D-M Wu 1, L Pai 1, N-F Chu 1,2, P-K Sung 3, M-S Lee 1, JT Tsai 3, L-L Hsu 3, M-C Lee 3 and C-A Sun 1 *

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1 (2001) 25, ß 2001 Nature Publishing Group All rights reserved /01 $ PAPER Prevalence and clustering of cardiovascular risk factors among healthy adults in a Chinese population: the MJ Health Screening Center Study in Taiwan D-M Wu 1, L Pai 1, N-F Chu 1,2, P-K Sung 3, M-S Lee 1, JT Tsai 3, L-L Hsu 3, M-C Lee 3 and C-A Sun 1 * 1 School of Public Health, National Defense Medical Center, Taipei, Taiwan, Republic of China; 2 Department of Community Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China; and 3 MJ Health Screening Center, Taipei, Taiwan, Republic of China OBJECTIVE: To gain insight into the prevalence and clustering of multiple cardiovascular risk factors in a healthy Chinese adult population in Taiwan. DESIGN: A cross-sectional study was carried out in SUBJECTS: A total of subjects ( men and women) who were aged y and attended a private health screening center for health examination of their own volition. MEASUREMENTS: Multiple cardiovascular risk factors including cigarette smoking, overweight (23 kg=m 2 body mass index (BMI) < 25 kg=m 2 ) and obesity (BMI 25 kg=m 2 ), lipid disorder (a ratio of total cholesterol level to the level of high density lipoprotein cholesterol > 5 or use of lipid-lowering drugs), hypertension (systolic blood pressure 140 mmhg or diastolic blood pressure 90 mmhg or use of anti-hypertensive medications), and diabetes mellitus (fasting serum plasma glucose level 126 mg=dl or use of anti-diabetic medications) were determined. RESULTS: In comparison to women, men had a higher prevalence of current smoking (42.1 vs 5.6%), overweight (25.1 vs 17.1%) and obesity (33.1 vs 21.5%), lipid disorder (45.1 vs 19.6%), hypertension (17.4 vs 13.2%), as well as diabetes mellitus (4.1 vs 3.4%). The prevalence of men or women having two or more of the cardiovascular risk factors of interest was 54.3 and 21.7%, respectively. With advancing age, the prevalence of risk factors became greater for both genders. More importantly, the clustering of risk factors increased monotonically with increasing BMI levels for men and women. CONCLUSIONS: The prevalence and clustering of cardiovascular risk factors are commonplace in this healthy Chinese adult population. Considering the significant association between clustering of risk factors under study and BMI levels, this study gives an indication that population-based multifactorial interventions may work out favorably for specific groups. (2001) 25, Keywords: prevalence; clustering; cardiovascular risk factors; body mass index Introduction Over the last two decades, chronic diseases such as cardiovascular disease (CVD), metabolic disorders and malignant neoplasms have accounted for a significant fraction of death tolls worldwide. 1 It is well known that cigarette smoking, obesity, lipid disorder, elevated blood pressure and diabetes *Correspondence: C-A Sun, National Defense Medical Center, School of Public Health, No. 161, Section 6 Ming-Chuan East Road, Taipei 114, Taiwan, Republic of China. sunca@ms36.hinet net Received 24 November 2000; revised 12 February 2001; accepted 22 February 2001 mellitus are primary risk factors for CVD. 2 8 In addition, it has also been recognized that many CVD risk factors are associated with each other In Taiwan, cerebrovascular disease, ischemic heart disease and hypertensive diseases contributed to one-third of total mortality in Despite the emergence of cardiovascular-related disease as a major cause of death, few studies have examined the prevalence and clustering of CVD risk factors among Chinese adults in Taiwan. A complete assessment of the distribution and aggregate of well-established CVD risk factors not only depicts the total burden of these conditions but it is also useful in formulating effective strategies of prevention. Therefore, the main objectives of this study are to examine the prevalence of well-known CVD risk factors,

2 1190 including cigarette smoking, overweight and obesity, lipid disorder, hypertension, as well as diabetes mellitus and to assess the interdependence of these risk factors among healthy Chinese adults in Taiwan. Methods Study population The MJ Health Screening Center is a membership-oriented private institute with four health check-up clinics around Taiwan Island, which provides periodic health examination to its members. In 1996, there were individuals attending the MJ Health Screening Center for health examination of their own volition. We purposely excluded individuals who were younger than 20 y (n ¼ 3203) or were 60 y or older (n ¼ ) as well as those who had missing values for variables used in the analyses (n ¼ ), resulting in a total of subjects (including men and women) available for analysis. Examinations included anthropometric and blood pressure measurements, physical examination, as well as assessment of nutritional status. Each examinee completed a self-administered questionnaire at the time of screening to gather information on sociodemographic characteristics, lifestyle features including habits of cigarette smoking and alcohol consumption, as well as personal and family history of major chronic diseases. In addition, venipuncture for fasting blood for biochemical analyses was also performed. The achievement of standardization of screening activities was possible by a common detailed protocol and common training and certification procedures of examination or measurement-performing personnel. A detailed description of the MJ Health Screening Center Study is given in a previous publication. 13 The protocol for this research on human subjects was approved by the Review Committee at The MJ Health Screening Center. Data collection Anthropometric and blood pressure measures and smoking status determinations. Body weight and height were measured by an auto-anthropometer, Nakamura KN-5000A (Nakamura, Tokyo, Japan). Body weight was measured to the nearest 0.1 kg with subjects barefoot and wearing light indoor clothing. Body height was recorded to the nearest 0.1 cm. Body mass index (BMI) was calculated as weight in kilograms divided by the square of height in meters. Overweight and obesity were evaluated by the BMI and were classified as normal (BMI < 23 kg=m 2 ), overweight (23 BMI < 25 kg=m 2 ), and obesity (BMI 25 kg=m 2 ) based on the World Health Organization (WHO) recently proposed classification system for Asian populations. 14 Blood pressure was measured twice, on the right arm, with the subject in a sitting position, after 5 min of rest, using a computerized auto-mercury-sphygmomanometer, Citizen CH-5000 (Citizen, Tokyo, Japan). Two measurements were taken at 10 min intervals. The mean of these two readings was used in analysis. In this study, hypertension was defined as systolic blood pressure (SBP) 140 mmhg or diastolic blood pressure (DBP) 90 mmhg or use of anti-hypertensive drugs. 15 In addition, smoking status was determined by selfreported questionnaire. Each participant was classified as a current smoker, ex-smoker or nonsmoker. Biochemical parameters. To reduce extraneous betweenperson variation, we collected a 12 h fasting blood sample only from subjects who had maintained their usual dietary pattern during the previous 3 days. Serum concentrations of total cholesterol (TC) and high density lipoprotein-cholesterol (HDL-C) were measured enzymatically 16,17 on the Hitachi 7150 autoanalyzer (Hitachi, Tokyo, Japan). Likewise, fasting serum glucose (FSG) level was measured on the same autoanalyzer. All specimens were analyzed by the central laboratory at MJ Health Screening Center. The laboratory practises strict internal and external quality control techniques. The calibrates used were supplied by the manufacturer. In this study, we defined lipid disorder by a ratio of TC to HDL-C greater than In addition, subjects taking lipid-lowering medications were also included in the definition of lipid disorder. Meanwhile, diabetes mellitus (DM) was defined by the level of FSG 126 mg=dl or use of anti-diabetic medications. Statistical analysis Distributions of CVD risk factors measured in study subjects were expressed using age- and gender-specific mean values ( standard deviation) for continuous variables and age- and gender-specific proportions for discrete data. We assessed the clustering of CVD risk factors as the number of prevalent conditions (smoking, obesity, lipid disorder, hypertension and diabetes mellitus) for each subject, with a range of 0 (none of these conditions) to > 3 (more than three conditions). Furthermore, we used chi-square statistics to examine whether obesity was associated with a clustering of CVD risk factors. A two-tailed P-value < 0.05 was considered statistically significant. All statistical analyses were performed by using the statistical package SAS (Statistical Analysis Software release 6.12, Cary, NC, USA). Results The age-specific distributions of cardiovascular risk factors in both genders are shown in Table 1. As expected, mean values of BMI, TC, SBP, DBP and FSG generally increased with age and the average level of HDL-C rose slightly with age in both genders. In men, there was no significant change in the prevalence of current smoking by age group, but for women the percentage of current smoking decreased with age. In comparison to women, men had a higher mean value of BMI (23.8 vs 22.5 kg=m 2 ), TC (195.4 vs mg=dl), SBP (119.4 vs mmhg), DBP (74.4 vs 71.0 mmhg), and FSG

3 Table 1 Distributions of cardiovascular risk factors by specific age and gender groups Age group 1191 Risk factor Total Men n BMI (kg=m 2 ) a TC (mg=dl) a HDL-C (mg=dl) a SBP (mmhg) a DBP (mmhg) a FSG (mg=dl) a Smoking status b Nonsmoker Ex-smoker Current smoker Women n BMI (kg=m 2 ) a TC (mg=dl) a HDL-C (mg=dl) a SBP (mmhg) a DBP (mmhg) a FSG (mg=dl) a Smoking status b Nonsmoker Ex-smoker Current smoker BMI, body mass index; TC, serum total cholesterol; HDL-C, high density lipoprotein-cholesterol; SBP, systolic blood pressure; DBP, diastolic blood pressure; FSG, fasting serum glucose. a Expressed as mean standard deviation. b Expressed as percentage. Table 2 Age- and gender-specific prevalence of cardiovascular risk factors in the study population Age group Total Risk factor a n (%) n (%) n (%) n (%) n (%) Men Overweight b Obesity b Lipid disorder b Hypertension b Diabetes mellitus b Women Overweight b Obesity b Lipid disorder b Hypertension b Diabetes mellitus b a Data on smoking shown in Table 1. b Overweight, 23 kg=m 2 body mass index (BMI) < 25 kg=m 2 ; obesity, BMI 25 kg=m 2 ; lipid disorder, serum level of total cholesterol divided by serum level of high density lipoprotein-cholesterol > 5 or use of lipid-lowering drugs; hypertension, systolic blood pressure 140 mmhg or diastolic blood pressure 90 mmhg or use of anti-hypertensive medications; diabetes mellitus, fasting serum glucose 126 mg=dl or use of anti-diabetic medications. (99.5 vs 96.1 mg=dl), but a lower average level of HDL-C (41.5 vs 49.2 mg=dl). The prevalence of current smoking in men was much higher than that in women (42.1 vs 5.6%). Table 2 presents the age-specific prevalence of CVD risk factors of interest in both genders. Generally speaking, the prevalences of overweight, hypertension and diabetes

4 1192 mellitus increased with advancing age in both genders. In men, the prevalence of obesity as well as lipid disorder rose from younger adulthood up to the age group of y and then dropped. Nevertheless, the proportions increased monotonically with age in women. Another observation was that, in comparison to women, men had a higher prevalence of overweight (25.1 vs 17.1%) and obesity (33.1 vs 21.5%), lipid disorder (45.1 vs 19.6%), hypertension (17.4 vs 13.2%), as well as diabetes mellitus (4.1 vs 3.4%). The prevalence of combinations of CVD risk factors by age group for both genders is displayed in Figure 1. In men, 15.6% had none of the CVD risk factors of interest, 30.1% had one risk factor (usually smoking), 30.9% had two of the risk factors (usually smoking and lipid disorder), and 23.4% had three or more of the risk factors (usually smoking, lipid disorder and overweight=obesity). The proportion of men without any risk factor or with one risk factor decreased with advancing age, whereas the percentage of men with two or more of the risk factors rose with increasing age. In women, 48.2% had none of the CVD risk factors, 30.1% had one risk factor (usually lipid disorder), 15.7% had two of the risk factors (usually lipid disorder and overweight=obesity), and 6.0% had three or more of the risk factors of interest (usually lipid disorder, overweight=obesity and hypertension). The proportion of women without any risk factor dropped with increasing age, while the percentage of women with one or more of the risk factors increased with advancing age. Overall, clustering of two or more of the CVD risk factors of interest was more prominent in men than in women (54.3 vs 21.7%). Furthermore, with advancing age, the percentage of men or women with the aggregation of two or more of the risk factors increased 1.9-fold and 7.8-fold, respectively, across the age range studied. Because overweight and obesity have reached epidemic proportions worldwide 19,20 and the metabolic consequences of obesity are well documented in Western populations, 21,22 we examined the relation between overweight=obesity and the clustering of other CVD risk factors of interest. As a consequence, we performed an analysis on the clustering of CVD risk actors according to the WHO recently proposed BMI criterion 14 in both genders. The resultant findings are presented in Figure 2. It is clear that the percentage of subjects with two or more of the risk factors of interest increased monotonically with increasing BMI in both genders. With increasing BMI levels, the percentage of men with two or more of the risk factors increased from 18.5% in those with the BMI value of less than 23 kg=m 2 to 84.0% in those with the highest value of BMI ( 25 kg=m 2 ). Similarly, clustering of two or more of the risk factors was quite prominent in women with the highest level of BMI (59.5%) as compared to those in the lowest value of BMI ( < 23 kg=m 2 ; 2.9%). Figure 1 Age-specific prevalence of combinations of cardiovascular risk factors (RF) in men (top panel) and in women (bottom panel) in Taiwan. Discussion CVD is the most common cause of mortality in developed countries, 1 but the effects of CVD in other regions of the world have been overlooked. Taiwan, like other Asian countries, has experienced rapid economic growth, along with profound lifestyle transformation. There is evidence that Asian countries will experience a similar epidemic of CVD to that observed in Western populations. 23 Despite the emergence of cardiovascular-related disease as a major cause of death, scant data are available on the prevalence and clustering of CVD risk factors in the Chinese population in Taiwan. In this cross-sectional screening with a sizable population of apparently healthy adults, we found that the CVD risk factors including cigarette smoking, lipid disorder, overweight and obesity, hypertension, as well as diabetes mellitus are highly prevalent conditions in men (84.4% had at least one of the risk factors of interest). These CVD risk factors were also prevalent in women (51.8% had at least one of the risk factors studied). A similar observation was also documented in the Korea Medical Insurance Corporation Study. 24 In the present study, lipid disorder was the most prominent risk factor in men and overweight=obesity was the most prevalent risk factor in women.

5 Figure 2 Prevalence of cardiovascular risk factors (RF) clustering by the distribution of body mass index for both genders in Taiwan Chinese. The prevalence of overweight, lipid disorder, hypertension and diabetes mellitus were higher in men than in women and these prevalences increased with advancing age in both genders. In contrast, there was a distinct pattern of age-specific prevalence of obesity between men and women. In men, the prevalence increased from 20.4% in young adults to 41.4% in middle age but declined from middle age to 38.9% in the age group of y, whereas the percentage of obese women increased monotonically with increasing age. Furthermore, the prevalence was higher in men than in women up to 50 y of age and then the percentage in women increased to exceed it. These observations were consistent with results from previous studies. 19,24,25 In recent years, obesity has reached epidemic proportions globally. 19,20 Currently, nearly one-quarter of the US population is considered to be overweight (defined as a BMI ¼ kg=m 2 ), and an additional one-quarter is obese (defined as BMI 30 kg=m 2 ). 26 Interestingly, we observed comparable figures of overweight (21.1%) and obesity (27.4%) in this Chinese population based on the WHO recently proposed classification system by BMI in Asian populations. 14 In contrast, the prevalence of obesity was relatively low at 3.7% in this Chinese population using the definitions derived from affluent communities. 26 The current study results suggest that the basis for the classification of overweight and obesity used in Western populations may not apply to populations at the lower end of the BMI distribution in a typical Western population. It has been recognized that CVD risk factors are associated with each other and their effects tend to be synergistic rather than additive. 9 11,25,27,28 Thus, assessment of the prevalence of multiple risk factors is crucial to identify a high-risk population. In the present study, combinations of CVD risk factors were frequently observed in men of all ages and in older women. The percentage of men with two or more CVD risk factors ranged from 36.0% in young adults to 67.4% in the age group of y; the corresponding figures in women were 6.5% and 50.3%, respectively (Figure 1). Moreover, we observed a marked rise in the frequency of the clustering of CVD risk factors with increasing age in both genders. Our data are in agreement with previous studies. 24,29 Another interesting note was that multiple risk factors seem already to be clustered within young male adults, as indicated in a previous report. 30 These findings suggest that clustering of CVD risk factors is commonplace in this healthy Chinese adult population and this clustering seems to exist already within young men and to persist thereafter. Of particular note, overweight=obesity is highly correlated with clustering of other CVD risk factors of interest in this healthy Chinese adult population (Figure 2). Indeed, obesity has been found to significantly relate to clustering of CVD risk factors among school children in Taiwan. 11 Furthermore, data from very lean Chinese populations also confirmed an independent relation between body mass and CVD risk factors. 31,32 Obesity in adult populations is frequently associated with a host of adverse health outcomes, including hypertension, atherogenic lipid profiles, and glucose metabolic disorders 22,33 37 and is also linked to an increased risk of mortality Taken together, the strong relation between obesity and clustering of CVD risk factors repeatedly observed in school children and this healthy Chinese adult population suggests that the adverse metabolic effects associated with overweight and obesity exist on a continuum (ie tracking of clustering of CVD risk factors in obese individuals). Noticeably, this obesity-associated clustering of CVD risk factors extends to populations with lower BMI levels (such as lean Chinese population). The results of the present study needs to be interpreted within the context of study limitations. A potential limitation is the representativeness of our study participants, who were undergoing a routine health check-up at a private health screening center. It is possible that this study population represents a higher socioeconomic and nutritional status than the general population. Hence, the prevalence estimates in our study population may not represent the true 1193

6 1194 national prevalence of the risk factors of interest. The crosssectional nature of this study also limits inferences regarding some of the associations noted in the current study, particularly the relationship of CVD risk factors with age. In summary, the analyses presented here document a high prevalence of CVD risk factors in these healthy Chinese adult men and women. In addition, our data confirm a significant association between overweight=obesity and clustering of well-recognized CVD risk factors previously observed in Western population. 9,10,25 Considered in light of the synergistic effect of combinations of risk factors on coronary risk, 25,27,28 this study underscores the need to identify individuals at high risk for developing CVD risk factors (ie obese individuals) and at the same time it gives an indication that population-based multifactoral interventions may work out favorably for special groups. References 1 Murray CJL, Lopez AD. 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