Relationship between BMI, abdominal obesity and the incidence of type 2 diabetes in Chinese adults: a prospective study
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摘要:
目的 分析中国成人BMI和腹型肥胖与2型糖尿病(diabetes mellitus type 2，T2DM)发病风险的关联。 方法 选取1993、1997、2000、2004、2006、2009和2011年中国健康与营养调查中未出现T2DM且第1次进入调查队列的12 085名成年居民作为研究对象，1997―2015年作为随访终点。采用Cox比例风险模型分析不同BMI和腰围联合分组与T2DM的发病风险比；亚组分析以BMI且腰围正常组作为参照组，分析BMI正常且腹型肥胖组T2DM的发病风险。 结果 共纳入12 085人进入分析，中位随访9.04年(共计128 760人年)，随访期间共观察到775例T2DM患者(男性450例，女性325例)。调整相关的混杂因素后，以BMI且腰围正常者为参照，超重肥胖且腰围正常、BMI正常且腹型肥胖、超重肥胖且腹型肥胖者的T2DM发病风险分别增加1.26倍(HR=2.26，95% CI：1.84~2.78)、1.32倍(HR=2.32，95% CI：1.64~3.28)和2.87倍(HR=3.87，95% CI：3.18~4.70)。亚组分析中发现基线慢性病对BMI正常且腹型肥胖与T2DM发病风险间的关联存在效应修饰作用(P交互=0.045)。 结论 与BMI相比，腰围异常者发生T2DM的风险更高，在糖尿病早期预防计划中，应重点关注该类人群，尤其是同时罹患其他慢性病者。 Abstract:Objective To analyze the association of BMI and waist circumference with the risk of developing diabetes mellitus type 2(T2DM) in Chinese population. Methods The 12 085 adult residents who did not develop T2DM and entered the survey cohort for the first time in the China Health and Nutrition Survey in 1993, 1997, 2000, 2004, 2006, 2009, and 2011 were selected as the study subjects, and 1997-2015 was used as the follow-up endpoint. The Cox proportional risk model was used to analyze the risk ratios of T2DM in different combined BMI and waist circumference groups. Subgroup analysis with normal BMI and waist circumference group as the reference group, to analyze the risk of T2DM in normal BMI and abdominal obesity group. Results A total of 12 085 individuals were included in the analysis, with a median follow-up of 9.04 years(128 760 person-years), 775 T2DM events (450 males and 325 females) were observed during the follow-up period. After adjusting for related confounding factors, the risk of T2DM increased 1.26 times (HR=2.26, 95% CI: 1.84-2.78), 1.32 times (HR=2.32, 95% CI: 1.64-3.28), and 2.87 times (HR=3.87, 95% CI: 3.18-4.70) in overweight obese with normal, normal BMI with abdominal obesity, and overweight obese with abdominal obesity, respectively, using normal BMI with normal as the reference. In the subgroup analysis, baseline chronic disease was found to modify the association between normal BMI with abdominal obesity and the risk of T2DM (Pinteraction=0.045). Conclusions People with abnormal waist circumference are at a higher risk of developing T2DM compared to BMI and should be the focus of early diabetes prevention programs, especially if they have other chronic diseases at the same time. -
Key words:
- Body mass index /
- Abdominal obesity /
- Diabetes mellitus type 2 /
- Prospective cohort study
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表 1 研究对象的基线特征
Table 1. Baseline characteristics of the study population
变量Variable BMI＜24 /(kg·m-2)且腰围正常
BMI＜24 /(kg·m-2) and waist circumference normalBMI≥24 /(kg·m-2)且腰围正常
BMI≥24 /(kg·m-2) and waist circumference normalBMI＜24 /(kg·m-2)且腹型肥胖
BMI＜24 /(kg·m-2) and abdominal obesityBMI≥24 /(kg·m-2)且腹型肥胖
BMI≥24 /(kg·m-2) and abdominal obesityH/χ2值
valueP值
value性别① Gender① 7.45 0.059 男Male 4 154(53.57) 914(50.98) 236(49.06) 1 106(53.79) 女Female 3 601(46.43) 879(49.02) 245(50.94) 950(46.21) 年龄/岁② Age/year② 35(18) 41(16) 46(22) 46(19) 1 025.13 ＜0.001 居住地① Residence① 168.62 ＜0.001 城市City 2 857(36.84) 835(46.57) 255(53.01) 1 018(49.51) 农村Rural 4 898(63.16) 958(53.43) 226(46.99) 1 038(50.49) 文化程度① Education① 101.85 ＜0.001 小学及以下Primary and below 2 108(27.18) 415(23.15) 119(24.74) 454(22.08) 初中Junior high school 3 210(41.39) 691(38.54) 157(32.64) 778(37.84) 中专和高中Secondary and high school 1 865(24.05) 529(29.50) 151(31.39) 592(28.79) 本科及以上Bachelor degree or above 572(7.38) 158(8.81) 54(11.23) 232(11.28) 婚姻① Marital status① 275.64 ＜0.001 未婚No married 1 141(14.71) 117(6.53) 27(5.61) 81(3.94) 已婚Married 6 400(82.53) 1 625(90.63) 429(89.19) 1 880(91.44) 离婚/丧偶/分居Divorced/Widowed/Separated 214(2.76) 51(2.84) 25(5.20) 95(4.62) 吸烟 ①③ Smoking ①③ 92.21 ＜0.001 从不Never 4 932(63.94) 1 198(66.96) 329(68.83) 1 367(66.88) 现在Current 2 700(35.00) 556(31.08) 141(29.50) 602(29.45) 以前Former 82(1.06) 35(1.96) 8(1.67) 75(3.67) 现在饮酒 ①③ Drinking ①③ 9.32 0.025 否No 4 699(61.07) 1 065(59.83) 300(63.29) 1 180(57.76) 是Yes 2 995(38.93) 715(40.17) 174(36.71) 863(42.24) 体力活动/MET-(h·周-1) ①
Physical activity /MET-(h·week-1) ①302.09 ＜0.001 低Low 2 935(37.85) 520(29.00) 128(26.61) 462(22.47) 中Moderate 2 595(33.46) 599(33.41) 159(33.06) 650(31.61) 高High 2 225(28.69) 674(37.59) 194(40.33) 944(45.91) 脂肪供能比/% ①③ Fat supply ratio/% ①③ 324.93 ＜0.001 低Low 2 920(38.38) 466(26.51) 123(25.95) 428(21.20) 中Moderate 2 482(32.62) 625(35.55) 166(35.02) 683(33.83) 高High 2 206(29.00) 667(37.94) 185(39.03) 908(44.97) 基线慢性病 ①③ Baseline chronic disease ①③ 1 042.99 ＜0.001 有Have 785(10.12) 375(20.91) 118(24.53) 820(39.88) 无Not have 6 969(89.88) 1 418(79.09) 363(75.47) 1 236(60.12) 注：①以[人数(占比/%)]表示；②以[M(IQR)]表示；③代表数据存在缺失，吸缺失60人，现在饮酒缺失94人，脂肪供能比缺失226人，基线慢性病缺失1人。
Note: ① [Number of people (proportion /%)]; ② [M(IQR)]; ③ Data were missing, with 60 smoking missing, 94 current drinking missing, 226 fat supply ratio missing, and 1 baseline chronic disease missing.
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表 2 不同BMI和腹型肥胖分组与T2DM的发病关系
Table 2. Relationship between different BMI and abdominal obesity groups and the incidence of T2DM
变量Variable BMI＜24 /(kg·m-2)且腰围正常
BMI＜24 /(kg·m-2) and waist circumference normalBMI≥24 /(kg·m-2)且腰围正常
BMI≥24 /(kg·m-2) and waist circumference normalBMI＜24 /(kg·m-2)且腹型肥胖
BMI＜24 /(kg·m-2) and abdominal obesityBMI≥24 /(kg·m-2)且腹型肥胖
BMI≥24 /(kg·m-2) and abdominal obesityT2DM 发病人数Morbidity number 327 150 44 254 随访人年Follow up person year 91 217 17 847 4 060 15 637 发病密率/1 000人年-1 Incidence density/1 000 person year-1 3.58 8.41 10.84 16.24 HR值value (95% CI) 模型1 Model 1 1.00 2.55(2.10~3.09) 3.51(2.56~4.82) 5.59(4.73~6.61) 模型2 Model 2 1.00 2.20(1.80~2.68) 2.59(1.87~3.58) 3.99(3.33~4.77) 模型3 Model 3 1.00 2.26(1.84~2.78) 2.32(1.64~3.28) 3.87(3.18~4.70) 注：1. T2DM，2型糖尿病。
2. 各协变量因素均不符合等比例风险假设，在模型中将性别、文化程度、居住地、婚姻、吸烟、现在饮酒和基线慢性病作为分层因素；将年龄、体力活动、脂肪供能比加上时间交互项。模型1仅纳入肥胖分组；模型2在模型1基础上进一步调整性别、年龄、文化程度、居住地和婚姻；模型3在模型2基础上进一步调整：吸烟、现在饮酒、体力活动、脂肪供能比和基线慢性病。
Note: 1. T2DM，diabetes mellitus type 2.
2. None of the covariates were consistent with the proportional risk hypothesis. Gender, education, residence, marriage, smoking, drinking, and baseline chronic disease were stratified in the model. Age, total physical activity, fat supply ratio plus time interaction term. Model 1 only obesity group was included; Model 2 further adjusting gender, age, education, residence and marriage based on Model 1. Model 3 was further adjusted based on Model 2: smoking, drinking, physical activity, fat supply ratio, and baseline chronic disease.
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表 3 不同BMI和腹型肥胖分组与T2DM发病关系的亚组分析
Table 3. Subgroup analysis of the relationship between different BMI and abdominal obesity groups and the incidence of T2DM
因素Fators 新发病例数
Morbidity number随访人年
Follow up person year发病密率/1 000人年-1
Incidence density/1 000 person year-1HR值value
(95% CI)P交互
Pinteraction性别Gender 0.726 男Male 450 71 421 6.30 2.48(1.54~3.98) 女Female 325 57 339 5.67 2.22(1.38~3.56) 年龄/岁Age/year 0.320 ＜45 372 93 858 3.96 2.03(1.07~3.86) ≥45 403 34 902 11.55 2.28(1.53~3.41) 居住地Residence 0.585 城市City 343 44 038 7.79 2.53(1.61~3.96) 农村Rural 432 84 722 5.10 2.32(1.41~3.83) 文化程度Education 0.060 初中及以下Junior high school and below 538 92 964 5.79 3.07(2.09~4.52) 高中及以上High school and above 237 35 796 6.62 1.37(0.73~2.60) 婚姻Marital status 0.307 未婚No married 36 14 205 2.53 7.87(1.75~35.3) 已婚Married 739 114 554 6.45 2.31(1.65~3.24) 吸烟Smoking 0.876 否No 468 81 339 5.75 2.19(1.45~3.30) 是Yes 300 46 685 6.43 2.57(1.44~4.60) 现在饮酒Drinking 0.810 否No 419 75 504 5.55 2.16(1.39~3.36) 是Yes 349 52 095 6.70 2.66(1.57~4.50) 体力活动/MET-(h·周-1) Physical activity /MET-(h·week-1) 0.173 低Low 307 54 507 5.63 2.86(1.65~4.95) 中Moderate 289 46 595 6.20 3.07(1.86~5.06) 高High 179 27 658 6.47 1.43(0.69~2.98) 脂肪供能比/% Fat supply ratio/% 0.255 低Low 257 52 544 4.89 2.49(1.33~4.66) 中Moderate 275 41 651 6.60 2.97(1.81~4.87) 高High 231 32 285 7.16 1.59(0.82~3.08) 基线慢性病Baseline chronic disease 0.045 无Not have 560 110 916 5.05 1.98(1.29~3.06) 有Have 215 17 821 12.06 3.44(1.94~6.12) 注：1. T2DM，2型糖尿病。
2. 以BMI＜24 kg/m2且腰围正常者为对照，报告BMI＜24 kg/m2且腹型肥胖者发生T2DM风险效应值；各模型调整性别、年龄、文化程度、居住地、婚姻、吸烟、现在饮酒、体力活动、脂肪供能比和基线慢性病，除各分层因素。
Note: 1. T2DM，diabetes mellitus type 2.
2. With BMI＜24 kg/m2 and normal waist circumference as the control group, the risk effect value of T2DM in BMI＜24 kg/m2 and abdominal obesity was reported. The models adjusted for sex, age, education, residence, marriage, smoking, drinking, physical activity, fat supply ratio, and baseline chronic disease, excluding stratified factors.
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