Published on in Vol 10 (2024)

Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/46088, first published .
Arterial Stiffness and Obesity as Predictors of Diabetes: Longitudinal Cohort Study

Arterial Stiffness and Obesity as Predictors of Diabetes: Longitudinal Cohort Study

Arterial Stiffness and Obesity as Predictors of Diabetes: Longitudinal Cohort Study

Original Paper

1Department of Radiology, China-Japan Union Hospital of Jilin University, Jilin University, Changchun, China

2Centre for Precision Health, School of Medical and Health Sciences, Edith Cowan University, WA, Australia

3School of Medical Imaging, Dalian Medical University, Dalian, China

4Center of Informatics, Beijing Xiaotangshan Hospital, Beijing, China

5Department of Anesthesiology,China-Japan Union Hospital of Jilin University, Jilin University, Changchun, China

*these authors contributed equally

Corresponding Author:

Te Zhang, PhD

Department of Anesthesiology,China-Japan Union Hospital of Jilin University, Jilin University

No.126, Sendai Street, Erdao District

Changchun, 130022

China

Phone: 86 13894857383

Email: zhangte19@mails.jlu.edu.cn


Background: Previous studies have confirmed the separate effect of arterial stiffness and obesity on type 2 diabetes; however, the joint effect of arterial stiffness and obesity on diabetes onset remains unclear.

Objective: This study aimed to propose the concept of arterial stiffness obesity phenotype and explore the risk stratification capacity for diabetes.

Methods: This longitudinal cohort study used baseline data of 12,298 participants from Beijing Xiaotangshan Examination Center between 2008 and 2013 and then annually followed them until incident diabetes or 2019. BMI (waist circumference) and brachial-ankle pulse wave velocity were measured to define arterial stiffness abdominal obesity phenotype. The Cox proportional hazard model was used to estimate the hazard ratio (HR) and 95% CI.

Results: Of the 12,298 participants, the mean baseline age was 51.2 (SD 13.6) years, and 8448 (68.7%) were male. After a median follow-up of 5.0 (IQR 2.0-8.0) years, 1240 (10.1%) participants developed diabetes. Compared with the ideal vascular function and nonobese group, the highest risk of diabetes was observed in the elevated arterial stiffness and obese group (HR 1.94, 95% CI 1.60-2.35). Those with exclusive arterial stiffness or obesity exhibited a similar risk of diabetes, and the adjusted HRs were 1.63 (95% CI 1.37-1.94) and 1.64 (95% CI 1.32-2.04), respectively. Consistent results were observed in multiple sensitivity analyses, among subgroups of age and fasting glucose level, and alternatively using arterial stiffness abdominal obesity phenotype.

Conclusions: This study proposed the concept of arterial stiffness abdominal obesity phenotype, which could improve the risk stratification and management of diabetes. The clinical significance of arterial stiffness abdominal obesity phenotype needs further validation for other cardiometabolic disorders.

JMIR Public Health Surveill 2024;10:e46088

doi:10.2196/46088

Keywords



The latest estimates showed that there were 537 million adults with diabetes worldwide in 2021, which was expected to reach 783 million by 2045 [1], leading to a heavy socioeconomic burden with huge costs for glucose therapy and complications treatment [2,3]. Therefore, early detection and prevention of diabetes are of great importance, which requires the precise identification of risk markers to promote the risk stratification and management of diabetes onset.

Multifactorial risk factor evaluation and management is a recommended strategy for preventing diabetes and its complications. Arterial stiffness is an age-related process that results from adverse changes in the structure and function of the elastic arterial vessel wall [4]. Previous studies have shown a close relationship between increased arterial stiffness and diabetes [5]. Arterial stiffness is an important risk factor for diabetes [6-8] and diabetes could accelerate the process of arterial stiffness, conversely [9]. At the same time, it is well known that obesity is commonly associated with a range of metabolic abnormalities, including insulin resistance, atherogenic dyslipidemia, and metabolic syndrome [10]. By far, obesity is the most important modifiable risk factor for diabetes onset and glucose intervention [11], formulating the term “diabesity” to describe the combined adverse health effects and close relationship between obesity and diabetes [12]. Obesity is defined as a common chronic disorder due to excess body fat and has become a global epidemic issue [13]. The diagnosis and classification of obesity are usually based on BMI and waist circumference for abdominal obesity. Of note, not all individuals with obesity are at the same risk of metabolic complications, leading to the concept of metabolic health obesity phenotype [14,15]. Although individuals with obesity in a metabolically healthy state have a relatively reduced risk of developing diabetes, they are still at a higher risk compared to the metabolically healthy normal-weight group [15]. Thus, the assessment of metabolic health obesity phenotype allows for better identification of people at different risk of diabetes onset. Of note, the metabolic health status assessment needs a complex physical examination and blood test. On the contrary, arterial stiffness measurement using pulse wave velocity is a simple, repeatable, and noninvasive process [16]. However, the combined effect of obesity and arterial stiffness status on diabetes onset has not been fully investigated to date.

Therefore, this study proposed the concept of arterial stiffness obesity phenotype and investigated the joint effect of increased arterial stiffness and abdominal obesity on incident diabetes. We hypothesized that arterial stiffness abdominal obesity phenotype could better stratify the risk of diabetes onset in the general population.


Study Population and Design

This study used data from the Beijing Xiaotangshan Examination Center [17], which is a large-scale longitudinal cohort study investigating the risk factors and biomarkers of cardiometabolic disorders. Beijing Xiaotangshan Examination Center included participants undergoing physical examinations from 2008, which is still ongoing and forms dynamic open cohort data with annual resurveys. In this study, a total of 12,505 participants aged 18 years or older who underwent the first comprehensive health examination without diabetes between 2008 and 2013 were primarily included as baseline. Then, we excluded 207 participants due to being underweight (n=126), being 18 years of age or younger (n=22), or lacking fasting glucose data (n=59) at baseline. Finally, 12,298 participants were selected and annually followed to incident diabetes or the end of 2019, including 8184 participants with available data on waist circumference as shown in Figure 1.

Figure 1. Flowchart of this study. This cohort study included 12,298 eligible participants from 2008 to 2019 in Beijing, China.

Data Collection and Definition

The data on demographic characteristics, lifestyle, disease history, and medication use were collected through a standard questionnaire and face-to-face interview. Educational level was categorized as illiteracy or primary school (primary), middle school or high school (secondary), and bachelor’s degree or above (third). Smoking and drinking status was divided into current or not. Physical activity was defined as having moderate or intense activity at work or during leisure time more than 4 times and 80 minutes each week. The disease history of dyslipidemia and hypertension was self-reported.

The physical examination and biochemical data were measured by the trained staff and acquired from the electronic record system of Beijing Xiaotangshan Hospital, including height, weight, waist circumference, and blood pressure. BMI was calculated as weight in kilograms divided by height in meters squared. Obesity was defined as BMI ≥28 kg/m2, and abdominal obesity was defined as waist circumference ≥90 cm for male individuals and ≥85 cm for female individuals, using the standard for the Chinese population [18,19]. The concentrations of fasting glucose and glycated hemoglobin A1c (HbA1c) were tested using the automatic biochemical analyzers Roche Cobas C 701 and SYSMEX HLC-723G8. Diabetes was defined as fasting glucose ≥7.0 mmol/L, HbA1c ≥6.5%, or use of any glucose-lowering medication or self-reported diagnosis history of diabetes.

Arterial stiffness level was measured by brachial-ankle pulse wave velocity (baPWV) using the Omron Colin BP-203RPE III device (Omron Health Care). Elevated arterial stiffness was defined as baPWV ≥1400 cm/s, as previously described [18,19]. The ankle-brachial index (ABI) was calculated as the pressure ratio between posterior tibial artery and brachial artery.

Arterial Stiffness Abdominal Obesity Phenotype

Arterial stiffness obesity phenotype was divided into four groups: (1) normal arterial stiffness and no obesity (NASNO), (2) normal arterial stiffness and obesity (NASO), (3) elevated arterial stiffness and no obesity (ASNO), and (4) elevated arterial stiffness and obesity (ASO). On the other hand, waist circumference is another index to inflect the accumulation of abdominal fat, which is more closely associated with the risk of diabetes. Thus, arterial stiffness abdominal obesity phenotype was divided into four groups: (1) normal arterial stiffness and no abdominal obesity (NASNAO), (2) normal arterial stiffness and abdominal obesity (NASAO), (3) elevated arterial stiffness and no abdominal obesity (ASNAO), and (4) elevated arterial stiffness and abdominal obesity (ASAO).

Statistical Analysis

Baseline characteristics were described using mean (SD) and frequency (proportion) according to arterial stiffness abdominal obesity phenotype. The incidence rate and cumulative incidence of diabetes were calculated.

We used Kaplan-Meier curves to present the cumulative hazard of diabetes onset stratified by arterial stiffness obesity and arterial stiffness abdominal obesity phenotype. The effect of arterial stiffness (or obesity) on incident diabetes was evaluated stratified by obesity (arterial stiffness) status. Then, the Cox proportional hazard model was used to explore the longitudinal association of arterial stiffness abdominal obesity phenotype with incident diabetes. Hazard ratios (HRs) and 95% CIs were calculated in the following models: model 1 was primarily adjusted for age and sex, and model 2 was further adjusted for education level, physical activity, current smoking, current drinking, dyslipidemia or not, hypertension or not, mean arterial pressure (MAP), and fasting glucose concentration. We adjusted the level of MAP in the regression analysis as MAP was more dependent on baPWV level compared to systolic blood pressure and diastolic blood pressure. The interaction effect between arterial stiffness and abdominal obesity was tested as a multiplicative term. We performed multiple sensitivity analyses, including additionally adjusting HbA1c levels, excluding participants using antihypertensive medication, or repeating analyses among participants with an ABI >0.9. To address the dynamic changes of arterial stiffness abdominal obesity phenotype between baseline and follow-up, we repeated the analyses among participants of stable arterial stiffness abdominal obesity status. In addition, the effect of arterial stiffness abdominal obesity phenotype on diabetes onset was explored in subgroups of sex, age, and baseline fasting glucose level.

All statistical analyses were performed using R software (version 4.1.0; R Foundation for Statistical Computing), and a 2-sided P value <.05 was considered statistically significant.

Ethical Considerations

This study was conducted in accordance with the principles of the Declaration of Helsinki and approved by the Ethics Committee of the Beijing Xiaotangshan Center (XTS021431). The study data were anonymous. All participants provided written informed consent before taking part in this study.


Of the 12,298 participants, the mean baseline age was 51.2 (13.6) years, and 8448 (68.7%) were male. Table 1 shows the detailed baseline characteristics according to arterial stiffness obesity phenotype, and characteristics according to arterial stiffness abdominal obesity phenotype are shown in Table S1 in Multimedia Appendix 1. During a median follow-up of 5.0 (IQR 2.0-8.0) years, diabetes occurred in 1240 participants. The incidence rates were 9.57, 27.83, 30.32, and 50.55 per 1000 person-years among NASNO, NASO, ASNO, and ASO groups (Table S2 in Multimedia Appendix 1) and 6.85, 20.04, 24.42, and 48.10 per 1000 person-years among NASNAO, NASAO, ASNAO, and ASAO groups, respectively (Table S3 in Multimedia Appendix 1).

Table 1. Baseline characteristics of 12,298 participants according to arterial stiffness obesity phenotype. This cohort study included eligible participants from 2008 to 2019 in Beijing, China. SI conversion factor: to convert fasting plasma glucose to mg/dL, multiply by 18.0.
CharacteristicNASNOa (n=5764)NASOb (n=1250)ASNOc (n=3952)ASOd (n=1332)
Participants (N=12,298), n (%)5764 (46.9)1250 (10.2)3952 (32.1)1332 (10.8)
Sex (male), n (%)3339 (57.9)1014 (81.1)3008 (76.1)1087 (81.6)
Age (years), mean (SD)45.03 (9.56)45.41 (9.77)60.11 (13.98)56.85 (13.45)
BMIe (kg/m2), mean (SD)24.09 (2.29)30.57 (9.62)24.79 (2.08)30.29 (9.73)
Waistf (cm), mean (SD)81.24 (8.56)96.54 (6.97)86.12 (7.21)97.99 (7.38)
Abdominal obesityg, n (%)928 (21.9)875 (93.1)866 (38.8)740 (96.4)
Educational level, n (%)

Primary802 (13.9)191 (15.3)626 (15.8)208 (15.6)

Secondary3283 (57)697 (55.8)2293 (58)771 (57.9)

Third1679 (29.1)362 (29)1033 (26.1)353 (26.5)
Physical activity, n (%)2173 (37.7)489 (39.1)1550 (39.2)477 (35.8)
Current smoking, n (%)1703 (29.5)426 (34.1)1233 (31.2)410 (30.8)
Current drinking, n (%)3493 (60.6)786 (62.9)2357 (59.6)832 (62.5)
Dyslipidemia, n (%)74 (1.3)21 (1.7)216 (5.5)65 (4.9)
Hypertension, n (%)419 (7.3)300 (24)1594 (40.3)727 (54.6)
MAPh,i (mmHg), mean (SD)85.73 (9.32)93.76 (9.43)95.36 (10.25)100.3 (10.76)
Fasting glucose (mmol/L), mean (SD)5.14 (0.49)5.41 (0.54)5.38 (0.55)5.61 (0.57)
HbA1cj (%), mean (SD)5.42 (0.35)5.53 (0.34)5.56 (0.36)5.64 (0.38)

aNASNO: normal arterial stiffness and no obesity.

bNASO: normal arterial stiffness and obesity.

cASNO: elevated arterial stiffness and no obesity.

dASO: elevated arterial stiffness and obesity.

eCalculated as weight in kilograms divided by height in meters squared.

fWaist circumference was measured only in 8184 participants.

gAbdominal obesity was defined as a waist circumference of ≥90 cm for male individuals and ≥85 cm for female individuals. Due to data missing on waist circumference, the total numbers of NASNA, NASO, ASNO and ASO were 4237, 940, 2232 and 768, respectively.

hMAP: mean arterial pressure.

iMAP = 1/3 × systolic pressure + 2/3 × diastolic pressure.

jHbA1c: glycated hemoglobin A1c.

Figure 2 presents the cumulative hazard of incident diabetes according to arterial stiffness obesity phenotype and arterial stiffness abdominal obesity phenotype. Of note, people with obesity had a significantly higher risk of diabetes onset regardless of arterial stiffness status (P<.001; Figure S1A and B in Multimedia Appendix 1). Equally, those with elevated arterial stiffness had a higher risk of diabetes regardless of obesity status (Figure S1C and D in Multimedia Appendix 1). Figure S2A-D in Multimedia Appendix 1 present the mutual effect of arterial stiffness and abdominal obesity.

Figure 2. Kaplan-Meier curves of incident diabetes according to arterial stiffness obesity (left) phenotype and arterial stiffness abdominal obesity (right) phenotype. The left and right sides include 12,298 and 8184 eligible participants, respectively, from 2008 to 2019. ASAO: elevated arterial stiffness and abdominal obesity; ASNAO: elevated arterial stiffness and no abdominal obesity; ASNO: elevated arterial stiffness and no obesity; ASO: elevated arterial stiffness and obesity; NASAO: normal arterial stiffness and abdominal obesity; NASNAO: normal arterial stiffness and no abdominal obesity; NASNO: normal arterial stiffness and no obesity; NASO: normal arterial stiffness and obesity.

In the joint model, both continuous BMI (adjusted HR 1.06, 95% CI 1.04-1.07; P<.001) and baPWV (adjusted HR 1.18, 95% CI 1.11-1.25; P<.001) levels were significantly associated with diabetes onset. In the adjusted model, the highest risk of incident diabetes was observed in the ASO group (HR 1.94, 95% CI 1.60-2.35), followed by ASNO (HR 1.63, 95% CI 1.37-1.94) and NASO (HR 1.64, 95% CI 1.32-2.04) groups, compared with NASNO (Table 2). The interaction terms of general obesity and arterial stiffness were statistically significant (P<.05). Similarly, ASAO had the highest risk (HR 2.30, 95% CI 1.71-3.11), followed by NASAO (HR 1.30, 95% CI 0.95-1.78) and ASNAO (HR 1.67, 95% CI 1.20-2.32) groups, compared with NASNAO.

Table 2. Association of arterial stiffness abdominal obesity phenotype with incident diabetes.
Definition and variableModel 1aModel 2b

HRc (95% CI)P valueHR (95% CI)P value
Definition 1d (n=12,298)

Continuous (per SD)


BMI (SD 5.5 kg/m2)1.049 (1.034-1.065)<.0011.055 (1.038-1.071)<.001


baPWVe (SD 285 cm/s)1.403 (1.347-1.461)<.0011.176 (1.107-1.249)<.001

Categorical


NASNOfReferenceReferenceReferenceReference


NASOg2.716 (2.191-3.366)<.0011.642 (1.321-2.041)<.001


ASNOh2.248 (1.894-2.668)<.0011.632 (1.373-1.940)<.001


ASOi3.908 (3.246-4.705)<.0011.935 (1.595-2.348)<.001

P value for interactionN/Aj<.001N/A.01
Definition 2k (n=8184)

Continuous (per SD)


Waist (SD 10.0 cm)1.810 (1.657-1.977)<.0011.817 (1.646-2.005)<.001


baPWV (SD 285 cm/s)1.492 (1.400-1.591)<.0011.263 (1.151-1.386)<.001

Categorical


NASNAOlReferenceReferenceReferenceReference


NASAOm2.473 (1.826-3.349)<.0011.299 (0.951-1.775).10


ASNAOn2.450 (1.783-3.366)<.0011.671 (1.202-2.324).002


ASAOo4.707 (3.529-6.278)<.0012.303 (1.705-3.113)<.001

P value for interactionN/A.04N/A.06

aModel 1: age and sex adjusted.

bModel 2: age, sex, education, physical activity, smoking, drinking, dyslipidemia, hypertension, mean arterial pressure, and fasting glucose level adjusted.

cHR: hazard ratio.

dDefinition 1: arterial stiffness obesity phenotype is defined using brachial-ankle pulse wave velocity and BMI.

ebaPWV: brachial-ankle pulse wave velocity.

fNASNO: normal arterial stiffness and no obesity.

gNASO: normal arterial stiffness and obesity.

hASNO: elevated arterial stiffness and no obesity.

iASO: elevated arterial stiffness and obesity.

jN/A: not applicable.

kDefinition 2: arterial stiffness abdominal obesity phenotype is defined using brachial-ankle pulse wave velocity and waist circumference.

lNASNAO: normal arterial stiffness and no abdominal obesity.

mNASAO: normal arterial stiffness and abdominal obesity.

nASNAO: elevated arterial stiffness and no abdominal obesity.

oASAO: elevated arterial stiffness and abdominal obesity.

The results remained consistent even after adjusting for baseline HbA1c levels, excluding those using antihypertensive medication and participants with an ABI ≤0.9. Analyses among people with stable arterial stiffness abdominal obesity phenotype did not significantly change the results (Table 3).

Figure 3 presents the subgroup analyses of sex, age, and baseline fasting glucose level. Of note, only ASAO group had a significantly increased risk of diabetes among male and baseline glucose above 5.6 mmol/L compared with NASNAO.

Table 3. Adjusted regression results of sensitivity analysis. Analyses were adjusted for age, sex, education, physical activity, smoking, drinking, dyslipidemia, hypertension, mean arterial pressure, and fasting glucose level.
Sensitivity and variableDefinition 1aDefinition 2b

HRc (95% CI)P valueHR (95% CI)P value
Sensitivity 1d

NASNAOeReferenceReferenceReferenceReference

NASAOf0.953 (0.625-1.452).820.908 (0.574-1.436).68

ASNAOg1.380 (0.993-1.919).061.488 (0.933-2.374).10

ASAOh1.581 (1.103-2.266).011.763 (1.144-2.717).01
Sensitivity 2i

NASNAOReferenceReferenceReferenceReference

NASAO1.643 (1.306-2.066)<.0011.305 (0.952-1.789).10

ASNAO1.699 (1.416-2.039)<.0011.669 (1.192-2.336).003

ASAO2.019 (1.642-2.482)<.0012.319 (1.709-3.149)<.001
Sensitivity 3j

NASNAOReferenceReferenceReferenceReference

NASAO1.790 (1.156-2.774).0091.807 (0.974-3.353).06

ASNAO1.494 (1.095-2.039).012.141 (1.143-4.013).02

ASAO2.018 (1.442-2.824)<.0013.052 (1.706-5.46)<.001
Sensitivity 4k

NASNAOReferenceReferenceReferenceReference

NASAO1.638 (1.317-2.038)<.0011.316 (0.962-1.8).09

ASNAO1.624 (1.364-1.933)<.0011.698 (1.219-2.365).002

ASAO1.952 (1.607-2.371)<.0012.32 (1.713-3.141)<.001

aDefinition 1: arterial stiffness obesity phenotype is defined using brachial-ankle pulse wave velocity and BMI.

bDefinition 2: arterial stiffness abdominal obesity phenotype is defined using brachial-ankle pulse wave velocity and waist circumference.

cHR: hazard ratio.

dSensitivity 1: glycated hemoglobin A1c was additionally adjusted in the analysis; 3899 participants were enrolled in the current analysis under definition 1 and 3626 participants enrolled under definition 2.

eNASNAO: normal arterial stiffness and no abdominal obesity.

fNASAO: normal arterial stiffness and abdominal obesity.

gASNAO: elevated arterial stiffness and no abdominal obesity.

hASAO: elevated arterial stiffness and abdominal obesity.

iSensitivity 2: participants using antihypertensive medication were excluded from the analysis; 11,325 participants were enrolled in the current analysis under definition 1 and 7836 participants enrolled under definition 2.

jSensitivity 3: analyses performed among participants with stable arterial stiffness abdominal obesity phenotype at baseline and follow-up; 4818 participants were enrolled in the current analysis under definition 1 and 2905 participants enrolled under definition 2.

kSensitivity 4: analyses performed among participants of ankle-brachial index >0.9; 12,161 participants were enrolled in the current analysis under definition 1 and 8122 participants enrolled under definition 2.

Figure 3. Effect of arterial stiffness abdominal obesity phenotype on diabetes stratified by sex, age, and baseline glucose level. Definition 1: arterial stiffness obesity phenotype is defined using brachial-ankle pulse wave velocity and BMI. Definition 2: arterial stiffness abdominal obesity phenotype is defined using brachial-ankle pulse wave velocity and waist circumference. Analyses were adjusted for age, sex (if not stratified), education, physical activity, smoking, drinking, dyslipidemia, hypertension, mean arterial pressure, and fasting glucose level. Normal arterial stiffness and abdominal obesity (NASNAO) was set as the reference group. ASAO: elevated arterial stiffness and abdominal obesity; ASNAO: elevated arterial stiffness and no abdominal obesity; HR: hazard ratio.

Overview

In this study, we proposed the concept of arterial stiffness obesity phenotype using noninvasive and simple measurements. We found that arterial stiffness obesity phenotype could improve the risk stratification of diabetes onset. People with ASO had the highest risk of incident diabetes, independent of their baseline glucose level. The results remained consistent among multiple sensitivity analyses and subgroups of sex, age, and fasting glucose level.

Many studies have suggested a relationship between arterial stiffness and diabetes, indicating that arterial stiffness could predict the development of diabetes [5,6,8]. A Kailuan study of 14,159 participants found that arterial stiffness appeared to precede the increase in fasting glucose [7]. Notably, the independent association between arterial stiffness and diabetes was not consistent among all studies. A large prospective observational study of Japanese company employees found that atherosclerosis was observed only in those with diabetes combined with hypertension, and the increased arterial stiffness may not be associated with the onset of diabetes or prediabetes alone [20]. On the other hand, obesity is an important risk factor involved in the etiopathogenesis of diabetes and is the most important culprit of insulin resistance [21,22]. In a meta-analysis in the United States and Europe, men with obesity had a 7-fold higher risk of diabetes, and women with obesity had a 12-fold higher risk [23]. A longitudinal study from the United Kingdom investigated 369,362 participants aged between 2 and 15 years and found that most of the patients with diabetes were obese (47.1%) [24]. Similar results have been found in other countries [25]. Studies have shown that the distribution of adipose tissue is a key factor in the development of insulin resistance, independent of the stage of obesity [26]. A growing body of evidence suggests that obesity cannot be assessed by BMI. Individuals of normal weight but with excess visceral adipose tissue are at high risk of diabetes, while individuals with obesity who can expand their subcutaneous adipose tissue mass, especially in the hip and femoral regions, may be at much lower risk than expected [11]. Thus, both excess body weight (BMI) and ectopic fat (such as abdominal obesity) determine the risk of diabetes onset. This study supplemented the evidence about the combined effect of arterial stiffness and obesity or abdominal obesity on the incident diabetes using a larger cohort. Compared with the ideal vascular function and nonobese group, the highest risk of diabetes was observed in the elevated arterial stiffness with obesity or abdominal obesity group. Additionally, there exists a potential interaction effect between general obesity and arterial stiffness on diabetes onset.

Metabolic health obesity phenotype has been proposed as a health index [27]. In general, people with different metabolic health obesity phenotypes have a differentiated risk of type 2 diabetes, cardiovascular diseases, and all-cause mortality [28-32]. The number and severity of metabolic abnormalities could further identify the risk of adverse outcomes [33,34]. In terms of diabetes, data suggest that the risk of developing diabetes is 5-20 times higher in metabolically unhealthy people with obesity than in the metabolically healthy nonobese group, and the risk is 4 times higher for the metabolically healthy obese group [35]. However, the definition of metabolic health status needs physical examinations (blood pressure), blood test (glucose and lipid), and a questionnaire survey (disease history and medication use). In this study, we proposed the concept of arterial stiffness abdominal obesity phenotype to stratify people at different risks of diabetes onset. The measurements of arterial stiffness and obesity status are simple, fast, and noninvasive, which enhance the applicability of arterial stiffness abdominal obesity phenotype in the risk stratification and management of diabetes.

Potential mechanisms linking arterial stiffness and diabetes include endothelial dysfunction, chronic inflammation, oxidative stress, microvascular dysfunction, and shared genetic background [7,8,36]. First, endothelial dysfunction is associated with arterial stiffness [37]. Arterial stiffness may lead to increased arterial pulse pressure and pulsation shear, resulting in endothelial dysfunction and metabolic dysregulation [38]. It has been suggested that endothelial dysfunction can cause the development of diabetes, and there is a common pathway that may link arterial stiffness and endothelial dysfunction to the development of diabetes, or possibly that these 2 factors reinforce each other [8,39]. Second, arterial stiffness may lead to microvascular dysfunction, which in turn leads to damage to low-resistance organs (eg, the pancreas), resulting in reduced tissue perfusion, including insulin-mediated muscle perfusion. This will lead to impaired glucose metabolism, insulin resistance, and an elevated fasting glucose level [7,40]. In this process, endothelial dysfunction and impaired endothelium-dependent vasodilation may exacerbate insulin resistance by limiting glucose delivery to key target tissues [41]. Third, increased oxidative stress and chronic low-grade inflammation may be common risk factors for atherosclerosis and diabetes [42,43].

The mechanisms underpinning the relationship of obesity with diabetes are only partially understood. Most of the hypotheses about obesity causing diabetes in recent years have been based on the coexistence of insulin resistance. Randle et al [44], for the first time, explained the relationship between obesity and diabetes by the “glucose-fatty acid cycle,” proposing a theory that obesity inhibits the glycolytic enzymes pyruvate dehydrogenase, phosphofructokinase, and hexokinase, thus causing an imbalance in glucose metabolism [45]. Another hypothesis is that adipose tissue is a secretory organ that produces and releases a variety of factors that may lead to insulin resistance. Most of the data suggested that tumor necrosis factor alpha (TNF-α) plays a mediating role [46]. Upregulated TNF-α induces multiple adverse effects, such as impaired insulin signaling and inhibition of glucose transporter type 4 expression, which inhibits glucose uptake [47]. TNF-α could reduce the expression of lipocalin, a protein that is abundantly expressed in adipocytes and has direct antidiabetic and antiatherosclerotic effects [48]. In addition, there are several hypotheses about signaling pathways of adipose tissue inflammation [49], endoplasmic reticulum stress [50], oxidative stress [51], and accumulation of immune cells [52], which are related to insulin resistance and insulin secretion.

This cohort study proposed the concept of arterial stiffness abdominal obesity phenotype to stratify the risk of incident diabetes. However, the results should be interpreted in the context of limitations. First, baPWV measures the stiffness of both the elastic aorta and muscular artery, and other index of arterial stiffness such as carotid-femoral pulse wave velocity was not collected in this study. Second, this was an observational study design, and we were unable to claim the causal effect of arterial stiffness obesity groups on diabetes onset. Third, although we adjusted for the important confounding factors, including fasting glucose level, there was still a possibility of residual confounding bias, such as dietary factors. The observed results require further validation in other populations.

Conclusions

The findings indicated the combined effect of arterial stiffness and obesity status on diabetes onset, independent of fasting glucose level. This study proposed the concept of arterial stiffness abdominal obesity phenotype, providing a noninvasive and simple panel for the risk stratification and potential management of diabetes.

Data Availability

The data sets generated and analyzed during this study are available from the corresponding author on reasonable request.

Authors' Contributions

TZ and LL are co-corresponding authors for this study.

Conflicts of Interest

None declared.

Multimedia Appendix 1

Supplementary tables and figures.

DOC File , 173 KB

  1. Sun H, Saeedi P, Karuranga S, Pinkepank M, Ogurtsova K, Duncan BB, et al. IDF diabetes atlas: global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045. Diabetes Res Clin Pract. 2022;183:109119. [CrossRef] [Medline]
  2. Tinajero MG, Malik VS. An update on the epidemiology of type 2 diabetes: a global perspective. Endocrinol Metab Clin North Am. 2021;50(3):337-355. [CrossRef] [Medline]
  3. Dugani SB, Mielke MM, Vella A. Burden and management of type 2 diabetes in rural United States. Diabetes Metab Res Rev. 2021;37(5):e3410. [FREE Full text] [CrossRef] [Medline]
  4. Jia G, Aroor AR, Jia C, Sowers JR. Endothelial cell senescence in aging-related vascular dysfunction. Biochim Biophys Acta Mol Basis Dis. 2019;1865(7):1802-1809. [FREE Full text] [CrossRef] [Medline]
  5. Prenner SB, Chirinos JA. Arterial stiffness in diabetes mellitus. Atherosclerosis. 2015;238(2):370-379. [CrossRef] [Medline]
  6. Kim JM, Kim SS, Kim IJ, Kim JH, Kim BH, Kim MK, et al. Arterial stiffness is an independent predictor for risk of mortality in patients with type 2 diabetes mellitus: the REBOUND study. Cardiovasc Diabetol. 2020;19(1):143. [FREE Full text] [CrossRef] [Medline]
  7. Zheng M, Zhang X, Chen S, Song Y, Zhao Q, Gao X, et al. Arterial stiffness preceding diabetes: a longitudinal study. Circ Res. 2020;127(12):1491-1498. [FREE Full text] [CrossRef] [Medline]
  8. Tian X, Zuo Y, Chen S, Zhang Y, Zhang X, Xu Q, et al. Hypertension, arterial stiffness, and diabetes: a prospective cohort study. Hypertension. 2022;79(7):1487-1496. [FREE Full text] [CrossRef]
  9. Kimoto E, Shoji T, Shinohara K, Inaba M, Okuno Y, Miki T, et al. Preferential stiffening of central over peripheral arteries in type 2 diabetes. Diabetes. 2003;52(2):448-452. [FREE Full text] [CrossRef] [Medline]
  10. Andersen CJ, Murphy KE, Fernandez ML. Impact of obesity and metabolic syndrome on immunity. Adv Nutr. 2016;7(1):66-75. [FREE Full text] [CrossRef] [Medline]
  11. Piché ME, Tchernof A, Després JP. Obesity phenotypes, diabetes, and cardiovascular diseases. Circ Res. 2020;126(11):1477-1500. [FREE Full text] [CrossRef] [Medline]
  12. Ng ACT, Delgado V, Borlaug BA, Bax JJ. Diabesity: the combined burden of obesity and diabetes on heart disease and the role of imaging. Nat Rev Cardiol. 2021;18(4):291-304. [CrossRef] [Medline]
  13. World Health Organization. Obesity: preventing and managing the global epidemic. report of a WHO consultation. World Health Organ Tech Rep Ser. 2000;894:i-xii:1-253. [Medline]
  14. Tsatsoulis A, Paschou SA. Metabolically healthy obesity: criteria, epidemiology, controversies, and consequences. Curr Obes Rep. 2020;9(2):109-120. [CrossRef] [Medline]
  15. Blüher M. Metabolically healthy obesity. Endocr Rev. 2020;41(3):bnaa004. [FREE Full text] [CrossRef] [Medline]
  16. Milan A, Zocaro G, Leone D, Tosello F, Buraioli I, Schiavone D, et al. Current assessment of pulse wave velocity: comprehensive review of validation studies. J Hypertens. 2019;37(8):1547-1557. [CrossRef] [Medline]
  17. Wu Z, Jiang Y, Zhou D, Chen S, Zhao Y, Zhang H, et al. Sex-specific association of subclinical hypothyroidism with incident metabolic syndrome: a population-based cohort study. J Clin Endocrinol Metab. 2022;107(6):e2365-e2372. [FREE Full text] [CrossRef] [Medline]
  18. Yamashina A, Tomiyama H, Takeda K, Tsuda H, Arai T, Hirose K, et al. Validity, reproducibility, and clinical significance of noninvasive brachial-ankle pulse wave velocity measurement. Hypertens Res. 2002;25(3):359-364. [FREE Full text] [CrossRef] [Medline]
  19. Wu Z, Zhou D, Liu Y, Li Z, Wang J, Han Z, et al. Association of TyG index and TG/HDL-C ratio with arterial stiffness progression in a non-normotensive population. Cardiovasc Diabetol. 2021;20(1):134. [FREE Full text] [CrossRef] [Medline]
  20. Nakano H, Shiina K, Takahashi T, Fujii M, Iwasaki Y, Matsumoto C, et al. Bidirectional longitudinal relationships between arterial stiffness and hypertension are independent of those between arterial stiffness and diabetes: a large-scale prospective observational study in employees of a Japanese Company. J Am Heart Assoc. 2022;11(13):e025924. [FREE Full text] [CrossRef] [Medline]
  21. Reinehr T. Type 2 diabetes mellitus in children and adolescents. World J Diabetes. 2013;4(6):270-281. [FREE Full text] [CrossRef] [Medline]
  22. Pulgaron ER, Delamater AM. Obesity and type 2 diabetes in children: epidemiology and treatment. Curr Diab Rep. 2014;14(8):508. [FREE Full text] [CrossRef] [Medline]
  23. Wilding JPH. The importance of weight management in type 2 diabetes mellitus. Int J Clin Pract. 2014;68(6):682-691. [FREE Full text] [CrossRef] [Medline]
  24. Abbasi A, Juszczyk D, van Jaarsveld CHM, Gulliford MC. Body mass index and incident type 1 and type 2 diabetes in children and young adults: a retrospective cohort study. J Endocr Soc. 2017;1(5):524-537. [FREE Full text] [CrossRef] [Medline]
  25. Colosia AD, Palencia R, Khan S. Prevalence of hypertension and obesity in patients with type 2 diabetes mellitus in observational studies: a systematic literature review. Diabetes Metab Syndr Obes. 2013;6:327-338. [FREE Full text] [CrossRef] [Medline]
  26. Al Amiri E, Abdullatif M, Abdulle A, Al Bitar N, Afandi EZ, Parish M, et al. The prevalence, risk factors, and screening measure for prediabetes and diabetes among Emirati overweight/obese children and adolescents. BMC Public Health. 2015;15:1298. [FREE Full text] [CrossRef] [Medline]
  27. Rey-López JP, de Rezende LF, Pastor-Valero M, Tess BH. The prevalence of metabolically healthy obesity: a systematic review and critical evaluation of the definitions used. Obes Rev. 2014;15(10):781-790. [CrossRef] [Medline]
  28. Mongraw-Chaffin M, Foster MC, Anderson CAM, Burke GL, Haq N, Kalyani RR, et al. Metabolically healthy obesity, transition to metabolic syndrome, and cardiovascular risk. J Am Coll Cardiol. 2018;71(17):1857-1865. [FREE Full text] [CrossRef] [Medline]
  29. Eckel N, Meidtner K, Kalle-Uhlmann T, Stefan N, Schulze MB. Metabolically healthy obesity and cardiovascular events: a systematic review and meta-analysis. Eur J Prev Cardiol. 2016;23(9):956-966. [FREE Full text] [CrossRef] [Medline]
  30. Zheng R, Zhou D, Zhu Y. The long-term prognosis of cardiovascular disease and all-cause mortality for metabolically healthy obesity: a systematic review and meta-analysis. J Epidemiol Community Health. 2016;70(10):1024-1031. [CrossRef] [Medline]
  31. Hamer M, Stamatakis E. Metabolically healthy obesity and risk of all-cause and cardiovascular disease mortality. J Clin Endocrinol Metab. 2012;97(7):2482-2488. [FREE Full text] [CrossRef] [Medline]
  32. Kuk JL, Rotondi M, Sui X, Blair SN, Ardern CI. Individuals with obesity but no other metabolic risk factors are not at significantly elevated all-cause mortality risk in men and women. Clin Obes. 2018;8(5):305-312. [FREE Full text] [CrossRef] [Medline]
  33. Caleyachetty R, Thomas GN, Toulis KA, Mohammed N, Gokhale KM, Balachandran K, et al. Metabolically healthy obese and incident cardiovascular disease events among 3.5 million men and women. J Am Coll Cardiol. 2017;70(12):1429-1437. [FREE Full text] [CrossRef] [Medline]
  34. Hamer M, Johnson W, Bell JA. Improving risk estimates for metabolically healthy obesity and mortality using a refined healthy reference group. Eur J Endocrinol. 2017;177(2):169-174. [FREE Full text] [CrossRef] [Medline]
  35. Bell JA, Kivimaki M, Hamer M. Metabolically healthy obesity and risk of incident type 2 diabetes: a meta-analysis of prospective cohort studies. Obes Rev. 2014;15(6):504-515. [FREE Full text] [CrossRef] [Medline]
  36. Muhammad I, Borné Y, Östling G, Kennbäck C, Gottsäter M, Persson M, et al. Arterial stiffness and incidence of diabetes: a population-based cohort study. Diabetes Care. 2017;40(12):1739-1745. [FREE Full text] [CrossRef] [Medline]
  37. Muris DMJ, Houben AJHM, Schram MT, Stehouwer CDA. Microvascular dysfunction is associated with a higher incidence of type 2 diabetes mellitus: a systematic review and meta-analysis. Arterioscler Thromb Vasc Biol. 2012;32(12):3082-3094. [FREE Full text] [CrossRef] [Medline]
  38. Petrie JR, Guzik TJ, Touyz RM. Diabetes, hypertension, and cardiovascular disease: clinical insights and vascular mechanisms. Can J Cardiol. 2018;34(5):575-584. [FREE Full text] [CrossRef] [Medline]
  39. Cameron JD, Bulpitt CJ, Pinto ES, Rajkumar C. The aging of elastic and muscular arteries: a comparison of diabetic and nondiabetic subjects. Diabetes Care. 2003;26(7):2133-2138. [FREE Full text] [CrossRef] [Medline]
  40. Levy BI, Schiffrin EL, Mourad JJ, Agostini D, Vicaut E, Safar ME, et al. Impaired tissue perfusion: a pathology common to hypertension, obesity, and diabetes mellitus. Circulation. 2008;118(9):968-976. [FREE Full text] [CrossRef] [Medline]
  41. Balletshofer BM, Rittig K, Enderle MD, Volk A, Maerker E, Jacob S, et al. Endothelial dysfunction is detectable in young normotensive first-degree relatives of subjects with type 2 diabetes in association with insulin resistance. Circulation. 2000;101(15):1780-1784. [FREE Full text] [CrossRef] [Medline]
  42. Odegaard AO, Jacobs DR, Sanchez OA, Goff DC, Reiner AP, Gross MD. Oxidative stress, inflammation, endothelial dysfunction and incidence of type 2 diabetes. Cardiovasc Diabetol. 2016;15:51. [FREE Full text] [CrossRef] [Medline]
  43. Yasmin; McEniery CM, Wallace S, Mackenzie IS, Cockcroft JR, Wilkinson IB. C-reactive protein is associated with arterial stiffness in apparently healthy individuals. Arterioscler Thromb Vasc Biol. 2004;24(5):969-974. [FREE Full text] [CrossRef] [Medline]
  44. Randle PJ, Garland PB, Hales CN, Newsholme EA. The glucose fatty-acid cycle. Its role in insulin sensitivity and the metabolic disturbances of diabetes mellitus. Lancet. 1963;281(7285):785-789. [CrossRef] [Medline]
  45. Kahn SE, Hull RL, Utzschneider KM. Mechanisms linking obesity to insulin resistance and type 2 diabetes. Nature. 2006;444(7121):840-846. [CrossRef] [Medline]
  46. Hotamisligil GS, Shargill NS, Spiegelman BM. Adipose expression of tumor necrosis factor-alpha: direct role in obesity-linked insulin resistance. Science. 1993;259(5091):87-91. [CrossRef] [Medline]
  47. Hauner H, Petruschke T, Russ M, Röhrig K, Eckel J. Effects of tumour necrosis factor alpha (TNF alpha) on glucose transport and lipid metabolism of newly-differentiated human fat cells in cell culture. Diabetologia. 1995;38(7):764-771. [CrossRef] [Medline]
  48. Hotamisligil GS, Peraldi P, Budavari A, Ellis R, White MF, Spiegelman BM. IRS-1-mediated inhibition of insulin receptor tyrosine kinase activity in TNF-alpha- and obesity-induced insulin resistance. Science. 1996;271(5249):665-668. [CrossRef] [Medline]
  49. Shoelson SE, Lee J, Goldfine AB. Inflammation and insulin resistance. J Clin Invest. 2006;116(7):1793-1801. [FREE Full text] [CrossRef] [Medline]
  50. Cnop M, Foufelle F, Velloso LA. Endoplasmic reticulum stress, obesity and diabetes. Trends Mol Med. 2012;18(1):59-68. [CrossRef] [Medline]
  51. Furukawa S, Fujita T, Shimabukuro M, Iwaki M, Yamada Y, Nakajima Y, et al. Increased oxidative stress in obesity and its impact on metabolic syndrome. J Clin Invest. 2004;114(12):1752-1761. [FREE Full text] [CrossRef] [Medline]
  52. Kintscher U, Hartge M, Hess K, Foryst-Ludwig A, Clemenz M, Wabitsch M, et al. T-lymphocyte infiltration in visceral adipose tissue: a primary event in adipose tissue inflammation and the development of obesity-mediated insulin resistance. Arterioscler Thromb Vasc Biol. 2008;28(7):1304-1310. [FREE Full text] [CrossRef] [Medline]


ABI: ankle-brachial index
ASAO: elevated arterial stiffness and abdominal obesity
ASNAO: elevated arterial stiffness and no abdominal obesity
ASNO: elevated arterial stiffness and no obesity
ASO: elevated arterial stiffness and obesity
baPWV: brachial-ankle pulse wave velocity
HbA1c: glycated hemoglobin A1c
HR: hazard ratio
MAP: mean arterial pressure
NASAO: normal arterial stiffness and abdominal obesity
NASNAO: normal arterial stiffness and no abdominal obesity
NASNO: normal arterial stiffness and no obesity
NASO: normal arterial stiffness and obesity
TNF-α: tumor necrosis factor alpha


Edited by A Mavragani, T Sanchez; submitted 29.01.23; peer-reviewed by H Hou, X Tan; comments to author 28.08.23; revised version received 28.08.23; accepted 24.10.23; published 08.02.24.

Copyright

©Cancan Cui, Zhiyuan Wu, Jia Zheng, Jiaqi Chu, Jiajing Zhu, Yitian Qi, Zhenming Zhang, Zhijia Wang, Mengchao Zhang, Zhanhao Mo, Liangkai Cheng, Lei Ding, Xiaoping Kang, Lin Liu, Te Zhang. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 08.02.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Public Health and Surveillance, is properly cited. The complete bibliographic information, a link to the original publication on https://publichealth.jmir.org, as well as this copyright and license information must be included.