Intelligent-supported Adaptive Community-based Tiered Intervention program for cardiovascularkidneymetabolic health

INTERVENTION: Intervention group I:Whole population intervention group: Whole‐population intervention for all enrolled residents in the community, including building supportive healthy environments, health management follow‐ups, and lifestyle guidance.;Control group:Usual care;Intervention group II:Precision graded intervention group: Continuous health monitoring/assessment and tiered intervention.; CONDITION: Cardiometabolic disease PRIMARY OUTCOME: Incidence of cardiovascular disease; INCLUSION CRITERIA: Community Selection Criteria: 1. No other ongoing enhanced chronic disease prevention and control projects. 2. Willing and able to organize on‐site surveys and manage interventions. 3. Moderate economic level and population size. 4. Well‐developed medical information system with access to insurance data, death records, and disease monitoring data. 5. Convenient transportation. Inclusion Criteria for Study Participants: 1. Residents aged 40‐79; 2. No previous diagnosis of atherosclerotic heart disease or heart failure by a doctor; 3. No previous diagnosis of stroke (including ischemic or hemorrhagic stroke) by a doctor; 4. Willing to sign the informed consent form.