The study drew on the National Health and Nutrition Examination Survey, or NHANES, covering survey cycles from 2007 to 2018, with mortality outcomes linked to the National Death Index through December 31, 2019. After applying survey weights, the analytic cohort represented approximately 106.9 million US adults, with a mean age of 47.2 years. Rather than relying on body mass index alone, the investigators stratified participants into four distinct body composition phenotypes using two measurements: BMI, which captures overall mass relative to height, and the waist-to-height ratio, which serves as a practical proxy for central or abdominal adiposity. The four groups were obesity with central adiposity, obesity without central adiposity, normal weight with central adiposity, and normal weight without central adiposity.

The distribution of these phenotypes across the American population proved revealing in its own right. A slim majority, 53.3 percent of the weighted cohort, fell into the normal weight without central adiposity category, the presumed metabolically healthy baseline. Another 33.9 percent carried both a high BMI and a high waist-to-height ratio, the classic pattern of generalized obesity. But two smaller and often overlooked groups drew the researchers’ attention: 8.1 percent of adults had normal BMI values but prominent central fat stores, a phenomenon sometimes called normal weight central adiposity, while 4.7 percent were obese by BMI yet lacked significant abdominal fat accumulation. These last two groups complicate the simple arithmetic of conventional obesity screening.

The central outcome of the investigation was cardiovascular-kidney-metabolic multimorbidity, defined as the coexistence of two or more of the following conditions: hypertension, hyperlipidemia, diabetes, chronic kidney disease, or established cardiovascular disease. This clustering of cardiometabolic disorders, increasingly framed under the umbrella of cardiovascular-kidney-metabolic syndrome, has been recognized by the American Heart Association as a major and growing driver of cardiovascular events and death. The syndrome reflects the intimate physiological coupling of the heart, kidneys, and metabolic organs: insulin resistance accelerates atherosclerosis, declining kidney function worsens volume overload and hypertension, and adipose tissue dysfunction amplifies inflammatory signaling that damages vascular beds throughout the body.

When the researchers tabulated multimorbidity prevalence across body composition phenotypes, a clear hierarchy emerged. Normal weight individuals with central adiposity had the highest rate of cardiovascular-kidney-metabolic multimorbidity at 46.5 percent, meaning nearly half of these apparently slim adults already carried at least two of the five defining conditions. This exceeded the multimorbidity burden observed in people with obesity with central adiposity, and it dwarfed the rates seen in the two phenotypes without abdominal fat excess. In other words, the single group that conventional BMI-based screening would most reliably classify as low risk was, by this metric, the sickest.

Mortality analyses sharpened the message considerably. Using survey-weighted Cox proportional hazards models, which allow researchers to estimate the association between a characteristic and the timing of death while adjusting for confounding factors and accounting for the complex sampling design of NHANES, the team found that normal weight adults with central adiposity faced an adjusted hazard ratio of 1.87 for all-cause mortality compared with the reference group, a statistically significant elevation with a 95 percent confidence interval of 1.08 to 3.25 and a p value of 0.025. Even more dramatic was the association with cardiovascular death: the adjusted hazard ratio reached 7.76, with a 95 percent confidence interval of 1.01 to 59.76 and a p value of 0.049. While the wide confidence interval reflects the relatively small number of events in this subgroup and should temper strong causal interpretation, the direction and magnitude of the association are consistent with a substantially elevated cardiovascular risk.

Kaplan-Meier survival curves, a standard technique for visualizing the probability of surviving over time across groups, reinforced the statistical models. Participants who combined cardiovascular-kidney-metabolic multimorbidity with the normal weight central adiposity phenotype demonstrated the poorest long-term survival of any group in the analysis, with the difference between curves reaching statistical significance at p less than 0.001. This convergence of evidence, spanning prevalence estimates, adjusted hazard modeling, and nonparametric survival analysis, points toward a coherent conclusion: the combination of a slim silhouette and a protruding waistline represents a particularly dangerous metabolic signature when it coexists with clustered cardiometabolic disease.

The biological plausibility behind these findings rests on the distinct behavior of visceral adipose tissue compared with subcutaneous fat. Fat deposited around internal organs is not an inert energy reservoir; it is a hormonally and immunologically active tissue that drains directly into the portal circulation, delivering free fatty acids and inflammatory cytokines to the liver and promoting insulin resistance, dyslipidemia, and hepatic steatosis. Visceral fat accumulation is also closely linked to ectopic fat deposition in the liver, pancreas, and heart itself, mechanisms that have been implicated in the progression of metabolic dysfunction-associated steatotic liver disease, type 2 diabetes, and atherosclerotic cardiovascular disease. A person with a normal BMI but a high waist-to-height ratio may therefore harbor a metabolically hostile internal environment that is invisible to weight-based screening, while some individuals with obesity and preserved fat distribution may be relatively protected.

The study arrives at a moment when the scientific community is actively rethinking how obesity itself should be defined. A recent international commission has proposed diagnostic criteria for clinical obesity that move beyond BMI toward measures of fat distribution and organ dysfunction, and prior research has repeatedly shown that waist-to-height ratio outperforms BMI as a screening tool for cardiometabolic risk factors. The new findings extend this literature into the specific arena of cardiovascular-kidney-metabolic multimorbidity and long-term survival in a nationally representative population. The authors conclude that normal weight individuals with central adiposity bear the greatest CKM burden and mortality risk, a result that highlights the limitations of BMI-based risk assessment and argues for incorporating simple anthropometric measures of central fat, such as the waist-to-height ratio, into routine clinical screening. For clinicians, the practical implication is straightforward: a tape measure around the waist may identify high-risk patients that the scale alone would miss, and for the public, the reassuring sight of a normal number on the bathroom scale should not be mistaken for a clean bill of cardiometabolic health.

Subject of Research: The association of body composition phenotypes with cardiovascular-kidney-metabolic multimorbidity and long-term mortality in a US population-based cohort

Article Title: Body composition phenotypes are key predictors of cardiovascular-kidney-metabolic multimorbidity and long-term mortality: insights from a population-based cohort study

Article References: Kong, G., Intaran, M. A. U., Soh, E. S. W., Yazicioglu, Y., Goh, R., Nagarajan, S., Wang, J.-W., Zhou, X., Zhou, X.-D., Zheng, M.-H., Chan, M. Y., Mehta, A., le Roux, C. W., Mamas, M. A., Khan, M. S., & Chew, N. W. S. (2026). Body composition phenotypes are key predictors of cardiovascular-kidney-metabolic multimorbidity and long-term mortality: insights from a population-based cohort study. Clinical Research in Cardiology. https://doi.org/10.1007/s00392-026-03010-5

Image Credits: AI Generated

DOI: 10.1007/s00392-026-03010-5

Keywords: cardiovascular-kidney-metabolic syndrome, central adiposity, body mass index, waist-to-height ratio, obesity, NHANES, multimorbidity, mortality, visceral fat, cardiometabolic risk, population-based cohort study, risk screening

The numbers behind the review are stark. The latest National Health and Morbidity Survey, conducted in 2023, recorded an adult overweight and obesity prevalence of 54.4 percent, placing Malaysia second highest among Association of Southeast Asian Nations members. When the threshold is lowered to a body mass index of 23 kilograms per square metre, the cut-off increasingly considered appropriate for Asian populations, the proportion of adults at risk climbs to roughly 70 percent. Globally, obesity affected 38 percent of adults in 2020 and is projected to exceed half the world’s population by 2035, making Malaysia a case study in how rapidly middle-income nations are absorbing the metabolic consequences of nutritional transition.

The research team, led by Quan-Hziung Lim and colleagues, conducted a structured search across Web of Science, PubMed and Google Scholar, screening 3626 articles before settling on the final 179. The majority of these studies, nearly 70 percent, addressed the epidemiology of obesity, while fewer than 9 percent focused on developing new treatment modalities. Most relied on community-sampled data rather than nationally representative surveys, and the overwhelming majority were cross-sectional in design. Although randomised controlled trials increased from just three in the previous decade to 25 in the current one, most lasted less than a year, and longitudinal cohorts and pragmatic real-world trials remain scarce. This pattern, the authors note, closely mirrors the findings of an earlier scoping review covering 2008 to 2017, suggesting that the methodological profile of Malaysian obesity research has shifted only modestly over time.

One of the most consequential themes to emerge concerns how obesity itself should be measured. Malaysian studies consistently demonstrate that metabolic risk emerges well below conventional body mass index thresholds. Women with normal BMI but elevated body fat percentage, so-called normal-weight obese individuals, showed substantially higher odds of abdominal obesity, hypertriglyceridemia and hypertension. From a BMI of 23 onward, associations with undiagnosed diabetes, high blood pressure and elevated cholesterol become firmly established, and refined analyses suggest optimal hypertension prediction thresholds of around 23 kilograms per square metre for men and 24 for women. Meanwhile, waist-to-height ratio above approximately 0.5 repeatedly outperformed BMI in predicting excess adiposity and cardiometabolic disease, leading the authors to argue that a dual measurement strategy combining BMI with abdominal measures offers a pragmatic, low-cost route to earlier detection.

The review also documents a paradox familiar from international literature: in a large retrospective cohort, overweight individuals had lower all-cause mortality than those in the normal range, yet overweight and obesity contributed 7 percent of the national cancer burden, second only to tobacco smoking. Above a BMI of 30, more than three-quarters of Malaysians with obesity already carry at least one metabolic complication, and the probability of transitioning from metabolically healthy to unhealthy obesity rises by 4.4 percent with each passing year. Severe obesity at or above 35 kilograms per square metre conferred excess cardiovascular mortality for the population overall. Psychosocial evidence, though thinner, points to elevated rates of depression among people with obesity, with healthcare workers who reported depression showing double the odds of obesity, and pandemic-era surveys linking overweight status to mild-to-severe depressive symptoms.

Predisposition patterns are equally revealing. Malaysian women consistently show higher rates and risks of obesity than men, with 33 to 64 percent greater odds, and steeper increases in BMI and waist circumference with age. Prevalence peaks in middle age and declines in older adults, though the authors caution this may reflect survivorship bias rather than genuine protection. Ethnic disparities are pronounced, with Malay, Indian and other Bumiputera groups showing consistently higher odds of overweight and obesity compared with Chinese Malaysians, a pattern echoed in neighbouring Singapore. Genetic research remains exploratory, identifying variants in genes such as LEPR, ADIPOQ and FTO among local populations, but with limited immediate clinical applicability. More actionable are occupational findings: night-shift work doubled the risk of metabolic syndrome among manufacturing workers, and nurses showed particularly elevated obesity rates.

Dietary drivers form a third major thread. A quasi-historical analysis linked Malaysia’s rising obesity to a 30 percent caloric oversupply, with shifts toward wheat, sugar, meat and animal-based protein. Across multiple studies, excess intake of protein, meat, sugar, sodium and ultra-processed foods, combined with inadequate consumption of fruits, vegetables and fibre, was consistently associated with higher obesity risk. Emerging chrononutrition research suggests that meal timing matters, with late-day energy and carbohydrate intake increasing metabolic risk among people with obesity. On the policy front, the picture is sobering: four years after its introduction, nearly 80 percent of Malaysians remained unaware of the Malaysian Healthy Plate messaging concept, healthy diets remain costly, and food insecurity among rural women was paradoxically linked with higher obesity rates.

Interventional research offers cautious grounds for optimism. Twenty-two community-based lifestyle studies were reviewed, ranging from pedometer-based walking programmes to combined diet and exercise packages. The government-initiated MyBFF@home programme for urban housewives produced modest but significant reductions in weight, BMI and visceral fat at six months, though sustainability at twelve months was variable. A structured face-to-face workplace programme achieved 7 percent weight loss, substantially outperforming an online equivalent, while group-based approaches were more effective than individual counselling. Notably, 91 percent of interventions operated at the micro level, targeting individual behaviour, with almost no macro-level policy interventions tested. Modelling work suggests that meaningful weight loss through physical activity alone requires roughly 1500 MET-minutes per week, equivalent to six to seven hours of moderate activity, a bar that nearly half of sedentary Malaysians are unlikely to clear without dietary change.

Clinical treatment presents a mixed frontier. Most approved obesity medications, including newer incretin-based therapies such as semaglutide and tirzepatide, are available in Malaysia, but monthly out-of-pocket costs of 800 to 1800 ringgit are prohibitive against a median monthly income of roughly 2800 ringgit, and only about 10 percent of people with obesity are ever offered pharmacotherapy. Metabolic and bariatric surgery has expanded rapidly since 1996, with procedures more than doubling between 2010 and 2016, delivering substantial weight loss and metabolic improvement at costs between 11,000 and 30,000 ringgit. Barriers persist on both sides of the consultation: patients report weight stigma, self-blame and misperception of their own weight status, while clinicians cite time constraints and limited training. The authors conclude that Malaysia stands at a critical inflection point, requiring coordinated, whole-of-society action, stronger longitudinal and policy research, and equitable access to effective therapies to prevent the deepening of a Stage 3 obesity profile in which the burden concentrates among the poorest.

Subject of Research: Mapping and narrative review of adult overweight and obesity research in Malaysia from 2015 to 2024

Article Title: The landscape of adult obesity in Malaysia: a mapping of evidence and contemporary narrative review

Article References: Lim, Q.-H., Khoo, J.-K., Ooi, Y.-G., Ramachandaram, A., & Ratnasingam, J. (2026). The landscape of adult obesity in Malaysia: a mapping of evidence and contemporary narrative review. The Lancet Regional Health – Western Pacific, 74, Article 101963. https://doi.org/10.1016/j.lanwpc.2026.101963

Image Credits: AI Generated

DOI: 10.1016/j.lanwpc.2026.101963

Keywords: obesity, Malaysia, overweight, body mass index, waist-to-height ratio, public health, nutrition transition, lifestyle intervention, bariatric surgery, GLP-1 receptor agonists, National Health and Morbidity Survey, noncommunicable diseases