Status and transition of normal-weight central obesity and the risk of cardiovascular diseases: A population-based cohort study in China

A Body Shape Index (ABSI) as a risk factor for all-cause mortality among US adults with type 2 diabetes: evidence from the NHANES 1999-2018

Background and objective

A Body Shape Index (ABSI) serves as a potential indicator of fat distribution, offering a more reliable association with all-cause mortality compared to overall adiposity. The present cohort study aims to explore the relationship between ABSI and all-cause mortality in US adults with Type 2 Diabetes (T2D).

Methods

For this cohort study, we extracted information on 5,461 US adults with T2D from the National Health and Nutrition Examination Survey (NHANES) and the NHANES Linked Mortality File. Trends in ABSI from 1999 to 2018 were calculated and analyzed using partial Mann-Kendall tests. To assess the relationship between ABSI and all-cause mortality, as well as the robustness of the association results, we employed weighted restricted cubic splines (RCS), weighted Cox proportional hazards models, sensitivity analyses, and stratified analyses. Additionally, we conducted time-dependent receiver operating characteristic (ROC) curve analysis to evaluate ABSI's predictive capability for all-cause mortality over 3, 5, and 10 years.

Results

Among US adults with Type 2 Diabetes (T2D), the mean ABSI gradually increased from 0.08333 to 0.08444 between 1999 and 2018. Following a median follow-up period of 90 months, 1,355 deaths (24.8% of the participants) occurred due to all causes. A left J-shaped association was observed between ABSI and all-cause mortality, with a 39% increased risk among US adults with T2D who had an ABSI below 0.08105 after full adjustment.

Conclusion

Our research has demonstrated a significant association between an elevated ABSI and the risk of all-cause mortality among US adults with T2D. These findings support the potential use of ABSI as a noninvasive tool to estimate mortality risk among US adults with T2D.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-025-01570-3.

Physical activity, cardiovascular disease, and mortality across obesity levels

Aims

High physical activity (PA) is associated with decreased risk of cardiovascular disease (CVD) and mortality. However, whether PA can be sufficient to reduce the risk of CVD and mortality contributing to adiposity remains unclear. From the standpoint of predictive, preventive, and personalized medicine (PPPM/3PM), joint assessment of PA and adiposity provides novel insights for individual risk assessment, targeted prevention, and personalized intervention of CVD.

Methods

This prospective cohort study included 92,931 participants in the Kailuan study in Tangshan, followed between the years 2006 and 2020. Adiposity was assessed by body mass index (BMI) and waist circumference (WC). The CVD incidence and all-cause mortality associated with 3 PA levels (low, medium, and high PA) were analyzed by applying Cox regression models to different adiposity subgroups.

Results

After a median follow-up period of 14.02 years, 9997 incident CVD cases and 12,586 deaths occurred. Surprisingly, low PA and lean body mass were at a lower risk for CVD than other phenotypes. Participants with high PA still had a 35% higher CVD risk from obesity (hazard ratio (HR) BMI: 1.35, 95% confidence interval (CI): 1.18-1.54) and a 10% higher CVD risk from central obesity (HRcentral obesity: 1.10, 95% CI: 1.00-1.21) than those with lean. However, only in obese individuals, high PA has a protective effect on CVD (HR: 0.78, 95% CI: 0.64-0.95). Overall obesity and high PA were not associated with increased risk of all-cause mortality, whereas high PA could not attenuate mortality risk associated with central obesity.

Conclusion

High PA did not attenuate the risk of CVD associated with adiposity compared with lean body mass among the Chinese population, whereas the combination of high PA and healthy WC might improve healthy aging and longevity. In addition, this study revealed the importance of maintaining muscle health in obese individuals via PA or other ways. It provides a novel strategy for mitigating the risk of CVD by exercising intervention or maintaining body mass, thereby enhancing effective prevention and targeted intervention.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13167-025-00397-5.

Normal-weight obesity subtypes and 10-year risks of major vascular diseases in 0.3 million adults

BACKGROUND & AIMS

Obesity directly contributes to the progression of cardiovascular disease, but little is known about the association and risk attribution of normal-weight obesity subtypes with the incidence of major vascular events (MVEs) and their subtypes.

METHODS

This is a prospective cohort study based on the China Kadoorie Biobank (CKB). A total of 308,071 individuals with no prior vascular diseases or cancer were included at baseline. The incidence of MVEs and their subtypes were recorded during follow-up. Adjusted hazard ratios (HRs) for each disease were yielded by Cox regression.

RESULTS

During a median follow-up of 10.3 years, 62,040 MVEs occurred, with the adjusted HRs (95 % confidence intervals) were 1.11 (1.09-1.13) for normal-weight general obesity (NWGO), 1.27 (1.23-1.31) for normal-weight central obesity (NWCO), and 1.30 (1.27-1.33) for normal-weight central and general obesity (NWCGO). For subtypes of MVEs, increased waist circumference (WC) was associated with excess risk of ischaemic heart disease (IHD) independent of body fat percent (BF%) levels (HR range: 1.30-1.69 in men; 1.36-1.55 in women), while the risk plateaued with rising BF% within each WC quartile. However, even in men with lower WC (≤78 cm [median]), the risks of cerebrovascular disease (CeVD), particularly ischaemic stroke (IS), were increased with higher BF% (all P < 0.01). Conversely, in women, independent dose-response associations were primarily observed between increasing WC and CeVD, with the highest risk observed for IS (HR 1.38, 1.31-1.47).

CONCLUSIONS

This study provided novel, sex-specific evidence that normal-weight obesity subtypes were associated with distinct risks of subtypes of MVEs, with elevated risks predominantly attributable to WC in women and both WC and BF% in men.

Association between waist circumference or weight change after smoking cessation and incidence of cardiovascular disease or all-cause death in Korean adults with type 2 diabetes

Objective

To investigate the association among smoking cessation, weight or waist circumference change post-cessation, and cardiovascular disease (CVD) or all-cause death among patients with type 2 Diabetes (T2D).

Materials and methods

This retrospective cohort study included 32,142 patients with T2D classified according to changes in smoking status, post-cessation weight, and waist circumference. Especially for recent or long-term quitters, participants who changed from current to none/former smoker or from non-smoker to former smoker were defined as recent quitters, and those who changed from former to none/former smoker were defined as long-term quitters. CVD or all-cause death risk was evaluated.

Results

A total of 5,845 participants were newly diagnosed with CVD, and 3,723 died during follow-up. After adjusting for potential confounding factors, compared with current smokers, the hazard ratios (HRs) for CVD were 0.94 (95% confidence interval [CI]: 0.85-1.03), 0.82 (95% CI: 0.74-0.90), and 0.82 (95% CI: 0.75-0.90) for recent quitters, long-term quitters, non-smokers, respectively; 0.88 (95% CI: 0.78-0.99), 0.68 (95% CI: 0.57-0.81), and 0.82 (95% CI: 0.67-1.00) for long-term quitters with no waist circumference gain, long-term quitters with waist circumference gain of 0.1-5.0 cm, and long-term quitters with waist circumference gain ≥5.0 cm, respectively; and 0.79 (95% CI: 0.71-0.89), 0.85 (95% CI: 0.74-0.98), and 0.84 (95% CI: 0.60-1.17) for long-term quitters with no weight gain, long-term quitters with weight gain of 2-5 kg, and long-term quitters with weight gain ≥5 kg, respectively. Similar associations were observed for all-cause death.

Conclusions

Patients with T2D should maintain their weight and waist circumference after long-term smoking cessation to prevent CVD. It is more important for them to maintain weight rather than waist circumference to prevent all-cause death.

Normal Weight Central Obesity and its Impact on Type 2 Diabetes Mellitus

PURPOSE OF REVIEW

The aim of this review is to provide an updated commentary on the current literature examining the impact of normal weight obesity (NWO) and normal weight central obesity (NWCO) on type 2 diabetes mellitus in adults.

RECENT FINDINGS

Total 14 studies were included, comprising 9 cross-sectional and 5 cohort studies with 334,438 subjects. The quality of evidence was mixed. The pooled prevalence of NWO was 16.1% (95% CI: 12.7-19.4) and NWCO was 21.1% (95% CI: 12.2-30.1). The prevalence of NWO and NWCO higher in females and non-Asians. This review also showed that type 2 diabetes was significantly associated with NWO and NWCO (pooled OR: 1.82 [1.62, 2.04], p < 0.01, I2 = 64%). Subgroup analyses revealed consistent relationships between type 2 diabetes and NWO/NWCO across sex, region and definition approach. There was a relative high prevalence of NWO and NWCO, particularly in females and non-Asian populations. There was a consistent association of NWO/NWCO with type 2 diabetes. Implications for future research to guide intervention optimization in clinical practice and public health promotion are provided.

Association of combined body mass index and central obesity with cardiovascular disease in middle-aged and older adults: a population-based prospective cohort study

BACKGROUND

Cardiovascular diseases (CVDs) pose a significant threat to public health. Evidence indicates that the combination of central obesity and normal body mass index (BMI) is associated with an increased risk of cardiovascular disease and mortality. However, limited evidences exists in middle aged and elderly adults in China.

METHODS

This was a prospective cohort study that utilized a nationally representative sample of 6,494 adults aged 45 years and above. These individuals participated in the China Health and Retirement Longitudinal Study spanning from 2011 to 2018. Height, weight and waist circumference (WC) were measured, and BMI was calculated by height and weight. Other variables were obtained through self-reported questionnaires. Association analysis was conducted using Cox proportional hazard regression models.

RESULTS

A total of 10,186 participants were investigated, with 57,185 person-years of follow-up. During this period, 1,571 CVDs occurred, including 1,173 heart diseases and 527 strokes. After adjusting for various factors including age, gender, education, marital status, smoking status, alcohol intake, social activity, hypertension, dyslipidemia, diabetes, cancer, chronic lung diseases, liver disease, kidney disease, digestive disease, ENP(emotional, nervous, or psychiatric problems), memory related disease, arthritis or rheumatism, asthma, self-rated health and depression, the results revealed that compared to those with normal WC normal body mass index (BMI), individuals with central obesity normal BMI had a 27.9% higher risk of CVD incidence (95% confidence interval [CI]:1.074-1.524), and a 33.4% higher risk of heart disease incidence (95% CI:1.095-1.625), while no significant association was found with stroke. Additionally, those with normal WC high BMI showed a 24.6% higher risk of CVD incidence (95% CI:1.046-1.483), and a 29.1% higher risk of heart disease incidence (95% CI:1.045-1.594), again with no significant association with stroke. Finally, individuals with central obesity high BMI exhibited a 49.3% higher risk of CVD incidence (95% CI:1.273-1.751), a 61% higher risk of heart disease incidence (95% CI:1.342-1.931), and a 34.2% higher risk of stroke incidence (95% CI:1.008-1.786). Age- and sex- specific analyses further revealed varying trends in these associations.

CONCLUSIONS

We discovered that the combined association of body mass index(BMI) and central obesity with CVD incidence exhibited a significantly enhanced predictive value. Specifically, a high BMI with central obesity was notably linked to an increased risk of CVD incidence. Additionally, central obesity with a normal BMI or a normal WC coupled with a high BMI significantly augmented the risk of heart disease incidence, but not stroke. Notably, male and middle-aged adults demonstrated a greater propensity for heart disease incidence. Our study underscores the importance of maintaining an optimal BMI and preventing abdominal obesity in promoting cardiovascular health.

Causal factors of cardiovascular disease in end-stage renal disease with maintenance hemodialysis: a longitudinal and Mendelian randomization study

Background

The risk factors of cardiovascular disease (CVD) in end-stage renal disease (ESRD) with hemodialysis remain not fully understood. In this study, we developed and validated a clinical-longitudinal model for predicting CVD in patients with hemodialysis, and employed Mendelian randomization to evaluate the causal 6study included 468 hemodialysis patients, and biochemical parameters were evaluated every three months. A generalized linear mixed (GLM) predictive model was applied to longitudinal clinical data. Calibration curves and area under the receiver operating characteristic curves (AUCs) were used to evaluate the performance of the model. Kaplan-Meier curves were applied to verify the effect of selected risk factors on the probability of CVD. Genome-wide association study (GWAS) data for CVD (n = 218,792,101,866 cases), end-stage renal disease (ESRD, n = 16,405, 326 cases), diabetes (n = 202,046, 9,889 cases), creatinine (n = 7,810), and uric acid (UA, n = 109,029) were obtained from the large-open GWAS project. The inverse-variance weighted MR was used as the main analysis to estimate the causal associations, and several sensitivity analyses were performed to assess pleiotropy and exclude variants with potential pleiotropic effects.

Results

The AUCs of the GLM model was 0.93 (with accuracy rates of 93.9% and 93.1% for the training set and validation set, sensitivity of 0.95 and 0.94, specificity of 0.87 and 0.86). The final clinical-longitudinal model consisted of 5 risk factors, including age, diabetes, ipth, creatinine, and UA. Furthermore, the predicted CVD response also allowed for significant (p < 0.05) discrimination between the Kaplan-Meier curves of each age, diabetes, ipth, and creatinine subclassification. MR analysis indicated that diabetes had a causal role in risk of CVD (β = 0.088, p < 0.0001) and ESRD (β = 0.26, p = 0.007). In turn, ESRD was found to have a causal role in risk of diabetes (β = 0.027, p = 0.013). Additionally, creatinine exhibited a causal role in the risk of ESRD (β = 4.42, p = 0.01).

Conclusions

The results showed that old age, diabetes, and low level of ipth, creatinine, and UA were important risk factors for CVD in hemodialysis patients, and diabetes played an important bridging role in the link between ESRD and CVD.

Relationship between normal weight central obesity and arterial stiffness in Chinese adults with hypertension

BACKGROUND AND AIMS

Normal weight central obesity (NWCO) is a category of obesity that is characterized by having a normal BMI and presence of abdominal obesity. Recently, studies have reported that NWCO was associated with the cardiovascular diseases. The researches exploring the relationship between NWCO and arterial stiffness are limited. So this study intended to investigate the relationship between NWCO and arterial stiffness in Chinese adults with hypertension.

METHODS AND RESULTS

This study is a sub-study of the China H-type Hypertension Registry Study. We included 8580 Chinese hypertensive patients with normal weight (18.5 kg/m2 ≤BMI <24 kg/m2). Central obesity was defined as waist-height ratio ≥0.5, and participants were categorized into two groups: NWCO and normal weight and no central obesity (NWNO). Using the brachial-ankle pulse wave conduction velocity (baPWV) assessed the arterial stiffness. Multiple linear regression analysis was used to evaluate relationship between NWCO and baPWV. Multiple logistic regression analysis was used to evaluate relationship between NWCO and arterial stiffness. Of 8580 participants, 4327 (50.4 %) were NWCO. The multiple linear regression analysis demonstrated that people with NWCO had higher baPWV value (total people: β = 38.33, 95%CI 22.82-53.84; men: β = 39.87, 95%CI 18.43-61.32; women: β = 29.65, 95%CI 7.20-52.09) compared with NWNO. The baPWV ≥1800 cm/s was defined as arterial stiffness, and the multiple logistic regression analysis showed that people with NWCO associated higher arterial stiffness risk (total people: OR = 1.25, 95%CI 1.12-1.39; men: OR = 1.29, 95%CI 1.11-1.50; women: OR = 1.18, 95%CI 1.01-1.38).

CONCLUSION

NWCO is significantly related to increased risk of arterial stiffness in Chinese adults with hypertension.