To explore the association between different metabolic body weight subtypes and the risk of cardiovascular disease（CVD）incidence in middle-aged and elderly populations.

The study utilized data from the China Health and Retirement Longitudinal Study（CHARLS）, with the initial data collection phase implemented in 2011. By the end of the cohort follow-up in 2020, The final analytical sample comprised 6 353 eligible participants. Participants were classified into 6 and 4 metabolic subtypes respectively using combinations of body mass index, waist-to-height ratio, and ATP-III criteria. Cox regression was employed to explore the association between each metabolic subtype and the incidence of CVD.

During a 9-year follow-up, 1 825 individuals developed CVD. Of the total study population, 11.4%（n=730）met the criteria for obesity, with 16.0% of these obese individuals demonstrating a metabolically healthy profile. Compared to individuals who were of normal weight and metabolically healthy, those with metabolically healthy obesity（MHO）exhibited an increased risk of CVD（HR=1.70, 95% CI: 1.18-2.46）, while the risk was even higher in individuals with metabolically abnormal obesity（HR=2.48, 95% CI: 2.07-2.97）.Sensitivity analysis（using the four subtypes defined by waist-to-height ratio）found consistent results. Stratification by BMI revealed that, within normal weight and overweight populations, the risk of CVD was significantly elevated in metabolically abnormal groups compared to metabolically healthy groups. Subgroup analyses did not identify interactions between age, gender, education level,smoking, or drinking status and the various metabolic subtypes.

In middle-aged and elderly adults, MHO is linked to a higher risk of CVD. Among normal weight and overweight individuals, the risk of CVD is higher in metabolically abnormal groups than in metabolically healthy groups.MHO is not a benign subtype, and obese individuals need to enhance their weight management and lose weight in a reasonable manner.