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Tackling social and behavioural risk factors for cardiovascular diseases in Chinese women. Chinese women have benefited more than men from improvements in social determinants of health in decreasing the burden of cardiovascular diseases in recent decades; however, Chinese women, especially those in the younger generation, are facing new challenges, argue Siyan Zhan and colleagues

Since the founding of the People’s Republic of China, the socioeconomic and political status of women has largely improved and brought about better living conditions and reduced the burden of cardiovascular diseases, especially among middle aged and older women. In this section, we briefly introduce these improvements and the mechanisms underlying the reduction of cardiovascular disease burden in Chinese women. As a guarantee of improvements in other social determinants, political positions for Chinese women have been significantly promoted in the past 70 years. The proportions of female members in the two most important Chinese political congresses increased by more than 10% from the first to the 13th session.4 An increase in the number of female decision makers increased the opportunities to focus on promoting women’s health. In addition to political status, other socioeconomic determinants, including education, occupation, and income, also improved among Chinese women during this period. Compared with those for men, improvements for women were more obvious and made greater contributions to reducing the burden of cardiovascular diseases.

As a guarantee of improvements in other social determinants, political positions for Chinese women have been significantly promoted in the past 70 years. The proportions of female members in the two most important Chinese political congresses increased by more than 10% from the first to the 13th session.4 An increase in the number of female decision makers increased the opportunities to focus on promoting women’s health. In addition to political status, other socioeconomic determinants, including education, occupation, and income, also improved among Chinese women during this period. Compared with those for men, improvements for women were more obvious and made greater contributions to reducing the burden of cardiovascular diseases. Gender equity in education has improved tremendously in China. Male and female literacy rates in China were 79.2% and 51.1%, respectively, in 1982 and 98.6% and 95.6% in 2020.5 As well as the gender specific improvement in education, a gender specific effect of education on cardiovascular diseases has also been seen in China. The China Kadoorie Biobank showed that the association of lower educational attainment with a higher risk of ischaemic heart disease was stronger for women than for men.6 The Prospective Urban and Rural Epidemiological study in China also showed that the burden of cardiovascular diseases attributed to low education was greater in women than in men (11.3% v 8.7%).7

ociation of lower educational attainment with a higher risk of ischaemic heart disease was stronger for women than for men.6 The Prospective Urban and Rural Epidemiological study in China also showed that the burden of cardiovascular diseases attributed to low education was greater in women than in men (11.3% v 8.7%).7 As a consequence of the improvement in education among Chinese women, the gender gaps in employment and income have narrowed. In 2022 the female and male labour force participation rate was 61.1% and 72.6%, respectively.8 Ownership of bank accounts and houses among women is increasing.9 A large meta-analysis derived primarily from studies conducted in high income countries showed that the inverse associations of socioeconomic status measured by occupation and income with coronary heart disease and stroke were stronger in women than in men.10 Therefore, women may benefit more from improvements in socioeconomic status than do men. The improvement in socioeconomic status has changed material circumstances for both better and worse in China. However, Chinese women have benefited from better material circumstances. For example, the transition from traditional fuels to clean energy sources has led to a reduced risk of cardiovascular disease mortality in women, who do most of the housework.11 The employment rate among Chinese women has greatly increased, but the occupational risk exposure is much lower in women than in men, which also partially explains why Chinese women have had a lower increase in cardiovascular risk than men.

k of cardiovascular disease mortality in women, who do most of the housework.11 The employment rate among Chinese women has greatly increased, but the occupational risk exposure is much lower in women than in men, which also partially explains why Chinese women have had a lower increase in cardiovascular risk than men. For material circumstances during early life, previous epidemiological studies of births in China during the famine around the 1960s showed that women had a greater risk of cardiovascular disease caused by earlier exposure to famine compared with men, which suggested that Chinese women might benefit more than men from a sufficient food supply.12 Although the improvement in food equity in recent decades might have reduced cardiovascular disease risks in Chinese women, the existing gap in child and maternal malnutrition between the sexes cannot be ignored.2 More actions to increase food availability for women need to be implemented.

ociation of lower educational attainment with a higher risk of ischaemic heart disease was stronger for women than for men.6 The Prospective Urban and Rural Epidemiological study in China also showed that the burden of cardiovascular diseases attributed to low education was greater in women than in men (11.3% v 8.7%).7 As a consequence of the improvement in education among Chinese women, the gender gaps in employment and income have narrowed. In 2022 the female and male labour force participation rate was 61.1% and 72.6%, respectively.8 Ownership of bank accounts and houses among women is increasing.9 A large meta-analysis derived primarily from studies conducted in high income countries showed that the inverse associations of socioeconomic status measured by occupation and income with coronary heart disease and stroke were stronger in women than in men.10 Therefore, women may benefit more from improvements in socioeconomic status than do men.

The improvement in socioeconomic status has changed material circumstances for both better and worse in China. However, Chinese women have benefited from better material circumstances. For example, the transition from traditional fuels to clean energy sources has led to a reduced risk of cardiovascular disease mortality in women, who do most of the housework.11 The employment rate among Chinese women has greatly increased, but the occupational risk exposure is much lower in women than in men, which also partially explains why Chinese women have had a lower increase in cardiovascular risk than men. For material circumstances during early life, previous epidemiological studies of births in China during the famine around the 1960s showed that women had a greater risk of cardiovascular disease caused by earlier exposure to famine compared with men, which suggested that Chinese women might benefit more than men from a sufficient food supply.12 Although the improvement in food equity in recent decades might have reduced cardiovascular disease risks in Chinese women, the existing gap in child and maternal malnutrition between the sexes cannot be ignored.2 More actions to increase food availability for women need to be implemented.

The reduction in the burden of cardiovascular diseases among Chinese women, especially older women, has been attributed to the remarkable improvement in social determinants mentioned above. However, potential challenges exist in other social determinants of cardiovascular health in younger women. In this section, we discuss the potential risks of cardiovascular diseases caused by socioeconomic and political factors, behavioural factors, psychosocial factors, and health systems. As the basis for improving social determinants, gender equity was proposed in the constitution of China in 1954 and included as a basic state policy 40 years later. The Chinese government has proposed gender equity policies from the top level design perspective and formulated more than 20 national laws and regulations relating to women’s rights and interests. However, almost all of these female specific health related policies focused on maternal health, and none of them is related to cardiovascular disease.

roposed gender equity policies from the top level design perspective and formulated more than 20 national laws and regulations relating to women’s rights and interests. However, almost all of these female specific health related policies focused on maternal health, and none of them is related to cardiovascular disease. As part of Asian culture, the custom of “male domination and female subordination” still exists in parts of China, which means that women tend to remain in traditional roles. As “carrying on the family line” is one of the most critical responsibilities in traditional culture, more attention may be paid to “bikini boundaries” in women’s health to boost fertility.13 In addition, as a multiethnic country, the ethnic disparities in cardiovascular disease burden in China cannot be ignored. In addition to genetic differences, unique cultural backgrounds, particular behaviours, and unbalanced healthcare resources might play vital roles in the development and progression of cardiovascular disease.

, as a multiethnic country, the ethnic disparities in cardiovascular disease burden in China cannot be ignored. In addition to genetic differences, unique cultural backgrounds, particular behaviours, and unbalanced healthcare resources might play vital roles in the development and progression of cardiovascular disease. In addition to the macro environment, individual behaviour is also a major determinant of cardiovascular disease risk. Economic prosperity in China has led to unhealthy lifestyles, including inadequate physical activity and unhealthy diets. For example, the increase in public transport facilities and family cars has contributed to the decline of active commuting in China. The decline in physical activity was more obvious among women than among men from 1991 to 2011.14 The proportion of domestic activities increased among men but decreased among women. More importantly, owing to the popularity of information technology products, sedentary behaviour is becoming increasingly common, particularly in younger Chinese women.

was more obvious among women than among men from 1991 to 2011.14 The proportion of domestic activities increased among men but decreased among women. More importantly, owing to the popularity of information technology products, sedentary behaviour is becoming increasingly common, particularly in younger Chinese women. With the increase in agricultural productivity and the abolishment of food rationing in China, dietary patterns have transitioned to consumption of more meat, dairy products, eggs, and edible oils. As a result of industrialisation and marketisation, processed food and fast food have led to high consumption of sugar, fat, and salt in the population. Both men and women in China have a greater risk of having an unhealthy diet than they did in the past. Although previous studies reported a greater rate of unhealthy diets in Chinese men than in Chinese women from 2013 to 2018, Chinese women might face more complex exposure to unhealthy diets.14 For example, the main dietary risk factor in China is over-nutrition rather than malnutrition, but excessive food restrictions resulting in weight loss are becoming more common among young women.

in Chinese men than in Chinese women from 2013 to 2018, Chinese women might face more complex exposure to unhealthy diets.14 For example, the main dietary risk factor in China is over-nutrition rather than malnutrition, but excessive food restrictions resulting in weight loss are becoming more common among young women. As one of the highly prevalent risks for cardiovascular disease, smoking remains the most common unhealthy behaviour in China. Studies have found that the effects of smoking on the incidence of major coronary events and intracerebral haemorrhage and on mortality from ischaemic heart disease and ischaemic stroke are greater in women than in men.15 Although the prevalence of smoking has decreased in China,14 the prevalence among young and middle aged women has slightly increased in recent years, which might be due to mounting stress, the demand for weight loss, and misunderstandings about gender equity.2 Moreover, the rate of alcohol consumption has increased in China. Despite men having a higher prevalence of alcohol consumption, women have had a more evident increase in alcohol consumption.2 The dramatically increased proportion of alcohol consumption among women might be attributed to more frequent social activities owing to their improved social position. Therefore, future cardiovascular prevention policies need to pay more attention to unhealthy lifestyles such as smoking and alcohol consumption among young Chinese women.16

eased proportion of alcohol consumption among women might be attributed to more frequent social activities owing to their improved social position. Therefore, future cardiovascular prevention policies need to pay more attention to unhealthy lifestyles such as smoking and alcohol consumption among young Chinese women.16 The conflict between traditional culture and modern roles means that the pressure to have children has increased for Chinese women, especially since the abolishment of the family planning policy. Chinese women of childbearing age might experience greater stress regarding procreation and parenthood. The negative feedback of pressure leads to a vicious cycle of fertility reduction. Moreover, the pressure to have multiple children might also have increased. As the number of pregnancies and deliveries increases, longer and more frequent maternity leave will result in career stagnation. The psychosocial burden of severe career damage has increased among women.

a vicious cycle of fertility reduction. Moreover, the pressure to have multiple children might also have increased. As the number of pregnancies and deliveries increases, longer and more frequent maternity leave will result in career stagnation. The psychosocial burden of severe career damage has increased among women. Since the short baby boom in recent years, the burden of providing care for grandchildren has increased, especially among women. Although the Nurses’ Health Study showed no association between care giving stress and incident coronary heart disease in the American population, the cultural differences between western countries and China might lead to heterogeneous outcomes.17 Compared with that in western countries, the childcare workload might be heavier in China. Moreover, owing to the younger generation’s higher educational and economic levels, a significant gap in babysitting patterns across generations might trigger conflicts, particularly between grandmothers and mothers.

outcomes.17 Compared with that in western countries, the childcare workload might be heavier in China. Moreover, owing to the younger generation’s higher educational and economic levels, a significant gap in babysitting patterns across generations might trigger conflicts, particularly between grandmothers and mothers. The rate of participation in primary health insurance among Chinese women reached 95% in 2020, leading to 650 million female beneficiaries, 3.4 times more than in 2011.4 Although considerable advances in medical resources for Chinese women have been achieved, the attention given to cardiovascular health in Chinese women is still limited. An imbalance between the sexes remains in cardiovascular disease prevention and management. Studies have indicated a lower probability of drug use for secondary prevention of cardiovascular disease and of invasive diagnostic and therapeutic procedures for acute ischaemic heart disease among women than among men.18 19 Individual socioeconomic status accounted for only a small proportion of the sex differences in coronary angiography and coronary revascularisation. The primary reason is unconscious bias or beliefs in physicians and patients. The proportion of female participants in cardiovascular trials in China between 2010 and 2017 was approximately 40%.20 Therefore, women are under-represented in cardiovascular research.

in coronary angiography and coronary revascularisation. The primary reason is unconscious bias or beliefs in physicians and patients. The proportion of female participants in cardiovascular trials in China between 2010 and 2017 was approximately 40%.20 Therefore, women are under-represented in cardiovascular research. Compared with western countries, the concern for women’s cardiovascular health among the medical community in China is insufficient. The American Heart Association and American Stroke Association published 12 guidelines and statements specific to women, whereas the Chinese Society of Cardiology published only four guidelines.

As the basis for improving social determinants, gender equity was proposed in the constitution of China in 1954 and included as a basic state policy 40 years later. The Chinese government has proposed gender equity policies from the top level design perspective and formulated more than 20 national laws and regulations relating to women’s rights and interests. However, almost all of these female specific health related policies focused on maternal health, and none of them is related to cardiovascular disease. As part of Asian culture, the custom of “male domination and female subordination” still exists in parts of China, which means that women tend to remain in traditional roles. As “carrying on the family line” is one of the most critical responsibilities in traditional culture, more attention may be paid to “bikini boundaries” in women’s health to boost fertility.13 In addition, as a multiethnic country, the ethnic disparities in cardiovascular disease burden in China cannot be ignored. In addition to genetic differences, unique cultural backgrounds, particular behaviours, and unbalanced healthcare resources might play vital roles in the development and progression of cardiovascular disease.

In addition to the macro environment, individual behaviour is also a major determinant of cardiovascular disease risk. Economic prosperity in China has led to unhealthy lifestyles, including inadequate physical activity and unhealthy diets. For example, the increase in public transport facilities and family cars has contributed to the decline of active commuting in China. The decline in physical activity was more obvious among women than among men from 1991 to 2011.14 The proportion of domestic activities increased among men but decreased among women. More importantly, owing to the popularity of information technology products, sedentary behaviour is becoming increasingly common, particularly in younger Chinese women. With the increase in agricultural productivity and the abolishment of food rationing in China, dietary patterns have transitioned to consumption of more meat, dairy products, eggs, and edible oils. As a result of industrialisation and marketisation, processed food and fast food have led to high consumption of sugar, fat, and salt in the population. Both men and women in China have a greater risk of having an unhealthy diet than they did in the past. Although previous studies reported a greater rate of unhealthy diets in Chinese men than in Chinese women from 2013 to 2018, Chinese women might face more complex exposure to unhealthy diets.14 For example, the main dietary risk factor in China is over-nutrition rather than malnutrition, but excessive food restrictions resulting in weight loss are becoming more common among young women.

The conflict between traditional culture and modern roles means that the pressure to have children has increased for Chinese women, especially since the abolishment of the family planning policy. Chinese women of childbearing age might experience greater stress regarding procreation and parenthood. The negative feedback of pressure leads to a vicious cycle of fertility reduction. Moreover, the pressure to have multiple children might also have increased. As the number of pregnancies and deliveries increases, longer and more frequent maternity leave will result in career stagnation. The psychosocial burden of severe career damage has increased among women. Since the short baby boom in recent years, the burden of providing care for grandchildren has increased, especially among women. Although the Nurses’ Health Study showed no association between care giving stress and incident coronary heart disease in the American population, the cultural differences between western countries and China might lead to heterogeneous outcomes.17 Compared with that in western countries, the childcare workload might be heavier in China. Moreover, owing to the younger generation’s higher educational and economic levels, a significant gap in babysitting patterns across generations might trigger conflicts, particularly between grandmothers and mothers.

The rate of participation in primary health insurance among Chinese women reached 95% in 2020, leading to 650 million female beneficiaries, 3.4 times more than in 2011.4 Although considerable advances in medical resources for Chinese women have been achieved, the attention given to cardiovascular health in Chinese women is still limited. An imbalance between the sexes remains in cardiovascular disease prevention and management. Studies have indicated a lower probability of drug use for secondary prevention of cardiovascular disease and of invasive diagnostic and therapeutic procedures for acute ischaemic heart disease among women than among men.18 19 Individual socioeconomic status accounted for only a small proportion of the sex differences in coronary angiography and coronary revascularisation. The primary reason is unconscious bias or beliefs in physicians and patients. The proportion of female participants in cardiovascular trials in China between 2010 and 2017 was approximately 40%.20 Therefore, women are under-represented in cardiovascular research. Compared with western countries, the concern for women’s cardiovascular health among the medical community in China is insufficient. The American Heart Association and American Stroke Association published 12 guidelines and statements specific to women, whereas the Chinese Society of Cardiology published only four guidelines.

China’s rapid economic prosperity has greatly improved socioeconomic status and living environments, as well as dramatically changed lifestyles and reduced psychosocial stress in women. However, compared with women in developed countries, Chinese women with higher socioeconomic positions are more likely to have unhealthy behaviours. Similarly to other East Asian countries, cultural backgrounds and demographic structures might increase cardiovascular disease burden through psychological stress and lack of attention to prevention and management of cardiovascular disease in Chinese women. Furthermore, insufficient concern about cardiovascular disease in Chinese women of all ages is a common problem (box 1). Sex specific under-diagnosis and under-treatment of cardiovascular disease might lead to underestimation of the disease burden among Chinese women. Better healthcare among women due to improved structural determinants of health may reverse the disadvantages of cardiovascular disease burden in women compared with men. Maintaining these improvements in socioeconomic status and material circumstances might lead to a decline in the cardiovascular disease burden. However, unhealthy lifestyles and increased pressure might counteract the positive effects of improving social determinants. Masculism Lack of public attention Low socioeconomic status Worse material circumstances Over-conservative interventions for cardiovascular disease Unhealthy lifestyles Occupational stress Fertility pressure

China’s rapid economic prosperity has greatly improved socioeconomic status and living environments, as well as dramatically changed lifestyles and reduced psychosocial stress in women. However, compared with women in developed countries, Chinese women with higher socioeconomic positions are more likely to have unhealthy behaviours. Similarly to other East Asian countries, cultural backgrounds and demographic structures might increase cardiovascular disease burden through psychological stress and lack of attention to prevention and management of cardiovascular disease in Chinese women. Furthermore, insufficient concern about cardiovascular disease in Chinese women of all ages is a common problem (box 1). Sex specific under-diagnosis and under-treatment of cardiovascular disease might lead to underestimation of the disease burden among Chinese women. Better healthcare among women due to improved structural determinants of health may reverse the disadvantages of cardiovascular disease burden in women compared with men. Maintaining these improvements in socioeconomic status and material circumstances might lead to a decline in the cardiovascular disease burden. However, unhealthy lifestyles and increased pressure might counteract the positive effects of improving social determinants. Masculism Lack of public attention Low socioeconomic status Worse material circumstances Over-conservative interventions for cardiovascular disease Unhealthy lifestyles Occupational stress Fertility pressure Therefore, measures involving multiple levels and multiple roles are urgently needed to reduce the burden of cardiovascular diseases in Chinese women. Specific policies for women’s cardiovascular health should be developed. Strengthened clinical practices for and research on cardiovascular diseases in women are needed to eliminate the sex specific bias of cardiovascular disease related healthcare. Health education targeted at female patients is helpful for preventing overly conservative attitudes towards decision making related to control of cardiovascular disease. As young Chinese women are facing new challenges to cardiovascular disease prevention such as sedentary behaviours, over-nutrition, smoking, alcohol consumption, and bearing and raising children, diversified publicity should be reinforced and expanded. More friendly built environments with low economic and time costs for healthy behaviours should be provided to relieve pressures.

ular disease prevention such as sedentary behaviours, over-nutrition, smoking, alcohol consumption, and bearing and raising children, diversified publicity should be reinforced and expanded. More friendly built environments with low economic and time costs for healthy behaviours should be provided to relieve pressures. Countries or regions with similar cultures to China and in a similar stage of rapid economic development are facing or will face a dramatic increase in the burden of cardiovascular diseases. Implications from China suggest that improving women’s social and behavioural risk factors could offset part of the cardiovascular disease burden resulting from globalisation, urbanisation, and industrialisation. Since 1950, the burden of cardiovascular diseases has increased in China, with tremendous and varied changes in social and behavioural risk factors, especially among women Under the Asian cultural background, China’s rapid globalisation, urbanisation, and industrialisation have led to gender disparities in cardiovascular disease and its risk factors Although improving structural determinants has partially offset the burden of cardiovascular diseases in Chinese women, the younger generation is facing new challenges such as sedentary behaviours, smoking, alcohol consumption, and bearing and raising children, which increase the burden of cardiovascular diseases The implementation of comprehensive interventions involving multiple levels and roles for cardiovascular disease prevention and control targeted at women, especially those in the younger generation, is urgently needed