To evaluate the association between sleep duration, snoring and diabetes according to gender and menopausal status in rural China. METHODS: The data were part of the baseline survey of China Kadoorie Biobank, from a rural county in the south-east costal Zhejiang province. Participants including 24,027 men and 33,677 women aged 30-79 years were enrolled during 2004-2008. Multivariable logistic regression was used to calculate adjusted odds ratios (ORs) and 95 % confidence intervals (CIs) for diabetes. RESULTS: Sleep duration was shown to have a U-shaped association with diabetes in women, in particular in postmenopausal women after adjustment for potential confounders. Compared with 7-h sleepers, ORs (95 % CIs) of sleep duration ≤5 and ≥10 h for diabetes were 1.32 (1.02-1.69) and 1.30 (1.03-1.65), respectively, in postmenopausal women (P for quadratic trend = 0.016). However, this U-shaped association was not obvious in men and premenopausal women. Frequently snoring was positively associated with diabetes in all participants. However, this association was not independent of socioeconomic status, health behaviors, obesity and chronic diseases. With increasing sleep duration, the proportion of frequently snoring increased in all participants (P trend <0.05). Postmenopausal women had 23 % (95 % CI 6-44 %) higher odds of diabetes compared with premenopausal women, and the duration of menopause had cumulative effects on diabetes. CONCLUSIONS: Short and long sleep durations were significantly associated with diabetes in postmenopausal women, independent of potential confounders. The proportion of frequently snoring had linear trend with sleep duration. Postmenopausal status and the duration of menopause increased the odds of diabetes.

COPD and its association with smoking in the Mainland China: a cross-sectional analysis of 0.5 million men and women from ten diverse areas.

PURPOSE: In adult Chinese men, smoking prevalence is high, but little is known about its association with chronic respiratory disease, which is still poorly diagnosed and managed. METHODS: A nationwide study recruited 0.5 million men and women aged 30-79 years during 2004-2008 from ten geographically diverse areas across the Mainland China. Information was collected from each participant regarding smoking and self-reported physician diagnosis of chronic bronchitis/emphysema (CB/E), along with measurement of lung function indices. Logistic regression was used to yield sex-specific odds ratios (ORs) relating smoking to airflow obstruction (AFO), defined as forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) <0.7 and CB/E, adjusting for age, areas, education, and income. RESULTS: Overall 74% of men were ever regular smokers; among them, 7.2% had AFO compared with 5.4% in never-smokers, yielding an OR of 1.42 (95% confidence interval [CI]: 1.34-1.50). The risk was strongly associated with amount smoked and starting to smoke at a younger age. Among ex-smokers, the OR was more extreme for those who had quit due to illness (OR: 1.86, 95% CI: 1.77-1.96) than those who had quit by choice (OR:1.08, 95% CI: 1.01-1.16). CB/E prevalence was also significantly elevated in ex-smokers who had quit because of ill health (OR:2.79, 95% CI: 2.64-2.95), but not in regular smokers (OR:1.04, 95% CI: 0.96-1.11). Female smokers was rare (3%), but carried an excess risk for AFO (OR:1.53, 95% CI: 1.43-1.65) and, to a lesser extent, for CB/E (OR:1.28, 95% CI: 1.15-1.42). CONCLUSION: In Mainland China, adult smokers, particularly ex-smokers who had quit because of illness, had significantly higher prevalence of chronic respiratory disease. AFO appeared to be more strongly associated with smoking than self-reported chronic respiratory disease.

[Association between sleep duration and stroke in adults].

OBJECTIVE: To explore the association between sleep duration and stroke in adults. METHODS: Baseline data of 57 704 subjects who were aged 30-79 years and enrolled into China Kadoorie Biobank (CKB) study from Tongxiang county, Zhejiang province were analyzed. Multiple logistic regression analysis was conducted to investigate the putative association between sleep duration and stroke after adjusting for potential confounders. RESULTS: The mean age of the subjects was (53.15 ± 10.20) years in males and (51.72 ± .69) years in females, respectively. There were 14.43% of males and 15.30% of females reporting sleep durations ≤ 6 hours per day and 5.39% of males and 5.95% of females reporting long duration of sleep (≥ 10 hours per day). The prevalence of stroke was 0.92% in males compared with 0.44% in females. The prevalence of stroke showed a U-shaped distribution with sleep duration. Compared with 7 hours sleep duration per day, long sleep duration (≥ 10 hours per day) was associated with stroke. The odds ratios (OR) were 2.11 (95%CI: 1.32-3.37) for males and 2.13 (95%CI: 1.24-3.65) for females after adjusting for age, socioeconomic status, health behaviors and health status. No statistical significant association was found between short sleep duration and stroke. Meanwhile, frequent sleep snoring was found to be associated with stroke in females (OR=1.63, 95% CI: 1.11-2.40). CONCLUSION: Longer sleep duration was found to be associated with higher risk of stroke in both males and females. Frequent sleep snoring would increase the risk of stroke in females.