Abstract
BACKGROUND: A novel, comprehensive definition of metabolic health, incorporating systolic blood pressure < 130 mmHg without antihypertensive medication, sex-specific waist-to-hip ratio thresholds (< 0.95 for women and < 1.03 for men), and no prevalent diabetes, has recently been proposed for mortality risk stratification. We aimed to explore its association with cardiovascular disease (CVD) across body mass index (BMI) categories among U.S. adults. METHODS: This cross-sectional study included 11,499 U.S. adults from the National Health and Nutrition Examination Survey 2017-August 2023. Metabolic health was defined by the above criteria. BMI categories were normal weight (BMI < 25 kg/m2), overweight (25–30 kg/m2), and obesity (≥ 30 kg/m2). The association between metabolic health and CVD was assessed using a multivariable weighted logistic regression model. RESULTS: Among the 11,499 individuals, 10,383 were categorized into non-CVD while 1,116 were categorized into CVD. Compared to metabolically healthy individuals, the adjusted odds ratio (OR) for CVD among metabolically unhealthy status was 2.07 (95% confidence interval [CI]: 1.60–2.67, P < 0.001). Stratified by BMI, metabolically unhealthy status was associated with higher odds of prevalent CVD in overweight (OR: 2.89, 95% CI: 1.75–4.78, P < 0.001) and obese (OR: 2.38, 95% CI: 1.59–3.58, P < 0.001) individuals, but not in normal weight individuals (OR:1.07, 95% CI: 0.64–1.80, P = 0.74). CONCLUSIONS: In this U.S. population-based study, metabolically unhealthy status correlates with high CVD risk among overweight and obese individuals, but not in normal weight individuals. Our findings support targeted metabolic health interventions for CVD prevention in overweight and obese groups within the U.S. context. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s41043-025-01003-0.