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1.  Secular Trends in Prevalence of Overweight and Obesity among Adults in Rural Tianjin, China from 1991 to 2011: A Population-Based Study 
PLoS ONE  2014;9(12):e116019.
Obesity is associated with cardiovascular diseases and has become the main public health issue in western countries and urban China. However, the prevalence and secular trends of obesity in rural China are currently unknown. The aim of this study was to investigate secular trends in the prevalence of overweight and obesity among rural adults in northern China between 1991 and 2011.
The prevalence of overweight and obesity was assessed in adults aged 35–74 years living in a rural area in northern China by comparing two surveys that were conducted in 1991 and 2011, respectively.
The age-adjusted prevalence of overweight increased from 24.5% in 1991 to 42.0% in 2011, and the prevalence of obesity increased from 5.7% in 1991 to 19.6% in 2011. Over the 21-year period, there were significant increases in the prevalence of overweight and obesity for both men and women in all age groups; however, the greatest increase was observed in men aged 35–44 years, with an 10.3-fold increase in obesity prevalence. The prevalence of obesity increased significantly in all risk factors categories, including education levels, blood pressure categories, diabetes previous history, current smoking situation and alcohol drinking situation over the past 21 years overall (p<0.05). The greatest increase in obesity prevalence appeared among those who consumed alcohol (increased by 8.0-fold). Next, there was a 5.3-fold increase in the prevalence of obesity in illiterate residents.
The prevalence of overweight and obesity has increased rapidly among rural adults in Tianjin over the past 21 years, with the most dramatic increase observed in young men. Therefore, the burden of obesity should serve as a call for action.
PMCID: PMC4278845  PMID: 25544990
2.  Additive effects of postchallenge hyperglycemia and low-density lipoprotein particles on the risk of arterial stiffness in healthy adults 
To determine the effects of post-challenge hyperglycemia potentiate low-density lipoprotein cholesterol (LDL) particles on the risk of arterial stiffness in non-diabetic adults.
During 2009–2011, 592 adults without clinical diabetes (fasting glucose <7.0 mmol/L) or known coronary heart disease or stroke were recruited. All subjects underwent standard 75-g oral glucose tolerance test (OGTT) after overnight fasting. The glucose area under curve (GluAUC) after OGTT was defined as the postchallenge glucose load. Levels of LDL-C and small dense LDL-C (sdLDL-C) were measured. Arterial stiffness in terms of brachial–ankle pulse wave velocity (baPWV) was also measured.
The baPWV in tertile distributions were significantly associated with all conventional cardiovascular risk factors, LDL-C, and sdLDL-C. Multivariate logistic regression analyses revealed that LDL-C (or sdLDL-C) combined with one of the seven glycemic indices (glucose levels at 0, 30, 60, 90, and 120 min; GluAUC; HbA1C) was associated with arterial stiffness after covariates being adjusted. Further interaction analyses showed only concurrent higher levels of both glycemic indices and atherogenic LDL-C or sdLDL-C have significant risk for arterial stiffness.
Additive effects of both postchallenge hyperglycemia and LDL subclass particles potentiate the risk of arterial stiffness. The adverse joint effects of hyperlipidemia and postchallenge hyperglycemia on subclinical cardiovascular function provide important information in primary prevention of cardiovascular disease in subjects without clinical diabetes.
PMCID: PMC4280693  PMID: 25431283
Postchallenge hyperglycemia; sdLDL-C; LDL-C; Arterial stiffness; OGTT
3.  Arterial function of carotid and brachial arteries in postmenopausal vegetarians 
Vegetarianism is associated with a lower risk of cardiovascular disease. However, studies of arterial function in vegetarians are limited.
This study investigated arterial function in vegetarianism by comparing 49 healthy postmenopausal vegetarians with 41 age-matched omnivores. The arterial function of the common carotid artery was assessed by carotid duplex, while the pulse dynamics method was used to measure brachial artery distensibility (BAD), compliance (BAC), and resistance (BAR). Fasting blood levels of glucose, lipids, lipoprotein (a), high-sensitivity C-reactive protein, homocysteine, and vitamin B12 were also measured.
Vegetarians had significantly lower serum cholesterol, high-density and low-density lipoprotein, and glucose compared with omnivores. They also had lower vitamin B12 but higher homocysteine levels. Serum levels of lipoprotein (a) and high-sensitivity C-reactive protein were no different between the two groups. There were no significant differences in carotid beta stiffness index, BAC, and BAD between the two groups even after adjustment for associated covariates. However, BAR was significantly lower in vegetarians than in omnivores. Multiple linear regression analysis revealed that age and pulse pressure were two important determinants of carotid beta stiffness index and BAD. Vegetarianism is not associated with better arterial elasticity.
Apparently healthy postmenopausal vegetarians are not significantly better in terms of carotid beta stiffness index, BAC, and BAD, but have significantly decreased BAR than omnivores. Prevention of vitamin B12 deficiency might be beneficial for cardiovascular health in vegetarians.
PMCID: PMC3166191  PMID: 21915169
postmenopausal women; vegetarians; carotid stiffness; brachial arterial distensibility
4.  The Health Effects of a Forest Environment on Subclinical Cardiovascular Disease and Heath-Related Quality of Life 
PLoS ONE  2014;9(7):e103231.
Assessment of health effects of a forest environment is an important emerging area of public health and environmental sciences.
To demonstrate the long-term health effects of living in a forest environment on subclinical cardiovascular diseases (CVDs) and health-related quality of life (HRQOL) compared with that in an urban environment.
Materials and Methods
This study included the detailed health examination and questionnaire assessment of 107 forest staff members (FSM) and 114 urban staff members (USM) to investigate the long-term health effects of a forest environment. Air quality monitoring between the forest and urban environments was compared. In addition, work-related factors and HRQOL were evaluated.
Levels of total cholesterol, low-density lipoprotein cholesterol, and fasting glucose in the USM group were significantly higher than those in the FSM group. Furthermore, a significantly higher intima-media thickness of the internal carotid artery was found in the USM group compared with that in the FSM group. Concentrations of air pollutants, such as NO, NO2, NOx, SO2, CO, PM2.5, and PM10 in the forest environment were significantly lower compared with those in the outdoor urban environment. Working hours were longer in the FSM group; however, the work stress evaluation as assessed by the job content questionnaire revealed no significant differences between FSM and USM. HRQOL evaluated by the World Health Organization Quality of Life-BREF questionnaire showed FSM had better HRQOL scores in the physical health domain.
This study provides evidence of the potential beneficial effects of forest environments on CVDs and HRQOL.
PMCID: PMC4113370  PMID: 25068265
5.  Total white blood cell count or neutrophil count predict ischemic stroke events among adult Taiwanese: report from a community-based cohort study 
BMC Neurology  2013;13:7.
Evidence about whether white blood cell (WBC) or its subtypes can act as a biomarker to predict the ischemic stroke events in the general population is scanty, particularly in Asian populations. The aim of this study is to establish the predictive ability of total WBC count or subtypes for long-term ischemic stroke events in the cohort population in Taiwan.
The Chin-Shan Community Cohort Study began from 1990 to 2007 by recruiting 1782 men and 1814 women of Chinese ethnicity. Following a total of 3416 participants free from ischemic stroke events at baseline for a median of 15.9 years; we documented 187 new incident cases.
The multivariate relative risk for the comparison of the participants in the fifth and first WBC count quintiles was 1.67 (95% confidence interval [CI], 1.02–2.73; P for trend=0.03), and the corresponding relative risk for neutrophil count was 1.93 (95% CI, 1.13–3.29; P for trend=0.02). The discriminative ability by WBC and neutrophil counts were similar (area under the receiver operating characteristic curve, 0.600 for adding WBC, 0.610 for adding neutrophils, 0.595 for traditional risk factor model). In addition, the net reclassification improvement (NRI) values between the neutrophil and white blood cell count models were not significant (NRI, =-2.60%, P=0.35), indicating the similar discrimination performance for both WBC and neutrophil counts.
WBC and neutrophil count had a similar ability to predict the long-term ischemic stroke events among Taiwanese.
PMCID: PMC3641985  PMID: 23317415
White blood cell count; Neutrophil count; Ischemic stroke event
6.  An Investigation of the Use of Traditional Chinese Medicine in Stroke Patients in Taiwan 
Background. The use of complementary and alternative medicine in critical illness is increasing worldwide. This study investigates how traditional Chinese medicine (TCM) is used in stroke patients. Methods. Using Taiwan National Health Insurance reimbursement claims, we compared the annual use of TCM between stroke patients and general population, identifying 15,330 patients with a new onset of stroke in 2000–2009. The sociodemographic status and medical comorbidities between stroke patients receiving TCM services and those without using the service were compared. Results. The use of TCM was higher in stroke patients than in the general population, 27.9% versus 25.4% in 2000 and 32.7% versus 27.8% in 2009, respectively, and grew consistently from 2000 to 2009. Among stroke patients, women, younger patients, white-collar employees, higher-income residents, and those living in areas with more TCM physicians were more likely to use TCM. Stroke patients using rehabilitation services were more likely to have more TCM visits (OR = 2.28, 95% CI = 1.96–2.66) and higher expenditure on TCM (OR = 2.67, 95% CI = 2.29–3.12) compared with stroke patients without rehabilitation. Conclusion. TCM is popular and well accepted in Taiwan. Patients with stroke have a higher TCM utilization rate than people without stroke.
PMCID: PMC3530233  PMID: 23304199
7.  Differential effects of the changes of LDL cholesterol and systolic blood pressure on the risk of carotid artery atherosclerosis 
The effects of baseline and changes in blood pressure and low density lipoprotein (LDL) cholesterol on the carotid intima media thickness (IMT) have not been well documented.
A total of 2572 adults (mean age 53.8 years, 54.6% women) in a Taiwanese community undertook three blood pressure and LDL cholesterol examinations over 6 years. Latent growth curve modeling was used to investigate the effects of baseline and change in blood pressure and LDL cholesterol on IMT.
Greater baseline LDL and blood pressure were associated with an increase in IMT (0.005 ± 0.002 mm per 1 mg/dL [p = 0.006] and 0.041 ± 0.004 mm mmHg [p <0.0001], respectively. Change in blood pressure was associated with a significant increase in IMT (0.047±0.016, P = 0.004), whilst the association between change in LDL and change in IMT was not statistically significant (0.008±0.006, P = 0.20).
Carotid IMT was associated with baseline blood pressure and LDL cholesterol, yet only changes of blood pressure, not LDL cholesterol, were related to carotid IMT during the 6-year observation.
PMCID: PMC3445849  PMID: 22900906
Latent growth curve modeling; Carotid intima media thickness; Blood pressure; LDL cholesterol
8.  Does Hepatitis C Virus Infection Increase Risk for Stroke? A Population-Based Cohort Study 
PLoS ONE  2012;7(2):e31527.
The relationship between hepatitis C virus infection and risk of stroke remains inconsistent. This study evaluates the risk of stroke in association with chronic hepatitis C infection in a longitudinal population-based cohort.
We identified 4,094 adults newly diagnosed with hepatitis C infection in 2002–2004 from the Taiwan National Health Insurance Research Database. Comparison group consisted of 16,376 adults without hepatitis C infection randomly selected from the same dataset, frequency matched by age and sex. Events of stroke from 2002–2008 were ascertained from medical claims (International Classification of Diseases, Ninth Revision, Clinical Modification, ICD-9-CM, codes 430–438). Multivariate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated for potential associated factors including HCV infection, age, sex, low-income status, urbanization, cessation of cigarette smoking, alcohol-related illness, obesity, history of chronic diseases and medication use.
During 96,752 person-years of follow-up, there were 1981 newly diagnosed stroke cases. The HRs of stroke associated with medical conditions such as hypertension, diabetes and heart disease were 1.48 (95% CI 1.33 to 1.65), 1.23 (95% CI 1.11 to 1.36) and 1.17 (95% CI 1.06 to 1.30), respectively, after adjustment for covariates. The cumulative risk of stroke for people with hepatitis C and without hepatitis C infections was 2.5% and 1.9%, respectively (p<0.0001). Compared with people without hepatitis C infection, the adjusted HR of stroke was 1.27 (95% CI 1.14 to 1.41) for people with hepatitis C infection.
Chronic hepatitis C infection increases stroke risk and should be considered an important and independent risk factor.
PMCID: PMC3282756  PMID: 22363662
9.  Carotid Artery Intima-Media Thickness, Carotid Plaque and Coronary Heart Disease and Stroke in Chinese 
PLoS ONE  2008;3(10):e3435.
Our aim was to prospectively investigate the association between carotid artery intima-media thickness (IMT) as well as carotid plaque and incidence of coronary heart disease (CHD) and stroke in Chinese, among whom data are limited.
Methods and Findings
We conducted a community-based cohort study composed of 2190 participants free of cardiovascular disease at baseline in one community. During a median 10.5-year follow up, we documented 68 new cases of coronary heart disease and 94 cases of stroke. The multivariate relative risks (RRs) associated with a change of 1 standard deviation of maximal common carotid IMT were 1.38 (95% confidence interval [CI], 1.12–1.70) for CHD and 1.47 (95% CI, 1.28–1.69) for stroke. The corresponding RRs with internal carotid IMT were 1.47 (95% CI, 1.21–1.79) for CHD and 1.52 (95% CI, 1.31–1.76) for stroke. Carotid plaque measured by the degree of diameter stenosis was also significantly associated with increased risk of CHD (p for trend<0.0001) and stroke (p for trend<0.0001). However, these associations were largely attenuated when adjusting for IMT measurements.
This prospective study indicates a significant association between carotid IMT and incidence of CHD and stroke in Chinese adults. These measurements may be useful for cardiovascular risk assessment and stratification in Chinese.
PMCID: PMC2562458  PMID: 18927612
10.  Effects of Occupational Noise Exposure on 24-Hour Ambulatory Vascular Properties in Male Workers 
Environmental Health Perspectives  2007;115(11):1660-1664.
Epidemiologic studies have demonstrated that occupational noise exposure is associated with hypertension, but the related mechanism in vascular structural changes is unclear.
This panel study aimed to investigate effects of occupational noise exposure on ambulatory vascular structural properties in male workers.
We recruited 20 volunteers and divided them into a high-noise–exposure group of 15 and a low-noise–exposure group of 5 based on environmental noise measurement in an automobile manufacturing company. We determined individual noise exposure and measured personal ambulatory vascular property parameters simultaneously during 24 hr. Linear mixed-effects regression models were used to estimate transient and sustained effects of noise exposure on vascular parameters by adjusting some confounders collected from self-administrated questionnaires and health checkups.
The high-noise–exposed (85 ± 8 dBA) workers had significantly higher systemic vascular resistance (SVR) than the low-noise–exposed workers (59 ± 4 dBA) during work and sleep periods. Contrarily, low-noise–exposed workers had significantly higher brachial artery compliance (BAC), brachial artery distensibility (BAD), and systemic vascular compliance (SVC; marginal, p = 0.07) than high-noise–exposed workers during off-duty periods. We also found that high-noise–exposed workers had significantly lower BAC (1.38 ± 0.55 %mL/mmHg) and BAD (1.29 ± 0.51 %/mmHg), as well as lower SVC (0.24 ± 0.10 mL/L/mmHg), but higher SVR (1.93 ± 0.67 mL/L/min) compared with low-noise–exposed workers over a 24-hr period.
Our findings suggest that in automobile workers, occupational noise exposure may have sustained, not transient, effects on vascular properties and also enhances the development of hypertension.
PMCID: PMC2072860  PMID: 18008000
ambulatory arterial stiffness; ambulatory vascular properties; automobile workers; occupational noise exposure; panel study
11.  Heritability and major gene effects on left ventricular mass in the Chinese population: a family study 
Genetic components controlling for echocardiographically determined left ventricular (LV) mass are still unclear in the Chinese population.
We conducted a family study from the Chin-San community, Taiwan, and a total of 368 families, 1145 subjects, were recruited to undergo echocardiography to measure LV mass. Commingling analysis, familial correlation, and complex segregation analysis were applied to detect component distributions and the mode of inheritance.
The two-component distribution model was the best-fitting model to describe the distribution of LV mass. The highest familial correlation coefficients were mother-son (0.379, P < .0001) and father-son (0.356, P < .0001). Genetic heritability (h2) of LV mass was estimated as 0.268 ± 0.061 (P < .0001); it decreased to 0.153 ± 0.052 (P = .0009) after systolic blood pressure adjustment. Major gene effects with polygenic components were the best-fitting model to explain the inheritance mode of LV mass. The estimated allele frequency of the gene was 0.089.
There were significant familial correlations, heritability and a major gene effect on LV mass in the population-based families.
PMCID: PMC1579230  PMID: 16945138
12.  Segregation analysis of apolipoprotein A1 levels in families of adolescents: A community-based study in Taiwan 
BMC Genetics  2006;7:4.
Apolipoprotein (Apo) A1 is a protective factor for cardiovascular events. This study aimed to perform complex segregation analyses of Apo A1 levels in families of adolescents systematically ascertained from the junior high school students in a rural community. Both siblings and parents of the adolescent probands were recruited for the study. Apo A1 concentrations were measured by turbidimetric immunoassay methods. After adjustment for gender, age, body mass index, smoking and drinking status, residual values of Apo A1 were subjected to subsequent analyses.
Significant mother-father and parent-offspring correlations were found. Commingling analyses indicated that a four-component distribution model was needed to account for the Apo A1 variation. Segregation analysis using regressive models revealed that the best-fit model of Apo A1 was a model of environmental effect plus familial correlation (heritability = 23.9%), in which a significant mother-father correlation existed. Models containing major gene effect could be rejected.
These results suggest that variations of Apo A1 levels in the normal range, especially during adolescence, are likely to be influenced by multiple factors without significant contribution from major genes.
PMCID: PMC1360683  PMID: 16423305
13.  Effects of Particle Size Fractions on Reducing Heart Rate Variability in Cardiac and Hypertensive Patients 
Environmental Health Perspectives  2005;113(12):1693-1697.
It is still unknown whether the associations between particulate matter (PM) and heart rate variability (HRV) differ by particle sizes with aerodynamic diameters between 0.3 μm and 1.0 μm (PM0.3–1.0), between 1.0 μm and 2.5 μm (PM1.0–2.5), and between 2.5 μm and 10 μm (PM2.5–10). We measured electrocardiographics and PM exposures in 10 patients with coronary heart disease and 16 patients with either prehypertension or hypertension. The outcome variables were standard deviation of all normal-to-normal (NN) intervals (SDNN), the square root of the mean of the sum of the squares of differences between adjacent NN intervals (r-MSSD), low frequency (LF; 0.04–0.15 Hz), high frequency (HF; 0.15–0.40 Hz), and LF:HF ratio for HRV. The pollution variables were mass concentrations of PM0.3–1.0, PM1.0–2.5, and PM2.5–10. We used linear mixed-effects models to examine the association between PM exposures and log10-transformed HRV indices, adjusting for key personal and environmental attributes. We found that PM0.3–1.0 exposures at 1- to 4-hr moving averages were associated with SDNN and r-MSSD in both cardiac and hypertensive patients. For an interquartile increase in PM0.3–1.0, there were 1.49–4.88% decreases in SDNN and 2.73–8.25% decreases in r-MSSD. PM0.3–1.0 exposures were also associated with decreases in LF and HF for hypertensive patients at 1- to 3-hr moving averages except for cardiac patients at moving averages of 2 or 3 hr. By contrast, we found that HRV was not associated with either PM1.0–2.5 or PM2.5–10. HRV reduction in susceptible population was associated with PM0.3–1.0 but was not associated with either PM1.0–2.5 or PM2.5–10.
PMCID: PMC1314907  PMID: 16330349
air pollution; autonomic system; epidemiology; heart rate variability; particulate matter
14.  Consistency of genetic inheritance mode and heritability patterns of triglyceride vs. high density lipoprotein cholesterol ratio in two Taiwanese family samples 
BMC Genetics  2003;4:7.
Triglyceride/HDL cholesterol ratio (TG/HDL-C) is considered as a risk factor for cardiovascular events. Genetic components were important in controlling the variation in western countries. But the mode of inheritance and family aggregation patterns were still unknown among Asian-Pacific countries. This study, based on families recruited from community and hospital, is aimed to investigate the mode of inheritance, heritability and shared environmental factors in controlling TG/HDL-C.
Two populations, one from community-based families (n = 988, 894 parent-offspring and 453 sibling pairs) and the other from hospital-based families (n = 1313, 76 parent-offspring and 52 sibling pairs) were sampled. The population in hospital-based families had higher mean age values than community-based families (54.7 vs. 34.0). Logarithmic transformed TG/ HDL-C values, after adjusted by age, gender and body mass index, were for genetic analyses. Significant parent-offspring and sibling correlations were also found in both samples. The parent-offspring correlation coefficient was higher in the hospital-based families than in the community-based families. Genetic heritability was higher in community-based families (0.338 ± 0.114, p = 0.002), but the common shared environmental factor was higher in hospital-based families (0.203 ± 0.042, p < 0.001). Commingling analyses showed that more than one-component distribution models were the best-fit models to explain the variance in both populations. Complex segregation analysis by regressive models revealed that in both samples the best-fit model of TG/HDL-C was the model of environmental effects plus familial correlation, in which significant parent-offspring and sibling correlations were demonstrated. Models of major gene effects were rejected in both samples.
Variations of TG/HDL-C in the normal ranges were likely to be influenced by multiple factors, including environmental and genetic components. Higher genetic factors were proved in younger community-based families than in older hospital-based families.
PMCID: PMC155683  PMID: 12710891

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