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. 2025 Jul 9:16:1609585.
doi: 10.3389/fendo.2025.1609585. eCollection 2025.

Association between cardiometabolic Index and obstructive sleep apnea and the mediating role of smoking: a cross-sectional study

Yifan Zhou #  1 , Jinghao Yu #  2 , Haitao Tan #  1 , Jun Xiao #  3
Affiliations

Association between cardiometabolic Index and obstructive sleep apnea and the mediating role of smoking: a cross-sectional study

Yifan Zhou et al. Front Endocrinol (Lausanne). .

Abstract

Background: The cardiometabolic Index (CMI) serves as a metric for evaluating the functional and metabolic health of the heart. It aids healthcare professionals in assessing cardiac health, predicting the risk of cardiovascular diseases, and determining the effectiveness of various treatments. Despite its significance, there is a scarcity of studies examining the relationship between CMI and obstructive sleep apnea (OSA). Consequently, our objective was to clarify the relationship between CMI and OSA.

Methods: We conducted a cross-sectional study using data from the 2015-2018 National Health and Nutrition Examination Survey (NHANES), focusing on a cohort of adults aged 20 years and older. To assess the prevalence of OSA, we employed the Sleep Questionnaire (SLQ) included in the NHANES dataset, which identifies OSA based on symptom-based survey items. Various analytical methods were utilized to examine the relationship between CMI and OSA, including multivariate logistic regression, restricted cubic splines (RCS), threshold effect analysis, subgroup analyses, and mediation effect analyses.

Results: In this study, we included 3,912 participants, among whom 1,997 were diagnosed with OSA, resulting in a prevalence of 51%. After thoroughly accounting for relevant covariates, a positive correlation between the CMI and OSA was observed [OR (95% CI): 1.31 (1.21, 1.42), p < 0.001]. This association was further corroborated through restricted cubic spline (RCS) analyses. Additionally, threshold effect analyses indicated a significant inflection point, with the prevalence of OSA increasing significantly with CMI and then leveling off. Further subgroup analyses demonstrated a significant interaction based on smoking status (p < 0.05). Finally, mediation analyses confirmed that smoking served as a mediator in the relationship between CMI and OSA, exhibiting a mediation effect size of 0.002115.

Conclusion: In the adult population of the United States, a positive nonlinear relationship exists between the CMI and the prevalence of OSA. Smoking status partially mediates this association. Additionally, the findings from the threshold effects analysis indicate that maintaining CMI within an appropriate range can significantly decrease the likelihood of developing OSA.

Keywords: CMI; NHANES; OSA; mediating effect; smoking.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Inclusion exclusion flowchart.
Figure 2
Figure 2
Smooth curve fitting of association between CMI and OSA. The solid portion and the shaded portion represent the predicted values and 95% confidence intervals, respectively. The model is model 3 after adjusting for all relevant covariates.
Figure 3
Figure 3
Association between CMI and OSA. For each stratification element we used Model 3 (fully adjusted model) for the adjustment analysis, except for the stratificationfactors themselves.
Figure 4
Figure 4
Analysis of intermediation effects. This figure shows the mediation model of the independent variable CMI, smoking as the mediating variable, and the dependent variable OSA. (A) Effect Values and Confidence Intervals for the CMI, OSA and smoking Mediating Effects (ACME, average causal mediation effects; ADE, Average Direct Effect). (B) Path diagram of mediation analysis of the relationship between smoking on CMI and OSA.
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