Obesity Patterns, Metabolic Abnormality, and Diabetic Kidney Disease in Patients with Type 2 Diabetes

Figures & data

Table 1 Characteristics of the Study Population with and without DKD

	All	Without DKD	With DKD	P value
	(n = 4079)	(n = 2957)	(n = 1122)
Age, years	67.3 ± 8.7	66.5 ± 8.3	69.5 ± 9.2	<0.001
Female, n (%)	2196 (53.8)	1591 (53.8)	605 (53.9)	0.95
Current smoker, n (%)	726 (17.8)	511 (17.3)	215 (19.2)	0.16
Current drinker, n (%)	682 (16.7)	500 (16.9)	182 (16.2)	0.60
High school education or above, n (%)	2075 (50.9)	1547 (52.3)	528 (47.1)	0.011
Duration of diabetes, years	8 (4–15)	8 (3–13)	10 (5–18)	<0.001
Use of medications, n (%)
Antidiabetic drugs	2928 (71.8)	2052 (69.4)	876 (78.1)	<0.001
Antihypertensive drugs	1797 (44.1)	1208 (40.9)	589 (52.5)	<0.001
Lipid lowering drugs	1542 (37.8)	1105 (37.4)	437 (38.9)	0.35
Systolic BP, mmHg	145.2 ± 19.7	142.6 ± 18.8	151.9 ± 20.4	<0.001
Diastolic BP, mmHg	78.9 ± 10.8	78.6 ± 10.4	79.8 ± 11.6	0.004
Triglycerides, mmol/L	1.53 (1.10–2.19)	1.47 (1.07–2.10)	1.71 (1.21–2.35)	<0.001
Total cholesterol, mmol/L	5.11 ± 1.19	5.10 ± 1.15	5.12 ± 1.30	0.60
LDL-C, mmol/L	3.15 ± 0.84	3.15 ± 0.82	3.15 ± 0.89	0.99
HDL-C, mmol/L	1.21 ± 0.29	1.22 ± 0.30	1.17 ± 0.28	<0.001
Fasting glucose, mmol/L	7.7 ± 2.4	7.5 ± 2.2	8.3 ± 2.9	<0.001
HbA1c, %	7.5 ± 1.4	7.3 ± 1.3	7.8 ± 1.6	<0.001
C-peptide, ng/mL	1.64 ± 0.80	1.57 ± 0.75	1.81 ± 0.90	<0.001
Fasting insulin, pmol/L	49.7 (34.0–74.0)	47.0 (32.7–69.4)	58.0 (39.0–87.7)	<0.001
BMI, kg/m^2	24.9 ± 3.6	24.7 ± 3.5	25.6 ± 3.7	<0.001
Waist circumference, cm	90.2 ± 9.7	89.4 ± 9.4	92.5 ± 10.2	<0.001
WHR	0.91 ± 0.06	0.91 ± 0.06	0.93 ± 0.07	<0.001
eGFR, mL/min/1.73 m^2	87.3 ± 15.8	90.2 ± 11.6	79.7 ± 21.9	<0.001
UACR, mg/g	13.1 (7.5–29.5)	9.8 (6.4–15.3)	58.5 (35.8–132.9)	<0.001

Note: Data are presented as mean ± SD, median (interquartile range), or number (percentage).

Abbreviations: BMI, body mass index; BP, blood pressure; DKD, diabetic kidney disease; eGFR, estimated glomerular filtration rate; HbA_1c, glycated hemoglobin; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; UACR, urinary albumin-to-creatinine ratio; WHR, waist-to-hip ratio.

Table 2 Prevalence Ratios (95% CIs) of DKD According to BMI and WHR Categories

	Cases/n (%)	Model 1^a		Model 2^b		Model 3^c
		PR (95% CI)	P value	PR (95% CI)	P value	PR 2(95% CI)	P value
Overall
BMI, kg/m^2
Per 1 kg/m^2 increase		1.06 (1.05–1.07)	<0.001	1.05 (1.03–1.06)	<0.001	1.04 (1.03–1.06)	<0.001
<24	395/1723 (22.9)	1 (reference)		1 (reference)		1 (reference)
24–27.9	455/1619 (28.1)	1.23 (1.10–1.38)	<0.001	1.12 (1.00–1.25)	0.059	1.09 (0.97–1.23)	0.15
≥28	272/737 (36.9)	1.67 (1.47–1.90)	<0.001	1.51 (1.32–1.71)	<0.001	1.44 (1.26–1.65)	<0.001
WHR
Per 0.10 increase		1.30 (1.20–1.40)	<0.001	1.17 (1.09–1.27)	<0.001	1.12 (1.03–1.21)	0.007
<0.90/0.85 (male/female)	220/1019 (21.6)	1 (reference)		1 (reference)		1 (reference)
0.90–0.94/0.85–0.89	354/1376 (25.7)	1.11 (0.96–1.29)	0.16	1.02 (0.88–1.17)	0.82	0.98 (0.85–1.13)	0.74
≥0.95/0.90	548/1684 (32.5)	1.38 (1.20–1.58)	<0.001	1.21 (1.06–1.39)	0.004	1.10 (0.96–1.27)	0.17
Non-use of antidiabetic drugs
BMI, kg/m^2
Per 1 kg/m^2 increase		1.06 (1.03–1.10)	<0.001	1.04 (1.01–1.07)	0.011	1.04 (1.01–1.08)	0.009
<24	91/481 (18.9)	1 (reference)		1 (reference)		1 (reference)
24–27.9	99/473 (20.9)	1.10 (0.86–1.42)	0.45	0.95 (0.74–1.21)	0.45	0.95 (0.73–1.21)	0.68
≥28	56/197 (28.4)	1.50 (1.11–2.01)	0.008	1.28 (0.96–1.70)	0.093	1.28 (0.95–1.72)	0.11
WHR
Per 0.10 increase		1.31 (1.13–1.52)	<0.001	1.06 (0.91–1.24)	0.43	1.02 (0.87–1.20)	0.77
<0.90/0.85 (male/female)	56/327 (17.1)	1 (reference)		1 (reference)		1 (reference)
0.90–0.94/0.85–0.89	76/367 (20.7)	1.22 (0.89–1.67)	0.22	0.99 (0.73–1.36)	0.97	0.95 (0.69–1.30)	0.74
≥0.95/0.90	114/457 (24.9)	1.39 (1.03–1.87)	0.030	1.02 (0.75–1.39)	0.88	0.95 (0.69–1.30)	0.73
Use of antidiabetic drugs
BMI, kg/m^2
Per 1 kg/m^2 increase		1.06 (1.04–1.07)	<0.001	1.05 (1.03–1.06)	<0.001	1.04 (1.03–1.06)	<0.001
<24	304/1242 (24.5)	1 (reference)		1 (reference)		1 (reference)
24–27.9	356/1146 (31.1)	1.27 (1.12–1.45)	<0.001	1.17 (1.03–1.34)	0.015	1.14 (1.00–1.31)	0.047
≥28	216/540 (40.0)	1.72 (1.49–1.98)	<0.001	1.58 (1.37–1.82)	<0.001	1.50 (1.29–1.74)	<0.001
WHR
Per 0.10 increase		1.29 (1.18–1.42)	<0.001	1.20 (1.09–1.31)	<0.001	1.13 (1.03–1.24)	0.010
<0.90/0.85 (male/female)	164/692 (23.7)	1 (reference)		1 (reference)		1 (reference)
0.90–0.94/0.85–0.89	278/1009 (27.5)	1.08 (0.91–1.28)	0.36	1.01 (0.86–1.18)	0.92	0.97 (0.82–1.14)	0.69
≥0.95/0.90	434/1227 (35.4)	1.38 (1.18–1.61)	<0.001	1.25 (1.08–1.45)	0.004	1.13 (0.97–1.32)	0.13

Notes: ^aModel 1 was adjusted for age and sex, ^bModel 2 was adjusted for variables in model 1 plus education, smoking status, alcohol drinking, diabetes duration, HbA_1c, use of antidiabetic agents (for overall population), systolic BP, use of antihypertensive agents, HDL-C, and triglycerides. ^cModel 3 was adjusted for variables in model 2 plus WHR or BMI.

Abbreviations: BMI, body mass index; CI, confidence interval; DKD, diabetic kidney disease; PR, prevalence ratio; WHR, waist-to-hip ratio.

Table 3 Prevalence Ratios (95% CIs) of DKD According to Obesity Patterns

General Obesity^a	Abdominal Obesity^b	Cases/n (%)	Model 1^c		Model 2^d
			PR (95% CI)	P value	PR (95% CI)	P value
Overall
No	No	202/963 (21.0)	1 (reference)		1 (reference)
	Yes	648/2379 (27.2)	1.18 (1.03–1.36)	0.018	1.06 (0.93–1.22)	0.37
Yes	No	18/56 (32.1)	1.34 (0.85–2.13)	0.21	1.23 (0.81–1.87)	0.34
	Yes	254/681 (37.3)	1.74 (1.48–2.03)	<0.001	1.51 (1.29–1.76)	<0.001
Non-use of antidiabetic drugs
No	No	52/310 (16.8)	1 (reference)		1 (reference)
	Yes	138/644 (21.4)	1.24 (0.92–1.67)	0.15	0.95 (0.71–1.28)	0.75
Yes	No	4/17 (23.5)	0.83 (0.27–2.55)	0.75	0.73 (0.26–2.04)	0.55
	Yes	52/180 (28.9)	1.76 (1.24–2.50)	0.001	1.30 (0.92–1.85)	0.14
Use of antidiabetic drugs
No	No	150/653 (23.0)	1 (reference)		1 (reference)
	Yes	510/1735 (29.4)	1.17 (1.00–1.37)	0.053	1.08 (0.93–1.26)	0.32
Yes	No	14/39 (35.9)	1.55 (0.97–2.49)	0.069	1.44 (0.92–2.26)	0.11
	Yes	202/501 (40.3)	1.73 (1.45–2.06)	<0.001	1.54 (1.30–1.83)	<0.001

Notes: ^aBMI ≥28.0 kg/m^{2, b}WHR ≥0.95/0.90 (male/female), ^cModel 1 was adjusted for age and sex, ^dModel 2 was adjusted for variables in model 1 plus education, smoking status, alcohol drinking, diabetes duration, HbA_1c, use of antidiabetic agents (for overall population), systolic BP, use of antihypertensive agents, HDL-C, and triglycerides.

Abbreviations: BMI, body mass index; CI, confidence interval; DKD, diabetic kidney disease; PR, prevalence ratio; WHR, waist-to-hip ratio.

Table 4 Associations of BMI and WHR Categories and Metabolic Status with Prevalent DKD

	0–1 Metabolic Abnormality		2 Metabolic Abnormalities		3 Metabolic Abnormalities		P for Interaction
	PR (95% CI)^a	P value	PR (95% CI)	P value	PR (95% CI)	P value
Overall
BMI, kg/m^2
Per 1 kg/m^2 increase	1.07 (1.04–1.10)	<0.001	1.04 (1.02–1.07)	<0.001	1.03 (1.01–1.05)	0.004	0.22
<24	1 (reference)		1.40 (1.14–1.74)	0.002	1.64 (1.32–2.03)	<0.001	0.33
24–27.9	1.33 (1.06–1.67)	0.014	1.45 (1.18–1.79)	<0.001	1.84 (1.51–2.24)	<0.001
≥28	1.82 (1.37–2.44)	<0.001	1.86 (1.48–2.34)	<0.001	2.39 (1.94–2.95)	<0.001
WHR
Per 0.10 increase	1.12 (0.93–1.33)	0.23	1.08 (0.93–1.26)	0.29	1.19 (1.06–1.34)	0.003	0.71
<0.90/0.85 (male/female)	1 (reference)		1.42 (1.08–1.86)	0.012	1.34 (1.00–1.81)	0.053	0.45
0.90–0.94/0.85–0.89	1.08 (0.82–1.41)	0.59	1.20 (0.93–1.53)	0.16	1.53 (1.19–1.96)	<0.001
≥0.95/0.90	1.14 (0.88–1.48)	0.33	1.38 (1.08–1.75)	0.009	1.71 (1.36–2.16)	<0.001
Non-use of antidiabetic drugs
BMI, kg/m^2
Per 1 kg/m^2 increase	1.06 (0.99–1.14)	0.10	1.06 (1.01–1.12)	0.032	1.04 (0.98–1.09)	0.21	0.68
<24	1 (reference)		1.76 (1.12–2.77)	0.015	2.07 (1.30–3.30)	0.002	0.50
24–27.9	1.51 (0.93–2.45)	0.094	1.71 (1.10–2.67)	0.018	1.42 (0.85–2.35)	0.18
≥28	1.45 (0.69–3.05)	0.33	2.07 (1.22–3.53)	0.007	2.69 (1.66–4.35)	<0.001
WHR
Per 0.10 increase	1.12 (0.78–1.62)	0.54	1.06 (0.84–1.34)	0.61	1.22 (0.91–1.63)	0.19	0.65
<0.90/0.85 (male/female)	1 (reference)		1.61 (0.94–2.74)	0.08	1.24 (0.63–2.45)	0.54	0.71
0.90–0.94/0.85–0.89	0.99 (0.54–1.80)	0.97	1.41 (0.85–2.33)	0.18	1.73 (1.03–2.91)	0.039
≥0.95/0.90	1.21 (0.72–2.06)	0.47	1.49 (0.91–2.45)	0.11	1.58 (0.96–2.61)	0.071
Use of antidiabetic drugs
BMI, kg/m^2
Per 1 kg/m^2 increase	1.08 (1.04–1.12)	<0.001	1.04 (1.02–1.07)	0.002	1.03 (1.01–1.05)	0.008	0.25
<24	1 (reference)		1.30 (1.03–1.66)	0.029	1.53 (1.20–1.95)	<0.001	0.46
24–27.9	1.28 (0.99–1.66)	0.064	1.38 (1.09–1.75)	0.007	1.91 (1.53–2.38)	<0.001
≥28	1.93 (1.41–2.63)	<0.001	1.79 (1.39–2.30)	<0.001	2.33 (1.85–2.94)	<0.001
WHR
Per 0.10 increase	1.10 (0.90–1.35)	0.37	1.08 (0.89–1.31)	0.42	1.19 (1.05–1.36)	0.006	0.83
<0.90/0.85 (male/female)	1 (reference)		1.36 (1.00–1.87)	0.053	1.35 (0.97–1.89)	0.075	0.31
0.90–0.94/0.85–0.89	1.10 (0.81–1.48)	0.55	1.12 (0.84–1.50)	0.43	1.46 (1.10–1.95)	0.009
≥0.95/0.90	1.11 (0.82–1.50)	0.50	1.33 (1.01–1.75)	0.043	1.73 (1.33–2.26)	<0.001

Notes: ^aThe model was adjusted for age, sex, education, smoking status, alcohol drinking, diabetes duration, HbA1c, use of antidiabetic agents (for overall population), and WHR or BMI. BMI <24 kg/m² or WHR <0.90/0.85 (male/female) with 0–1 metabolic abnormality was used as the reference category, respectively.

Abbreviations: BMI, body mass index; CI, confidence interval; DKD, diabetic kidney disease; PR, prevalence ratio; WHR, waist-to-hip ratio.

Figure 1 Associations of obesity patterns and metabolic status with prevalent DKD and albuminuria. Patients were divided into 12 groups based on the cross-categorization of overweight or obesity and abdominal obesity and the number of metabolic abnormalities. The model was adjusted for age, sex, education, smoking status, alcohol drinking, diabetes duration, HbA_1c, and use of antidiabetic agents. Patients who had normal BMI without abdominal obesity and 0–1 metabolic abnormality were regarded as the reference group.

Abbreviations: DKD, diabetic kidney disease; PR, prevalence ratio.