Preamble

Burden of Cardiovascular Disease Attributable to Metabolic Factors in China (2019) and Trend Projections for 2030

Abstract

Objective: To analyze the burden of cardiovascular disease (CVD) attributable to metabolic risk factors in China in 2019 and to predict the trends in disease burden through 2030.

Methods: Data were extracted from the Global Burden of Disease Study 2019 (GBD 2019). Indicators including deaths, disability-adjusted life years (DALYs), and their respective age-standardized rates (ASMR and ASDR) were used to describe the CVD burden attributable to five metabolic factors: high systolic blood pressure (SBP), high low-density lipoprotein cholesterol (LDL-C), high fasting plasma glucose (FPG), high body mass index (BMI), and kidney dysfunction. Joinpoint regression was employed to analyze the trends in ASMR and ASDR from 1990 to 2019. Furthermore, the Bayesian Age-Period-Cohort (BAPC) model was utilized to project the CVD burden attributable to these metabolic factors through 2030.

Results: In 2019, the number of CVD deaths in China attributable to metabolic factors reached 3.41 million, with high SBP remaining the leading risk factor. From 1990 to 2019, the ASMR and ASDR for CVD attributable to metabolic factors showed a general downward trend; however, the absolute number of deaths and DALYs continued to rise. Projections indicate that by 2030, the absolute burden of CVD attributable to metabolic factors in China will continue to increase, primarily driven by population aging and the rising prevalence of high BMI and high FPG.

Conclusion: While age-standardized rates have declined, the total burden of CVD attributable to metabolic factors in China remains severe. Targeted interventions focusing on blood pressure control, weight management, and glucose regulation are critical to achieving the goals of "Healthy China 2030."

Introduction

Cardiovascular disease (CVD) remains the leading cause of death and disability in China, posing a significant challenge to public health and the socio-economic landscape. With the rapid transition in lifestyles and the acceleration of population aging, metabolic risk factors—including hypertension, dyslipidemia, hyperglycemia, and obesity—have become increasingly prevalent.

According to the *Report on Cardiovascular

1.300250 天津市，天津中医药大学第二附属医院

Tianjin, Tianjin University of Traditional Chinese Medicine; Tianjin, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine

背景

Metabolic factors have become the primary driver of the continuous rise in the burden of cardiovascular disease (CVD) in China. This study evaluates the trends in CVD burden attributable to metabolic risk factors in China from 1990 to 2021 and utilizes the Bayesian Age-Period-Cohort (BAPC) model to predict developmental trends for the period of 2022–2035.

方法

Using the Global Burden of Disease (GBD) 2021 database, this study employed the Population Attributable Fraction (PAF) method to quantify the contributions of Level 1 and major Level 2 risk factors—including hypertension, air pollution, smoking, high LDL cholesterol, and dietary risks—to cardiovascular disease (CVD) mortality and disability-adjusted life years (DALYs). Joinpoint regression analysis was utilized to examine the annual trends in CVD burden attributable to metabolic factors from 1990 to 2021, and the average annual percent change (AAPC) in the burden attributed to major metabolic factors was calculated. Finally, a Bayesian Age-Period-Cohort (BAPC) model was applied to predict the burden trends for the period 2022–2035.

结果

From 1990 to 2021, the age-standardized disability-adjusted life year (DALY) rate for cardiovascular disease (CVD) attributable to metabolic factors in China decreased by 4.3% (from 3,927.3 per 100,000 to 3,756.4 per 100,000), while the corresponding mortality rate increased by 24.9% (from 169.3 per 100,000 to 211.5 per 100,000). In 2021, the population attributable fractions (PAFs) of metabolic factors for CVD DALYs and mortality were 68.6% and 70.1%, respectively. Hypertension remained the leading pathogenic factor throughout the study period, with its PAFs for DALYs and mortality reaching 53.3% and 55.4%, respectively.

Among the four primary metabolic factors, the disease burden associated with high body mass index (BMI) showed the most significant growth. The DALY rate attributable to high BMI rose from 281.04 per 100,000 to 396.09 per 100,000 (Average Annual Percentage Change [AAPC] = 1.08%, $P < 0.0001$), and the mortality rate increased from 13.73 per 100,000 to 18.80 per 100,000 (AAPC = 1.00%, $P < 0.0001$). In contrast, the burdens associated with high fasting plasma glucose and high low-density lipoprotein (LDL) cholesterol exhibited smaller fluctuations; their DALY and mortality rates remained relatively stable during this period, and most differences in AAPC were not statistically significant.

Gender and age-stratified results indicate that the burden is heaviest among elderly males, with the gender gap widening as age increases. Projections based on the Bayesian Age-Period-Cohort (BAPC) model suggest a continuous downward trend in the CVD burden through 2035. Specifically, the mortality rate for males is predicted to decrease from 291.97 per 100,000 in 2022 to 183.33 per 100,000 in 2035, while for females, it is expected to drop from 149.26 per 100,000 to 103.00 per 100,000. Similarly, the DALY rate for males is projected to fall from 5,296.99 per 100,000 to 3,274.07 per 100,000, and for females, from 2,863.17 per 100,000 to 1,814.15 per 100,000. The forecast indicates a distinct downward inflection point for the male population around the year 2030, whereas the female population is expected to maintain a steady decline. The Mean Absolute Percentage Error (MAPE) for all four indicators was below 2%, demonstrating high predictive accuracy.

结论

High BMI and hypertension are the primary metabolic risk factors. Projections indicate that the attributable burden of these factors may continue to rise, with a heavier burden observed in males and the elderly. Furthermore, BMI-related risks are particularly prominent among young and middle-aged populations. Consequently, stratified prevention and control strategies should be strengthened.

Keywords: Cardiovascular disease; Metabolic factors; Global Burden of Disease; DALYs; Mortality; Prediction

Burden of Cardiovascular Diseases Attributable to Metabolic Risk Factors in China 1990 and Projected Trends from 2022

Xufang, Shengwei ZHANG, Bowen, Zhenjuan, Ruixuan
Tianjin University of Traditional Chinese Medicine, Tianjin 300250, China
Tianjin 301617, China
Tianjin University of Traditional Chinese Medicine, Tianjin 300381, China

Background

Metabolic risk factors have become a primary driver of the increasing burden of factors in China from 1990 to 2021 and project the future burden through 2035 using the BAPC model.

Methods

Based on data ZHEN R，GU X F，GAO S W，et al. Burden of cardiovascular diseases attributable to metabolic risk factors in China 1990—2021 and projected trends from 2022—2035[J]. Chinese General Practice，2026. [Epub ahead of print].

Editorial Office of Chinese General Practice. This is an open access article under the CC BY-NC-ND 4.0 license.

Chinese General Practice from the Global Burden of Disease Study 2021（GBD 2021），we quantified the contributions of level 1 and major level 2 risk factors（e.g.，high blood pressure，air pollution，smoking，high LDL cholesterol，and dietary risks） to CVD mortality and disability-adjusted life years（DALYs） using the population attributable fraction（PAF） method. Joinpoint regression was applied to estimate the average annual percent change（AAPC） of CVD burden attributable to metabolic factors from 1990 to 2021. A Bayesian age-period-cohort（BAPC） model was used to project future burden trends from 2022 to 2035.

Results

From 1990 to 2021，the age-standardized DALY rate of CVDs attributable to metabolic factors declined by 4.3%（3 927.3 per 100 000 to 3 756.4 per 100 000），while the mortality rate increased by 24.9%（169.3 per 100 000 to 211.5 per 100 000）. In 2021，metabolic factors accounted for 68.6% of CVD-related DALYs and 70.1% of CVD deaths. Elevated systolic blood pressure remained the leading risk factor，contributing 53.3% and 55.4% to DALYs and deaths，respectively. Among the four main metabolic risks，high body mass index（BMI） showed the most significant increase，with the attributable DALY rate rising from 281.04 to 396.09 per 100，000（ 1.08%， 0.000 1），and the mortality rate increasing from 13.73 per 100 000 to 18.80 per 100 000（ 1.00%， 0.000 1）. In contrast，the burden associated with high fasting plasma glucose and high LDL cholesterol changed minimally，with most AAPCs showing no statistical significance. Age-and sex-stratified analyses model suggest a continued decline in CVD burden by 2035: for males，the mortality rate is projected to decrease from 291.97 per 100 000 to 183.33 per 100 000 and the DALY rate from 5 296.99 per 100 000 to 3 274.07 per 100 000; for females，mortality is projected to decline from 149.26 to 103.00 per 100，000 and DALYs from 2 863.17 per 100 000 to 1 814.15 per 100 000. A clear downward inflection point is expected around 2030 in males，while a steady decline is projected for females. All model predictions had mean absolute percentage errors（MAPE） below 2%，indicating high predictive accuracy.

Conclusion

High BMI and high blood pressure remain the predominant metabolic risk factors for CVDs in China. The projected burden attributable to these risks is expected to continue rising，with males and older adults experiencing a higher burden. Younger adults are increasingly affected by BMI-related risks，highlighting the need for targeted，stratified prevention strategies.

Keywords: Cardiovascular disease; Metabolic risk factors; Global Burden of Disease; DALYs; Mortality; Projection

Cardiovascular disease (CVD) has remained the leading cause of death globally and among Chinese residents for many years, posing a significant threat to population health and socioeconomic development. According to the latest data from the Global Burden of Disease (GBD) study, the number of global CVD deaths reached 19.8 million in 2021, accounting for 32% of all deaths. Notably, China has the highest number of CVD deaths in the world, highlighting a particularly prominent disease burden \cite{1-2}. With China's rapid economic development and population aging, the prevalence and mortality rates of CVD have shown a continuous upward trend, placing a heavy strain on the healthcare system and society. Among the numerous risk factors for CVD, the role of metabolic risk factors has become increasingly prominent. Metabolic abnormalities—such as hypertension, hyperglycemia, elevated low-density lipoprotein cholesterol (LDL-C), and high body mass index (BMI)—have become the primary drivers of the rising CVD burden in China. Multiple large-scale epidemiological surveys and prospective cohort studies have confirmed that the prevalence of these metabolic abnormalities continues to rise among Chinese adults, and the risk of CVD attributed to these factors is significantly higher than that attributed to traditional behavioral and environmental factors \cite{4-6}. Although China's chronic disease prevention and control system is constantly improving, the CVD burden related to metabolic risk factors remains severe.

The GBD 2021 study achieves standardized and comparable dynamic assessments of major diseases and risk factors at global, regional, and national levels by systematically integrating multi-source health data and applying indicators such as population attributable fraction (PAF) and disability-adjusted life years (DALYs) \cite{1, 7-8}. In recent years, research based on the GBD database has continuously revealed the overall trends and regional distribution characteristics of CVD burden changes in China and globally. However, there is still a lack of systematic analysis regarding the structural changes, gender differences, and age variations in the burden of CVD attributable to various metabolic risk factors in China from 1990 to 2021, as well as projections for future burden trends. Therefore, this study utilizes the GBD 2021 database to systematically evaluate the CVD burden and its trends attributable to major metabolic risk factors in China from 1990 to 2021. Furthermore, it employs the Bayesian Age-Period-Cohort (BAPC) model to predict burden levels for the period 2022–2035. This research aims to provide a scientific basis for optimizing chronic disease prevention and control strategies and for implementing interventions in key populations.

1.1 数据来源

The data used in this study were derived from the Global Burden of Disease (GBD) 2021 database. This database systematically evaluates 371 diseases and injuries, as well as 88 risk factors, across 204 countries and territories worldwide, covering metrics such as incidence, prevalence, and mortality. For this study, we extracted data from 1990 to 2021 regarding cardiovascular disease (CVD) in China attributable primarily to metabolic factors. Extracted indicators include the number of deaths, mortality rates, disability-adjusted life year (DALY) rates, age-standardized mortality rates (ASMR), and age-standardized DALY rates (ASDR). Additionally, we collected data on the disease burden of CVD attributable to specific metabolic risk factors, including high systolic blood pressure (hypertension), high fasting plasma glucose, high low-density lipoprotein cholesterol, and high body mass index (BMI).

In accordance with the Chinese General Practice standards, the GBD classifies the diagnosis of CVD based on the International Classification of Diseases, 10th Revision (ICD-10). The study population encompasses the entire Chinese population from 1990 to 2021, stratified by sex and age groups, including young and middle-aged adults (15–49 years) and middle-aged and elderly adults (50–69 years).

70 岁及以上（老年）

This study examines the cardiovascular disease (CVD) burden in China. The analysis encompasses three distinct groups—the total Chinese population, males, and females—with a specific focus on the evolving trends regarding the impact of metabolic risk factors on CVD mortality and disability-adjusted life years (DALYs).

To simulate future trends in disease burden, this study constructed a Bayesian Age-Period-Cohort (BAPC) model based on observational data from 1990 to 2021 to predict the age-standardized mortality rates and DALY rates of CVD in the Chinese population from 2022 to 2035. The prediction results were stratified by gender, maintaining consistency with the analytical methods used for historical trends \cite{13-14}. This study utilized the Population Attributable Fraction (PAF) method to quantify the contribution of major metabolic risk factors to the CVD burden. PAF is calculated based on risk factor exposure levels and relative risk (RR) to evaluate the proportion of CVD attributable to each factor, providing clear guidance for public health interventions. Four major metabolic factors were modeled individually, and Joinpoint analysis was performed on their respective age-standardized mortality and DALY rates. Trend significance was determined by comparing the average annual percentage change (AAPC) of each factor. Joinpoint regression models were employed to analyze the annual percentage change (APC) in age-standardized CVD mortality and DALY rates attributable to metabolic factors from 1990 to 2021. Developed by the National Cancer Institute (NCI), Joinpoint regression is particularly suited for identifying temporal inflection points in disease burden. For the predictive analysis, the BAPC model was used to estimate age-standardized CVD mortality and DALY rates for the period 2022–2035. The model was implemented using the BAPC and INLA packages in R software, which allow for the capture of long-term trends and the calculation of prediction error metrics, such as Mean Absolute Percentage Error (MAPE) and Root Mean Square Error (RMSE), to evaluate model fit and predictive accuracy.

2 结果

Trends in the Burden of Cardiovascular Disease Attributable to Metabolic Risk Factors in China (per 100,000 population)

The trends in cardiovascular disease (CVD) mortality and Disability-Adjusted Life Year (DALY) rates attributable to metabolic risk factors in China from 1990 to 2021 exhibited significant fluctuations, with peaks and troughs occurring in similar periods, as shown in [FIGURE:1]. Between 1998 and 2004, the mortality rate for the total population reached its maximum increase (4.60, 95% CI = 2.02–4.82), reflecting a sharp rise in the burden of cardiovascular disease during this period. From 2004 to 2007, mortality rates briefly declined (-1.08, 95% CI = -1.47 to -0.53), showing a trend of negative growth. Subsequently, mortality rates rose again between 2010 and 2021, with a significant increase observed from 2018 to 2021 (2.61, 95% CI = 1.69–3.79).

The trends in CVD burden for female and male populations were generally consistent with those of the total population. However, mortality rates among males showed more pronounced increases during the periods of 1990–1998 (1.99, 95% CI = 1.70–2.23) and 2010–2021.

The growth rate was 1.72 (95% CI = 1.56–1.86). Regarding changes in DALY rates, the most substantial increase occurred between 1998 and 2004 (3.73, 95% CI = 3.57–3.87). From 2004 to 2007, the DALY rate experienced negative growth (-0.84, 95% CI = -1.13 to -0.53), reflecting a weakened impact of metabolic risk factors during that interval.

The overall value was 1.59 (95% CI = 1.55–1.64), while the values for females and males were 1.14 (95% CI = 1.10–1.18) and 1.90 (95% CI = 1.86–1.94), respectively. These differences were statistically significant ($P < 0.0001$), as detailed in [TABLE:1] and Table 2.

Comparison of Attribution Rates Between Metabolic Factors and Other Major Risk Factors

The distribution of Population Attributable Fractions (PAF) for CVD DALYs and mortality attributable to metabolic, behavioral, and environmental/occupational risk factors in China in 2021 shows that metabolic risk factors accounted for 68.6% (95% CI = 60.6%–75.1%) of CVD DALYs and 70.1% (95% CI = 62.4%–76.6%) of CVD deaths. These figures are significantly higher than those for behavioral risk factors (PAF of 46.8% for DALYs and 43.5% for mortality) and environmental/occupational risk factors (PAF of 39.0% for DALYs and 40.6% for mortality).

Among specific risk factors, high systolic blood pressure (hypertension) had the greatest impact on DALYs and DALY rates (per 100,000 population) over the years. Note: Figure A presents the DALY rates for the total, male, and female populations; Figure B presents the mortality rates for the total, male, and female populations; DALY rate refers to the Disability-Adjusted Life Year rate.

Trends in the disease burden attributable to metabolic risk factors in CVD in China from 1990 to 2021

Annual changes in cardiovascular disease (CVD) mortality attributable to metabolic risk factors among the total population, as well as specifically among men and women in China from 1990 to 2021, were analyzed using the Annual Percentage Change (APC) and Average Annual Percentage Change (AAPC). The Population Attributable Fractions (PAFs) for CVD mortality were 53.3% (95% CI = 43.4%–62.0%) and 55.4% (95% CI = 45.7%–64.1%), respectively, both of which ranked highest among all risk factors.

The contributions of high LDL cholesterol (DALYs PAF = 18.0%, mortality PAF = 16.1%) and high fasting plasma glucose (DALYs PAF = 9.8%, mortality PAF = 10.5%) were also higher than those of most behavioral and environmental risks. In comparison, the DALYs PAFs for non-metabolic factors such as air pollution, smoking, and dietary risks were 28.0%, 22.4%, and 29.3%, respectively, while their corresponding mortality PAFs were 28.6%, 18.7%, and 27.7%, as shown in Table 3 [TABLE:3].

Regarding the trends in disease burden for the four major metabolic factors, high systolic blood pressure (hypertension) was the leading contributor to the CVD burden. In 1990 and 2021, the DALY rates for high systolic blood pressure were 3,695.71 per 100,000 and 2,728.48 per 100,000, respectively, while the mortality rates were 201.79 per 100,000 and 155.21 per 100,000. The AAPC for the age-standardized DALY rate and age-standardized mortality rate were -0.06% (95% CI = -0.34%–0.21%, $P = 0.6539$) and 0.11% (95% CI = -0.25%–0.48%, $P = 0.5395$), respectively; neither change was statistically significant ($P > 0.05$). Conversely, the burden associated with high BMI increased rapidly. Its DALY rate rose from 281.04 per 100,000 in 1990 to 396.09 per 100,000 in 2021, with an AAPC of 1.08% (95% CI = 0.89%–1.27%, $P < 0.0001$). The mortality rate increased from 13.73 per 100,000 to 18.80 per 100,000, with an AAPC of 1.00% (95% CI = 0.77%–1.22%, $P < 0.0001$), both of which were statistically significant. The distribution of PAFs for DALYs and deaths from CVD attributable to metabolic, behavioral, and environmental/occupational risk factors in China for 2021 is detailed in the results, specifically highlighting high LDL cholesterol and environmental/occupational risks.

These changes were statistically significant ($P < 0.05$). The DALY rate for high fasting plasma glucose decreased from 521.36 per 100,000 in 1990 to 500.31 per 100,000 in 2021, with an AAPC of -0.99% (95% CI = -1.13% to -0.86%, $P < 0.0001$). Meanwhile, the mortality rate remained relatively stable, moving from 29.37 per 100,000 to 29.28 per 100,000. High LDL cholesterol...

Annual changes in the adjusted years of life with CVD attributable to metabolic risk factors in the total population and in men and women in China from 1990 to 2021

Chinese General Practice

The DALY rate associated with high LDL cholesterol decreased from 953.85/100,000 to 920.69/100,000, while the mortality rate increased slightly from 43.10/100,000 to 44.97/100,000. Neither of these changes reached statistical significance ($P > 0.05$), as shown in [TABLE:4] and Table 5.

Trend of standardized DALYs rate attributed to metabolic risk factors in China from 1990 to 2021

High BMI: 281.04, 396.09, 1.08 (0.89–1.27), 11.09, $P < 0.0001$

High fasting plasma glucose: 521.36, 500.31, -0.99 (-1.13 to -0.86), -14.61, $P < 0.0001$

High LDL cholesterol: Trends in standardized mortality attributable to metabolic risk factors in China, 1990–2021

High BMI: 13.73, 18.80, 1.00 (0.77–1.22), 8.62, $P < 0.0001$

High fasting plasma glucose: 29.37, 29.28, -0.86 (-1.06 to -0.66), -8.45, $P < 0.0001$

Analysis of changes in cardiovascular disease (CVD) mortality and disability-adjusted life years (DALYs) rates attributable to metabolic risk factors across different age groups and genders in China from 1990 to 2021 indicates that both mortality and DALYs rates increased with age, with rates for males consistently higher than those for females. In 2021, the mortality rate for males aged 70 and above was 7,538.3 per 100,000, compared to 5,516.8 per 100,000 for females; DALYs rates were 57,642.6 per 100,000 and 42,911.7 per 100,000, respectively. The disease burden was lowest in the 15–49 age group, where the 2021 mortality rates were 15.4 per 100,000 for males and 11.1 per 100,000 for females, with DALYs rates of 1,237.4 per 100,000 and 925.8 per 100,000, respectively. The burden for the 50–69 and 70+ age groups was significantly higher than that of the 15–49 group and increased progressively with age. Male burden remained higher than female burden across all age groups, with the gender disparity most pronounced in the 70+ population. Between 1990 and 2021, CVD mortality and DALYs rates attributable to metabolic factors generally followed a "rise then fall" trend across all age groups. The burden remained highest for those aged 70 and above and lowest for those aged 15–49, as shown in [FIGURE:2].

Projections for CVD mortality and DALYs rates attributable to metabolic risks in China from 2022 to 2035 show that the male mortality rate is expected to be 291.97 per 100,000 in 2022, decreasing slightly to 294.49 per 100,000 in 2025, then falling to 272.34 per 100,000 by 2030, and further to 183.33 per 100,000 by 2035. The magnitude of the decline increases significantly in the latter half of the projection period. The curve bends downward starting in 2025; the dark blue main trend line and the grayish-blue prediction interval illustrate an acceleration in the rate of change alongside expanding uncertainty. Female mortality exhibits a more linear downward trend, decreasing steadily from 149.26 per 100,000 in 2022 to 128.20 per 100,000 in 2030, and reaching 103.00 per 100,000 by 2035, with a relatively stable annual rate of decline. The narrow prediction interval around the main trend line indicates high concentration in the projected results. For males, the DALYs rate was 5,296.99 per 100,000 in 2022, decreasing slightly to 5,273.63 per 100,000 by 2025, after which the decline accelerates to 4,580.42 per 100,000 in 2030 and 3,274.07 per 100,000 in 2035. A clear downward inflection point appears after 2025, with the graph showing a marked negative slope. The female DALYs rate starts at 2,863.17 per 100,000 in 2022, falling to 2,469.02 per 100,000 in 2030 and 1,814.15 per 100,000 in 2035. This steady annual decline and narrow prediction interval suggest a stable trend with low uncertainty, as shown in [FIGURE:3].

For the male population, all four indicators show a distinct downward turning point around 2030, whereas the female population exhibits a continuous and balanced decline. The uncertainty prediction bands in the figures expand gradually after 2030, particularly for the male group, suggesting that males are more susceptible to potential influencing factors within the projection.

DALYs rate (per 100,000); Year; Year. Note: A represents DALYs rates by gender and age group; B represents mortality rates by gender and age group.

Trends in the burden of CVD attributed to metabolic risk factors by gender and age groups in China from 1990 to 2021

The evaluation results for the prediction accuracy of the model indicate that the Mean Absolute Percentage Error (MAPE) for all indicators is below 2%. Specifically, the MAPE for mortality rate predictions is 1.54% for males and 1.59% for females, while the MAPE for DALYs rate predictions is 0.98% for males and 1.02% for females. The overall error is minimal, demonstrating that the model possesses strong fitting capabilities and predictive stability, as shown in Table 5 [TABLE:5].

Accuracy metrics of BAPC model projections for cardiovascular mortality and DALYs attributable to metabolic risks in China: MAPE (%), Age-standardized mortality rate, Age-standardized DALYs rate. Note: MSE = Mean Square Error, RMSE = Root Mean Square Error, MAE = Mean Absolute Error.

3 讨论

Abstract and Results

This study systematically analyzed the trends in cardiovascular disease (CVD) burden attributable to metabolic risk factors in China from 1990 to 2021 based on the GBD 2021 database. Furthermore, the BAPC model was employed to predict future burden levels from 2022 to 2035. The results indicate that over the past 30 years, CVD mortality attributable to metabolic factors has continued to rise. While the DALYs rate peaked around 2005 and has since shown a downward trend—suggesting that improvements in medical care have enhanced quality of life—the overall burden remains severe. Among the four major metabolic risk factors evaluated, high systolic blood pressure (hypertension) consistently remained the primary driver of the CVD-attributable burden, maintaining a dominant contribution to both mortality and DALYs rates over the long term. Although the absolute burden associated with high BMI is relatively low, its growth rate was the most significant, reflecting the rapid accumulation of obesity-related risks in the Chinese population. In contrast, the attributable burdens of high fasting plasma glucose and high LDL cholesterol remained relatively stable with limited fluctuations.

Gender and age stratification results show that the metabolic-attributable burden of CVD was consistently higher in men than in women and increased significantly with age. Men aged 70 and older represent the group with the heaviest burden and should be prioritized for intervention. Furthermore, although the burden level among the 15–49 age group is relatively low, a gradual upward trend has emerged, suggesting that metabolic abnormalities are shifting toward younger populations and that early prevention is of critical importance. BAPC model projections indicate that if current risk exposure levels remain unchanged, CVD mortality and DALYs rates are expected to decline slowly between 2022 and 2035. However, this decline is limited; combined with the Joinpoint model analysis of high BMI-related burden trends, it is possible that the burden may continue to grow. Overall, the contribution of metabolic factors to CVD will remain persistently high.

The results of this study demonstrate that high BMI and hypertension constitute the core components of the metabolic risk burden for CVD in China. Specifically, obesity can promote the activation of the sympathetic nervous system and the renin-angiotensin-aldosterone system (RAAS) via leptin. It induces insulin resistance, chronic inflammation (elevated interleukin-6 and C-reactive protein), oxidative stress, and endothelial dysfunction, accompanied by microvascular rarefaction and autonomic nervous system dysregulation, thereby leading to increased vascular resistance and atherosclerosis. Simultaneously, hypertension causes structural damage through long-term blood pressure elevation, including left ventricular remodeling, arterial stiffness, and neurohormonal abnormalities (such as angiotensin II and endothelin), which significantly increase the risk of heart failure, stroke, and coronary heart disease.

1990 C

Year (Year) Note: Figure A shows the predicted mortality rate trends for males, Figure B shows the predicted mortality rate trends for females, Figure C shows the predicted DALYs rate trends for males, and Figure D shows the predicted DALYs rate trends for females.

Age-standardized projections of cardiovascular disease mortality and DALYs attributable to metabolic risks in China，2021-2035

Chinese General Practice. To address this situation, the Chinese government has proposed the "Healthy China 2030" strategy, which integrates hypertension and obesity control into national priority tasks. This strategy is implemented through comprehensive intervention strategies, including community screening, family doctor contract services, dual monitoring of weight and blood pressure, low-salt diets, and exercise education. Similarly, the WHO recommends promoting low-salt healthy diets, encouraging physical activity, managing weight, and implementing screening and intervention programs for high-risk populations.

As a significant driver of cardiovascular disease (CVD), metabolic syndrome requires intervention strategies centered on life-cycle management and risk-stratified control. Expert consensus emphasizes that for populations with metabolic abnormalities who have not yet developed organic diseases, the starting point for intervention should be moved forward. This involves establishing an integrated screening-assessment-follow-up pathway based in the community. Regarding specific measures, healthy lifestyles should be popularized—including weight control, sodium restriction, increased physical activity, and improved sleep quality—while metabolic management should be strengthened through regular monitoring of BMI, blood pressure, blood glucose, and lipid profiles. Furthermore, a graded intervention strategy is recommended for high-risk groups: primary prevention focuses on lifestyle interventions; secondary prevention initiates pharmacological treatment upon the detection of metabolic abnormalities; and tertiary prevention requires the construction of chronic disease follow-up and multidisciplinary management mechanisms. Building on this, international evidence indicates that glucagon-like peptide-1 (GLP-1) receptor agonists, such as semaglutide, can reduce the risk of major cardiovascular events in populations with high BMI and high CVD risk, providing new options for individualized intervention. In summary, the prevention and control of metabolic syndrome should not be limited to controlling single indicators but should instead implement a systematic strategy of stratified classification, comprehensive intervention, and focused monitoring to effectively curb the risk of early-onset and progressive CVD.

The main limitations of this study are as follows: (1) GBD data are model-based, and some regions lack original metabolic exposure monitoring data, which may affect the accuracy of burden assessments for specific regions or populations; (2) the BAPC model is built on the assumption of stable trends and cannot reflect the disturbances caused by external factors such as sudden public health interventions, the popularization of new drugs, or technological progress, thereby affecting the adaptability of the predictions; (3) this study did not include interactive risk factors such as behavior and environment, failing to comprehensively evaluate the synergies between multiple risk factors. Future research could combine real-world data to construct multi-dimensional predictive models covering metabolic, behavioral, and environmental factors, thereby enhancing the accuracy of CVD disease burden assessments and the targeting of public health interventions.

4 小结

Based on the GBD 2021 data, this study finds that hypertension remains the primary metabolic risk factor for the cardiovascular disease (CVD) burden in China, with the burden attributable to high BMI showing particularly significant growth. Predictive results suggest that without effective interventions, CVD-related mortality and disability-adjusted life years (DALYs) will remain at high levels through 2035. While the disease burden is heaviest among men and the elderly, the associated risks are rising rapidly among young and middle-aged populations. It is essential to strengthen screening for high-risk groups, enhance the monitoring of metabolic indicators, and implement multi-level interventions to shift the focus of CVD prevention and control toward earlier stages and more precise strategies.

Author Contributions: Zhen Rui was responsible for the conception and design of the study, the collection and organization of research data, and the drafting of the manuscript. Gu Xufang, Gao Shengwei, and Zhang Bowen were responsible for the revision, quality control, and proofreading of the paper, as well as overall supervision and management. Ren Zhenjuan and Yang Ruixuan were responsible for the editing and organization of figures and tables. The authors declare no conflicts of interest.

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(Received: 2025-08-15; Revised: 2025-11-28) (Editor: Zou Lin)