Physical Activity and Cardiovascular Risk in Type 2 Diabetes With Normal Body Mass Index and Abdominal Obesity: A Nationwide Cohort Study

Background The prognostic implications of abdominal obesity and moderate‐to‐vigorous physical activity (MVPA) in patients with type 2 diabetes who have a normal body mass index remain unclear. Methods This nationwide retrospective cohort study included 323 029 adults with newly diagnosed type 2 diabetes and a normal body mass index (<23 kg/m 2 ) between January 1, 2010, and December 31, 2023, from the Korean National Health Insurance Service database. Abdominal obesity was defined using sex‐specific waist circumference thresholds (≥90 cm for men, ≥80 cm for women). MVPA was assessed through standardized self‐reported questionnaires administered during routine health screenings. The primary outcome was major adverse cardiovascular and cerebrovascular events, defined as a composite of all‐cause death, myocardial infarction, ischemic stroke, or hospitalization for heart failure. Results Among the study population, 34 033 (10.5%) had abdominal obesity. During a median follow‐up of 6.0 years (interquartile range, 2.6–9.0 years), abdominal obesity was associated with a higher risk of major adverse cardiovascular and cerebrovascular events (adjusted hazard ratio [HR], 1.13 [95% CI, 1.09–1.17]). Among patients with abdominal obesity, regular MVPA after diagnosis (27.1%) was associated with a significantly lower risk of major adverse cardiovascular and cerebrovascular events (adjusted HR 0.74 [95% CI, 0.68–0.80]), all‐cause mortality (adjusted HR 0.72 [95% CI, 0.65–0.80]), ischemic stroke (adjusted HR 0.77 [95% CI, 0.66–0.89]), and hospitalization for heart failure (adjusted HR 0.75 [95% CI, 0.60–0.93]). The cardiovascular protective effects of MVPA were consistent regardless of statin or antidiabetic medication use. Conclusions In patients with type 2 diabetes and a normal body mass index, abdominal obesity was independently associated with a higher risk of major adverse cardiovascular and cerebrovascular events. Regular engagement in MVPA showed consistent cardiovascular benefits in this population, irrespective of pharmacotherapy. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT07071545.