Nutrition, Metabolism & Cardiovascular Diseases (2010) 20, 394e404

available at www.sciencedirect.com

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REVIEW

Epidemiology of cardiovascular disease in

Asian women
D. Hu a,*, D. Yu b

a
Department of Preventive Medicine, Shenzhen University School of Medicine, 3688 Nanhai Avenue, Shenzhen,
Guangdong 518060, China
b
Division of Community Health Sciences, St Georges University of London, Cranmer Terrace, London SW17 0RE, UK

Received 30 April 2009; received in revised form 5 February 2010; accepted 18 February 2010

KEYWORDS Abstract This article presents data on CVD and risk factors in Asian women. Data were ob-
CVD; tained from available cohort studies and statistics for mortality from the World Health Orga-
Asia; nization. CVD is becoming an important public health problem among Asian women. There
Women; are high rates of CHD mortality in Indian and Central Asian women; rates are low in southeast
Hypertension; and east Asia. Chinese and Indian women have very high rates and mortality from stroke;
Obesity; stroke is also high in central Asian and Japanese women. Hypertension and type 2 DM are as
Diabetes mellitus; prevalent as in western women, but rates of obesity and smoking are less common. Lifestyle
Smoking interventions aimed at prevention are needed in all areas.
2010 Elsevier B.V. All rights reserved.

Background example, it had been reported that in China, a country with

Worldwide, cardiovascular disease (CVD) is the leading
cause of death among women, accounting for one third of
all deaths [1,2]. In many countries, more women than men
die every year of CVD, a fact largely unknown by physicians
[3]. Even in developed countries such as the United States
(US) despite research based gains in the treatment of CVD,
it remains the leading killer for women [4]. CVD prevention
in Asian women is an important issue for world health,
because half of the worlds population lives in Asia. For
* Corresponding author. Tel.: 86 755 86671909; fax: 86 755
86671906.
E-mail address: hud@szu.edu.cn (D. Hu).
a population of approximately 1.3 billion, the heart disease
and stroke mortality rates (per 100,000 person) for Chinese
women are 268.5 and 242.3, respectively [5].
Moreover, the age-standardized prevalence rates of
dyslipidemia and hypertension in women aged 35e74 years
are 53% and 25%, respectively [6], however, the enormity of
CVD as an Asian health issue and the need for prevention of
risk factors in the first place was underscored in the past
[7]. As the life expectancy and Asian economy continues to
increase and the rapid urbanization and industrialization in
many Asian countries, the burden of CVD on women will
therefore also continue to increase accordingly without
effective prevention and control strategies and measures.
In this article, we discuss the mortality and incidence of
coronary heart disease (CHD) and stroke and prevalence of

0939-4753/$ - see front matter 2010 Elsevier B.V. All rights reserved.
doi:10.1016/j.numecd.2010.02.016
Epidemiology of cardiovascular disease in Asian women
several most important risk factors for CVD among Asian
women on the basis of extensive reviews of cohort studies.
We also discuss whether these risk factors differ from those
of western countries. Along with this, we discuss some
important issues for CVD prevention for Asian women. We
perform an extensive literature search for this review with
a primary focus on cohort studies by country in Asia.
Statistics for mortality data were obtained from the World
Health Organization (WHO) [8]. Diseases and risk factors
were defined as below according to The International
Statistical Classification of Diseases and Related Health
Problems 10th Revision (ICD-10) issued by WHO: stroke
(I60eI64), haemorrhagic stroke (I61eI62), ischemic stroke
(I63eI64), coronary heart disease (I20eI25), acute
myocardial infarction (I21eI22), other ischemic heart
disease (I24eI25), essential hypertension (I10), obesity
(E66), type 2 diabetes mellitus (E15eE16).
CHD
Mortality
Fig. 1 shows the available data from the WHO on age-
adjusted mortality of CHD for Asian women. Mortality
from CHD varies by regions. Generally, high CHD mortality
was more common in central Asian countries
(Turkmenistan, Uzbekistan, Kyrgyzstan, and Mongolia). The
incidence of myocardial infarction is higher in India
compared with other Asian countries.
Overall, the mortality rates of acute myocardial infarc-
tion and other ischemic heart diseases were lower in the
Figure 1 Age-standardized death rates per 100,000 of CHD for women across countries in different regions of Asia in 2002. Data
from the World Health Organization, Department of Measurement and Health Information. Coronary heart disease is classified as
acute myocardial infarction and other ischemic heart disease.
395
eastern (China Hong Kong, China Mainland, Japan, and
Republic of Korea) and south eastern (Philippines,
Singapore, and Thailand) Asian women; in that area the
Thai women had the lowest and Singaporean women the
highest mortality rates for acute myocardial infarction (4.4
and 33.1 per 100,000 person years for Thai and Singaporean
women, respectively) and other ischemic heart diseases
(7.4 and 29.9 per 100,000 person years for Thai and Singa-
porean women, respectively). India located at southern
Asia, and Uzbekistan and Kyrgyzstan located at central Asia
had apparently high rates especially for other ischemic
heart diseases; the rates were even higher than that in
some western countries like Australia, United Kingdom
(UK), and US.
Incidence of myocardial infarction
The limited data available on incidence data of myocardial
infarction for Asian women are shown in Table 1. The
incidence of myocardial infarction was 31.5, 18.0, 32.6,
and 22.0 per 100,000 person years for Chinese [9], Japanese
[10], Singapore [11], and Indian [12] women, respectively.
For western women, the incidence was 117.8 and 100.0 per
100,000 person years in US [13] and German [14],
respectively.
Stroke
Women in eastern and central Asia were more likely to have
high mortality of stroke. Higher incidence of stroke was
seen in China and India.
396 D. Hu, D. Yu

Table 1 Age-adjusted incidence of myocardial infarction for women among selected Asian and western countries.
Region Survey year Age MI incidence (per 100,000
person years)
Asian countries
China, mainland
WHO MONICA [9] 1984e1993 35e64 31.5
Japan
Takashima, Shiga [10] 1988e1998 25e74 18.0
Singapore
K.-H. Mak [11] 1999 20e64 32.6
India
S.L. Chadha [12] 1993 25e64 220
Western countries
United states
Framingham heart study [13] 1990e1999 40e89 117.8
Germany
The population-based MONICA/KORA 2000e2002 25e74 100
registry of acute myocardial infarction [14]

Mortality of stroke
The age-adjusted mortality of stroke varies greatly in Asian
women (Fig. 2). It seems that the Chinese women had the
highest rate (242.3 per 100,000 person years) worldwide,
and those who live in the central region of Asia also had
higher mortality rates of stroke (139.8 and 131.5 per
100,000 person years for Kazakhstan and Kyrgyzstan
women, respectively). Moderate levels are found in women
in Japan (103.6), India (95.0), and Republic of Korea (63.7).
The most interesting is that the rate for Chinese women in
Hong Kong (47.4) was significantly lower than that in the
mainland China, and Indian women had rates 6.5-fold
higher than Sri Lanka women (95.0 vs. 14.4 per 100,000
person years).
Incidence of stroke
Data for the incidence of stroke are very limited too, in Asian
countries, the available data show that the incidence of
ischemic and haemorrhagic stroke was 111.8 and 28.9 per
100,000 person years for Chinese women [15], 48.8 and 39.6
per 100,000 person years for women in Republic of Korea
[16], 38.0 and 31.0 per 100,000 person years for Japanese
women [17], respectively. For Indian women [18] the inci-
dence of stroke was 141.0 per 100,000 person years (Table 2).

Figure 2 Age-standardized death rates per 100,000 of stroke for women across countries in different regions of Asia in 2002. Data
from the World Health Organization, Department of Measurement and Health Information.
Epidemiology of cardiovascular disease in Asian women
Among three western countries, the incidence of ischemic
and haemorrhagic stroke was 90.0 and 10.0 per 100,000
person years for US women [19], 179.1 and 49.1 per 100,000
person years for German women [20], 147.0 and 12.0 per
100,000 person years for UK women [21], respectively.
Secular trend of CVD
The data for the secular trend on CVD in Asian women are
very limited especially the incidence data [22,23]. The
available data for the stroke incidence among Chinese
women indicate that it was relatively lower from 1984 to
1989, and then started to increase continuously since 1989.
From 1989 to 1995, the stroke incidence rates increased
from 195.2 to 294.8 per 100,000 person years and reached
at the highest level 311.1 per 100,000 person years in 1998
(Fig. 3). The incidence rates for CHD fluctuated during
1984e1997. The lowest incidence of CHD was 62 per
100,000 person years in 1984, and the highest was 136 per
100,000 person years in 1990. Even though, the general
trend was relatively stable (Fig. 3).
The mortality data of stroke and CHD for several Asian
and western countries and regions are compared in Figs. 4
and 5 [24].
During four 5-year periods (1965e1969, 1975e1979,
1985e1989, and 1995e1998) in Hong Kong, stroke mortality
decreased (from 67 to 32 per 100,000 person years), whereas
CHD mortality increased (from 16.2 to 26.6 per
100,000 person years), as well as in Singapore whose stroke
mortality decreased (from 74.1 to 48.6 per 100,000 person
years) and CHD mortality increased (from 49.5 to 72.9 per
100,000 person years). However, Japan was different from
Hong Kong and Singapore, in which stroke and CHD mortality
both decreased (from 150.2 to 38.4 per 100,000 person years
for stroke, from 27.5 to 17.5 per 100,000 person years for
CHD). In Australia and New Zealand, both stroke mortality
Table 2 Age-adjusted incidence of stroke for women among selected Asian and western countries.
Region Survey year
Asian countries
China, mainland
Sino-MONICA-Beijing project [15] 1984e2004
Republic of Korea
Korea Medical Insurance 1993e2002
Corporation study [16]
Japan
Okinawa, Japan [17] 1990
India
Mumbai, India [18] 2005e2006
Western countries
United states
The Minnesota stroke survey [19] 1990
Germany
The Erlangen Stroke 1996
Project (ESPro) [20]
United Kingdom
Oxford Vascular Study [21] 2004
#
Indicates the incidence of stroke (not classified as subtypes).
397
and CHD mortality decreased during four 5-year periods as
well as the patterns in UK and US.
In general, stroke mortality all decreased either in Asian
countries or in western countries. CHD mortality also
showed a decline trend in western countries and Asian
countries or regions except Japan.
Risk factors for CVD
Although there are many risk factors for CVD, we just
discuss the prevalence of hypertension, type 2 diabetes
mellitus, obesity, and tobacco smoking which are confirmed
to be closely related to CVD in this article.
Hypertension
In general, women in western countries had high preva-
lence of hypertension, for example, the rates were 28.0%,
32.1%, and 28.8% for German [25], UK [26], and US [27]
women, respectively. Asian women are usually with lower
prevalence of hypertension except for Indian women, in
which 38.2% of them were hypertensive [28]. In eastern
Asian countries, the prevalence of hypertension was
observed as 24.5% among women of Republic of Korea [29].
The prevalence was 18.0% and 18.6% in China [30] and
Japan [31], respectively. In central Asia, the prevalence of
hypertension among women in Uzbekistan [32] was 16.7%.
In south eastern Asia, the prevalence rates of hypertension
were 20.1%, 20.9%, and 25.0% in Singapore [33], Thailand
[34], and Malaysia [35], respectively (Fig. 6).
Although it is one of the most important modifiable risk
factors for CVD, hypertension receives less attention in Asia
than in most developed countries [36]. In south Asia, the
awareness, treatment and control were 44.3%, 35.4% and
8.9% for Indian women [37]. In eastern Asia these were
50.8%, 33.8%, and 10.5% for Chinese women [30], 46.0%,
38.0% and 13.2% for Japanese women [38], 33.5%, 27.0%,
Age Incidence (per 100,000 person years)
Ischemic stroke Haemorrhage stroke
25e74 111.8 28.9
35e59 48.8 39.6
All 38 31
25 141#
30e74 90 10
25e74 179.1 49.1
All 147 12
398 D. Hu, D. Yu

350 Stroke
CHD
3 1 1 .1

Incidence, 1/100000 person-year

300 2 9 4 .8
287 2 8 1 .6
2 7 1 .3 2 7 4 .3
2 6 7 .6
2 5 8 .4
250 2 4 6 .4 2 4 3 .6
2 3 1 .6 2 3 6 .9
2 2 0 .5
200 201 2 0 3 .3
1 9 5 .2

150
136
128
116 121
108 112
100 97 95
90
81 83 78 83
62
50

0
1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

YEAR
Figure 3 Secular trend for incidence of stroke and CHD among women in Beijing area, China, from 1984 to 1999.

and 14.0% for women of Republic of Korea [39], respec- CVD [45e48]. Effective population control of hypertension
tively. In south eastern Asia, these were 37.0%, 25.0%, and demands an improvement in awareness (among both health
6.0% for Malaysian women [40], 47.0%, 31.0%, and 13.8% for professionals and the general population) [49]. Until the
Thailand women [41], respectively. However, high aware- last decade, however, the picture regarding awareness,
ness, treatment, and control were very common in western treatment and control of hypertension was far from optimal
countries (Table 3). The awareness, treatment, and control even for western countries [50].
were 66.0%, 41.0%, and 19.3% for Australian women [42], The high incidence of stroke among Asian women may be
73.9%, 64.5%, and 34.2% for women in US [27], 63.9%, related in part to lower awareness and control for hyper-
52.4%, and 23.0% for women in UK [43], 73.6%, 51.3%, and tension in women in Asian countries. In US a High Blood
24.7% for Germany women [44], respectively. Adequate Pressure Education Program was associated with increase in
control of hypertension can effectively reduce the risks of awareness, treatment, and control for hypertension from

160
1 5 0 .2
STROKE
140
Hong Kong
Japan
Mortality, 1/100000 person-year

120 Singapore
Australia
1 0 4 .4 New Zealand
100
9 4 .9 9 5 .7 UK
8 7 .9 USA
80
7 4 .1 7 4 .3
7 1 .4
6 76 .8 6 6 .7
60 6 1 .3
55 23 ..89
4 8 .6
4 6 .2
44 34 ..56
40 3 8 .47
3 0 .9 33 21
2 7 .5
20

0
1965-69 1975-79 1985-89 1995-98
YEAR
Figure 4 Secular trend for mortality of stroke among women in Asian countries or areas, and western countries, during four
5-year periods.
Epidemiology of cardiovascular disease in Asian women 399

180
CHD
166 Hong Kong
160
Japan
1 4 9 .2
Singapore
140

Mortality, 1/100000 person-year

Australia
1 3 1 .5 New Zealand
124
120 1 1 8 .87 UK
USA

100 9 7 .8

88 647 ..492
80
7 6 .8
7 2 .9
6 8 .5 6 7 .1
6 3 .8 6 4 .6
60 5 8 .7
5 4 .4
4 9 .5
4 4 .6
40
3 2 .4 3 1 .5
2 7 .5 2 5 .3 2 6 .6
20 1 7 .8 1 7 .5
1 6 .2

0
1965-69 1975-79 1985-89 1995-98
YEAR
Figure 5 Secular trend for mortality of CHD among women in Asian countries or areas, and western countries, during four 5-year
periods.

68.5%, 5.31%, and 26.1% in 1988e1994 raised up to 71.8%,
61.4%, and 35.1% in 1999e2004, respectively [27]. There-
fore, more national education program of hypertension
should be implemented in Asian countries especially for the
developing ones and targeted at those women living in rural
and less educated [51,52].
Type 2 diabetes mellitus
It seems that type 2 diabetes is prevalent for most Asian
women, and some were even with the prevalence over the
level of US women (Fig. 6). The prevalence of type 2 dia-
betes mellitus was 4.2% among women in UK [53] as well as
it among women in Germany [54]. US women was with the
highest prevalence of 10.2% [55]. In south Asia, there were
14.0% of Indian women with type 2 diabetes mellitus [56].
In south eastern Asia, the prevalence was 7.2%, 9.9% and
12.4% for women in Singapore [33], Thailand [57], and
Malaysia [58], respectively. In central Asia, the prevalence
was 4.4% for Uzbekistan women [59]. The prevalence was
4.2%, 5.8%, and 6.3% for women in Japan [60], China [61],
and Republic of Korea [62], respectively.
Obesity
Compared with western countries, obesity was less prevalent
in most Asian women (Fig. 6). The prevalence was 21.2%,
24.0% and 34.0% for German [63], UK [53] and US [64] women,

Figure 6 Prevalence of hypertension, diabetes mellitus, overall obesity, and tobacco smoking among Asian and western coun-
tries women.
400 D. Hu, D. Yu

Table 3 Data source of awareness, treatment, and control of hypertension.

Region Survey year Age Prevalence (%)
Awareness Treatment Control
Asian countries
India
Zachariah MG [37] 2001e2002 40e60 44.3 35.4 8.9
China, mainland
China national nutrition and 2002 18 50.8 33.8 10.5
health survey 2002 [30]
Japan
Asai Y [38] 1992e1995 55 46.0 38.0 13.2
Republic of Korea
Korean national health and 2001 20e60 33.5 27.0 14.0
nutrition survey 2001 [39]
Malaysia
NHMS [40] 1996 30 37.0 25.0 6.0
Thailand
Howteerakul N [41] 2003 35e60 47.0 31.0 13.8
Western countries
Australia
The WHO MONICA project [42] 1994 35e64 66.0 41.0 19.3
United States
NHANES 1999e2004 [27] 1999e2004 18 73.9 64.5 34.2
United Kingdom
The health survey for 2003 16 63.9 52.4 23.0
England 2003 [43]
Germany
Meisinger C [44] 1997e2001 25e74 73.6 51.3 24.7

respectively. In south eastern Asia, the prevalence was 6.7%,
8.8%, and 7.6% in Singapore [65], Thailand [66], and Malaysia
[67], respectively. In southern Asia, 3.5% of Indian [68]
women were with obesity. In central Asia, the prevalence
was 7.0% among women in Uzbekistan [32]. In eastern Asia,
the prevalence was 3.3%, 3.7%, and 3.0% in Japan [69], China
[70], and Republic of Korea [71], respectively.
Although it seems that obesity was not a serious issue for
Asian women according to above data, it should be pointed
out that it might be the underestimation by using the WHO
cutoffs, because several researches had found appropriate
cutoffs would be lower than WHO cutoffs for differences in
ethnicity [52]. Moreover if using these new appropriate
cutoffs designated for Asian women, obesity would also be
an important public health problem.
Tobacco (cigarette) smoking
In general, tobacco smoking for Asian women was not common
compared with western countries [72,73] (Fig. 6). The preva-
lence was 7.2% in India [74]. Among eastern Asian countries, this
prevalence was 3.1%, 5.9%, and 6.1% for Chinese [75], Japanese
[76], and women of Republic of Korea [77], respectively.
In south eastern Asia, the prevalence was 3.2%, 2.7% and
1.6% in Singapore [78], Thailand [79], and Malaysia [79],
respectively. In central Asia, the prevalence was 1.5%
among women in Uzbekistan [80].
Although low prevalence of active cigarette smoking in
Asian women population, passive cigarette smoking is
a serious problem, because Asia is the largest region for
producing cigarette production and Asian men have higher
rates of smoking than western men [81]. Moreover, in most
Asian countries, indoor smoking is not always forbidden and
smoking at home is more common [81]. Unfortunately,
there are no data on passive smoking and its relation to CVD
in Asian women.
Lifestyle interventions and CVD
Smoking cessation
Although men were still more likely to smoke than women,
cigarette smoking appears to be more hazardous to wom-
ens cardiovascular health than men. Compared with
female nonsmokers, high premature incidence of MI is more
common among female smokers [82]. Even smoking as few
as 1e4 cigarettes per day has been associated with
a doubled risk for developing CHD. However, smoking
cessation can lead to as much as a 33% decrease in CVD risk
within 2 years [83]. In Asia, although rates of smoking are
not high in women, it has been estimated that in 2005 there
were 134.8 thousand Chinese women whose death was
attributable to tobacco smoking, and there were 9.8 and
7.3 thousand Chinese women who died of stroke and
coronary heart disease attributable to tobacco [75].
Therefore, smoking cessation counseling is urgent needed
for CVD intervention despite the far lower smoking rate for
women in all Asian countries [81,84]. In studies of smoking
cessation, women were less likely than men to maintain
long-term smoking abstinence following an unaided
Epidemiology of cardiovascular disease in Asian women
attempt to quit, and higher cessation rates were seen for
both men and women with higher levels of education and in
white-collar occupations [85]. Women were less motivated
to quit smoking and reported higher levels of job stress than
the men [85]. Women who are trying to stop smoking are
more likely to be successful if they have support. In the
Womens Initiative for Nonsmoking (WINS) trial, a high
incidence of depression was shown among individuals trying
to stop smoking, further reinforcing the recommendation of
using behavioral interventions along with therapy for
depression [86]. Furthermore, national education program
and legislations on quitting smoking should be carried out in
the whole population in all Asian countries. Especially,
indoor smoking in public places should be forbidden
because it is harmful for women and children who are the
most vulnerable to passive smoking [81].
Diet
The dietary pattern of Asian women was quite different
from women in western countries. The pattern accepted by
the former was loaded heavily on soybean products, fish,
seaweeds, vegetables, fruits and green tea, whereas die-
tary for western women was loaded heavily on animal-
derived food (beef, pork, ham, sausage, chicken, liver and
butter), coffee and alcoholic beverage [87].
The INTERMAP study compared the intake of energy,
macronutrients among China, Japan, UK and US, which
revealed that the total intake of energy for women in UK
(1827 kcl/day) and US (1876 kcl/day) was higher than their
counterpart for women in China (1733 kcl/day) and Japan
(1733 kcl/day) [88].
The amount of total protein intake in total energy
among women in four countries was 12.2%, 16.1%, 16.1%,
and 15.6% for China, Japan, UK, and US, respectively.
Western women were more likely to intake animal protein
(both 10.1% for US and UK women, whereas 2.2% and 8.8%
for Chinese and Japanese women, respectively) as well as
Asian women were more likely to intake vegetable protein
(10.1% and 7.3% for Chinese and Japanese women,
respectively, whereas 6.1% and 5.3% for UK and US women,
respectively) [88].
Moreover, high intake of total fat intake was more
common among western women compared with Asian
women (19.5%, 26.1%, 32.5% and 32.6% in total energy for
Chinese, Japanese, UK and US women, respectively) [89].
Even worse, the fat being harmful for CVD i.e. SFA (4.8%,
7.1%, 12.2%, and 10.6% for Chinese, Japanese, UK and US
women, respectively), MFA (7.8%, 9.4%, 10.8%, and 12.0%
for Chinese, Japanese, UK and US women, respectively),
and trans-FA (0.2%, 0.5%, 1.3%, and 1.9% for Chinese,
Japanese, UK and US women, respectively) were more
likely to intake by western women, but the healthy fat like
omega-3 FA (0.5%, 1.4%, 0.7%, and 0.8% for Chinese,
Japanese, UK and US women, respectively) was not signif-
icantly different among four countries [88].
The INTERMAP study also indicated that the dietary
sodium intake was higher and potassium intake conversely
was lower among Asian women than their counterparts
among western women [88].
Because the above discussed dietary factors are closely
related to the CVD risk among women, the healthy dietary
pattern is strongly recommended for Asian women. The
401
healthy dietary includes whole grains, fresh fruits and
vegetables, proteins (fish, lean meat, chicken or pork,
nuts or legumes), fat-free or low-fat dairy products, as
well as foods that are low in saturated fats and added
sugars in combination with portion control [89e91]. The
reducing sodium intake and increasing potassium supple-
ment are also important dietary intervention measures for
CVD [92].
Physical activity
Physical activities were associated low risk of CVD, for
example, Asian women who experienced 1e3 and 4
episodes physical activity per week have lower risk for CVD
(OR Z 0.89 for 1e3 episodes physical activity, OR Z 0.71
for 4 episodes physical activity per week, respectively)
compared with those experienced <1 episodes physical
activity per week [93]. Regular physical activity is also
essential for health and psychological well-being [94].
Although 63.2% Chinese women experienced daily
moderate or vigorous activities (30 or more minutes per
time) [95], and 63.5%, 16.1%, 13.2%, and 7.3% of Asian
women spent <0, 0e1.5, 1.5e5.0, >5.0 h per week on
vigorous physical activity [96], physical inactivity is more
prevalent in urban and elderly Asian women [97,98].
Frequently reported barriers to exercise include lack of
time, access, low awareness of the benefits of physical
activity, and safe environments in which to work out [99].
Because physical activity is not enough among Asian
women [99], it would be necessary to set up national
education program on physical activity for Asian women to
increase the awareness of physical activity.
Conclusion
CVD is becoming an important public health problem among
Asian women. High mortality of CHD is seen in India and
central Asian women, women in south eastern and eastern
Asia have significantly lower rates for CHD. The incidence
of CHD is very limited in this region; the available data
indicate the similar trends with mortality distributions. The
central Asian, Indian, and Japanese women have higher
mortality of stroke, Chinese women are with the highest.
High incidence of stroke was also seen among Chinese and
Indian women. Hypertension is becoming prevalent,
however, the awareness, treatment, and control rates for
hypertension are low among women in most Asian coun-
tries, suggesting that risk factor treatment in general is
low. Type 2 diabetes mellitus reaches the level of that in
western women for most Asian women, but obesity and
tobacco smoking are less common in Asian women.
Although it revealed that psychosocial factors might have
important effects on CVD along with the traditional risk
factors [100], there is no available data for Asian women.
Although this paper broadly reviewed and compared the
epidemiological data in most Asian women, the difficulty is
the comparability regarding demographic characteristics,
research period, sample representative, and other features
for the study participants and countries, therefore, the
interpretation should be cautious. In conclusion, in order to
counter and delay the upcoming epidemic situation to
reduce the burden of CVD in Asian women, more effective
402
intervention programs such as educational programs and
lifestyle modification are urgently needed.
References
[1] Lloyd-Jones DM, Larson MG, Beiser A, Levy D. Lifetime risk of
developing coronary heart disease. Lancet 1999;353(9147):
89e92.
[2] Sanderson JE, Mayosi B, Yusuf S, Reddy S, Hu S, Chen Z, et al.
Global burden of cardiovascular disease. Heart 2007;93(10):
1175.
[3] Mosca L, Linfante AH, Benjamin EJ, Berra K, Hayes SN,
Walsh BW, et al. National study of physician awareness and
adherence to cardiovascular disease prevention guidelines.
Circulation 2005;111(4):499e510.
[4] Mosca L, Grundy SM, Judelson D, King K, Limacher M,
Oparil S, et al. AHA/ACC scientific statement: consensus
panel statement. Guide to preventive cardiology for women.
American Heart Association/American College of Cardiology.
J Am Coll Cardiol 1999;33(6):1751e5.
[5] He J, Gu D, Wu X, Reynolds K, Duan X, Yao C, et al. Major
causes of death among men and women in China. N Engl J
Med 2005;353(11):1124e34.
[6] Gu D, Gupta A, Muntner P, Hu S, Duan X, Chen J, et al.
Prevalence of cardiovascular disease risk factor clustering
among the adult population of China: results from the
international collaborative study of cardiovascular disease in
Asia (InterAsia). Circulation 2005;112(5):658e65.
[7] Epping-Jordan JE, Galea G, Tukuitonga C, Beaglehole R.
Preventing chronic diseases: taking stepwise action. Lancet
2005;366(9497):1667e71.
[8] WHO Statistical Information System. Causes of death:
mortality and health status. WHO data and statistics. Avail-
able at, http://www.who.int/research/en/; 2008.
[9] Wu Z, Yao C, Zhao D, Wu G, Wang W, Liu J, et al. Cardio-
vascular disease risk factor levels and their relations to CVD
rates in China e results of Sino-MONICA project. Eur J Car-
diovasc Prev Rehabil 2004;11(4):275e83.
[10] Yoshida M, Kita Y, Nakamura Y, Nozaki A, Okayama A,
Sugihara H, et al. Incidence of acute myocardial infarction in
Takashima, Shiga, Japan. Circ J 2005;69(4):404e8.
[11] Mak KH, Chia KS, Kark JD, Chua T, Tan C, Foong BH, et al.
Ethnic differences in acute myocardial infarction in
Singapore. Eur Heart J 2003;24(2):151e60.
[12] Chadha SL, Ramachandran K, Shekhawat S, Tandon R,
Gopinath N. A 3-year follow-up study of coronary heart
disease in Delhi. Bull World Health Organ 1993;71(1):
67e72.
[13] Parikh NI, Gona P, Larson MG, Fox CS, Benjamin EJ,
Murabito JM, et al. Long-term trends in myocardial infarction
incidence and case fatality in the National Heart, Lung, and
Blood Institutes Framingham Heart study. Circulation 2009;
119(9):1203e10.
[14] Lowel H, Meisinger C, Heier M, Hormann A. The population-
based acute myocardial infarction (AMI) registry of the
MONICA/KORA study region of Augsburg. Gesundheitswesen
2005;67(Suppl. 1):S31e7.
[15] Zhao D, Liu J, Wang W, Zeng Z, Cheng J, Sun J, et al.
Epidemiological transition of stroke in China: twenty-one-
year observational study from the Sino-MONICA-Beijing
project. Stroke 2008;39(6):1668e74.
[16] Kim HC, Nam CM, Jee SH, Suh I. Comparison of blood
pressure-associated risk of intracerebral hemorrhage and
subarachnoid hemorrhage: Korea Medical Insurance Corpo-
ration study. Hypertension 2005;46(2):393e7.
[17] Kimura Y, Takishita S, Muratani H, Kinjo K, Shinzato Y,
Muratani A, et al. Demographic study of first-ever stroke and
D. Hu, D. Yu
acute myocardial infarction in Okinawa, Japan. Intern Med
1998;37(9):736e45.
[18] Dalal PM, Malik S, Bhattacharjee M, Trivedi ND, Vairale J,
Bhat P, et al. Population-based stroke survey in Mumbai,
India: incidence and 28-day case fatality. Neuroepidemiology
2008;31(4):254e61.
[19] Shahar E, Mcgovern PG, Pankow JS, Doliszny KM, Smith MA,
Blackburn H, et al. Stroke rates during the 1980s. The Min-
nesota stroke survey. Stroke 1997;28(2):275e9.
[20] Kolominsky-Rabas PL, Sarti C, Heuschmann PU, Graf C,
Siemonsen S, Neundoerfer B, et al. A prospective
community-based study of stroke in Germany e the Erlangen
Stroke Project (ESPRO): incidence and case fatality at 1, 3,
and 12 months. Stroke 1998;29(12):2501e6.
[21] Rothwell PM, Coull AJ, Giles MF, Howard SC, Silver LE,
Bull LM, et al. Change in stroke incidence, mortality, case-
fatality, severity, and risk factors in Oxfordshire, UK from
1981 to 2004 (Oxford Vascular Study). Lancet 2004;
363(9425):1925e33.
[22] Sun JY, Zhao D, Wang W, Liu J, Cheng J, Jia YN. [The
changing case-fatality of acute stroke in Beijing during 1984
to 2000]. Zhonghua Nei Ke Za Zhi 2007;46(5):362e5.
[23] Zhao DWZ, Wang W, Yao L, Zhou M. The trend of incidence
rate of acute coronary events from 1984 to 1997 in Beijing
area: Sino-MONICA project. Zhonghua Xin Xue Guan Bing Za
Zhi 2000;28(1):14e7.
[24] Levi F, Lucchini F, Negri E, La Vecchia C. Trends in mortality
from cardiovascular and cerebrovascular diseases in
Europe and other areas of the world. Heart 2002;88(2):
119e24.
[25] Prevalence of hypertension in German. Available at, http://
www.who.int/infobase/reportviewer.aspx?
rptcodeZall&uncodeZ276&dmZ18&surveycodeZ102311a1
[accessed 2008].
[26] CHD 2005: blood pressure. Chapter 9 of the BHF coronary
heart disease statistics. Published June 2005. Available at,
http://www.heartstats.org/datapage.asp?idZ5340
[accessed 2007].
[27] Cutler JA, Sorlie PD, Wolz M, Thom T, Fields LE, Roccella EJ.
Trends in hypertension prevalence, awareness, treatment,
and control rates in United States adults between 1988e1994
and 1999e2004. Hypertension 2008;52(5):818e27.
[28] Gupta R, Kaul V, Bhagat N, Agrawal M, Gupta VP, Misra A,
et al. Trends in prevalence of coronary risk factors in an
urban Indian population: Jaipur Heart Watch-4. Indian Heart
J 2007;59(4):346e53.
[29] Jo I, Ahn Y, Lee J, Shin KR, Lee HK, Shin C. Prevalence, aware-
ness, treatment, control and risk factors of hypertension in
Korea: the Ansan study. J Hypertens 2001;19(9):1523e32.
[30] Wu Y, Huxley R, Li L, Anna V, Xie G, Yao C, et al. Prevalence,
awareness, treatment, and control of hypertension in China:
data from the China national nutrition and health survey
2002. Circulation 2008;118(25):2679e86.
[31] Tsutsumi A, Kayaba K, Tsutsumi K, Igarashi M. Association
between job strain and prevalence of hypertension: a cross
sectional analysis in a Japanese working population with
a wide range of occupations: the Jichi Medical School cohort
study. Occup Environ Med 2001;58(6):367e73.
[32] Mishra V, Arnold F, Semenov G, Hong R, Mukuria A. Epide-
miology of obesity and hypertension and related risk factors
in Uzbekistan. Eur J Clin Nutr 2006;60(12):1355e66.
[33] Bhalla V, Fong CW, Chew SK, Satku K. Changes in the levels of
major cardiovascular risk factors in the multi-ethnic pop-
ulation in Singapore after 12 years of a national non-
communicable disease intervention programme. Singapore
Med J 2006;47(10):841e50.
[34] International Health Policy Program e Thailand. Innovative
financing of health promotion. Regional strategy for health
Epidemiology of cardiovascular disease in Asian women
promotion for South-East Asia. Regional consultative
meeting. Chiang Mai, Thailand, 26 June 2006.
[35] Prevalence of hypertension in Malaysia. Available at, http://
www.who.int/infobase/reportviewer.aspx?rptcodeZ
all&uncodeZ458&dmZ18&surveycodeZ102705a1
[accessed 2008].
[36] Wilson BJ, Watson MS, Prescott GJ, Sunderland S,
Campbell DM, Hannaford P, et al. Hypertensive diseases of
pregnancy and risk of hypertension and stroke in later life:
results from cohort study. BMJ 2003;326(7394):845.
[37] Zachariah MG, Thankappan KR, Alex SC, Sarma PS, Vasan RS.
Prevalence, correlates, awareness, treatment, and control
of hypertension in a middle-aged urban population in Kerala.
Indian Heart J 2003;55(3):245e51.
[38] Asai Y, Ishikawa S, Kayaba K, Goto T, Nago N, Kario K, et al.
[Prevalence, awareness, treatment, and control of hyper-
tension in Japanese rural communities]. Nippon Koshu Eisei
Zasshi 2001;48(10):827e36.
[39] Choi KM, Park HS, Han JH, Lee JS, Lee J, Ryu OH, et al.
Prevalence of prehypertension and hypertension in a Korean
population: Korean national health and nutrition survey
2001. J Hypertens 2006;24(8):1515e21.
[40] Lim TO, Morad Z. Prevalence, awareness, treatment and
control of hypertension in the Malaysian adult population:
results from the national health and morbidity survey 1996.
Singapore Med J 2004;45(1):20e7.
[41] Howteerakul N, Suwannapong N, Sittilerd R, Rawdaree P.
Health risk behaviours, awareness, treatment and control of
hypertension among rural community people in Thailand.
Asia Pac J Public Health 2006;18(1):3e9.
[42] Antikainen RL, Moltchanov VA, Chukwuma Sr C,
Kuulasmaa KA, Marques-Vidal PM, Sans S, et al. Trends in the
prevalence, awareness, treatment and control of hyperten-
sion: the WHO MONICA project. Eur J Cardiovasc Prev Rehabil
2006;13(1):13e29.
[43] Primatesta P, Poulter NR. Improvement in hypertension
management in England: results from the health survey for
England 2003. J Hypertens 2006;24(6):1187e92.
[44] Meisinger C, Heier M, Volzke H, Lowel H, Mitusch R,
Hense HW, et al. Regional disparities of hypertension prev-
alence and management within Germany. J Hypertens 2006;
24(2):293e9.
[45] Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJ.
Selected major risk factors and global and regional burden of
disease. Lancet 2002;360(9343):1347e60.
[46] Toto RD. Treatment of hypertension in chronic kidney
disease. Semin Nephrol 2005;25(6):435e9.
[47] Yusuf S, Thom T, Abbott RD. Changes in hypertension treat-
ment and in congestive heart failure mortality in the United
States. Hypertension 1989;13(5 Suppl.):I74e9.
[48] Yu D, Huang J, Hu D, Chen J, Cao J, Li J, et al. Prevalence
and risk factors of prehypertension among Chinese adults. J
Cardiovasc Pharmacol 2008;52(4):363e8.
[49] Zanchetti A. THE new WHO Expert Committee report on hyper-
tension control. Clin Exp Hypertens 1996;18(3e4):371e85.
[50] Kearney PM, Whelton M, Reynolds K, Whelton PK, He J.
Worldwide prevalence of hypertension: a systematic review.
J Hypertens 2004;22(1):11e9.
[51] Muntner P, Gu D, Wu X, Duan X, Wenqi G, Whelton PK, et al.
Factors associated with hypertension awareness, treatment,
and control in a representative sample of the Chinese pop-
ulation. Hypertension 2004;43(3):578e85.
[52] Hu D, Xie J, Fu P, Zhou J, Yu D, Whelton PK, et al. Central
rather than overall obesity is related to diabetes in the
Chinese population: the InterAsia study. Obesity (Silver
Spring) 2007;15(11):2809e16.
[53] National Statistics. Health survey for England 2006, vol. 1.
Cardiovascular disease and risk factors in adults.
403
[54] Prevalence of diabetes in Germany. Available at: http://
www.who.int/infobase/reportviewer.aspx?rptcodeZ
all&uncodeZ276&dmZ2&surveycodeZ102311d128
[accessed 2008].
[55] American Diabetes Association. Total prevalence of diabetes
& pre-diabetes. Available at, http://www.diabetes.org/
diabetes-basics/diabetes-statistics/.
[56] Gupta R, Sarna M, Thanvi J, Rastogi P, Kaul V, Gupta VP. High
prevalence of multiple coronary risk factors in Punjabi Bhatia
Community: Jaipur Heart Watch-3. Indian Heart J 2004;
56(6):646e52.
[57] Aekplakorn W, Stolk RP, Neal B, Suriyawongpaisal P,
Chongsuvivatwong V, Cheepudomwit S, et al. The prevalence
and management of diabetes in Thai adults: the interna-
tional collaborative study of cardiovascular disease in Asia.
Diabetes Care 2003;26(10):2758e63.
[58] Prevalence of diabetes in Malaysia. Available at, http://
www.who.int/infobase/reportviewer.aspx?rptcodeZ
all&uncodeZ458&dmZ2&surveycodeZ102705a1 [accessed
2008].
[59] King H, Djumaeva S, Abdullaev B, Gacic Dobo M. Epidemi-
ology of glucose intolerance and associated factors in
Uzbekistan: a survey in Sirdaria province. Diabetes Res Clin
Pract 2002;55(1):19e27.
[60] Iseki K, Oshiro S, Tozawa M, Ikemiya Y, Fukiyama K,
Takishita S. Prevalence and correlates of diabetes mellitus in
a screened cohort in Okinawa, Japan. Hypertens Res 2002;
25(2):185e90.
[61] Gu D, Reynolds K, Duan X, Xin X, Chen J, Wu X, et al. Prev-
alence of diabetes and impaired fasting glucose in the
Chinese adult population: international collaborative study
of cardiovascular disease in Asia (InterAsia). Diabetologia
2003;46(9):1190e8.
[62] Prevalence of diabetes in Republic of Korea. Available at,
http://www.who.int/infobase/reportviewer.aspx?rptcodeZ
all&uncodeZ410&dmZ2&surveycodeZ102569a1 [accessed
2008].
[63] Helmert USH. Trends in the development and prevalence of
obesity in Germany between 1985 and 2002. Gesundheits-
wesen 2004;66(7):409e15.
[64] Obesity in the US. Fast facts. Available at: http://obesity1.
tempdomainname.com/subs/fastfacts/obesity_US.shtml
[accessed 2005].
[65] Cheah JS. Obesity in Singapore. Ann Acad Med Singapore
2001;30(6):561e2.
[66] Kantachuvessiri A. Obesity in Thailand. J Med Assoc Thai
2005;88(4):554e62.
[67] Prevalence of obesity in Malaysia. Available at, http://www.
who.int/infobase/reportviewer.aspx?rptcodeZ
all&uncodeZ458&dmZ5&surveycodeZ100263a1 [accessed
2008].
[68] Prevalence of obesity in India. Available at, http://www.
who.int/infobase/reportviewer.aspx?rptcodeZ
all&uncodeZ356&dmZ5&surveycodeZ102703a1 [accessed
2008].
[69] Prevalence of obesity in Japan. Available at, http://www.
who.int/infobase/reportviewer.aspx?rptcodeZ
all&uncodeZ392&dmZ5&surveycodeZ101431a1 [accessed
2008].
[70] Reynolds K, Gu D, Whelton PK, Wu X, Duan X, Mo J, et al.
Prevalence and risk factors of overweight and obesity in
China. Obesity (Silver Spring) 2007;15(1):10e8.
[71] Prevalence of obesity in Republic of Korea. Available at,
http://www.who.int/infobase/reportviewer.aspx?rptcodeZ
all&uncodeZ410&dmZ5&surveycodeZ101921a1 [accessed
2008].
[72] Morbidity and Mortality Weekly Report. Centers for disease
control and prevention, U.S.A. cigarette smoking among
404
adults e United States, <http://www.cdc.gov/mmwr/
preview/mmwrhtml/mm5644a2.htm>; 2006. Available
at[accessed 2007].
[73] Prevalence of cigarette smoking in German. Available at,
http://www.who.int/infobase/reportviewer.aspx?rptcodeZ
all&uncodeZ276&dmZ8&surveycodeZ102640a1 [accessed
2008].
[74] Prevalence of cigarette smoking in India. Available at,
http://www.who.int/infobase/reportviewer.aspx?rptcodeZ
all&uncodeZ356&dmZ8&surveycodeZ101711a1 [accessed
2008].
[75] Gu D, Kelly TN, Wu X, Chen J, Samet JM, Huang JF, et al.
Mortality attributable to smoking in China. N Engl J Med
2009;360(2):150e9.
[76] Inoue M, Hanaoka T, Sasazuki S, Sobue T, Tsugane S. Impact
of tobacco smoking on subsequent cancer risk among middle-
aged Japanese men and women: data from a large-scale
population-based cohort study in Japan e the JPHC study.
Prev Med 2004;38(5):516e22.
[77] Jeon HJ, Hahm BJ, Lee HW, Hong JP, Bae JN, Park JI, et al.
Prevalence, correlates, and comorbidity of 12-month
tobacco dependence among ever-smokers in South Korea,
during 1984e2001. J Korean Med Sci 2008;23(2):207e12.
[78] Available at: http://www.who.int/cardiovascular_diseases/
en/cvd_atlas_29_world_data_table.pdf.
[79] Available at: <http://www.nationmaster.com/graph/hea_
smo_pre_fem_of_adu-health-smoking-prevalence-females-
adults>.
[80] WHO. Highlights on health in Uzbekistan. Available at,
http://www.euro.who.int/document/e71959.pdf; 1999.
[81] Yang GH, Zhong NS. Effect on health from smoking and use of
solid fuel in China. Lancet 2008;372(9648):1445e6.
[82] Nelson LM. Clinical practice. Primary ovarian insufficiency. N
Engl J Med 2009;360(6):606e14.
[83] Kawachi I, Colditz GA, Stampfer MJ, Willett WC, Manson JE,
Rosner B, et al. Smoking cessation and time course of
decreased risks of coronary heart disease in middle-aged
women. Arch Intern Med 1994;154(2):169e75.
[84] Yang G, Kong L, Zhao W, Wan X, Zhai Y, Chen LC, et al.
Emergence of chronic non-communicable diseases in China.
Lancet 2008;372(9650):1697e705.
[85] Gritz ER, Thompson B, Emmons K, Ockene JK, Mclerran DF,
Nielsen IR. Gender differences among smokers and quitters
in the working well trial. Prev Med 1998;27(4):553e61.
[86] Froelicher ES, Christopherson DJ, Miller NH, Martin K.
Womens initiative for nonsmoking (WINS) IV: description of
277 women smokers hospitalized with cardiovascular
disease. Heart Lung 2002;31(1):3e14.
[87] Nakamura Y, Ueshima H, Okamura T, Kadowaki T,
Hayakawa T, Kita Y, et al. A Japanese diet and 19-year
mortality: national integrated project for prospective
observation of non-communicable diseases and its trends in
the aged, 1980. Br J Nutr 2009;101(11):1696e705.
[88] Zhou BF, Stamler J, Dennis B, Moag-Stahlberg A, Okuda N,
Robertson C, et al. Nutrient intakes of middle-aged men and
women in China, Japan, United Kingdom, and United States
in the late 1990s: the INTERMAP study. J Hum Hypertens
2003;17(9):623e30.
D. Hu, D. Yu
[89] Albert CM, Oh K, Whang W, Manson JE, Chae CU,
Stampfer MJ, et al. Dietary alpha-linolenic acid intake and
risk of sudden cardiac death and coronary heart disease.
Circulation 2005;112(21):3232e8.
[90] Smith Jr SC, Jackson R, Pearson TA, Fuster V, Yusuf S,
Faergeman O, et al. Principles for national and regional
guidelines on cardiovascular disease prevention: a scientific
statement from the world heart and stroke forum. Circula-
tion 2004;109(25):3112e21.
[91] Howard BV, Van Horn L, Hsia J, Manson JE, Stefanick ML,
Wassertheil-Smoller S, et al. low-fat dietary pattern and risk
of cardiovascular disease: the womens health initiative
randomized controlled dietary modification trial. JAMA 2006;
295(6):655e66.
[92] Gu D, He J, Wu X, Duan X, Whelton PK. Effect of potassium
supplementation on blood pressure in Chinese: a random-
ized, placebo-controlled trial. J Hypertens 2001;19(7):
1325e31.
[93] Lam TH, Ho SY, Hedley AJ, Mak KH, Leung GM. Leisure time
physical activity and mortality in Hong Kong: caseecontrol
study of all adult deaths in 1998. Ann Epidemiol 2004;14(6):
391e8.
[94] Hambrecht R, Walther C, Mobius-Winkler S, Gielen S,
Linke A, Conradi K, et al. Percutaneous coronary angioplasty
compared with exercise training in patients with stable
coronary artery disease: a randomized trial. Circulation
2004;109(11):1371e8.
[95] Muntner P, Gu D, Wildman RP, Chen J, Qan W, Whelton PK,
et al. Prevalence of physical activity among Chinese adults:
results from the international collaborative study of cardio-
vascular disease in Asia. Am J Public Health 2005;95(9):
1631e6.
[96] Henderson SO, Haiman CA, Wilkens LR, Kolonel LN, Wan P,
Pike MC. Established risk factors account for most of the
racial differences in cardiovascular disease mortality. PLoS
One 2007;2(4):E377.
[97] Goldstein LB, Adams R, Alberts MJ, Appel LJ, Brass LM,
Bushnell CD, et al. Primary prevention of ischemic stroke:
a guideline from the American Heart Association/American
Stroke Association Stroke Council: cosponsored by the
Atherosclerotic Peripheral Vascular Disease Interdisciplinary
Working Group; Cardiovascular Nursing Council; Clinical
Cardiology Council; Nutrition, Physical Activity, and Metab-
olism Council; and the Quality of Care and Outcomes
Research Interdisciplinary Working Group: the American
Academy of Neurology affirms the value of this guideline.
Stroke 2006;37(6):1583e633.
[98] Li TY, Rana JS, Manson JE, Willett WC, Stampfer MJ,
Colditz GA, et al. Obesity as compared with physical activity
in predicting risk of coronary heart disease in women.
Circulation 2006;113(4):499e506.
[99] Lloyd-Jones DM, Leip EP, Larson MG, Dagostino RB, Beiser A,
Wilson PW, et al. Prediction of lifetime risk for cardiovas-
cular disease by risk factor burden at 50 years of age.
Circulation 2006;113(6):791e8.
[100] Sauer WH, Berlin JA, Kimmel SE. Effect of antidepressants and
their relative affinity for the serotonin transporter on the risk of
myocardial infarction. Circulation 2003;108(1):32e6.