- Email: [email protected]
Cardiometabolic Disease Is Prevalent in Normal-Weight Chinese Adults
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
VOL. 68, NO. 14, 2016
ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER
Letters cardiometabolic disease (CMD) is also common in
Cardiometabolic Disease Is Prevalent in NormalWeight Chinese Adults
normal-weight persons (2), we investigated the distribution of CMD stages among overweight/obese people, as well as those with normal weight. The China National Diabetes and Metabolic Disorders Study is a representative cross-sectional survey of Chinese adults (3). 45,093 participants aged $20
The American Association of Clinical Endocrinolo-
years with complete metabolic index data were
gists and the American College of Endocrinology
included in this analysis. Drawing from the CMD
(AACE/ACE)
a
staging system (4) and the AACE/ACE obesity diag-
complications-centric obesity management strategy
nostic algorithm (1), CMD was classified as no
for pre-diabetes, metabolic syndrome (MetS), and
CMD, mild-to-moderate CMD, or severe CMD. Mild-
type
to-moderate CMD included 1 or 2 of the following
2
position
diabetes
statement
mellitus
(1).
proposed
Considering
that
F I G U R E 1 The Standardized Proportion of CMD Stage and Predicted Probability of CMD Stage Across BMI
A
B
70 Severe CMD
60 19.6
1.0 Severe CMD Mild-to-moderate CMD No CMD
Mild-to-moderate CMD No CMD
0.8
Predicted Probability
Proportion (%)
50
40 26.6
30 20.7
0.6
0.4
20 0.2 10
20.9 10.4
0.0
1.9
0 Normal weight
Overweight /obesity
Absolute number of persons grouped by CMD stage and BMI category CMD No Mild-to-moderate Severe
Normal weight (million)
Overweight /obesity (million)
192.6 245.2 180.5
17.6 96.1 190.5
15
20
25
30
35
40
BMI(Kg/m2) Predicted probability of CMD stage at different BMI (Kg/m2) cut-offs Cut-offs of BMI (Kg/m2) CMD 18.5 No Mild-to-moderate Severe
23
24
25
28
30
35
0.486 0.251 0.193 0.138 0.037 0.010 0.012 0.326 0.385 0.393 0.377 0.311 0.246 0.173 0.189 0.364 0.413 0.484 0.652 0.744 0.814
(A) The standardized proportion of CMD stage. (B) Predicted probability of CMD stage across BMI. The shaded area represents the 95% confidence interval. The dependent variable was CMD stages; the independent variables were BMI as a piecewise linear function, sex, age, education levels, physical activity, smoking status, alcohol consumption status, family history of diabetes, hypertension, and cardiovascular disease, residence (urban/rural, southern/northern), and economic development. BMI ¼ body mass index; CMD ¼ cardiometabolic disease.
1600
JACC VOL. 68, NO. 14, 2016
Letters
OCTOBER 4, 2016:1599–605
risk factors: central obesity (waist circumference
However, as a cross-sectional study, a low BMI may
$90 cm in men and $85 cm in women); elevated
be caused by pre-existing CMD or other chronic
triglycerides;
diseases.
reduced
high-density
lipoprotein
cholesterol; and elevated blood pressure. Severe CMD
In summary, our results showed that about 75% of
included pre-diabetes, MetS, type 2 diabetes mellitus,
Chinese adults had mild-to-severe CMD, of whom
or cardiovascular disease. MetS was defined as
about six-tenths were of normal weight. Prevention
having 3 or more CMD risk factors described in the
and treatment of CMD should be considered for
preceding text. Pre-diabetes was defined as fasting
Chinese adults with both normal weight and over-
plasma glucose $100 mg/dl and <126 mg/dl, and/or
weight/obesity.
2-h plasma glucose $140 mg/dl and <200 mg/dl and with no previous diagnosis of diabetes. Overweight/ obesity was defined as body mass index (BMI) $25 kg/m 2. Cardiovascular disease was as previously defined (5). The proportions were weighed on the basis of the 2006 Chinese population structure using SUDAAN (version 10; RTI International, Research Triangle Park, North Carolina). The regression models were constructed using data from participants with BMI from the 0.1 to 99.9 percentiles using Stata/SE (version 13.1, StataCorp LP, College Station, Texas). First, the linear spline functions of BMI (kg/m 2 ) were created with 6 knots (18.5, 23, 24, 25, 28, and 30). A multinomial logistic regression of CMD stages was then performed against a linear spline of BMI, which had a lower Akaike information criterion than
ACKNOWLEDGMENTS The authors thank all of the
members of the China National Diabetes and Metabolic Disorders Study Group for their contributions to the study. Xuhong Hou, MD, PhD Peizhu Chen, BS Gang Hu, MD, PhD Yue Chen, MD, PhD Siyu Chen, BS Xiaojing Ma, MD, PhD Lei Chen, MD, PhD Zhaojun Yang, MD, PhD Wenying Yang, MD *Weiping Jia, MD, PhD on behalf of the China National Diabetes and Metabolic Disorders Study Group
the model with BMI as a continuous variable.
*Department of Endocrinology and Metabolism
Finally, we plotted the probability of CMD stages
Shanghai Jiao Tong University Affiliated Sixth People’s
against BMI using the local polynomial smoothed
Hospital
line
method.
A
p
value
<0.05
(2-tailed)
was
significant. About 20.9% of the total population were of normal
600 Yishan Road Shanghai 200233, China E-mail: [email protected]
weight and had no CMD (192.6 million adults); 26.6%
http://dx.doi.org/10.1016/j.jacc.2016.07.737
were of normal weight, but had mild-to-moderate
Please note: This study was funded by the Chinese Medical Association Foundation and the Chinese Diabetes Society, the Biomedical Engineering Cross Research Foundation of Shanghai Jiao Tong University (YG2015MS18). The funders had no role in the design, data collection, and analysis of this study, in the preparation and approval of the letter. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Xuhong Hou and Peizhu Chen contributed equally to this work.
CMD (245.2 million adults); 19.6% were of normal weight, but had severe CMD (180.5 million adults); 1.9% had overweight/obesity, but no CMD (17.6 million adults); 10.4% had overweight/obesity and mild-to-moderate CMD (96.1 million adults); and 20.7% had overweight/obesity and severe CMD (190.5
REFERENCES
increased with increasing BMI from 18.5 kg/m 2 to
1. Garvey WT, Garber AJ, Mechanick JI, et al. American Association of Clinical Endocrinologists and American College of Endocrinology position statement on the 2014 advanced framework for a new diagnosis of obesity as a chronic disease. Endocr Pract 2014;20:977–89.
30 kg/m 2, then slowed down and reached about 80%
2. Wildman RP, Muntner P, Reynolds K, et al. The obese without
million adults), respectively. The probability of severe CMD, but not mild-to-moderate CMD, quickly
at BMI of 35 kg/m 2 (Figure 1). The present study found a much lower proportion of metabolically healthy overweight or obesity (1.9%) and a higher proportion of metabolically unhealthy normal weight (46.2%) compared with that in previous studies with white populations (2). There are 2 major reasons for the difference: the present study used a strict criterion of CMD for metabolic health, and Chinese adults have a higher risk of CMD than their white counterparts at a given BMI cutoff.
cardiometabolic risk factor clustering and the normal weight with cardiometabolic risk factor clustering: prevalence and correlates of 2 phenotypes among the US population (NHANES 1999-2004). Arch Intern Med 2008;168: 1617–24. 3. Yang W, Lu J, Weng J, et al. Prevalence of diabetes among men and women in China. N Engl J Med 2010;362:1090–101. 4. Guo F, Moellering DR, Garvey WT. The progression of cardiometabolic disease: validation of a new cardiometabolic disease staging system applicable to obesity. Obesity (Silver Spring) 2014;22:110–8. 5. Yang ZJ, Liu J, Ge JP, et al. Prevalence of cardiovascular disease risk factor in the Chinese population: the 2007-2008 China National Diabetes and Metabolic Disorders Study. Eur Heart J 2012;33:213–20.
VOL. 68, NO. 14, 2016
ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER
Letters cardiometabolic disease (CMD) is also common in
Cardiometabolic Disease Is Prevalent in NormalWeight Chinese Adults
normal-weight persons (2), we investigated the distribution of CMD stages among overweight/obese people, as well as those with normal weight. The China National Diabetes and Metabolic Disorders Study is a representative cross-sectional survey of Chinese adults (3). 45,093 participants aged $20
The American Association of Clinical Endocrinolo-
years with complete metabolic index data were
gists and the American College of Endocrinology
included in this analysis. Drawing from the CMD
(AACE/ACE)
a
staging system (4) and the AACE/ACE obesity diag-
complications-centric obesity management strategy
nostic algorithm (1), CMD was classified as no
for pre-diabetes, metabolic syndrome (MetS), and
CMD, mild-to-moderate CMD, or severe CMD. Mild-
type
to-moderate CMD included 1 or 2 of the following
2
position
diabetes
statement
mellitus
(1).
proposed
Considering
that
F I G U R E 1 The Standardized Proportion of CMD Stage and Predicted Probability of CMD Stage Across BMI
A
B
70 Severe CMD
60 19.6
1.0 Severe CMD Mild-to-moderate CMD No CMD
Mild-to-moderate CMD No CMD
0.8
Predicted Probability
Proportion (%)
50
40 26.6
30 20.7
0.6
0.4
20 0.2 10
20.9 10.4
0.0
1.9
0 Normal weight
Overweight /obesity
Absolute number of persons grouped by CMD stage and BMI category CMD No Mild-to-moderate Severe
Normal weight (million)
Overweight /obesity (million)
192.6 245.2 180.5
17.6 96.1 190.5
15
20
25
30
35
40
BMI(Kg/m2) Predicted probability of CMD stage at different BMI (Kg/m2) cut-offs Cut-offs of BMI (Kg/m2) CMD 18.5 No Mild-to-moderate Severe
23
24
25
28
30
35
0.486 0.251 0.193 0.138 0.037 0.010 0.012 0.326 0.385 0.393 0.377 0.311 0.246 0.173 0.189 0.364 0.413 0.484 0.652 0.744 0.814
(A) The standardized proportion of CMD stage. (B) Predicted probability of CMD stage across BMI. The shaded area represents the 95% confidence interval. The dependent variable was CMD stages; the independent variables were BMI as a piecewise linear function, sex, age, education levels, physical activity, smoking status, alcohol consumption status, family history of diabetes, hypertension, and cardiovascular disease, residence (urban/rural, southern/northern), and economic development. BMI ¼ body mass index; CMD ¼ cardiometabolic disease.
1600
JACC VOL. 68, NO. 14, 2016
Letters
OCTOBER 4, 2016:1599–605
risk factors: central obesity (waist circumference
However, as a cross-sectional study, a low BMI may
$90 cm in men and $85 cm in women); elevated
be caused by pre-existing CMD or other chronic
triglycerides;
diseases.
reduced
high-density
lipoprotein
cholesterol; and elevated blood pressure. Severe CMD
In summary, our results showed that about 75% of
included pre-diabetes, MetS, type 2 diabetes mellitus,
Chinese adults had mild-to-severe CMD, of whom
or cardiovascular disease. MetS was defined as
about six-tenths were of normal weight. Prevention
having 3 or more CMD risk factors described in the
and treatment of CMD should be considered for
preceding text. Pre-diabetes was defined as fasting
Chinese adults with both normal weight and over-
plasma glucose $100 mg/dl and <126 mg/dl, and/or
weight/obesity.
2-h plasma glucose $140 mg/dl and <200 mg/dl and with no previous diagnosis of diabetes. Overweight/ obesity was defined as body mass index (BMI) $25 kg/m 2. Cardiovascular disease was as previously defined (5). The proportions were weighed on the basis of the 2006 Chinese population structure using SUDAAN (version 10; RTI International, Research Triangle Park, North Carolina). The regression models were constructed using data from participants with BMI from the 0.1 to 99.9 percentiles using Stata/SE (version 13.1, StataCorp LP, College Station, Texas). First, the linear spline functions of BMI (kg/m 2 ) were created with 6 knots (18.5, 23, 24, 25, 28, and 30). A multinomial logistic regression of CMD stages was then performed against a linear spline of BMI, which had a lower Akaike information criterion than
ACKNOWLEDGMENTS The authors thank all of the
members of the China National Diabetes and Metabolic Disorders Study Group for their contributions to the study. Xuhong Hou, MD, PhD Peizhu Chen, BS Gang Hu, MD, PhD Yue Chen, MD, PhD Siyu Chen, BS Xiaojing Ma, MD, PhD Lei Chen, MD, PhD Zhaojun Yang, MD, PhD Wenying Yang, MD *Weiping Jia, MD, PhD on behalf of the China National Diabetes and Metabolic Disorders Study Group
the model with BMI as a continuous variable.
*Department of Endocrinology and Metabolism
Finally, we plotted the probability of CMD stages
Shanghai Jiao Tong University Affiliated Sixth People’s
against BMI using the local polynomial smoothed
Hospital
line
method.
A
p
value
<0.05
(2-tailed)
was
significant. About 20.9% of the total population were of normal
600 Yishan Road Shanghai 200233, China E-mail: [email protected]
weight and had no CMD (192.6 million adults); 26.6%
http://dx.doi.org/10.1016/j.jacc.2016.07.737
were of normal weight, but had mild-to-moderate
Please note: This study was funded by the Chinese Medical Association Foundation and the Chinese Diabetes Society, the Biomedical Engineering Cross Research Foundation of Shanghai Jiao Tong University (YG2015MS18). The funders had no role in the design, data collection, and analysis of this study, in the preparation and approval of the letter. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Xuhong Hou and Peizhu Chen contributed equally to this work.
CMD (245.2 million adults); 19.6% were of normal weight, but had severe CMD (180.5 million adults); 1.9% had overweight/obesity, but no CMD (17.6 million adults); 10.4% had overweight/obesity and mild-to-moderate CMD (96.1 million adults); and 20.7% had overweight/obesity and severe CMD (190.5
REFERENCES
increased with increasing BMI from 18.5 kg/m 2 to
1. Garvey WT, Garber AJ, Mechanick JI, et al. American Association of Clinical Endocrinologists and American College of Endocrinology position statement on the 2014 advanced framework for a new diagnosis of obesity as a chronic disease. Endocr Pract 2014;20:977–89.
30 kg/m 2, then slowed down and reached about 80%
2. Wildman RP, Muntner P, Reynolds K, et al. The obese without
million adults), respectively. The probability of severe CMD, but not mild-to-moderate CMD, quickly
at BMI of 35 kg/m 2 (Figure 1). The present study found a much lower proportion of metabolically healthy overweight or obesity (1.9%) and a higher proportion of metabolically unhealthy normal weight (46.2%) compared with that in previous studies with white populations (2). There are 2 major reasons for the difference: the present study used a strict criterion of CMD for metabolic health, and Chinese adults have a higher risk of CMD than their white counterparts at a given BMI cutoff.
cardiometabolic risk factor clustering and the normal weight with cardiometabolic risk factor clustering: prevalence and correlates of 2 phenotypes among the US population (NHANES 1999-2004). Arch Intern Med 2008;168: 1617–24. 3. Yang W, Lu J, Weng J, et al. Prevalence of diabetes among men and women in China. N Engl J Med 2010;362:1090–101. 4. Guo F, Moellering DR, Garvey WT. The progression of cardiometabolic disease: validation of a new cardiometabolic disease staging system applicable to obesity. Obesity (Silver Spring) 2014;22:110–8. 5. Yang ZJ, Liu J, Ge JP, et al. Prevalence of cardiovascular disease risk factor in the Chinese population: the 2007-2008 China National Diabetes and Metabolic Disorders Study. Eur Heart J 2012;33:213–20.