| ObjectiveTo estimate the attributable mortality of high level low-density lipoprotein cholesterol(LDL-C)exposure on Chinese population.To analyze the differences of attributable mortality among different regions,urban or rural,and provinces in China.Explore the implementation status and difficulties of prevention and control measures in a certain area with high level LDL-C exposure,thus to provide statistical support and put forward suggestions for further implementation of public health intervention measures to control dyslipidemia among Chinese population.MethodsIn this study,both quantitative and qualitative methods were used.Counterfactual analysis method was used to estimate the high LDL-C attributable mortality,and in-depth interview method was used to analyze the prevention and control measures of dyslipidemia in typical areas with high LDL-C attributable burden.Based on the data from China Chronic Disease and Risk Factor Surveillance 2013,the exposure level of LDL-C among adults aged≥25 years old were obtained.Based on the 2017 national Disease Surveillance Point system(DSPs),the mortality data of ischemic heart disease(IHD)and ischemic stroke(IS)related to high LDL-C as well as all-cause of death group by different age groups,provinces and urban or rural were abstained through garbage codes redistribution and under-report adjustment.Theoretical minimum risk exposure level(TMREL)of LDL-C and the relative risks(RR)between high LDL-C and attributable diseases(IHD and IS)by each age groups were obtained from the Global Burden of Disease(GBD)2017.Based on the Counterfactual theory,population attributable fractions(PAFs)and its 95%confidence interval(95%CI)were calculated by different age groups and gender and geographical divisions.High LDL-C was defined as the level of serum LDL-C higher than TMREL(with a uniform distribution between 0.7-1.3 mmol/L)in this study.Through the combination of PAF,mortality and annual average population of the DSPs in 2017,the attributable mortality rate of high LDL-C exposure were estimated,and the age-standardized attributable mortality rate was estimated using the 2010 national population censes standard population.The differences between different gender,age groups,and geographical divisions of high LDL-C attributable mortality rate and PAF were analyzed.According to the value of PAF of high LDL-C to IHD or IS,31 provinces were ranked.Then we chose the province ranked the first PAF as the research site to carry out qualitative interviews.In-depth interviews were conducted among 5 staffs engaged in chronic disease control and prevention from the chosen province’s provincial,municipal and district level centers for disease control and prevention(CDC),2 public health workers in Community Health Service Center(or station)and 2 staffs in township health center respectively.Interviews were conducted face to face and live records were made after conducting informed consent of the interviewees.The interview content was translated word by word,and the key words of the translated text were extracted and analyzed through the framework analysis method.Results1.The exposure level of LDL-CA total of 170 296 subjects over 25 years old were included in this study.In 2013,the weighted mean value of LDL-C among people aged≥ 25 years old in China was 2.93±0.87mmol/L,that of men(2.94±0.87mmol/L)was higher than that of women(2.93 ±0.87mmol/L),and that of urban areas(2.99±0.88mmol/L)was higher than that of rural areas(2.87±0.85mmol/L).The highest value was 3.06±0.89mmol/L in the eastern population,followed by 2.86±0.87mmol/L in the western population and the lowest was 2.83±0.84mmol/L in the central population(P<0.01).Guangdong showed the highest mean value of LDL-C(3.37mmol/L),followed by Hainan(3.20mmol/L)and Liaoning(3.17mmol/L).Qinghai showed the lowest mean value of LDL-C(3.37mmol/L).Western provinces such as Gansu and Tibet showed low level of LDL-C.2.The attributable mortality of high LDL-C(1)In 2017,10.09%(95%CI:9.83%-10.35%)of the total deaths in China could be attributed to the high LDL-C,which was higher in women than in men and higher in urban residents than rural residents.The PAF of high LDL-C towards all-cause mortality was the highest in the central population(10.93%,95%CI:10.57%-11.35%),followed by the eastern and western population.The highest three provinces were Jilin(15.93%,95%CI:15.44%-16.40%),Heilongjiang(15.68%,95%CI:15.12%-16.20%)and Liaoning(15.34%,95%CI:14.84%-15.84%).The lowest three provinces were Tibet(4.05%,95%CI:3.83%-4.26%),Zhejiang(5.59%,95%CI:5.33%-5.85%),and Qinghai(5.63%,95%CI:5.38%-5.89%).(2)The main causes of mortality attributable to high level LDL-C were IHD and IS,with PAF of 40.62%(95%CI:39.63%-41.62%)and 19.32%(95%CI:18.74%-19.88%),respectively.In terms of PAF to IHD or IS,women were higher than men,urban population were higher than rural population,eastern population were higher than central population and western population.The value of PAF of high LDL-C to IHD was highest in Hainan Province(48.49%,95%CI:47.11%-49.79%),followed by Guangdong(47.70%,95%CI:45.34%-50.41%),Liaoning(45.75%,95%CI:44.32%-47.19%).The lowest was showing in Qinghai(33.55%,95%CI:32.11%-35.06%).(3)The attributable mortality rate of high LDL-C was 69.70/100 000,that of men and women was 72.14/100 000 and 67.17/100 000,respectively.The all-cause mortality rate of LDL-C in urban and rural population was 64.04/100 000 and 72.86/100 000,respectively.The attributable mortality rates in the eastern,central and western regions were 67.57/100 000,81.27/100 000 and 59.40/100 000,respectively.As for the age-standardized mortality rate,men were higher than women.the rural population were higher than the urban population,the central population showed the highest(65.88/100000),followed by the western population(54.36/100 000)and the eastern population(50.35/100 000)showed the lowest.Ningxia,Heilongjiang and Xinjiang showed the highest age-standardized attributable mortality rate,which were 113.61/100 000,103.48/100 000 and 96.91/100 000 respectively.Shanghai,Zhejiang and Tibet showed the lowest standardized attributable mortality rate,which were 21.09/100 000,21.39/100 000 and 25.04/100 000 respectively.The attributable mortality of high LDL-C to IHD and IS was 53.82/100 000 and 15.98/100 000 respectively.The attributable mortality rate of IHD in each group was higher than that of IS.3.The qualitative analysis results showed that current preventive interventions towards dyslipidemia in Hainan Province(ranked the first in the value of mortality standardized PAF of high LDL-C to IHD)were limited:(1)The interviewees mastered some knowledge towards lipid health,but payed little attention to the prevention of dyslipidemia;(2)The policy documents produced by provincial government were mainly aimed at health promotion.Few intervention programs were specially carried out to treat dyslipidemia,which were mainly integrated into the management of hypertension and diabetes.(3)The role of CDC and primary community health workers towards dyslipidemia was mainly surveillance and health promotion.As the management of dyslipidemia is not included in the national basic public health service,the routine work didn’t require controlling of dyslipidemia.(4)The main difficulties were:1)the effect of health education was not ideal;2)the coverage of blood lipid detection in community health service center or township health center was limited,and the cost of testing was too high for individuals;3)the medical departments cooperation was limited for lack of financial support and referral mechanism;4)the workload at the basial community health service centers was too heavy.There were few primary medical care workers who could provide health guidance for patients due to insufficient manpower and limited professional ability;5)the poor self-health awareness among residents,low coordination,and lack of trust in community health service personnel;6)policy and financial support should be strengthened;7)the "migrant elderly" were difficult to receive health care or management as they merely migrated to Hainan in cold winter seasons;8)the medical insurance for lipid regulating agents and the coverage of medical reimbursement spotswere limited.Some community health service stations were not qualified to be fixed-points of medical insurance,so the accessibility of lipid regulating agents was limited.Conclusion The burden of mortality attributed to high LDL-C accounted for 40.62%,19.32%,and 10.09%of deaths from IHD,IS,and all-causes of death,respectively in 2017.As an important risk factor of IHD and IS,high LDL-C has become a serious threat to the health of Chinese people,varied from different geographical divisions,age groups and gender.Further study should be carried out in typical regions to take targeted prevention and control measures.At present,the prevention and control measures for dyslipidemia in Hainan were limited,and faced with a series of difficulties,such as insufficient funds,limited coverage of medical insurance reimbursement for lipid-lowing agents,and insufficient cooperation from the residents,etc.It was necessary to draw more attention from the relevant government departments and formulate prevention strategies in the primary prevention to reduce the burden of cardiovascular disease caused by LDL-C and other dyslipidemia. |
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