Increased serum triglyceride concentrations and abdominal adiposity were associated with increased mortality in women
ACP J Club. 1994 May-June;120:79. doi:10.7326/ACPJC-1994-120-3-079
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• Correction: Increased serum triglyceride concentrations and abdominal adiposity were associated with increased mortality in women
Bengtsson C, Björkelund C, Lapidus L, Lissner L. Associations of serum lipid concentrations and obesity with mortality in women: 20 year follow up of participants in prospective population study in Gothenburg, Sweden. BMJ. 1993; Nov 27;307:1385-8.
To quantify the association among serum cholesterol and triglyceride concentrations, general and abdominal obesity, and mortality in women.
Cohort analytic study with 20 years of follow-up.
Community-based study in Gothenburg, Sweden.
1462 women aged 38, 46, 50, 54, or 60 years were randomly selected from the community. After 20 years of follow-up, vital status was ascertained in all but 12 women.
Assessment of risk factors
At baseline, blood samples were taken from participants after an overnight fast for measurement of total serum cholesterol and serum triglyceride concentrations. Weight, height, body mass index (BMI), standing waist-to-hip ratio (WHR), and smoking habits were also ascertained.
Main outcome measures
Total mortality and death from myocardial infarction (MI).
170 of the 1450 women (12%) followed for 20 years died, 26 (15%) from MI. The age-adjusted relative risk (RR) comparing the highest quarter of serum triglyceride concentration with the lower 3 quarters was 1.86 (95% CI 1.30 to 2.67) for total mortality and 4.01 (CI 1.80 to 8.91) for death from MI. The age-adjusted RR comparing the highest quarter of WHR with the lower 3 quarters was 1.67 (CI 1.18 to 2.36) for total mortality and 3.62 (CI 1.74 to 7.53) for death from MI. The RRs remained unchanged after adjustment for serum cholesterol level and BMI, respectively. Although age-adjusted RRs for serum cholesterol level and BMI were 2.44 (CI 1.07 to 5.55) and 2.26 (CI 1.05 to 4.86), respectively, for death from MI, they were not significant for total death and were not significant for total or MI-related death on multiple logistic regression analysis. Using multiple logistic regression analysis, serum triglyceride concentration and WHR were the strongest independent risk factors for total mortality and death from MI. These associations were unchanged after adjustment for smoking habits.
Increased serum triglyceride concentration and abdominal adiposity were associated with increased risk for total mortality and death from myocardial infarction in women. Increased serum cholesterol concentration and increased general adiposity were not associated with risk for total mortality and were only minimally associated with death from myocardial infarction.
Sources of funding: Swedish Medical Research Council; Foundation of King Gustav V and Queen Victoria; Faculty of Medicine of Gothenburg University; Gothenburg Medical Society.
For article reprint: Professor C. Bengtsson, Department of Primary Health Care, Vasa Hospital, S-41133 Gothenburg, Sweden. FAX 46-31-778-1704.
The study by Bengtsson and colleagues suggests that abdominal obesity and serum triglyceride levels are potentially more important risk factors for coronary heart disease (CHD) in women than are general obesity or serum cholesterol levels. Larger studies, such as the Framingham Study and the Nurses' Health Study, have documented well the importance of general obesity as a risk factor for CHD morbidity and mortality in women. A 5-year follow-up study of 42 000 postmenopausal Iowa women showed that women in the top quintile of self-reported WHR had double the risk for death as those in the lowest quintile; however, no risk increase was seen with the highest quintile of BMI (1). WHR is a better measure of abdominal visceral (not superficial) adipose tissue than is BMI and is more strongly associated with features of insulin resistance, such as diabetes mellitus, hypertension, hypertriglyceridemia, and lower levels of high-density lipoprotein (HDL) cholesterol. Using multivariate analysis, this study implicates hypertriglyceridemia as an important risk factor for CHD and total mortality in women. Given this increased multivariate risk, how does one clinically address hypertriglyceridemia? The predictive CHD risk for triglycerides > 150 mg/dL in women (in the Framingham Study) occurred only at HDL cholesterol levels < 40 mg/dL (2). Thus, hypertriglyceridemia > 200 mg/dL in a woman with an HDL cholesterol level < 40 mg/dL, or a low-density lipoprotein (LDL)/HDL ratio > 5.0, or from a family with increased CHD, suggests a potentially atherogenic lipid profile. Unfortunately, the study, which began in 1968, did not measure HDL cholesterol, low values of which might have explained the higher risk for hypertriglyceridemia. In such patients, lowering triglyceride levels through weight loss should always be encouraged; in the presence of a very high LDL/HDL ratio or in a woman who already has CHD, triglyceride levels may need pharmacologic treatment along with that for elevated LDL cholesterol levels.
Donald Smith, MD
Mount Sinai School of MedicineNew York, New York, USA