Chen Jiaheng, Li Yu Ting, Niu Zimin, He Zhanpeng, Xie Yao Jie, Hernandez Jose, Huang Wenyong, Wang Harry H X
School of Public Health, Sun Yat-Sen University, Guangzhou, People's Republic of China.
State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, People's Republic of China.
Diabetes Obes Metab. 2024 Jul;26(7):2796-2810. doi: 10.1111/dom.15598. Epub 2024 May 2.
The paradoxical protective association between overweight/obesity and diabetic microvascular complications (DMC), a phenomenon well-known as the obesity paradox, has been considered a non-causal association based on methodological influences. We aimed to investigate the association of generalized and abdominal obesity, as measured by body mass index (BMI) and waist circumference (WC), respectively, with DMC in patients with type 2 diabetes (T2D), using a causal inference approach.
We enrolled 1436 patients with clinically diagnosed T2D but not DMC at baseline in a community-based prospective cohort in China between 2017 and 2019 and followed them annually until 2022 with new-onset DMC recorded. Marginal structural Cox models with inverse probability weighting were constructed to determine the causal association. Subgroup analyses were performed to identify potential effect modifiers.
We observed 360 incident DMC cases, including 109 cases of diabetic nephropathy (DN) and 277 cases of diabetic retinopathy (DR) during four follow-up visits. Multivariable-adjusted hazard ratios (95% confidence intervals) for overall DMC, DN and DR were 1.037 (1.005-1.071), 1.117 (1.062-1.175) and 1.018 (0.980-1.059) for 1 kg/m increase in BMI, and 1.005 (0.994-1.017), 1.034 (1.018-1.051) and 1.000 (0.987-1.014) for 1 cm increase in WC, respectively. Similar patterns were observed across the BMI and WC categories, while the positive association appeared to be more pronounced in women.
Generalized but not abdominal obesity was associated with an increased risk for the overall DMC, whereas both obesities were causally related to DN, albeit not DR, in T2D. Routine weight management should not be neglected in diabetes care, particularly in women.
超重/肥胖与糖尿病微血管并发症（DMC）之间存在矛盾的保护关联，即众所周知的肥胖悖论现象，基于方法学影响，该关联被认为是非因果关联。我们旨在采用因果推断方法，分别研究以体重指数（BMI）和腰围（WC）衡量的全身性肥胖和腹型肥胖与2型糖尿病（T2D）患者DMC的关联。
2017年至2019年期间，我们在中国一个基于社区的前瞻性队列中纳入了1436例基线时临床诊断为T2D但无DMC的患者，并每年对他们进行随访，直至2022年，记录新发DMC情况。构建了具有逆概率加权的边际结构Cox模型以确定因果关联。进行亚组分析以识别潜在的效应修饰因素。
在四次随访中，我们观察到360例新发DMC病例，包括109例糖尿病肾病（DN）和277例糖尿病视网膜病变（DR）。BMI每增加1 kg/m²，总体DMC、DN和DR的多变量调整风险比（95%置信区间）分别为1.037（1.005 - 1.071）、1.117（1.062 - 1.175）和1.018（0.980 - 1.059）；WC每增加1 cm，相应的风险比分别为1.005（0.994 - 1.017）、1.034（1.018 - 1.051）和1.000（0.987 - 1.014）。在BMI和WC类别中观察到类似模式，而这种正相关在女性中似乎更明显。
全身性肥胖而非腹型肥胖与总体DMC风险增加相关，而在T2D中，两种肥胖均与DN存在因果关系，尽管与DR无关。在糖尿病护理中，常规体重管理不应被忽视，尤其是在女性中。
