血压在体质指数与心血管疾病发生风险间的中介效应

张曾航; 郭晓雷; 殷召雪; 王增武; 张丙银; 苏玉娟; 鹿子龙; 张吉玉; 庞名芮; 任甜梦; 马吉祥

doi:10.11847/zgggws1140656

血压在体质指数与心血管疾病发生风险间的中介效应

doi: 10.11847/zgggws1140656

1.
中国疾病预防控制中心，北京 102206
2.
山东省疾病预防控制中心
3.
中国医学科学院阜外医院国家心血管病防治中心社区防治部
4.
山东第一医科大学（山东省医学科学院）

详细信息

作者简介:
张曾航（1996 – ），男，河南南阳人，硕士在读，研究方向：慢性病预防与控制

通信作者:
马吉祥，E-mail：majix@163.com

中图分类号: R 181.3⁺7
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- 被引次数: 0
出版历程
- 接收日期: 2022-10-20
- 网络出版日期: 2023-01-11
- 刊出日期: 2023-03-10

Mediating role of blood pressure on the association of body mass index with cardiovascular disease risk

1.
Chinese Center for Disease Control and Prevention, Beijing 102206, China

摘要

摘要: 目的探讨血压在体质指数（BMI）与心血管疾病（CVD）发生风险间的中介效应，为CVD的预防控制提供参考依据。方法于2011年6 — 9月采用多阶段分层随机抽样方法在山东省抽取15600名常住居民进行问卷调查、体格检查和实验室检测，通过山东省心脑血管疾病和死因监测系统随访到13688名常住居民截至2021年10月11日的CVD结局信息；采用单因素和多因素Cox比例风险回归模型分析BMI与CVD发生风险的关系，拟合基于Cox比例风险回归模型的限制性立方样条（RCS）分析BMI与CVD发生风险之间的剂量 – 反应关系，并采用依次检验法分析血压在BMI与CVD发生风险间的中介效应。结果山东省有效调查的15350名常住居民中，利用居民身份证号码共匹配到13688名居民截至2021年10月11日的CVD结局信息，随访率为89.17 %，共随访133733.79人年，中位随访时间为10.25年；剔除51名主要研究数据缺失者以及基线自报有冠心病病史254例和有脑卒中病史115例后，对最终纳入13268名研究对象进行分析。截至随访观察终点时发生CVD结局事件者492例，发病密度为367.90/10万人年；低体重组、正常体重组、超重组和肥胖组居民发生CVD结局事件者分别为22、173、183和114例，发病密度分别为380.08/10万人年、285.84/10万人年、410.42/10万人年和499.25/10万人年。在调整了性别、年龄、文化程度、婚姻状况、家庭年均收入、居住地、地区、是否吸烟、是否饮酒、是否身体活动不足、是否高血压、是否糖尿病、是否血脂异常、每日盐摄入量和每日油摄入量等混杂因素后，多因素Cox比例风险回归模型分析结果显示，超重组居民发生CVD结局事件的风险为正常体重组居民的1.253倍（HR = 1.253，95 % CI = 1.014～1.548）；剂量 – 反应关系分析显示BMI与CVD发生风险呈“J”形关系（χ²_总趋势 = 29.87，P_总趋势 = 0.004；χ²_非线性 = 7.08，P_非线性 = 0.069）；中介效应分析显示，BMI与CVD发生风险的直接效应为0.038（Z = 11.644，P < 0.001），收缩压（SBP）、舒张压（DBP）和是否高血压的中介效应分别为0.022（Z = 12.354，P < 0.001）、0.041（Z = 10.859，P < 0.001）和0.133（Z = 11.506，P < 0.001），其中介作用百分比分别为36.67 %、51.90 %和77.78 %。结论血压在BMI与CVD发生风险间的关联中具有较强的中介效应，应重点关注超重或肥胖个体的血压变化情况并及时进行干预和指导。
- 心血管疾病（CVD） /
- 发生风险 /
- 体质指数(BMI) /
- 高血压 /
- 中介效应
Abstract: Objective To investigate mediating role of blood pressure on the association of body mass index (BMI) with cardiovascular disease (CVD) risk and to provide evidence for control of CVD risk. Methods Using stratified multistage random sampling and a self-designed questionnaire, a baseline survey including face-to-face interview, physical examination and laboratory tests were conducted among 15 600 permanent urban/rural residents aged 18 – 69 years during June – September, 2021 in Shandong province; then the residents were followed up to October 11, 2021 through the Cardiovascular Diseases and Mortality Surveillance System to collect the information on the prevalence of CVD. Univariate and multivariate Cox proportional risk regression model was used to analyze the association of body mass index (BMI) with the risk of CVD. The dose-response relationship between BMI and CVD risk was described with restricted cubic splines (RCS). The mediating role of blood pressure on the association of BMI with CVD risk was assessed with sequential test. Results Of all the residents at the baseline survey, 89.17% (13 688) were followed up; after excluding those with previous history of coronary heart disease (n = 254) and stroke (n = 115) and those without valid outcome information, 13 268 participants were finally included in the analysis, with a total follow-up of 133 733.79 person-years and a median follow-up period of 10.25 years. By the end of the follow-up among the participants, totally 492 CVD incidences were identified and the CVD incidence density was 367.90/100 000 person-years. The number of CVD incidence was 22, 173, 183, and 114 among the participants with low-weight, normal-weight, overweight, and obesity, with the corresponding CVD incidence densities (1/100 000 person-years) of 380.08, 285.84, 410.42, and 499.25, respectively. After adjusting for age, gender, education, marital status, annual household income, living area (urban/rural), geographical region of residence (central/southeast/northwest), smoking, alcohol drinking, physical activity, daily salt intake, daily oil intake, and disease history of hypertension, diabetes or dyslipidemia, multivariate Cox proportional risk regression model analysis showed that the participants with overweight were at an increased risk of CVD incidence (hazard risk [HR] = 1.253, 95% confidence interval [95% CI]: 1.014 – 1.548) compared to those with normal weight. Dose-response analysis revealed a J-shaped relationship between BMI and the risk of CVD (χ²_overall = 29.87, P _overall = 0.004; χ²_nonlinear = 7.08, P_nonlinear = 0.069). Mediating effect analysis demonstrated that the direct effect of BMI on CVD incidence risk was 0.038 (Z = 11.644, P < 0.001) and the mediating effect of systolic blood pressure (SBP), diastolic blood pressure (DBP) and hypertension was 0.022 (Z = 12.354, P < 0.001), 0.041 (Z = 10.589, P < 0.001) and 0.133 (Z = 11.506, P < 0.001). The mediating effect percentages of SBP, DBP pressure and hypertension were 36.67%, 51.90% and 77.78%, respectively. Conclusion Blood pressure has a strong mediating effect on the association of BMI with CVD risk. The results suggested that more attention and intervention on the changes of blood pressure need to be promoted among overweight and obesity populations.
- cardiovascular diseases /
- incidence risk /
- body mass index /
- hypertension /
- mediating effect

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表 1 不同BMI亚组常住居民基线特征计数资料比较

特征		低体重组（n = 576）		正常体重组（n = 5991）		超重组（n = 4423）		肥胖组（n = 2278）		χ² 值	P 值
特征		n	%	n	%	n	%	n	%	χ² 值	P 值
性别	男性	275	47.74	3050	50.91	2220	50.19	1082	47.50	3.529	0.060
	女性	301	52.26	2941	49.09	2203	49.81	1196	52.50
文化程度 ^a	小学及以下	171	29.79	1956	32.72	1581	35.81	807	35.47	17.460	< 0.001
	初中及以上	403	70.21	4022	67.28	2834	64.19	1468	64.53
婚姻状况 ^a	非在婚	184	31.94	851	14.21	355	8.03	182	7.99	348.797	< 0.001
	在婚	392	68.06	5138	85.79	4066	91.97	2096	92.01
家庭年均收入（元）	< 5000	275	47.74	2701	45.08	1 920	43.41	1007	44.21	9.275	0.010
	5000～15000	246	42.71	2811	46.92	2044	46.21	1049	46.05
	> 15000	55	9.55	479	8.00	459	10.38	222	9.75
居住地	城市	176	30.56	1567	26.16	1278	28.89	706	30.99	13.286	0.001
	农村	400	69.44	4424	73.84	3145	71.11	1572	69.01
地区	鲁东	127	22.05	1300	21.70	1049	23.73	561	24.63	14.087	0.001
	鲁中南	224	38.89	2295	38.31	1727	39.05	889	39.03
	鲁西北	225	39.06	2396	39.99	1647	37.24	828	36.35
是否吸烟 ^a	否	402	70.03	4009	66.98	3064	69.38	1660	72.90	20.098	< 0.001
	是	172	29.97	1976	33.02	1352	30.62	617	27.10
是否饮酒 ^a	否	386	68.08	3492	59.47	2547	58.62	1330	59.72	3.519	0.061
	是	181	31.92	2381	40.53	1798	41.38	897	40.28
是否身体活动不足 ^a	否	104	18.12	4973	83.40	3557	80.77	1827	80.66	9.882	0.002
	是	470	81.88	990	16.60	847	19.23	438	19.34
是否高血压	否	528	91.67	5282	88.17	3380	76.42	1358	59.61	863.721	< 0.001
	是	48	8.33	709	11.83	1043	23.58	920	40.39
是否糖尿病 ^a	否	565	98.26	5759	96.45	4089	92.72	2028	89.14	188.084	< 0.001
	是	10	1.74	212	3.55	321	7.28	247	10.86
是否血脂异常	否	531	92.19	5495	91.72	3783	85.53	1849	81.17	200.374	< 0.001
	是	45	7.81	496	8.28	640	14.47	429	18.83
注：a 数据有缺失。

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表 2 不同BMI亚组常住居民基线特征计量资料比较（$\bar x \pm s$）

特征	低体重组	正常体重组	超重组	肥胖组	H 值	P 值
年龄（岁$）$	36.08 ± 16.67	40.3 ± 14.23	43.54 ± 13.22	43.16 ± 13.14	493.796	< 0.001
SBP（mm Hg）	112.04 ± 17.43	117.2 ± 16.71	123.86 ± 17.73	129.68 ± 19.38	1126.838	< 0.001
DBP（mm Hg）	71.47 ± 9.66	75.37 ± 10.25	81.05 ± 10.71	86.76 ± 11.67	2011.076	< 0.001
FPG（mmol/L）	5.21 ± 1.21	5.41 ± 1.18	5.71 ± 1.44	5.95 ± 1.55	637.752	< 0.001
TC（mmol/L）	3.94 ± 0.86	4.20 ± 0.93	4.52 ± 0.95	4.65 ± 0.93	669.313	< 0.001
TG（mmol/L）	0.83 ± 0.61	1.09 ± 1.36	1.62 ± 1.89	2.09 ± 2.36	1685.161	< 0.001
HDL-C（mmol/L）	1.53 ± 0.39	1.49 ± 0.36	1.38 ± 0.33	1.29 ± 0.30	695.315	< 0.001
LDL-C（mmol/L）	1.86 ± 0.50	2.06 ± 0.58	2.31 ± 0.60	2.42 ± 0.63	1039.482	< 0.001
每日摄盐量（g，$\bar x \pm s$）	7.12 ± 3.45	7.52 ± 3.95	7.78 ± 4.18	7.85 ± 4.22	9619.187	0.475
每日摄油量（g，$\bar x \pm s$）	34.75 ± 38.99	39.72 ± 242.98	36.09 ± 23.71	40.84 ± 182.2	209.533	0.380

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