Uric acid-to-high-density lipoprotein ratio and diabetes mellitus in stroke survivors: A cross-sectional analysis of NHANES 1998 to 2018

Diabetes mellitus (DM) significantly elevates cerebrovascular risk in stroke survivors, yet metabolic predictors specific to this population remain underexplored. The uric acid-to-high-density lipoprotein cholesterol ratio (UHR) encapsulates pro-oxidant and anti-atherogenic pathways relevant to DM pathogenesis, but its clinical utility in stroke cohorts is unestablished. This cross-sectional study analyzed 1999 to 2018 National Health and Nutrition Examination Survey data from 964 adults with stroke history (representing 3,481,079 U.S. adults). UHR was standardized into sex-stratified z-scores. DM was defined by American Diabetes Association criteria. Generalized variance inflation factors (GVIF) confirmed absence of multicollinearity (all GVIF(1/(2*Df)) < 5). Weighted multivariable logistic regression assessed UHR-DM associations across 3 models: unadjusted (model 1), sex/age-adjusted (model 2), and fully adjusted for clinical covariates (model 3). Restricted cubic splines evaluated nonlinearity, piecewise regression identified effect thresholds, and time-dependent receiver operating characteristic analysis assessed predictive performance with inverse probability weighting. Mediation analysis quantified body mass index (BMI)'s intermediary role. Elevated UHR z-scores demonstrated dose-dependent DM associations, with quartile 4 (Q4) exhibiting 3.12-fold higher odds (95% confidence interval [CI]: 1.86-5.25, P < .001) in model 3. Restricted cubic splines revealed significant nonlinearity (P < .05), identifying UHR z-score = -0.419 (raw value = 0.088) as an inflection point: below this threshold, each 1-unit increase conferred 3.39-fold higher DM risk (95% CI: 1.56-7.40, P = .002); above it, risk increased 1.20-fold (95% CI: 1.08-1.45, P = .041). BMI mediated 38% of the total effect (β = 0.04, 95% CI: 0.03-0.06; P < .001). A rea under the curve (AUC) for UHR z-scores predicting DM improved from 0.61 (unadjusted) to 0.68 (model 3-adjusted). Subgroup analyses showed effect modification by sex (P for interaction < .05). In stroke survivors, UHR elevation independently suggests DM risk through threshold-dependent mechanisms, with BMI mediating over one-third of this relationship. UHR assessment could enhance DM risk stratification in poststroke care.