Determinants of Metabolic Syndrome and Type 2 Diabetes in the Absence of Obesity: The Jackson Heart Study

CONTEXT: Multiple studies suggest that adults who were normal weight at diabetes diagnosis are at higher risk for all-cause mortality than those who had overweight or obesity at diagnosis. OBJECTIVE: While obesity is a known risk factor for cardiometabolic disease, differences in body fat distribution in those without obesity are understudied, especially in African Americans. METHODS: In 1005 participants of the Jackson Heart Study, without cardiovascular disease at baseline, we used logistic regression to investigate the longitudinal association of body fat distribution by CT scan with metabolic syndrome (MetS) or type 2 diabetes (T2D). We used the harmonized International Diabetes Federation criteria to define MetS. We included only normal weight or overweight participants (BMI: 18.5 to < 30.0 kg/m(2)). We created separate models for MetS and T2D adjusted for a standard set of covariates. We excluded participants with prevalent MetS or T2D, respectively in sensitivity. RESULTS: Higher visceral fat, subcutaneous fat, BMI, and insulin resistance (HOMA-IR) were significantly associated with MetS and T2D after adjustment. Visceral fat was strongly associated with both outcomes (MetS OR = 2.07 [1.66-2.68]; T2D OR = 1.51 [1.21-1.88]), and the association for MetS persisted in the normal weight only group. Estimates were robust to sensitivity analysis and were only modestly mediated by insulin resistance. Physical activity was not associated with MetS or T2D. CONCLUSION: Visceral fat is strongly associated with developing MetS, even in normal weight individuals, suggesting that excess visceral fat plays a role in cardiometabolic risk beyond that of overall adiposity and obesity in African Americans.