Abstract: Aim: This study aimed to examine the influence of central obesity on the clustering patterns of adverse levels of metabolic syndrome (MetS) risk variables among adults with normal weight in a low-income rural Chinese cohort. Subject and methods: The study cohort consisted of 1,821 adults, aged 35–74 years. Central obesity was defined as a waist to height ratio ≥ 0.5 among adults with normal weight (body mass index = 18.5–24.9). MetS risk variables included blood pressure (BP), fasting triglycerides and glucose, and high-density lipoprotein cholesterol (HDL-C). Results: Centrally obese subjects had significantly higher levels of all the MetS risk variables than those without central obesity. The central obesity group had a higher prevalence of MetS (clustering of three or more variables) than the control group (13.9 vs 5.8%, p < 0.001). Importantly, the cluster of high triglycerides, low HDL-C, and high BP showed the greatest difference (p < 0.001) between the two groups. In multivariable logistic regression analyses, adjusting for age, sex, smoking, and alcohol drinking, the centrally obese group vs the control group was 2.25 times more likely to have MetS (p < 0.01). Among the four types of three variable clusterings, central obesity was significantly associated with the cluster of high triglycerides, low HDL-C, and high BP (odds ratio = 3.51, p < 0.01). Conclusion: These findings indicate that the central obesity detected by the waist to height ratio plays a pivotal role in the clustering of MetS risk variables among normal-weight Chinese adults, suggesting the importance of prevention of MetS by reducing central obesity in a population with a lower prevalence of obesity.