Residual Atherogenic Dyslipidemia in Normal-Weight Adults: The Role of Visceral Adiposity and Metabolic Dysfunction.

Among 166,008 Spanish workers with normal BMI, 8.0% had an elevated TG/HDL-c ratio, indicating residual atherogenic dyslipidemia.

• Cross-sectional study of workers aged 18-69 years with BMI 18.5-24.9 kg/m2 who had standardized occupational health examinations between 2022 and 2024.
• Residual atherogenic dyslipidemia was primarily assessed with the triglyceride-to-HDL cholesterol ratio (TG/HDL-c).
• Despite normal BMI, 11.8% had central adiposity, 11.4% had low HDL cholesterol, and 17.9% had elevated blood pressure.

Normal-weight individuals with elevated TG/HDL-c had a worse adiposity and cardiometabolic profile than those without.

• They had significantly higher waist circumference, WtHR, METS-VF, triglycerides, non-HDL cholesterol, fasting glucose, blood pressure, and TyG index (all p < 0.001).
• Visceral adiposity was estimated using WtHR and the Metabolic Score for Visceral Fat (METS-VF).

Lipid and metabolic parameters worsened progressively across METS-VF quartiles, and elevated TG/HDL-c prevalence rose steeply.

• Prevalence of elevated TG/HDL-c increased from 2.7% in the lowest METS-VF quartile to 15.8% in the highest quartile.
• A progressive worsening of lipid and metabolic parameters was observed with increasing METS-VF quartile.

Men had a much higher prevalence of residual atherogenic dyslipidemia than women.

• Prevalence was 12.2% in men versus 3.9% in women (p < 0.001).
• Male sex showed consistent associations with elevated TG/HDL-c across multivariable models.

Unhealthy lifestyle factors were strongly associated with adverse lipid-metabolic profiles.

• Physical inactivity, smoking, poor Mediterranean diet adherence, and regular alcohol consumption were strongly associated with adverse profiles.
• Physical inactivity, smoking, and low Mediterranean diet adherence showed consistent associations with elevated TG/HDL-c across multivariable models.

In multivariable logistic regression, BMI and METS-VF were independently associated with elevated TG/HDL-c, but WtHR ≥ 0.50 was not after adjustment.

• Separate models were used for each adiposity measure.
• Impaired fasting glucose and elevated blood pressure also showed consistent associations with elevated TG/HDL-c across models.

The authors conclude that BMI alone substantially underestimates hidden cardiometabolic risk and that normal-weight adults are metabolically heterogeneous.

• Residual atherogenic dyslipidemia is linked to visceral adiposity, metabolic dysfunction, and unfavorable lifestyle behaviors.
• The findings highlight the limitations of BMI as a sole marker of cardiometabolic health.