The Association Between Body Mass Index and All-Cause Mortality in Patients With Type 2 Diabetes Mellitus: A 5.5-Year Prospective Analysis

Development and validation of the prediction model for mortality in patients with diabetic kidney disease in intensive care unit: a study based on medical information Mart for intensive care

We aimed to explore factors associated with mortality of diabetic kidney disease (DKD), and to establish a prediction model for predicting the mortality of DKD. This was a cohort study. In total, 1,357 DKD patients were identified from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database, with 505 DKD patients being identified from the MIMIC-III as the testing set. The outcome of the study was 1-year mortality. COX proportional hazard models were applied to screen the predictive factors. The prediction model was conducted based on the predictive factors. A receiver operating characteristic (ROC) curve with the area under the curve (AUC) was calculated to evaluate the performance of the prediction model. The median follow-up time was 365.00 (54.50,365.00) days, and 586 patients (43.18%) died within 1 year. The predictive factors for 1-year mortality in DKD included age, weight, sepsis, heart rate, temperature, Charlson Comorbidity Index (CCI), Simplified Acute Physiology Score (SAPS) II, and Sequential Organ Failure Assessment (SOFA), lymphocytes, red cell distribution width (RDW), serum albumin, and metformin. The AUC of the prediction model for predicting 1-year mortality in the training set was 0.771 [95% confidence interval (CI): 0.746-0.795] and the AUC of the prediction model in the testing set was 0.795 (95% CI: 0.756-0.834). This study establishes a prediction model for predicting mortality of DKD, providing a basis for clinical intervention and decision-making in time.

The Obesity Paradox and Mortality in Older Adults: A Systematic Review

“Obesity paradox” describes the counterintuitive finding that aged overweight and obese people with a particular disease may have better outcomes than their normal weight or underweight counterparts. This systematic review was performed to summarize the publications related to the obesity paradox in older adults, to gain an in-depth understanding of this phenomenon. PubMed©, Embase©, and Scopus© were used to perform literature search for all publications up to 20 March 2022. Studies were included if they reported data from older adults on the relation between BMI and mortality. The following article types were excluded from the study: reviews, editorials, correspondence, and case reports and case series. Publication year, study setting, medical condition, study design, sample size, age, and outcome(s) were extracted. This review has been registered with PROSPERO (no. CRD42021289015). Overall, 2226 studies were identified, of which 58 were included in this systematic review. In all, 20 of the 58 studies included in this review did not find any evidence of an obesity paradox. Of these 20 studies, 16 involved patients with no specific medical condition, 1 involved patients with chronic diseases, and 2 involved patients with type 2 diabetes mellitus. Seven out of the nine studies that looked at short-term mortality found evidence of the obesity paradox. Of the 28 studies that examined longer-term mortality, 15 found evidence of the obesity paradox. In the studies that were conducted in people with a particular medical condition (n = 24), the obesity paradox appeared in 18 cases. Our work supports the existence of an obesity paradox, especially when comorbidities or acute medical problems are present. These findings should help guide strategies for nutritional counselling in older populations.

Body mass index and all-cause mortality in patients with newly diagnosed type 2 diabetes mellitus in South Korea: a retrospective cohort study

OBJECTIVES

The lower risk of death in overweight or obese patients, compared with normal-weight individuals, has caused confusion for patients with diabetes and healthcare providers. This study investigated the relationship between body mass index (BMI) and mortality in patients with type 2 diabetes.

DESIGN

A retrospective cohort study.

SETTING

We established a national population database by merging the Korea National Health Insurance (KNHI) claims database, the National Health Check-ups Database and the KNHI Qualification Database of South Korea.

PARTICIPANTS

A total of 53 988 patients who were newly diagnosed with type 2 diabetes (E11 in International Classification of Diseases, 10th Edition) in 2007, had available BMI data, lacked a history of any serious comorbidity, received diabetes medication and did not die during the first 2 years were followed up for a median of 8.6 years.

PRIMARY OUTCOME MEASURES

All-cause mortality.

RESULTS

The mean BMI was 25.2 (SD 3.24) kg/m², and the largest proportion of patients (29.4%) had a BMI of 25-27.4 kg/m². Compared with a BMI of 27.5-29.9 kg/m² (the reference), mortality risk continuously increased as BMI decreased while the BMI score was under 25 (BMI <18.5 kg/m²: adjusted HR (aHR) 2.71, 95% CI 2.24 to 3.27; BMI 18.5-20.9 kg/m²: aHR 1.94, 95% CI 1.70 to 2.22; BMI 21-22.9 kg/m²: aHR 1.51, 95% CI 1.34 to 1.70; and BMI 23-24.9 kg/m²: aHR 1.14, 95% CI 1.01 to 1.28). For patients aged ≥65 years, the inverse association was connected up to a BMI ≥30 kg/m² group (aHR 0.76, 95% CI 0.59 to 0.98). However, the associations for men, patients aged <65 years and ever smokers resembled a reverse J curve, with a significantly greater risk of death in patients with a BMI ≥30 kg/m².

CONCLUSIONS

This study suggests that, for patients with type 2 diabetes at a normal weight, distinct approaches are needed in terms of promoting muscle mass improvement or cardiorespiratory fitness, rather than maintaining weight status. Improved early diagnosis considering the inverse association between BMI and mortality is also needed.

The obesity paradox and diabetes

BACKGROUND

Obesity has been proven to be a risk factor for type 2 diabetes mellitus (T2DM) through numerous pathogenetic mechanisms. Unexpectedly, some studies suggest that subjects with overweight/obesity and T2DM have better clinical outcome than their normal weight peers. This finding is described as "obesity paradox" and calls into question the importance of weight loss in this specific population.

OBJECTIVE

This article is a narrative overview on the obesity and type 2 diabetes mellitus, particularly regarding the obesity paradox in T2DM patients.

METHODS

We used as sources MEDLINE/PubMed, CINAHL, EMBASE, and Cochrane Library, from inception to March 2020; we chose 30 relevant papers regarding the association of obesity with clinical outcome and mortality of patients affected by T2DM.

RESULTS

Many studies report that in patients with T2DM, overweight and obesity are associated with a better prognosis than underweight or normal weight, suggesting the presence of an obesity paradox. However, these studies have numerous limitations due to their mainly retrospective nature and to numerous confounding factors, such as associated pathologies, antidiabetic treatments, smoking habit, lack of data about distribution of body fat or weight history.

CONCLUSION

Literature data regarding the phenomenon of obesity paradox in T2DM patients are controversial due to the several limitations of the studies; therefore in the management of patients with overweight/obesity and T2DM is recommended referring to the established guidelines, which indicate diet and physical activity as the cornerstone of the treatment.

LEVEL OF EVIDENCE

Level V: narrative review.

Obesity Indicators and Health-related Quality of Life - Insights from a Cohort of Morbidly Obese, Middle-aged South Indian Women

OBJECTIVE

The global prevalence of obesity is increasing and has nearly doubled in the last decade, disproportionately impacting less-developed countries. The aim of this cross-sectional study was to analyse health-related quality of life (HRQOL) in morbidly obese women attending a bariatric clinic in India, and assess potential obesity indicators that can be utilised in under-resourced settings, to better understand HRQOL of individual patients.

METHODS

Anthropometric measurements were collected, including waist circumference, hip circumference, waist-hip ratio, waist-height ratio and body mass index (BMI). HRQOL was assessed using an obesity-related quality-of-life questionnaire focused on the impact of obesity on physical distress, self-esteem, sexual life and work life.

RESULTS

The average BMI of study participants was 39.6 kg/m2, with an average HRQOL of 40.2%. The strongest correlation was noted between BMI and HRQOL (R2=0.16). Exploratory analyses demonstrated that patients with higher BMI quartiles had lower scores for physical impact and psychosocial impact, and higher scores for sexual health, comfort with food, and experience with dieting compared to patients in lower quartiles.

CONCLUSION

In South Indian, middle-aged, morbidly obese women, HRQOL is lower than average and is highly correlated with BMI, with different BMI levels having higher impacts in different subcategories, supporting the need for an individualised therapeutic focus for each patient.

A potent risk model for predicting new-onset acute coronary syndrome in patients with type 2 diabetes mellitus in Northwest China

AIMS

Type 2 diabetes mellitus (T2DM) is now very prevalent in China. Due to the lower rate of controlled diabetes in China compared to that in developed countries, there is a higher incidence of serious cardiovascular complications, especially acute coronary syndrome (ACS). The aim of this study was to establish a potent risk predictive model in the economically disadvantaged northwest region of China, which could predict the probability of new-onset ACS in patients with T2DM.

METHODS

Of 456 patients with T2DM admitted to the First Affiliated Hospital of Xi'an Jiaotong University from January 2018 to January 2019 and included in this study, 270 had no ACS, while 186 had newly diagnosed ACS. Overall, 32 demographic characteristics and serum biomarkers of the study patients were analysed. The least absolute shrinkage and selection operator regression was used to select variables, while the multivariate logistic regression was used to establish the predictive model that was presented using a nomogram. The area under the receiver operating characteristics curve (AUC) was used to evaluate the discriminatory capacity of the model. A calibration plot and Hosmer-Lemeshow test were used for the calibration of the predictive model, while the decision curve analysis (DCA) was used to evaluate its clinical validity.

RESULTS

After random sampling, 319 and 137 T2DM patients were included in the training and validation sets, respectively. The predictive model included age, body mass index, diabetes duration, systolic blood pressure (SBP), diastolic blood pressure (DBP), low-density lipoprotein cholesterol, serum uric acid, lipoprotein(a), hypertension history and alcohol drinking status as predictors. The AUC of the predictive model and that of the internal validation set was 0.830 [95% confidence interval (CI) 0.786-0.874] and 0.827 (95% CI 0.756-0.899), respectively. The predictive model showed very good fitting degree, and DCA demonstrated a clinically effective predictive model.

CONCLUSIONS

A potent risk predictive model was established, which is of great value for the secondary prevention of diabetes. Weight loss, lowering of SBP and blood uric acid levels and appropriate control for DBP may significantly reduce the risk of new-onset ACS in T2DM patients in Northwest China.

Influence of Diabetic Retinopathy on the Relationship Between Body Mass Index and Mortality in Patients with Poorly Controlled Type 2 Diabetes

PURPOSE

An "obesity paradox" has been observed in patients with type 2 diabetes. However, the optimal body mass index (BMI) for survival may be influenced by the stage of diabetes. We examined the relationship between BMI and mortality in patients with type 2 diabetes and the influence of diabetic retinopathy (DR).

PATIENTS AND METHODS

This is a retrospective cohort composing patients with type 2 diabetes who were admitted due to poor glucose control. Presence of DR was confirmed by ophthalmologists. The primary outcome was all-cause mortality. The association between BMI and mortality was assessed using a Cox proportional hazards model with adjustment for age, sex, and traditional risk factors.

RESULTS

A total of 2053 patients were enrolled. Over median follow-up of 6.7 years, there were 1060 deaths. Patients were classified into five categories based on admission BMI (kg/m²): <18.5, 18.5‒23, 23‒25, 25‒27 (reference), 25‒30 and >30. Mortality risk was significantly higher in the <18.5 kg/m², 18.5-23 kg/m², and 23-25 kg/m² categories than in the reference category (P <0.001). The similar obesity paradox was observed in the subgroup of patients without DR. However, in patients with DR, only patients with BMI <18.5 kg/m² had significantly increased mortality than those in the reference category. The presence of DR significantly modified the shape of the association between BMI and mortality (P = 0.019).

CONCLUSION

The obesity paradox exists in patients with poorly controlled type 2 diabetes. The presence of DR appears to significantly influence the shape of the association between BMI and mortality.

Survival of Chinese people with type 2 diabetes and diabetic kidney disease: a cohort of 12 -year follow-up

Background

The prevalence of type 2 diabetes has grown significantly in China. However, little is known about the survival outcome of people with type 2 diabetes and diabetic kidney disease (DKD). The purpose of this study is to examine the survival of this population and the risk factors for mortality in one suburb cohort of Beijing, China.

Methods

Four hundred and forty-five people with DKD (48.8% male, age at onset of diabetes 48.8 ± 11.0 years, age at enrollment 57.5 ± 11.6 years) were enrolled in one suburb of Beijing, China between January 1st, 2003 and December 31st, 2015. Mortality ascertainment was censored by December 31st, 2015. Survival analysis was performed by Kaplan–Meier analysis, and Cox proportional hazards regression models were served for risk factor analysis of mortality. The Chiang method was used to estimate life expectancy by age.

Results

A total of 78 deaths were identified during the 3232 person-years of follow-up. Multivariate Cox regression analysis showed significantly higher risks of mortality with respect to older age, higher systolic blood pressure (SBP), lower body mass index (BMI) and lower estimated glomerular filtration rate (eGFR). The life expectancy at age of 50 was estimated to be 12.3 (95%, CI: 9.0–16.1) years. Circulatory disease was the leading cause of death in this population (accounting for 43.6% of all deaths), followed by diabetic complications (33.3%) and respiratory disease (6.4%).

Conclusions

Data from one Chinese cohort from 2003 through 2015 showed that people with DKD faced higher risk of death and shorter life expectancy. Factors significantly increasing risk of death included older age, higher SBP, lower BMI and lower eGFR. There is an urgent need to early detection, closely monitoring and effective intervention on DKD.

A Multicenter Large-Scale Retrospective Analysis of the Correlation between Body Mass Index and All-Cause Mortality in Patients with Type 2 diabetes Mellitus: A Seven-Year Real-World Study

Aims: To investigate the association between body mass index (BMI) and all-cause mortality in patients with type 2 diabetes mellitus (T2DM) and to determine any sex-specific differences in this association. Methods: We retrospectively enrolled patients with T2DM and investigated the annual death data for seven years starting from 2010. All-cause mortality was calculated using Life Tables analysis. Multivariate Cox proportional hazards analysis was performed to identify the association between BMI and mortality. Results: During a mean survey period of 7.33 ± 1.42 years (X± SD), 996 of the 17259 patients enrolled died, resulting in an all-cause mortality rate of 5.77%, with no significant difference between women and men (6.04% vs. 5.56%; x² = 1.766, P = 0.184). The top three causes of death were ischemic heart disease, cerebrovascular disease, and chronic kidney failure. A total of 87, 266, 332, and 311 patients with a BMI of <18.5, 18.5-23.99, 24.0-27.99, and ≥28.0 kg/m², respectively, died, with the corresponding mortality rate calculated at 15.45%, 3.30%, 5.80%, and 10.70%, respectively. The BMI value associated with the highest all-cause mortality was <18.5 kg/m², but this association was only significant in women aged <50 years (HR: 3.12; 95% CI, 1.62-4.34; P < 0.001). Conclusions: In patients with T2DM, a low BMI in women aged <50 years predicted high all-cause mortality.

Association of Serum Calcium Level with Waist Circumference and Other Biochemical Health-care Predictors among Patients with Type 2 Diabetes

INTRODUCTION

This study aimed to find the association of serum calcium level with abdominal obesity according to the waist circumference (WC) and the associated factors.

MATERIALS AND METHODS

A cross-sectional study was carried out at private health-care center. A total of 291 patients, aged 18 years and above, with type 2 diabetes mellitus who attended the clinic from May 2017 through March 2018 were included. Sociodemographic, clinical, and laboratory data were obtained from the medical records of patients. Statistical analysis was carried out using the Statistical Package for the Social Sciences software (SPSS, version 23). Abdominal obesity was defined by WC ≥ 80cm in women and ≥94cm in men.

RESULTS

A total number of 291 participants participated in the study. Among these participants, 42.6% (n = 124) were male and 57.4% (n = 167) were female. The average age of respondents was 55.99 ± 9.81 years. Among the male participants, 90 (72.6%) (95% confidence interval [CI]: 64.6%-80.5%) were abdominally obese as were 154 participants (92.2%) (95% CI: 88.1%-96.3%) among females. Overall, 244 participants (83.8%) (95% CI: 79.6%-88.1%) were abdominally obese. The results of statistical modeling showed that gender, smoking status, physical activity, and serum calcium are strong determinants of abdominal obesity.

CONCLUSION

This study revealed a significant association of abdominal obesity and serum calcium level among patients with diabetes.

Healthy lifestyle and normal waist circumference are associated with a lower 5-year risk of type 2 diabetes in middle-aged and elderly individuals: Results from the healthy aging longitudinal study in Taiwan (HALST)

Type 2 diabetes mellitus (DM) is known to be closely associated with lifestyle and obesity and has a prevalence that increases with age. This study aimed to assess the short-term composite effect of diet, physical activity, psychosocial health, and waist circumference (WC) on the incidence of DM in the elderly and to provide a lifestyle-based predictive index.We used baseline measurements (2009-2013) of 5349 community-dwelling participants (aged 55 years and older, 52% female) of the Healthy Aging Longitudinal Study in Taiwan (HALST) for fasting plasma glucose, HbA1C, serum cholesterol, triglycerides, blood pressures, WC, and outcomes of home-visit questionnaire. Principal component analysis (PCA) was used to identify participants with a healthy lifestyle (HLF: higher diet, physical activity, and psychosocial scores) and a lower WC, with cutoffs determined by the receiver-operating characteristics. A Cox regression model was applied to 3424 participants without DM at baseline by linking to their National Health Insurance records (median follow-up of 3.1 years).In total, 247 new DM cases (7.2%) were identified. The HLF and lower WC group had a relative risk (RR) of DM of 0.54 (95% CI 0.35-0.82) compared to the non-HLF and higher WC group. When stratified by the presence of impaired glucose tolerance (IGT) or metabolic syndrome (MS), only participants with IGT/MS showed significant risks (RR 0.55; 95% CI 0.33-0.92). However, except for WC, the individual lifestyle factors were nonsignificant in the overall model without PCA.A composite protective effect of HLF and normal WC on DM within 5 years was observed, especially in those with IGT or MS. Psychosocial health constituted an important lifestyle factor in the elderly. The cutoffs identified could be used as a lifestyle-based risk index for DM. Maintaining an HLF to prevent DM is especially important for the elderly.

Weight change after initiation of oral hypoglycemic monotherapy for diabetes predicts 5-year mortality: An observational study

PURPOSE

To investigate whether weight change in the first year after initiating an oral hypoglycemic agent (OHA) for type 2 diabetes treatment is associated with mortality in a national cohort.

PROCEDURES

We prospectively followed Veterans Health Administration patients with type 2 diabetes initiating treatment with an OHA and not receiving any other diabetes pharmacotherapy for at least one year. Information on OHAs, weight, co-morbidities, other medications, demographics, and laboratory measurements was obtained from electronic medical records. Logistic regression was used to estimate 5-year mortality odds by weight change during the first year after OHA treatment initiation.

FINDINGS

Patients (mean age 65years, 97% male, mean BMI 32.3kg/m2) initiating OHA monotherapy between 2003 and 2008 totaled 145,198 (metformin n=89,111, glipizide n=27,100, glyburide n=25,226, rosiglitazone n=3,761). Most patients (65%) maintained a stable weight (change ⩽5% from baseline) during the first year after OHA initiation. Those losing >5% of baseline weight had a significantly higher odds of death over the subsequent 5-years ranging from 1.64 to 2.13 depending on OHA type. In the metformin group, weight gain >5% of baseline was also associated with higher odds of 5-year mortality. The same results were obtained after conducting three sensitivity analyses that excluded patients for the following reasons: weight loss in the one year prior to OHA initiation, weight change >100lbs, or weight change >50lbs.

CONCLUSIONS

Weight loss was associated with higher odds of 5-year mortality among patients initiating an OHA, as was weight gain for metformin only.

Obesity, metabolic health, and mortality in adults: a nationwide population-based study in Korea

BMI, metabolic health status, and their interactions should be considered for estimating mortality risk; however, the data are controversial and unknown in Asians. We aimed to investigate this issue in Korean population. Total 323175 adults were followed-up for 96 (60–120) (median [5–95%]) months in a nationwide population-based cohort study. Participants were classified as “obese” (O) or “non-obese” (NO) using a BMI cut-off of 25 kg/m². People who developed ≥1 metabolic disease component (hypertension, diabetes, dyslipidaemia) in the index year were considered “metabolically unhealthy” (MU), while those with none were considered “metabolically healthy” (MH). The MUNO group had a significantly higher risk of all-cause (hazard ratio, 1.28 [95% CI, 1.21–1.35]) and cardiovascular (1.88 [1.63–2.16]) mortality, whereas the MHO group had a lower mortality risk (all-cause: 0.81 [0.74–0.88]), cardiovascular: 0.73 [0.57–0.95]), compared to the MHNO group. A similar pattern was noted for cancer and other-cause mortality. Metabolically unhealthy status was associated with higher risk of all-cause and cardiovascular mortality regardless of BMI levels, and there was a dose-response relationship between the number of incident metabolic diseases and mortality risk. In conclusion, poor metabolic health status contributed more to mortality than high BMI did, in Korean adults.

The Obesity Paradox in Type 2 Diabetes and Mortality

The obesity paradox for survival among individuals with type 2 diabetes has been observed in some but not all studies. Conflicting evidence for the role of overweight and obesity in all-cause mortality may largely be a result of differences in study populations, epidemiological methods, and statistical analysis. For example, analyses among populations with long-term prevalent diabetes and the accrual of other chronic health conditions are more likely to observe that the sickest participants have lower body weights, and therefore, relative to normal weight, overweight and even obesity appear advantageous. Other mortality risk factors, such as smoking, also confound the relationship between body weight and survival, but this behavior varies widely in intensity and duration, making it difficult to assess and effectively adjust for in statistical models. Disentangling the potential sources of bias is imperative in understanding the relevance of excess body weight to mortality in diabetes. In this review, we summarize methodological considerations underlying the observed obesity paradox. Based on the available evidence, we conclude that the obesity paradox is likely an artifact of biases, and once these are accounted for, it is evident that compared with normal body weight, excess body weight is associated with a greater mortality risk.

Evaluation of serum lipid profile, body mass index, and waistline in Chinese patients with type 2 diabetes mellitus

OBJECTIVE

People with type 2 diabetes are at an increased risk of hypertension, arteriosclerosis, heart disease, and stroke. Glucose intolerance (insulin resistance) is the main feature of type 2 diabetes. Obesity leads to insulin resistance, dyslipidemia, etc. The aim of this study was to assess the biochemical parameters and measures of obesity in type 2 diabetes mellitus (T2DM).

METHODS

A total of 2,273 males and 6,547 females previously healthy volunteers (aged 41-95 years old) were recruited by open invitation. The basic information, including age, sex, height, weight, body mass index (BMI), waistline, hipline, menstrual cycle, and medical history, was collected by questionnaire survey and physical examination. Serum lipid profile, liver transaminase, blood glucose, postprandial blood glucose, and hemoglobin A1c were obtained after 12 hours of fasting.

RESULTS

According to our results, diabetic patients presented serum lipid abnormality. Elevated triglyceride (TG) levels (≥1.7 mmol/L) were noted in 19.69% of males and 20.40% of females, and reduced high-density lipoprotein cholesterol (HDL-C) levels (≤1.15 mmol/L) were noted in 21.96% of males and 15.74% of females. The combination of elevated TG and reduced HDL-C was the most prevalent of the combined lipid abnormalities. In contrast, no differences were observed in the levels of low-density lipoprotein cholesterol and total cholesterol. Moreover, there were statistically significant differences in the levels of BMI and waistline between T2DM and non-T2DM participants. After adjustment for BMI, logistic regression analysis revealed that the subjects with BMI ≤20 kg/m(2) and >30 kg/m(2) had a significantly elevated hazard ratio of T2DM compared with participants having a BMI range of 20-30 kg/m(2) in both males and females. However, there was a significant difference between T2DM patients and non-T2DM patients in waistline (χ (2)=8.57, P<0.001) than in BMI parameter (χ (2)=6.29, P<0.001).

CONCLUSION

The present study shows for the first time that low levels of HDL-C, high levels of TG, and abnormal levels in BMI and waistline increase the risk of type 2 T2DM in Chinese people.