Association between insulin-induced weight change and CVD mortality: Evidence from a historic cohort study of 18,814 patients in UK primary care

Associations of obesity indices change with cardiovascular outcomes: a dose-response meta-analysis

BACKGROUND

Little is known about the degrees and shapes of associations of changes in obesity indices with cardiovascular disease (CVD) and mortality risks. We aimed to conduct a dose-response meta-analysis for the associations of changes in weight, body mass index (BMI), waist circumference (WC), waist-to-hip ratio, and waist-to-height ratio with CVD events, CVD-specific deaths, and all-cause mortality.

METHODS

We searched MEDLINE via OvidSP, Embase via OvidSP, Web of Science, CINAHL, and Scopus for articles published before January 8th, 2023. Dose-response relationships were modeled using the one-stage mixed-effects meta-analysis. Random-effects models were used to pool the relative risk (RR) and 95% confidence interval (CI).

RESULTS

We included 122 articles. Weight change was negatively associated with deaths from CVD and any cause, while WC change elevated CVD-specific mortality. Non-linear relationships also confirmed the adverse effects of increased WC on CVD-specific mortality. Additionally, gains of 5 kg in weight and 1 kg/m2 in BMI or more were associated with elevated CVD events, especially among young adults and individuals without CVD. Conversely, reductions of 5 kg in weight and 1 kg/m2 in BMI or more were associated with higher CVD-specific and all-cause deaths than increased counterparts, particularly among old adults and individuals with CVD. Similar non-linear relationships between relative changes in weight and BMI and deaths from CVD and any cause were observed.

CONCLUSIONS

The effects of changes in weight and BMI on CVD outcomes were affected by age and cardiovascular health. Tailored weight management and avoidance of increased WC should be recommended.

Association of magnitude of weight loss and weight variability with mortality and major cardiovascular events among individuals with type 2 diabetes mellitus: a systematic review and meta-analysis

Background

Weight management is strongly promoted for overweight or obese patients with type 2 diabetes (T2DM) by current guidelines. However, the prognostic impact of weight loss achieved without behavioural intervention on the mortality and cardiovascular (CV) outcomes in diabetic patients is still contested.

Methods

We searched the PubMed, Embase, and Cochrane Library databases for studies that investigated the association of weight loss or weight variability with mortality and CV outcomes. Results of studies that measured weight loss by percentage weight loss from baseline and stratified it as > 10% and 5–10% or studies that computed weight variability were pooled using random effects model. Study quality was evaluated using the Newcastle–Ottawa Scale.

Results

Thirty eligible studies were included in the systematic review and 13 of these were included in the meta-analysis. Large weight loss (> 10%) was associated with increased risk of all-cause mortality (pooled hazard ratio (HR) 2.27, 95% CI 1.51–3.42), composite of major CV events (pooled HR 1.71, 95% CI 1.38–2.12) and CV mortality (pooled HR 1.50, 95% CI 1.27–1.76) among T2DM patients. Moderate weight loss showed no significant association with all-cause mortality (pooled HR 1.17, 95% CI 0.97–1.41) or CV outcomes (pooled HR 1.12, 95% CI 0.94–1.33). Weight variability was associated with high hazard of all-cause mortality (pooled HR 1.54, 95% CI 1.52–1.56).

Conclusions

Large weight loss and large fluctuations in weight are potential markers of increased risk of mortality and CV events in T2DM patients. Maintaining a stable weight may have positive impact in these patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01503-x.

Weight change and risk of cardiovascular disease among adults with type 2 diabetes: more than 14 years of follow-up in the Tehran Lipid and Glucose Study

BACKGROUND

To examine the impact of weight change on incident cardiovascular disease and coronary heart disease (CVD/CHD) among an Iranian population with type 2 diabetes mellitus (T2DM).

METHODS

The study population included 763 participants with T2DM aged ≥ 30 years without a history of CVD and cancer at baseline. Two weight measurements done at baseline and about 3 years later. Based on their weight change, they categorized into: > 5% loss, 3-5% loss, stable (± < 3%), 3-5% gain, > 5% gain. Participants were then followed for incident CVD/CHD annually up to 20 March 2018. Multivariable Cox proportional hazard models, adjusted for age, sex, body mass index, educational level, current smoking, glucose-lowering drug use, family history of CVD, hypertension, hypercholesterolemia, chronic kidney disease, and fasting plasma glucose (FPG) were applied to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) of weight change categories for incident CVD/CHD, considering stable weight as reference.

RESULTS

After the weight change measurement, during a median follow-up of 14.4 years, 258 CVD and 214 CHD occurred. Over 5% weight gain was associated with reduced risks of CVD and CHD development by the HRs of 0.70 [95% CI 0.48-1.01; P-value: 0.058] and 0.61 [0.40-0.93], respectively, in multivariable analysis. After further adjustment for FPG change, the HRs of weight gain > 5% were attenuated to 0.75 [0.51-1.10; P-value: 0.138] and 0.66 [043-1.01; P-value: 0.053] for incident CVD and CHD, respectively. The effect of weight loss > 5% was in opposite direction among those older versus younger than 60 years; with suggestive increased risk (not statistically significant) of incident CHD/CVD for the older group. Moreover, weight gain > 5% significantly reduced the risk of CHD only among those older than 60 years (P-value for interaction < 0.2). Furthermore, weight gain > 5% had an association with lower risk of CVD and CHD among sulfonylurea users (0.56 [0.32-0.98] for CVD and 0.54 [0.29-0.99] for CHD).

CONCLUSIONS

Our results with a long-term follow-up showed that weight gain > 5% was associated with better CVD/CHD outcomes among Iranian participants with T2DM, especially older ones. Moreover, we did not find an unfavorable impact on incident CVD/CHD for sulfonylurea-induced weight gain.

Weight change and mortality and cardiovascular outcomes in patients with new-onset diabetes mellitus: a nationwide cohort study

BACKGROUND

Because weight control is a cornerstone of diabetes management, it is important to understand the relationship of weight change to risk of cardiovascular disease (CVD) among patients with type 2 diabetes mellitus (DM). We aimed to investigate whether changes in weight early after diagnosis influence the incidence of CVD and all-cause mortality in patients with type 2 DM.

METHODS

Using nationally representative data from the Korean National Health Insurance System, 173,246 subjects with new-onset DM who underwent health examinations during 2007-2012 were included. Weight was measured at the time of diabetes diagnosis and 2 years later. Weight change over 2 years was divided into five categories of 5% weight change, from weight loss ≥ - 10% to weight gain ≥ 10%.

RESULTS

There were 3113 deaths (1.8%), 2060 cases of stroke (1.2%), and 1767 myocardial infarctions (MIs) (1.0%) during a median follow-up of 5.5 years. Subjects with weight gain ≥ 10% had a significantly higher risk of stroke (hazard ratio [HR] 1.51, 95% confidence interval [CI] 1.23-1.84), compared with the group with stable weight. There was no significant association between weight change after diagnosis of DM and incident MI. All-cause mortality showed a U-shaped curve according to weight change. The group with weight loss ≥ - 10% had the highest HR for all-cause mortality (HR 1.86; 95% CI 1.61-2.14) and the HR for weight gain ≥ 10% was 1.61 (95% CI 1.37-1.89).

CONCLUSIONS

Weight changes of more than 10% after diabetes diagnosis were associated with higher mortality and over 10% weight gain was associated with increased risk of stroke.

Insulin therapy, weight gain and prognosis

Insulin therapy is mainly used by people with type 2 diabetes who have failed other therapies and have become insulin-deficient. This group represents about a quarter of all people with type 2 diabetes. Almost all those with type 2 diabetes who start insulin therapy or intensify it gain weight, which may potentially diminish the prognostic advantage of improved glycaemia. To date, all available guidelines emphasize both the attainment of glycated haemoglobin (HbA1c) goals and weight control, without directing the clinician as to which element is of a higher priority. The following review attempts to clarify the issue using the available literature. The body of evidence presented in this review indicates that glycaemic management with exogenous insulin replacement is of a much higher priority than weight gain. Lower weight or weight loss do not show prognostic benefit in advanced stages of diabetes; therefore, weight gain should not discourage providers from achieving and maintaining HbA1c goals with insulin therapy, regardless of insulin dosage or other medications.