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Background: Little is known about the long-term risks of stroke and ischemic heart disease (IHD) in women who had a hysterectomy alone (HA) or with bilateral oophorectomy (HBO) for benign diseases, particularly in China where the burden of cardiovascular diseases (CVD) is high. We assessed mean levels of cardiovascular risk factors and relative risks of stroke and IHD in Chinese women who had a HA or HBO. Methods: A total of 302 510 women, aged 30 to 79 years were enrolled in the China Kadoorie Biobank from 2004 to 2008 and followed up for a mean of 9.8 years. The analysis involved premenopausal women without prior cardiovascular disease or cancer at enrollment. We calculated adjusted hazard ratios for incident cases of CVD and their pathological types (ischemic stroke, hemorrhagic stroke, and IHD) after HA and HBO. Analyses were stratified by age and region and adjusted for levels of education, household income, smoking status, alcohol consumption, physical activity, body mass index, systolic blood pressure, diabetes, self-reported health, and number of pregnancies. Results: Among 282 722 eligible women, 8478 had HA, and 1360 had HBO. Women who had HA had 9% higher risk of CVD after HA (hazard ratio, 1.09 [95% CI, 1.06–1.12]) and 19% higher risk of CVD after HBO (1.19 [95% CI, 1.12–1.26]) compared with women who did not. Both HA and HBO were associated with higher risks of ischemic stroke and IHD but not with hemorrhagic stroke. The relative risks of CVD associated with HA and HBO were more extreme at younger age of surgery. Conclusions: Women who had either HA or HBO have higher risks of ischemic stroke and IHD, and these risks should be evaluated when discussing these interventions. Additional screening for risk factors for CVD should be considered in women following HA and HBO operations, especially if such operations are performed at younger age.

Background Tobacco smoking is estimated to account for more than 1 million annual deaths in China, and the epidemic continues to increase in men. Large nationwide prospective studies linked to different health records can help to periodically assess disease burden attributed to smoking. We aimed to examine associations of smoking with incidence of and mortality from an extensive range of diseases in China. Methods We analysed data from the prospective China Kadoorie Biobank, which recruited 512 726 adults aged 30–79 years, of whom 210 201 were men and 302 525 were women. Participants who had no major disabilities were identified through local residential records in 100–150 administrative units, which were randomly selected by use of multistage cluster sampling, from each of the ten diverse study areas of China. They were invited and recruited between June 25, 2004, and July 15, 2008. Upon study entry, trained health workers administered a questionnaire assessing detailed smoking behaviours and other key characteristics (eg, sociodemographics, lifestyle, and medical history). Participants were followed up via electronic record linkages to death and disease registries and health insurance databases, from baseline to Jan 1, 2018. During a median 11-year follow-up (IQR 10–12), 285 542 (55·7%) participants were ever hospitalised, 48 869 (9·5%) died, and 5252 (1·0%) were lost to follow-up during the age-at-risk of 35–84 years. Cox regression yielded hazard ratios (HRs) associating smoking with disease incidence and mortality, adjusting for multiple testing. Findings At baseline, 74·3% of men and 3·2% of women (overall 32·4%) ever smoked regularly. During follow-up, 1 137 603 International Classification of Diseases, 10th revision (ICD-10)-coded incident events occurred, involving 476 distinct conditions and 85 causes of death, each with at least 100 cases. Compared with never-regular smokers, ever-regular smokers had significantly higher risks for nine of 18 ICD-10 chapters examined at age-at-risk of 35–84 years. For individual conditions, smokers had significantly higher risks of 56 diseases (50 for men and 24 for women) and 22 causes of death (17 for men and nine for women). Among men, ever-regular smokers had an HR of 1·09 (95% CI 1·08–1·11) for any disease incidence when compared with never-regular smokers, and significantly more episodes and longer duration of hospitalisation, particularly those due to cancer and respiratory diseases. For overall mortality, the HRs were greater in men from urban areas than in men from rural areas (1·50 [1·42–1·58] vs 1·25 [1·20–1·30]). Among men from urban areas who began smoking at younger than 18 years, the HRs were 2·06 (1·89–2·24) for overall mortality and 1·32 (1·27–1·37) for any disease incidence. In this population, 19·6% of male (24·3% of men residing in urban settings and 16·2% of men residing in rural settings) and 2·8% of female deaths were attributed to ever-regular smoking. Interpretation Among Chinese adults, smoking was associated with higher risks of morbidity and mortality from a wide range of diseases. Among men, the future smoking-attributed disease burden will increase further, highlighting a pressing need for reducing consumption through widespread cessation and uptake prevention. Funding British Heart Foundation, Cancer Research UK, Chinese Ministry of Science and Technology, Kadoorie Charitable Foundation, UK Medical Research Council, National Natural Science Foundation of China, Wellcome Trust.

Background and aims Observational studies have associated resting heart rate with incident diabetes. Whether the associations are causal remains unclear. We aimed to examine the shape and strength of the associations and assessed the causal relevance of such associations in Chinese adults. Methods and results The China Kadoorie Biobank enrolled 512,891 adults in China. Cox proportional hazard regression models was conducted to estimate hazard ratios (HRs) for the associations of resting heart rate with type 2 diabetes and total diabetes. Among 92,724 participants, 36 single-nucleotide polymorphisms (SNPs) related to resting heart rate were used to construct genetic risk score. We used Mendelian randomization analyses to make the causal inferences. During a median follow-up of 9 years, 7872 incident type 2 diabetes and 13,349 incident total diabetes were documented. After regression dilution bias adjustment, each 10 bpm higher heart rate was associated with about a 26% higher risk of type 2 diabetes (HR, 1.26 [95% CI, 1.23, 1.29]) and 23% higher risk of total diabetes (HR, 1.23 [95% CI, 1.20, 1.26]). Instrumental variable analyses showed participants at top quintile compared with those at bottom quintile had 30% higher risk for type 2 diabetes (HR, 1.30 [95% CI, 1.17, 1.43]), and 10% higher risk for total diabetes (HR, 1.10 [95% CI, 1.02, 1.20]). Conclusions This study provides evidence that resting heart rate is an important risk factor for diabetes risk. The results suggest that novel treatment approaches targeting reduction of high heart rate for incidence of diabetes may be worth further investigation.

Background Lean body mass has been identified as a key determinant of left ventricular mass and wall thickness. However, the importance of lean body mass or other body‐size measures as normative determinants of carotid intima‐media thickness ( cIMT ), a widely used early indicator of atherosclerosis, has not been well established. Methods and Results Carotid artery ultrasound measurements of cIMT and carotid artery plaque burden (derived from plaque number and maximum size) and measurements of body size, including height, body mass index, weight, body fat proportion, and lean body mass ([1−body fat proportion]×weight), were recorded in 25 020 participants from 10 regions of China. Analyses were restricted to a healthy younger subset (n=6617) defined as never or long‐term ex‐regular smokers aged cIMT , but was not associated with plaque burden: overall, each 10 kg higher lean body mass was associated with a 0.03 (95% CI , 0.03–0.04) mm higher cIMT ( P =5×10 −33 ). Fat mass, height, and other body‐size measures were more weakly associated with cIMT . Conclusions The strong association of lean body mass with cIMT, but not with plaque burden, in healthy adults suggests a normative relationship rather than reflecting atherosclerotic pathology. Common mechanisms may underlie the associations of lean body mass with cIMT and with nonatherosclerotic vascular traits.

Rationale Little evidence from large-scale cohort studies exists about the relationship of solid fuel use with hospitalization and mortality from major respiratory diseases. Objectives To examine the associations of solid fuel use and risks of acute and chronic respiratory diseases. Methods A cohort study of 277,838 Chinese never-smokers with no prior major chronic diseases at baseline. During 9 years of follow-up, 19,823 first hospitalization episodes or deaths from major respiratory diseases, including 10,553 chronic lower respiratory disease (CLRD), 4,398 chronic obstructive pulmonary disease (COPD), and 7,324 acute lower respiratory infection (ALRI), were recorded. Cox regression yielded adjusted hazard ratios (HRs) for disease risks associated with self-reported primary cooking fuel use. Measurements and Main Results Overall, 91% of participants reported regular cooking, with 52% using solid fuels. Compared with clean fuel users, solid fuel users had an adjusted HR of 1.36 (95% confidence interval, 1.32–1.40) for major respiratory diseases, whereas those who switched from solid to clean fuels had a weaker HR (1.14, 1.10–1.17). The HRs were higher in wood (1.37, 1.33–1.41) than coal users (1.22, 1.15–1.29) and in those with prolonged use (≥40 yr, 1.54, 1.48–1.60; Conclusions Among Chinese adults, solid fuel use for cooking was associated with higher risks of major respiratory disease admissions and death, and switching to clean fuels or use of ventilated cookstoves had lower risk than not switching.

Background Self‐rated health ( SRH ) is a strong predictor of mortality in different populations. However, the associations between SRH measures and risk of ischemic heart disease ( IHD ) have not been extensively explored, especially in a Chinese population. Methods and Results More than 500 000 adults from 10 cities in China were followed from baseline (2004–2008) through December 31, 2013. Global and age‐comparative SRH were reported from baseline questionnaires. Incident IHD cases were identified through links to well‐established disease registry systems and the national health insurance system. During 3 423 542 person‐years of follow‐up, we identified 24 705 incident cases of IHD . In multivariable‐adjusted models, both global and age‐comparative SRH was significantly associated with incident IHD . Compared with excellent SRH , the hazard ratios for good, fair, and poor SRH were 1.02 (95% confidence interval [CI], 0.98–1.07), 1.32 (95% CI, 1.27–1.37), and 1.76 (95% CI, 1.68–1.85), respectively. Compared with better age‐comparative SRH , the hazard ratios for same and worse age‐comparative SRH were 1.23 (95% CI, 1.19–1.27) and 1.78 (95% CI, 1.70–1.86), respectively. The associations persisted in all subgroup analyses, although they were slightly modified by study location, education, and income levels. Conclusions A simple questionnaire for self‐assessment of health status was significantly associated with incident IHD in Chinese adults. Individuals and healthcare providers can use SRH measures as a convenient tool for assessing future IHD risk.

BACKGROUND: Adherence to a combination of healthy lifestyle factors has been related to a considerable reduction of cardiovascular risk in white populations; however, little is known whether such associations persist in nonwhite populations like the Asian population. OBJECTIVES: This study aimed to examine the associations of a combination of modifiable, healthy lifestyle factors with the risks of ischemic cardiovascular diseases and estimate the proportion of diseases that could potentially be prevented by adherence to these healthy lifestyle patterns. METHODS: This study examined the associations of 6 lifestyle factors with ischemic heart disease and ischemic stroke (IS) in the China Kadoorie Biobank of 461,211 participants 30 to 79 years of age who did not have cardiovascular diseases, cancer, or diabetes at baseline. Low-risk lifestyle factors were defined as nonsmoking status or having stopped smoking for reasons other than illness, alcohol consumption of

Background Increasing evidence has suggested that major depression ( MD ) is associated with an increased risk of ischemic heart disease ( IHD ). We examined this association in Chinese adults using data from the China Kadoorie Biobank study. Methods and Results Over 0.5 million adults aged 30 to 79 years were followed from baseline interview (2004–2008) until December 31, 2013. Past year MD was measured with the modified Chinese version of Composite International Diagnostic Interview‐Short Form at baseline. Incident IHD cases were identified through linkage to related medical databases, and defined as having International Statistical Classification of Diseases and Related Health Problems 10th Revision codes of I20 to I25. Cox proportional hazards regression models were used to estimate hazard ratios and 95% CI s for the MD ‐ IHD association with adjustment for sociodemographic variables and established cardiovascular risk factors. During 3 423 542 person‐years of follow‐up, 24 705 incident IHD cases were documented. Higher IHD incidence was observed in participants with MD compared with those without (8.76 versus 7.21 per 1000 person‐years), and the multivariable‐adjusted hazard ratio was 1.32 (95% CI 1.15–1.53). Geographic location modified the association ( P for interaction=0.005), and a positive association was observed in urban residents (hazard ratio 1.72; 95% CI 1.39–2.14) but not rural residents (1.13; 0.93–1.37). Compared with participants without depressive symptoms, the hazard ratio (95% CI ) of IHD was 1.13 (1.04–1.23) for those with depressive symptoms only and 1.33 (1.15–1.53) for those with MD . Conclusions Past year major depression was associated with an increased risk of IHD in Chinese adults, independent of other major cardiovascular risk factors.

To understand the incidence of central obesity and its characteristics, and explore the effects of lifestyle factors on incidence of central obesity in Chinese adults aged 35-74 years.A total of 27 020 Chinese adults aged 35 to 74 years were enrolled in a prospective follow-up study (the study cohort was built from 1998 to 2000, respectively) during 2007 and 2008. Central obesity was defined as waist circumference ≥ 90 cm in men, ≥ 85 cm and ≥ 80 cm in women, respectively. Multivariate logistic regression was used to estimate relative risks (RR) of central obesity for lifestyle factors after adjusting factors including genders, age, southern and geographic region, urbanization, lifestyles, and so on.Among Chinese adults aged 35-74 years, the standardized annual incidence of central obesity (waist ≥ 90 cm) was 2.19% for men and this rate decreased gradually with age among people younger than 65 years old. The incidence of central obesity was 2.64% (waist ≥ 85 cm) and 4.06% (waist ≥ 80 cm) for women, respectively, and this rate increased obviously among people aged 55 to 74 years. Participants with ≥ 12 years' education (RR = 0.84, 95%CI:0.74-0.96) had a lower risk of central obesity(waist ≥ 90 cm for men, waist ≥ 85 cm for women). And this risk increased as the monthly household per capita income increased. Compared with the reference group, people involved in housework or retirees (RR = 1.17; 95% CI: 1.01-1.36), drinking alcohol (RR = 1.15, 95% CI: 1.01-1.32) or scented tea (RR = 1.49, 95%CI:1.28-1.72) had a higher risk of developing central obesity, while drinking milk (RR = 0.85, 95% CI: 0.74-0.97) or black tea (RR = 0.74, 95% CI: 0.58-0.95), had a lower risk of developing central obesity.A healthy lifestyle plays a key role in the prevention and control of central obesity in Chinese adults, and a healthy way of lifestyle should be promoted in the whole society to decelerate the epidemic of the central obesity.

The objective is to examine the association between physical activity level (PAL) and incident type 2 diabetes among middle-age and older Chinese men and women in urban China.This prospective study included 6348 participants (age 35 to 74 yr) who were free of diabetes and cardiovascular disease at baseline. PAL was estimated on the basis of self-reported overall physical activity on a typical day. According to PAL, participants were classified into four groups: sedentary (PAL, 1.00-1.39), low active (PAL, 1.40-1.59), active (PAL, 1.60-1.89), and very active (PAL,1.89). The association of PAL with incident diabetes was examined by Cox proportional hazards model.During 7.9 yr of follow-up (50,293 person-years), 478 incident cases of type 2 diabetes were identified. After adjustment for age, sex, geographic region, educational level, smoking, alcohol use, and family history of diabetes, the HR (95% CI) values for type 2 diabetes across increasing categories of PAL were 1.00 (reference), 0.82 (0.62-1.09), 0.63 (0.47-0.83), and 0.47 (0.36-0.61), respectively (P for trend0.0001). Additional adjustment for baseline body mass index or waist circumference attenuated the magnitude of risk reduction, but it remained significant. The inverse association between PAL and risk of incident diabetes was persistent in subgroup analyses according to age, sex, hypertension, smoking, body mass index, waist circumference, and fasting plasma glucose level.Higher PAL is associated with substantial reduction in risk of type 2 diabetes. Our findings suggest the importance of a physically active lifestyle in the prevention of diabetes.

To examine the incidence of obesity and its modifiable risk factors in Chinese adults aged 35-74 years.A total of 27 020 participants aged 35 to 74 years from two prospective cohort studies in China were followed up in the years of 2007 and 2008. Obesity and overweight were defined as body mass index ≥ 28.0, and 24.0-27.9 kg/m(2), respectively. Relative risks of obesity for risk factors were computed by using logistic regression.The annual incidence rates of obesity and overweight were 6.97 ‰ and 24.83 ‰ in Chinese adults aged 35-74 years, respectively. Women had a higher incidence of obesity than men (7.74 ‰ vs. 6.10 ‰). Participants in northern China had a higher incidence than those in southern (9.29 ‰ vs. 5.10 ‰) part of the country. Adults in rural had a higher incidence than those in urban (7.28 ‰ vs. 6.52 ‰). After adjusting for the baseline variables, such as gender, age, geographic region, degree of urbanization, the relative risk for obesity was 0.82 (95% CI:0.68-0.99) for participants with ≥ 12 years' education, compared with those12 years. Participants with middle income, less physical activity at work/housework or being retirees, consuming more red meat and scented tea etc, had higher risk of incidence of obesity. Participants who consumed milk and moderate amount of fruits, would show a lower risk of obesity.The incidence of obesity was 6.97 ‰ in Chinese middle and older adults. Our results underscored that the promotion of healthy lifestyle which include issues as increasing physical activity, consuming moderate amount of fruits and milk but less red meat, drinking less scented tea etc, could play key roles in obesity prevention and control among the Chinese adults, especially among people with low education level or with middle income.