Association between the Metabolic Score for Visceral Fat (METS-VF) and incident hypertension in middle-aged and older Chinese adults: a nationwide prospective cohort study

Emerging evidence highlights the critical role of visceral adiposity in the pathogenesis of hypertension, with the Metabolic Score for Visceral Fat (METS-VF) emerging as a novel biomarker that requires validation in Chinese populations. This prospective cohort study included adults aged ≥ 45 years without hypertension at baseline from the China Health and Retirement Longitudinal Study (CHARLS).From the 2011–2012 CHARLS cohort, 6775 participants were included in the final analysis after excluding those with age < 45, insufficient follow - up, missing clinical data, or baseline hypertension with incomplete questionnaires. We evaluated the longitudinal association between METS-VF and hypertension incidence and compared its predictive performance with conventional adiposity indices, including the visceral adiposity index (VAI) and lipid accumulation product (LAP). Hypertension cases were identified through biennial assessments over a median follow-up of 8 years. A total of 2,845 incident hypertension cases were documented. Multivariable Cox regression models revealed a significant dose-response relationship, with participants in the highest METS-VF quartile exhibiting a 2.11-fold higher risk of hypertension compared to those in the lowest quartile (95% CI: 1.85–2.42; P < sub > trend</sub > < 0.001). The absolute 8-year hypertension risk was 18.3% higher in the highest versus lowest quartile. Restricted cubic spline analysis identified a nonlinear threshold effect at a METS-VF value of 5.68, beyond which hypertension risk increased sharply by 134% (HR = 2.34). Each one-unit increase in METS-VF was associated with a 2.4% elevated hypertension risk (HR = 1.02, 95% CI: 1.00-1.05). Receiver operating characteristic analysis demonstrated that METS-VF had superior discriminative ability (AUC = 0.62) compared to LAP (AUC = 0.60) and VAI (AUC = 0.57), with statistically significant differences in predictive accuracy (P < 0.05). Subgroup analyses confirmed consistent associations across age, sex, and BMI categories (all P < sub > interaction</sub > > 0.05). METS-VF serves as an independent predictor of hypertension in middle-aged and older Chinese adults, outperforming conventional indices. The substantial absolute risk difference—an 18.3% higher 8-year hypertension risk in the highest versus lowest METS-VF quartile—underscores its clinical relevance. The identified risk threshold and superior predictive ability support its potential use in clinical risk stratification and preventive strategies.