Sex-specific performance of composite metabolic-adiposity indices in identifying hypertension and carotid atherosclerosis: a cross-sectional study of 154,873 Chinese adults

The comparative superiority among the triglyceride-glucose (TyG) index and its obesity-related composite indicators in identifying hypertension and carotid atherosclerosis (CAS) remains unknown. This study aims to evaluate and compare the discriminative ability of these indices in a large-scale population to identify the optimal marker for cardiovascular risk assessment. This cross-sectional study included 154,873 participants who underwent routine physical examinations and carotid ultrasonography. Binary logistic regression, restricted cubic spline (RCS), receiver operating characteristic (ROC) analyses, and mediation analyses were used to evaluate the associations of TyG, TyG-waist circumference (TyG-WC), TyG-waist-to-height ratio (TyG-WHtR), and TyG-body mass index (TyG-BMI) with hypertension and CAS. The mean age of participants was 45.7 ± 12.5 years, with 42.1% being female and 91.0% being married. A total of 16,235(10.5%) participants had hypertension, and 81,337 (52.5%) had CAS. Comparing the highest to the lowest quartile, TyG-WHtR demonstrated the strongest association with hypertension (OR = 8.644, 95% CI: 7.927-9.426) and CAS (OR = 2.173, 95% CI: 2.086-2.263). RCS analyses revealed monotonic increases for hypertension and complex nonlinear patterns for CAS. Stratified analyses revealed distinct phenotypic signatures. For hypertension, risk magnitudes were markedly amplified in younger adults (≤ 60 years) (P for interaction < 0.001 for all indices). For CAS, a significant interaction between sex and the indices was observed (P for interaction < 0.05 for TyG, TyG-WHtR, and TyG-BMI): TyG-WHtR exhibited the strongest association in women (OR = 1.504), whereas in men, the isolated TyG index was inversely associated with CAS, and only TyG-BMI showed a significant positive association (OR = 1.091). Mediation analyses revealed that obesity indicators (WHtR, BMI) demonstrated substantial direct associations with on outcomes, with TyG providing negligible or partial mediation, which may account for the stronger associations observed with composite indices. TyG-obesity composite indices are strongly associated with hypertension and CAS, particularly in younger adults. TyG-WHtR is optimal for women and the general population, while TyG-BMI is superior for men. These easily accessible and cost-effective metrics can serve as practical tools for early cardiovascular risk screening in primary care. Implementing such age-targeted and sex-specific risk stratification could facilitate more precise and timely preventive interventions.