目的 厦门市湖里区是全国慢性病防治改革试点地区。本研究旨在调查厦门市湖里区常住居民中与心血管疾病相关的危险因素——高血压、糖尿病、高脂血症和肥胖慢性病的发病情况,并探讨合适的社区健康管理模式。方法 采用按比例分层随机抽样方法,调查在厦门市湖里区居住时间>6个月的≥18周岁的常住居民的高血压、糖尿病、高脂血症和肥胖患病率以及社区健康管理现状。结果 本次抽样调查的时间为2013年7月,共抽取得到3 300例研究对象,获得3 240份有效问卷,有效应答率为98.18%。其中,男性1 583例（48.86%）,女性1 657例（51.14%）。总的高血压、糖尿病、高脂血症和肥胖患病率分别为21.36%、5.31%、4.48%和10.74%。男性高血压、糖尿病、高脂血症和肥胖患病率分别为22.30%、6.51%、7.08%和8.09%,女性分别为20.46%、4.16%、1.99%和13.28%。本研究样本中,至少接受过1项健康管理干预的慢性病患者占9.26%（300/3 240）。结论厦门市湖里区常住居民的慢性病患病率高于中国的平均水平,表明心血管疾病危险因素在厦门市湖里区常住居民中呈现出一定的流行。实施社区健康管理有助于防治慢性病,改善患者康复效果,同时减轻经济和家庭负担。

Objective: Huli District in Xiamen is a national reform pilot area for chronic disease prevention and treatment. The purpose of this study is to investigate the prevalence of hypertension, diabetes, hyperlipidemia and obesity which are the risk factors related to cardiovascular diseases, and explore the appropriate corresponding modes of community health management in permanent residents living in Huli District, Xiamen.Methods: Using proportional stratified random sampling method, the prevalence of hypertension, diabetes, hyperlipidemia and obesity and the status of community health management in the residents more than 18 years of age living in Huli District, Xiamen for more than six months were investigated.Results: This survey was conducted in July 2013, and a total of 3 300 cases were included in this study, and 3 240 eligible questionnaires were obtained from 1 583 males (48.86%) and 1 657 females (51.14%); the effective response rate was 98.18%. The overall prevalence rates of hypertension, diabetes, hyperlipidemia and obesity were 21.36%, 5.31%, 4.48% and 10.74%, respectively. The prevalence rates of hypertension, diabetes, hyperlipidemia and obesity were 22.30%, 6.51%, 7.08% and 8.09%, respectively in males, and 20.46%, 4.16%, 1.99% and 13.28% in females, respectively. In this sample, the proportion of chronic disease patients received at least one intervention of health management was 9.26% (300/3 240).Conclusion: The prevalence rates of chronic diseases in residents in Huli District, Xiamen are higher than the average level in China, which indicates that the risk factors of cardiovascular diseases have a certain prevalence in the residents in Huli District. The implementation of community health management can help to prevent and treat the chronic diseases, improve the rehabilitation efficacy for patients, and reduce the economic and family burden.