The study focused on disability-adjusted life years, or DALYs, a metric that combines years of life lost to premature death with years lived in disability. In 2023, metabolic risk-attributable PAD accounted for 100,298 DALYs in China and 704,214 DALYs across G20 countries. Compared with 1990, these figures represent increases of 210.9 percent and 114.6 percent, respectively. In other words, the absolute burden in China has grown nearly twice as fast as the G20 average, a disparity the researchers attribute largely to the country’s exceptionally rapid demographic transition.

Decomposition analysis, a statistical technique that separates the contributions of population growth, aging, and epidemiological change to observed disease burden shifts, showed that demographic forces were the dominant drivers. In China, population growth contributed 65.4 percent and aging 46.3 percent to the increase in DALYs, while epidemiological changes, which capture shifts in risk factor exposure, preventive measures, and medical technology, actually reduced the burden by 11.7 percent. In the G20 countries, population growth contributed 104.2 percent, aging 34.4 percent, and epidemiological changes offset the burden by 38.6 percent. The smaller offsetting effect in China suggests that advances in prevention and treatment have not yet kept pace with the country’s metabolic disease epidemic.

The specific metabolic risks driving PAD include kidney dysfunction, high fasting plasma glucose, high body-mass index, and high systolic blood pressure. Kidney dysfunction emerged as the leading contributor, accounting for 28.3 percent of the population-attributable burden in China and 31.1 percent in G20 countries, followed by high fasting plasma glucose at 27.4 percent and 27.1 percent, respectively. High body-mass index contributed 11.5 percent in China and 20.3 percent in G20 countries, while high systolic blood pressure accounted for 12.9 percent and 12.5 percent. Notably, the population-attributable fractions for high fasting plasma glucose and high body-mass index increased markedly in both settings from 1990 to 2023, with China experiencing a greater rise than the G20 average.

The biological plausibility of these associations is well established. Chronic kidney disease shares pathophysiological features with PAD, including chronic inflammation and oxidative stress, which accelerate vascular aging and atherosclerosis. The incidence of PAD in patients with end-stage kidney disease is approximately four to six times higher than in the general population, with mortality rates doubling. Diabetes, characterized by elevated fasting plasma glucose, is a recognized risk factor for PAD and is associated with major adverse limb events and cardiovascular events. Its age-standardized prevalence has increased by 71.5 percent in China over the past three decades. Overweight and obesity, which raise body-mass index, now affect 402 million adults in China, the largest number worldwide.

Sex and age disparities in the burden were striking. In China, females consistently bore higher DALYs and age-standardized DALY rates than males, a pattern that differs from the G20 distribution, where males generally had higher rates in younger age groups but were surpassed by females above age 75. In China, DALYs peaked in the 70 to 74 years age group for both sexes, while age-standardized rates continued to rise with advancing age. Females above 55 years had significantly higher DALYs and rates than males. The researchers suggest that biological differences, greater comorbidity loads, healthcare accessibility, and social behavioral factors may explain the elevated burden in Chinese females, particularly among older women in whom diminished estrogen protection, high metabolic syndrome prevalence, and delayed healthcare-seeking compound the risk.

Using an autoregressive integrated moving average model, the team projected future trends through 2035. The model, which combines autoregressive, integration, and moving average components to capture trends and cyclical patterns in time series data, was validated using the Kwiatkowski-Phillips-Schmidt-Shin test for stationarity, the Akaike and Bayesian information criteria for model selection, and the Ljung-Box test for residual randomness. Separate models were fitted for males, females, and both sexes combined. The projections indicate that metabolic risk-attributable PAD DALYs in China will reach 153,890 by 2035, a growth of 53.4 percent compared with 2023. In the G20 countries, DALYs are expected to increase by 32 percent over the same period. The age-standardized DALY rate in China is projected to rise by 1.6 percent overall, while the G20 rate is expected to decline by 8.8 percent.

The divergence between absolute and age-standardized trends is a recurring theme in the study. From 1990 to 2023, the age-standardized DALY rate of metabolic risk-attributable PAD declined by 11.4 percent in China and 23.8 percent in G20 countries, reflecting improvements in prevention and management. Yet the absolute burden continued to rise because population growth and aging outpaced these gains. China ranked eighth among G20 members in the growth magnitude of absolute DALYs and ninth in the decline magnitude of age-standardized rates. The researchers note that the relatively modest decline in China’s age-standardized rate may be linked to rapid urbanization, lifestyle changes, and the high prevalence of metabolic diseases in the last decade.

The findings carry significant implications for public health strategy in China and beyond. The researchers propose interventions at three levels: strengthening early screening and comprehensive management for older adults with multiple metabolic comorbidities, promoting healthy lifestyle interventions and controlling metabolic risk factors at the population level, and establishing a chronic disease prevention and control system adapted to the characteristics of an aging society while optimizing medical resource allocation. They emphasize the importance of age- and sex-tailored screening protocols, particularly for high-risk populations with multiple metabolic comorbidities. As China’s second baby boomers, born between 1962 and 1975, begin to retire, the combined effects of population aging and metabolic risks are expected to intensify, placing growing pressure on the country’s public health system. The study underscores that without targeted prevention and intervention strategies addressing the dual challenges of demographic change and metabolic disease, the burden of PAD in China will continue to escalate through 2035 and beyond.

Subject of Research: Burden trends and disparities of metabolic risk-attributable peripheral arterial disease in China (1990–2035): a comparative analysis with G20 countries

Article Title: Burden trends and disparities of metabolic risk-attributable peripheral arterial disease in China (1990–2035): a comparative analysis with G20 countries

Article References: Yuan, J., Guo, B., Li, F., Yi, Q., Tu, L., Tang, B., & Li, Z. (2026). Burden trends and disparities of metabolic risk-attributable peripheral arterial disease in China (1990–2035): a comparative analysis with G20 countries. International Journal of Public Health, 71, Article 1610164. https://doi.org/10.3389/ijph.2026.1610164

Image Credits: AI Generated

DOI: 10.3389/ijph.2026.1610164

Keywords: Burden, trends, disparities, metabolic, risk-attributable, peripheral, arterial, disease, China, comparative, analysis, countries