Beyond BMI: The Role of Visceral Adipose Tissue in Cardiometabolic Risk Stratification Among Children and Adolescents with Obesity—A Systematic Review

Background and Objective: Body mass index (BMI) is widely used to classify obesity in children and adolescents but does not characterize fat distribution. Visceral adipose tissue (VAT) may provide information on cardiometabolic risk beyond BMI. This systematic review aimed to synthesize evidence on the associations between VAT and cardiometabolic risk in children and adolescents with obesity and to evaluate whether VAT provides additional information beyond BMI. Methods: PubMed and Scopus were searched for English-language studies published between 1 January 2016 and 28 February 2026. Eligible studies included participants aged 6–19 years, assessed VAT using dual-energy X-ray absorptiometry (DXA), magnetic resonance imaging (MRI), computed tomography (CT), or ultrasonography (USG), and reported at least one cardiometabolic outcome. Two reviewers independently screened the records. Methodological quality was assessed using the appropriate Joanna Briggs Institute Critical Appraisal Tools or the Newcastle–Ottawa Scale. Because of methodological and clinical heterogeneity, the findings were synthesized narratively. The review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement. Results: Twenty studies were included, most of which were cross-sectional. Higher VAT was generally associated with insulin resistance, adverse lipid profiles, elevated blood pressure, inflammatory biomarkers, and early vascular dysfunction, although findings were not uniform across all populations and outcomes. In several studies, associations remained significant after adjustment for BMI or other measures of general adiposity, suggesting that VAT may capture cardiometabolic risk not reflected by BMI alone. DXA was the most frequently used assessment method. Conclusions: VAT may complement BMI in cardiometabolic risk assessment among children and adolescents with obesity. However, predominantly cross-sectional evidence, methodological heterogeneity, and the absence of standardized pediatric thresholds preclude firm conclusions about its incremental predictive value or routine clinical use. Prospective studies directly comparing VAT and BMI are required.