sign in sign up
<<
Home , Metabolic syndrome

Cardiovascular and Metabolic Risk ORIGINAL ARTICLE

BMI Versus the Metabolic Syndrome in Relation to Cardiovascular Risk in Elderly Chinese Individuals

1,2 1 YAO HE, MD, PHD SHANXIANG ZHU, MPH have suggested that the association be- 3 5 BIN JIANG, MD, PHD LI FAN, MD tween BMI and risk of CVD became non- 4 5 JIE WANG, MD, PHD XIAOYING LI, MD significant after adjustment for metabolic 1 2 KANG FENG, MD FRANK B. HU, MD, PHD 1 syndrome (14). In this study, we exam- QING CHANG, MD ined the relative associations of BMI ver- sus metabolic syndrome with the prevalence of CVD in a population-based OBJECTIVE — The purpose of this study was to evaluate the associations of BMI versus survey of elderly Chinese individuals in metabolic syndrome with cardiovascular diseases (CVDs) in elderly Chinese individuals. Beijing, China. RESEACH DESIGN AND METHODS — We conducted a population-based cross- sectional study in an urban sample of 2,334 elderly subjects (943 men and 1,391 women). RESEARCH DESIGN AND Subjects were classified by BMI (Յ18.5, Ͻ24, Ͻ28, and Ն28 kg/m2) and the presence or METHODS — This study was a popu- absence of metabolic syndrome, which was defined by International Federation (IDF) lation-based cross-sectional survey of in- criteria. CVDs included clinically diagnosed coronary heart disease (CHD), , and periph- dividuals aged Ն60 years living in the eral arterial disease (PAD). Wanshoulu Community of Haidian Dis- trict, a metropolitan area representative of Ն 2 RESULTS — The prevalence rates of (BMI 25 kg/m ) and metabolic syndrome the geographic and economic characteris- according to the IDF criteria were 56.3% (53.9% in men and 57.9% in women) and 46.3% tics in Beijing, China. A two-stage strati- (34.8% in men and 54.1% in women), respectively. Increasing BMI was strongly associated with a higher risk of CHD, stroke, and PAD even after adjustments for metabolic syndrome and other fied sampling method was used. First, CVD risk factors. Stratified analysis of participants with or without metabolic syndrome showed nine residential communities or streets that BMI was independently associated with CHD, stroke, and PAD. (about 300–600 households) were ran- domly selected from a total of 94 residen- CONCLUSIONS — Both overweight and metabolic syndrome are highly prevalent in this tial communities in the Wanshoulu area elderly Chinese population. BMI, as a measure of overall adiposity, is strongly associated with in Beijing. Second, all households were increased prevalence of CVD independent of metabolic syndrome. chosen from the selected streets, but only one eligible participant was randomly se- Diabetes Care 30:2128–2134, 2007 lected from each household. Between April 2001 and March 2002, 2,680 peo- hina is experiencing rapid economic recent report in elderly individuals in ur- ple aged 60–95 years were selected and growth and aging of its population. ban China, the prevalence rates of meta- invited for . The 2,334 subjects C Resulting changes in lifestyle and bolic syndrome by the National (943 men and 1,391 women) attended longer life expectancy have led to an in- Cholesterol Education Program (10) and five clinics where detailed health evalua- creased burden of cardiovascular diseases new International Diabetes Federation tions were completed, yielding a response (CVDs) and other chronic diseases (1,2). (IDF) (11) criteria were 30.5 and 46.3%, rate of 87.1% (83.5% in men and 89.7% A nationwide study from China indicates and the individuals with metabolic syn- in women); these subjects accounted for that Ͼ30% of adults are overweight, and drome defined by either criteria had sig- 11.4% of elderly residents in the Wan- the prevalence of metabolic syndrome is nificantly elevated risks for CVD (12). shoulu area. 13.7% (3). and metabolic syn- However, the role of obesity as an inde- The details of data collection have drome frequently coexist, and both are pendent etiologic factor for CVD remains been reported elsewhere (12). Height was associated with CVD risk (4–9). In our controversial (13,14). Previous studies measured in meters (without shoes) and ●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●● weight in kilograms (with heavy clothing

1 2 removed and 1 kg deducted for remaining From the Institute of Geriatrics, Chinese PLA General Hospital, Beijing, China; , Harvard School garments). circumference was mea- of Public Health, Boston, Massachusetts; 3Acupuncture, Chinese PLA General Hospital, Beijing, China; the 4Clinic of PLA Communication, Beijing, China; and 5Geriatric Cardiology, Chinese PLA General Hospital, sured while subjects were standing with a Beijing, China. soft tape midway between the lowest rib Address correspondence and reprint requests to Dr. Yao He, Institute of Geriatrics, Chinese PLA General and the iliac crest. Two blood pressure Hospital, 28 Fuxing Road, Beijing 100853, China. E-mail: [email protected] or [email protected]. recordings were obtained from the right Received for publication 23 November 2006 and accepted in revised form 23 April 2007. Published ahead of print at http://care.diabetesjournals.org on 27 April 2007. DOI: 10.2337/dc06-2402. arms of patients in a sitting position after Abbreviations: CHD, coronary heart disease; CVD, ; ECG, electrocardiogram; IDF, 30 min of rest; measurements were taken International Diabetes Federation; PAD, peripheral artery disease; WHO, World Health Organization. in 5-min intervals, and mean values were A table elsewhere in this issue shows conventional and Syste`me International (SI) units and conversion calculated. We also performed other factors for many substances. physical examinations and tests (includ- © 2007 by the American Diabetes Association. The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby ing an electrocardiogram [ECG], an marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. ankle-arm systolic blood pressure index,

2128 DIABETES CARE, VOLUME 30, NUMBER 8, AUGUST 2007 2129 He and Associates Table 1—Clinical and metabolic characteristics in subjects with BMI <18.5, <24, <28, and >28 kg/m2

BMI Յ 2 2 2 Ն 2 Characteristics 18.5 kg/m 18.6–23.9 kg/m 24.0–27.9 kg/m 28.0 kg/m Total Ptrend n (female/male) 118 (71/47) 615 (357/258) 1,083 (629/454) 518 (334/184) 2,334 (1,391/943) Age (years) 70.7 Ϯ 7.6 67.8 Ϯ 6.0 67.3 Ϯ 5.7 67.5 Ϯ 5.7 67.6 Ϯ 6.0 Ͻ0.001 Systolic blood pressure (mmHg) 130.6 Ϯ 22.6 134.0 Ϯ 20.6 136.1 Ϯ 20.2 143.6 Ϯ 22.1 136.9 Ϯ 21.1 Ͻ0.001 Diastolic blood pressure (mmHg) 72.4 Ϯ 11.5 75.3 Ϯ 10.3 77.6 Ϯ 10.5 79.3 Ϯ 9.4 77.1 Ϯ 10.4 Ͻ0.001 Waist circumference (cm) 71.9 Ϯ 6.3 80.6 Ϯ 6.5 88.6 Ϯ 6.1 97.2 Ϯ 7.1 87.6 Ϯ 9.4 Ͻ0.001 Total cholesterol (mmol/l) 5.11 Ϯ 0.96 5.36 Ϯ 2.39 5.34 Ϯ 1.42 5.37 Ϯ 1.01 5.34 Ϯ 1.65 0.363 (mmol/l) 1.07 Ϯ 0.66 1.37 Ϯ 1.13 1.63 Ϯ 1.07 1.68 Ϯ 0.87 1.55 Ϯ 1.04 Ͻ0.001 HDL cholesterol (mmol/l) 1.61 Ϯ 0.40 1.46 Ϯ 0.33 1.35 Ϯ 0.47 1.31 Ϯ 0.29 1.38 Ϯ 0.40 Ͻ0.001 LDL cholesterol (mmol/l) 2.93 Ϯ 0.85 3.23 Ϯ 0.88 3.29 Ϯ 0.79 3.40 Ϯ 1.45 3.28 Ϯ 1.01 Ͻ0.001 Fasting (mmol/l) 5.52 Ϯ 1.77 6.01 Ϯ 2.05 6.15 Ϯ 1.80 6.37 Ϯ 1.96 6.13 Ϯ 1.91 Ͻ0.001 Current smoking Men 18 (38.3) 72 (28.0) 106 (23.4) 37 (20.1) 233 (24.7) 0.007 Women 14 (19.7) 32 (9.0) 51 (8.1) 23 (6.9) 120 (8.6) 0.003 Current drinking Men 13 (27.7) 87 (33.9) 137 (30.2) 46 (25.0) 283 (30.0) 0.135 Women 3 (4.2) 20 (5.6) 36 (5.7) 12 (3.6) 71 (5.1) 0.409 CHD Men 11 (23.4) 63 (24.5) 144 (31.8) 73 (39.7) 291 (31.9) Ͻ0.001 Women 16 (22.5) 111 (31.1) 236 (37.6) 129 (38.7) 492 (35.4) 0.002 Stroke 2007 Men 11 (23.4) 37 (14.4) 73 (16.1) 41 (22.3) 162 (17.2) 0.245 Women 9 (12.7) 40 (11.2) 102 (16.3) 52 (15.6) 203 (14.6) 0.100 UGUST PAD Men 3 (6.4) 33 (12.8) 71 (15.7) 32 (17.4) 139 (14.7) 0.042 8, A Women 15 (21.1) 73 (20.4) 144 (22.9) 90 (26.9) 322 (23.1) 0.053

Family histories of CHD or stroke 30 (25.4) 205 (33.4) 406 (37.6) 195 (37.6) 836 (35.8) 0.010 NUMBER Ϯ

Data are means SD or n (%). 30, VOLUME , ARE C IABETES D BMI, metabolic syndrome, and CVD in China

Table 2—Prevalence of individual metabolic syndrome components and component numbers in subjects with BMI <18.5, <24, <28, and >28 kg/m2

BMI Յ 2 2 2 Ն 2 18.5 kg/m 18.6–23.9 kg/m 24.0–27.9 kg/m 28.0 kg/m Ptrend Metabolic status Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Individual component High blood pressure 57.4 56.3 56.8 67.3 64.7 65.8 72.8 75.3 74.3 88.0 82.6 84.6 Ͻ0.001 Ͻ0.001 Ͻ0.001 21.3 32.4 28.0 40.9 44.7 43.1 57.4 54.6 55.8 64.1 61.4 62.4 Ͻ0.001 Ͻ0.001 Ͻ0.001 4.3 11.3 8.5 12.1 25.8 20.1 26.9 36.1 32.3 31.5 43.7 39.4 Ͻ0.001 Ͻ0.001 Ͻ0.001 Low HDL cholesterol 4.3 16.9 11.9 7.8 27.8 19.4 18.8 40.4 31.4 25.5 41.9 36.1 Ͻ0.001 Ͻ0.001 Ͻ0.001 Central obesity 2.1 8.5 5.9 12.5 44.8 31.4 61.1 91.9 79.0 97.8 100 99.2 Ͻ0.001 Ͻ0.001 Ͻ0.001 Metabolic syndrome 0 1.6 0.9 7.5 24.4 17.3 38.9 64.8 53.9 71.7 76.0 74.5 Ͻ0.001 Ͻ0.001 Ͻ0.001 Numbers of components Ն1 68.1 77.5 73.7 79.2 88.5 84.6 94.7 98.4 96.9 100 100 100 Ͻ0.001 Ͻ0.001 Ͻ0.001 Ն2 17.0 35.2 28.0 42.4 68.5 57.8 77.0 90.1 84.6 96.2 95.2 95.6 Ͻ0.001 Ͻ0.001 Ͻ0.001 Ն3 4.3 9.9 7.6 13.3 33.4 25.0 46.4 65.8 57.6 72.8 76.0 74.9 Ͻ0.001 Ͻ0.001 Ͻ0.001 Ն4 0 2.8 1.7 4.3 14.6 10.3 16.6 33.4 26.4 29.9 43.4 38.6 Ͻ0.001 Ͻ0.001 Ͻ0.001 5 0 0 0 0 2.5 1.5 2.4 10.7 7.2 8.2 15.0 12.5 Ͻ0.001 Ͻ0.001 Ͻ0.001 Data are %. and typical symptoms) to diagnose coro- be inappropriate for Asian populations central obesity (Ն90 and Ն80 cm in Chi- nary heart disease (CHD) and peripheral (e.g., Chinese). In the present study, nese men and women, respectively) plus artery disease (PAD). BMI was classified into four categories: any two of the following four factors: 1) Յ18.5, 18.6–23.9, 24.0–27.9, and high blood pressure (Ն130/85 mmHg or Classification of BMI Ն28.0 kg/m2. These categories are known treatment for ); 2) BMI was calculated as body weight in based on the criteria of the Cooperative hypertriglyceridemia (fasting plasma trig- kilograms divided by the square of Meta-Analysis Group of the Working lycerides Ն1.7 mmol/l); 3) fasting HDL height in meters. According to World Group on Obesity in China (15). cholesterol Ͻ1.0 mmol/l in men and Health Organization (WHO) criteria Ͻ1.3 mmol/l in women; and 4) hypergly- (4), overweight was defined as a BMI Definition of metabolic syndrome cemia (fasting glucose level of Ն 5.6 Ն25.0 kg/m2 . However, WHO- We used the 2005 IDF definition of met- mmol/l (Ն100 mg/dl) or known treat- recommended cut points for BMI may abolic syndrome. This definition includes ment for diabetes) (11).

Table 3—ORs of CHD, stroke, PAD, and total vascular diseases (CVD) according to BMI categories

BMI Յ 2 2 2 Ն 2 18.5 kg/m 18.6–23.9 kg/m 24.0–27.9 kg/m 28.0 kg/m Ptrend CHD Model 1* 0.63 (0.39–1.02) 1.00 (Ref) 1.42 (1.14–1.77) 1.63 (1.27–2.10) Ͻ0.001 Model 2† 0.64 (0.40–1.04) 1.00 (Ref) 1.42 (1.14–1.77) 1.62 (1.25–2.09) Ͻ0.001 Model 3‡ 0.68 (0.42–1.10) 1.00 (Ref) 1.26 (1.00–1.59) 1.33 (1.01–1.77) 0.005 Stroke Model 1* 1.20 (0.70–2.08) 1.00 (Ref) 1.40 (1.04–1.87) 1.57 (1.13–2.18) 0.049 Model 2† 1.17 (0.67–2.02) 1.00 (Ref) 1.34 (1.00–1.80) 1.45 (1.04–2.03) 0.139 Model 3‡ 1.21 (0.69–2.10) 1.00 (Ref) 1.20 (0.88–1.64) 1.16 (0.80–1.67) 0.014 PAD Model 1* 0.67 (0.38–1.18) 1.00 (Ref) 1.25 (0.96–1.62) 1.47 (1.09–1.98) 0.01 Model 2† 0.62 (0.35–1.09) 1.00 (Ref) 1.24 (0.95–1.62) 1.46 (1.08–1.97) 0.007 Model 3‡ 0.65 (0.37–1.14) 1.00 (Ref) 1.13 (0.86–1.50) 1.27 (0.92–1.77) 0.030 CVD Model 1* 0.70 (0.46–1.07) 1.00 (Ref) 1.53 (1.25–1.88) 1.99 (1.56–2.53) Ͻ0.001 Model 2† 0.69 (0.45–1.05) 1.00 (Ref) 1.51 (1.23–1.86) 1.93 (1.51–2.47) Ͻ0.001 Model 3‡ 0.73 (0.48–1.11) 1.00 (Ref) 1.36 (1.10–1.70) 1.62 (1.23–2.11) Ͻ0.001 Data are OR (95% CI). *Model 1: adjusted for sex and age (years). †Model 2: adjusted for sex, age (years), marital status, education (Յ6, 7–12, or Ն13 years), (Ͻ1, 1–3, or Ն 4 h/day), alcohol drinking (current drinkers vs. noncurrent drinkers), cigarette smoking (never, current, or former), and family histories of CHD or stroke. ‡Model 3: adjusted for sex, age (years), marital status, education (Յ6, 7–12, or Ն13 years), exercise (Ͻ1, 1–3, or Ն4 h/day), alcohol drinking (current drinkers vs. noncurrent drinkers), cigarette smoking (never, current, or former), family histories of CHD or stroke, and metabolic syndrome (yes/no). Ref, referent.

2130 DIABETES CARE, VOLUME 30, NUMBER 8, AUGUST 2007 He and Associates aaaeO 9%C) Mdl1 dutdfrsxadae(er) Mdl2 dutdfrsx g yas,mrtlsau,euain( education status, marital (years), age sex, for adjusted 2: †Model (years). age and sex for adjusted 1: *Model CI). (95% OR are Data 4— Table (MS) rnesv.nncretdikr) iaet mkn nvr urn,o omr,adfml itre fCDo toe e,referent. Ref, stroke. or CHD of histories family and former), or current, (never, smoking cigarette drinkers), current non vs. drinkers CHD CVD PAD Stroke oe *07 04–.7 .3(.662)10 Rf .0(.926)11 08–.6 .4(.726)19 13–.5 .1(1.36–2.42) 1.81 (1.31–2.95) 1.97 (1.57–2.66) 2.04 (0.89–1.56) 1.18 (1.09–2.66) 1.70 (Ref) 1.00 (0.06–6.27) 0.63 (0.44–1.17) 0.72 1* Model oe †07 04–.1 .5(.658)10 Rf .4(.127)11 08–.7 .4(.626)20 13–.4 .9(1.34–2.41) 1.79 (1.33–3.04) 2.01 (1.56–2.66) 2.04 (0.89–1.57) 1.18 (1.11–2.73) 1.74 (Ref) 1.00 (0.06–5.89) 0.65 (0.45–1.21) 0.74 2† Model oe †05 03–.6 .9(.72.5 .0(e)11 06–.7 .3(.314)14 10–.1 .7(.725)14 10–.8 0.009 (1.58–2.75) 2.09 0.012 (1.65–3.69) 2.47 (1.04–2.08) 1.47 0.022 (1.07–2.10) (1.69–2.79) 1.50 2.17 (0.97–2.54) 1.57 0.005 (0.97–2.53) (0.96–1.60) 1.57 1.24 (1.13–2.42) (1.08–2.01) 1.66 1.47 (1.25–2.66) (1.09–2.03) (0.99–2.36) 1.82 1.48 1.53 (0.79–2.42) (0.73–1.46) 1.39 1.03 (0.83–2.51) (0.74–1.47) (Ref) 1.45 1.04 1.00 (1.28–2.57) (0.68–1.97) 1.81 1.15 (1.36–2.72) (0.69–2.00) (0.24–24.28) 1.92 1.18 2.41 (0.73–1.59) (Ref) 1.08 1.00 (0.76–1.63) (Ref) (0.48–1.14) 1.12 1.00 0.74 (0.80–2.64) (0.37–21.15) 1.45 2.79 (0.84–2.75) (0.35–20.23) 1* 1.52 2.67 Model (Ref) (0.32–1.06) 1.00 0.58 (Ref) (0.35–1.16) 1.00 0.64 (0.21–21.26) 2† 2.10 Model (0.20–20.42) 1* 2.02 Model (0.70–2.31) 1.25 (0.74–2.31) 1.30 2† Model 1* Model Diagnosis of CVD (1.53–2.67) 2.02 (1.63–3.65) 2.44 (1.66–2.75) 2.14 (0.95–1.59) 1.23 (1.00–2.38) 1.54 (Ref) 1.00 (0.22–22.89) 2.79 (0.47–1.13) 0.73 2† Model Hypertension was defined as diastolic blood pressure of Ն90 mmHg, systolic blood pressure of Ն140 mmHg, or cur- BMI with subjects in (CVD) diseases vascular total and PAD, stroke, CHD, for ORs the of analysis Stratified rent medication for hypertension. CHD and stroke were defined using the WHO

Multinational Monitoring of Trends and ( MS Determinants in Cardiovascular Diseases

(MONICA) criteria (16). Major CHD Ϫ )MS( events included Յ (n ϭ 68) and confirmed angina (n ϭ 715). kg/m 18.5 Myocardial infarction was diagnosed by a representative set of ECGs, cardiac en-

zyme values, and typical symptoms. An- 2 gina was defined as use of nitroglycerin, experience of typical chest pain, and ECG ϩ changes compatible with ischemic heart )MS( disease (58% of the cases were validated by an exercise test or B-mode ultrasonog- raphy but were not randomly selected). There were 365 cases of stroke (235 isch- emic, 70 hemorrhagic, and 60 other Ϫ 862. kg/m 18.6–23.9 types). were defined as events re- )MS( quiring hospitalization; this information was verified from local hospital records and 83% of the cases were confirmed by computed tomography scans and mag- 2 netic resonance imaging. Subjects with a ϩ fasting plasma glucose Ն7.0 mmol/l )MS( and/or a 2-h plasma glucose Ն11.1

mmol/l during an oral glucose tolerance BMI test and/or who were receiving antidia- betic medications were diagnosed with diabetes. PAD was assessed as positive in- Ϫ termittent claudication by a WHO/Rose kg/m 24.0–27.9 questionnaire or an ankle-arm systolic )MS( blood pressure index Ͻ0.9 (17). Յ Statistical analysis or 7–12, 6,

Data were entered (double entry) and < 2 managed by Microsoft Access (Microsoft, 18.5, ϩ Redmond, WA). We calculated sex- Ն 3yas,eecs ( exercise years), 13 )MS( specific prevalence rates of overweight < and metabolic syndrome. We used logis- 24, tic regression to calculate odds ratios < (ORs) and their 95% CIs. We also con- and 28, ducted both stratified analyses and multi- ple logistic regression analyses to examine Ͻ > ,13 or 1–3, 1, Ϫ the independent and combined effects of syndrome metabolic without or with 28 )MS( BMI and the metabolic syndrome. The Ն 80kg/m 28.0 statistical package used was SPSS (version Ն

11; SPSS, Chicago, IL). We adjusted for (current drinking alcohol h/day), 4 potential confounders (age, marital sta- tus, years of education, smoking and al- 2 cohol drinking, physical exercise, and family histories of CHD or stroke). ϩ )

RESULTS — According to the WHO definition for overweight (BMI Ն25.0 kg/ Ͻ Ͻ Ͻ 2 Ͻ P 0.001 0.001 0.001 0.001

m ) and the IDF criteria for metabolic trend syndrome, prevalence rates for over- weight and metabolic syndrome in this

DIABETES CARE, VOLUME 30, NUMBER 8, AUGUST 2007 2131 BMI, metabolic syndrome, and CVD in China

Figure 1—Multivariate-adjusted ORs of CHD, stroke, PAD, and CVD in subjects with BMI Յ18.5, Ͻ24, Ͻ28, and Ն28 kg/m2 with (f)or without ( ) metabolic syndrome (MS). elderly Chinese population were 56.3% versus metabolic status on CHD, stroke, public health worldwide (4), especially in (53.9% in men and 57.9% in women) and PAD, and total CVD. Both elevated BMI economically developing countries such 46.3% (34.8% in men and 54.1% in and the metabolic syndrome were associ- as China. In the past two decades, preva- women), respectively. ated with increased risk of CVD. Among lence rates of overweight and obesity in General characteristics of the 2,334 those who were obese (BMI Ն28.0 kg/ China have increased dramatically (6), subjects (943 men and 1,391 women) m2), the risk of CHD and CVD was similar which has led to increased occurrence of categorized by BMI are shown in Table 1. between those with and without meta- chronic diseases, especially type 2 diabe- We found a clear increasing trend in risk bolic syndrome. Interestingly, the ORs for tes and CVD in Chinese populations. factors for CVD and clinical outcomes stroke and PAD in individ- According to the WHO definition of from subjects with lower BMI to those uals with the metabolic syndrome were overweight and the IDF criteria for meta- with higher BMI. The Pearson correlation the highest of all groups (OR 2.10 [95% bolic syndrome, prevalence rates of over- coefficient between BMI and waist cir- CI 0.21–21.26] and 2.79 [0.37–21.15]). weight and metabolic syndrome in this cumference was 0.78 (P Ͻ 0.0001). The interactions between BMI and study were 56.3 and 46.3%, respectively. Table 2 shows the proportion of metabolic syndrome in CHD, stroke, These figures are lower than those in the metabolic syndrome components (i.e., PAD, and CVD were tested in multivariate same age-group in the U.S. (18,19) but hyperglycemia, high blood pressure, logistic models by adjusting for sex, age, higher than those seen in other studies hypertriglyceridemia, low HDL choles- marital status, education, and other co- conducted in Chinese populations terol level, and central obesity) and the variates. None of the interaction terms (3,6,20–22). The relatively high preva- number of components in the four BMI was statistically significant (P ϭ 0.09, lence rates of CHD (32% in men and 35% groups (i.e., Յ18.5, Ͻ24, Ͻ28, and 0.70, 0.73, and 0.16, respectively). in women) and stroke (17% in men and Ն28 kg/m2). Table 3 shows the ORs Figure 1 shows multivariate adjusted 15% in women) in this population are (95% CI) for CHD, stroke, PAD, and ORs of CHD, stroke, PAD, and CVD in probably due to the higher average age of total CVD for the subjects with BMI subjects in all BMI groups (i.e., Յ18.5, our participants (69 years for men and 67 Յ18.5, Ͻ24, Ͻ28, and Ն28 kg/m2.In- Ͻ24, Ͻ28, and Ն28 kg/m2) with or with- years for women) and our selection of an creasing BMI was strongly associated out metabolic syndrome; 95% CIs are urban elderly population in Beijing. with increased risk of CHD, stroke, shown in Table 4. There was a significant Because the WHO-recommended PAD, and total CVD, and these associa- dose-response relation between the in- BMI cut points may be inappropriate for tions were somewhat attenuated but re- creasing categories of BMI and risk of the Chinese population, we used the BMI mained statistically significant even CHD, PAD, and CVD in subjects without cut point criteria of the Cooperative Meta- after adjustments for the presence or ab- metabolic syndrome. Analysis Group of the Working Group on sence of metabolic syndrome. Obesity in China (i.e., Յ18.5 kg/m2,un- Table 4 shows the result of stratified CONCLUSIONS — Overweight and derweight; 18.6–23.9 kg/m2, normal analysis of the relative association of BMI obesity are rapidly growing threats to weight; 24.0–27.9 kg/m2, overweight;

2132 DIABETES CARE, VOLUME 30, NUMBER 8, AUGUST 2007 He and Associates and Ն28.0 kg/m2, obese) (15). The re- that waist circumference may be more In summary, the present study indi- spective corresponding prevalence rates strongly correlated with resis- cates that both overweight and metabolic of overweight and obesity in this study tance and chronic inflammation, the syndrome are highly prevalent in urban were 46.4 and 22.2%. As expected, there underlying mechanism for the meta- China. Our findings support a strong as- was a strong positive correlation between bolic syndrome (26). This observation sociation of the metabolic syndrome and increasing BMI and the prevalence of met- has served as the rationale for including CVD, as well as an independent role of abolic syndrome (Table 2). waist circumference instead of BMI as BMI in predicting the risk of CVD in el- The relation of BMI to metabolic syn- one of the diagnostic criteria for the derly Chinese individuals. BMI can be drome and its role as an independent risk metabolic syndrome. However, the more easily applied in clinical practice factor for CVD have been recent topics of measures of BMI and waist circumfer- than the diagnosis of the metabolic syn- debate (9,13). In 2004, the Women’s ence do not completely overlap (r ϭ drome. Developing effective public health Ischemia Syndrome Evaluation (WISE) 0.78). Numerous epidemiological stud- strategies for the prevention and treat- study reported that metabolic syndrome ies have shown that BMI and fat distri- ment of overweight and metabolic syn- but not BMI predicted future cardiovas- bution independently predict various drome should be an urgent priority to cular risk in women referred for coronary metabolic disorders (27). Our data sug- reduce the social and public health bur- angiography (14). Other epidemiological gest that BMI can provide an additional den of CVD in China. studies, however, have reported that obe- predictive value for CVD risk beyond sity and metabolic syndrome are indepen- the metabolic syndrome. Therefore, in dent cardiovascular risk factors (4–9). clinical practice, both BMI and waist Acknowledgments— This study was sup- The present study shows that both BMI circumference should be measured and ported by research grants from the National and the metabolic syndrome are indepen- monitored for CVD risk assessment, es- Natural Science Foundation of China dently associated with CHD, stroke, PAD, pecially in high-risk populations. (30057006) and Beijing Natural Science Foundation (7062063). F.B.H. is partly sup- and total CVD. In particular, among those To the best our knowledge, this re- ported by an American Heart Association who did not meet the diagnostic criteria port is the first to evaluate the relative ef- Established Investigator Award. for the metabolic syndrome, there was a fects of body weight versus metabolic dose-response relationship between in- syndrome on CVD in a population-based creasing BMI and higher prevalence of study in China. As an independent risk References CVD. Interestingly, among those who factor of CVD, BMI is easier to measure in 1. Wu Z, Yao C, Zhao D, Wu G, Wang W, Ն 2 were obese (BMI 28.0 kg/m ), the risk primary intervention settings than the di- Liu J, Zeng Z, Wu Y: Sino-MONICA of CHD and CVD was similar between agnosis of metabolic syndrome and, thus, project: a collaborative study on trends those with and without the diagnosis of is of clinical importance. It is also easily and determinants in cardiovascular dis- metabolic syndrome (Table 4). These data accepted by clinicians and the general eases in China. Part I: morbidity and mor- suggest that assessment of CVD risk can- public and, thus, is well-suited for use in tality monitoring. Circulation 103:462– not depend completely on the diagnosis health education and promotion in pri- 468, 2001 of metabolic syndrome. Obese subjects mary care settings. 2. Yao C, Wu Z, Wu Y: The changing pattern who do not meet the criteria for metabolic The cross-sectional nature of this of cardiovascular diseases in China. World syndrome should be evaluated and man- study did not allow us to assess the tem- Health Stat Q 46:113–118, 1993 3. Gu D, Reynolds K, Wu X, Chen J, Duan X, aged for CVD risk assessment and reduc- poral relationship between the metabolic Reynolds RF, Whelton PK, He J: Preva- tion as aggressively as those who have syndrome and CVD and, thus, limits lence of the metabolic syndrome and metabolic syndrome. The positive associ- causal inference. However, the temporal overweight among adults in China. Lancet ation between BMI and CVD was weaker associations of BMI and metabolic syn- 365:1398–405, 2005 among those with metabolic syndrome, drome with CVD have been well estab- 4. World Health Organization: Obesity: pre- and this finding is probably due to the fact lished in previous studies. The higher OR venting and managing the global epidem- that BMI and waist circumference are of stroke and PAD in underweight sub- ic: report of a WHO consultation. World highly correlated and that the effects of jects with metabolic syndrome might be Health Org Tech Rep Ser 894:1–253, 2000 waist circumference were already taken due to the fact that elderly individuals 5. Han TS, van Leer EM, Seidell JC, Lean into account in the definition of the met- with metabolic syndrome were more ME: Waist circumference action levels in the identification of cardiovascular risk abolic syndrome. This pattern of BMI as likely to lose weight. This was a random factors: prevalence study in a random an independent risk factor for both CHD cluster–selected sample with a relatively sample. BMJ 311:1401–1405, 1995 and stroke in Chinese adults is consistent high response rate. Of the eligible sub- 6. Zhou B, Wu Y, Yang J, Li Y, Zhang H, with data from other Chinese prospective jects, ϳ13% dropped out of the study Zhao L: Overweight is an independent studies (23–25). (e.g., left original residence or did not risk factor for cardiovascular disease in BMI is a measure of overall adipos- complete interviews or examinations), Chinese populations. Obes Rev 3:147– ity, whereas waist circumference is a but no statistically significant differences 156, 2002 marker of central obesity. In our and in demo- 7. Isomaa B, Almgren P, Tuomi T, Forsen B, other studies, there was a strong corre- graphic characteristics such as age, sex, Lahti K, Nissen M, Taskinen MR, Groop lation between BMI and waist circum- education, and marital status were de- L: Cardiovascular morbidity and mortal- ity associated with the metabolic syn- ference. However, BMI was strongly tected between responders and nonre- drome. Diabetes Care 24:683–689, 2001 correlated with the metabolic syndrome sponders. Because our study population 8. Lakka HM, Laaksonen DE, Lakka TA, Ni- in our population, a correlation that was might not be a representative sample, the skanen LK, Kumpusalo E, Tuomilehto J, not completely accounted for by waist prevalence of metabolic syndrome may Salonen JT: The metabolic syndrome and circumference. It has been suggested not generalize to other parts of China. total and cardiovascular disease mortality

DIABETES CARE, VOLUME 30, NUMBER 8, AUGUST 2007 2133 BMI, metabolic syndrome, and CVD in China

in middle-aged men. JAMA 288:2709– factors of certain related diseases in Chi- a Chinese population with high post- 2716, 2002 nese adults—study on optimal cut-off prandial glucose. Diabetes Care 27: 9. Krauss RM, Winston M, Fletcher BJ, points of and waist cir- 429–2437, 2004 Grundy SM: Obesity: impact on cardio- cumference in Chinese adults. Biomed En- 22. Wang JJ, Li HB, Kinnunen L, Hu G, Jarvi- vascular disease. Circulation 98:1472– viron Sci 15:83–96, 2002 nen TM, Miettinen ME, Yuan S, Tuom- 1476, 1998 16. WHO MONICA Project: Multinational ilehto J How well does the metabolic 10. Nation Institutes of Health: Executive Monitoring of Trends and Determinants in syndrome defined by five definitions pre- summary of the Third Report of the Na- Cardiovascular Diseases (MONICA Project) dict incident diabetes and incident coro- tional Cholesterol Education Program and Manual of Operation. Geneva, World nary heart disease in a Chinese population? (NCEP) Expert Panel on Detection, Health Organization, Cardiovascular Dis- 192:161–168 Evaluation, and Treatment of High ease Unit, 1983 23. Zhou BF: Effect of body mass index on Blood Cholesterol in Adults (Adult 17. He Y, Jiang Y, Wang J, Fan L, Li XY, Hu all-cause mortality and incidence of car- Treatment Panel III). JAMA 285:2486– FB: Prevalence of peripheral arterial dis- diovascular diseases—report for meta- 2497, 2001 ease and its association with smoking in a analysis of prospective studies open 11. Alberti KG, Zimmet P, Shaw J: The meta- population-based study in Beijing, China. optimal cut-off points of body mass index bolic syndrome-a new worldwide defini- J Vasc Surg 44:333–338, 2006 in Chinese adults. Biomed Environ Sci 15: tion. Lancet 306:1059–1062, 2005 18. Overweight Obesity and Health Risk: Na- 245–252, 2002 12. He Y, Jiang B, Wang J, Feng K, Chang Q, tional Task Force on the Prevention and 24. Yuan JM, Ross RK, Gao YT, Yu MC: Body Fan L, Li XY, Hu FB: Prevalence of the Treatment of Obesity. Arch Intern Med weight and mortality: a prospective eval- metabolic syndrome and its relation to the 160:898–904, 2000 risk of cardiovascular disease in an elderly 19. Ford ES, Giles WH, Dietz WH: Prevalence uation in a cohort of middle-aged men in Chinese population. J Am Coll Cardiol 47: of the metabolic syndrome among US Shanghai, China. Int J Epidemiol 27:824– 1588–1594, 2006 adults: findings from the third National 832, 1998 13. Pradhan AD, Skerrett PJ, Manson JE: Obe- Health and Nutrition Examination Sur- 25. Gu D, He J, Duan X, Reynolds K, Wu X, sity, diabetes, and coronary risk in women. vey. JAMA 287:356–359, 2002 Chen J, Huang G, Chen CS, Whelton PK: J Cardiovasc Risk 9:323–330, 2002 20. Wang JJ, Hu G, Miettinen ME, Tuom- Body weight and mortality among men 14. Kip KE, Marroquin OC, Kelley DE, John- ilehto J: The metabolic syndrome and and women in China. JAMA 295:776– son BD, Kelsey SF, Shaw LJ, Rogers WJ, incident diabetes: assessment of four 783, 2006 Reis SE: Clinical importance of obesity suggested definitions of the metabolic 26. Eckel RH, Grundy SM, Zimmet PZ: The versus the metabolic syndrome in cardio- syndrome in a Chinese population with metabolic syndrome. Lancet 365:1415– vascular risk in women: a report from the high post-prandial glucose. Horm Metab 1428, 2005 Women’s Ischemia Syndrome Evaluation Res 36:708–715, 2004 27. Douketis JD, Sharma AM: Obesity and (WISE) study. Circulation 109:706–713, 21. Wang JJ, Qiao Q, Miettinen ME, Lappa- cardiovascular disease: pathogenic 2004 lainen J, Hu G, Tuomilehto J: The met- mechanisms and potential benefits of 15. Zhou BF: Predictive values of body mass abolic syndrome defined by factor weight reduction. Semin Vasc Med 5:25– index and waist circumference for risk analysis and incident in 33, 2005

2134 DIABETES CARE, VOLUME 30, NUMBER 8, AUGUST 2007