随着人们生活水平的提高,生活方式、饮食习惯的改变,以及人口的老龄化,慢性非传染性疾病的患病率也在逐年上升,其并发症己成为我国人群最主要的死亡原因,并消耗着大量的医疗资源,在给国家和家庭带来沉重负担的同时,也产生了一系列的社会问题。通过对慢性病患者的早期发现和随访管理,使其病情稳定,延缓并发症的发生。对高危人群进行干预和筛选,对普通人群实施以促进健康为 With the improvement of people’s living standards, lifestyle changes, eating habits and the aging of population, the prevalence of chronic non-communicable diseases is also increasing year by year. The complication has become the leading cause of death in our population. Consumption of a large number of medical resources has brought a heavy burden on the country and family, but also created a series of social problems. Through the early detection of patients with chronic diseases and follow-up management, to stabilize and delay the occurrence of complications. Intervention and screening of high-risk groups, the general population to promote health