BRIEF RESEARCH REPORT article
Front. Med.
Sec. Family Medicine and Primary Care
This article is part of the Research TopicLifestyle behaviors and chronic diseases: pathways, interventions, knowledge and public health challengesView all 9 articles
More Evidence of the Health Risks of Normal Weight Obesity: The Association with Systemic Inflammation
Provisionally accepted
Rachel Liu-Galvin1*
Frank A. Orlando2
Aaron A Saguil2
Ara Jo1Kristy B Smith2Andrew M Miller2
Danielle Susanne Nelson2Elizabeth C. Sanders2
Arch Mainous1,2- 1University of Florida Department of Health Services Research Management & Policy, Gainesville, United States
- 2University of Florida Department of Community Health and Family Medicine, Gainesville, United States
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Background: Normal weight obesity (NWO) – a normal body mass index (BMI) with high body fat percentage (BF%) – has been linked to increased cardiometabolic risk. This study examined whether NWO is associated with systemic inflammation. Methods: Using 2017-2018 NHANES data, we categorized adult respondents aged 18-59 with BMI ≥18.5 into four groups: 1) Reference: Normal BMI (18.5–24.9) with normal BF% (<25% males/<35% females) 2) NWO: Normal BMI with high BF% (≥25% males/≥35% females) 3) Elevated BMI (≥25) with normal BF% 4) Elevated BMI with high BF% Survey-weighted logistic regression examined associations with elevated hs-CRP (>3.0 mg/L), adjusting for age and race/ethnicity. Sex-stratified analyses were also conducted. Results: Inflammation prevalence was 32.7% overall, highest among individuals with elevated BMI and high BF% (43.6%). Compared to the reference group, individuals with NWO had over threefold increased odds of inflammation (AOR 3.34 [95% CI: 1.83, 6.08]); individuals with elevated BMI and high BF% had over sixfold increased odds (AOR 6.19 [95% CI: 3.66, 10.50]). Elevated BMI with normal BF% was not significantly associated with inflammation. In sex-stratified analyses, NWO was associated with inflammation in both males (AOR 4.44 [95% CI: 1.62, 12.10]) and females (AOR 2.78 [95% CI: 1.40, 5.52]). Elevated BMI and high BF% was also associated with inflammation in both sexes. Conclusions: In this cross-sectional study, NWO was associated with inflammation, although causality cannot be inferred. Reliance on BMI alone may misclassify cardiometabolic risk therefore BF% should be considered in clinical assessments.
Keywords: Body composifion, Body fat %, Body Mass Index, Inflammation, CRP - C-reactive protein, screening, Cardiometabolic Health, Normal weight obesity
Received: 30 Aug 2025; Accepted: 28 Oct 2025.
Copyright: © 2025 Liu-Galvin, Orlando, Saguil, Jo, Smith, Miller, Nelson, Sanders and Mainous. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Rachel Liu-Galvin, rachel.galvin@phhp.ufl.edu
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