Fasting and postchallenge hyperglycemia and risk of cardiovascular disease in Chinese: The Chin-Shan Community Cardiovascular Cohort study

doi:10.1016/j.ahj.2008.06.019

American Heart Journal

Volume 156, Issue 5, November 2008, Pages 996-1002

https://doi.org/10.1016/j.ahj.2008.06.019 Get rights and content

Background

Whether fasting glucose is superior to postchallenge glucose or insulin level for prediction of cardiovascular disease (CVD) remains controversial. The aim of our study was to compare fasting, postchallenge glucose and other markers as predictors of CVD in a community-based prospective cohort study among 2,165 adult participants.

Methods

A standard 75-g oral glucose tolerance test was performed, with measurements of fasting and 2-hour postchallenge plasma glucose and insulin levels. We defined the CVD outcome as incident coronary heart disease and stroke. Cox regression model was used to estimate the relative risk (RR) for CVD.

Results

A total of 166 individuals developed major CVD events during 10.5 years of follow-up. Both fasting and postchallenge glucose were significantly associated with CVD risk (adjusted RR in the highest quartile vs the lowest quartile 1.74, 95% confidence interval [CI] 1.06-2.86 for fasting glucose; RR in highest quartile 2.05, 95% CI 1.23-3.42 for postchallenge glucose). Postchallenge and fasting glucose had similar areas of receiver operative characteristics curves (0.65, 95% CI 0.58-0.72 for postchallenge glucose; 0.65, 95% CI 0.58-0.72 for fasting glucose). In mutually adjusted models, fasting and postchallenge glucose remained significant risk factors for CVD, whereas insulin resistance variables became nonsigificant.

Conclusions

These findings show that fasting and postchallenge glucose concentrations are independent predictors of CVD risk among ethnic Chinese in Taiwan.

Section snippets

Study participants

Details of this cohort study have been published previously.9, 10, 11 Briefly, the Chin-Shan Community Cardiovascular Cohort (CCCC) study began in 1990 by recruiting 1,703 men and 1,899 women aged ≥35 years in the Chin-Shan township. Information about anthropometry, lifestyle, and medical conditions was assessed by interview questionnaires in 2-year cycles, and the validity and reproducibility of the collected data and measurements have been reported in detail elsewhere.¹⁰ The participants were

Results

Participants with higher fasting glucose or postchallenge glucose levels were older, heavier, and had higher prevalence of metabolic syndrome and diagnosed diabetes (Table I). Participants with higher postchallenge glucose had similar characteristics in terms of obesity, lifestyle factors, and socioeconomic status as those with higher fasting glucose.

Table II showed the RRs of CVD events during 10.5 years of follow-up across quartiles of markers baseline. After adjustment for cardiovascular

Discussion

In this prospective cohort of middle-aged to older ethnic Chinese, higher levels of fasting and postchallenge glucose were significantly associated with increased risk of CVD. Insulin resistance indices (HOMA and QUICKI) were also associated with CVD risk, but these associations became nonsignificant after further adjustment for the metabolic syndrome.

Several previous studies showed postchallenge glucose was more strongly associated with CVD than fasting glucose.15, 16, 17, 18, 19 The

Acknowledgments

We thank the participants in the Chin-Shan community for their participation.

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Constructing a point-based prediction model for the risk of coronary artery disease in a Chinese community: A report from a cohort study in Taiwan
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Detailed Information about anthropoimetric, lifestyle and medical conditions were assessed by interview questionnaires and physical examinations in biannual cycles for the initial 6 years, and the validity and reliability of the collected data and measurements have been reported in details elsewhere [9,11,12]. The procedure for clinical and biochemical measures has been reported elsewhere [9,12,13]. In brief, blood pressure was measured twice in the right arm using a mercury sphygmomanometer with the subject seated comfortably and arms supported and positioned at the level of the heart, and the average of the blood pressure measurements was used.
Prediction equations and point system derived from large-scale health check-up data for estimating diabetic risk in the Chinese population of Taiwan
2011, Diabetes Research and Clinical Practice
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However, a study showed that the AUC for undiagnosed diabetes was 67.8% for HbA1c alone, and it is comparable to risk score estimated from the information on age, waist circumference, and diabetes in parents or siblings (ROC = 67.3%) [21]. Two-hour oral glucose has been shown to have greater association than fasting glucose with cardiovascular morbidity and mortality [22,23]. Our study did not have information on oral glucose, since the 2 h oral glucose tolerance test (OGTT) is more difficult and expensive to implement.
To develop tools for predicting diabetes development in middle-aged Chinese adults living in Taiwan.
This study made use of data from 24,899 non-diabetic adults aged ≥35 years who received health examination service from a private health check-up clinic during the period of 1994–1996 and had one or more examinations before December 31, 2006. The proportional hazard model and the receiver operating characteristic (ROC) curve method were used respectively to construct the prediction equation and assess the model's performance. A point system is developed for the ease to calculate diabetes risk.
Increased risk of diabetes development was associated with older age, lower education level, alcohol abstinence, abdominal obesity, elevated body mass index (BMI), blood pressure (BP), triglycerides, and impaired fasting glucose. Model 1, incorporating personal socio-demographic and lifestyle characteristics, BMI, and waist circumference (WC), had an area-under-curve (AUC) of 0.717. The AUC increased to 0.726 (model 2) when BP was introduced and to 0.823 (model 3) when both BP and clinical chemistry measures were added. The AUCs in the testing set for models 1, 2, and 3 were 0.688, 0.694, and 0.799 respectively.
These predictive equations of diabetic risk were easy to use by clinical professions and general subjects.
Cardiovascular risk in patients with fasting blood glucose levels within normal range
2010, American Journal of Cardiology
Citation Excerpt :
An alternative explanation might be that higher fasting glucose levels act through the other risk factors. The association between fasting dysglycemia less than the diabetic threshold and cardiovascular morbidity and mortality in the nondiabetic population has been the subject of many studies of various populations.2–9 These studies have demonstrated greater cardiovascular risk for patients with impaired fasting glucose levels compared to those with fasting glucose levels within the normal range.
Fasting glucose levels elevated beyond the normal range have been associated with increased cardiovascular risk. However, it is unknown whether this association exists for variations of fasting glucose within the normal range. The present study was conducted using the computerized database of the Sharon-Shomron District of Clalit Health Services. Included in the present study were subjects with fasting glucose levels within the normal range (<100 mg/dl). We excluded patients with a history of cardiovascular disease or diabetes. The primary outcome was the incidence of coronary revascularization with either percutaneous coronary intervention or coronary artery bypass grafting. The 28,263 participants (age 53.7 ± 12.2 years) were divided into quartiles according to the fasting glucose level (75.4 ± 4.5, 83.6 ± 1.7, 88.9 ± 1.4, and 95.1 ± 2.2 mg/dl). During a mean follow-up of 5.9 ± 0.7 years, 424 subjects required coronary revascularization. A progressive increase was seen in the risk of coronary revascularization as the fasting glucose levels increased within the normal range (hazard ratio 1.73, 95% confidence interval 1.3 to 2.3, p >0.001, between the fourth and first quartiles). However, this association lost its statistical significance after adjustments for the conventional coronary risk factors (hazard ratio 1.17, 95% confidence interval 0.85 to 1.62, p = 0.328). In conclusion, elevated fasting glucose levels within the normal range were associated with an increased cardiovascular risk. This association was caused by the greater prevalence of the other conventional risk factors and not by the glucose level itself.
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All of the studies of IFG 100 adjusted for age, smoking status, blood pressure, and lipids. The 8 publications with information about the estimated RR associated with IGT included 53,512 participants (19,21,25,30,38,39,42,44). All publications included men and women, and 3 were from Asia, 2 from Europe, 2 from the U.S., and 1 from Australia.
Our objective was to estimate the magnitude of the relative risk (RR) for cardiovascular disease associated with impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) from published prospective observational studies.
Hyperglycemia is a known risk factor for cardiovascular disease. However, the magnitude of the RR for cardiovascular disease associated with IFG and IGT is unclear.
We searched PubMed from 1997 through 2008 for relevant publications and performed a meta-analysis.
In 18 publications with information about IFG (110 to 125 mg/dl) (IFG 110), estimates of RR ranged from 0.65 to 2.50. The fixed-effects summary estimate of RR was 1.20 (95% confidence interval [CI]: 1.12 to 1.28). In 8 publications with information about IFG (100 to 125 mg/dl) (IFG 100), estimates of RR ranged from 0.87 to 1.40. The fixed-effects summary estimate of RR was 1.18 (95% CI: 1.09 to 1.28). In 8 publications with information about IGT, estimates of RR ranged from 0.83 to 1.34. The fixed-effects summary estimate of RR was 1.20 (95% CI: 1.07 to 1.34). Five studies combined IFG and IGT, yielding a fixed-effects summary estimate of RR of 1.10 (95% CI: 0.99 to 1.23). No significant difference between the summary estimates for men and women were detected (IFG 110: men: 1.17 [95% CI: 1.05 to 1.31], women: 1.30 [95% CI: 1.10 to 1.54]; IFG 100: men: 1.23 [95% CI: 1.06 to 1.42], women: 1.16 [95% CI: 0.99 to 1.36]).
Impaired fasting glucose and IGT are associated with modest increases in the risk for cardiovascular disease.
Effects of lifestyle intervention and meal replacement on glycaemic and body-weight control in Chinese subjects with impaired glucose regulation: A 1-year randomised controlled trial
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2024, BMJ Supportive and Palliative Care

View all citing articles on Scopus

: Doctor Frank Hu's research is partly supported by the American Heart Association Established Investigator Award.

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Clinical InvestigationDiabetes and MetabolismFasting and postchallenge hyperglycemia and risk of cardiovascular disease in Chinese: The Chin-Shan Community Cardiovascular Cohort study

Background

Methods

Results

Conclusions

Section snippets

Study participants

Results

Discussion

Acknowledgments

Metabolism

Diabetes Res Clin Pract

Med Hypotheses

Atherosclerosis

Prev Vet Med

J Clin Epidemiol

Diabetes Res Clin Pract

Impaired glucose tolerance and impaired fasting glycaemia: the current status on definition and intervention

Diabet Med

Impaired glucose tolerance and fasting hyperglycaemia have different characteristics

Diabet Med

Different mechanisms for impaired fasting glucose and impaired postprandial glucose tolerance in humans

Diabetes Care

Homeostasis model assessment: insulin resistance and ?cell function from fasting plasma glucose and insulin concentrations in man

Diabetologia

Quantitative insulin sensitivity check index: a simple, accurate method for assessing insulin sensitivity in humans

J Clin Endocrinol Metab

Chin-Shan Community Cardiovascular Cohort in Taiwan: baseline data and five-year follow-up morbidity and mortality

Journal of Clinical Epidemiology

Hyperinsulinemia and related atherosclerotic risk factors in the population at cardiovascular risk: a community-based study

Clinical Chemistry

Clinical Investigation
Diabetes and Metabolism
Fasting and postchallenge hyperglycemia and risk of cardiovascular disease in Chinese: The Chin-Shan Community Cardiovascular Cohort study