TNF and endothelial dysfunction: Similarly, expanded and dysfunctional adipose tissue, particularly visceral fat, is a potent source of pro-inflammatory cytokines (e.g., IL-6, TNF-α) and adipokines (e.g., leptin) that can drive both neutrophilia and lymphopenia, thus elevating NLR, while also promoting endothelial dysfunction and vascular remodeling through direct mechanisms [45,46].