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Background  Diversity in the reported prevalence of metabolically healthy obesity (MHO), suggests that modifiable factors may be at play. We evaluated differences in dietary patterns and physical activity between MHO and metabolically unhealthy obesity (MUO).    Methods  Cross-sectional data of 9270 obese individuals (30–69 years) of the Lifelines Cohort Study was used. MHO was defined as obesity and no metabolic syndrome risk factors and no cardiovascular disease history. MUO was defined as obesity and ≥2 metabolic syndrome risk factors. Sex-specific associations of dietary patterns (identified by principal component analysis) and physical activity with MHO were assessed by multivariable logistic regression (reference group: MUO). Analyses were adjusted for multiple covariates.    Results  Among 3442 men and 5828 women, 10.2% and 24.4% had MHO and 56.9% and 35.3% MUO, respectively. We generated four obesity-specific dietary patterns. Two were related to MHO, and in women only. In the highest quartile (Q) of  ‘bread, potatoes and sweet snacks’  pattern, odds ratio (OR) (95% CI) for MHO was 0.52 (0.39–0.70). For the healthier pattern  ‘fruit, vegetables and fish’ , an OR of 1.36 (1.09–1.71) in Q3 and 1.55 (1.21–1.97) in Q4 was found for MHO. For physical activity, there was a positive association between moderate physical activity and vigorous physical activity in the highest tertile and MHO in women and men, respectively (OR 1.19 (1.01–1.41) and OR 2.02 (1.50–2.71)).    Conclusion  The healthier diet -characterized by  ‘fruit, vegetables and fish’ - and moderate physical activity in women, and vigorous physical activity in men may be related to MHO. The (refined) carbohydrate-rich  ‘bread, potatoes and sweet snacks’  dietary pattern was found to counteract MHO in women.    Electronic supplementary material  The online version of this article (10.1186/s12937-018-0319-0) contains supplementary material, which is available to authorized users.

Dietary patterns and physical activity in the metabolically (un)healthy obese: the Dutch Lifelines cohort study