AbstractObjectiveTo investigate the relationship between body fat distribution and risk of cardiometabolic and microvascular events among individuals with prediabetes or diabetes with normal body mass index (BMI).MethodsA total of 17,232 participants with prediabetes or diabetes from UK Biobank (UKB) with 12‐year follow‐up and 499 diabetic participants from China with 2‐year follow‐up with normal BMI were included. Anthropometric measurements of waist circumference (WC), waist‐to‐hip ratio (WHR) and waist‐to‐height ratio (WHtR), and body fat composition assessment of trunk‐to‐leg fat ratio (TLFR) were obtained. Outcomes included incident all‐cause and cardiovascular mortality and macrovascular and microvascular diseases.ResultsIn British cohort, participants with central obesity defined by WHR had 27%–54% higher risk of incident all‐cause mortality (hazard ratio (HR) 1.42, 95% confidence interval (CI): 1.23–1.64), cardiovascular mortality (HR 1.54 [1.15–2.07]), myocardial infarction (HR = 1.43 [1.15, 1.78]), stroke (HR 1.26 [0.90, 1.75]), heart failure (HR = 1.27 [1.00, 1.61]), diabetic nephropathy (HR 1.33 [1.07, 1.65]), and diabetic retinopathy (DR) (HR = 1.48 [1.12, 1.96]) than those without obesity. Central obesity defined by WC and WHtR was associated with 40%–44% and 23%–98% higher risks of developing diabetic events, respectively. In the Chinese cohort, individuals with abdominal obesity, defined by WC (HR 1.44) or WHtR (HR 1.43) but not by WHR, carried more than 40% higher risk of developing DR than those without it. Higher TLFR carried 1.30–2.85 times higher risk of CVD and microvascular diseases among the dysglycemic population.ConclusionsBody fat distribution diseases among individuals with prediabetes or diabetes are associated with an increased risk of cardiometabolic and microvascular diseases independent of BMI.