Several CTI-related indices were associated with mortality within glycemic-status strata, but findings do not establish effect modification, group-specific applicability, or validated clinical utility, and these indices should be considered epidemiological markers.
Key Findings
Results
CTI-ABSI was associated with both all-cause and cardiovascular mortality among participants with abnormal glycemia.
Hazard ratio per weighted standard deviation for CTI-ABSI was 1.21 (95% CI, 1.10–1.34) for all-cause mortality among participants with abnormal glycemia.
Hazard ratio per weighted standard deviation for CTI-ABSI was 1.43 (95% CI, 1.18–1.73) for cardiovascular mortality among participants with abnormal glycemia.
CTI-ABSI integrates C-reactive protein, triglyceride glucose index, and A Body Shape Index (ABSI).
Analysis used complex-survey weighted Cox models with restricted cubic splines and time-dependent receiver operating characteristic curves.
Results
CTI-WWI was associated with both all-cause and cardiovascular mortality among participants with abnormal glycemia.
Hazard ratio per weighted standard deviation for CTI-WWI was 1.19 (95% CI, 1.07–1.33) for all-cause mortality among participants with abnormal glycemia.
Hazard ratio per weighted standard deviation for CTI-WWI was 1.49 (95% CI, 1.20–1.85) for cardiovascular mortality among participants with abnormal glycemia.
CTI-WWI integrates C-reactive protein, triglyceride glucose index, and weight-adjusted waist index (WWI).
These estimates are among the largest hazard ratios observed across the CTI-related indices evaluated.
Results
CTI-ABSI and CTI-WWI demonstrated relatively higher single-marker AUCs compared to other CTI-related indices in several analyses, but incremental improvements beyond clinical factors were small.
Time-dependent receiver operating characteristic curves were used to assess discrimination.
Incremental improvements in discrimination beyond established clinical factors were described as small.
Six indices were compared: CTI, CTI-BMI, CTI-BRI, CTI-WWI, CTI-ABSI, and CTI-WHtR.
The paper cautions that higher single-marker AUCs do not establish validated clinical utility.
Results
Glycemic-status interactions between CTI-related indices and mortality outcomes were not statistically significant.
Interaction tests were performed across glycemic-status strata: normal glycemia, abnormal glycemia, and diabetes.
The absence of significant interaction indicates findings do not establish effect modification or group-specific applicability.
Analyses were conducted continuously and by weighted quartiles within each glycemic stratum.
Sensitivity analyses were also performed to assess robustness of findings.
Methods
During follow-up of 13,867 adults, 2,197 all-cause deaths and 687 cardiovascular deaths occurred.
The study included 13,867 adults from the National Health and Nutrition Examination Survey (NHANES) cycles 1999–2010 and 2015–2018.
Participants were classified into normal glycemia, abnormal glycemia, or diabetes groups.
Complex-survey weighted Cox proportional hazards models were used to account for the survey design.
Multiple CTI-related composite indices were evaluated: CTI, CTI-BMI, CTI-BRI, CTI-WWI, CTI-ABSI, and CTI-WHtR.
Conclusions
Several CTI-related indices were associated with mortality within glycemic-status strata, but the authors conclude these should be considered epidemiological markers rather than clinically validated tools.
Associations were observed across multiple CTI-related indices and glycemic strata.
The authors explicitly state findings 'do not establish effect modification, group-specific applicability, or validated clinical utility.'
The composite indices integrate inflammation (C-reactive protein), insulin resistance (triglyceride glucose index), and body shape measures.
The authors recommend treating these indices as 'epidemiological markers.'
What This Means
This research examined whether composite health indices that combine markers of inflammation, insulin resistance, and body shape could predict the risk of death in people with different blood sugar levels. Using data from nearly 14,000 American adults followed over several years, researchers tested six different indices against outcomes of all-cause and cardiovascular death. They found that two indices in particular—CTI-ABSI and CTI-WWI, which incorporate waist-related body shape measures—were associated with higher risks of both all-cause and cardiovascular death, especially among people with abnormal blood sugar levels (such as prediabetes). For example, people with higher CTI-WWI scores in the abnormal glycemia group had roughly 49% higher cardiovascular mortality risk per standard deviation increase.
However, the study found several important limitations to these associations. When the researchers tested whether blood sugar status changed the relationship between these indices and mortality (a statistical concept called effect modification), the answer was no—meaning the indices did not perform meaningfully differently across normal glycemia, prediabetes, or diabetes groups. Additionally, while these indices showed some ability to distinguish who was at higher risk of death, their improvement over standard clinical information already available to doctors was small.
This research suggests that these composite indices may be useful as population-level epidemiological markers for tracking health trends, but they are not yet validated tools for guiding individual clinical decisions. The study highlights the ongoing challenge of translating statistical associations from large surveys into tools that meaningfully improve patient care beyond what clinicians already use.
Liao J, Yang J, Zhao Y, Tang Z, Wang M, Jiang S, et al.. (2026). Associations of C-reactive protein-triglyceride glucose-related indices with mortality across glycemic states: a nationwide prospective cohort study.. Diabetes research and clinical practice. https://doi.org/10.1016/j.diabres.2026.113541