In craniopharyngioma patients, an important clinical feature is an adverse metabolic profile due to hypothalamic damage and pituitary deficiencies. Previously, we showed that the frequency of the metabolic syndrome (MetS) in craniopharyngioma patients was 46% (as compared to 15% in the Swedish and 26% in Dutch population). In this research, high body mass index (BMI>30kg/m2 was used as a as definition for obesity, which does not take body composition into account. Our hypothesis is that MetS (according to the adjusted Joint Interim Statement (Alberti 2009; Wijnen 2017)) and adiposity are underestimated in our cohort of craniopharyngioma patients if evaluated with BMI (Wijnen 2017). To examine this, we performed a cross-sectional study including 95 patients. We defined the MetS component obesity with high BMI (>30kg/m2), high body fat percentage (BF%) and high fat mass index (FMI) (depending on age and sex) at the moment of DXA-scan and compared the frequencies. In our study, 34-53 craniopharyngioma patients had metabolic syndrome at last DXA-scan (45-51%) depending on the definition of obesity, which was in any case higher than in the general population (P<0.05). Occurrence of MetS was higher if obesity was measured by BF% (52% vs. 42%, P=0.031) or FMI (51% vs. 43%, P=0.063) compared to BMI at last DXA-scan. Obesity occurred in 57% as assessed with BMI vs. 70% with BF% (P=0.031) and 59% with FMI (P=1.00). For MetS, an almost perfect agreement was found if increased BMI was used or either increased BF% (Cohen’s Kappa 0.82-0.90, P<0.001) or FMI (Cohen’s Kappa 0.85-0.88, P<0.001). Agreement between the measures of obesity is fair (Kappa 0.37, P=0.002 at last DXA-scan) if high BMI is compared with high BF%. In conclusion, craniopharyngioma patients are at risk for the MetS and obesity. DXA-scan could contribute in evaluation of obesity, but the metabolic phenotype is so extreme that the contribution in identification or confirmation of MetS seems limited.