Craniopharyngiomas (CP) are benign tumors in the sellar region with an aggressive local behavior. CP patients with have an adverse metabolic profile due to hypothalamic damage and pituitary deficiencies. Obesity is an important feature of the metabolic syndrome (MetS). In earlier research, the prevalence of MetS was 46% in CP patients, which is significantly higher than for the general population (15% in the Swedish and 26% in Dutch population). However, in this research, increased BMI was used as a as definition for obesity. BMI does not take body composition into account. BMI misclassifies more than 50% of childhood cancer survivors as normal, while DXA observes an increased body fat percentage (BF%) (Blijdorp 2012). Our hypothesis is that MetS (as before defined by IDFTFEP and others (Alberti 2009; Wijnen 2017) and adiposity is underestimated in our cohort of 95 CP patients by simply using BMI. In the present retrospective cross-sectional study, the MetS criterion obesity was defined based on BMI (A) and DXA-measured BF% (B) and fat mass index (FMI) (C) at first DXA-scan (FD) and last DXA-scan (LD). MetS was higher compared to the general population in all definitions (at LD respectively A 47% vs. 22%; P<0.05, B 46% vs. 20%, P<0.05, C 54% vs. 19%, P<0.05). A Cohen’s kappa measurement of agreement was set out with MetS and obesity. For MetS, an almost perfect agreement was found if increased BMI was compared with either increased BF% (Kappa 0.82-0.88, P<0.001) or FMI (Kappa 0.85-0.88, P<0.001). For obesity, agreement is fair (Kappa 0.37, P=0.002 at LD) to moderate (Kappa 0.53, P<0.001 at FD) if BMI is compared BF%. Occurrence of MetS was significantly lower when measured with FMI compared to BMI at FD (40% vs. 43%, P<0.001), but higher at LD (45% vs. 40%, P<0.001) and higher when BF% is compared to BMI (51% vs. 45%, P<0.001 at FD, 47% vs. 40%, P<0.001 at LD). In conclusion, CP patients are at risk for the MetS. Although occurrence of the MetS is even higher if estimated with BF% by DXA-scan, agreement when defined with BMI is good.