Challenging the visceral fat paradigm: abdominal subcutaneous adiposity dominates cardiometabolic risk in young, lean Indians

Abstract Background Visceral adiposity is widely regarded as the pathogenic component of central obesity in cardiometabolic disease. However, emerging evidence suggests that abdominal subcutaneous adiposity may also confer metabolic risk in South Asian populations, although data in young, lean individuals are scarce. We investigated associations of MRI-measured abdominal subcutaneous adipose tissue (ASAT) and visceral adipose tissue (VAT) with cardiometabolic risk markers in young rural Indian adults. Methods We quantified ASAT and VAT using MRI in 590 participants (310 men) aged 18 years from the Pune Maternal Nutrition Study cohort. Sex-specific multiple regression models were used to examine associations with glucose–insulin indices, blood pressure, lipids, adipokines, and inflammatory markers. Results ASAT showed broad and consistent associations with adverse cardiometabolic profiles, including higher 120-min glucose, dyslipidaemia, elevated blood pressure, leptin, CRP and leukocyte count, and lower insulin sensitivity and adiponectin, particularly in men; in women, ASAT was associated with most cardiometabolic risk markers except HDL-cholesterol. In contrast, VAT was associated with fewer risk markers and exhibited weaker, sex-specific patterns of association. Across outcomes, associations with ASAT were generally stronger than those observed for VAT. Conclusions In young, lean Indians, abdominal subcutaneous adiposity exhibits stronger associations with insulin resistance, dyslipidaemia and inflammation than visceral adiposity, challenging the prevailing VAT-centric paradigm derived largely from Western populations. These findings provide human evidence that the hierarchy of metabolic risk across abdominal fat depots is population-specific. This suggests genetic and early-life risk stratification, and supports early targeted preventive strategies. Research Insights What is currently known about this topic? (max. 3 highlights, each < 100 characters) Indians have higher central obesity-adiposity than Europeans at similar BMI. Western data links VAT with cardiometabolic risk, while ASAT is protective. VAT & ASAT risk patterns vary across native and migrant South Asians. What is the key research question? (formatted as a question, < 100 characters) How do VAT and ASAT associate with cardiometabolic risk in lean rural Indian youth? What is new? (max. 3 highlights, each < 100 characters) ASAT shows stronger links with cardiometabolic risk than VAT in rural Indian youth. ASAT may contribute to high diabetes and CVD risk at low BMI in young Indians. How might this study influence clinical practice? (max. 1 highlight, < 100 characters) Early-life ASAT accumulation may raise later cardiometabolic risk, supporting early prevention strategies.