Triglycerides and mortality risk in diabetes

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21 February 2022

This report from the National Health and Nutrition Examination Surveys (NHANES) showed that a higher fasting triglyceride level was associated with a higher risk of diabetes-related death.

Wadström BN, Wang Y. Higher fasting triglyceride predicts higher risks of diabetes mortality in US adults. Lipids in Health and Disease 2021;20:181.

STUDY SUMMARY

Objective:

To investigate the association of fasting triglycerides (TG) with diabetes mortality.

Study design:

Cohort analysis of the NHANES (1988-2014) data.

Study population:

27,067 subjects (22,909 without diabetes and 3673 with diabetes) with mean age 49 years and fasting TG data included in NHANES III (1988-1999) and NHANES IV (1999-2014).

Primary variable:

Diabetes-related mortality, i.e., diabetes was listed as an underlying cause of death. Diabetes was defined as fasting plasma glucose ≥126 mg/dL, or HbA1c ≥ 6.5%, or taking hypoglycaemic drugs, or self-reported diagnosis.

Methods:

Cox proportional hazards models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) of TG for diabetes mortality. The model was adjusted for age, sex, ethnicity, obesity, poverty-income ratio, education, physical activity, alcohol consumption, smoking status, survey period, hypercholesterolemia, hypertension, diabetes, and family history of diabetes.

Results:

During 319,758 person-years of follow-up (mean follow-up 12.0 years), 582 participants died from diabetes. A 1-natural-log-unit increase in TG was associated with a 40% higher risk of diabetes mortality; this association was evident in people with and without diabetes at baseline (Table 1). Compared with people with TG in the lowest quintile, people with TG levels in the highest quintile had an 85% higher risk of diabetes death (HR, 1.85; 95% CI, 1.25–2.73; p = 0.002)

Table 1. Association of TG and diabetes mortality

	N	HR (95% confidence interval)	p-value
All subjects	26,582	1.40 (1.20–1.64)	<0.001
Subjects without diabetes	22,909	1.45 (1.09–1.92)	0.011
Subjects with diabetes	3,673	1.32 (1.09–1.58)	0.004

Authors’ conclusion:

This study demonstrated that higher fasting TG was associated with a higher risk of diabetes mortality. TG may need to be routinely monitored in clinic for the risk assessment for diabetes.

COMMENT

In 2019, diabetes was the ninth leading cause of death worldwide (1). Over the last 20 years, diabetes-related mortality has increased by more than 70% with an even larger increase among males (2). Increasingly, this burden of disease will be in lower and middle-income countries, aligned with trends in escalating diabetes prevalence in these regions. Identifying modifiable factors associated with diabetes prognosis is therefore crucial to impact diabetic mortality.

The current report from NHANES adds important information. Elevated TG, which are prevalent in individuals with type 2 diabetes, typically in combination with low plasma concentration of high-density lipoprotein cholesterol (atherogenic dyslipidemia) (3), are associated with an increased risk of diabetes mortality. These findings are strengthened by the size of the cohort, prospective study design and adjustment for confounding factors in the analysis. The authors acknowledge, however, that the study does not provide information regarding the underlying mechanism(s) of this association. Taken together, the results of this analysis provide further support for therapeutic targeting of elevated TG in the routine management of diabetes patients.

References

1. World Health Organization. Diabetes. Key facts. 10 November 2021. https://www.who.int/news-room/fact-sheets/detail/diabetes
2. World Health Organization. The top 10 causes of death. 9 December 2020. https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death
3. Halcox JP, Banegas JR, Roy C, et al. Prevalence and treatment of atherogenic dyslipidemia in the primary prevention of cardiovascular disease in Europe: EURIKA, a cross-sectional observational study. BMC Cardiovasc Disord 17, 160 (2017).

Key words

triglyceride, diabetes, diabetes mortality; NHANES