{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T18:43:13Z","timestamp":1785436993385,"version":"3.56.0"},"reference-count":45,"publisher":"MDPI AG","issue":"5","license":[{"start":{"date-parts":[[2026,4,28]],"date-time":"2026-04-28T00:00:00Z","timestamp":1777334400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000098","name":"U.S. National Institutes of Health","doi-asserted-by":"publisher","award":["5R01HD012252-34"],"award-info":[{"award-number":["5R01HD012252-34"]}],"id":[{"id":"10.13039\/100000098","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000098","name":"U.S. National Institutes of Health","doi-asserted-by":"publisher","award":["5R01DK111201-05"],"award-info":[{"award-number":["5R01DK111201-05"]}],"id":[{"id":"10.13039\/100000098","id-type":"DOI","asserted-by":"publisher"}]},{"award":["5R01HD012252-34"],"award-info":[{"award-number":["5R01HD012252-34"]}],"id":[{"id":"https:\/\/ror.org\/01cwqze88","id-type":"ROR","asserted-by":"publisher"}]},{"award":["5R01DK111201-05"],"award-info":[{"award-number":["5R01DK111201-05"]}],"id":[{"id":"https:\/\/ror.org\/01cwqze88","id-type":"ROR","asserted-by":"publisher"}]},{"DOI":"10.13039\/100004917","name":"Cancer Prevention and Research Institute of Texas","doi-asserted-by":"crossref","award":["RP210042"],"award-info":[{"award-number":["RP210042"]}],"id":[{"id":"10.13039\/100004917","id-type":"DOI","asserted-by":"crossref"}]},{"award":["RP210042"],"award-info":[{"award-number":["RP210042"]}],"id":[{"id":"https:\/\/ror.org\/0003xa228","id-type":"ROR","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Metabolites"],"abstract":"<jats:p>Objective: To examine the associations of metabolic health and obesity phenotypes with liver fat accumulation and hepatic steatosis in adults. Methods: We analyzed 676 non-Hispanic white adults (18\u201395 years; 55.8% female) from the Fels Longitudinal Study using a cross-sectional design. Participants were classified into metabolically healthy normal weight (MHNW), metabolically healthy obesity (MHO), metabolically unhealthy normal weight (MUNW), and metabolically unhealthy obesity (MUO) phenotypes. Metabolically unhealthy status was defined as the presence of \u22651 metabolic dysfunction, consistent with prior epidemiological definitions; secondary analyses using \u22652 were also performed. Obesity was defined using DXA-derived body fat percentage. Liver fat (%) was quantified using magnetic resonance imaging, and hepatic steatosis was defined as liver fat &gt; 5.56%. Multivariable linear and probit regression models were used to evaluate associations, adjusting for demographic and lifestyle covariates; secondary models additionally examined dietary intake. Results: Mean liver fat was 5.95% (SE = 0.23), and steatosis was present in 29.8% of participants. Compared to MHNW individuals, liver fat was significantly higher in MHO (mean 3.77% vs. 2.67%), MUNW (4.63%), and MUO (8.47%) phenotypes. After covariate adjustment, liver fat was 33.8% (95% CI: 13.7\u201357.5%) higher in MHO, 28.1% (10.1\u201349.0%) higher in MUNW, and 113.0% (85.3\u2013144.7%) higher in MUO relative to MHNW. Corresponding increases in steatosis probabilities were observed across phenotypes. No individual dietary component or dietary pattern was significantly associated with liver fat after adjustment. Conclusions: Metabolically healthy obesity was associated with higher liver fat and steatosis probability compared with metabolically healthy normal weight, with levels comparable to metabolically unhealthy normal weight individuals. These findings suggest that the absence of overt metabolic abnormalities does not necessarily indicate a metabolically benign state with respect to liver fat accumulation. Given the cross-sectional design, these results should be interpreted as associations rather than causal relationships.<\/jats:p>","DOI":"10.3390\/metabo16050299","type":"journal-article","created":{"date-parts":[[2026,4,28]],"date-time":"2026-04-28T09:55:39Z","timestamp":1777370139000},"page":"299","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Cross-Sectional Associations of Metabolically Healthy Obesity, Lifestyle Factors, and Steatotic Liver Disease in Adults from the Fels Longitudinal Study"],"prefix":"10.3390","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5819-4405","authenticated-orcid":false,"given":"Ariana L.","family":"Garza","sequence":"first","affiliation":[{"name":"School of Public Health, UTHealth Houston, Brownsville, TX 78520, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6365-7411","authenticated-orcid":false,"given":"Audrey C.","family":"Choh","sequence":"additional","affiliation":[{"name":"Department of Epidemiology, School of Public Health, UTHealth Houston, Brownsville, TX 78520, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6250-5723","authenticated-orcid":false,"given":"John","family":"Blangero","sequence":"additional","affiliation":[{"name":"South Texas Diabetes and Obesity Institute, School of Medicine, University of Texas Rio Grande Valley, Brownsville, TX 78520, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2337-7965","authenticated-orcid":false,"given":"Cici X.","family":"Bauer","sequence":"additional","affiliation":[{"name":"Department of Biostatistics, School of Public Health, UTHealth Houston, Houston, TX 77030, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stefan A.","family":"Czerwinski","sequence":"additional","affiliation":[{"name":"School of Health and Rehabilitation Sciences, College of Medicine, Ohio State University, Columbus, OH 43210, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4088-304X","authenticated-orcid":false,"given":"Miryoung","family":"Lee","sequence":"additional","affiliation":[{"name":"Department of Epidemiology, School of Public Health, UTHealth Houston, Brownsville, TX 78520, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,4,28]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Scully, T., Ettela, A., LeRoith, D., and Gallagher, E.J. (2021). Obesity, type 2 diabetes, and cancer risk. Front. Oncol., 10.","DOI":"10.3389\/fonc.2020.615375"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"64","DOI":"10.1111\/jgh.12271","article-title":"Characteristics and diagnosis of NAFLD\/NASH","volume":"28","author":"Hashimoto","year":"2013","journal-title":"J. Gastroenterol. Hepatol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"S104","DOI":"10.1016\/j.jhep.2008.01.009","article-title":"Non-alcoholic fatty liver disease: The mist gradually clears","volume":"48","author":"Day","year":"2008","journal-title":"J. Hepatol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"2297","DOI":"10.2337\/dc09-0574","article-title":"Are metabolically normal but obese individuals at lower risk for all-cause mortality?","volume":"32","author":"Kuk","year":"2009","journal-title":"Diabetes Care"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"2906","DOI":"10.1210\/jc.2006-0594","article-title":"Body mass index, metabolic syndrome, and risk of type 2 diabetes or cardiovascular disease","volume":"91","author":"Meigs","year":"2006","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"210","DOI":"10.2337\/dc10-0665","article-title":"Prevalence, metabolic features, and prognosis of metabolically healthy obese Italian individuals: The Cremona study","volume":"34","author":"Calori","year":"2011","journal-title":"Diabetes Care"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"389","DOI":"10.1093\/eurheartj\/ehs174","article-title":"The intriguing metabolically healthy but obese phenotype: Cardiovascular prognosis and role of fitness","volume":"34","author":"Ortega","year":"2013","journal-title":"Eur. Heart J."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"R209","DOI":"10.1530\/EJE-14-0540","article-title":"Mechanisms in Endocrinology: Are metabolically healthy obese individuals really healthy?","volume":"171","year":"2014","journal-title":"Eur. J. Endocrinol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"342","DOI":"10.1016\/j.soard.2017.11.032","article-title":"Patients with clinically metabolically healthy obesity are not necessarily healthy subclinically: Further support for bariatric surgery in patients without metabolic disease?","volume":"14","author":"Haskins","year":"2018","journal-title":"Surg. Obes. Relat. Dis."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1133","DOI":"10.1038\/ajg.2016.178","article-title":"Metabolically healthy obesity and the development of nonalcoholic fatty liver disease","volume":"111","author":"Chang","year":"2016","journal-title":"Am. J. Gastroenterol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1884","DOI":"10.1111\/liv.14184","article-title":"Metabolically healthy versus unhealthy obesity and risk of fibrosis progression in non-alcoholic fatty liver disease","volume":"39","author":"Kim","year":"2019","journal-title":"Liver Int."},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Camhi, S.M., Crouter, S.E., Hayman, L.L., Must, A., and Lichtenstein, A.H. (2015). Lifestyle behaviors in metabolically healthy and unhealthy overweight and obese women: A Preliminary Study. PLoS ONE, 10.","DOI":"10.1371\/journal.pone.0138548"},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"de Rooij, B.H., van der Berg, J.D., van der Kallen, C.J., Schram, M.T., Savelberg, H.H.C.M., Schaper, N.C., Dagnelie, P.C., Henry, R.M.A., Kroon, A.A., and Stehouwer, C.D.A. (2016). Physical activity and sedentary behavior in metabolically healthy versus unhealthy Obese and Non-Obese Individuals\u2014The Maastricht Study. PLoS ONE, 11.","DOI":"10.1371\/journal.pone.0154358"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"17428","DOI":"10.1038\/s41598-022-22361-3","article-title":"Relationship between liver fat content and lifestyle factors in adults with metabolic syndrome","volume":"12","author":"Laine","year":"2022","journal-title":"Sci. Rep."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1922","DOI":"10.1016\/j.clnu.2023.08.013","article-title":"Diet composition, nutrient substitutions and circulating fatty acids in relation to ectopic and visceral fat depots","volume":"42","author":"Mora","year":"2023","journal-title":"Clin. Nutr."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1512","DOI":"10.1007\/s00261-015-0385-0","article-title":"Quantification of liver, pancreas, kidney, and vertebral body MRI-PDFF in non-alcoholic fatty liver disease","volume":"40","author":"Idilman","year":"2015","journal-title":"Abdom. Imaging"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1444","DOI":"10.1002\/hep.28012","article-title":"Quantitative magnetic resonance imaging of hepatic steatosis: Validation in ex vivo human livers","volume":"62","author":"Bannas","year":"2015","journal-title":"Hepatology"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"422","DOI":"10.1148\/radiol.12120896","article-title":"Nonalcoholic Fatty Liver Disease: MR Imaging of Liver Proton Density Fat Fraction to Assess Hepatic Steatosis","volume":"267","author":"Tang","year":"2013","journal-title":"Radiology"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"E462","DOI":"10.1152\/ajpendo.00064.2004","article-title":"Magnetic resonance spectroscopy to measure hepatic triglyceride content: Prevalence of hepatic steatosis in the general population","volume":"288","author":"Szczepaniak","year":"2005","journal-title":"Am. J. Physiol. Endocrinol. Metab."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"679","DOI":"10.1002\/hep.23280","article-title":"Obesity and nonalcoholic fatty liver disease: Biochemical, metabolic, and clinical implications","volume":"51","author":"Fabbrini","year":"2010","journal-title":"Hepatology"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"275","DOI":"10.1002\/jbmr.5650110217","article-title":"A multicenter comparison of dual-energy X-ray absorptiometers: In vivo and in vitro measurements of bone mineral content and density","volume":"11","author":"Economos","year":"1996","journal-title":"J. Bone Miner. Res."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1526","DOI":"10.1002\/jbmr.5650111020","article-title":"Evaluation of periprosthetic bone using dual-energy X-ray absorptiometry: Precision of the method and effect of operation on bone mineral density","volume":"11","author":"Kroger","year":"1996","journal-title":"J. Bone Miner. Res."},{"key":"ref_23","unstructured":"Siemens Healthineers AG (2009). Syngo MR-B15V Operator\u2019s Manual, Siemens Healthineers AG."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"806","DOI":"10.1007\/s00330-007-0801-0","article-title":"Assessment of the variations in fat content in normal liver using a fast MR imaging method in comparison with results obtained by spectroscopic imaging","volume":"18","author":"Irwan","year":"2008","journal-title":"Eur. Radiol."},{"key":"ref_25","unstructured":"Hologic Inc (2015). QDR Series X-Ray Densitometers Manual, Hologic Inc."},{"key":"ref_26","unstructured":"Lohman, T.G., Roche, A.F., and Martorell, R. (1988). Anthropometric Standardization Reference Manual, Human Kinetics."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"936","DOI":"10.1093\/ajcn\/36.5.936","article-title":"A short questionnaire for the measurement of habitual physical activity in epidemiological studies","volume":"36","author":"Baecke","year":"1982","journal-title":"Am. J. Clin. Nutr."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"51","DOI":"10.1093\/oxfordjournals.aje.a114086","article-title":"Reproducibility and validity of a semiquantitative food frequency questionnaire","volume":"122","author":"Willett","year":"1985","journal-title":"Am. J. Epidemiol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"791","DOI":"10.1038\/ijo.2010.5","article-title":"Diagnostic performance of body mass index to identify obesity as defined by body adiposity: A systematic review and meta-analysis","volume":"34","author":"Okorodudu","year":"2010","journal-title":"Int. J. Obes."},{"key":"ref_30","unstructured":"World Health Organization (2000). Obesity: Preventing and Managing the Global Epidemic, WHO."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1617","DOI":"10.1001\/archinte.168.15.1617","article-title":"The Obese without Cardiometabolic Risk Factor Clustering and the Normal Weight with Cardiometabolic Risk Factor Clustering: Prevalence and correlates of 2 phenotypes among the US population (NHANES 1999\u20132004)","volume":"168","author":"Wildman","year":"2008","journal-title":"Arch. Intern. Med."},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Gayoso-Diz, P., Otero-Gonz\u00e1lez, A., Rodriguez-\u00c1lvarez, M.X., Gude, F., Garc\u00eda, F., De Francisco, A., and Quintela, A.G. (2013). Insulin resistance (HOMA-IR) cut-off values and the metabolic syndrome in a general adult population: Effect of gender and age: EPIRCE cross-sectional study. BMC Endocr. Disord., 13.","DOI":"10.1186\/1472-6823-13-47"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"281","DOI":"10.1590\/S0004-27302009000200020","article-title":"HOMA1-IR and HOMA2-IR indexes in identifying insulin resistance and metabolic syndrome: Brazilian Metabolic Syndrome Study (BRAMS)","volume":"53","author":"Geloneze","year":"2009","journal-title":"Arq. Bras. Endocrinol. Metabol."},{"key":"ref_34","unstructured":"SAS Institute Inc (2013). SAS\/STAT 13.1 User\u2019s Guide, SAS Institute Inc."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1198","DOI":"10.1086\/301844","article-title":"Quantitative trait linkage analysis","volume":"62","author":"Almasy","year":"1998","journal-title":"Am. J. Hum. Genet."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"711","DOI":"10.1111\/joim.13035","article-title":"Ethnic influence on nonalcoholic fatty liver disease prevalence and lack of disease awareness in the United States, 2011\u20132016","volume":"287","author":"Le","year":"2020","journal-title":"J. Intern. Med."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"2073","DOI":"10.1016\/j.cgh.2020.01.020","article-title":"Dallas Steatosis Index Identifies Patients With Nonalcoholic Fatty Liver Disease","volume":"18","author":"McHenry","year":"2020","journal-title":"Clin. Gastroenterol. Hepatol."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"211","DOI":"10.1177\/2042018811419157","article-title":"An Endocrine Perspective of Nonalcoholic Fatty Liver Disease (NAFLD)","volume":"2","author":"Lomonaco","year":"2011","journal-title":"Ther. Adv. Endocrinol. Metab."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1510","DOI":"10.1038\/oby.2010.90","article-title":"Increased whole-body adiposity without a concomitant increase in liver fat is not associated with augmented metabolic dysfunction","volume":"18","author":"Magkos","year":"2010","journal-title":"Obesity"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"1726","DOI":"10.1002\/oby.20200","article-title":"Ectopic fat and adipokines in metabolically benign overweight\/obese women: The kronos early estrogen prevention study","volume":"21","author":"Ogorodnikova","year":"2013","journal-title":"Obesity"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"1609","DOI":"10.1001\/archinte.168.15.1609","article-title":"Identification and Characterization of Metabolically Benign Obesity in Humans","volume":"168","author":"Stefan","year":"2008","journal-title":"Arch. Intern. Med."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"846","DOI":"10.1002\/hep.21496","article-title":"The NAFLD fibrosis score: A noninvasive system that identifies liver fibrosis in patients with NAFLD","volume":"45","author":"Angulo","year":"2007","journal-title":"Hepatology"},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"Ntani, G., Inskip, H., Osmond, C., and Coggon, D. (2021). Consequences of ignoring clustering in linear regression. BMC Med. Res. Methodol., 21.","DOI":"10.1186\/s12874-021-01333-7"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"S102","DOI":"10.1161\/01.cir.0000437739.71477.ee","article-title":"2013 AHA\/ACC\/TOS guideline for the management of overweight and obesity in adults: A report of the American College of Cardiology\/American Heart Association Task Force on Practice Guidelines and The Obesity Society","volume":"129","author":"Jensen","year":"2014","journal-title":"Circulation"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"1043","DOI":"10.1038\/ejcn.2010.114","article-title":"Metabolically healthy obesity: Different prevalences using different criteria","volume":"64","author":"Velho","year":"2010","journal-title":"Eur. J. Clin. Nutr."}],"container-title":["Metabolites"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2218-1989\/16\/5\/299\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,30]],"date-time":"2026-04-30T04:17:42Z","timestamp":1777522662000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2218-1989\/16\/5\/299"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,28]]},"references-count":45,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2026,5]]}},"alternative-id":["metabo16050299"],"URL":"https:\/\/doi.org\/10.3390\/metabo16050299","relation":{},"ISSN":["2218-1989"],"issn-type":[{"value":"2218-1989","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,28]]}}}