Background Insulin resistance (IR) plays an important role in the progression of hypertension (HTN); therefore, early identification of IR is clinically important for preventing HTN. Our study aims to explore the relationship between the metabolic score for IR (METS-IR) and HTN in Chinese population who maintained non-overweight. Methods A total of 4678 adults who underwent annual health check-up in our institution from 2010 to 2017, did not have HTN at the first check-up and maintained non-overweight at follow-up were selected as subjects. The baseline METS-IR was calculated and the outcome was incident HTN. Cox proportional hazards regression models were used to evaluate hazards ratios of HTN for METS-IR. Additionally, sensitive analyses and stratification analyses were used to deeply verify the relationship of METS-IR with HTN. The dose–response association between METS-IR and HTN risk was investigated using restricted the cubic spline analysis fitted for the Cox proportional hazards model. Results Compared with the first quartiles of METS-IR, the risk of incident HTN was increased by 58% [hazard ratio (HR) 1.58, 95% confidence interval (CI) 1.12–2.22] and 96% (HR 1.96, 95% CI 1.40–2.76) in the Q3 group and the Q4 group, respectively. The results remained consistent when analyses were restricted to people without abnormal high-density lipoprotein cholesterol, triglyceride or fasting plasma glucose level at baseline. A linear dose–response relationship between METS-IR and HTN risk was identified (HR 1.08, 95% CI 1.04–1.12). Conclusions The risk of incident HTN was associated with elevated METS-IR levels in non-overweight individuals. METS-IR could help predict the risk of HTN in non-overweight individuals.

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