OBJECTIVETo determine the prevalence of metabolically healthy obesity (MHO) in children and examine the demographic, adiposity, and lifestyle predictors of MHO status. RESEARCH DESIGN AND METHODSThis cross-sectional study included 8-17 year olds with a BMI ‡85th percentile who were enrolled in a multidisciplinary pediatric weight management clinic from 2005-2010. Demographic, anthropometric, lifestyle, and cardiometabolic data were retrieved by retrospective medical record review. Participants were dichotomized as either MHO or metabolically unhealthy obese (MUO) according to two separate classification systems based on: 1) insulin resistance (IR) and 2) cardiometabolic risk (CR) factors (blood pressure, serum lipids, and glucose). Multivariable logistic regression was used to determine predictors of MHO using odds ratios (ORs) with 95% CIs. RESULTSThe prevalence of MHO-IR was 31.5% (n = 57 of 181) and MHO-CR was 21.5% (n = 39 of 181). Waist circumference (OR 0.33 [95% CI 0.18-0.59]; P = 0.0002) and dietary fat intake (OR 0.56 [95% CI 0.31-0.95]; P = 0.04) were independent predictors of MHO-IR; moderate-to-vigorous physical activity (OR 1.80 [95% CI 1.24-2.62]; P = 0.002) was the strongest independent predictor of MHO-CR. CONCLUSIONSUp to one in three children with obesity can be classified as MHO. Depending on the definition, adiposity and lifestyle behaviors both play important roles in predicting MHO status. These findings can inform for whom health services for managing pediatric obesity should be prioritized, especially in circumstances when boys and girls present with CR factors.In Canada, numerous multidisciplinary clinics offer weight management care for children with obesity (1), most of which are affiliated with children's hospitals. The supply of these services is exceeded by the potential demand since there are .2 million young Canadians (2,3) who are either overweight or obese and eligible to receive health services in these clinics. Because of the demand for weight management care, in circumstances when services are limited or difficult to access, there is a need to prioritize service delivery in these specialized centers for those individuals who are at greatest cardiometabolic health risk. By distinguishing individuals with obesity based on their relative health risks, those at lower health risk can be guided to less intensive services (e.g., self-management resources or outpatient dietitian counseling), whereas their peers at higher health risk can be directed to more intensive services (e.g., multidisciplinary obesity management or bariatric surgery). The heterogeneous