AUCTORES
Globalize your Research
Research Article | DOI: https://doi.org/10.31579/2692-9759/074
1Resident at Hôtel-Dieu de France hospital, Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon.
2Clinical Research Center at Hôtel-Dieu de France Hospital, Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon.
3Department of Endocrinology at Hôtel-Dieu de France hospital, Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon.
*Corresponding Author: Isabelle Jambart, Resident at Hôtel-Dieu de France hospital, Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon.
Citation: I Jambart, G Sleilaty, S Jambart, R Medlej, G Halaby, et al. (2021) Relative Fat Mass, a new tool for measuring obesity, could predict the complications of type 2 diabetes. Journal of Endocrinology and Disorders. 5(3): Doi:10.31579/2640-1045/074
Copyright: © 2021 Isabelle Jambart. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 28 April 2021 | Accepted: 25 May 2021 | Published: 27 May 2021
Keywords: relative fat mass; body mass index; cardio metabolic risk
Aim/background: Obesity is a chronic disease contributing to many metabolic illnesses, in particular type 2 diabetes. The Relative Fat Mass (RFM) is a tool recently introduced for obesity which better predicts the level of visceral fat than the Body Mass Index (BMI). The aim of this study is to determine whether RFM is a better predictor of the cardiometabolic risk factors and the complications of type 2 diabetes than BMI.
Materials and methods: This is a cross sectional study. A list of information was collected from endocrinologists treating type 2 diabetic patients in a primary healthcare clinic and a tertiary hospital in Beirut. This list allowed us to evaluate the micro and macro vascular complications of type 2 diabetic patients, to assess their risk factors and to calculate their RFM and BMI.
Results: We analyzed the data of 359 patients. Higher RFM was associated with higher systolic blood pressure (p < 0.05), and both RFM and BMI were significantly correlated to higher CRP, triglyceride levels and liver enzymes. However, the BMI was better associated with other cardiometabolic risk factors such as the total cholesterol (p = 0,003), LDL cholesterol (p = 0,002) and HbA1c (p = 0,01) than RFM. Both RFM and BMI were correlated with higher microalbuminuria (p < 0.001) but unlike BMI, higher RFM was associated with higher creatinine level (p = 0.317 versus 0.047 respectively) and therefore better linked to diabetic nephropathy than BMI. More importantly, we observed an unprecedented result, associating RFM to diabetic neuropathy: a normal RFM excludes diabetic neuropathy with a high probability of 82.5%. Furthermore, a RFM cutoff value of 30.76 in men and 43.31 in women showed an increased risk of developing diabetic neuropathy by 2.464. No association was observed between RFM and diabetic retinopathy.
Conclusion: The RFM better predicts microvascular complications of diabetes than BMI except for retinopathy. It is also associated with a worse profile of metabolic syndrome. This study is unique in its discovery of the potential role of RFM as a tool which could rule out neuropathy in diabetic patients.
Obesity constitutes nowadays a real epidemic health problem [1]. It is defined as excess body fat and contributes greatly to the occurrence of several metabolic diseases, such as diabetes, hypertension, dyslipidaemia and many others which are responsible for cardiovascular complications [2]. It is also correlated to an increased incidence of complications in diabetic patients [3, 4]. This makes obesity a major public health issue, and in 1997, the World Health Organization defined it as a chronic disease rather than a simple aesthetic matter.
In clinical practice, the gold standard to measure obesity is the Body Mass Index (BMI). It is easy to calculate, reliable, and gives a better estimation of the body fat than weight alone. However, it has many limitations. It varies according to ethnicity [5, 6] and is not representative of the amount of visceral fat [7] which, by itself, constitutes an independent risk factor for morbidity [8-12]. BMI does not take into consideration the distribution of fat mass and fat free mass [13-16]. People with identical BMI can vary widely in percent body fat, which can lead to misclassification of body-fat defined obesity.
Another way of measuring obesity is waist circumference. It is simple, not related to height, and associates with visceral fat but it is also dependent on ethnicity [5, 17]. Evidence has shown that measuring waist circumference in clinical practice provides both independent and additive information to BMI for predicting morbidity and risk of death [18].
Anthropometric measures of body fat such as DEXA (Dual Energy X ray Absorptiometry), computerized tomography, MRI and biometric impedance evaluate visceral fat in a more precise manner than waist circumference [19-21] but are mostly dedicated to research because of their cost.
In 2018, a new tool, the Relative Fat Mass (RFM), was developed and many studies have shown that it is more accurate than BMI to estimate body fat percentage and more precise in the clinical diagnosis of obesity [22-26].
Since RFM is a very recently discovered tool, studies comparing the correlation of RFM and BMI to type 2 diabetes complications are rare.
The objective of this study is to determine whether RFM is a better predictor of the cardiometabolic risk factors and the complications of type 2 diabetes than BMI.
This is a cross-sectional study that took place in Lebanon from December 2018 to December 2019.
A series of information was collected from endocrinologists affiliated to a primary healthcare clinic and a tertiary hospital in Beirut, treating patients with type 2 diabetes (appendix). This information allowed us to evaluate the micro and macro vascular complications of these patients, to assess their risk factors and to calculate their RFM and BMI.
Inclusion criteria are type 2 diabetic patients treated by these endocrinologists. Patients with an HbA1c < 6.5% were excluded to make sure not to include patients taking antidiabetic medications for other purposes than diabetes.
The RFM formula includes height and waist circumference and is calculated as follows:
a – (20 x height / waist circumference) ; a being 64 for men and 76 for women [7].
A statistical analysis was performed using the SPSS v16.0 computer program. The statistical tests used are the T-test, the ROC curve (Receiver Operating Characteristic), as well as the Chi-square test.
359 patients were recruited, 221 men (61.6%), and 138 women (38.4%). The average age was 61 years old and the median BMI was 29.07 kg / m2. Microvascular complications were found in 44.6 % of patients and macrovascular complications in 62.7%. Characteristics of the patients are listed in table 1. The average RFM was 31.4 for men (Standard Deviation SD 3.32), and 44.1 for women (SD 3.93). RFM in men and women was normally distributed (Figure 1) and standardized in order to use a single value in the correlation calculations. The average for both genders was 36.27 (Figure 2).
For the cardiometabolic risk factors, higher RFM was associated with higher systolic blood pressure (p < 0.05) whereas no correlation was found between RFM and diastolic blood pressure (p = 0.072). The RFM, as well as the BMI, were both significantly correlated to higher CRP and triglycerides levels and liver enzymes. Unlike RFM, BMI was significantly correlated to higher HbA1c (p-value of 0.010 vs 0.060 for RFM), total cholesterol (p-value of 0.003 vs 0.316 for RFM) and LDL-c (p-value 0.002 vs 0.179 for RFM). The HDL-c did not show any significant correlation to neither RFM nor BMI.
Regarding the macrovascular complications of diabetes, there was no statistically significant correlation between RFM and stenting, coronary artery bypass graft or peripheral arterial disease.
However, when assessing the microvascular complications of diabetes, we found an interesting correlation between RFM and diabetic nephropathy and neuropathy but not retinopathy. Indeed, unlike BMI, higher RFM was associated with higher creatinine level (p = 0.317 vs 0.047 respectively) and both RFM and BMI were correlated with higher microalbuminuria (p < 0.001). Furthermore, the area under the curve of true positives (sensitivity) as a function of false positives (1-specificity) of RFM had a statistically significant correlation with diabetic neuropathy (p = 0.016), unlike that of BMI (Figure 3 and Table 2). RFM was found to have a negative predictive value of 82.5% for the diagnosis of diabetic neuropathy (Table 3). A RFM cutoff value of 30.76 in men and 43.31 in women showed an increased risk of developing diabetic neuropathy by 2.464 (CI 1.468 - 4.137).
This is, to our knowledge, the first study on RFM performed on a population of diabetic patients assessing the correlation between RFM as an obesity marker and diabetic complications.
Nowadays, BMI is the most commonly and widely used obesity marker. Other markers such as waist circumference are also used by physicians. Numerous recent studies [22-26] proved the validity of RFM as a tool for measuring obesity or visceral fat. RFM was superior to BMI in diagnostic accuracy for obesity among men, women, and across ethnic groups [27]. Compared with abnormal BMI, abnormal RFM better predicted obesity among men and women using dual energy X-ray absorptiometry (DXA) as the gold standard (19); it was also found to be superior to BMI as a predictor of diabetes. According to Woolcott and Bergamn, the threshold of RFM beyond which a patient is considered obese and therefore at higher risk of mortality was set at 40 in women and 30 in men [26]. In our diabetic population, 68.6% of men and 87.9% of women have an RFM > 30 and > 40 respectively and thus are considered obese. When using the BMI with a cut-off of 30, only 44.4% of men and 44.3% of women are considered obese. This reflects the increasing prevalence of obesity among diabetic patients in our population using the RFM tool and therefore their increased risk of morbidity.
Our study emphasizes the correlation of RFM to higher triglycerides level as it was demonstrated by Leiba et al in their study showing that RFM is a better predictor of dyslipidemia and metabolic syndrome than Body Mass Index [29]. However, we found that BMI was better than RFM in its correlation to total cholesterol and LDL cholesterol. Furthermore, as shown by Kobo et al [22], RFM as the obesity criterion of metabolic syndrome encompasses a larger proportion of the population as suffering from metabolic syndrome. Indeed, our study better correlates RFM to some of the components of the metabolic syndrome: systolic blood pressure, triglycerides and obesity.
Machado et al [29] compared the roles of RFM and BMI as predictors of the severity of non-alcoholic fatty liver disease. They did not observe any significant difference between both tools [30]. This is in line with the results of our study which did not reveal any significant difference between the correlations of RFM and BMI with the markers of liver function: AST, ALT, GGT, alkaline phosphatase.
This study is the first to find an interesting correlation between RFM and diabetic nephropathy and neuropathy.
The high negative predictive value implies that RFM would be a good screening tool for diabetic neuropathy, since a normal RFM could eliminate the presence of neuropathy with a probability of 82.5%. In addition, a high RFM (> 30.76% in men and 43.31% in women), implies a risk of neuropathy multiplied by 2.464. However, although the risk more than doubled, that probability/risk still does not exceed 34.3%, which is not enough to make RFM a diagnostic tool for neuropathy. It would be interesting to confirm these findings with another study in a new population of diabetics. This study would verify whether patients with normal RFM indeed do not have diabetic neuropathy. It would also be noteworthy to identify the reasons why RFM is correlated to diabetic neuropathy and nephropathy only, and not to diabetic retinopathy and other macrovascular complications.
Our study has some limitations. It is a cross-sectional study, which reduces its power. In addition, the population comprises diabetic patients treated by endocrinologists affiliated to two health care centres. This means that we cannot generalize the results to the rest of the Lebanese population, or to the Lebanese diabetic patients. This study only includes diabetic patients with an HbA1C greater than or equal to 6.5. The results are therefore not applicable to patients with pre-diabetes. Finally, the majority of patients with type 2 diabetes who visit their endocrinologist are already being treated for their diabetes, which means that those of them who have an HbA1C below 6.5% thanks to their treatment were eliminated from the study.
The RFM is a very promising new clinical tool, which has been proven to be superior to BMI in predicting the percentage of body fat mass associated with DEXA scan results. It is also associated with a worse profile of metabolic syndrome. This study is unique in its discovery of a relationship between RFM and diabetic neuropathy and nephropathy, and the potential role of RFM as a factor that might rule out neuropathy in diabetic patients. However, further studies are needed to validate this finding.
Annex
List of information collected from patients:
- Age, sex, weight, height, waist circumference
- Date of onset of diabetes
- Blood pressure
- HbA1C and blood glucose
- Creatinine and micro-albuminuria (ACR)
- CRP
- Diabetic neuropathy (diagnosed by questioning patients and carrying out a targeted physical examination: tuning fork, thread)
- Diabetic ophthalmopathy (Normal or pathological fundus)
- Complete liver panel: AST, ALT, GGT, alkaline phosphatases
- Lipid profile: total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides
- Cardiovascular history: stent, coronary artery bypass graft, mesenteric ischemia, stroke, peripheral artery disease.
ACR: albumin/creatinine ratio
BMI: body mass index
CABG: coronary artery bypass graft
DBP: diastolic blood pressure
F: female
M: male
RFM: relative fat mass
SBP: systolic blood pressure
Declarations:
Ethics approval: approved by the ethics committee of Hôtel-Dieu de France Hospital and the Faculty of Medicine of Saint Joseph University.
Consent for Publication: not applicable
Availability of Data and material: The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.
Competing interests: the authors declare that they have no competing interests.
Funding: None
Authors’ contribution: GH and IJ wrote the manuscript and established the research plan. DA, GHajje, GHalabi, MHGY, RM and SJ helped in the collection of the data required from each patient. GS analyzed and interpreted the data collected. All authors read and approved the final manuscript.
Acknowledgements: Not applicable
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
