Refining Obesity Metrics for Hypertension Risk Stratification in Macao: A 15-Year Multi- Indicator Comparative Study Based on Four Waves of Population Surveillance

Background : Obesity is a major modifiable risk factor for hypertension, yet the predictive performance of various anthropometric indices differs across populations. Macao lacks population-based evidence on which obesity measures best identify individuals at risk of hypertension. Methods: Data were obtained from four waves of the Macao SAR Physical Fitness Surveillance (2005, 2010, 2015, and 2020), comprising 14,288 adults aged 20–59 years. Seven obesity indices—body mass index (BMI), waist circumference (WC), waist-to-height ratio (WHtR), waist-to-hip ratio (WHR), body roundness index (BRI), a body shape index (ABSI), and conicity index (CI)—were analyzed. Logistic regression models estimated associations with hypertension after adjustment for confounders. Receiver operating characteristic (ROC) curves and the Youden index were used to assess predictive performance and identify optimal cutoffs. Results: WC exhibited the strongest associations with hypertension, with adjusted odds ratios (OR) of 1.89 (95% CI: 1.79–2.00), respectively. Among women, the predictive ability (AUC up to 0.748) exceeded that in men (AUC up to 0.689). WHtR and BRI achieved the highest discriminative accuracy in both sexes. The optimal WHtR cutoff for hypertension was 0.4941 in men and 0.4814 in women—lower than WHO-recommended global thresholds. The impact of central obesity was especially pronounced among younger women. Conclusions: WC and WHtR outperform BMI and novel indices in identifying hypertension risk among Macao adults. The findings support adopting locally optimized WC and WHtR thresholds for early hypertension screening, particularly in younger women. Integrating these simple indicators into community health programs could enhance prevention and early detection strategies for hypertension in Asian populations.