Normal-weight visceral obesity promotes a higher 10-year atherosclerotic cardiovascular disease risk in patients with type 2 diabetes mellitus-a multicenter study in China

Abstract

Background: Visceral obesity is associated with high cardiovascular events risk in type 2 diabetes mellitus (T2DM). Whether normal-weight visceral obesity will pose a higher atherosclerotic cardiovascular disease (ASCVD) risk than body mass index (BMI)-defined overweight or obese counterparts with or without visceral obesity remains unclear. We aimed to explore the relationship between general obesity and visceral obesity and 10-year ASCVD risk in patients with T2DM.

Methods: Patients with T2DM (6997) who satisfied the requirements for inclusion were enrolled. Patients were considered to have normal weight when 18.5 kg/m² ≤ BMI < 24 kg/m²; overweight when 24 kg/m² ≤ BMI < 28 kg/m²; and obesity when BMI ≥ 28 kg/m². Visceral obesity was defined as a visceral fat area (VFA) ≥ 100 cm². Patients were separated into six groups based on BMI and VFA. The odd ratios (OR) for a high 10-year ASCVD risk for different combinations of BMI and VFA were analysed using stepwise logistic regression. Receiver operating characteristic (ROC) curves for diagnosing the high 10-year ASCVD risk were constructed, and areas under the ROC curves were estimated. Potential non-linear relationships between VFA levels and high 10-year ASCVD risk were examined using restricted cubic splines (knot = 4). Multilinear regression was used to identify factors affecting VFA in patients with T2DM.

Results: In patients with T2DM, subjects with normal-weight visceral obesity had the highest 10-year ASCVD risk among the six groups, which had more than a 2-fold or 3-fold higher OR than those who were overweight or obese according to BMI but did not have visceral obesity (all P < 0.05). The VFA threshold for high 10-year ASCVD risk was 90 cm². Multilinear regression showed significant differences in the effect of age, hypertension, drinking, fasting serum insulin, fasting plasma glucose, 2 h postprandial C-peptide, triglyceride, total cholesterol, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol on VFA in patients with T2DM (all P < 0.05).

Conclusions: T2DM patients with normal-weight visceral obesity had a higher 10-year ASCVD risk than BMI-defined overweight or obese counterparts with or without visceral obesity, which should initiate standardised management for ASCVD primary prevention.

Keywords: Atherosclerotic cardiovascular disease risk; Multicentre study; Normal weight; Obesity paradox; Type 2 diabetes mellitus; Visceral obesity.

Fig. 1

Flow chart of patient recruitment

Fig. 2

The proportion of high 10-year ASCVD risk according to BMI/VFA status in patients with T2DM. Patients were considered to have normal weight when 18.5 kg/m² ≤ BMI < 24 kg/m²; overweight when 24 kg/m² ≤ BMI < 28 kg/m²; and obesity when BMI ≥ 28 kg/m². Visceral obesity was defined as VFA ≥ 100 cm²

Fig. 3

ORs and 95% CIs for high 10-year ASCVD risk according to BMI/VFA status in T2DM patients. The results were adjusted by age and sex

Fig. 4

ORs and 95% CIs for high 10-year ASCVD risk according to BMI/VFA status in T2DM patients. The results were adjusted by age and sex

Fig. 5

The calculation and comparison of AUCs for diagnosing high 10-year ASCVD risk in T2DM patients. The AUC of BMI, VFA, and BMI + VFA is respectively 0.511 (95% CI: 0.499–0.523), 0.556 (95% CI: 0.554–0.568) and 0.588 (95% CI: 0.576–0.599)

Fig. 6

The association between VFA and a high 10-year ASCVD risk in T2DM patients. The result was adjusted by age and sex

Fig. 7

The heatmap depicts the correlational relationships between the other variables and VFA in T2DM patients