Adiposity and Fat Distribution Impact on Hypertension, Cholesterol, and Diabetes 

Central adiposity shows varying effects on blood pressure, LDL cholesterol, and glycemic profile.  

Type II diabetes mellitus is responsible for microvascular and macrovascular complications, including retinopathy, neuropathy, coronary heart disease, and stroke. Obesity, hypertension, and dyslipidemia exacerbate other diabetes complications. According to previous clinical studies, adiposity and body fat distribution lead to cardiometabolic risk factors. This cross-sectional study aimed to analyze body fat and adiposity to determine its relationship with hemoglobin A1c, hypertension, and elevated low-density lipoprotein level among Chinese hospitalized patients with type 2 diabetes. Diabetes has a prevalence of 12.8% for adults living in China. 

4,562 patient hospital records were pulled, and those with repeated hospitalizations were excluded. 3,795 people from the Department of Endocrinology and Metabolism of Tianjin Medical University General Hospital from June 2013 to May 2018 were the sample population. 2,427 inpatients diagnosed with type 2 diabetes were randomized in the trial. Exclusion criteria included participants <20 or >90, weight <34kg or >90kg for women, for men <35kg and >92kg, amputations other than toes and fingers, BMI <14 kg/m2 or >35kg/m2 female and >31kg/m2 male, height <140 cm female or <120 cm men or >180 cm. An electronic medical record collected patients’ personal information.  Height, weight, and blood pressure were measured upon admission. Using a stadiometer, height was measured to the nearest 0.1 cm with light clothing and without shoes. BMI is the weight in kg divided by height in meters squared. Blood pressure was taken after 5 minutes of sitting using a sphygmomanometer.10-hour fasting blood levels were drawn. LDL levels were measured according to standardized enzyme techniques.  

Trained technicians took measurements of the whole body using dual-energy x-ray absorptiometry (DXA) using a prodigy densitometer. Also measured were a percentage of fat in the arms, legs, truncal, gynoid, and android regions, and fat mass, in a supine position, on a DXA table after removing metals and shoes. The manufacturer provided software that determined total and regional fat mass. The truncal region included the neck, chest, abdominal, and pelvic areas, which was an upper and lower boundary. The arm region and truncal region were separated, and the leg region was defined with and separated from the pelvic area. The lower region and android region were combined. The upper boundary is enclosed within the truncal region and combined with the gynoid region. Truncal-to-leg fat ratio and android-to-gynoid fat ratio calculated. Calibration of the DXA instrument was also done.  

Elevated HbA1c was defined as >7.0%, hypertension as systolic >140 mmHg and/or diastolic blood pressure >90 mmHg, and elevated LDL >2.6 mmol/L. Standard t-tests and Mann-Whitney U tests compared continuous variables and prevalence of categorical variables compared with x2 tests. Adiposity and cardiometabolic risk factors association were assessed with partial correlation analysis and linear regression analysis. BMI and adiposity parameters on the odds of elevated cardiovascular risk factors effect were estimated with logistic regression. Standardized z scores were calculated for body composition and BMI. Logistic regression is reported as odds ratio (ORs) with 95% confidence intervals. There were four models. Model 1 age, sex, duration of diabetes, health insurance, current smoking, alcohol drinking, and family history of diabetes. Model 2 was model 1 and if there were hypertensive, lipid-lowering, and glycemic lowering agents. Model 3 was model 2 and fat mass in BMI, BMI in fat mass, percentage of body fat, and fat distribution parameters. Model 4 adjusted for model 2 and adiposity index. Statistically, significant P values are <0.05.   

In general, women were older; BMI fat mass, percentage of fat, and LDL were higher than men. Their android-to-gynoid and truncal-to-leg fat ratio and diastolic blood pressure were lower. They used the most antihypertensive medications and had fewer total smokers and alcohol drinkers. Of 2,427 patients total, 74.9% had elevated HbA1c , 48.2% hypertension, 61.7% LDL and 67.2% had at least 2 cardiometabolic risk factors. Model 2 results are as follow: 1.14 (95% CI: 1.01-1.30) to 1.33 (95% CI: 1.16-1.54). ORs for model 3 elevated HbA1c were 0.82 (95% CI: 0.70-0.96) and 0.81 (95% CI: 0.68-0.96). For elevated LDL range was 1.16 (95% CI:1.00-1.35) to 1.27 (95% CI: 1.06-1.51). Hypertension subgroup analysis was 0.86 (95% CI:0.74-0.99) in women and 1.14 (95% CI: 0.98-1.34) in men. Model 2 ORs of cardiometabolic risk factors led to 1.13 (95% CI:1.03-1.25) to 1.35 (95% CI: 1.17-1.55). 

Effects of fat distribution on the cardiometabolic profile were shown more in women. Central adiposity led to poor control of blood pressure and LDL cholesterol. Fat in the lower body favored an improved glycemic profile. Subcutaneous tissue is metabolically protective of glucose. Increased adiposity can also worsen the above factors. This demonstrates the distribution of fat can improve cardiometabolic risk factors. Studies show prioritizing weight management for type 2 diabetes to be beneficial. Basal insulin and a glucagon-like-peptide (GLP-1 agonist) provide glycemic efficacy and weight loss. GLP-1 receptor agonists and sodium-dependent glucose transporter-2 inhibitors also induce weight reduction. Weight gain, redistribution of body fat, and increased adiposity were prevalent among patients initiated on insulin therapy. Diet and exercise are components to negate the increase in fat with monitoring and patient education.         

Practice Pearls: 

• Obesity, dyslipidemia, and hypertension are common cardiometabolic factors among patients with type 2 diabetes.  
• Lower body fat was associated with a more favorable glycemic level and, to the contrary, elevated lipid and blood pressure profile.  
• Treatments are modifying fat distribution benefits and weight loss for the cardiometabolic health of patients with type 2 diabetes. 

Ding, L., Fan, Different Indicators of Adiposity and Fat Distribution and Cardiometabolic Risk Factors in Patients with Type 2 Diabetes. Obesity, April 26, 2021 

Damisha Henderson Florida A&M University, College of Pharmacy and Pharmaceutical Sciences, Fourth Year PharmD Candidate 

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