Background: Serum ferritin (SF) has been correlated with one or more metabolic syndrome features associated with an increased risk for cardiovascular disease (CVD). This study explored the associations between SF and CVD risk factors among different body size phenotypes that were based on metabolic status and body mass index (BMI) categories. Methods: A cross-sectional study was performed using a cohort of 7,549 Chinese adults from the China Health and Nutrition Survey. Participants did not exhibit acute inflammation, were not underweight and were stratified based on their metabolic status and BMI categories. The metabolically at-risk status was defined as having two or more criteria of the Adult Treatment Panel-III metabolic syndrome definition, excluding waist circumference. Results: Compared with individuals without high SF, subjects with high SF had an increased risk of diabetes in the metabolically at-risk normal-weight (MANW) and metabolically at-risk overweight/obesity (MAO) groups. The multivariate-adjusted odds ratios (ORs) were 1.52 [95% confidence interval (Cls): 1.02, 2.28] and 1.63 (95% Cls: 1.27, 2.09), respectively. Adjusted ORs for hyperuricemia from high SF in metabolically healthy normal-weight (MHNW), metabolically healthy overweight/obesity (MHO), MANW, and MAO phenotypes were 1.78 (95% Cls: 1.26, 2.53), 1.42 (95% Cls: 1.03, 1.95), 1.66 (95% Cls: 1.17, 2.36), and 1.42 (95% Cls: 1.17, 1.73), respectively. Similarly, positive correlations of high SF with triglycerides, non-high-density lipoprotein cholesterol, and apolipoprotein B100 were observed in all phenotypes. No association between high SF and elevated low-density lipoprotein cholesterol were observed among participants who were metabolically at-risk, regardless of their BMI categories. However, the ORs for elevated low-density lipoprotein cholesterol from high SF were 1.64 (95% Cls: 1.29, 2.08) in the MHNW group and 1.52 (95% Cls:1.22, 1.91) in the MHO group, significantly. This study demonstrated that the highest ORs were in MAO with a high SF group for all unfavorable CVD risk factors except low-density lipoprotein cholesterol (all p < 0.001). Conclusions: The associations of high SF with the prevalence of CVD risk factors, including diabetes, dyslipidemia, and hyperuricemia, vary in individuals among different body size phenotypes. In the MAO group, subjects with high SF levels exhibited worse CVD risk profiles than individuals without high SF.

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