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Highlights • Not all individuals with prediabetes, T2D and/or MetS develop significant ASCVD. • Discordantly normal ApoB relative to high LDL-C may help explain such heterogeneity. • 51% of persons with metabolic disorders and high LDL-C had discordantly normal ApoB. • Lower ApoB associated with long-term absence of carotid plaque, while LDL-C did not. • Measurement of ApoB may be useful in young persons with metabolic disease., Objective A significant proportion of persons with metabolic syndrome (MetS), prediabetes, or type 2 diabetes (T2D) do not develop atherosclerotic cardiovascular disease (ASCVD). We sought to determine whether discordantly normal apolipoprotein B (ApoB) relative to elevated LDL-C may help to explain heterogeneity in ASCVD risk among persons with metabolic disorders. Methods There were 278 Bogalusa Heart Study participants with MetS (n=95), prediabetes (n=233), or T2D (n=31) and LDL-C ≥100 mg/dL who were free of carotid plaque at baseline (2001-02) and underwent carotid ultrasound at follow-up (2013-16). Multivariable modified Poisson regression estimated the long-term absence of carotid plaque for lower ApoB, continuously and categorically. Results Participants were on average 36.1 years old at baseline, 61.5% were women, and 31.7% were black. A total of 50.7% had discordantly normal ApoB (, Graphical abstract Image, graphical abstract