Published online May 15, 2026. doi: 10.4239/wjd.v17.i5.117583
Revised: January 16, 2026
Accepted: March 10, 2026
Published online: May 15, 2026
Processing time: 152 Days and 1.3 Hours
In people with type 2 diabetes (T2D), both visceral adiposity and remnant cholesterol have been associated with the cardiovascular risk that persists despite standard-of-care management. However, the relationship between visceral fat area (VFA) and remnant cholesterol–based indices, including residual cholesterol (RC) and the less-validated RC-inflammation index (RCII), remains uncertain.
To examine the associations between VFA and two remnant cholesterol-based indices—RC and RCII—in adults with T2D, and to characterise potential non-linear dose-response patterns, threshold effects, and subgroup differences.
This cross-sectional study enrolled 1180 adult patients with T2D. VFA was quantified and categorized into tertiles. RC and RCII were calculated from standard lipid and inflammatory parameters. We applied multivariable linear regression to explore how VFA relates to RC and RCII. VFA was analysed both as a continuous measure and in tertiles, with models adjusted for demographic characteristics, lifestyle behaviours and relevant clinical factors. Smoothing curve fitting and two-piecewise linear regression were applied to explore non-linear and threshold effects. Prespecified subgroup and interaction analyses were also performed.
Across increasing VFA tertiles, body mass index (BMI), waist circumference, triglycerides, C-reactive protein, and the median levels of RC and RCII increased progressively. In fully adjusted models, VFA was positively associated with both RC and RCII. For RC, the β coefficient was 7.59 (95%CI: 0.65-14.53) in participants with VFA in the intermediate tertile and increased to 10.96 (95%CI: 3.50-18.42) in those in the highest tertile, compared with the lowest tertile, with a significant trend across tertiles (P for trend = 0.0036). For RCII, the corresponding β values were 6.74 (95%CI: -2.50 to 15.98) and 12.56 (95%CI: 2.63-22.49), respectively (P for trend = 0.013). In two-piecewise models, RC showed a clear threshold at 126 cm2 (likelihood ratio test P < 0.001), whereas RCII showed only a borderline threshold signal with an inflection at 118 cm2 (likelihood ratio test P = 0.060), which should be considered exploratory. In subgroup analyses, the VFA-RC association appeared stronger in participants with BMI < 28 kg/m2, while subgroup differences for RCII were modest.
In adults with T2D, higher VFA was associated, after multivariable adjustment, with higher RC, with a broadly similar but weaker pattern for RCII. The VFA-RC association showed a clear non-linear pattern with a threshold at 126 cm2, whereas the RCII threshold signal at 118 cm2 was borderline and should be considered exploratory.
Core Tip: This cross-sectional study of adults with type 2 diabetes (T2D) quantified visceral fat area (VFA) and examined its associations with residual cholesterol (RC) and the RC-inflammation index (RCII; RC/C-reactive protein). Higher VFA was independently associated with higher RC, and showed a clear non-linear pattern with a threshold at 126 cm2. RCII showed a weaker association and only a borderline threshold signal at 118 cm2, which should be interpreted as exploratory. These findings suggest that quantifying VFA may help contextualize remnant cholesterol-related burden beyond conventional lipid measures in T2D.