{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T17:15:44Z","timestamp":1783530944500,"version":"3.55.0"},"reference-count":44,"publisher":"MDPI AG","issue":"3","license":[{"start":{"date-parts":[[2026,6,27]],"date-time":"2026-06-27T00:00:00Z","timestamp":1782518400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"ADEMA University School"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medical Sciences"],"abstract":"<jats:p>Background: BMI is widely used for obesity classification, yet it does not adequately reflect adiposity distribution and related metabolic risk. Normal-weight obesity (NWO), defined as excess adiposity despite normal BMI, has emerged as a clinically relevant phenotype associated with increased cardiometabolic risk. However, its prevalence and implications in young populations remain insufficiently characterized. Objective: To evaluate the prevalence of normal-weight obesity and its association with cardiometabolic risk markers in a cohort of young adults undergoing occupational health assessments. Methods: A cross-sectional study was conducted in 12,874 adults aged 22\u201330 years undergoing routine occupational health assessments. NWO was defined using a strict criterion (normal BMI with a waist-to-height ratio \u2265 0.5) and an expanded definition including additional adiposity markers derived from body fat percentage and visceral fat estimates. Anthropometric, adiposity-related, biochemical, and lifestyle data were collected using standardized protocols. Multivariable logistic regression models adjusted for age and sex were used to assess associations between NWO and cardiometabolic risk markers. Results: Among individuals with normal BMI (n = 9290), the prevalence of NWO was 1.79% (n = 166) using the strict definition and 2.30% (n = 214) with the expanded definition. Compared with metabolically healthy normal-weight individuals, those with NWO exhibited higher triglycerides, fasting glucose, and atherogenic lipid indices, along with lower HDL cholesterol (all p &lt; 0.05). In multivariable analyses, NWO was independently associated with elevated triglycerides (OR 4.99; 95% CI 2.90\u20138.58), an unfavorable triglyceride-to-HDL ratio (OR 7.44; 95% CI 5.19\u201310.65), and impaired fasting glucose (OR 3.87; 95% CI 2.19\u20136.82). Associations were consistent across sensitivity and sex-stratified analyses. Conclusions: Normal-weight obesity is present in a measurable proportion of young adults and is associated with an unfavorable cardiometabolic profile despite normal BMI. The triglyceride-to-HDL ratio was consistently associated with normal-weight obesity and showed marked differences across adiposity-defined phenotypes. These findings highlight the limitations of BMI-based classification alone and suggest that additional anthropometric and metabolic markers may help identify individuals with less favorable cardiometabolic characteristics.<\/jats:p>","DOI":"10.3390\/medsci14030354","type":"journal-article","created":{"date-parts":[[2026,6,29]],"date-time":"2026-06-29T05:49:33Z","timestamp":1782712173000},"page":"354","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Normal-Weight Obesity and Hidden Cardiometabolic Risk in Young Adults: Implications Beyond BMI-Based Classification"],"prefix":"10.3390","volume":"14","author":[{"given":"Alberto","family":"Ram\u00edrez Gallegos","sequence":"first","affiliation":[{"name":"Primary Care, Balearic Islands Health Service, 07010 Palma, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5222-5784","authenticated-orcid":false,"given":"Pedro Juan","family":"T\u00e1rraga L\u00f3pez","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, University of Castilla La Mancha (UCLM), 02008 Albacete, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"M\u00f3nica Silu","family":"Pi\u00f1a Dabreu","sequence":"additional","affiliation":[{"name":"ADEMA-University School, University of the Balearic Islands, 07009 Palma, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-3848-687X","authenticated-orcid":false,"given":"Lluis","family":"Rodas Ca\u00f1ellas","sequence":"additional","affiliation":[{"name":"ADEMA-University School, University of the Balearic Islands, 07009 Palma, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7439-8117","authenticated-orcid":false,"given":"\u00c1ngel Arturo","family":"L\u00f3pez-Gonz\u00e1lez","sequence":"additional","affiliation":[{"name":"ADEMA-University School, University of the Balearic Islands, 07009 Palma, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6887-4562","authenticated-orcid":false,"given":"Jos\u00e9 Ignacio","family":"Ram\u00edrez-Manent","sequence":"additional","affiliation":[{"name":"Primary Care, Balearic Islands Health Service, 07010 Palma, Spain"},{"name":"ADEMA-University School, University of the Balearic Islands, 07009 Palma, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,6,27]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1001","DOI":"10.1093\/eurjpc\/zwae281","article-title":"Global burden of cardiovascular diseases: Projections from 2025 to 2050","volume":"32","author":"Chong","year":"2025","journal-title":"Eur. J. Prev. Cardiol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"e254","DOI":"10.1161\/CIR.0000000000000950","article-title":"Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association","volume":"143","author":"Virani","year":"2021","journal-title":"Circulation"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"117","DOI":"10.1097\/NT.0000000000000092","article-title":"Body Mass Index: Obesity, BMI, and Health: A Critical Review","volume":"50","author":"Nuttall","year":"2015","journal-title":"Nutr. Today"},{"key":"ref_4","first-page":"31","article-title":"Equation C\u00f3rdoba body fat values according to sociodemographic variables and healthy habits in 386924 Spanish workers","volume":"39","author":"Vallejos","year":"2024","journal-title":"Acad. J. Health Sci."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"2515","DOI":"10.2147\/DMSO.S263063","article-title":"Diagnostic Accuracy of Body Mass Index (BMI) When Diagnosing Obesity in a Saudi Adult Population in a Primary Care Setting, Cross Sectional, Retrospective Study","volume":"13","author":"Alammar","year":"2020","journal-title":"Diabetes Metab. Syndr. Obes."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"299","DOI":"10.1080\/03014460.2022.2147585","article-title":"Comparing the performance of body mass index, waist circumference and waist-to-height ratio in predicting Malaysians with excess adiposity","volume":"49","author":"Low","year":"2022","journal-title":"Ann. Hum. Biol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1555","DOI":"10.1007\/s11886-023-01969-5","article-title":"Body Fat Distribution, Diabetes Mellitus, and Cardiovascular Disease: An Update","volume":"25","author":"Kang","year":"2023","journal-title":"Curr. Cardiol. Rep."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"825","DOI":"10.1002\/oby.24239","article-title":"Features, functions, and associated diseases of visceral and ectopic fat: A comprehensive review","volume":"33","author":"Luo","year":"2025","journal-title":"Obesity"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"616","DOI":"10.1016\/S2213-8587(20)30110-8","article-title":"Causes, consequences, and treatment of metabolically unhealthy fat distribution","volume":"8","author":"Stefan","year":"2020","journal-title":"Lancet Diabetes Endocrinol."},{"key":"ref_10","first-page":"53","article-title":"Comparative evolution of metabolic health status in obese individuals using novel and conventional anthropometric indexes: A decade-long analysis in Spanish workers","volume":"40","year":"2025","journal-title":"Acad. J. Health Sci."},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Liu-Galvin, R., Orlando, F.A., Saguil, A.A., Jo, A., Smith, K.B., Miller, A.M., Nelson, D.S., Sanders, E.C., and Mainous, A.G. (2025). More evidence of the health risks of normal weight obesity: The association with systemic inflammation. Front. Med., 12.","DOI":"10.3389\/fmed.2025.1695935"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"50","DOI":"10.1007\/s13679-025-00641-z","article-title":"Normal Weight Obesity Overview and Update: A narrative review","volume":"14","author":"Gualtieri","year":"2025","journal-title":"Curr. Obes. Rep."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"100416","DOI":"10.1016\/j.metop.2025.100416","article-title":"Prevalence of normal weight obesity among adults in Southeast Asia: Insights from a systematic review and meta-analysis","volume":"28","author":"Sruthi","year":"2025","journal-title":"Metabol. Open"},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Wasiluk, A., Saczuk, J., and Asienkiewicz, R. (2025). Anthropometric Obesity Phenotypes in Young Physically Active Men: The Role of Body Composition and Fat Distribution. Life, 15.","DOI":"10.3390\/life15121808"},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Mohammadian Khonsari, N., Khashayar, P., Shahrestanaki, E., Kelishadi, R., Mohammadpoor Nami, S., Heidari-Beni, M., Esmaeili Abdar, Z., Tabatabaei-Malazy, O., and Qorbani, M. (2022). Normal Weight Obesity and Cardiometabolic Risk Factors: A Systematic Review and Meta-Analysis. Front. Endocrinol., 13.","DOI":"10.3389\/fendo.2022.857930"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e3707","DOI":"10.1002\/dmrr.3707","article-title":"Normal-weight central obesity and risk of cardiovascular and microvascular events in adults with prediabetes or diabetes: Chinese and British cohorts","volume":"39","author":"Zhong","year":"2023","journal-title":"Diabetes Metab. Res. Rev."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"109","DOI":"10.1186\/s12933-025-02667-y","article-title":"Joint assessment of abdominal obesity and non-traditional lipid parameters for primary prevention of cardiometabolic multimorbidity: Insights from the China health and retirement longitudinal study 2011\u20132018","volume":"24","author":"Lai","year":"2025","journal-title":"Cardiovasc. Diabetol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"2141","DOI":"10.1038\/s41366-021-00858-7","article-title":"Normal weight obesity and unaddressed cardiometabolic health risk-a narrative review","volume":"45","author":"Wijayatunga","year":"2021","journal-title":"Int. J. Obes."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1065","DOI":"10.7326\/ANNALS-24-02547","article-title":"Implications of the European Association for the Study of Obesity\u2019s New Framework Definition of Obesity: Prevalence and Association With All-Cause Mortality","volume":"178","author":"Dicker","year":"2025","journal-title":"Ann. Intern. Med."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"C375","DOI":"10.1152\/ajpcell.00379.2020","article-title":"Adipose tissue inflammation and metabolic dysfunction in obesity","volume":"320","author":"Kawai","year":"2021","journal-title":"Am. J. Physiol. Cell Physiol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"3227","DOI":"10.1093\/eurheartj\/ehab484","article-title":"2021 ESC Guidelines on cardiovascular disease prevention in clinical practice","volume":"42","author":"Visseren","year":"2021","journal-title":"Eur. Heart J."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Chung, P.C., Hu, T.H., Chiao, C.H., Hwang, J.S., and Chan, T.C. (2025). The long-term effects of cardiometabolic risk factors on mortality and life expectancy: Evidence from a health check-up cohort study. BMC Cardiovasc. Disord., 25.","DOI":"10.1186\/s12872-025-04469-2"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1453","DOI":"10.1016\/S0140-6736(07)61602-X","article-title":"The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for Reporting Observational Studies","volume":"370","author":"Altman","year":"2007","journal-title":"Lancet"},{"key":"ref_24","first-page":"99","article-title":"Influence of sociodemographic variables and healthy habits on the values of type 2 diabetes risk scales","volume":"39","author":"Paublini","year":"2024","journal-title":"Acad. J. Health Sci."},{"key":"ref_25","first-page":"91","article-title":"Multimetric assessment of obesity in manual workers: The impact of age, smoking, diet, and physical activity","volume":"40","year":"2025","journal-title":"Acad. J. Health Sci."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1140","DOI":"10.3945\/jn.110.135566","article-title":"A short screener is valid for assessing Mediterranean diet adherence among older Spanish men and women","volume":"141","author":"Estruch","year":"2011","journal-title":"J. Nutr."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"425","DOI":"10.3345\/kjp.2016.59.11.425","article-title":"Waist-to-height ratio as a screening tool for obesity and cardiometabolic risk","volume":"59","author":"Yoo","year":"2016","journal-title":"Korean J. Pediatr."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"194","DOI":"10.1038\/s41430-018-0335-3","article-title":"Bioelectrical impedance analysis for body composition assessment: Reflections on accuracy, clinical utility, and standardisation","volume":"73","author":"Ward","year":"2019","journal-title":"Eur. J. Clin. Nutr."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"e3725","DOI":"10.1002\/dmrr.3725","article-title":"Phenotyping obesity: A focus on metabolically healthy obesity and metabolically unhealthy normal weight","volume":"40","author":"Agius","year":"2024","journal-title":"Diabetes Metab. Res. Rev."},{"key":"ref_30","first-page":"15","article-title":"Relevancia de los \u00edndices aterog\u00e9nicos como predictores precoces de riesgo cardiovascular en el contexto laboral de los profesionales sanitarios","volume":"39","author":"Vallejos","year":"2024","journal-title":"Acad. J. Health Sci."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"426","DOI":"10.1016\/j.pcad.2013.10.003","article-title":"The concept of normal weight obesity","volume":"56","author":"Oliveros","year":"2014","journal-title":"Prog. Cardiovasc. Dis."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"737","DOI":"10.1093\/eurheartj\/ehp487","article-title":"Normal weight obesity: A risk factor for cardiometabolic dysregulation and cardiovascular mortality","volume":"31","author":"Somers","year":"2010","journal-title":"Eur. Heart J."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"513","DOI":"10.1016\/j.numecd.2005.10.010","article-title":"Normal weight obese (NWO) women: An evaluation of a candidate new syndrome","volume":"16","author":"Martinoli","year":"2006","journal-title":"Nutr. Metab. Cardiovasc. Dis."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"633","DOI":"10.1038\/s41574-024-01008-5","article-title":"Metabolically healthy obesity: From epidemiology and mechanisms to clinical implications","volume":"20","author":"Schulze","year":"2024","journal-title":"Nat. Rev. Endocrinol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"715","DOI":"10.1016\/S2213-8587(19)30084-1","article-title":"Visceral and ectopic fat, atherosclerosis, and cardiometabolic disease: A position statement","volume":"7","author":"Neeland","year":"2019","journal-title":"Lancet Diabetes Endocrinol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1887","DOI":"10.1016\/j.jacc.2010.10.063","article-title":"Excess visceral adipose tissue\/ectopic fat the missing link in the obesity paradox?","volume":"57","year":"2011","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"Pluta, W., Dudzi\u0144ska, W., and Lubkowska, A. (2022). Metabolic Obesity in People with Normal Body Weight (MONW)-Review of Diagnostic Criteria. Int. J. Environ. Res. Public Health, 19.","DOI":"10.3390\/ijerph19020624"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"403","DOI":"10.2147\/DMSO.S34220","article-title":"Predicting cardiometabolic risk: Waist-to-height ratio or BMI. A meta-analysis","volume":"6","author":"Savva","year":"2013","journal-title":"Diabetes Metab. Syndr. Obes."},{"key":"ref_39","first-page":"107","article-title":"Association between sociodemographic variables, healthy habits and stress with insulin resistance risk scales","volume":"40","year":"2025","journal-title":"Acad. J. Health Sci."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"776","DOI":"10.1016\/j.eprac.2025.02.013","article-title":"Triglyceride to High-Density Lipoprotein Cholesterol Ratio as a Marker of Subclinical Coronary Atherosclerosis and Hepatic Steatosis in Familial Hypercholesterolemia","volume":"31","author":"Huangfu","year":"2025","journal-title":"Endocr. Pract."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"668","DOI":"10.25122\/jml-2022-0239","article-title":"Triglyceride\/high-density lipoprotein ratio as a predictor for insulin resistance in a sample of healthy Iraqi adults","volume":"16","author":"Ghani","year":"2023","journal-title":"J. Med. Life"},{"key":"ref_42","doi-asserted-by":"crossref","unstructured":"Baneu, P., V\u0103c\u0103rescu, C., Dr\u0103gan, S.R., Cirin, L., Laz\u0103r-H\u00f6cher, A.I., Cozgarea, A., Faur-Grigori, A.A., Cri\u0219an, S., Gai\u021b\u0103, D., and Luca, C.T. (2024). The Triglyceride\/HDL Ratio as a Surrogate Biomarker for Insulin Resistance. Biomedicines, 12.","DOI":"10.3390\/biomedicines12071493"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1007\/s11892-018-1031-3","article-title":"Gender and Sex Differences in Adipose Tissue","volume":"18","author":"Chang","year":"2018","journal-title":"Curr. Diabetes Rep."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1186\/2042-6410-3-13","article-title":"Sex differences in human adipose tissues\u2014The biology of pear shape","volume":"3","author":"Karastergiou","year":"2012","journal-title":"Biol. Sex Differ."}],"container-title":["Medical Sciences"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-3271\/14\/3\/354\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T16:31:44Z","timestamp":1783528304000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-3271\/14\/3\/354"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,27]]},"references-count":44,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2026,7]]}},"alternative-id":["medsci14030354"],"URL":"https:\/\/doi.org\/10.3390\/medsci14030354","relation":{},"ISSN":["2076-3271"],"issn-type":[{"value":"2076-3271","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,27]]}}}