Mozafar Saadati Hossein, Mehrabi Yadollah, Sabour Siamak, Mansournia Mohammad Ali, Hashemi Nazari Seyed Saeed
Department of Epidemiology, School of Public Health and safety Shahid Beheshti University of Medical Sciences Tehran Iran.
Department of Epidemiology and Biostatistics, School of Public Health Tehran University of Medical Sciences Tehran Iran.
Obes Sci Pract. 2020 Aug 18;6(6):628-637. doi: 10.1002/osp4.447. eCollection 2020 Dec.
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.
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).
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.
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.
体重指数（BMI）与糖尿病患者心血管疾病风险之间的关联存在争议。本研究使用靶向最大似然估计比较了BMI和中心性肥胖对糖尿病患者和非糖尿病患者中风的影响。
本分析纳入了社区动脉粥样硬化风险研究中12725名年龄在45 - 75岁的成年人，排除了现患病例和数据缺失的参与者。通过BMI、腰围、腰臀比（WHR）、腰高比（WHtR）、体型指数（BSI）和身体圆润度指数（BRI）来定义肥胖，将所有参与者分为肥胖和非肥胖两类。使用广义线性模型和TMLE（使用tmle软件包）来估计风险比（RR）。
在27年的随访期间，发生了1078例（8.47%）中风病例。在调整了人口统计学、行为、生物学和中心性肥胖变量后，BMI在糖尿病患者和非糖尿病患者中的影响均有所降低。在完整模型中，BMI对糖尿病患者的影响减弱得更多（RR：1.04 [0.90, 1.20]），而非糖尿病患者为（RR：1.11 [1.00, 1.24]）。这种减弱在非糖尿病患者中更多地与生物学变量相关，而在糖尿病患者中与中心性肥胖相关。关于中心性肥胖，对于糖尿病患者，BSI（RR [95% CI]：1.15 [0.96, 1.38]）和WHR（RR [95% CI]：1.15 [0.87, 1.52]）的影响最强且具有边缘显著性，对于非糖尿病患者，BSI（RR [95% CI]：1.10 [1.02, 1.20]）的影响显著。
在糖尿病患者中，BSI和WHR指数与中风发病率较高相关。未来的研究应考虑中心性肥胖如何影响按性别和年龄组分层的糖尿病患者中风发病率较高的情况。
