缺血性脑卒中患者的肥胖现况及其与代谢疾病和卒中预后关系的研究

发布时间：2018-09-03 11:32

【摘要】：背景：肥胖是全球面临的一个重要公共卫生问题，无论是在发达国家或是发展中国家，肥胖均呈快速增长的趋势。基于人群的研究显示，中国也面临着肥胖流行的问题，肥胖增加代谢性疾病的患病率。在一般人群中，肥胖增加脑卒中风险和死亡风险。但是在脑卒中患病人群中，存在“肥胖悖论”的现象，即肥胖的脑卒中患者预后更好，肥胖者更容易存活。中国脑卒中患者的肥胖现况尚不清楚，缺乏脑卒中患者肥胖与代谢疾病关系的研究，尚无中国人群肥胖悖论的资料，现有关于“肥胖悖论”的研究结果不相一致，脑卒中肥胖悖论的研究主要集中于体重指数（BMI）与死亡关系，缺乏关于其他肥胖指标及脑卒中其他预后的研究。目的：本研究旨在探讨中国缺血性脑卒中患者的肥胖现况，肥胖与代谢疾病的关系及不同肥胖指标对代谢疾病的预测作用，肥胖对脑卒中患者预后的影响。方法：以前瞻性、多中心的中国国家脑卒中登记研究（The China National StrokeRegistry，CNSR）中缺血性脑卒中患者为研究人群。CNSR同期收集在132家医院就诊患者的人口社会学特征、危险因素、临床特征和治疗，并对脑卒中患者结局进行前瞻性随访，结局包括全因死亡、神经功能预后和脑卒中复发。全身性肥胖依据世界卫生组织针对亚洲人群推荐的BMI切点：BMI18.5kg/m2为消瘦，18.5-22.9kg/m2为正常，23-27.4kg/m2为超重，≥27.5-32.4kg/m2为肥胖，≥32.5kg/m2为严重肥胖。中心性肥胖定义为腰围（WC）≥男85cm/女80cm，腰围身高比（WHtR）≥0.5。logistic回归分析肥胖与代谢性疾病的关系。以受试者工作特性（ROC）曲线分析各肥胖指标对≥1个代谢性疾病的预测价值。logistic回归分析肥胖指标与脑卒中预后关系。结果：中国国家脑卒中数据库共在全国132家医院同期连续性登记22216例发病14天内急性脑血管病患者，本研究共纳入10033例缺血性脑卒中患者，6210例（61.9%）男性，3823例（38.1%）女性。按BMI的标准，403例（4.0%）为消瘦，，3126例（31.2%）为正常体重，4932例（49.2%）为超重，1572例（15.7%）为肥胖；按腰围的标准，中心性肥胖6272例（62.5%）；按腰围身高比的标准，中心性肥胖6147例（61.3%）。18-45岁的青年缺血性脑卒中男性患者中肥胖占21.2%，高于其他年龄组男性患者的肥胖比例（P0.001），也高于同年龄组女性患者（15.4%）（P0.001）。超重/肥胖的比例，北方高于南方（69.2%vs56.7%）；东部最高（66.9%），中部次之（63.5%），西部最低（58.9%）；高经济收入区高于低经济收入区（66.2%vs63.5%）；高家庭人均月收入者（66.1%）高于低家庭人均月收入者（62.6%）；文化程度高者超重/肥胖的比例高，初中及以上文化程度者为69.4%，小学和文盲为59.3%。随着BMI、腰围及WHtR增大，高血压、糖尿病、脂代谢紊乱的比例增高，BMI由低到高组，高血压比例分别为49.1%、55.9%、65.2%、76.0%（P0.001），糖尿病比例分别为16.6%、20.7%、27.4%、33.1%（P0.001），脂代谢紊乱比例分别为38.2%、47.4%、52.1%、58.1%（P0.001）；腰围由低到高组，高血压比例分别为55.5%、61.7%、66.7%、70.7%（P0.001），糖尿病比例分别为19.4%、26.5%、27.3%、31.1%（P0.001），脂代谢紊乱比例分别为47.4%、49.5%、51.4%、56.6%（P0.001）；WHtR由低到高组，高血压比例分别为54.8%、61.8%、65.3%、71.3%（P0.001），糖尿病比例分别为19.0%、25.9%、26.4%、31.7%（P0.001），脂代谢紊乱比例分别为46.3%、48.1%、53.1%、56.5%（P0.001）。高BMI组合并高血压、糖尿病、脂代谢紊乱的比值比分别为2.69（95%CI2.35-3.06）、1.97（95%CI1.73-2.25）、1.45（95%CI1.29-1.63），高腰围组分别为2.00（95%CI1.78-2.26）、1.92（95%CI1.68-2.18）、1.44（95%CI1.29-1.61），高WHtR组分别为2.03（95%CI1.81-2.28）、1.96（95%CI1.72-2.23）、1.50（95%CI1.35-1.68）。在男性中，ROC曲线分析各肥胖指标诊断≥1个代谢疾病曲线下面积：BMI为0.604（95%CI0.591-0.616），WC为0.582（95%CI0.569-0.594），WHtR为0.583（95%CI0.570-0.595），在女性中， BMI为0.629（95%CI0.613-0.644），WC为0.609（95%CI0.593-0.624），WHtR为0.610（95%CI0.594-0.626），三者曲线下面积无差别。 10033例缺血性脑卒中患者中，9342例（93.1%）完成12月随访，691（6.9%）例失访。存活患者中，高BMI组的神经功能预后良好（mRS0-1）比例更高，3个月mRS0-1的比例：消瘦组51.7%，正常体重组54.9%，超重组60.0%，肥胖组59.3%，严重肥胖组59.5%（P0.001）。12个月mRS0-1的比例：消瘦组57.0%，正常体重组63.1%，超重组65.1%，肥胖组66.4%，严重肥胖组66.4%（P=0.018）。多因素logistic回归分析显示：超重与3个月神经功能预后良好独立相关（OR=1.26;95%CI,1.13-1.39），BMI与12个月神经功能预后无相关性。全因死亡的比例较高为消瘦组和严重肥胖组，3个月死亡比例：消瘦组15.7%，正常体重组8.3%，超重组7.7%，肥胖组7.3%，严重肥胖组12.1%（P0.001）。12个月死亡比例：消瘦组25.3%，正常体重组14.2%，超重组12.3%，肥胖组11.3%，严重肥胖组16.7%（P 0.001）。多因素logistic回归分析显示：严重肥胖与3个月死亡独立相关（OR2.13;95%CI1.15-3.68），与12个月死亡独立相关（OR1.46;95%CI1.09-2.50）。多因素logistic回归分析显示BMI与12个月脑卒中复发无相关性。中心性肥胖与脑卒中预后无相关性。结论： 1．中国缺血性脑卒中患者中，超重和肥胖较为普遍。18-45岁青年男性患者肥胖比例高；北方地区、经济收入高、文化水平高者肥胖比例更高。在缺血性脑卒中患者中，应注重肥胖的宣教和干预，尤其应关注上述人群和地区。 2．肥胖增加缺血性脑卒中患者高血压、糖尿病、脂代谢紊乱的患病率，肥胖与代谢性疾病关系密切。但肥胖指标对代谢性疾病预测价值有限，在所有缺血性脑卒中患者中应注意危险因素的检查。 3．缺血性脑卒中患者中，尽管超重者短期神经功能预后良好，严重肥胖增加死亡风险。需要更多的研究阐明肥胖与脑卒中预后关系，从而指导脑卒中的二级预防。
[Abstract]:Background:
Obesity is an important public health problem facing the world. Obesity is increasing rapidly in both developed and developing countries. Population-based studies show that China is also facing an obesity epidemic, with obesity increasing the prevalence of metabolic diseases. In the general population, obesity increases the risk of stroke and death. Risk. However, there is a "obesity paradox" in stroke patients, that is, obese stroke patients have a better prognosis, obese people are more likely to survive. The status of obesity in stroke patients in China is still unclear, there is no research on the relationship between obesity and metabolic diseases in stroke patients, and there is no data on the obesity paradox in Chinese population. The results of the obesity paradox are inconsistent. The obesity paradox of stroke is mainly focused on the relationship between body mass index (BMI) and death. There is no research on other obesity indicators and other prognosis of stroke.
Objective:
The purpose of this study was to investigate the prevalence of obesity in Chinese patients with ischemic stroke, the relationship between obesity and metabolic diseases, the predictive effect of different obesity indices on metabolic diseases, and the effect of obesity on the prognosis of stroke patients.
Method:
A prospective, multicenter, China National Stroke Registry (CNSR) study of ischemic stroke patients was conducted. CNSR collected demographic and sociological characteristics, risk factors, clinical characteristics, and treatment of patients in 132 hospitals at the same time. Prospective follow-up was conducted to determine the outcome of stroke patients. Systemic obesity was defined as waist circumference (WC) > male 85. The relationship between obesity and metabolic diseases was analyzed by logistic regression. The predictive value of obesity indices for more than 1 metabolic disease was analyzed by ROC curve. The relationship between obesity indices and stroke prognosis was analyzed by logistic regression.
Result:
A total of 22216 patients with acute cerebrovascular disease (ACVD) within 14 days were registered in 132 hospitals nationwide. This study included 1 033 patients with ischemic stroke, 6 210 (61.9%) were males and 3 833 (38.1%) were females.
According to BMI criteria, 403 (4.0%) were emaciated, 3126 (31.2%) were normal weight, 4932 (49.2%) were overweight, and 1572 (15.7%) were obese; according to waist circumference criteria, 6 272 (62.5%) were central obesity; according to waist circumference height ratio criteria, 6 147 (61.3%) were central obesity in young men aged 18-45 with ischemic stroke, 21.2% were obese, higher than that in young men aged 18-45. The proportion of obesity in male patients of other age groups (P 0.001) was also higher than that in female patients of the same age group (P 0.001). The proportion of overweight/obesity in the North was higher than that in the South (69.2% vs 56.7%), the highest in the East (66.9%), the second highest in the middle (63.5%) and the lowest in the West (58.9%); the highest in the high-income area was higher than that in the low-income area (66.2% vs 63.5%); and the average monthly per capita of high-income families. Income (66.1%) was higher than average monthly income (62.6%) in low-income families; overweight/obesity was higher in high-educated people, 69.4% in junior high school and above, and 59.3% in primary school and illiteracy.
With the increase of BMI, waist circumference and WHtR, the proportion of hypertension, diabetes mellitus and lipid metabolism disorder increased. BMI from low to high group was 49.1%, 55.9%, 65.2%, 76.0% (P 0.001), the proportion of diabetes mellitus was 16.6%, 20.7%, 27.4%, 33.1% (P 0.001), the proportion of lipid metabolism disorder was 38.2%, 47.4%, 52.1%, 58.1% (P 0.001). The proportion of hypertension was 55.5%, 61.7%, 66.7% and 70.7% (P 0.001), the proportion of diabetes mellitus was 19.4%, 26.5%, 27.3%, 31.1% (P 0.001), the proportion of lipid metabolism disorder was 47.4%, 49.5%, 51.4%, 56.6% (P 0.001), the proportion of hypertension was 54.8%, 61.8%, 65.3%, 71.3% (P 0.001), the proportion of diabetes mellitus was 19.0%, 25.9%, 26.4%, 31.7% respectively. (P 0.001), the proportion of dyslipidemia was 46.3%, 48.1%, 53.1%, 53.1%, 56.5% (P 0.001). The ratio of hyperBMI group with hypertension, diabetes mellitus, hyperlipidemia was 2.69 (95% CI 2.35-3.06), 1.97 (95% CI 1.73-2.25, 95% CI 1.73-2.25), 1.45 (95% CI 1.45 (95% CI 1.29-1.29-1.29-1.63), 2.00 (95% CI 1.78-78-2.78-2.26), 1.92 (95% CI 1.68-1.68-2.18), 1.44 (95% CI 1.44 (95% CI 2.45-95% CI 1.35-Group Among men, ROC curve analysis of obesity indicators diagnosed (> 1 metabolic disease curve area: BMI 0.604 (95% CI0.591-0.616), BMI 0.604 (95% CI0.591-0.616), WC 0.582 (95% CI0.569-0.594), WHtR 0.583 (95% CI0.560.570.570-0.590-0.595), WHtR 0.583 (95% CI0.583 (95% CI0.570.570.570-0.570-0.595) in women, BMI 0.620.629 (95% CI0.629-95% CI0.619-95% CI0.619-95% CI0 644), WC 0. 609 (95%CI0.593-0.624), WHtR was 0.610 (95%CI0.594-0.626), and there was no difference in the area under the three curve.
Among the 1 033 patients with ischemic stroke, 9 342 (93.1%) completed 12-month follow-up and 691 (6.9%) lost follow-up. Among the survivors, the high BMI group had a higher percentage of good neurological prognosis (mRS0-1). The proportion of mRS0-1 at 3 months was 51.7% in the emaciated group, 54.9% in the normal weight group, 60.0% in the overweight group, 59.3% in the obese group, 59.5% in the severe obesity group (P 0.001). Multivariate logistic regression analysis showed that overweight was independently associated with a good prognosis of neurological function at 3 months (OR = 1.26; 95% CI, 1.13-1.39), BMI was not associated with a 12-month prognosis of neurological function. The 3-month mortality rates in lean and severe obesity groups were 15.7% in emaciation group, 8.3% in normal weight group, 7.7% in overweight group, 7.3% in obesity group, 12.1% in severe obesity group (P 0.001). The 12-month mortality rates were 25.3% in emaciation group, 14.2% in normal weight group, 12.3% in overweight group, 11.3% in obesity group and 16.7% in severe obesity group (P 0.001). Weight and obesity were independently associated with 3-month mortality (OR2.13; 95% CI 1.15-3.68) and 12-month mortality (OR1.46; 95% CI 1.09-2.50). Multivariate logistic regression analysis showed that BMI was not associated with 12-month stroke recurrence. Central obesity was not associated with stroke prognosis.
Conclusion:
1. Overweight and obesity are prevalent among ischemic stroke patients in China. The obesity rate of male patients aged 18-45 is high. In northern China, the obesity rate is higher among those with high income and high education level.
2. Obesity increases the prevalence of hypertension, diabetes, lipid metabolism disorders in patients with ischemic stroke. Obesity is closely related to metabolic diseases. However, obesity indicators have limited predictive value for metabolic diseases. Risk factors should be examined in all patients with ischemic stroke.
3. In ischemic stroke patients, although overweight patients have good short-term neurological prognosis, severe obesity increases the risk of death. More research is needed to clarify the relationship between obesity and stroke prognosis, so as to guide secondary prevention of stroke.
【学位授予单位】：郑州大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R743.3;R589.2

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