High BMI-attributable burden of eight diseases relevant to the CKM framework in China: GBD 2023 estimates and projections to 2050

BACKGROUND: Cardiovascular-kidney-metabolic (CKM) syndrome is a recently defined clinical entity integrating metabolic risk factors, chronic kidney disease, and cardiovascular disease. Elevated body mass index (BMI) is a major modifiable risk factor for CKM syndrome, yet comprehensive long-term analyses of the high BMI-attributable burden in China remain scarce. METHODS: Using data from the Global Burden of Disease (GBD) 2023 study, we assessed the burden of eight selected CKM-related diseases attributable to high BMI (atrial fibrillation and flutter [AFF], chronic kidney disease due to hypertension [CKD-HTN] or diabetes mellitus type 2 [CKD-T2DM], diabetes mellitus type 2 [T2DM], hypertensive heart disease [HHD], ischemic heart disease [IHD], lower extremity peripheral arterial disease [LEPAD], and stroke) in China from 1990 to 2023. The primary outcomes were absolute deaths and DALYs and their age-standardized rates (ASRs) per 100,000 population. Joinpoint regression and ARIMA models were applied to analyze and project temporal trends in ASRs, age-period-cohort analysis was conducted using age-specific rates, and decomposition analysis quantified the contributions of population growth, population aging, and epidemiological change to changes in absolute deaths and DALYs. RESULTS: From 1990 to 2023, absolute deaths and DALYs for all eight selected diseases relevant to the CKM framework increased. IHD had the highest burden in 2023 (114,980 deaths; 2,923,595 DALYs), whereas AFF showed the greatest relative increase (11.4-fold). Descriptively, men generally had higher point estimates of death and DALY counts, ASMRs, and ASDRs for CKD-T2DM, CKD-HTN, IHD, and HHD, whereas women had higher corresponding estimates for AFF. Joinpoint regression identified sustained increases in AFF, IHD, T2DM, and LEPAD, with several inflection points around 2005. APC analysis showed pronounced age-related gradients and variations in period and cohort rate ratios. Decomposition analysis indicated that population aging was the predominant contributor to increasing mortality for most outcomes, while epidemiological change had heterogeneous effects and partially offset increases in CKD-T2DM and HHD. Model-based projections suggested heterogeneous future trajectories: increasing mortality and DALY rates for AFF, IHD, and LEPAD; increasing DALYs but slightly declining mortality for T2DM; broadly stable or slightly declining rates for stroke, CKD-T2DM, and CKD-HTN; and declining point estimates for HHD, although with substantial long-term uncertainty. CONCLUSION: High BMI-attributable stage 2-4 CKM burden has risen sharply in China and will continue to increase, driven mainly by worsening epidemiological risks. AFF, IHD, and LEPAD show the fastest growth. Men had higher age-standardized mortality and DALY rates for several selected diseases. Early-life obesity prevention and sex-tailored interventions are urgently needed.