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1.  Effect of aerobic exercise and low carbohydrate diet on pre-diabetic non-alcoholic fatty liver disease in postmenopausal women and middle aged men – the role of gut microbiota composition: study protocol for the AELC randomized controlled trial 
BMC Public Health  2014;14:48.
Background
Pre-diabetes and non-alcoholic fatty liver disease (NAFLD) are associated with an unhealthy lifestyle and pose extremely high costs to the healthcare system. In this study, we aim to explore whether individualized aerobic exercise (AEx) and low carbohydrate diet (LCh) intervention affect hepatic fat content (HFC) in pre-diabetes via modification of gut microbiota composition and other post-interventional effects.
Methods/design
A 6-month randomized intervention with 6-month follow-up is conducted from January 2013 to December 2015. The target sample size for intervention is 200 postmenopausal women and middle-aged men aged 50–65 year-old with pre-diabetes and NAFLD. The qualified subjects are randomized into 4 groups with 50 subjects in each group: 1 = AEx, 2 = LCh, 3 = AEx + LCh, and 4 = control. In addition, two age-matched reference groups (5 = pre-diabetes without NAFLD (n = 50) and 6 = Healthy without pre-diabetes or NAFLD (n = 50)) are included. The exercise program consists of progressive and variable aerobic exercise (intensity of 60 to 75% of initial fitness level, 3–5 times/week and 30–60 min/time). The diet program includes dietary consultation plus supplementation with a special lunch meal (40% of total energy intake/day) which aims to reduce the amount of carbohydrate consumption (30%). The control and reference groups are advised to maintain their habitual habits during the intervention. The primary outcome measures are HFC, serum metabolomics and gut microbiota composition. The secondary outcome measures include body composition and cytokines. In addition, socio-psychological aspects, social support, physical activity and diet will be performed by means of questionnaire and interview.
Discussion
Specific individualized exercise and diet intervention in this study offers a more efficient approach for liver fat reduction and diabetes prevention via modification of gut microbiota composition. Besides, the study explores the importance of incorporating fitness assessment and exercise in the management of patients with pre-diabetes and fatty liver disorders. If our program is shown to be effective, it will open new strategies to combat these chronic diseases.
Trial registration
Current Controlled Trials: ISRCTN42622771.
doi:10.1186/1471-2458-14-48
PMCID: PMC3897962  PMID: 24438438
Liver fat content; Glucose metabolism; Lipid metabolism; Gut microbiota; Metabonomics; Human; Clinical setting
2.  Prevalence of hyperuricemia and its related risk factors in healthy adults from Northern and Northeastern Chinese provinces 
BMC Public Health  2013;13:664.
Background
Hyperuricemia (HUA) is a potential risk factor for developing insulin resistance, hypertension, dyslipidemia and cardiovascular disease. Therefore, we studied the prevalence of HUA and associated risk factors in the population of two provinces in northern China.
Methods
Based on the research of Chinese Physiological Constant and Health Conditions conducted in 2008–2010, we enrolled 29,639 subjects in a randomized, stratified study in four sampling areas in Heilongjiang Province and the Inner Mongolia Autonomous Region. We collected 13,140 serum samples to determine biochemical indicators including uric acid(UA), glucose, blood lipids, liver function, and renal function, and finally a representative sample of 8439 aged 18 years and older was determined. We also defined and stratified HUA, hypertension, diabetes, obesity and lipid abnormalities according to international guidelines.
Results
There were significant differences in the UA levels between different genders and regions. The total prevalence of HUA is 13.7%. Men had a higher prevalence of HUA than women (21% vs. 7.9%; P < 0.0001). As age increased, HUA prevalence decreased in men but rose in women. The suburbs of big cities had the highest HUA prevalence (18.7%), and in high-prevalence areas the proportion of women with HUA also increased. A stepwise logistic regression model was used to filter out twelve HUA risk factors, including age, gender, residence, hypercholesterolemia, hypertriglyceridemia, impaired fasting glucose, hypertension, obesity, abdominal obesity, CKD, drinking and sleeping. After adjusting for these factors, the odds ratio of HUA was 1.92 times higher in men than in women. Compared with agricultural and pastoral areas, the odds ratio of having HUA was 2.14 for participants in the suburbs of big cities and 1.57 in the center of big cities.
Conclusions
The prevalence of HUA is high in northern China. The differences in HUA prevalence by geographic region suggested that unbalanced economic development and health education, therefore HUA prevention measures should be strengthened to improve quality of life and reduce health care costs.
doi:10.1186/1471-2458-13-664
PMCID: PMC3722003  PMID: 23866159
Prevalence; Hyperuricemia; Risk factors
3.  Epidemiology of general obesity, abdominal obesity and related risk factors in urban adults from 33 communities of northeast china: the CHPSNE study 
BMC Public Health  2012;12:967.
Background
Obesity increases the risk of many diseases. However, there has been little literature about the epidemiology of obesity classified by body mass index (BMI) or waist (abdominal obesity) among urban Chinese adults. This study is to fill the gap by assessing the prevalence of obesity and associated risk factors among urban Chinese adults.
Methods
A representative sample of 25,196 urban adults aged 18 to 74 years in Northeast China was selected and measurements of height, weight and waist circumference (WC) were taken from 2009–2010. Definitions of overweight and obesity by the World Health Organization (WHO) were used.
Results
The overall prevalence rates of general obesity and overweight classified by BMI were 15.0% (15.7% for men and 14.3% for women, p<0.01) and 19.2% (20.8% for men and 17.7% for women, p<0.01), respectively, and the overall prevalence rate of abdominal obesity was 37.6% (31.1% for men and women 43.9% for women, p<0.01). Multivariable logistic regression showed that the elderly and those who had a history of parental obesity, alcohol drinking, or former cigarette smoking were at high risk of obesity classified by BMI or WC, whereas those with a higher level of education, higher family income, or a healthy and balanced diet were at low risk of obesity. Analysis stratified by gender showed that men with a higher level education level, a white-collar job, a cadre job, or higher family income were the high risk group, and women with a higher level of education or higher family income were the low risk group.
Conclusions
Obesity and overweight have become epidemic in urban populations in China; associations of risk factors with obesity differ between men and women.
doi:10.1186/1471-2458-12-967
PMCID: PMC3509037  PMID: 23146089
General obesity; Abdominal obesity; Risk factors; Gender difference; Chinese urban adults
4.  The utility of fat mass index vs. body mass index and percentage of body fat in the screening of metabolic syndrome 
BMC Public Health  2013;13:629.
Background
It has been well documented that obesity is closely associated with metabolic syndrome (MetS). Although body mass index (BMI) is the most frequently used method to assess overweightness and obesity, this method has been criticized because BMI does not always reflect true body fatness, which may be better evaluated by assessment of body fat and fat-free mass. The objective of this study was to investigate the best indicator to predict the presence of MetS among fat mass index, BMI and percentage of body fat (BF %) and determine its optimal cut-off value in the screening of MetS in practice.
Methods
A cross-sectional study of 1698 subjects (aged 20–79 years) who participated in the annual health check-ups was employed. Body composition was measured by bioelectrical impedance analysis (BIA). Fat mass index (FMI) was calculated. Sex-specific FMI quartiles were defined as follows: Q1: <4.39, Q2:4.39- < 5.65, Q3:5.65- < 7.03, Q4:≥7.03,in men; and Q1:<5.25, Q2:5.25- < 6.33, Q3:6.33- < 7.93,Q4:≥7.93, in women. MetS was defined by National Cholesterol Education Program/Adult Treatment Panel III criteria. The association between FMI quartiles and MetS was assessed using Binary logistic regression. Receiver operating curve(ROC) analysis was used to determine optimal cutoff points for BMI,BF% and FMI in relation to the area under the curve(AUC),sensitivity and specificity in men and women.
Results
The adjusted odds ratios (95% CI) for the presence of MetS in the highest FMI quartile versus lowest quartile were 79.143(21.243-294.852) for men( P < 0.01) and 52.039(4.144-653.436) for women( P < 0.01) after adjusting age, BMI, BF%, TC, LDL, CRP, smoking status and exercise status, and the odds ratios were 9.166(2.157-38.952) for men( P < 0.01) and 25.574(1.945-336.228) for women( P < 0.05) when WC was also added into the adjustment. It was determined that BMI values of 27.45 and 23.85 kg/m2, BF% of 23.95% and 31.35% and FMI of 7.00 and 7.90 kg/m2 were the optimal cutoff values to predict the presence of MetS among men and women according to the ROC curve analysis. Among the indicators used to predict MetS, FMI was the index that showed the greatest area under the ROC curve in both sexes.
Conclusions
Higher FMI levels appear to be independently and positively associated with the presence of MetS regardless of BMI and BF%. FMI seems to be a better screening tool in prediction of the presence of metabolic syndrome than BMI and percentage of body fat in men and women.
doi:10.1186/1471-2458-13-629
PMCID: PMC3703297  PMID: 23819808
Metabolic syndrome X; Body composition; Fat mass index; Body mass index; Percentage of body fat; Screening
5.  Glycemic control among patients in China with type 2 diabetes mellitus receiving oral drugs or injectables 
BMC Public Health  2013;13:602.
Background
The prevalence of type 2 diabetes mellitus (T2DM) is increasing rapidly among Chinese adults, and limited data are available on T2DM management and the status of glycemic control in China. We assessed the efficacy of oral antidiabetes drugs (OADs), glucagon-like peptide-1 (GLP-1) receptor agonists, and insulin for treatment of T2DM across multiple regions in China.
Methods
This was a multicenter, cross-sectional survey of outpatients conducted in 606 hospitals across China. Data from all the patients were collected between April and June, 2011.
Results
A total of 238,639 patients were included in the survey. Eligible patients were treated with either OADs alone (n=157,212 [65.88%]), OADs plus insulin (n=80,973 [33.93%]), or OADs plus GLP-1 receptor agonists (n=454 [0.19%]). The OAD monotherapy, OAD + insulin, and OAD + GLP-1 receptor agonist groups had mean glycosylated hemoglobin (HbA1c) levels (±SD) of 7.67% (±1.58%), 8.21% (±1.91%), and 7.80% (±1.76%), respectively. Among those three groups, 34.63%, 26.21%, and 36.12% met the goal of HbA1c <7.0%, respectively. Mean HbA1c and achievement of A1c <7.0% was related to the duration of T2DM.
Conclusions
Less than one third of the patients had achieved the goal of HbA1c <7.0%. Glycemic control decreased and insulin use increased with the duration of diabetes.
doi:10.1186/1471-2458-13-602
PMCID: PMC3729491  PMID: 23800082
China; GLP-1 receptor agonists; HbA1c; Insulin; Oral antidiabetes drugs (OADs); Type 2 diabetes mellitus
6.  Burden of self-reported acute gastrointestinal illness in China: a population-based survey 
BMC Public Health  2013;13:456.
Background
Acute gastrointestinal illness (AGI) is an important public-health problem worldwide. Previous national studies of the incidence of AGI in China were performed decades ago, and detailed information was not available. This study therefore sought to determine the magnitude, distribution, and burden of self-reported AGI in China.
Methods
Twelve-month, retrospective face-to-face surveys were conducted in 20 sentinel sites from six provinces between July 2010 and July 2011.
Results
In total, 39686 interviews were completed. The overall adjusted monthly prevalence of AGI was 4.2% (95% confidence interval, 4.0–4.4), corresponding to 0.56 episodes of AGI per person-year. Rates of AGI were highest in children aged < 5 years. Healthcare was sought by 56.1% of those reporting illness. Of the cases who visited a doctor, 32.7% submitted a stool sample. The use of antibiotics was reported by 49.7% of the cases who sought medical care and 54.0% took antidiarrhoeals. In the multivariable model, gender, age, education, household type, residence, season, province and travel were significant risk factors of being a case of AGI.
Conclusions
This first population-based study in China indicated that AGI represents a substantial burden of health. Further research into the specific pathogens is needed to better estimate the burden of AGI and foodborne disease in China.
doi:10.1186/1471-2458-13-456
PMCID: PMC3655923  PMID: 23656835
7.  A summary index of infant and child feeding practices is associated with child growth in urban Shanghai 
BMC Public Health  2012;12:568.
Background
Recently, an infant and child feeding index (ICFI) constructed on brief recalls of breastfeeding, feeding frequency and food diversification was assumed to provide long-term prediction about child feeding practices. The aim of this study was to investigate the association between the cross-sectional ICFI (CS-ICFI) or longitudinal ICFI (L-ICFI) and child anthropometric indices in downtown Shanghai, China.
Methods
The prospective cohort study included 180 infants aged 5-7 mo with their main caregivers who were visited 3 times every 6 months over 12 months. A CS-ICFI was constructed for each visit by using data on feeding practices based on 24-h and 7-d recalls. An L-ICFI was constructed with use of the 3 CS-ICFIs. The associations between ICFI and length-for-age z score (LAZ), weight-for-age z score (WAZ), and weight-for-length z score (WLZ) were examined. The stability of the CS-ICFI was assessed by using repeatability coefficient (RC).
Results
The L-ICFI was positively associated with LAZ and WAZ at Visit 3(beta = 0.151, P = 0.040 and beta = 0.173, P = 0.024, respectively). Moreover, the CS-ICFI at Visit 1 was positively associated with LAZ, WAZ and WLZ (beta = 0.160, P = 0.029; beta = 0.191, P = 0.009; beta = 0.176, P = 0.020) at Visit 3, and the CS-ICFI at Visit 3 was also positively associated with LAZ (beta = 0.176, P = 0.016). Stability of the CS-ICFI was shown by the value of 0.14 (95% CI: 0.07, 0.31) of the RC, which differed significantly from 0 (P < 0.05).
Conclusions
The ICFI constructed on brief recalls based on cross-sectional studies can be used to evaluate the effects of child feeding practice on child growth.
doi:10.1186/1471-2458-12-568
PMCID: PMC3487749  PMID: 22839527
Child feeding practice; Brief recalls; Anthropometric indices; Repeatability coefficient
8.  Spatial-temporal analysis of malaria and the effect of environmental factors on its incidence in Yongcheng, China, 2006–2010 
BMC Public Health  2012;12:544.
Background
In 2003, Plasmodium vivax malaria has re-emerged in central eastern China including Yongcheng prefecture, Henan Province, where no case has been reported for eleven years. Our goals were to detect the space-time distribution pattern of malaria and to determine significant environmental variables contributing to malaria incidence in Yongcheng from 2006 to 2010, thus providing scientific basis for further optimizing current malaria surveillance and control programs.
Methods
This study examined the spatial and temporal heterogeneities in the risk of malaria and the influencing factors on malaria incidence using geographical information system (GIS) and time series analysis. Univariate analysis was conducted to estimate the crude correlations between malaria incidence and environmental variables, such as mosquito abundance and climatic factors. Multivariate analysis was implemented to construct predictive models to explore the principal environmental determinants on malaria epidemic using a Generalized Estimating Equation (GEE) approach.
Results
Annual malaria incidence at town-level decreased from the north to south, and monthly incidence at prefecture-level demonstrated a strong seasonal pattern with a peak from July to November. Yearly malaria incidence had a visual spatial association with yearly average temperature. Moreover, the best-fit temporal model (model 2) (QIC = 16.934, P<0.001, R2 = 0.818) indicated that significant factors contributing to malaria incidence were maximum temperature at one month lag, average humidity at one month lag, and malaria incidence of the previous month.
Conclusions
Findings supported the effects of environment factors on malaria incidence and indicated that malaria control targets should vary with intensity of malaria incidence, with more public resource allocated to control the source of infections instead of large scale An. sinensis control when malaria incidence was at a low level, which would benefit for optimizing the malaria surveillance project in China and some other countries with unstable or low malaria transmission.
doi:10.1186/1471-2458-12-544
PMCID: PMC3488337  PMID: 22823998
Malaria; Anopheles; Weather; Geographic information system; Modeling
9.  Impact of genital warts on health related quality of life in men and women in mainland China: a multicenter hospital-based cross-sectional study 
BMC Public Health  2012;12:153.
Background
Information on the health-related quality of life (HRQoL) of patients with genital warts (GW) in populations in mainland China is still limited. The aim of the study was to use a generic instrument to measure the impact of genital warts on HRQoL in men and women in this setting.
Methods
A multi-centre hospital-based cross-sectional study across 18 centers in China was conducted to interview patients using the European quality of life-5 dimension (EQ-5D) instrument; respondents' demographic and clinical data were also collected.
Results
A total of 1,358 GW patients (612 men, 746 women) were included in the analysis, with a mean age of 32.0 ± 10.6 years. 56.4% of the patients reported some problems in the dimension of Anxiety/Depression (highest), followed by Pain/Discomfort (24.7%) and Mobility (3.5%). The overall visual analogue scale (VAS) score of the study population was found to be 65.2 ± 22.0, and the EQ-5D index score was found to be 0.843 ± 0.129 using Japanese preference weights (the Chinese preference was unavailable yet). Patients with lower VAS means and EQ-5D index scores were more often female, living in urban area, and suffering multiple GW (all p values < 0.05), but the values did not differ notably by age (p values > 0.05).
Conclusions
The HRQoL of patients with GW was substantially lower, compared to a national representative general population in China (VAS = ~80); the findings of different subgroups are informative for future GW prevention and control efforts.
doi:10.1186/1471-2458-12-153
PMCID: PMC3359232  PMID: 22381149
10.  Prevalence of cardiovascular disease and risk factors in a rural district of Beijing, China: a population-based survey of 58,308 residents 
BMC Public Health  2012;12:34.
Background
Cardiovascular disease (CVD) is the leading cause of global disease burden. Although stroke was thought to be more prevalent than coronary heart disease (CHD) in Chinese, the epidemic pattern might have been changed in some rural areas nowadays. This study was to estimate up-to-date prevalence of CVD and its risk factors in rural communities of Fangshan District, Beijing, China.
Methods
A cross-sectional population survey was carried out by stratified cluster sampling. A total of 58,308 rural residents aged over 40 years were surveyed by face-to-face interview and physical examination during 2008 and 2010. The standardized prevalence was calculated according to adult sample data of China's 5th Population Census in 2000, and the adjusted prevalence odds ratio (POR) was calculated for the association of CHD/stroke with its cardiovascular risk factors in multivariate logistic regression models.
Results
Age- and sex-standardized prevalence was 5.6% for CHD (5.2% in males and 5.9% in females), higher than the counterpart of 3.7% (4.7% in males and 2.6% in females) for stroke. Compared with previous studies, higher prevalence of 7.7%, 47.2%, 53.3% in males and 8.2%, 44.8%, 60.7% in females for diabetes, hypertension and overweight/obesity were presented accordingly. Moreover, adjusted POR (95% confidence interval) of diabetes, obesity, stage 1 and stage 2 hypertension for CHD as 2.51 (2.29 to 2.75), 1.53 (1.38 to 1.70), 1.13 (1.02 to 1.26) and 1.35 (1.20 to 1.52), and for stroke as 2.24 (1.98 to 2.52), 1.25 (1.09 to 1.44), 1.44 (1.25 to 1.66) and 1.70 (1.46 to 1.98) were shown respectively in the multivariate logistic regression models.
Conclusions
High prevalence of CVD and probably changed epidemic pattern in rural communities of Beijing, together with the prevalent cardiovascular risk factors and population aging, might cause public health challenges in rural Chinese population.
doi:10.1186/1471-2458-12-34
PMCID: PMC3292979  PMID: 22248490
11.  The prevalence of hyperuricemia in China: a meta-analysis 
B, Liu | T, Wang | HN, Zhao | WW, Yue | HP, Yu | CX, Liu | J, Yin | RY, Jia | HW, Nie
BMC Public Health  2011;11:832.
Background
The prevalence of hyperuricemia varied in different populations and it appeared to be increasing in the past decades. Recent studies suggest that hyperuricemia is an independent risk factor for cardiovascular disease. However, there has not yet been a systematic analysis of the prevalence of hyperuricemia in China.
Methods
Epidemiological investigations on hyperuricemia in China published in journals were identified manually and on-line by using CBMDISC, Chongqing VIP database and CNKI database. Those Reported in English journals were identified using MEDLINE database. Selected studies had to describe an original study defined by strict screening and diagnostic criteria. The fixed effects model or random effects model was employed according to statistical test for homogeneity.
Results
Fifty-nine studies were selected, the statistical information of which was collected for systematic analysis. The results showed that the pooled prevalence of hyperuricemia in male was 21.6% (95%CI: 18.9%-24.6%), but it was only 8.6% (95%CI: 8.2%-10.2%) in female. It was found that thirty years was the risk point age in male and it was fifty years in female.
Conclusions
The prevalence of hyperuricemia is different as the period of age and it increases after 30 years in male and 50 in female. Interventions are necessary to change the risk factors before the key age which is 30 years in male and 50 in female.
doi:10.1186/1471-2458-11-832
PMCID: PMC3213156  PMID: 22032610
12.  Psychometric assessment of HIV/STI sexual risk scale among MSM: A Rasch model approach 
BMC Public Health  2011;11:763.
Background
Little research has assessed the degree of severity and ordering of different types of sexual behaviors for HIV/STI infection in a measurement scale. The purpose of this study was to apply the Rasch model on psychometric assessment of an HIV/STI sexual risk scale among men who have sex with men (MSM).
Methods
A cross-sectional study using respondent driven sampling was conducted among 351 MSM in Shenzhen, China. The Rasch model was used to examine the psychometric properties of an HIV/STI sexual risk scale including nine types of sexual behaviors.
Results
The Rasch analysis of the nine items met the unidimensionality and local independence assumption. Although the person reliability was low at 0.35, the item reliability was high at 0.99. The fit statistics provided acceptable infit and outfit values. Item difficulty invariance analysis showed that the item estimates of the risk behavior items were invariant (within error).
Conclusions
The findings suggest that the Rasch model can be utilized for measuring the level of sexual risk for HIV/STI infection as a single latent construct and for establishing the relative degree of severity of each type of sexual behavior in HIV/STI transmission and acquisition among MSM. The measurement scale provides a useful measurement tool to inform, design and evaluate behavioral interventions for HIV/STI infection among MSM.
doi:10.1186/1471-2458-11-763
PMCID: PMC3213074  PMID: 21970669
13.  Prevalence and association between obesity and metabolic syndrome among Chinese elementary school children: a school-based survey 
BMC Public Health  2010;10:780.
Background
China has experienced an increase in the prevalence of childhood overweight/obesity over the last decades. The purpose of this study was to examine the prevalence of obesity and metabolic syndrome among Chinese school children and determine if there is a significant association between childhood obesity and metabolic syndrome.
Methods
A cross-sectional study was conducted among 1844 children (938 males and 906 females) in six elementary schools at Guangzhou city from April to June 2009. The body mass index (BMI), waist circumference, blood pressure, Tanner stage, lipids, insulin and glucose levels were determined. Criteria analogous to ATPIII were used for diagnosis of metabolic syndrome in children.
Results
Among 1844 children aged 7-14 years, 205 (11.1%) were overweight, and 133 (7.2%) were obese. The prevalence of metabolic syndrome was 6.6% overall, 33.1% in obese, 20.5% in overweight and 2.3% in normal weight children. Multiple logistic regression analysis showed that BMI (3rd quartile)(OR 3.28; 95%CI 0.35-30.56), BMI (4th quartile)(OR 17.98; 95%CI 1.75-184.34), homeostasis model assessment (HOMA-IR) (2nd quartile) (OR2.36; 95% CI 0.46-12.09), HOMA-IR (3rd quartile) (OR 2.46; 95% CI 0.48-12.66), HOMA-IR (4th quartile) (OR3.87; 95% CI 0.72-20.71) were significantly associated with metabolic syndrome.
Conclusions
The current epidemic of obesity with subsequent increasing cardiovascular risk factors has constituted a threat to the health of school children in China. HOMA-IR and BMI were strong predictors of metabolic syndrome in children. Therefore, rigorous obesity prevention programs should be implemented among them.
doi:10.1186/1471-2458-10-780
PMCID: PMC3022853  PMID: 21176200
14.  Does Chinese culture influence psychosocial factors for heroin use among young adolescents in China? A cross-sectional study 
BMC Public Health  2010;10:563.
Background
Little empirical research has examined how cultural factors influence psychosocial factors for heroin drug use. The objectives of the study were to investigate the levels of individualism and collectivism among young adolescents and how cultural differences were associated with the constructs of the Theory of Planned Behavior and other psychosocial factors for heroin drug use.
Methods
A cross-sectional study was conducted among young adolescents in an HIV and heroin-stricken area in China. The Individualism-Collectivism Interpersonal Assessment Inventory (ICIAI) was used to measure cultural norms and values in the context of three social groups: family members, close friends, and classmates.
Results
A total of 220 boys and 241 girls were recruited and participated in an interview. Compared to boys, girls reported higher levels of the three specific-relationship ICIAIs, as well as higher levels of perceived behavioral control for heroin use, perceived peer control, and communication with parent about heroin use, but a lower level of favorable attitude towards heroin use. The levels of descriptive and subjective norms of heroin use were low in both girls and boys. Among boys, family ICIAI was positively associated with perceived behavioral control, and friend ICIAI was positively associated with perceived peer control and communication with parent. Among girls, family ICIAI was positively associated with perceived behavioral control and communication with parents about heroin use, but negatively with favorable attitudes to heroin use; friend ICIAI was positively associated with perceived peer control, and classmate ICIAI was negatively associated with favorable attitudes toward heroin use.
Conclusions
This study documents that collectivistic aspects of Chinese culture may influence psychosocial factors for heroin use, although the patterns are varied by gender. Findings provide an empirical basis for the development of culturally competent intervention programs for heroin use intervention and prevention.
doi:10.1186/1471-2458-10-563
PMCID: PMC2955002  PMID: 20858259
15.  Knowledge and risk behaviors related to HIV/AIDS, and their association with information resource among men who have sex with men in Heilongjiang province, China 
BMC Public Health  2010;10:250.
Backgroud
In Heilongjiang province, the HIV prevalence in men who have sex with men (MSM) is generally lower than other part of China. However, the official perception for their risk of HIV/AIDS infection has been increasing in the province over the years. Moreover, little information on HIV/AIDS was provided to the communities so that we have disadvantage of controlling HIV/AIDS epidemic in the region. The purpose of this study is to investigate the prevalence of HIV among MSM in Heilongjiang province, to assess their knowledge levels and risk behaviors related to HIV/AIDS, and to explore their associations with information resources.
Methods
A cross-sectional study using a standardized questionnaire and blood test was administered in 2008 by local interviewers to a sample (1353) of MSM in four cities in Heilongjiang province.
Results
Among 1353 MSM, 2.3% were identified with HIV infection. About 48.7% of the subjects had multiple male sexual partners and only 37.3% of the subjects had consistent condom use (use every time) in the past 6 months. Most had a fair level of knowledge on HIV/AIDS, with the highest mean knowledge score among the MSM from Jiamusi, those with income 2000-3000 RMB/month, those searching sexual partners via internet and those performed HIV testing over 1 year ago). However, some myths regarding viral transmission (e.g., via mosquito bites or sharing kitchen utensils) also existed. Resources of information from which knowledge and risk behaviors related to HIV/AIDS was most available were television (58.6%) among MSM, followed by sexual partner (51.6%), publicity material (51.0%) and internet (48.7%). Significantly statistical differences of mean knowledge score were revealed in favor of book (P = 0.0002), medical staff (P = 0.0007), publicity material (P = 0.005) and sexual partner (P = 0.02). Press (P = 0.04) and book (P = 0.0003) were contributory to the most frequent condom use (condom use every time), while medical staff (P = 0.005) and publicity material (P = 0.04) is associated with moderate rate of condom use (condom use often).
Conclusions
Although the prevalence of HIV infection is low among MSM in Heilongjiang province, the situation that the risk behaviors were frequent in the population is alarming. The study suggests that some strategies like condom use and education intervention are practical approaches and need to be strengthened.
doi:10.1186/1471-2458-10-250
PMCID: PMC2885333  PMID: 20470385
16.  The effect of health and nutrition education intervention on women's postpartum beliefs and practices: a randomized controlled trial 
BMC Public Health  2009;9:45.
Background
'Sitting month' is the Chinese tradition for postpartum customs. Available studies indicate that some of the traditional postpartum practices are potentially harmful for women's health. However, no intervention study aiming at postpartum practices has been performed. In this paper we evaluated the effect of a health and nutrition education intervention, which focused on improving postpartum dietary quality and optimal health behaviors.
Methods
The study design was a randomized controlled trial conducted in both urban and rural area of Hubei between August 2003 and June 2004. A total of 302 women who attended the antenatal clinic during the third trimester with an uncomplicated pregnancy were recruited. Women randomized to the education intervention group in both urban and rural area received two two-hour prenatal education sessions and four postpartum counseling visits. Control group women received usual health care during pregnancy and postpartum period. Women were followed up until 42 days postpartum. Outcome measures were nutrition and health knowledge, dietary behavior, health behavior and health problems during the postpartum period.
Results
Women in the intervention groups exhibited significantly greater improvement in overall dietary behaviors such as consumption of fruits, vegetables, soybean and soybean products as well as nutrition and health knowledge than those in the control groups. Significantly more women in the intervention groups give up the traditional behavior taboos. The incidence of constipation, leg cramp or joint pain and prolonged lochia rubra was significantly lower in the intervention groups as compared with the control groups.
Conclusion
The study shows that health and nutrition education intervention enable the women take away some of the unhealthy traditional postpartum practices and decrease the prevalence of postpartum health problems. The intervention has potential for adaptation and development to large-scale implementation.
Trial registration number
klACTRN12607000549426
doi:10.1186/1471-2458-9-45
PMCID: PMC2640472  PMID: 19183504
17.  Postpartum practices of puerperal women and their influencing factors in three regions of Hubei, China 
BMC Public Health  2006;6:274.
Background
'Sitting month' is a Chinese tradition for women's postpartum custom. The present study aims to explore the postpartum dietary and health practices of puerperal women and identify their influential factors in three selected regions of Hubei, China.
Methods
A cross-sectional retrospective study was conducted in the selected urban, suburban and rural areas in the province of Hubei from 1 March to 30 May 2003. A total of 2100 women who had given birth to full-term singleton infants in the past two years were selected as the participants. Data regarding postpartum practices and potentially related factors were collected through questionnaire by trained investigators.
Results
During the puerperium, 18% of the participants never ate vegetables, 78.8% never ate fruit and 75.7% never drank milk. Behaviour taboos such as no bathing, no hair washing or teeth brushing were still popular among the participants. About half of the women didn't get out of the bed two days after giving birth. The average time they stayed in bed during this period was 18.0 h. One third of them didn't have any outdoor activities in that time periods. The educational background of both women and their spouses, location of their residence, family income, postnatal visit, nutrition and health care educational courses were found to be the influencing factors of women's postpartum practices.
Conclusion
Traditional postpartum dietary and health behaviours were still popular among women in Hubei. Identifying the factors associated with traditional postpartum practices is critical to develop better targeting health education programs. Updated Information regarding postpartum dietary and health practices should be disseminated to women.
doi:10.1186/1471-2458-6-274
PMCID: PMC1636040  PMID: 17087836
18.  The effect of socioeconomic status on three-year mortality after first-ever ischemic stroke in Nanjing, China 
BMC Public Health  2006;6:227.
Background
Low socioeconomic status (SES) is associated with increased mortality after stroke in developed countries. This study was performed to determine whether a similar association also exists in China.
Methods
A total of 806 patients with first-ever ischemic stroke were enrolled in our study. From August 1999 to August 2005, the three-year all-cause mortality following the stroke was determined. Level of education, occupation, taxable income and housing space were used as indicators for SES. Stepwise univariate and multivariate COX proportional hazards models were used to study the association between the SES measures and the three-year mortality.
Results
Our analyses confirmed that occupation, taxable income and housing space were significantly associated with three-year mortality after first-ever stroke. Manual workers had a significant hazard ratio of 5.44 (95% CI 2.75 to 10.77) for death within three years when compared with non-manual workers. Those in the zero income group had a significant hazard ratio of 5.35 (95% CI 2.95 to 9.70) and those in the intermediate income group 2.10 (95% CI 1.24 to 3.58) when compared with those in the highest income group. Those in two of the three groups with the smallest housing space also had significant hazard ratios of 2.06 (95% CI 1.16 to 3.65) and 1.68 (95% CI 1.12 to 2.52) when compared with those in group with the largest housing space. These hazard ratios remained largely unchanged after multivariate adjustment for age, gender, baseline cardiovascular disease risk factors, and stroke severity. The analyses did not confirm an association with educational level.
Conclusion
Lower SES has a negative impact on the outcome of first-ever stroke in Nanjing, China. This confirms the need to improve preventive and secondary care for stroke among low SES groups.
doi:10.1186/1471-2458-6-227
PMCID: PMC1584410  PMID: 16961936
19.  Estimation of salt intake by 24-hour urinary sodium excretion: a cross-sectional study in Yantai, China 
BMC Public Health  2014;14:136.
Background
High levels of dietary sodium are associated with raised blood pressure and adverse cardiovascular health. To determine baseline salt intake, we investigated the average dietary salt intake from 24-hour urinary sodium excretion with a small sample of Yantai adults in the Shandong province of China.
Methods
One hundred ninety one adults aged 18–69 years were randomly selected from the Yantai adult population. Blood pressure, anthropometric indices and sodium excretion in a 24-hour urine collection were measured. Consumption of condiments was derived from 3-day weighted records. Completeness of urine collections was verified using creatinine excretion in relation to weight.
Results
The mean Na and K outputs over 24 hours were 201.5 ± 77.7 mmol/day and 46.8 ± 23.2 mmol/day, respectively (corresponding to 11.8 g NaCl and 1.8 g K). Overall, 92.1% of the subjects (96.9% of men and 87.1% of women) had intakes of over 6 g salt (NaCl)/d. The main sources of salt intake from weighed condiments records were from home cooking salt (74.7%) followed by soy sauce (15.0%). Salt intake from condiments and salt excretion were weakly correlated((r = 0.20, p = 0.005).A positive linear correlation between salt intake was associated with systolic blood pressure in all adjusted and unadjusted model (r = 0.16, p = 0.01). Each 100 mmol/day increase in sodium intake was associated with a 4.0 mmHg increase in systolic blood pressure.
Conclusion
Dietary salt intake in Yantai adults was high. Reducing the intake of table salt and soy sauce used in cooking will be an important strategy to reduce sodium intake among Yantai adults.
doi:10.1186/1471-2458-14-136
PMCID: PMC3921994  PMID: 24507470
Urinary sodium; Salt intake; Urine
20.  Objective assessment of urban built environment related to physical activity — development, reliability and validity of the China Urban Built Environment Scan Tool (CUBEST) 
BMC Public Health  2014;14:109.
Background
Some aspects of the neighborhood built environment may influence residents’ physical activity, which in turn, affects their health. This study aimed to develop an urban built environment evaluation tool and conduct necessary reliability and validity tests.
Methods
A 41-item urban built environment scan tool was developed to objectively assess the neighborhood built environment features related to physical activity. Six neighborhoods in Hangzhou were selected from three types of administrative planning units. A pair of auditors independently assessed all of the 205 street segments at the same time. Half of the segments (n = 104) were audited twice by the same auditor after a two-week time interval. Inter-rater reliability was assessed by comparing the audits of paired observers, while intra-rater reliability was evaluated by comparing an auditor’s repeated assessments of the same segments. The construct validity was tested using factor analysis.
Results
The inter-rater reliability for most items was above 0.8. The intra-rater reliability for most items was above 0.4, and was lower than corresponding inter-rater reliability. Six factors were extracted by factor analysis and the factor loading matrix showed good construct validity.
Conclusions
The CUBEST is a reliable and valid instrument that can be used to assess the physical activity-related built environment in Hangzhou, and potentially other cities in China.
doi:10.1186/1471-2458-14-109
PMCID: PMC3916581  PMID: 24495676
Environmental scan; Physical activity; Reliability; Validity
21.  Rates and risk factors for drug resistance tuberculosis in Northeastern China 
BMC Public Health  2013;13:1171.
Background
Drug-resistant tuberculosis (TB) has emerged as a major challenge toward TB control and prevention. In Lianyungang city, the extent and trend of drug resistant TB is not well known. The objective of the survey was to assess drug resistance pattern of MTB and risk factors for drug resistant TB, including multidrug resistance tuberculosis (MDR-TB) in this area.
Methods
We performed drug susceptibility testing on Mycobacterium tuberculosis (MTB) isolates with first- and second-line anti-tuberculosis drugs of 1012 culture positive TB cases by using the proportion method, who were consecutively enrolled from January 2011 to December 2012 in Lianyungang city, China. The patterns of drug resistance in MTB were investigated and multiple logistic regression analysis was performed to assess the risk factors for drug resistant TB.
Results
Among the 1012 strains tested, 308 (30.4%) strains were resistant to at least one first-line drug; the prevalence of MDR-TB was 88 (8.7%), 5 (0.5%) strains were found to be extensively drug-resistant tuberculosis (XDR-TB). Female gender was a risk factor for MDR-TB (adjusted odds ratio (aOR) 1.763, 95% CI (1.060-2.934). The aged 28–54 years was significantly associated with the risk of MDR-TB with an aOR: 2.224, 95% CI (1.158-4.273) when compared with those 65 years or older. Patients with previous treatment history had a more than 7-fold increased risk of MDR-TB, compared with those never previously treated.
Conclusions
The burden of drug resistant TB cases is sizeable, which highlights an urgent need to reinforce control, detection and treatment strategies for drug resistant TB.
doi:10.1186/1471-2458-13-1171
PMCID: PMC3878749  PMID: 24330553
Epidemiology; MDR-TB; Drug resistance; Drug susceptibility
22.  Thyroid volume, goiter prevalence, and selenium levels in an iodine-sufficient area: a cross-sectional study 
BMC Public Health  2013;13:1153.
Background
Selenium (Se) is a necessary element for the biosynthesis of thyroid hormones. We investigated the relationship between selenium status, thyroid volume, and goiter in a cross-sectional study in an iodine-sufficient area.
Methods
We selected residents of Chengdu (over 18 years old and living in the city for more than 5 years) using a stratified cluster sampling technique. Fifteen hundred subjects were selected for the study, which involved a questionnaire survey, physical examination, thyroid ultrasound, serum thyroid function test, and determination of serum selenium level. Thyroid volume was calculated from the thickness, width, length, and a corrective factor for each lobe. Ultimately, 1,205 subjects completed the investigation and were included in our study. Additionally, 80 school-age children were selected to provide urine samples for urinary iodine analysis. We analyzed the data using appropriate nonparametric and parametric statistical tests.
Results
The median urinary iodine value was 184 μg/L in school-age children, indicating iodine sufficiency. The median serum selenium level of the 1,205 subjects was 52.63 (interquartile range [IQR] : 40.40-67.00) μg/L. The median thyroid volume was 9.93 (IQR: 7.71-12.57) mL; both log-transformed serum selenium and log-transformed thyroid volume were Gaussian distributions (P = .638 and P = .046, respectively). The prevalences of goiter and thyroid nodules were 8.8% and 18.6%. The prevalences of positive thyroid autoantibodies, thyroperoxidase autoantibodies and thyroglobulin autoantibodies were 16.7%, 12.0%, and 11.1%, respectively. In the general linear regression model, there were positive associations between serum selenium and age, and body mass index. We found no association between serum selenium and thyroid-stimulating hormone. In simple linear regression analyses, we found no association between thyroid volume and serum selenium. There were no significant differences in serum selenium between persons with or without goiter. Serum selenium was not a risk factor for goiter.
Conclusion
In our study population, serum selenium was neither associated with thyroid volume nor with goiter in an iodine-sufficient area. More studies should be conducted by following non-goitrous persons over time and monitoring their selenium status.
doi:10.1186/1471-2458-13-1153
PMCID: PMC3878896  PMID: 24321191
Iodine; Selenium; Thyroid hormones; Thyroid volume; Thyroid goiter; Thyroid disease; Cross-sectional study
23.  Ten-year changes in the prevalence of overweight, obesity and central obesity among the Chinese adults in urban Shanghai, 1998–2007 — comparison of two cross-sectional surveys 
BMC Public Health  2013;13:1064.
Background
In China, obesity is expected to increase rapidly in both urban and rural areas. However, there have been no comprehensive reports on secular trends in obesity prevalence among Chinese adults in urban Shanghai, which is the largest city in southern China.
Methods
In 1998–2001 and again in 2007–2008, two independent population-based cross-sectional surveys were conducted in Shanghai to investigate the prevalence of metabolic disorders. These surveys obtained height, waist circumference (WC), and weight measurements for Chinese adults aged between 20 and 74 years who lived in urban communities. From the 1998–2001 survey, 4,894 participants (2,081 men and 2,813 women, mean age: 48.9 years) were recruited, and 4,395 participants (1,599 men and 2,796 women, mean age: 49.8 years) were recruited from the 2007–2008 survey. Using the World Health Organization criteria, overweight was defined as 25 kg/m2 ≤ BMI < 30 kg/m2 and obesity as BMI ≥ 30 kg/m2. Central obesity was defined as WC ≥ 90 cm in men or ≥85 cm in women. The differences in prevalence of obesity, central obesity and overweight between the two surveys were tested using multivariable logistic regression analyses.
Results
Compared to the 1998–2001 survey, in the 2007–2008 survey the BMI distribution for men and the WC distribution for both genders is shifted significantly to the right along the x-axis (all p < 0.001). Over the ten years, the prevalence of combined overweight and obesity increased 24% (from 31.5% to 39.1%, p < 0.001) in men, but decreased 8% (from 27.3% to 25.0%; p < 0.01) in women. The prevalence of central obesity increased 40% in men (from 19.5% to 27.3%; p < 0.01), but the increase was not significant in women (15.0% to 17.1%; p = 0.051). In the total population, only central obesity showed a significant change between the populations in the two surveys, increasing 29% (from 17.3% to 22.4%; p < 0.001).
Conclusions
Over this 10 year period, central obesity increased significantly in the Shanghai adult population. However, the prevalence of combined overweight and obesity was significantly increased in men but not in women.
doi:10.1186/1471-2458-13-1064
PMCID: PMC3833854  PMID: 24215220
Central obesity; Chinese adults; Cross-sectional survey; Overweight; Obesity; Prevalence; Urban
24.  Admission to hospital for pneumonia and influenza attributable to 2009 pandemic A/H1N1 Influenza in First Nations communities in three provinces of Canada 
BMC Public Health  2013;13:1029.
Background
Early reports of the 2009 A/H1N1 influenza pandemic (pH1N1) indicated that a disproportionate burden of illness fell on First Nations reserve communities. In addition, the impact of the pandemic on different communities may have been influenced by differing provincial policies. We compared hospitalization rates for pneumonia and influenza (P&I) attributable to pH1N1 influenza between residents of First Nations reserve communities and the general population in three Canadian provinces.
Methods
Hospital admissions were geocoded using administrative claims data from three Canadian provincial data centres to identify residents of First Nations communities. Hospitalizations for P&I during both waves of pH1N1 were compared to the same time periods for the four previous years to establish pH1N1-attributable rates.
Results
Residents of First Nations communities were more likely than other residents to have a pH1N1-attributable P&I hospitalization (rate ratio [RR] 2.8-9.1). Hospitalization rates for P&I were also elevated during the baseline period (RR 1.5-2.1) compared to the general population. There was an average increase of 45% over the baseline in P&I admissions for First Nations in all 3 provinces. In contrast, admissions overall increased by approximately 10% or less in British Columbia and Manitoba and by 33% in Ontario. Subgroup analysis showed no additional risk for remote or isolated First Nations compared to other First Nations communities in Ontario or Manitoba, with similar rates noted in Manitoba and a reduction in P&I admissions during the pandemic period in remote and isolated First Nations communities in Ontario.
Conclusions
We found an increased risk for pH1N1-related hospital admissions for First Nations communities in all 3 provinces. Interprovincial differences may be partly explained by differences in age structure and socioeconomic status. We were unable to confirm the assumption that remote communities were at higher risk for pH1N1-associated hospitalizations. The aggressive approach to influenza control in remote and isolated First Nations communities in Ontario may have played a role in limiting the impact of pH1N1 on residents of those communities.
doi:10.1186/1471-2458-13-1029
PMCID: PMC3840629  PMID: 24499143
25.  Exploration of pathways related to the decline in female circumcision in Egypt 
BMC Public Health  2013;13:921.
Background
There has been a large decline in female genital circumcision (FGC) in Egypt in recent decades. Understanding how this change has occurred so rapidly has been an area of particular interest to policymakers and public health officials alike who seek to further discourage the practice elsewhere.
Methods
We document the trends in this decline in the newest cohorts of young girls and explore the influences of three pathways—socioeconomic development, social media messages, and women’s empowerment—for explaining the observed trends. Using the 2005 and 2008 Egypt Demographic and Health Surveys, we estimate several logistic regression models to (1) examine individual and household determinants of circumcision, (2) assess the contributions of different pathways through which these changes may have occurred, and (3) assess the robustness of different pathways when unobserved community differences are taken into account.
Results
Across all communities, socioeconomic status, social media messages, and women’s empowerment all have significant independent effects on the risk of circumcision. However, after accounting for unobserved differences across communities, only mother’s education and household wealth significantly predict circumcision outcomes. Additional analyses of maternal education suggest that increases in women’s education may be causally related to the reduction in FGC prevalence.
Conclusions
Women’s empowerment and social media appear to be more important in explaining differences across communities; within communities, socioeconomic status is a key driver of girls’ circumcision risk. Further investigation of community-level women’s educational attainment for mothers suggests that investments made in female education a generation ago may have had echo effects on girls’ FGC risk a generation later.
doi:10.1186/1471-2458-13-921
PMCID: PMC3835453  PMID: 24090097
Female Circumcision; Adolescent health; Egypt

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