{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T15:17:40Z","timestamp":1783523860888,"version":"3.55.0"},"reference-count":36,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2026,2,10]],"date-time":"2026-02-10T00:00:00Z","timestamp":1770681600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background\/Objectives: Although body mass index (BMI) is a conventional screening tool for type 2 diabetes mellitus (T2D), its reliability as a sole indicator of metabolic health is controversial, and the metabolic profile of a subset of individuals with normal BMI is indicative of obesity-related complications. This study aimed to estimate the prevalence and predictors of undiagnosed diabetes among Metabolically Unhealthy Normal Weight (MUNW) adults. Methods: Data from the National Health and Nutrition Examination Survey (NHANES) 2017\u2013March 2020 were analyzed. Normal weight adults (BMI 18.5\u201324.9 kg\/m2) were categorized into Metabolically Healthy (MHNW) and Unhealthy (MUNW) phenotypes based on the presence of \u22652 metabolic risk factors, including elevated blood pressure, triglycerides, waist circumference, or low HDL cholesterol. The primary outcome was undiagnosed diabetes, defined as HbA1c \u2265 6.5% or Fasting Plasma Glucose \u2265 126 mg\/dL. Results: The study population represented approximately 60 million US adults. The prevalence of undiagnosed diabetes was nearly four times higher in the MUNW group (4.84%) compared to the MHNW group (1.28%). In multivariable logistic regression analysis, age and race emerged as significant predictors. Notably, Asian adults exhibited a significantly higher risk of undiagnosed diabetes (OR 6.10; 95% CI: 1.32\u201328.2) compared to White adults, independent of metabolic phenotype. Conclusions: Reliance solely on BMI may overlook undiagnosed diabetes in normal-weight adults, particularly those with metabolic clustering or of Asian descent. These findings underscore the importance of multidimensional risk assessment integration into preventive care, optimizing clinical management.<\/jats:p>","DOI":"10.3390\/jcm15041385","type":"journal-article","created":{"date-parts":[[2026,2,10]],"date-time":"2026-02-10T11:16:38Z","timestamp":1770722198000},"page":"1385","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Undiagnosed Diabetes in Metabolically Unhealthy Normal Weight Adults: A Cross-Sectional Analysis of National Health and Nutrition Examination Survey Cycle 2017\u20132020 in the United States"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3993-7947","authenticated-orcid":false,"given":"S\u00e1ndor","family":"P\u00e1l","sequence":"first","affiliation":[{"name":"Department of Transfusion Medicine, Department of Laboratory Medicine, University of P\u00e9cs Medical School, 7624 P\u00e9cs, Hungary"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0508-5747","authenticated-orcid":false,"given":"Annam\u00e1ria","family":"Sepsey","sequence":"additional","affiliation":[{"name":"Department of Bioanalysis, University of P\u00e9cs Medical School, 7624 P\u00e9cs, Hungary"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,2,10]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"655","DOI":"10.1016\/S2213-8587(22)00186-3","article-title":"Burden of Diabetes and Hyperglycaemia in Adults in the Americas, 1990\u20132019: A Systematic Analysis for the Global Burden of Disease Study 2019","volume":"10","author":"Cousin","year":"2022","journal-title":"Lancet Diabetes Endocrinol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"203","DOI":"10.1016\/S0140-6736(23)01301-6","article-title":"Global, Regional, and National Burden of Diabetes from 1990 to 2021, with Projections of Prevalence to 2050: A Systematic Analysis for the Global Burden of Disease Study 2021","volume":"402","author":"Ong","year":"2023","journal-title":"Lancet"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"462","DOI":"10.1210\/jc.2013-2832","article-title":"Risk of Developing Diabetes and Cardiovascular Disease in Metabolically Unhealthy Normal-Weight and Metabolically Healthy Obese Individuals","volume":"99","author":"Aung","year":"2013","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_4","first-page":"190","article-title":"National Health and Nutrition Examination Survey, 2017\u2013March 2020 Prepandemic File: Sample Design, Estimation, and Analytic Guidelines","volume":"2","author":"Akinbam","year":"2022","journal-title":"Natl. Cent. Health Stat."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"292","DOI":"10.1016\/j.cmet.2017.07.008","article-title":"Causes, Characteristics, and Consequences of Metabolically Unhealthy Normal Weight in Humans","volume":"26","author":"Stefan","year":"2017","journal-title":"Cell Metab."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"862","DOI":"10.1016\/j.metabol.2015.03.009","article-title":"Characterization of Metabolically Unhealthy Normal-Weight Individuals: Risk Factors and Their Associations with Type 2 Diabetes","volume":"64","author":"Eckel","year":"2015","journal-title":"Metabolism"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"29","DOI":"10.1016\/j.jhqr.2018.10.010","article-title":"Achieving quadruple aim goals through clinical networks: A systematic review","volume":"34","author":"Leigheb","year":"2019","journal-title":"J. Healthc. Qual. Res."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"e178","DOI":"10.1097\/pq9.0000000000000178","article-title":"A Strategy for the Renovation of a Clinical Pathways Program","volume":"4","author":"Nickels","year":"2019","journal-title":"Pediatr. Qual. Saf."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"49","DOI":"10.1016\/j.suc.2020.08.011","article-title":"Standardized Care Pathways as a Means to Improve Patient Safety","volume":"101","author":"Lancaster","year":"2021","journal-title":"Surg. Clin. N. Am."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"631","DOI":"10.5604\/12321966.1226858","article-title":"Prevalence of Metabolic Syndrome in Normal Weight Individuals","volume":"23","author":"Suliga","year":"2016","journal-title":"Ann. Agric. Environ. Med."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"102","DOI":"10.1111\/cen.13874","article-title":"Protective Role of Skeletal Muscle Mass against Progression from Metabolically Healthy to Unhealthy Phenotype","volume":"90","author":"Lee","year":"2018","journal-title":"Clin. Endocrinol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1375","DOI":"10.1002\/oby.23190","article-title":"Comparison of Muscle Mass and Quality between Metabolically Healthy and Unhealthy Phenotypes","volume":"29","author":"Kim","year":"2021","journal-title":"Obesity"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"501","DOI":"10.1017\/S0007114520004262","article-title":"Skeletal Mass Indices Are Inversely Associated with Metabolically Unhealthy Phenotype in Overweight\/Obese and Normal-Weight Men: A Population-Based Cross-Sectional Study","volume":"126","author":"Carvalho","year":"2020","journal-title":"Br. J. Nutr."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"e00200","DOI":"10.1042\/BSR20150007","article-title":"Undernutrition during Pregnancy in Mice Leads to Dysfunctional Cardiac Muscle Respiration in Adult Offspring","volume":"35","author":"Beauchamp","year":"2015","journal-title":"Biosci. Rep."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Viitasalo, A., Pahkala, K., Lehtim\u00e4ki, T., Viikari, J., Tammelin, T., Raitakari, O., and Kilpel\u00e4inen, T. (2022). Changes in BMI and Physical Activity from Youth to Adulthood Distinguish Normal-Weight, Metabolically Obese Adults from Those Who Remain Healthy. Front. Endocrinol., 13.","DOI":"10.3389\/fendo.2022.923327"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"805","DOI":"10.1097\/EDE.0b013e3181577511","article-title":"Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)","volume":"18","author":"Vandenbroucke","year":"2007","journal-title":"Epidemiology"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"67","DOI":"10.13066\/kspm.2023.18.4.67","article-title":"Factors Influencing Age-Related Loss of Skeletal Muscle Mass in Young Korean Men","volume":"18","author":"Hwang","year":"2023","journal-title":"J. Korean Soc. Phys. Med."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"829","DOI":"10.2147\/CIA.S36367","article-title":"Role of Leptin Resistance in the Development of Obesity in Older Patients","volume":"8","author":"Picard","year":"2013","journal-title":"Clin. Interv. Aging"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"e13806","DOI":"10.1111\/obr.13806","article-title":"Cardiometabolic Implications of Adipose Tissue Aging","volume":"25","author":"Ahmed","year":"2024","journal-title":"Obes. Rev."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1471","DOI":"10.1161\/CIR.0000000000001139","article-title":"Cardiovascular Disease Risk Factors in Women: The Impact of Race and Ethnicity: A Scientific Statement From the American Heart Association","volume":"147","author":"Mehta","year":"2023","journal-title":"Circulation"},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"US Preventive Services Task Force (2021). Screening for Prediabetes and Type 2 Diabetes: US Preventive Services Task Force Recommendation Statement. JAMA, 326, 736\u2013743.","DOI":"10.1001\/jama.2021.12531"},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Vicks, W.S., Lo, J.C., Guo, L., Rana, J.S., Zhang, S., Ramalingam, N.D., and Gordon, N.P. (2022). Prevalence of prediabetes and diabetes vary by ethnicity among U.S. Asian adults at healthy weight, overweight, and obesity ranges: An electronic health record study. BMC Public Health, 22.","DOI":"10.1186\/s12889-022-14362-8"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"74","DOI":"10.1161\/CIR.0000000000001145","article-title":"Epidemiology of Diabetes and Atherosclerotic Cardiovascular Disease Among Asian American Adults: Implications, Management, and Future Directions: A Scientific Statement From the American Heart Association","volume":"148","author":"Kwan","year":"2023","journal-title":"Circulation"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"316","DOI":"10.1002\/oby.23639","article-title":"Obesity among Asian American people in the United States: A review","volume":"31","author":"Li","year":"2023","journal-title":"Obesity"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"419","DOI":"10.1016\/S2213-8587(21)00088-7","article-title":"Ethnicity-specific BMI cutoffs for obesity based on type 2 diabetes risk in England: A population-based cohort study","volume":"9","author":"Caleyachetty","year":"2021","journal-title":"Lancet Diabetes Endocrinol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"814","DOI":"10.2337\/dc14-2071","article-title":"Optimum BMI Cut Points to Screen Asian Americans for Type 2 Diabetes","volume":"38","author":"Araneta","year":"2015","journal-title":"Diabetes Care"},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"American Diabetes Association Professional Practice Committee (2025). Diagnosis and Classification of Diabetes: Standards of Care in Diabetes\u20142025. Diabetes Care, 48, S27\u2013S49.","DOI":"10.2337\/dc25-S002"},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"M\u00e9ndez-Mancilla, A., Turij\u00e1n-Espinoza, E., Vega-C\u00e1rdenas, M., Hern\u00e1ndez-Hern\u00e1ndez, G.E., Uresti-Rivera, E.E., Vargas-Morales, J.M., and Portales-P\u00e9rez, D.P. (2024). miR-21, miR-221, miR-29 and miR-34 Are Distinguishable Molecular Features of a Metabolically Unhealthy Phenotype in Young Adults. PLoS ONE, 19.","DOI":"10.1371\/journal.pone.0300420"},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Xia, L., Dong, F., Gong, H., Xu, G., Wang, K., Liu, F., Pan, L., Zhang, L., Yan, Y., and Gaisano, H. (2017). Association between Indices of Body Composition and Abnormal Metabolic Phenotype in Normal-Weight Chinese Adults. Int. J. Environ. Res. Public Health, 14.","DOI":"10.3390\/ijerph14040391"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1253","DOI":"10.1007\/s40618-020-01417-z","article-title":"Cardiometabolic Index: A New Tool for Screening the Metabolically Obese Normal Weight Phenotype","volume":"44","author":"Liu","year":"2020","journal-title":"J. Endocrinol. Investig."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"2279","DOI":"10.1038\/s41598-021-81940-y","article-title":"Understanding the Genetic Architecture of the Metabolically Unhealthy Normal Weight and Metabolically Healthy Obese Phenotypes in a Korean Population","volume":"11","author":"Park","year":"2021","journal-title":"Sci. Rep."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"558","DOI":"10.1007\/s00125-018-4787-8","article-title":"Metabolic Health in Normal-Weight and Obese Individuals","volume":"62","author":"Schulze","year":"2018","journal-title":"Diabetologia"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1333","DOI":"10.1042\/CS20230586","article-title":"Aetiology of Type 2 Diabetes in People with a \u2018Normal\u2019 Body Mass Index: Testing the Personal Fat Threshold Hypothesis","volume":"137","author":"Taylor","year":"2023","journal-title":"Clin. Sci."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"358","DOI":"10.2337\/db15-0659","article-title":"Skeletal Muscle Phospholipid Metabolism Regulates Insulin Sensitivity and Contractile Function","volume":"65","author":"Funai","year":"2015","journal-title":"Diabetes"},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Endo, Y., Sinha, I., and Nourmahnad, A. (2020). Optimizing Skeletal Muscle Anabolic Response to Resistance Training in Aging. Front. Physiol., 11.","DOI":"10.3389\/fphys.2020.00874"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"75","DOI":"10.1042\/bse0420075","article-title":"Resistance Training, Insulin Sensitivity and Muscle Function in the Elderly","volume":"42","author":"Dela","year":"2006","journal-title":"Essays Biochem."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/4\/1385\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,10]],"date-time":"2026-02-10T11:49:29Z","timestamp":1770724169000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/4\/1385"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2,10]]},"references-count":36,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2026,2]]}},"alternative-id":["jcm15041385"],"URL":"https:\/\/doi.org\/10.3390\/jcm15041385","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2,10]]}}}