Many indices are now available to assess visceral obesity and the subsequent metabolic complications. The visceral adiposity index (VAI) is a sex-specific mathematical scoring system that was developed using simple, classical anthropometric and metabolic parameters, such as waist circumference (WC), body mass index, triglyceride (TG) levels, and high-density lipoprotein cholesterol, to identify insulin resistance and cardiometabolic risk [4]. In previous studies, VAI has been found to be independently associated with visceral adiposity assessed by abdominal computed tomography [45]. Recent studies have reported an association between high VAI and insulin resistance and subclinical atherosclerosis [67]. Another conceptually simple phenotype that could reflect one's cardiometabolic risk is the hypertriglyceridemic waist (HTGW) phenotype, which is simply defined by high TG and a large WC [8]. Recent studies have suggested that individuals with the HTGW phenotype have a high risk for subclinical atherosclerosis and are also at risk for the development of diabetes [910].

In the study by Janghorbani et al. [11], the authors reported an association of high VAI and the HTGW phenotype with incident hypertension (HTN) in a 7-year follow-up study of 1,375 first-degree non-diabetic and non-hypertensive relatives of patients with type 2 diabetes. The authors found that compared with those in the lowest VAI quintile at baseline, those in the highest baseline VAI quintile showed a 1.7-fold increased risk of incident HTN. Furthermore, those with the HTGW phenotype showed a 2.3-fold increased risk of incident HTN compared to those with a normal TG level and normal WC. This is a very interesting study in a well-characterized study population at high risk for diabetes development. The study was elegantly designed and well-performed, using appropriate analytic methods.

I have some suggestions and comments about this study. The first question is whether the authors considered the development of diabetes or other cardiovascular end-points in this study population. Previous studies have reported a high risk of diabetes development in subjects with the HTGW phenotype and a high risk of coronary artery calcification in subjects with a high baseline VAI [9]. Therefore, I wonder if similar results would be observed in this study population. Second, I wonder if the authors thought of analyzing whether metabolically healthy obese (MHO) subjects were present in this study population [12]. The debate about the existence of MHO individuals in various ethnic populations continues [13]. It would be interesting if the authors analyzed the level of risk that MHO subjects had for developing diabetes or HTN, since this study population is at a high risk for diabetes. Lastly, I think the authors should interpret the results with caution, since this study population is already at a high risk for metabolic derangement and diabetes.

I want to congratulate the authors on this beautiful work and expect to see in the future many excellent studies emerging from this well-structured Iranian cohort.