Journal of Obesity & Metabolic Syndrome



J Obes Metab Syndr 2023; 32(2): 181-182

Published online June 30, 2023

Copyright © Korean Society for the Study of Obesity.

Response: Triglyceride-Glucose Index Predicts Cardiovascular Outcome in Metabolically Unhealthy Obese Population: A Nationwide Population-Based Cohort Study (J Obes Metab Syndr 2022;31:178-86)

Yun Kyung Cho1,2, Hwi Seung Kim3, Joong-Yeol Park1,2, Woo Je Lee1,2, Ye-Jee Kim4, Chang Hee Jung1,2,*

1Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul; 2Asan Diabetes Center, Asan Medical Center, Seoul; 3Department of Internal Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, Gwangmyeong; 4Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

Correspondence to:
Chang Hee Jung
Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
Tel: +82-2-3010-1418
Fax: +82-2-3010-6962

Received: May 13, 2023; Reviewed : June 6, 2023; Accepted: June 6, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

The triglyceride glucose (TyG) index is considered a surrogate marker of cardiovascular disease (CVD) and mortality using the parameter of insulin resistance. Numerous studies have investigated the associations between the TyG index and cardiovascular outcomes, including cardiovascular mortality. A recent meta-analysis and systematic review evaluated associations between the TyG index and the risks of CVD and mortality in the general population.1 Twelve cohort studies involving 6,354,990 participants were analyzed. Higher TyG index values were significantly associated with an increased incidence of CVD; however, the TyG index was not correlated with mortality, including cardiovascular mortality in analyses.1 A subgroup analysis of the population without diabetes revealed no significant association between myocardial infarction incidence and the TyG index, indicating the heterogeneous implications of this index across populations.2 The present study contributes to the literature because we focused on the specific population in which the TyG index could be a useful surrogate marker for an elevated CVD risk.3 Our results demonstrated that the TyG index could predict CVD mortality only in participants with metabolically unhealthy obesity (MUO), and that the index is substantially and consistently associated with CVD regardless of the metabolic health phenotype or presence of obesity.3

In a letter to the editor, the author stated that assessing the predictive value of the TyG index for CVD outcomes would provide greater benefit if we considered changes in the TyG index as well as the obese metabolic health phenotype. Several recent studies have reported the significant effect of longitudinal changes in the TyG index on CVD risk. We appreciate the letter author for highlighting these important points. A study involving 62,443 healthy Chinese people found that CVD risk increased with quartile of change in the TyG index during a median follow-up of 7.01 years, and that adding change in the TyG index to a baseline risk model for CVD improved its predictive power.4 Another prospective cohort study involving 36,359 participants with a median observation period of 8 years similarly reported that, compared to a stable TyG level, both loss and gain were associated with increased risks of cardiometabolic diseases.5

Recently, cumulative exposure to particular risk factors has garnered considerable attention. Cui et al.6 calculated the cumulative TyG index by multiplying the average TyG index and the time between two consecutive examinations. They discovered that the CVD risk increased with each quartile of the cumulative TyG index, and that a longer duration of exposure to a higher TyG index was significantly correlated with increased CVD risk.6 The post hoc analysis of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial revealed that, in patients with type 2 diabetes mellitus, the cumulative TyG index independently predicts the incidence of major adverse cardiovascular events.7 Consequently, incorporating cumulative exposure to insulin resistance may improve the estimation of future CVD risk and assist physicians and patients in determining therapeutic and preventative strategies for CVD.

Moreover, as the letter author noted, the metabolically healthy phenotype and obesity status may change over time, and these changes may influence CVD risk. Our research team has reported that metabolically healthy obesity (MHO) phenotypes represent a heterogeneous group that is subject to change over time, and such change has substantial impacts on cardiovascular outcomes.8 Compared to individuals with stable MHO, the risk of cardiovascular events was 1.24-fold higher in individuals who transitioned to MUO.8

Collectively, incorporating the dynamic changes of the obese metabolic health phenotype and TyG index and evaluating their implications for the CVD risk would be intriguing. We anticipate that further research with longer follow-up and larger numbers of participants would reveal these intriguing associations.

Chang Hee Jung is an editorial board member of this journal; however, he was not involved in the peer reviewer selection, evalua-tion, or decision process for this article. No other potential conflicts of interest relevant to this article were reported.

  1. Liu X, Tan Z, Huang Y, Zhao H, Liu M, Yu P, et al. Relationship between the triglyceride-glucose index and risk of cardiovascular diseases and mortality in the general population: a systematic review and meta-analysis. Cardiovasc Diabetol 2022;21:124.
    Pubmed KoreaMed CrossRef
  2. Masot O, Cox A, Mold F, Sund-Levander M, Tingstrom P, Boersema GC, et al. Decision support-tools for early detection of infection in older people (aged> 65 years): a scoping review. BMC Geriatr 2022;22:552.
    Pubmed KoreaMed CrossRef
  3. Cho YK, Kim HS, Park JY, Lee WJ, Kim YJ, Jung CH. Triglyceride-glucose index predicts cardiovascular outcome in metabolically unhealthy obese population: a nationwide population-based cohort study. J Obes Metab Syndr 2022;31:178-86.
    Pubmed KoreaMed CrossRef
  4. Wang A, Tian X, Zuo Y, Chen S, Meng X, Wu S, et al. Change in triglyceride-glucose index predicts the risk of cardiovascular disease in the general population: a prospective cohort study. Cardiovasc Diabetol 2021;20:113.
    Pubmed KoreaMed CrossRef
  5. Xu W, Zhao H, Gao L, Guo L, Liu J, Li H, et al. Association of long-term triglyceride-glucose index level and change with the risk of cardiometabolic diseases. Front Endocrinol (Lausanne) 2023;14:1148203.
    Pubmed KoreaMed CrossRef
  6. Cui H, Liu Q, Wu Y, Cao L. Cumulative triglyceride-glucose index is a risk for CVD: a prospective cohort study. Cardiovasc Diabetol 2022;21:22.
    Pubmed KoreaMed CrossRef
  7. Tai S, Fu L, Zhang N, Yang R, Zhou Y, Xing Z, et al. Association of the cumulative triglyceride-glucose index with major adverse cardiovascular events in patients with type 2 diabetes. Cardiovasc Diabetol 2022;21:161.
    Pubmed KoreaMed CrossRef
  8. Cho YK, Kang YM, Yoo JH, Lee J, Park JY, Lee WJ, et al. Implications of the dynamic nature of metabolic health status and obesity on risk of incident cardiovascular events and mortality: a nationwide population-based cohort study. Metabolism 2019;97:50-6.
    Pubmed CrossRef