This study aimed to analyze the global disease burden of high Body Mass Index (BMI) and to evaluate and compare the predictive efficacy of three obesity diagnostic criteria—WHO, EASO, and AOU—alongside the Waist-to-Height Ratio (WHtR), for osteoporosis (OP), hip fracture (HF), major osteoporotic fracture (MOF) and cardiovascular diseases (CVD) in a clinical cohort.

Data on the high BMI burden in China and globally (1990-2021) were sourced from the Global Health Data Exchange (GHDx). A clinical study enrolled 17,949 participants from a single center in China. Obesity was diagnosed using WHO, EASO, and AOU criteria. Associations between WHtR (as continuous and categorical variable by tertiles) and the risks of CVD, HF, and MOF were analyzed using Cox proportional hazards models, with adjustments for multiple covariates.

From 1990 to 2021, the age-standardized rate of high BMI in China increased by 146.22% (AAPC=2.95%), exceeding the global increase of 70.89% (AAPC=1.74%). In the clinical cohort, the EASO obesity criteria demonstrated significant associations with CVD. WHtR, as a continuous variable, was a significant risk factor for CVD, HF, and MOF across all adjusted models. When analyzed by tertiles, the highest WHtR tertile was associated with significantly increased risks of CVD (HR=1.118), HF (HR=2.364), and MOF (HR=3.563) compared to the lowest tertile in fully adjusted models, showing a dose-response relationship. Restricted cubic spline models confirmed non-linear increases in risk with rising WHtR.

The high BMI burden is rising markedly, especially in China. WHtR is a potent and independent predictor for CVD, HF, and MOF risks. Its integration into clinical practice, particularly within frameworks like the EASO criteria, could enhance risk stratification and proactive intervention strategies for obesity-related comorbidities.