Sex-Specific Misclassification of Obesity When Using Body Mass Index in Young Healthcare Professionals: A Large...

Background: Body mass index (BMI) remains the standard tool for obesity screening; however, it does not account for body fat distribution or visceral adiposity, potentially leading to clinically relevant misclassification-particularly in young adults. Evidence on this issue in healthcare professionals is limited. Objective: To evaluate the extent of obesity misclassification when using BMI compared with alternative anthropometric and body composition indices, and to examine sex-specific associations between lifestyle factors and different adiposity phenotypes in young healthcare professionals. Methods: A large cross-sectional study was conducted in 12,874 medical residents, nursing residents, and age-matched controls (22-30 years). Obesity was defined using BMI (≥30 kg/m²), waist-to-height ratio (WtHR ≥ 0.5), Clínica Universidad de Navarra-Body Adiposity Estimator (CUN-BAE), body fat percentage, and bioimpedance-derived visceral fat. Multivariable logistic regression models adjusted for age, sex, professional group, smoking, physical activity, and Mediterranean diet adherence were fitted separately for each adiposity definition. Sex interaction terms were formally tested. Agreement between indices was assessed using Cohen's kappa. Results: Obesity prevalence varied substantially according to the index applied and was consistently higher when central or visceral adiposity measures were used. Agreement between BMI and alternative indices was only fair to moderate, with the lowest concordance observed for visceral fat (κ = 0.29; 95% CI 0.26-0.32). Male sex was strongly associated with visceral fat-defined obesity (aOR 4.76; 95% CI 3.82-5.92), while effect sizes were attenuated for BMI-defined obesity (aOR 1.41; 95% CI 1.32-1.51). Significant sex interactions were detected for visceral adiposity, particularly for physical activity (p = 0.001) and smoking (p = 0.002), indicating differential lifestyle associations according to fat distribution phenotype. Conclusions: BMI substantially underestimates clinically relevant central and visceral adiposity in young healthcare professionals. Sex-specific differences were observed in the association between lifestyle behaviors and visceral fat. These findings highlight the limitations of relying exclusively on BMI for obesity screening. Incorporating waist-based or body composition-derived measures may improve early risk identification and support targeted preventive strategies.