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Clinical Chemistry 51: 144-150, 2005. First published November 11, 2004; 10.1373/clinchem.2004.038646
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Right arrow Lipids, Lipoproteins, and Cardiovascular Risk Factors
(Clinical Chemistry. 2005;51:144-150.)
© 2005 American Association for Clinical Chemistry, Inc.

Lipids, Lipoproteins, and Cardiovascular Risk Factors

Serum Lipid Concentrations and Prevalence of Dyslipidemia in a Large Professional Population in Beijing

Zhiyan Li, Ruifeng Yang, Guobing Xua and Tiean Xia

1 Department of Clinical Laboratory, Peking University First Hospital, Beijing 100034, China.

aAuthor for correspondence. E-mail rockandfriend{at}yahoo.com.cn.


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Background: Lipid abnormalities are major risk factors for premature coronary artery diseases. We investigated serum lipids and the prevalence of dyslipidemia in a professional population in Beijing and compared these data with those obtained in a similar population during 1984–1986.

Methods: We studied 14 963 individuals 20–90 years of age. Health status was determined by questionnaires and physical check-ups. Total cholesterol (TC), LDL-cholesterol (LDL-C), HDL-cholesterol (HDL-C), and total triglycerides (TGs) were measured. TC >5.7 mmol/L, LDL-C >3.6 mmol/L, TGs >1.7 mmol/L, and HDL-C <0.9 mmol/L were defined as abnormal.

Results: Mean serum TC, LDL-C, and TG concentrations were increased compared with the values obtained in 1984–1986, with 52.7% of males and 42.9% of females having at least one abnormal lipid concentration. Hypercholesterolemia occurred in 6% of males and 2.8% of females in the younger group (20–39 years) and in 20.2% of males and 38.7% of females in the older group (>60 years). HDL-C was abnormally low in ~7% of males and in 1.6% of females. The prevalences of hypercholesterolemia, hypertriglyceridemia, and abnormally low HDL-C, especially the presence of slight hypertriglyceridemia, were higher than in 1984–1986 in all age groups. The increase was most prominent in the middle age group (40–59 years).

Conclusions: Hypercholesterolemia, hypertriglyceridemia, and abnormally low HDL-C have increased considerably over the past 20 years in professional populations in Beijing. Dietary changes and less physical activity resulting from rapid improvements in living conditions may be the causes for the increases. Enhanced preventive measures should be undertaken to modify these situations.


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
It has long been known that lipid abnormalities are major risk factors for premature coronary artery disease (CAD)1 (1)(2)(3)(4)(5). The usefulness of serum total cholesterol (TC) measurements in predicting initial CAD events has been established in numerous prospective epidemiologic studies (1)(6)(7)(8)(9). The atherogenic LDL-cholesterol (LDL-C) component and the inverse relationship between the HDL-cholesterol (HDL-C) concentration and CAD risk have also been established (7)(8)(9)(10)(11)(12). Large-scale controlled trials have shown that lowering cholesterol in otherwise healthy adults reduces the risk of CAD (13)(14)(15).

During the past 20 years, China has experienced remarkable socioeconomic development, with the mean income increasing by severalfold. Consequently, the lifestyles of people throughout the country have changed dramatically. Several epidemiologic studies in this country found that serum lipid concentrations were higher in a significant part of the population and that an increasing proportion of the population had dyslipidemia. From September to December of 2003, we measured serum TC, total triglyceride (TG), LDL-C, and HDL-C concentrations in a large-scale study of a professional population in Beijing to investigate the status of serum lipids and the prevalence of dyslipidemia.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
participants and survey protocols
A total of 14 963 (8572 males and 6391 females) professional people in Beijing, including corporation clerks, educational faculties (total, 95%), and students (total, 5%) 20–90 years of age who attended annual general health examinations were recruited in this study. Most of them were well educated (>75% had attended universities or graduate schools). Each participant was asked to fill out an informed consent and a questionnaire, which included history of CAD risk factors such as smoking, alcohol consumption, diabetes, and hypertension. The physical examination emphasized measurement of height, weight, and blood pressure. Body mass index was calculated by use of body weight (in kilograms) divided by height (in meters) squared. Blood pressure was measured three times, with participants resting for at least 30 min, by a cardiologist using a standard mercury sphygmomanometer. Blood samples were collected from the antecubital vein after an overnight fast for 12–14 h. After clotting, blood was centrifuged at 1200g for 10 min to obtain serum for glucose, TC, HDL-C, LDL-C, and TG measurements. Serum samples were stored at 4 °C, and the determinations were carried out within 24 h.

serum lipid and glucose measurements
Serum glucose was measured by the glucose oxidase method. TC and TG concentrations were measured by routine enzymatic methods. HDL-C was measured by a homogeneous method that used polymer and polyanion together to block the non-HDL lipoproteins. HDL particles were disrupted by detergent, releasing the cholesterol and cholesteryl esters. HDL-C was then determined enzymatically. All lipid reagents and the lipid calibrator were from Daiichi Pure Chemicals. Assays for lipids were performed in a Hitachi 7600 automated clinical chemistry analyzer. LDL-C was calculated by the Friedewald formula in individuals with serum TGs ≤4.5 mmol/L. Measurements were carried out in a clinical laboratory that followed the criteria of the WHO Lipid Reference Laboratories.

definitions and preferred cutoff values
According to the standard guidelines (16), obesity was defined as body mass index >30 kg/m2 and overweight as >25 kg/m2 (females) or >27 kg/m2 (males). Persons whose mean blood pressure was ≥140/90 mmHg or who were taking antihypertensive medications were classified as hypertension. Persons with a fasting blood glucose >7.0 mmol/L or who were taking antidiabetic medication were considered as having diabetes mellitus. Hypercholesterolemia was defined as TC >5.7 mmol/L, high LDL-C as LDL-C >3.6 mmol/L, hypertriglyceridemia as TGs >1.7 mmol/L, and low HDL-C as HDL-C <0.9 mmol/L. Dyslipidemia was defined by the presence of one or more than one abnormal serum lipid concentration. The Expert Panel on Recommendations for Prevention and Treatment of Dyslipidemia also set TC <5.2 mmol/L, LDL-C <3.1 mmol/L, HDL-C <1.03 mmol/L, and TGs <1.7 mmol/L as the desired values for serum lipids (17).

statistical analysis
Participants were divided into 14 age groups (17–19, 20–24, 25–29, 30–34, 35–39, 40–44, 45–49, 50–54, 55–59, 60–64, 65–69, 70–74, 75–79, and ≥80 years). Because the serum lipid values did not follow a gaussian distribution, continuous variables are presented as percentiles and qualitative variables are presented as absolute or relative frequencies. Appropriate variables were compared by either the U-test or the {chi}2 test. All reported P values are based on two-sided tests, and P <0.05 was considered as statistically significant. The statistical calculations were performed with SPSS 10.0 (SPSS, Inc.).


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
general features of the population
The numbers of individuals in the different age groups are shown in Table 1 , and the clinical features of the participants are shown in Table 2 . Males had a higher body mass index than females. As a consequence, the prevalence of obesity was higher in males than in females. Of the males, 37.9% were overweight, whereas 25.4% of females were overweight. Across all age groups, 30.2% of males and 25.8% of females had hypertension, and 7.5% of males and 5.6% of females had a history of diabetes mellitus. The prevalence of diabetes increased with age in both genders (P = 0.001 for trend; data not shown).


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  		Table 1. Number of individuals in each age group.


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  		Table 2. Clinical characteristics of participants.

serum lipids in different age and gender groups
The age- and sex-specific means and 5th, 50th, and 95th percentiles for serum lipids are shown in Table 3 . Median serum TC tended to increase with age up to ~70 years, after which it decreased gradually (Fig. 1 ). TC was lower in females than in males in the age groups <50 years and increased with age, indicating that changes in hormone secretion in the postmenopausal period affect lipid metabolism. In individuals >50 years of age, TC was higher in females than in males. LDL-C displayed a pattern of change with age similar to that of TC (Fig. 1 ). HDL-C was higher in females than in males in all age groups, with median concentrations of 1.27 mmol/L in males and 1.50 mmol/L in females. HDL-C changed little with age. Serum TGs increased significantly with age. The median TG concentration tended to increase with age in males up to age of 45 and in females up to age 65, after which it decreased gradually (Fig. 2 ). In the age groups younger than 60 years, TGs were higher in males than in females, but in the age groups older than 60 years, TGs were higher in females than in males.


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  		Table 3. Serum lipids by age and gender.



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  		Figure 1. Age trends for mean TC, LDL-C, and HDL-C in females (dashed lines) and males (solid lines).



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  		Figure 2. Age trends for median TG concentrations in females (dashed lines) and males (solid lines).

prevalence of dyslipidemia
On the basis of the diagnostic criteria mentioned above, dyslipidemia was observed in 52.7% males and 42.9% females, with significant difference between the two sexes (P <0.001). In adults >60 years of age, the prevalence rate was even higher: 68.4% and 78.2% for males and females, respectively.

The prevalence of dyslipidemia is shown in Table 4 . The desired TC concentration is <5.2 mmol/L (17), and 14.8% males and 8.8% females 20–39 years of age had serum TC above that value. In the middle age group (40–59 years), the prevalence was >35% in both genders. In older adults (≥60 years), 40.5% of males and 62% of females had TC above the desired concentration cutoff. On the basis of the diagnostic criteria for dyslipidemia in China, hypercholesterolemia (TC >5.7 mmol/L) occurred in 6% of males and 2.8% of females in the younger group, in ~20% in the middle age group, and in 20.2% of males and 38.7% of females in the older group. The prevalence of LDL-hypercholesterolemia followed the same trend as that for hypercholesterolemia. HDL-C was abnormally low more often in males than in females: ~20% of males and 4% of females had HDL-C <1.03 mmol/L. HDL-C (<0.91 mmol/L) was abnormally low in ~7% of males, but in only 1.6% of females. As shown in Table 4 , the prevalences of TC >5.2 mmol/L and TC >5.7 mmol/L were comparable to those of LDL-C >3.1 mmol/L and LDL-C >3.6 mmol/L, respectively. Therefore, based on the guidelines for the Chinese population, for TC concentrations <5.2 mmol/L (preferred concentrations), the LDL-C concentration should be <3.1 mmol/L.


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  		Table 4. Prevalence of dyslipidemias.

As shown in Table 4Up , 24.7% of males and 7.3% of females in the younger group had hypertriglyceridemia, as did 45.1% of males and 27.9% of females in the middle age group. In the older group, the prevalence of hypertriglyceridemia was higher in females (46.5%). We also found that there was a weak inverse correlation between TG and HDL-C concentrations (r = –0.348; P = 0.01). Of those with HDL-C <0.9 mmol/L, 12.2% of males and 2.7% of females had TGs >1.7 mmol/L.

Across the age groups, 13.7% of males and 12.7% of females had combined hyperlipidemia (hypercholesterolemia and hypertriglyceridemia). The rate was significantly lower than that of isolated high TGs or isolated high TC.

comparison of the results with results of 1984–1986 study in beijing
In 1984–1986, Li et al. (18) carried out a study similar to ours, in which 13 283 individuals (8027 males and 5256 females) from age 20 to >90 years were enrolled. The participants were professionals working in corporations, factories, schools, and hospitals as well as retired professionals in Beijing, but labor workers were not included. They also divided participants into age groups with an interval of 10 years. They used the same methods for blood collection and the same TC and TG assays as ours. HDL-C was measured by the phosphotungstic acid-Mg2+ method, which was different from our method. However, reports have shown no statistical differences between results obtained with the phosphotungstic acid-Mg2+ method and with the homogeneous method that we used (19)(20)(21)(22). In that study (18), laboratory assays were also controlled by the CDC Lipid Standardization Program. Consequently, these results can be used as the baseline for the evaluation of serum lipid changes in professional populations in Beijing over the past 20 years.

Differences in age-adjusted mean concentrations of serum lipids between our study and the 1984–1986 study (18) are shown in Table 5 . Over this period, the age-adjusted means for TC, LDL-C, and TG have increased and the age-adjusted mean for serum HDL-C has decreased in both genders. The most prominent change is an increase in serum TG concentrations.


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  		Table 5. Comparison of mean lipid concentrations with the study performed in 1984–1986 in Beijing (18).1

In the study by Li et al. (18), hypercholesterolemia was defined as TC >6.47 mmol/L and hypertriglyceridemia as TGs >2.36 mmol/L. They also listed the rates of serious hypercholesterolemia (>7.76 mmol/L) and hypertriglyceridemia (>5.65 mmol/L). For comparison of the two studies, we then recalculated these variables, using the cutoff points used by Li et al. (18). Over the past 20 years, the age-standardized prevalences of both mild and serious hypercholesterolemia, hypertriglyceridemia, and abnormally low HDL-C have increased in all age groups (Fig. 3 ). The most obvious change was in mild hypertriglyceridemia; the age-standardized prevalence rate has increased by more than twofold in all age groups. For hypercholesterolemia and hypertriglyceridemia, the increases in age-standardized prevalences were the largest in the middle age group.



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  		Figure 3. Comparison of the age-standardized prevalences of hypercholesterolemia (A), hypertriglyceridemia (B), and abnormally low HDL-C (C) between 1984 and 2003.

Statistical analyses were not performed because of a lack of related data in the study of 1984–1986.


   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
Serum lipid concentrations and the prevalence of dyslipidemia have changed considerably in professional populations in Beijing since 1984. Although the changes in the mean concentrations of TC, LDL-C, TGs, and HDL-C were significant, the most important findings of this survey were the considerable increases in hypercholesterolemia, hypertriglyceridemia, and abnormally low HDL-C, which are well-known risk factors for cerebrocardiovascular diseases, in all age groups. Changes of lifestyle definitely affected the prevalence of dyslipidemia found in this survey. Dietary habits have altered greatly in most people as a result of the rapid economic development and increased supply of animal protein in China. More fat was consumed during the past decade (23)(24). With the increase in income, many people turned from the traditional low-fat Chinese diet to "affluent diets" containing high amounts of fat (23). The proportion of energy from fat has been increasing (18.4% in 1982, 23.12% in 1991, and 34.99% in 1997) in the general Chinese population (25)(26). Meanwhile, the daily consumption of cereals has been decreasing (498 g/day in 1982, 464.59 g/day in 1991, and 390.25 g/day in 1997), and the consumption of animal protein has been increasing (68 g/day in 1982, 116.04 g/day in 1991, and 221.55 g/day in 1997) in urban areas. The above alterations of dietary habits are even more evident in inhabitants in big cities. For example, the mean energy, protein, and fat intake of an inhabitant of Beijing is 10 600 000 J/day (2533 Kcal/day), 96.8 g/day, and 129.6 g/day, respectively, dramatically higher than those in a balanced diet [10 040 000 J/day (2300 Kcal/day), 77 g/day, and, 70 g/day, respectively] (27). Energy intake from plant food in a balanced diet should be 80%, and this takes only 55% of the energy. Intake of animal protein should be <30% but has reached 57.5%. In addition, the amount of physical activity has decreased greatly in the past two decades. More people in Beijing now go to work by car, bus, or subway instead of on foot or by bike, and more use electrical appliances, such as washing machines, to reduce their housework. We also found that the increase in TG concentrations was more obvious. The main reason may be that high-calorie and high-fat diets dramatically affect TG concentrations.

Our results may not be indicative of the Chinese population as a whole because we selected a professional population in Beijing instead of using random sampling. However, this population represents a large inhabitant group, with average but stable incomes and living conditions, fewer physical activities, better health awareness, and higher educational backgrounds, that is increasing in the big cities in China.

In 1988, National Cholesterol Education Program Expert Panel delivered the first report on the detection, evaluation, and treatment of high cholesterol in adults (Adult Treatment Panel I) (6). As a result of efforts to control cholesterol and other risk factors, the occurrence of CAD has decreased in developed countries. In China, more attention has been paid to the control of TC through educational programs since 1990 (28). In 1997, the Expert Panel for the Prevention and Treatment of Dyslipidemia proposed a recommendation for curing dyslipidemia and set desired TC values as <5.2 mmol/L (17). In the present study, 13.6% of the participants had TC concentration above that value, but their TC concentrations had not reached the standard of hypercholesterolemia (TC >5.7 mmol/L). Lipid concentrations in these individuals should be measured more frequently, and they should be given extensive nutritional recommendations because they are at high risk of dyslipidemia and cerebrocardiovascular diseases. Guidelines for proper management of risk factors, targeting the prevention and treatment of atherosclerotic vascular diseases, have been published in the United States (6) and Europe (29). Most of these guidelines are also very helpful to China. Public health programs promoting a healthy diet and physical activities should be strengthened to alter the increasing prevalence of dyslipidemia in the Chinese population.

Abnormally low HDL-C is also a risk factor for CAD (30)(31). The second report of the National Cholesterol Education Program Adult Treatment Panel reaffirmed that HDL-C concentrations <0.91 mmol/L are a major risk factor for coronary heart diseases and HDL-C concentrations >1.55 mmol/L are protective (13). We found that HDL-C was low (<0.91 mmol/L) in 7.2% of males and 1.5% of females and the prevalence of higher HDL-C was lower in males than in females. The prevalence of abnormally low HDL-C has increased over the past 20 years (Fig. 3Up ). Presumably, the lifestyle factors affecting serum cholesterol are also involved in the increasing prevalence of abnormally low HDL-C.


   Footnotes
 
1 Nonstandard abbreviations: CAD, coronary artery disease; TC, total cholesterol; LDL-C and HDL-C, LDL- and HDL-cholesterol, respectively; and TG, triglyceride.


   References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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