Body Weight Variability and Risk of Cardiovascular Outcomes and Death in the Context of Weight Loss Intervention Among Patients With Type 2 Diabetes

Elucidating the role of weight loss and glycaemic control in patients with type 2 diabetes

AIMS

To investigate the independent contributions of glycated haemoglobin (HbA1c) reduction and weight loss to clinical outcomes in patients with type 2 diabetes (T2D) treated with antidiabetic drugs, including glucagon-like peptide-1 receptor agonists (GLP-1RAs).

MATERIALS AND METHODS

This observational, retrospective cohort study used deidentified electronic health record-derived data from patients evaluated at the Cleveland Clinic (1 January 2000-31 December 2020). Cohort A included 8876 patients with newly diagnosed T2D treated with any of six antidiabetic drug classes. Cohort B included 4161 patients with T2D initiating GLP-1RA treatment. The effects of body mass index (BMI) and HbA1c reduction, variability, and durability on clinical outcomes were investigated.

RESULTS

In Cohort A, each 1% BMI reduction was associated with 3%, 1%, and 4% reduced risk of heart failure (p = 0.017), hypertension (p = 0.006), and insulin initiation (p = 0.001), respectively. Each 1% (~11 mmol/mol) HbA1c reduction was associated with 4% and 29% reduced risk of hypertension (p = 0.041) and insulin initiation (p = 0.001), respectively. In Cohort B, each 1% BMI reduction was associated with 4% and 3% reduced risk of cardiovascular disease (p = 0.008) and insulin initiation (p = 0.002), respectively. Each 1% (~11 mmol/mol) HbA1c reduction was associated with 4% and 16% reduced risk of chronic kidney disease (p = 0.014) and insulin initiation (p = 1 × 10-4), respectively. Lower BMI variability and greater BMI durability were associated with decreased risk of clinical outcomes in both cohorts.

CONCLUSIONS

Antidiabetic medication-associated, and specifically GLP-1RA-associated, weight loss and HbA1c reductions independently reduce real-world clinical outcome risk.

Association between longitudinal changes in body composition and the risk of kidney outcomes in participants with overweight/obesity and type 2 diabetes mellitus

AIMS

To assess the relationship of longitudinal changes in fat mass (FM), lean mass (LM) and waist circumference (WC) with incident kidney outcomes in people with overweight/obesity and type 2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

A total of 3927 participants with baseline estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2 from the Look AHEAD (Action for Health in Diabetes) trial were included. The primary outcome was kidney outcomes, defined as a decrease in eGFR of at least 40% from baseline at follow-up visit, or end-stage kidney disease.

RESULTS

During a median follow-up of 8.0 years, 450 kidney outcomes were documented after the first 1 year. In the intensive lifestyle intervention (ILI) group, reductions in FM (per 10% decrease, adjusted hazard ratio [HR] 0.80, 95% confidence interval [CI] 0.69-0.94) and WC (per 10% decrease, adjusted HR 0.72, 95% CI 0.59-0.88) from baseline to 1-year follow-up were significantly associated with a lower risk of kidney outcomes. The change in LM was not significantly associated with risk of kidney outcomes (per 10% decrease, adjusted HR 0.78, 95% CI 0.58-1.06). In the diabetes support and education group (control group), no significant association was found between changes in body composition and kidney outcomes. Similar results were observed for the 4-year changes in body composition.

CONCLUSIONS

In this post hoc analysis of the Look AHEAD trial, longitudinal declines in FM and WC were associated with a lower risk of kidney outcomes in the ILI group in participants with overweight/obesity and T2DM.

Metabolic syndrome parameters' variability and stroke incidence in hypertensive patients: evidence from a functional community cohort

BACKGROUND

Stroke is a common complication of hypertension, but the predictive value of metabolic syndrome parameters' variability on stroke risk in individuals with hypertension remains unclear. Therefore, our objective was to investigate the relationship between metabolic syndrome parameters' variability and the risk of total stroke and its subtypes in hypertensive patients.

METHODS

This prospective cohort study included 17,789 individuals with hypertension from the Kailuan study since 2006. Metabolic syndrome parameters, including waist circumference (WC), fasting blood glucose (FBG), systolic blood pressure (SBP), high-density lipoprotein cholesterol (HDL-C), and triglyceride (TG), were collected at three follow-up visits in the 2006, 2008, and 2010 surveys. We assess the variability utilizing the coefficient of variation (CV), standard deviation (SD), average real variation (ARV), and variability independent of the mean (VIM), with CV initially assessed. Participants were categorized based on the number of high-variability metabolic syndrome parameters (0, 1, 2, ≥ 3). Stroke cases were identified by reviewing medical records. The associations between variability in metabolic syndrome parameters and the risk of total stroke and its subtypes were analyzed using Cox proportional hazard regression models.

RESULTS

During a median follow-up of 9.32 years, 1223 cases of stroke were recorded. Participants with ≥ 3 high-variability metabolic syndrome parameters had an increased risk of total stroke (HR: 1.29, 95%CI 1.09-1.52), as well as an increased risk of ischemic stroke (HR: 1.31, 95%CI 1.05-1.63) compared to those without high-variability parameters. The study also examined variability in each metabolic syndrome parameter, and significant associations with an increased risk of total stroke were observed for variability in SBP (HR: 1.24, 95%CI 1.05-1.46) and HDL-C (HR: 1.34, 95%CI 1.09-1.64).

CONCLUSIONS

Long-term fluctuations in metabolic syndrome parameters significantly increase the risk of total stroke, especially ischemic stroke. Maintaining low variability in metabolic syndrome parameters could benefit health, and hypertensive individuals must be regularly monitored.

Association of body mass index and blood pressure variability with 10-year mortality and renal disease progression in type 2 diabetes

BACKGROUND

Variability in biological parameters may be associated with adverse outcomes. The aim of the study was to determine whether variability in body mass index (BMI) and blood pressure is associated with all-cause, cardiovascular mortality and cancer mortality or with renal disease progression in subjects with type 2 diabetes.

METHODS

The diabetes database was accessed, and all the information on patient visits (consultations) carried out in the study period (1 January 2008-31 December 2019) was extracted and linked to the laboratory database and the mortality register.

RESULTS

The total number of patients included in the study population was 26,261, of whom 54.4% were male. Median (interquartile range, IQR) age was 60.2 (51.8-68.3) years. The coefficient of variability of BMI was independently associated with increased all-cause and cardiovascular, but not cancer, mortality. Glycated haemoglobin (HbA1c) was associated with increased all-cause, cardiovascular, and cancer mortality as well as with renal progression. Variability in systolic blood pressure, diastolic blood pressure, and pulse pressure was associated with increased all-cause and cardiovascular mortality in bivariate, but not in multivariate, analyses.

CONCLUSIONS

Variability in BMI was associated with increased all-cause and cardiovascular, but not cancer, mortality in a large real-world contemporary population. Our results also confirm the association of HbA1c with increased all-cause, cardiovascular, and cancer mortality as well as with renal progression.

The association of body mass index variability with cardiovascular disease and mortality: a mediation analysis of pooled cohorts

Aim

We aimed to investigate the effect of BMI variability on CVD and mortality and to explore the mediation effects of the main cardiovascular risk factors contributing to this association.

Method

Participants aged 40-65 years were pooled from three cohort studies(ARIC [Atherosclerosis Risk in Communities], MESA [Multi-ethnic Study of Atherosclerosis], and TLGS [Tehran Lipid and Glucose Study]. We employed root mean squared error of the fractional mixed model to calculate BMI variability in the measurement period. In the event assessment period, the hazard ratios for CVD and mortality were estimated using Cox proportional hazard regression models. In the next step, the mediation and interaction effects of fasting plasma glucose, total cholesterol, and systolic blood pressure were determined.

Results

A total of 19073 participants were included in this pooled analysis. During a median of 20.7 years of follow-up, 3900 (20.44%) CVD and 6480 (33.97%) all-cause mortality events were recorded. After adjusting for potential confounders, BMI variability was linked to the 1.3 (1.2-1.4) and 1.7 (1.6-1.8) increased risk of CVD and mortality, respectively. Fasting plasma glucose mediated approximately 24% and 8% of the effect of BMI variability on CVD and mortality, respectively. However, systolic blood pressure and total cholesterol did not have mediation effects in this association.

Conclusion

High BMI variability is independently associated with the development of CVD and mortality. This association is partly mediated through fasting plasma glucose. Modern cardiometabolic therapies that lower fasting glucose may reduce the risk of future CVD and mortality in individuals with high BMI variability.

High Variability of Body Mass Index Is Independently Associated With Incident Heart Failure

BACKGROUND

Heart failure (HF) is a serious condition with increasing prevalence, high morbidity, and increased mortality. Obesity is an established risk factor for HF. Fluctuation in body mass index (BMI) has shown a higher risk of cardiovascular outcomes. We investigated the association between BMI variability and incident HF.

METHODS AND RESULTS

In the UK Biobank, we established a prospective cohort after excluding participants with prevalent HF or cancer at enrollment. A total of 99 368 White participants with ≥3 BMI measures during >2 years preceding enrollment were included, with a median follow-up of 12.5 years. The within-participant variability of BMI was evaluated using standardized SD and coefficient of variation. The association of BMI variability with incident HF was assessed using Fine and Gray's competing risk model, adjusting for confounding factors and participant-specific rate of BMI change. Higher BMI variability measured in both SD and coefficient of variation was significantly associated with higher risk in HF incidence (SD: hazard ratio [HR], 1.05 [95% CI, 1.03-1.08], P<0.0001; coefficient of variation: HR, 1.07 [95% CI, 1.04-1.10], P<0.0001).

CONCLUSIONS

Longitudinal health records capture BMI fluctuation, which independently predicts HF incidence.

Association of midlife body-weight variability and cycles with earlier dementia onset: a nationwide cohort study

BACKGROUND

Given the rising awareness of health-related lifestyle modifications, the impact of changes in body weight (BW) on cognitive function and dementia generates significant concern. This study aimed to investigate the association between BW changes and dementia in a middle-aged Korean population.

METHODS

A retrospective, population-based longitudinal study was conducted utilizing data from the National Health Insurance Service (NHIS) database. Participants aged 40 years or older in 2011 who underwent at least five health checkups between 2002 and 2011 were followed-up for dementia until 2020. A total of 3,635,988 dementia-free Korean aged < 65 at baseline were examined. We analyzed the association between BW variability independent of the mean (VIM) with BW cycle, defined as either an upward or a downward direction of BW, and the risk of incident dementia.

RESULTS

The results showed an increased risk of dementia in the highest quartile of VIM quartile (hazard ratio [HR] 1.52, 95% confidence interval [CI] 1.47-1.58) compared to the lowest quartile of VIM. Additionally, the results showed an even higher increased risk of dementia in the highest BW cycle (≥ 2 cycles of 10% BW = HR 2.00, 95% CI 1.74-1.29). Notably, the combined concept of VIM with BW cycle showed an even higher dementia risk (highest quartile of VIM with ≥ 2 cycles of 10% BW = HR 2.37, 95% CI 2.05-2.74) compared to the baseline group (lowest quartile of VIM with < 3% BW cycle).

CONCLUSIONS

The present study highlights the importance of considering BW changes with BW variability along with the BW cycle to assess dementia risk in detail, providing valuable insights for preventive strategies.

Gender differences in midlife to later-life cumulative burden and variability of obesity measures and risk of all-cause and cause-specific mortality

BACKGROUND/OBJECTIVES

Previous studies have reported the gender-specific association between general and central obesity measures, using snapshot assessments, and mortality events. This study seeks to further explore this link by examining how the longitudinal cumulative burden and variability of obesity measures from midlife to later-life impact mortality events in the Atherosclerosis Risk in Communities (ARIC) study population, specifically in relation to gender differences.

SUBJECTS/METHODS

Using data from the ARIC study, a total of 7615 (4360 women) participants free of cardiovascular disease, cancer, and early mortality events were included in the data analysis. Longitudinal cumulative burden (estimated by the area under the curve (AUC) using a quadratic mixed-effects method) and variability (calculated according to average successive variability (ASV)) were considered as exposures, separately and all together. Cox proportional hazard regression models were used to estimate multivariable-adjusted standardized hazard ratios.

RESULTS

The mean age was 62.4 and the median follow-up was 16.9 years. In men, AUCs of waist-related obesity measures, and also ASVs of all obesity measures were associated with increased all-cause mortality risk. In women, waist circumference and waist-to-height ratio AUCs were associated with increased all-cause mortality risk. Regarding cardiovascular mortality, all adiposity measures ASVs in both genders and waist-related obesity measures AUCs in men were associated with increased risk. Significant gender differences were found for the associations between cumulative and variability of waist-to-hip ratio for all-cause mortality and all adiposity measures ASVs for cardiovascular mortality risk with higher impact among men.

CONCLUSIONS

Cumulative burden and variability in general and central obesity measures were associated with higher all-cause and cardiovascular mortalities among men. In women, general obesity measures variability, as well as cumulative and variability of central adiposity measure, increased all-cause mortality risk.

Trajectories of Body Mass Index and Risk for Diabetes Complications and All-Cause Mortality in Finnish Type 2 Diabetes Patients

Objective

We aimed to assess how longitudinal body mass index (BMI) trajectories are associated with diabetes complications and all-cause mortality in Finnish patients with type 2 diabetes (T2D).

Methods

In this cohort study, electronic health records from public primary and specialized healthcare services in all 13 municipalities of North Karelia, Finland, were utilized. This study included a total of 889 adults with newly diagnosed T2D in 2011 or 2012 (mean age at baseline 62.0 years). Individual BMI trajectories from the T2D diagnosis until 2014 were estimated and grouped by growth mixture modeling (GMM). Hazard ratios (HRs) with 95% confidence intervals (CIs) for microvascular complications, macrovascular complications, any diabetes complications, and all-cause mortality from 2015 to 2022 across BMI trajectory groups were estimated using Cox regression models.

Results

Three distinct BMI trajectory groups were identified using GMM and labeled as follows: "stable" (n = 774, 87.1%), "decreasing" (n = 87, 9.8%), and "increasing" (n = 28, 3.1%). During a median follow-up of 8 years, there were 119 (13.3%) patients with microvascular complications, 187 (21.0%) with macrovascular complications, 258 (29.0%) with any diabetes complications, and 180 (20.2%) deaths. Compared with the "stable" BMI, the "increasing" BMI was associated with an increased risk of microvascular complications (HR = 2.88, 95% CI: 1.32 to 6.28), macrovascular complications (HR = 2.52, 95% CI: 1.17 to 5.43), and any diabetes complications (HR = 2.21, 95% CI: 1.16 to 4.20). The "decreasing" BMI was associated with an increased risk of all-cause mortality (HR = 1.90, 95% CI: 1.14 to 3.15), compared to the "stable" BMI.

Conclusion

Our findings underscore the significance of continuous BMI monitoring and weight management in patients with T2D. Tailored treatments are crucial for efficiently preventing weight gain and reducing the risk of diabetes complications.

Association of variability in body size with neuroimaging metrics of brain health: a population-based cohort study

Background

The relationship between the fluctuation in body size and brain health is poorly understood. This study aimed to examine the associations of long-term variability in body mass index (BMI) and waist-to-hip ratio (WHR) with neuroimaging metrics that approximate brain health.

Methods

This cohort study recruited 1114 participants aged 25-83 years from a multicenter, community-based cohort study in China. We modeled the BMI and WHR trajectories of participants during 2006-2018 and assessed the BMI and WHR variability (direction and speed of change) by calculating the slope. Generalized linear models were applied to investigate the associations of BMI and WHR variability with MRI markers of brain tissue volume, white matter microstructural integrity, white matter hyperintensity (WMH), and cerebral small vessel disease (CSVD).

Findings

Progressive weight gain during follow-up was associated with lower global fractional anisotropy (beta = -0.18, 95% confidence interval [CI] -0.34 to -0.02), higher mean diffusivity (beta = 0.15, 95% CI 0.01-0.30) and radial diffusivity (beta = 0.17, 95% CI 0.02-0.32). Weight loss was also associated with a lower burden of periventricular WMH (beta = -0.26, 95% CI -0.48 to -0.03) and a lower risk of moderate-to-severe basal ganglia enlarged perivascular spaces (BG-EPVS, odds ratio [OR] = 0.41, 95% CI 0.20-0.83). Among overweight populations, weight loss was linked with smaller volumes of WMH (beta = -0.47, 95% CI -0.79 to -0.15), periventricular WMH (beta = -0.57, 95% CI -0.88 to -0.26), and deep WMH (beta = -0.36, 95% CI -0.69 to -0.03), as well as lower risk of CSVD (OR = 0.22, 95% CI 0.08-0.62), lacune (OR = 0.12, 95% CI 0.01-0.91) and moderate-to-severe BG-EPVS (OR = 0.24, 95% CI 0.09-0.61). In adults with central obesity, WHR loss was positively associated with larger gray matter volume (beta = 0.50, 95% CI 0.11-0.89), hippocampus volume (beta = 0.62, 95% CI 0.15-1.09), and parahippocampal gyrus volume (beta = 0.85, 95% CI 0.34-1.37). The sex-stratification and age-stratification analyses revealed similar findings with the main results, with the pattern of associations significantly presented in the individuals at mid-life and late-life.

Interpretation

Long-term stability of BMI level is essential for maintaining brain health. Progressive weight gain is associated with impaired white matter microstructural integrity. Weight and WHR losses are associated with improved general brain health. Our results contribute to a better understanding of the integrated associations between variations in obesity measures and brain health.

Funding

This study was supported by grants No. 62171297 (Han Lv) and 61931013 (Zhenchang Wang) from the National Natural Science Foundation of China, No. 7242267 from the Beijing Natural Science Foundation (Han Lv), and No. [2015] 160 from the Beijing Scholars Program (Zhenchang Wang).

Effects of body weight variability on risks of macro- and microvascular outcomes in individuals with type 2 diabetes: The Rio de Janeiro type 2 diabetes cohort

AIMS

To investigate the effects of body weight variability (BWV) on macro- and microvascular outcomes in a type 2 diabetes cohort.

METHODS

BWV parameters were assessed in 684 individuals. Multivariable Cox regressions examined associations between BWV parameters and cardiovascular outcomes (total cardiovascular events [CVEs], major CVEs [MACEs], cardiovascular deaths),all-cause mortality and microvascular outcomes. Interaction/subgroup analyses were performed according to being physically-active/sedentary and having/not lost ≥ 5 % of weight.

RESULTS

Median follow-up was 11 years over which 194 total CVEs (174 MACEs), and 223 all-cause deaths (110 cardiovascular), occurred. There were 215 renal, 152 retinopathy and 167 peripheral neuropathy development/worsening outcomes. In general, increased BWV was associated with higher risks of CVEs, MACEs, all-cause mortality, advanced renal failure and peripheral neuropathy outcomes, but not of microalbuminuria and retinopathy outcomes. On interaction/subgroup analyses, increased BWV was associated with higher risks of outcomes in sedentary individuals and in those who did not lose ≥ 5 % of body weight. In physically-active participants or in those who lost ≥ 5 % weight, the adjusted risks were null or protective.

CONCLUSIONS

Increased BWV was associated with most adverse outcomes; however, in those who were physically-active or consistently losing weight, it was not hazardous and might be even beneficial.

Weight cycling and risk of clinical adverse events in patients with heart failure with preserved ejection fraction: a post-hoc analysis of TOPCAT

Background

Previous studies hardly evaluated the association of variability of body mass index (BMI) or waist circumference with clinical adverse events and investigated whether weight cycling had an effect on the prognosis of patients with heart failure with preserved ejection fraction (HFpEF).

Methods

This study was a post-hoc analysis of TOPCAT. Three outcomes were evaluated: the primary endpoint, cardiovascular disease (CVD) death, and heart failure hospitalization. Among them, CVD death and hospitalization were outcomes of heart failure. Kaplan-Meier curves were used to describe the cumulative risk of outcome and were tested using the log-rank test. Cox proportional hazards regression models were used to calculate hazard ratios (HRs) and 95%CIs for outcomes. We also performed a subgroup analysis, and several subgroups were compared.

Results

A total of 3,146 patients were included. In the Kaplan-Meier curves, the coefficients of variation of both BMI and waist circumference were grouped according to quartiles, with the Q4 group having the highest cumulative risk (log-rank P < 0.001). In the coefficient of BMI variation and the outcomes, the HRs for group Q4 of coefficient of variation of BMI were 2.35 (95%CI: 1.82, 3.03) for the primary endpoint, 2.40 (95%CI: 1.69, 3.40) for death, and 2.33 (95%CI: 1.68, 3.22) for HF hospitalization in model 3 (fully adjusted model) compared with group Q1. In the coefficient of waist circumference variation and the outcomes, group Q4 had increased hazard of the primary endpoint [HR: 2.39 (95%CI: 1.84, 3.12)], CVD death [HR: 3.29 (95%CI: 2.28, 4.77)], and HF hospitalization [HR: 1.98 (95%CI 1.43, 2.75)] in model 3 (fully adjusted model) compared with group Q1. In the subgroup analysis, there was a significant interaction in the diabetes mellitus subgroup (P for interaction = 0.0234).

Conclusion

Weight cycling had a negative effect on the prognosis of patients with HFpEF. The presence of comorbid diabetes weakened the relationship between waist circumference variability and clinical adverse events.

Association of body weight change with all-cause and cause-specific mortality: A nationwide population-based study

AIMS

Weight gain and loss increase the risk of all-cause mortality. This study explored the association of short-term weight change with all-cause and cause-specific mortality in middle-aged to older people.

METHODS

This was a 8.4-year retrospective cohort study of 645,260 adults aged 40 to 80 who underwent health checkups twice within a 2-year interval between January 2009 and December 2012. Cox analyses were used to analyze the association between short-term weight change and all-cause and cause-specific mortality.

RESULTS

Weight gain and loss were associated with an increased risk of all-cause mortality: the hazard ratios were 2.05 (95% confidence interval [CI], 1.93-2.16), 1.21 (95% CI, 1.16-1.25), 1.12 (95% CI 1.08-1.17), and 1.60 (95% CI, 1.49-1.70) for the severe weight loss, moderate weight loss, moderate weight gain, and severe weight gain groups, respectively. This U-shaped association was also seen between weight change and cause-specific mortality. Within the weight loss group, those who regained weight after two years had a reduced mortality risk.

CONCLUSIONS

In a middle-aged and elderly population, weight gain or loss of more than 3% during a 2-year interval was related to an elevated risk of all-cause and cause-specific mortality.

High Variability of Body Mass Index Independently Associated with Incident Heart Failure

Background

Heart failure (HF) is a serious condition with increasing prevalence, high morbidity, and increased mortality. Obesity is an established risk factor for cardiovascular diseases, including HF. Fluctuation in body mass index (BMI) has shown a higher risk of cardiovascular outcomes. We investigated the association between BMI variability and incident HF.

Methods

In the UK Biobank, we established a prospective cohort after excluding participants with prevalent HF or cancer at enrollment. A total of 99,368 White (British, Irish, and any other white background) participants with ≥ 3 BMI measures during > 2 years preceding enrollment were included, with a median follow-up of 12.5 years. The within-participant variability of BMI was evaluated using standardized standard deviation (SD) and coefficient of variation (CV). The association of BMI variability with incident HF was assessed using Fine and Gray's competing risk model, and adjusted for age, sex, smoking history, alcohol consumption, diabetes, hypertension, history of heart attack, stroke, atrial fibrillation, lipids, estimated glomerular filtration rate and mean BMI per individual.

Results

In the fully adjusted model, higher BMI variability measured in both SD and CV were significantly associated with higher risk in HF incidence (SD: Hazard Ratio [HR] 1.05, 95% Confidence Interval [CI] 1.02 - 1.07, p = 0.0002; CV: HR 1.06, 95% CI 1.04 - 1.09, p < 0.0001).

Conclusions

Longitudinal health records capture BMI fluctuation, which independently predicts HF incidence. Integration of long-term BMI and other routinely measured health factors may improve risk prediction of HF and other cardiovascular outcomes.

The challenges and pitfalls of incorporating evidence from cardiovascular outcomes trials in health economic modelling of type 2 diabetes

The clinical evidence base for evaluating modern type 2 diabetes interventions has expanded greatly in recent years, with numerous efficacious treatment options available (including dipeptidyl peptidase-4 inhibitors, glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors). The cardiovascular safety of these interventions has been assessed individually versus placebo in numerous cardiovascular outcomes trials (CVOTs), statistically powered to detect differences in a composite endpoint of major adverse cardiovascular events. There have been growing calls to incorporate these data in the long-term modelling of type 2 diabetes interventions because current diabetes models were developed prior to the conduct of the CVOTs and therefore rely on risk equations developed in the absence of these data. However, there are numerous challenges and pitfalls to avoid when using data from CVOTs. The primary concerns are around the heterogeneity of the trials, which have different study durations, inclusion criteria, rescue medication protocols and endpoint definitions; this results in significant uncertainty when comparing two or more interventions evaluated in separate CVOTs, as robust adjustment for these differences is difficult. Analyses using CVOT data inappropriately can dilute clear evidence from head-to-head clinical trials, and blur healthcare decision making. Calibration of existing models may represent an approach to incorporating CVOT data into diabetes modelling, but this can only offer a valid comparison of one intervention versus placebo based on a single CVOT. Ideally, model development should utilize patient-level data from CVOTs to prepare novel risk equations that can better model modern therapies for type 2 diabetes.

Repercussions of absolute and time-rated BMI "yo-yo" fluctuations on cardiovascular stress-related morbidities within the vascular-metabolic CUN cohort

Aims

The association between body mass index (BMI) fluctuation and BMI fluctuation rate with cardiovascular stress morbidities in a Caucasian European cohort was evaluated to ascertain the impact of weight cycling.

Methods

A total of 4,312 patients of the Vascular-Metabolic CUN cohort (VMCUN cohort) were examined and followed up during 9.35 years ( ± 4.39). Cox proportional hazard ratio analyses were performed to assess the risk of developing cardiovascular stress-related diseases (CVDs) across quartiles of BMI fluctuation, measured as the average successive variability (ASV) (ASV = |BMIt0 - BMIt1| + |BMIt1 - BMIt2| + |BMIt2-BMIt3| +…+ |BMItn - 1 - BMItn|/n - 1), and quartiles of BMI fluctuation rate (ASV/year).

Results

There were 436 incident cases of CVD-associated events involving 40,323.32 person-years of follow-up. A progressively increased risk of CVD in subjects with greater ASV levels was found. Also, a higher level of ASV/year was significantly associated with an increased risk of developing CVD stress independent of confounding factors with a value of 3.71 (95% CI: 2.71-5.07) for those in the highest quartile and 1.82 (95% CI: 1.33-2.50) for those in the third quartile.

Conclusions

The BMI fluctuation rate seems to be a better predictor than BMI fluctuation of the potential development of cardiovascular stress morbidities. The time-rated weight fluctuations are apparently more determinant in increasing the risk of a CVD than the weight fluctuation itself, which is remarkable in subjects under "yo-yo" weight patterns for precision medicine.

Recent Updates on Associations among Various Obesity Metrics and Cognitive Impairment: from Body Mass Index to Sarcopenic Obesity

Obesity and obesity-associated morbidity continues to be a major public health issue worldwide. Dementia is also a major health concern in aging societies and its prevalence has increased rapidly. Many epidemiologic studies have shown an association between obesity and cognitive impairment, but this relationship is not as well established as other comorbidities. Conflicting results related to the age and sex of participants, and the methodology used to define obesity and dementia may account for the uncertainty in whether obesity is a modifiable risk factor for dementia. More recently, sarcopenia and sarcopenic obesity have been reported to be associated with cognitive impairment. In addition, new mediators such as the muscle-myokine-brain axis and gut-microbiota-brain axis have been suggested and are attracting interest. In this review, we summarize recent evidence on the link between obesity and cognitive impairment, especially dementia. In particular, we focus on various metrics of obesity, from body mass index to sarcopenia and sarcopenic obesity.

Type 2 Diabetes Incidence and Mortality: Associations with Physical Activity, Fitness, Weight Loss, and Weight Cycling

Cardiometabolic diseases, including cardiovascular disease (CVD) and type 2 diabetes (T2D), are the leading cause of death globally. Because T2D and obesity are strongly associated, weight loss is the cornerstone of treatment. However, weight loss is rarely sustained, which may lead to weight cycling, which is associated with increased mortality risk in patients with T2D. Meta-analyses show that weight loss is not generally associated with reduced mortality risk in T2D, whereas weight cycling is associated with increased all-cause and CVD mortality. This may be attributable in part to increased variability in CVD risk factors that often accompany weight cycling, which studies show is consistently associated with adverse CVD outcomes in patients with T2D. The inconsistent associations between weight loss and mortality risk in T2D, and consistent findings of elevated mortality risk associated with weight cycling, present a conundrum for a weight-loss focused T2D prevention and treatment strategy. This is further complicated by the findings that among patients with T2D, mortality risk is lowest in the body mass index (BMI) range of ~25-35 kg/ m 2 . Because this "obesity paradox" has been consistently demonstrated in 7 meta-analyses, the lower mortality risk for individuals with T2D in this BMI range may not be all that paradoxical. Physical activity (PA), cardiorespiratory fitness (CRF), and muscular fitness (MF) are all associated with reduced risk of T2D, and lower risk of CVD and all-cause mortality in individuals with T2D. Reducing sedentary behavior, independent of PA status, also is strongly associated with reduced risk of T2D. Improvements in cardiometabolic risk factors with exercise training are comparable to those observed in weight loss interventions, and are largely independent of weight loss. To minimize risks associated with weight cycling, it may be prudent to adopt a weight-neutral approach for prevention and treatment of individuals with obesity and T2D by focusing on increasing PA and improving CRF and MF without a specific weight loss goal.

Role of the N6-methyladenosine regulatory factor in reducing the risk of cardiovascular disease: subtype diagnosis following aerobic exercise-assisted weight loss

OBJECTIVES

This study aimed to construct a model based on different N6-methyladenosine (m6A) regulatory factors involved in reducing the risk of the development of cardiovascular diseases under conditions of aerobic exercise.

METHODS

We screened for significantly different expressions of m6A regulators from the GSE66175 dataset. Five candidate m6A regulators were identified using the random forest model to predict aerobic exercise-mediated fat loss and reduction of the risk of cardiovascular disease. A nomogram model was established for analysis, and the consensus clustering method was used to distinguish between the two m6A clusters (clusters A and B). The single-sample gene set-enrichment analysis method was used to assess the abundance of immune cells in the samples related to cardiovascular anomalies. We determined the relationship between the functions of 29 immune cells and m6A clusters.

RESULTS

Twelve significantly and differentially expressed m6A regulators in the control and aerobic exercise groups were screened out, and it was observed that METTL13 correlated positively with the expression levels of the YTH domain containing 1 (YTHDC1), YTH N (6)-methyl adenosine RNA binding protein 1, and leucine-rich pentatricopeptide repeat-containing. The fat mass and obesity-associated gene negatively correlated with YTHDC1 and the fragile X mental retardation 1 protein. The random forest and support vector machine models were used to screen the ELAV-like RNA binding protein 1 (ELAVL1), RNA binding motif protein 15B (RBM15B), insulin-like growth factor binding protein 1 (IGFBP1), Wilms tumor 1-associated protein (WTAP), and zinc finger CCCH-type containing 13 (ZC3H13) genes. Analysis of the line graph model and the results obtained using decision curve analysis revealed the efficiency of the model. Gene ontology enrichment analysis was used to analyze the m6A regulatory gene model, and the results suggested that it was associated with RNA splicing. The results obtained using the Kyoto Encyclopedia of Genes and Genomes enrichment analysis method suggests that the genes were associated with Alzheimer's disease and neurodegeneration pathways associated with multiple diseases. The m6A regulatory gene model was associated with most of the immune cells infiltrating tumors and was also closely related to genes associated with lipid metabolism.

CONCLUSIONS

The m6A regulatory factor plays an important role in reducing the risk of cardiovascular disease under conditions of aerobic exercise-assisted weight loss. It is also associated with the metabolic pathways of low-density lipoprotein, high-density lipoprotein, and triglyceride.

Cardiovascular effects of intensive lifestyle intervention in adults with overweight/obesity and type 2 diabetes according to body weight time in range

BACKGROUND

We aimed to assess whether the cardiovascular effects of intensive lifestyle intervention (ILI) vary for those who can maintain the lower body weight after weight loss through ILI.

METHODS

In the secondary analysis of the Look AHEAD trial, we identified the status of weight loss for the participants in the ILI arm based on body weight time in range (TIR). These participants were allocated to three groups according to body weight TIR: 0% (n = 727), >0% to 50% (n = 656), and >50% to 100% (n = 811). For each group, cardiovascular outcomes were compared with matched participants receiving diabetes support & education (DSE) using 1:1 propensity score matching and Cox regression.

FINDINGS

During a median of 9·5 years of follow-up, participants with TIR of >50% to 100% can effectively maintain their body weight after weight loss through ILI; participants with TIR of 0% or >0% to 50% do not achieve or maintain weight loss. Compared with the corresponding matched participants in the DSE arm, participants with TIR of >50% to 100% in the ILI arm had a 45% lower risk of the primary outcome (HR 0·55, 95% CI 0·40-0·76), and no significant effects were found on the risk of the primary outcome in participants with TIR of 0% (HR 1·12, 95% CI 0·86-1·46) or >0% to 50% (HR 1·14, 95% CI 0·85-1·52).

INTERPRETATION

In adults with overweight/obesity and type 2 diabetes, ILI might help in lowering the risk of cardiovascular events when the lower body weight is maintained after weight loss.

FUNDING

None.

Elevated levels of body mass index and waist circumference, but not high variability, are associated with an increased risk of atrial fibrillation

BACKGROUND

Although obesity has been associated with risk of atrial fibrillation (AF), the associations of variability of obesity measures with AF risk are uncertain, and longitudinal studies among Chinese population are still lacking. We aimed to evaluate the impacts of obesity and variability of body mass index (BMI) and waist circumference (WC) on the risk of atrial fibrillation (AF) in a large Chinese cohort study.

METHODS

A total of 44,135 participants of the Kailuan Study who were free of cancer and cardiovascular disease and underwent three consecutive surveys from 2006 to 2010 were followed for incident AF until 2020. Average BMI and WC over time and variability were calculated. Cox proportional hazards regression models were used to assess hazard ratios (HRs) and 95% confidence intervals (CIs) for the associations of obesity and variability in BMI and WC with AF risk.

RESULTS

During a mean follow-up of 9.68 years, there were 410 cases of incident AF. In multivariable-adjusted models, compared with normal BMI/WC, individuals with general obesity and abdominal obesity had increased risk of AF, with corresponding HRs of 1.73 (95% CI: 1.31-2.30) and 1.38 (95% CI: 1.11-1.60), respectively. The short-term elevation in AF risk persisted for the obese even after adjustment for updated biologic intermediaries and weight. Variability in BMI and WC were not associated with the risk of AF. The restricted cubic spline models indicated significant linear relationships between levels of WC and BMI and risk of AF.

CONCLUSIONS

Elevated levels of BMI and WC were associated with an increased risk of AF, whereas variability in BMI and WC were not. Therefore, achieving optimal levels of BMI and WC could be valuable in AF prevention.

Association of magnitude of weight loss and weight variability with mortality and major cardiovascular events among individuals with type 2 diabetes mellitus: a systematic review and meta-analysis

Background

Weight management is strongly promoted for overweight or obese patients with type 2 diabetes (T2DM) by current guidelines. However, the prognostic impact of weight loss achieved without behavioural intervention on the mortality and cardiovascular (CV) outcomes in diabetic patients is still contested.

Methods

We searched the PubMed, Embase, and Cochrane Library databases for studies that investigated the association of weight loss or weight variability with mortality and CV outcomes. Results of studies that measured weight loss by percentage weight loss from baseline and stratified it as > 10% and 5–10% or studies that computed weight variability were pooled using random effects model. Study quality was evaluated using the Newcastle–Ottawa Scale.

Results

Thirty eligible studies were included in the systematic review and 13 of these were included in the meta-analysis. Large weight loss (> 10%) was associated with increased risk of all-cause mortality (pooled hazard ratio (HR) 2.27, 95% CI 1.51–3.42), composite of major CV events (pooled HR 1.71, 95% CI 1.38–2.12) and CV mortality (pooled HR 1.50, 95% CI 1.27–1.76) among T2DM patients. Moderate weight loss showed no significant association with all-cause mortality (pooled HR 1.17, 95% CI 0.97–1.41) or CV outcomes (pooled HR 1.12, 95% CI 0.94–1.33). Weight variability was associated with high hazard of all-cause mortality (pooled HR 1.54, 95% CI 1.52–1.56).

Conclusions

Large weight loss and large fluctuations in weight are potential markers of increased risk of mortality and CV events in T2DM patients. Maintaining a stable weight may have positive impact in these patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01503-x.