Use of the waist-to-height ratio to predict cardiovascular risk in patients with diabetes: Results from the ADVANCE-ON study

Association of lifestyle with reduced stroke risk in 41 314 individuals with diabetes: Two prospective cohort studies in China

AIM

To investigate the associations of individual and combined healthy lifestyle factors (HLS) with the risk of stroke in individuals with diabetes in China.

METHODS

This prospective analysis included 41 314 individuals with diabetes [15 191 from the Comprehensive Research on the Prevention and Control of the Diabetes (CRPCD) project and 26 123 from the China Kadoorie Biobank (CKB) study]. Associations of lifestyle factors, including cigarette smoking, alcohol consumption, physical activity, diet, body shape and sleep duration, with the risk of stroke, intracerebral haemorrhage (ICH) and ischaemic stroke (IS) were assessed using Cox proportional hazard models.

RESULTS

During median follow-up periods of 8.02 and 9.05 years, 2499 and 4578 cases of stroke, 2147 and 4024 of IS, and 160 and 728 of ICH were documented in individuals with diabetes in the CRPCD and CKB cohorts, respectively. In the CRPCD cohort, patients with ≥5 HLS had a 14% lower risk of stroke (hazard ratio (HR): 0.86, 95% confidence interval (CI): 0.75-0.98) than those with ≤2 HLS. In the CKB cohort, the adjusted HR (95% CI) for patients with ≥5 HLS were 0.74 (0.66-0.83) for stroke, 0.74 (0.66-0.83) for IS, and 0.57 (0.42-0.78) for ICH compared with those with ≤2 HLS. The pooled adjusted HR (95% CI) comparing patients with ≥5 HLS versus ≤2 HLS was 0.79 (0.69-0.92) for stroke, 0.80 (0.68-0.93) for IS, and 0.60 (0.46-0.78) for ICH.

CONCLUSIONS

Maintaining a healthy lifestyle was associated with a lower risk of stroke, IS and ICH among individuals with diabetes.

A literature review of quality assessment and applicability to HTA of risk prediction models of coronary heart disease in patients with diabetes

This literature review had two objectives: to identify models for predicting the risk of coronary heart diseases in patients with diabetes (DM); and to assess model quality in terms of risk of bias (RoB) and applicability for the purpose of health technology assessment (HTA). We undertook a targeted review of journal articles published in English, Dutch, Chinese, or Spanish in 5 databases from 1st January 2016 to 18th December 2022, and searched three systematic reviews for the models published after 2012. We used PROBAST (Prediction model Risk Of Bias Assessment Tool) to assess RoB, and used findings from Betts et al. 2019, which summarized recommendations and criticisms of HTA agencies on cardiovascular risk prediction models, to assess model applicability for the purpose of HTA. As a result, 71 % and 67 % models reporting C-index showed good discrimination abilities (C-index >= 0.7). Of the 26 model studies and 30 models identified, only one model study showed low RoB in all domains, and no model was fully applicable for HTA. Since the major cause of high RoB is inappropriate use of analysis method, we advise clinicians to carefully examine the model performance declared by model developers, and to trust a model if all PROBAST domains except analysis show low RoB and at least one validation study conducted in the same setting (e.g. country) is available. Moreover, since general model applicability is not informative for HTA, novel adapted tools may need to be developed.

Association of obesity with cardiovascular disease in the absence of traditional risk factors

BACKGROUND

The association between obesity and cardiovascular disease (CVD) in people without traditional CVD risk factors is unclear. This study aimed to investigate the association of obesity with CVD and its subtypes in people without traditional CVD risk factors.

METHODS

Based on the Kailuan cohort study, the included participants were divided into different groups according to levels of body mass index (BMI) and waist height ratio (WHtR), respectively. Multivariate Cox proportional hazard models were used to evaluate the associations.

RESULTS

This study included 31,955 participants [men 63.99%; mean age (48.14 ± 3.33) years]. During a median follow-up period of 12.97 (interquartile range: 12.68-13.17) years, 1298 cases of CVD were observed. Compared with the normal BMI group, the hazard ratios (HRs) for CVD, stroke, and myocardial infarction (MI) in the BMI obese group were 1.31 (95% confidence interval [CI] 1.11-1.55), 1.21 (95%CI 1.01-1.46), 1.62 (95%CI 1.13-2.33), respectively. Compared with the WHtR non-obese group, the HRs for CVD, stroke, and MI in the obese group were 1.25(95%CI 1.11-1.41), 1.18 (95%CI 1.03-1.34), 1.57 (95%CI 1.18-2.09), respectively. There was an interaction between age and WHtR (P for interaction was 0.043). The association between WHtR and CVD was stronger in people under 60 years old, with a HR of 1.44 (95%CI 1.24-1.67).

CONCLUSION

We found that obesity increased the risk of CVD in people without traditional CVD risk factors. The association of WHtR with CVD was stronger in people under 60 years old.

Comparative Evaluation of Waist-to-Height Ratio and BMI in Predicting Adverse Cardiovascular Outcome in People With Diabetes: A Systematic Review

Central obesity is strongly associated with cardiovascular risk in people with diabetes. BMI does not reflect a regional fat distribution. The other anthropometric indices, which are markers of central obesity, like waist circumference and waist-hip ratio, are subject to age, sex, and ethnic variations. An index like waist-to-height ratio (WHtR), which considers central obesity, outperforms BMI in predicting cardiometabolic risk. With a single cut-off of 0.5, irrespective of age, sex, and ethnic variations, WHtR has a wide application in screening obesity in population settings. Previous systematic analyses were conducted in the general population, assessing cardiometabolic risk. The current study is the first systematic analysis to compare the applicability of WHtR and BMI in predicting both cardiovascular risk and adverse cardiovascular outcomes in people with diabetes. It includes prospective cohort studies, cross-sectional studies, and randomized control trials to generate evidence. The summary scores indicate that WHtR is probably a better indicator than BMI to assess cardiovascular risk in people with diabetes. A future meta-analysis will pave the way for more robust evidence.

Is waist-to-height ratio the best predictive indicator of cardiovascular disease incidence in hypertensive adults? A cohort study

Background

Cardiovascular disease (CVD) brings high mortality and economic burden to patients, especially in rural areas. Simple, low-cost abdominal adiposity measures may help identify individuals with increased CVD risk. It is unclear that which obesity indices is the best to predict CVD in hypertensive people.

Methods

Northeast China Rural Cardiovascular Health Study (NCRCHS) is a prospective cohort study in a general population in Northeast China. The study examined the cardiovascular health from 2013 to 2015, and follow-up captured the CVD incidence in 2018. Baseline waist-to-height ratio (WHtR), waist circumference (WC), waist-to-hip (WHR)and body mass index (BMI) were calculated and analyzed in relation to the CVD incidence.

Results

A total of 4244 hypertensive adults without pre-existing CVD at baseline were included in this analysis (age 35–92 years; 2108 men). Over a median follow-up of 4.66 years, a total of 290 CVD cases (6.83%) were documented during the follow-up. Baseline WHtR showed a significant positive association with CVD incidence, even after adjusting for age, sex, diabetes, drinking, smoking, SBP, DBP, Triglyceride, HDL-C, LDL-C, and TC (Hazard Ratios per SD of WHtR ranging from 1.03 to 1.31, p = 0.017). Reclassification and discrimination analyses indicated WHtR addition could improve the conventional model for predicting adverse outcomes within 4 years. Moreover, WHtR predicted the CVD incidence better than other obesity indices (BMI, WC, WHR).

Conclusion

These findings support a positive association between WHtR and CVD incidence in CVD-free hypertensive adults. WHtR can be used to predict CVD incidence in hypertensive adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02646-1.

Obesity among type 2 diabetes mellitus at Sidama Region, Southern Ethiopia

Background

Type 2 diabetes is becoming highly prevalent worldwide and it is one of the leading causes of mortality. The cause of mortality among these patients is mostly related to the dominant presence of modifiable cardiovascular risk factors such as obesity. The aim of the current study is therefore to determine the prevalence of obesity and its associated factors among patients with type 2 diabetes mellitus at Sidama region, Ethiopia.

Method

Institution-based cross-sectional study design was implemented to determine the prevalence of obesity and its associated factor among patients with type two diabetes at Hawassa University Comprehensive Specialized Hospital and Yirgalem General Hospital from October 16 2018 to December 21, 2018. A simple random sampling technique was implemented to select 314 study participants. After obtaining consent, different patients’ related data were collected using a questionnaire. Patients’ records were also reviewed. 4ml of the blood sample was collected from each study participant and analyzed for lipid profile test. Blood glucose level was done using COBAS INTEGRA 6000. A binary logistic regression was used to assess factors that have an association with obesity. A P-value of <0.05 was considered statistically significant.

Result

The majority of the study participants (67.2%) were male and 61.8% of the study participants were aged >45years. The overall prevalence of overweight and obesity among the study participants was 36.3% and 18.8% respectively. About 41% of the study participants have a normal BMI. Females were more obese (28.2% Vs 14.2%) than males and BMI stratification by sex was statistically significant (P = 0.02). Sex (AOR = 3.0, CI = 1.6–5.7, P-Value = 0.001) and TG (AOR = 3.6, CI = 1.6–8.3, P-Value = 0.003) are factors that were independently associated with obesity among type 2 DM patients.

Conclusion

Overweight and obesity among type two diabetic patients were prevalent. In addition, obesity and overweight disorder are common among T2DM and gender and triglycerides levels were associated with obesity.

Trends of Overweight and Obesity in Male Adolescents: Prevalence, Socioeconomic Status, and Impact on Cardiovascular Risk in a Central European Country

Background

Obesity is one of the most important health-related problems of the twenty-first century. Data on its prevalence in Austria remain scarce. Aim of this study was to determine current trends of overweight and obesity, associated comorbidities and socioeconomic status in all 18-year-old male Austrian citizens, and its potential impact on the demand for bariatric surgery in the future.

Methods

Data from compulsory military conscription examinations in all 18-year-old males from 2003 to 2018 were obtained from the Federal ministry of Defense’s database. Measurements of height, weight, and subsequent body mass index (BMI) calculations in 874, 220 adolescents were subdivided into yearly cohorts. Comorbidities, educational status, and nicotine abuse were evaluated.

Results

Mean BMI increased from 22.0 ± 3.95 kg/m² in 2003 to 22.8 ± 4.69 kg/m² in 2018 (p < 0.001). Overweight and obesity °I–III increased from 15.3%, 4.2%, 1.2%, and 0.4% (2003) to 20.4%, 7.1%, 2.5%, and 0.8% (2018), respectively. Cardiovascular risk, reflected by the waist-to-height ratio, increased significantly over time (p < 0.0001). Additionally, data showed a significant association of nicotine abuse in overweight or obese adolescents (p < 0.0001). Significantly less adolescents with obesity graduated from high school (p < 0.0001). Overall, 25.7% of adolescents with obesity were considered ineligible for military service.

Conclusions

BMI and cardiovascular risk steadily increased over the last 15 years in Austrian male adolescents. A significant shift from normal weight to overweight was observed, while higher obesity classes doubled over this observational period. This study also revealed a significant association of BMI and lower educational status.

Graphical Abstract

Trends of overweight and obesity in male adolescents: prevalence, socio-economic status and impact on cardiovascular risk in a central European country

Low awareness of non-alcoholic fatty liver disease in patients with type 2 diabetes in Swedish Primary Health Care

OBJECTIVES

Non-alcoholic fatty liver disease (NAFLD) is more common in patients with type 2 diabetes mellitus (T2DM) compared to individuals without. Recent guidelines recommend screening for NAFLD in patients with T2DM. Our aim was to investigate the prevalence of NAFLD in patients with T2DM in a Swedish primary health care setting, how they are cared for and assess the risk of biochemical signs of advanced fibrosis.

MATERIAL AND METHODS

In this cohort study, patients with T2DM from five primary health care centers were included. Medical records were retrospectively reviewed and living habits, medical history, results of diagnostic imaging and anthropometric and biochemical features were noted in a standardized form. The risk of steatosis and advanced fibrosis was assessed using commonly used algorithms (FLI, HSI, NAFLD-LFS, NAFLD ridge score, FIB-4 and NFS).

RESULTS

In total 350 patients were included. Diagnostic imaging had been performed in 132 patients and of these, 34 (26%) had steatosis, which was not noted in the medical records in 16 (47%) patients. One patient with steatosis had been referred to a hepatologist. Of assessable patients, 71-97% had a high to intermediate risk of steatosis and 29-65% had an intermediate to high risk of advanced fibrosis according to the algorithms used.

CONCLUSION

This study indicates a high prevalence of NAFLD among T2DM patients in Swedish primary care. Patients with known NAFLD were followed up to a very low extent. Using fibrosis algorithms in primary health care would result in many patients needing further assessment in secondary care.

Association between dietary related factors and central obesity among married women: China Health and Nutrition Survey

Waist-to-height ratio (WHtR) with a cut-off value of 0.5 has been recognized as an anthropometric indicator of central obesity to predict the risk of the chronic disease. The aim of our study was to identify dietary related risk factors of central obesity based on WHtR. We used cross-sectional data from the China Health and Nutrition Survey (CHNS) in 2011 obtained from 2881 married women aged 19-55. The association of dietary related factors and central obesity was analyzed using binary logistic regression and back-propagation artificial neural network. Overall, central obesity prevalence was 48.4% (1394/2881). Compared to the population of women without central obesity, the population of women with central obesity had an older average age (41.84 ± 6.89 years vs 38.45 ± 7.91 years, P < 0.001), and meanwhile an average lower per capita annual income (13904 ± 15916 CNY vs 16753 ± 19163 CNY, P < 0.001). Our analysis indicated that the score of dietary knowledge (adjusted odds ratio (aOR), 0.956; 95% confidence interval (CI), 0.936-0.976) and the score of food preferences (aOR, 0.961; 95% CI, 0.926-0.997) were significantly associated with lower risk of central obesity; whereas fast food (aOR, 1.002; 95% CI, 1.000-1.003) was associated with higher risk of central obesity. The study showed the score of dietary knowledge (15.5%), fast foods (10.2%), and the score of food preferences (8.8%) were the most important modifiable factors for central obesity. In summary, aging, fast food intake, and lower per capita annual income were positively associated with higher prevalence of central obesity, while higher scores of dietary knowledge and food preferences were negatively correlated. More nutrition education programs should be implemented by the government to strengthen the pro-healthy dietary behaviors.

Waist-to-height ratio has a stronger association with cardiovascular risks than waist circumference, waist-hip ratio and body mass index in type 2 diabetes

AIMS

To compare the associations between four anthropometric indices including waist-to-height ratio (WHtR), waist circumference (WC), waist-hip-ratio (WHR) and body mass index (BMI) and cardio-cerebrovascular events (CCBVEs) in Chinese T2DM patients.

METHODS

The associations of four anthropometric measures with CCBVEs and metabolic syndrome (MetS) were compared by multiple regression model in 3108 T2DM patients. CCBVEs was defined as a history of myocardial infarction, angina, angioplasty, coronary artery bypass surgery, transient ischemic attack, ischemic or hemorrhagic stroke.

RESULTS

After controlling for age, sex and diabetes duration, the prevalence of CCBVEs and MetS significantly increased across the WHtR, WC, WHR and BMI quartiles in T2DM patients, respectively. However, when controlling for these four anthropometric measurements together, although four anthropometric measures were closely associated with MetS prevalence, only WHtR quartile was significantly associated with CCBVEs prevalence (6.5%, 13.8%, 16.9% and 21.3%, p < 0.001 for trend). After adjusting for multiple confounders including four anthropometric parameters, a regression analysis revealed that only WHtR was independently and positively associated with the presence of CCBVEs (p = 0.029).

CONCLUSIONS

Compared with WC, WHR and BMI, WHtR have a stronger association with CCBVEs in T2DM subjects. WHtR maybe a better indicator than other anthropometric measurements for evaluating cardiovascular risks in T2DM.

Waist-to-height ratio, waist circumference, body mass index, waist divided by height0.5 and the risk of cardiometabolic multimorbidity: A national longitudinal cohort study

BACKGROUND AND AIMS

Cardiometabolic multimorbidity (CM) is an increasing public health burden. This study aimed to evaluate the association of waist-to-height ratio (WHtR), waist circumference (WC), waist divided by height^0.5 (WHT.5R) and body mass index (BMI) with the risk of CM.

METHODS AND RESULTS

We used data from the China Health and Retirement Longitudinal Study (CHARLS). A total of 10,521 participants aged 45 years and over were recruited, including 8807 individuals with 0 cardiometabolic diseases at baseline (stage I) and 1714 individuals with 1 cardiometabolic disease at baseline (stage II). CM was defined as self-reporting of two or more of the following conditions: stroke, diabetes and heart disease. Logistic regression was conducted to estimate the odds ratios (ORs) and 95% confidence intervals (CIs). The net reclassification index (NRI) and integrated discrimination improvement (IDI) were used to evaluate the incremental predictive value beyond conventional factors. In stage I, an increased risk of CM was observed among participants with WHtR ≥0.5 (OR: 1.76, 95% CI: 1.05-2.97), WC ≥ 90 cm (men) + WC ≥ 80 cm (women) (OR: 2.06, 95% CI: 1.29-3.27), WHT.5R ≥ 6.54 cm^0.5 (OR: 1.81, 95% CI: 1.16-2.83) or BMI ≥24 kg/m² (OR: 1.48, 95% CI: 0.98-2.24). Furthermore, the NRI and IDI of WHtR, WC and WHT.5R were all higher than those of BMI. In stage II, the adjusted ORs (95% CIs) of WHtR, WC, WHT.5R and BMI were 2.04 (1.24-3.35), 1.89 (1.29-2.77), 1.86 (1.24-2.78) and 1.47 (1.06-2.04), respectively. In addition, WC exhibited the highest NRI and IDI.

CONCLUSION

WHtR, WC, WHT.5R and BMI are independent predictors of CM in the middle-aged and older Chinese population. WHtR, WC and WHT.5R show better abilities in predicting CM than BMI.

Body roundness index is a superior indicator to associate with the cardio-metabolic risk: evidence from a cross-sectional study with 17,000 Eastern-China adults

Background

To investigate the ability of body shape index (ABSI), body roundness index (BRI), waist circumference (WC), body mass index (BMI), waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), and body adiposity index (BAI) for predicting non-adipose cardio-metabolic risk.

Methods

A total of 17,360 Chinese subjects aged 18–95 years old who escaped cardiovascular disease (CVD) or diabetes were recruited in the cross-sectional study. Anthropometric and biochemical parameters were assessed. Receiver operating characteristic curve (ROC) and multinomial logistic regression were conducted to examine the association of anthropometric indicators with cardio-metabolic risk factors.

Results

The mean age of subjects were 53.7(13.1) years, 41.6 % were males. The areas under the curve (AUC) demonstrated that WC, BMI, WHR, WHtR and BRI were able to predict high cardio-metabolic risk (AUC > 0.70). Meanwhile, multinomial logistic regression showed BRI was significantly associated with high cardio-metabolic risk (OR 3.27, 95% CI 3.01–3.55). The optimal cut-off values of BRI for high cardio-metabolic risk were (< 60 y: 3.49 vs. ≥60 y: 3.46) in males and (< 60 y: 3.47 vs. ≥60 y: 3.60) in females.

Conclusions

WC, BMI WHR, and WHtR were potential obesity indicators in discriminating high cardio-metabolic risk, while BAI or ABSI was not. Moreover, BRI revealed superior predictive capacity and significant association with accumulated cardio-metabolic risk factors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-01905-x.

Abdominal obesity and risk of CVD: a dose-response meta-analysis of thirty-one prospective studies

This meta-analysis aimed to study the relationship between abdominal obesity and the risk of CVD by waist circumference (WC), waist:hip ratio (WHR) and waist:height ratio (WHtR). We systematically searched PubMed, Embase and Web of Science. Prospective studies that estimated cardiovascular events by WC, WHR and WHtR were included in this study. Pooled relative risks with 95 % CI were calculated using random effects models. A total of thirty-one studies were included in the meta-analysis, including 669 560 participants and 25 214 cases. Compared the highest with the lowest category of WC, WHR and WHtR, the summary risk ratios were 1·43 (95 % CI, 1·30, 1·56, P < 0·001), 1·43 (95 % CI, 1·33, 1·54, P < 0·001) and 1·57 (95 % CI, 1·37, 1·79, P < 0·001), respectively. The linear dose-response analysis revealed that the risk of CVD increased by 3·4 % for each 10 cm increase of WC, and by 3·5 and 6·0 % for each 0·1 unit increase of WHR and WHtR in women, respectively. In men, the risk of CVD increased by 4·0 % for each 10 cm increase of WC, and by 4·0 and 8·6 % for each 0·1 unit increase of WHR and WHtR, respectively. Collectively, abdominal obesity is associated with an increased risk of CVD. WC, WHR and WHtR are good indicators for the prediction of CVD.

Factors Associated with the 4-Year Estimated Incidence of Type 2 Diabetes Mellitus by Sex in Korean Adults: Secondary Data Analysis

It is important to prevent the increase in the prevalence of diabetes mellitus (DM) worldwide by efficiently managing its controllable risk factors. This study aimed to identify factors associated with the 4-year estimated incidence of type 2 DM (T2DM) by sex and provide basic data for a sex-specific strategic approach to lifestyle modification. We performed a secondary data analysis using raw data from the seventh Korea National Health and Nutrition Examination Survey (KNHANES, 2016-2018). The KNHANES is a descriptive correlational survey designed to examine sex differences in the factors associated with the 4-year estimated incidence of T2DM. This study included 9,614 Korean adults (4,134 men and 5,480 women) aged 40-69 years without a diagnosis of T2DM. For the statistical analysis, a complex sample analysis was performed for sex comparison using the χ ²-test or one-way analysis of variance; a multiple regression analysis was performed to analyze the sex-specific influencing variables of 4-year estimated T2DM incidence. The waist-to-height ratio, an indicator of central obesity in adults, showed the strongest association with the 4-year estimated incidence of T2DM in both groups (male: β = 0.33, p ≤ 0.001; female: β = 0.38, p ≤ 0.001). The influencing variables were the monthly drinking rate (β = 0.07, p ≤ 0.001) and sleep time (β = -0.03, p < 0.05) in men and the sedentary time in women (β = 0.03, p < 0.05). The overall explanatory power of these variables was 11.3% for men and 14.3% for women. Thus, significant sex differences were found in the 4-year estimated incidence of T2DM. Therefore, intervention programs need to be sex-specific to enhance the efficacy of the interventions in reducing the incidence of T2DM, and such intervention programs should be administered with a strategic approach differentiated by sex.

Estimating the effects of body mass index and central obesity on stroke in diabetics and non-diabetics using targeted maximum likelihood estimation: Atherosclerosis Risk in Communities study

OBJECTIVES

The association of body mass index (BMI) with the risk of cardiovascular disease among diabetic patients is controversial. This study compared the effects of BMI and central obesity on stroke in diabetics and non-diabetics using targeted maximum likelihood estimation.

MATERIALS AND METHODS

This analysis included 12 725 adults aged 45-75 years, after excluding prevalence cases and participants with missing data, from the Atherosclerosis Risk in Communities study. Obesity was defined with BMI, waist circumference, waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), body shape index (BSI) and body roundness index (BRI), which categorized all participants as obese and non-obese. Generalized linear models and TMLE (with the tmle package) were used to estimate risk ratio (RR).

RESULTS

During 27 years of follow-up, 1078 (8.47%) cases of stroke occurred. After adjustment for demographic, behavioural, biologic and central obesity variables, the effect of BMI decreased in both diabetics and non-diabetics. The effect of BMI in diabetics was more attenuated, in full model, (RR: 1.04 [0.90, 1.20]) rather than non-diabetics (RR: 1.11 [1.00, 1.24]). This attenuation was more related to biologic variables in non-diabetics and central obesity in diabetics. With respect to central obesity, BSI (RR [95% CI]: 1.15 [0.96, 1.38]) and WHR (RR [95% CI]: 1.15 [0.87, 1.52]) had strongest and marginally significant effects for diabetics and BSI (RR [95% CI]: 1.10 [1.02, 1.20]) for non-diabetics.

CONCLUSIONS

Among diabetics, BSI and WHR indices were associated with a higher incidence of stroke. Future studies should consider how central obesity affects higher incidence of stroke among diabetics stratified by sex and age groups.

Factors associated with improvement in waist-to-height ratio among newly diagnosed type 2 diabetes patients treated with acarbose or metformin: A randomized clinical trial study

BACKGROUND

The waist-to-height ratio (WHtR) is a promising anthropometric measure used to evaluate cardiovascular risk in diabetes and metabolic syndrome patients. The metformin and acarbose in Chinese as the initial hypoglycaemic treatment trial demonstrated that acarbose and metformin reduced the WHtR after 24 wk of treatment.

AIM

To investigate the factors associated with a decrease in the WHtR in newly diagnosed Chinese type 2 diabetes patients receiving acarbose or metformin monotherapy.

METHODS

At 24 wk, 343 patients in the acarbose treatment and 333 patients in the metformin treatment were included in this analysis. On the basis of the reduction in the WHtR, these participants were divided into the following two groups: Low ΔWHtR group and high ΔWHtR group. Metabolic and related parameters associated with a high ΔWHtR were investigated using univariate and multivariate logistic regression analyses.

RESULTS

A significant decrease in the WHtR was observed in both treatment groups (acarbose: -0.015, 95% confidence interval [CI]: -0.018 to -0.012, P < 0.001; metformin: -0.013, 95%CI: -0.016 to -0.010, P < 0.001). In both the acarbose and metformin groups, the WHtR of the women was more likely to be reduced than that of the men. In the acarbose group, a lower baseline area under the curve of glucagon-like peptide 1 (AUCGLP-1) was associated with a high ΔWHtR (odds ratio [OR] = 0.796, P < 0.001), while a higher baseline AUCGLP-1 was associated with a high ΔWHtR in the patients treated with metformin (OR = 1.133, P = 0.025). Regarding the changes from baseline, an increase in AUCGLP-1 was associated with a high ΔWHtR in the acarbose (OR = 1.121, P = 0.016) but not metformin group. A higher reduction in high-density lipoprotein cholesterol/non-high-density lipoprotein cholesterol was also associated with a high ΔWHtR in the acarbose arm (OR = 20.735, P = 0.001). In the metformin arm, a higher reduction in fasting plasma glucose (OR = 0.843, P = 0.039) and total cholesterol was associated with a high ΔWHtR (OR = 0.743, P = 0.013).

CONCLUSION

A lower glucagon-like peptide 1 level and higher increase in glucagon-like peptide 1 are associated with a high reduction in the WHtR in newly diagnosed Chinese diabetes patients receiving treatment with acarbose.

Sex-specific associations between cardiovascular risk factors and myocardial infarction in patients with type 2 diabetes: The ADVANCE-ON study

AIM

To examine possible sex differences in the excess risk of myocardial infarction (MI) consequent to a range of conventional risk factors in a large-scale international cohort of patients with diabetes, and to quantify these potential differences both on the relative and absolute scales.

MATERIALS AND METHODS

Eleven thousand and sixty-five participants (42% women) with type 2 diabetes in the ADVANCE trial and its post-trial follow-up study, ADVANCE-ON, were included. Cox regression models were used to estimate hazard ratios (HRs) for associations between risk factors and MI (fatal and non-fatal) by sex, and the women-to-men ratio of HRs (RHR).

RESULTS

Over a median of 9.6 years of follow-up, 719 patients experienced MI. Smoking status, smoking intensity, higher systolic blood pressure (SBP), HbA1c, total and LDL cholesterol, duration of diabetes, triglycerides, body mass index (BMI) and lower HDL cholesterol were associated with an increased risk of MI in both sexes. Furthermore, some variables were associated with a greater relative risk of MI in women than men: RHRs were 1.75 (95% CI: 1.05-2.91) for current smoking, 1.53 (1.00-2.32) for former smoking, 1.18 (1.02-1.37) for SBP, and 1.13 (95% CI, 1.003-1.26) for duration of diabetes. Although incidence rates of MI were higher in men (9.3 per 1000 person-years) compared with women (5.8 per 1000 person-years), rate differences associated with risk factors were greater in women than men, except for HDL cholesterol and BMI.

CONCLUSIONS

In patients with type 2 diabetes, smoking, higher SBP and longer duration of diabetes had a greater relative and absolute effect in women than men, highlighting the importance of routine sex-specific approaches and early interventions in women with diabetes.

Observational analyses from ADVANCE and ADVANCE-ON

AIMS

To explain, and document, the epidemiological work associated with the action in diabetes and vascular disease: preterax and diamicron-modified release controlled evaluation (ADVANCE) clinical trial.

MATERIALS AND METHODS

ADVANCE was designed as a randomized controlled multicentre factorial trial in high-risk patients with diabetes. The two interventions were blood pressure lowering medications versus placebo, and intensive glucose control versus standard glucose control. Following termination of the trial, an observational study of surviving participants, able to join, was mounted: the ADVANCE - observational study (ADVANCE-ON). Other epidemiological analyses that were undertaken treated the trial as a cohort study, including using biomarkers from the blood samples taken from ADVANCE subjects as risk exposures.

RESULTS

More than 50 publications have reported epidemiological results from ADVANCE. The main results from ADVANCE-ON suggested attenuated benefits of ADVANCE's blood pressure lowering treatment on all-cause and cardiovascular death, but no such long-term benefits for intensive glucose control, although this did give persistent benefit for end-stage renal disease. The other epidemiological studies found, amongst other things, strong effects of NT-terminal pro-B-type natriuretic peptide and high-sensitivity cardiac troponin T on macrovascular events, microvascular events and all-cause death.

CONCLUSIONS

Embedding post-randomization and epidemiological analyses into clinical trials is worthwhile and can be highly productive in advancing scientific knowledge.

The Risks of Cardiovascular Disease and Mortality Following Weight Change in Adults with Diabetes: Results from ADVANCE

CONTEXT

Weight loss is strongly recommended for overweight and obese adults with type 2 diabetes. Unintentional weight loss is associated with increased risk of all-cause mortality, but few studies have examined its association with cardiovascular outcomes in patients with diabetes.

OBJECTIVE

To evaluate 2-year weight change and subsequent risk of cardiovascular events and mortality in established type 2 diabetes.

DESIGN AND SETTING

The Action in Diabetes and Vascular Disease: Preterax and Diamicron-MR Controlled Evaluation was an international, multisite 2×2 factorial trial of intensive glucose control and blood pressure control. We examined 5 categories of 2-year weight change: >10% loss, 4% to 10% loss, stable (±<4%), 4% to 10% gain, and >10% gain. We used Cox regression with follow-up time starting at 2 years, adjusting for intervention arm, demographics, cardiovascular risk factors, and diabetes medication use from the 2-year visit.

RESULTS

Among 10 081 participants with valid weight measurements, average age was 66 years. By the 2-year examination, 4.3% had >10% weight loss, 18.4% had 4% to 10% weight loss, and 5.3% had >10% weight gain. Over the following 3 years of the trial, >10% weight loss was strongly associated with major macrovascular events (hazard ratio [HR], 1.75; 95% confidence interval [CI], 1.26-2.44), cardiovascular mortality (HR, 2.76; 95% CI, 1.87-4.09), all-cause mortality (HR, 2.79; 95% CI, 2.10-3.71), but not major microvascular events (HR, 0.91; 95% CI, 0.61-1.36), compared with stable weight. There was no evidence of effect modification by baseline body mass index, age, or type of diabetes medication.

CONCLUSIONS

In the absence of substantial lifestyle changes, weight loss may be a warning sign of poor health meriting further workup in patients with type 2 diabetes.

A simple cut-off for waist-to-height ratio (0·5) can act as an indicator for cardiometabolic risk: recent data from adults in the Health Survey for England

The National Institute for Health and Care Excellence (NICE) has acknowledged the value of waist-to-height ratio (WHtR) as an indicator for ‘early health risk’. We used recent UK data to explore whether classification based on WHtR identifies more adults at cardiometabolic risk than the ‘matrix’ based on BMI and waist circumference, currently used for screening. Data from the Health Survey for England (4112 adults aged 18+ years) were used to identify cardiometabolic risk, indicated by raised glycated Hb, dyslipidaemia and hypertension. HbA1c, total/HDL-cholesterol and systolic blood pressure (BP) were more strongly associated with WHtR than the ‘matrix’. In logistic regression models for HbA1c ≥ 48 mmol/mol, total/HDL-cholesterol > 4 and hypertension (BP > 140/90 mmHg or on medication), WHtR had a higher predictive value than the ‘matrix’. AUC was significantly greater for WHtR than the ‘matrix’ for raised HbA1c and hypertension. Of adults with raised HbA1c, 15 % would be judged as ‘no increased risk’ using the ‘matrix’ in contrast to 3 % using WHtR < 0·5. For hypertension, comparative values were 23 and 9 %, and for total/HDL-cholesterol > 4, 26 and 13 %. Nearly one-third of the ‘no increased risk’ group in the ‘matrix’ had WHtR ≥ 0·5 and hence could be underdiagnosed for cardiometabolic risk. WHtR has the potential to be a better indicator of cardiometabolic risks associated with central obesity than the current NICE ‘matrix’. The cut-off WHtR 0·5 in early screening translates to a simple message, ‘your waist should be less than half your height’, that allows individuals to be aware of their health risks.

Comparison of the Four Anthropometric Indexes and Their Association With Stroke: A Population-Based Cross-Sectional Study in Jilin Province, China

Background: Stroke is a leading cause of long-term adult disability and death in China, and primary prevention is essential for stroke. The aim of this study is to compare the four anthropometric indexes (body mass index, waist circumference, waist-to-hip ratio, and waist-to-height ratio) and identify the index that is most closely related to stroke in areas with high incidence of stroke.

Methods: A total of 4,052 participants aged 40 years or older were selected by the multistage stratified cluster sampling method in Dehui City in Jilin province, China. Face-to-face interviews and physical examinations were conducted to collect the participants' information. Descriptive data analyses were conducted. Multivariable logistic analyses were used to explore the adjusted association between stroke and body fat measuring indexes.

Results: For body mass index (adjusted odds ratio (OR): 1.13, 95% confident interval (CI): 0.77–1.65), waist circumference (adjusted OR: 1.32, 95% CI: 0.88–1.99), and waist-to-hip ratio (adjusted OR: 1.34, 95% CI: 0.92–1.93), the patients in the highest quartile did not have a higher risk of stroke than those in the lowest quartile. For waist-to-height ratio, the patients in the highest quartile were more likely have a stroke than those in the lowest quartile (adjusted OR: 1.81, 95% CI: 1.16–2.82). The area under the curve of waist-to-height ratio, waist-to-hip ratio, waist circumference, and body mass index for stroke were 0.627 (95% CI: 0.595–0.659; sensitivity: 65.10%; specificity: 56.00%), 0.596 (95% CI: 0.593–0.629; sensitivity: 69.90%, specificity: 45.90%), 0.612 (95% CI: 0.579–0.644; sensitivity: 52.70%, specificity: 64.70%), and 0.548 (95% CI: 0.514–0.583; sensitivity: 57.90%, specificity: 51.10%), respectively.

Conclusions: The waist-to-height ratio was more closely related to the prevalence of stroke than body mass index, waist circumference, and weight-to-hip ratio among the study participants aged ≥ 40 years.

Association of type 2 diabetes with anthropometrics, bone mineral density, and body composition in a large-scale screening study of Korean adults

OBJECTIVES

Type 2 diabetes mellitus (T2DM) is a common, chronic disease that is closely associated with anthropometric indices related to obesity. However, no study published to date has simultaneously examined the associations of T2DM with anthropometrics, bone mineral density (BMD), and body composition variables. The present study aimed to evaluate the associations of T2DM with anthropometrics, BMD and body composition variables and to identify the best indicator of T2DM in Korean adults.

METHODS

The data used in this study were obtained from the Korea National Health and Nutrition Examination Survey conducted from 2008 to 2011. A total of 7,835 participants aged from 40 to 90 years were included in this study. A binary logistic regression analysis was performed to examine the significance of differences between the groups with and without T2DM, and the areas under the receiver operating characteristic (AUCs) curves were calculated to compare the predictive power of all variables.

RESULTS

In men, waist-to-height ratio (WHtR) displayed the strongest association with T2DM (adjusted odds ratio (OR) = 1.838 [1.513-2.233], adjusted p<0.001), and waist circumference (WC) and WHtR were the best indicators (WC: AUC = 0.662 [0.639-0.685], WHtR: AUC = 0.680 [0.658-0.703]) of T2DM among all the variables. In women, left leg (LL) and right leg (RL) fat displayed strong negative associations with T2DM (LL fat: adjusted OR = 0.367 [0.321-0.419], adjusted p<0.001, RL fat: adjusted OR = 0.375 [0.329-0.428], adjusted p<0.001), and WC and WHtR were excellent indicators (WC: AUC = 0.730 [0.709-0.750], WHtR: AUC = 0.747 [0.728-0.766]) of T2DM among all the variables. In particular, the WHtR in men and LL and RL fat in women exhibited the strongest associations with T2DM, and the predictive power of the WC and WHtR was stronger than BMD, fat, and muscle mass variables in both men and women. Additionally, the predictive power of the WC and WHtR was stronger in women than in men.

DISCUSSION

Of the anthropometric indices, BMD, and body fat and muscle variables, the best indicators of T2DM were WC and WHtR in both Korean men and women. The results of the present investigation will provide basic information for clinical studies of patients with T2DM and evidence for the prevention and management of T2DM.

GDF15 reflects beta cell function in obese patients independently of the grade of impairment of glucose metabolism

BACKGROUND AND AIMS

Growth differentiation factor 15 (GDF15) is a strong predictor of cardiovascular morbidity and mortality found to be both marker and target of impaired glucose metabolism. GDF15 increases following glucose administration and is up-regulated in obesity and diabetes. We investigate here the relationship between GDF15 and beta cell function.

METHODS AND RESULTS

In this cross-sectional study we evaluated GDF15 concentrations in 160 obese subjects (BMI 35-63 kg/m², age 39.4 ± 18.6 years, m/f 38/122) who underwent a 75 g oral glucose tolerance test (OGTT). Based on the OGTT results, the cohort was divided into two groups: 1) normal fasting glucose and normal glucose tolerance (n = 80), 2) impaired fasting glucose, impaired glucose tolerance or type 2 diabetes (n = 80). The relationship of GDF15 to fasting and OGTT-based dynamic insulin sensitivity and insulin secretion parameters was evaluated. GDF15 was higher in the prediabetes and diabetes groups and correlated with HbA1c, glucose, insulin as well as baseline and dynamic indices of insulin sensitivity and estimated beta cell function. Multiple regression analysis revealed that age, waist-to-height ratio, glomerular filtration rate and prehepatic beta cell function, but not the grade of impairment of glucose metabolism, were independent predictors of GDF15. Subgroup analysis showed that of all parameters of glucose metabolism only C-peptide, fasting prehepatic beta cell function and insulinogenic index remained significantly related to GDF15 in both groups.

CONCLUSION

We conclude that in patients with severe obesity, GDF15 strongly relates to beta cell function and should be further investigated as a potential therapeutic target and biomarker guiding treatment options.

Pattern of Obesity Among Patients with Type 2 Diabetes at a Tertiary Healthcare Center in Northern Nigeria

PURPOSE

Type 2 diabetes poses a major global health threat both in the developed and developing countries. Factors responsible for the soaring epidemic of T2DM in the developing countries include urbanization, ageing population, physical inactivity and increasing obesity rates. Our aim was to determine the pattern of obesity among patients with T2DM at the Aminu Kano Teaching Hospital (AKTH), Kano, Northwestern Nigeria.

PATIENTS AND METHODS

We consecutively recruited 220 patients with type 2 diabetes attending the diabetes clinic of AKTH for the study. Patients with Type 1 diabetes, patients who could not stand or are wheelchair bound and pregnant women were excluded from the study. A pretested questionnaire was used to collect data on socio-demographic characteristics, treatment history for diabetes and history of hypertension from each participant.

RESULTS

Of the 220 patients recruited for this study, 97(44.1%) were men, while 123(55.9%) were women. The prevalence of generalized obesity among the study participants was 27.4% (women -30.9% vs men- 22.7%, X²=4.76, p=0.190). Grades I. II and III obesity were found in 17.3%, 5.9% and 3.2% of the study participants, respectively. All the participants with grade III obesity were women. Central obesity defined by WC was detected in 111(50.5%) [20(20.6%) men and 91(73.9%) women, X²=1.93, p=0.001]. Obesity defined by WHR was recorded in 182(82.7%) participants [80(43.9%) men and 102(56.0%) women, X²= 1.97, 0.001]. Using a cut-off of ≥0.5, abnormal WhtR was detected in 179(81.4%) [72(40.2%) men and 107(59.8%) women, X²= 5.82, p=0.01], while using a cut-off of ≥0.6, abnormal WhtR was detected in 84(38.2%) participants [29 (34.5%) men and 55(65.5%) women, X²=6.38, p=0.09]. Hypertension was detected in 103(46.8%) participants, with a higher prevalence among women compared with men [46.3. % vs 47.4%, X²= 1.03 p=0.87].

CONCLUSION

The prevalence of obesity in our cohort of patients with type 2 diabetes was high. The predominant form of obesity was central obesity, which was most prevalent when indexed by WHR. The WhtR was as good as the WHR, but fared better than WC in detecting central obesity in our patients.

Fitness versus adiposity in cardiovascular disease risk

Obesity and low cardiorespiratory fitness are both established predictors of cardiovascular disease morbidity and mortality. Whether the protective effects of fitness outweigh the deleterious effects of obesity, however, remains a topic of debate. To extend knowledge of the relative influence of fitness and fatness on cardiovascular disease outcomes, however, attention must be paid to measurement quality. Eliminating inherent bias of self-report and including the highest quality assessments of cardiorespiratory fitness and fatness simultaneously are imperative for head-to-head comparisons. Studies must move beyond body mass index and total body fat percentage to differentiate the heterogenous effects of various adipose tissue depots on cardiovascular risk. Imaging techniques that measure visceral adiposity and other risk-laden ectopic adipose depots while also quantifying cardioprotective adipose depots such as lower body subcutaneous fat and even non-adipose tissues such as skeletal muscle may further illuminate the influence of body composition on cardiovascular health. This review underscores key studies within a large body of literature that provide the foundation for the fit-vs.-fat debate in the context of cardiovascular disease risk, and identifies important considerations for future research.