Association between triglyceride, high-density lipoprotein cholesterol and type 2 diabetes mellitus: a prospective cohort study
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摘要:
目的 评估TG、HDL-C及TG/HDL-C与2型糖尿病发病风险的关系。 方法 以“金昌队列”基线调查中30 546名未患2型糖尿病者为研究对象，运用Cox比例风险回归模型、限制性立方样条法估计TG、HDL-C及TG/HDL-C对2型糖尿病发病风险及剂量-反应关系。采用受试者工作特征曲线评估其对2型糖尿病发病风险的预测能力，确定最佳预测指标及其临界值。 结果 调整混杂因素后，在总人群中高TG、低HDL-C、高TG/HDL-C是2型糖尿病发病的危险因素，其发病风险比(hazard ratio, HR)分别为1.082(95% CI: 1.053~1.111, P < 0.001)、0.730(95% CI: 0.595~0.897, P=0.003)与1.061(95% CI: 1.038~1.085, P < 0.001)，且均存在一定的剂量-反应关系。TG/HDL-C预测价值高于TG和HDL-C，其曲线下面积分别为0.652、0.646、0.600，最佳临界值为1.14、1.67 mmol/L、1.40 mmol/L。 结论 高TG、低HDL-C及高TG/HDL-C是2型糖尿病发病的独立危险因素，TG/HDL-C对2型糖尿病发病的预测能力较强。 Abstract:Objective To evaluate the association between triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), TG/HDL-C and the risk of type 2 diabetes (T2D). Methods A total of 30 546 people without T2D from the Jinchang cohort baseline survey were enrolled. Cox proportional hazards regression and restricted cubic spline were used to estimate the relationship between TG, HDL-C and TG/HDL-C on the risk and dose response of T2D. Receiver operating characteristic curve was conducted to evaluate the predictive ability on the risk of T2D, and determine the optimal predictive index and its critical value. Results After adjusting for confounding factors, high TG, low HDL-C and high TG/HDL-C in the general population were risk factors for T2D, with the HRs of 1.082 (95% CI: 1.053-1.111, P < 0.001), 0.730 (95% CI: 0.595-0.897, P=0.003) and 1.061(95% CI: 1.038-1.085, P < 0.001), respectively. The predictive value of TG/HDL-C was higher than those of TG and HDL-C, and their areas under the curve were 0.652, 0.646 and 0.600, respectively. The optimal cut-offs were 1.14, 1.67 mmol/L and 1.40 mmol/L for TG/HDL-C, TG and HDL-C. Conclusions High TG, low HDL-C and high TG/HDL-C are independent risk factors for the risk of T2D. TG/HDL-C has the strongest predictive ability on the incidence of T2D. -
图 1 TG、HDL-C、TG/HDL-C与2型糖尿病发病的剂量-反应关系
Figure 1. Dose response diagram of TG, HDL-C, TG/HDL-C and T2D
图 2 TG、HDL-C和TG/HDL-C预测2型糖尿病发病的ROC曲线图
Figure 2. ROC curves of TG, HDL-C and TG/HDL-C for predicting T2D incidence
表 1 新发2型糖尿病和非2型糖尿病人群基线特征比较[n(%)]
Table 1. Comparison of baseline characteristics between incident T2D and non-T2D populations [n(%)]
变量 糖尿病组(n=1 094) 非糖尿病组(n=29 452) 总人群(N=30 546) t/χ2/W值 P值a 性别 48.03 < .001 男 766(70.02) 17 542(59.56) 18 308 女 328(29.98) 11 910(40.44) 12 238 年龄(x±s, 岁) 54.78±12.21 45.25±12.38 45.59±12.50 -25.33 < .001 文化程度 12 556 672.00 < .001 初中或以下 622(56.86) 10 409(35.34) 11 031 高中或中专 280(25.59) 8 387(28.48) 8 667 大专或以上 192(17.55) 10 656(36.18) 10 848 职业 70.73 < .001 干部 120(11.97) 3 845(13.06) 3 965 技术人员 40(3.66) 1 402(4.76) 1 442 内勤服务人员 104(9.51) 1 265(4.30) 1 369 工人 830(75.87) 22 940(77.89) 23 770 家庭月收入(元) 12.28 < .001 ＜2 000 618(56.49) 15 049(51.10) 15 667 ≥2 000 476(43.51) 14 403(48.90) 14 879 婚姻状况 12.27 < .001 已婚 981(89.67) 25 310(85.94) 26 291 其他 113(10.33) 4 142(14.06) 4 255 吸烟 593(54.20) 12 875(43.72) 13 468 47.08 < .001 饮酒 324(29.62) 6 552(22.25) 6 876 32.84 < .001 体育锻炼 448 174 806.50 < .001 从不 101(9.23) 3 301(11.21) 3 402 偶尔 376(34.37) 12 605(42.80) 12 981 经常 617(56.40) 13 546(45.99) 14 163 高盐饮食 16 623 615.50 0.745 重 277(25.32) 6 513(22.11) 6 790 适中 503(46.00) 15 179(51.54) 15 682 清淡 314(28.70) 7 760(26.35) 8 074 高脂饮食 16 649 539.50 0.816 重 248(22.70) 5 490(18.64) 5 738 适中 557(50.91) 17 171(58.30) 17 728 清淡 289(26.42) 6 791(23.06) 7 080 高糖饮食 447 758 311.00 < .001 重 190(17.37) 6 123(20.79) 6 313 适中 310(28.34) 11 309(38.40) 11 619 清淡 594(54.30) 12 020(48.81) 12 614 糖尿病家族史 189(17.28) 4 241(14.40) 4 430 7.04 0.008 高血压 584(53.82) 7 458(25.57) 8 042 427.94 < .001 BMI(x±s, kg/m2) 25.68±3.23 23.32±3.20 23.41±3.23 -23.70 0.563 FPG(x±s, mmol/L) 5.98±0.62 5.03±0.54 5.07±0.56 -50.22 < .001 TC(x±s, mmol/L) 4.90±0.96 4.68±0.88 4.69±0.89 -8.06 < .001 TG(x±s, mmol/L) 2.52±1.87 1.88±1.46 1.91±1.48 -11.07 < .001 HDL-C(x±s, mmol/L) 1.26±0.32 1.38±0.35 1.38±0.35 12.02 < .001 LDL-C(x±s, mmol/L) 3.17±0.78 3.04±0.74 3.05±0.74 -23.07 0.046 TG/HDL-C(x±s, mmol/L) 2.28±2.31 1.56±1.71 1.59±1.74 -10.08 < .001 注：a表示独立样本t检验/ χ2检验/Wilcoxon秩和检验。 
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表 2 总人群中不同血脂水平对2型糖尿病发病风险的影响
Table 2. Influence of different lipid levels on the risk of T2D in total
指标 N n(%) HR(95% CI)值c P值 χ趋势2值 P趋势值 TG a(mmol/L) 1.082(1.053~1.111) < 0.001 Q1(< 1.11) 9 228 130(1.41) 1.000 251.83 < 0.001 Q2(1.11~<1.51) 6 480 211(3.26) 1.738(1.390~2.713) < 0.001 Q3(1.51~<2.31) 7 884 338(4.29) 1.931(1.565~2.382) < 0.001 Q4(≥2.31) 6 954 415(5.97) 2.467(2.003~3.038) < 0.001 HDL-C a(mmol/L) 0.730(0.595~0.897) 0.003 Q1(< 1.14) 7 779 402(5.17) 1.000 101.46 0.044 Q2(1.14~<1.35) 7 793 294(3.77) 0.996(0.854~1.162) 0.963 Q3(1.35~<1.59) 7 571 236(3.12) 0.930(0.785~1.102) 0.401 Q4(≥1.59) 7 403 162(2.19) 0.818(0.671~0.997) 0.047 TG/HDL-C b 1.061(1.038~1.085) < 0.001 Q1(< 0.72) 7 566 94(1.23) 1.000 262.02 < 0.001 Q2(0.72~<1.14) 7 442 218(2.85) 1.728(1.349~2.212) < 0.001 Q3(1.14~<1.88) 7 319 341(4.45) 2.099(1.655~2.663) < 0.001 Q4(≥1.88) 7 125 441(5.83) 2.435(1.921~3.087) < 0.001 注：a血脂指标作为连续型变量每增加1个单位时2型糖尿病HR(95% CI)值; b无计量单位; c调整了年龄、性别、职业、文化程度、收入、婚姻状况、体育锻炼、吸烟、饮酒、饮食盐油糖的摄入情况、糖尿病家族史、BMI、高血压。
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表 3 男性人群中不同血脂水平对2型糖尿病发病风险的影响
Table 3. Influence of different lipid levels on the risk of T2D in males
指标 N n(%) HR(95% CI)值c P值 χ趋势2值 P趋势值 TG a(mmol/L) 1.064(1.031~1.098) < 0.001 87.980 < 0.001 Q1(< 1.11) 4 176 80(1.92) 1.000 Q2(1.11~<1.51) 3 648 144(3.95) 1.720(1.305~2.268) < 0.001 Q3(1.51~<2.31) 5 179 232(4.48) 1.799(1.388~2.333) < 0.001 Q4(≥2.31) 5 305 310(5.84) 2.198(1.702~2.837) < 0.001 HDL-C a(mmol/L) 0.687(0.531~0.889) 0.004 43.894 0.032 Q1(< 1.14) 6 211 343(5.52) 1.000 Q2(1.14~<1.35) 5 267 207(3.93) 0.966(0.810~1.152) 0.700 Q3(1.35~<1.59) 3 987 136 (3.41) 0.871(0.709~1.069) 0.186 Q4(≥1.59) 2 843 80(2.81) 0.773(0.599~0.997) 0.048 TG/HDL-C b 1.053(1.028~1.079) < 0.001 99.168 < 0.001 Q1(< 0.72) 2 947 51(1.73) 1.000 Q2(0.72~<1.14) 4 223 133(3.15) 1.576(1.138~2.183) 0.006 Q3(1.14~<1.88) 5 182 232(4.48) 1.867(1.370~2.524) < 0.001 Q4(≥1.88) 5 956 350(5.88) 2.189(1.614~2.969) < 0.001 注：a血脂指标作为连续型变量每增加1个单位时2型糖尿病HR(95% CI)值; b无计量单位; c调整了年龄、性别、职业、文化程度、收入、婚姻状况、体育锻炼、吸烟、饮酒、饮食盐油糖的摄入情况、糖尿病家族史、BMI、高血压。
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表 4 女性人群中不同血脂水平对2型糖尿病发病风险的影响
Table 4. Influence of different lipid levels on the risk of T2D in females
指标 N n(%) HR(95% CI)值c P值 χ趋势2值 P趋势值 TG a(mmol/L) 1.144(1.077~1.214) < 0.001 155.300 < 0.001 Q1(< 1.11) 5 052 50(0.99) 1.000 Q2(1.11~<1.51) 2 832 67(2.37) 1.618(1.105~2.370) 0.013 Q3(1.51~<2.31) 2 705 106(3.92) 1.82(1.269~2.620) 0.001 Q4(≥2.31) 1 649 105(6.37) 2.714(1.890~3.898) < 0.001 HDL-C a(mmol/L) 0.777(0.551, 1.095) 0.149 25.275 0.421 Q1(< 1.14) 1 568 59(3.76) 1.000 Q2(1.14~<1.35) 2 526 87(3.44) 1.117(0.796~1.566) 0.700 Q3(1.35~<1.59) 3 584 100(2.79) 1.020(0.733~1.418) 0.186 Q4(≥1.59) 4 560 82(1.80) 0.920(0.650~1.303) 0.048 TG/HDL-C b 1.103(1.046~1.162) < 0.001 138.914 < 0.001 Q1(< 0.72) 4 713 43(0.91) 1.000 Q2(0.72~<1.14) 3 437 85(2.47) 1.749(1.194~2.561) 0.004 Q3(1.14~<1.88) 2 478 109(4.40) 2.102(1.443~3.062) < 0.001 Q4(≥1.88) 1 610 91(5.65) 2.423(1.650~3.558) < 0.001 注：a血脂指标作为连续型变量每增加1个单位时2型糖尿病HR(95% CI)值; b无计量单位; c调整了年龄、性别、职业、文化程度、收入、婚姻状况、体育锻炼、吸烟、饮酒、饮食盐油糖的摄入情况、糖尿病家族史、BMI、高血压。
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表 5 TG、HDL-C与TG/HDL-C对2型糖尿病发病的预测价值
Table 5. Predictive value of TG, HDL-C and TG/HDL-C on T2D incidence
血脂指标 切点
(mmol/L)灵敏度
(%)特异度
(%)约登指数 AUC(95% CI)值 P值a 总人群 TG/HDL-C 1.14 71.12 51.40 0.225 0.652(0.646~0.657) TG(mmol/L) 1.67 64.44 57.03 0.215 0.646(0.640~0.651) 0.040 HDL-C(mmol/L) 1.40 71.21 42.64 0.139 0.600(0.595~0.606) < 0.001 男性 TG/HDL-C 1.20 72.85 43.47 0.163 0.615(0.608~0.622) TG(mmol/L) 1.74 63.58 52.29 0.159 0.606(0.598~0.613) 0.001 HDL-C(mmol/L) 1.20 55.61 56.82 0.124 0.585(0.578~0.592) < 0.001 女性 TG/HDL-C 0.86 78.66 51.18 0.298 0.694(0.686~0.702) TG(mmol/L) 1.50 64.33 65.21 0.295 0.697(0.689~0.706) 0.470 HDL-C(mmol/L) 1.43 58.84 56.14 0.150 0.594(0.585~0.603) < 0.001 注：a与TG/HDL-C指标的ROC曲线下面积比较的Z检验。
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