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Summary Background China has experienced a remarkable epidemiological and demographic transition during the past three decades. Far less is known about this transition at the subnational level. Timely and accurate assessment of the provincial burden of disease is needed for evidence-based priority setting at the local level in China. Methods Following the methods of the Global Burden of Disease Study 2013 (GBD 2013), we have systematically analysed all available demographic and epidemiological data sources for China at the provincial level. We developed methods to aggregate county-level surveillance data to inform provincial-level analysis, and we used local data to develop specific garbage code redistribution procedures for China. We assessed levels of and trends in all-cause mortality, causes of death, and years of life lost (YLL) in all 33 province-level administrative units in mainland China, all of which we refer to as provinces, for the years between 1990 and 2013. Findings All provinces in mainland China have made substantial strides to improve life expectancy at birth between 1990 and 2013. Increases ranged from 4·0 years in Hebei province to 14·2 years in Tibet. Improvements in female life expectancy exceeded those in male life expectancy in all provinces except Shanghai, Macao, and Hong Kong. We saw significant heterogeneity among provinces in life expectancy at birth and probability of death at ages 0–14, 15–49, and 50–74 years. Such heterogeneity is also present in cause of death structures between sexes and provinces. From 1990 to 2013, leading causes of YLLs changed substantially. In 1990, 16 of 33 provinces had lower respiratory infections or preterm birth complications as the leading causes of YLLs. 15 provinces had cerebrovascular disease and two (Hong Kong and Macao) had ischaemic heart disease. By 2013, 27 provinces had cerebrovascular disease as the leading cause, five had ischaemic heart disease, and one had lung cancer (Hong Kong). Road injuries have become a top ten cause of death in all provinces in mainland China. The most common non-communicable diseases, including ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and cancers (liver, stomach, and lung), contributed much more to YLLs in 2013 compared with 1990. Interpretation Rapid transitions are occurring across China, but the leading health problems and the challenges imposed on the health system by epidemiological and demographic change differ between groups of Chinese provinces. Localised health policies need to be implemented to tackle the diverse challenges faced by local health-care systems. Funding China National Science & Technology Pillar Program 2013 (2013BAI04B02) and Bill & Melinda Gates Foundation.

Summary Background China has undergone rapid demographic and epidemiological changes in the past few decades, including striking declines in fertility and child mortality and increases in life expectancy at birth. Popular discontent with the health system has led to major reforms. To help inform these reforms, we did a comprehensive assessment of disease burden in China, how it changed between 1990 and 2010, and how China's health burden compares with other nations. Methods We used results of the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010) for 1990 and 2010 for China and 18 other countries in the G20 to assess rates and trends in mortality, causes of death, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE). We present results for 231 diseases and injuries and for 67 risk factors or clusters of risk factors relevant to China. We assessed relative performance of China against G20 countries (significantly better, worse, or indistinguishable from the G20 mean) with age-standardised rates and 95% uncertainty intervals. Findings The leading causes of death in China in 2010 were stroke (1·7 million deaths, 95% UI 1·5–1·8 million), ischaemic heart disease (948 700 deaths, 774 500–1 024 600), and chronic obstructive pulmonary disease (934 000 deaths, 846 600–1 032 300). Age-standardised YLLs in China were lower in 2010 than all emerging economies in the G20, and only slightly higher than noted in the USA. China had the lowest age-standardised YLD rate in the G20 in 2010. China also ranked tenth (95% UI eighth to tenth) for HALE and 12th (11th to 13th) for life expectancy. YLLs from neonatal causes, infectious diseases, and injuries in children declined substantially between 1990 and 2010. Mental and behavioural disorders, substance use disorders, and musculoskeletal disorders were responsible for almost half of all YLDs. The fraction of DALYs from YLDs rose from 28·1% (95% UI 24·2–32·5) in 1990 to 39·4% (34·9–43·8) in 2010. Leading causes of DALYs in 2010 were cardiovascular diseases (stroke and ischaemic heart disease), cancers (lung and liver cancer), low back pain, and depression. Dietary risk factors, high blood pressure, and tobacco exposure are the risk factors that constituted the largest number of attributable DALYs in China. Ambient air pollution ranked fourth (third to fifth; the second highest in the G20) and household air pollution ranked fifth (fourth to sixth; the third highest in the G20) in terms of the age-standardised DALY rate in 2010. Interpretation The rapid rise of non-communicable diseases driven by urbanisation, rising incomes, and ageing poses major challenges for China's health system, as does a shift to chronic disability. Reduction of population exposures from poor diet, high blood pressure, tobacco use, cholesterol, and fasting blood glucose are public policy priorities for China, as are the control of ambient and household air pollution. These changes will require an integrated government response to improve primary care and undertake required multisectoral action to tackle key risks. Analyses of disease burden provide a useful framework to guide policy responses to the changing disease spectrum in China. Funding Bill & Melinda Gates Foundation.

Summary China has experienced an epidemiological transition shifting from the infectious to the chronic diseases in much shorter time than many other countries. The pace and spread of behavioural changes, including changing diets, decreased physical activity, high rates of male smoking, and other high risk behaviours, has accelerated to an unprecedented degree. As a result, the burden of chronic diseases, preventable morbidity and mortality, and associated health-care costs could now increase substantially. China already has 177 million adults with hypertension; furthermore, 303 million adults smoke, which is a third of the world's total number of smokers, and 530 million people in China are passively exposed to second-hand smoke. The prevalence of overweight people and obesity is increasing in Chinese adults and children, because of dietary changes and reduced physical activity. Emergence of chronic diseases presents special challenges for China's ongoing reform of health care, given the large numbers who require curative treatment and the narrow window of opportunity for timely prevention of disease.

Summary Background Unlike almost every other country in the world, the prevalence of both schizophrenia and suicide in China is higher in women than in men. Schizophrenia and suicide are important public-health problems for China that might be related to each other. We present prevalence data for schizophrenia and estimate relative and attributable risk of suicide in people with schizophrenia in mainland China. Methods We used data from the national psychiatric epidemiology study, the Ministry of Health's mortality registry, the census, and the national psychological autopsy study to estimate frequencies and rates of schizophrenia, suicide, and suicide in people with schizophrenia aged 15 years and older in mainland China during 1995–99. Findings We estimated 4·25 million people with schizophrenia in China, and 284 614 suicides and 28 737 suicides in people with schizophrenia yearly. Prevalence of schizophrenia was higher in women than men (relative risk 1·77 [95% CI 1·15–2·72]), and greater in urban than rural areas (1·62 [1·10–2·40]). Risk of suicide was greater in women than men (1·22 [1·20–1·23]) and in rural than urban areas (3·61 [3·56–3·66]). Relative risk of suicide in individuals with schizophrenia compared with those without was 23·8 (18·8–30·2); the proportion of all suicides attributable to schizophrenia was 9·7% (7·7–12·1). Relative risk of suicide in rural residents with schizophrenia versus those without was higher in men than in women (ratio of two relative risks 2·02 [1·13–3·63]), but in urban residents with schizophrenia the ratio was lower in men than women (0·56 [0·21–1·49]). Interpretation Risk factors for suicide vary in people with different mental disorders, so identification of illness-specific risk profiles would improve prediction of suicide and help tailor prevention efforts. The difference in suicide rates by sex and residential location in individuals with schizophrenia might be one of several contributing factors to the unique epidemiological pattern of schizophrenia in China.

Summary Background Suicide is the fifth most important cause of death in China, but the reasons for the high rate and unique pattern of characteristics of those who kill themselves are unknown. Methods We pretested, and then administered a comprehensive interview to family members and close associates of 519 people who committed suicide and of 536 people who died from other injuries (controls) randomly selected from 23 geographically representative sites in China. Findings After adjustment for sex, age, location of residence, and research site, eight significant predictors of suicide remained in the final unconditional logistic regression model. In order of importance they were: high depression symptom score, previous suicide attempt, acute stress at time of death, low quality of life, high chronic stress, severe interpersonal conflict in the 2 days before death, a blood relative with previous suicidal behaviour, and a friend or associate with previous suicidal behaviour. Suicide risk increased substantially with exposure to multiple risk factors: none of the 265 deceased people who were exposed to one or fewer of the eight risk factors died by suicide, but 30% (90/299) with two or three risk factors, 85% (320/377) with four or five risk factors, and 96% (109/114) with six or more risk factors died by suicide. Interpretation Despite substantial differences between characteristics of people who commit suicide in China and the west, risk factors for suicide do not differ greatly. Suicide prevention programmes what concentrate on a single risk factor are unlikely to reduce suicide rates substantially; preventive efforts should focus on individuals exposed to multiple risk factors.

Background With rapid economic development in China, disease patterns have changed in the past two decades. This study considered mortality trends for ischaemic heart disease and stroke using data from 102 continuous disease surveillance points from 1991 to 2009. Methods We analysed 102 continuous disease surveillance points, covering 7·3 million people in 1991–2000 and expanded to a population of 52·0 million in the same areas in 2001–2009. The data were adjusted using garbage code redistribution and under-report rate, and mapped from the International Classification of Diseases revision 9 (ICD9) to ICD10. The mortality rates for ischaemic heart disease and stroke were further adjusted by crude death proportion multiplied by the envelope of total death, which was calculated using log r t = a + bt , where r t denotes the mortality rate at time point t . The trend b was estimated from the logarithm of the annual mortality rate (log rt ) using Poisson regression. Age-standardised death rates were computed using China's 2010 census population structure. We obtained agreement from the Chinese Center for Disease Control and Prevention to use data from the Disease Surveillance Point System. Patient consent and ethics approval were not necessary because all data analysed have previously been published. Findings Ischaemic heart disease age-standardised mortality rates increased in all regions, from 38·24 per 100 000 people in 1991 to 88·72 per 100 000 people in 2009 (log r t =–94·9602+0·0495× t ), especially in northeast, central, and southwest China. Before 2007, the rates for both sexes in urban areas were higher than in rural areas, but after 2007, the rates were higher in rural areas than in urban areas. For stroke, the overall age-standardised mortality rates remained stable in 1991–2009; however, the rates increased in northeast and central China but decreased in north and east China. The mortality rates in rural areas increased by 6% every year from 1991 to 2009, whereas in urban areas, mortality rates slowly rose for women ( b =1·6%) and fluctuated for men. For people younger than 70 years, the proportions of deaths were 30·9% for ischaemic heart disease and 32·6% for stroke in 2006–09, which is a substantial decline from 42·7% and 40·9%, respectively, in 1991–95. Interpretation By observing relatively unchanged areas (ie, the same surveillance points that were expanded to cover larger areas) from 1991 to 2009, the overall age-standardised mortality rate for ischaemic heart disease increased and that of stroke remained stable. These trends are likely to be a result of increased fat content in diets, blood lipid concentrations, and body weights. The different patterns of ischaemic heart disease and stroke in different geographical regions, and divergences in urban and rural areas, are an indication of varying health control strategies and health-care services. Funding China Medical Board Grant on CMB-CP in Burden of Diseases in China (12-107).