Background <p>Metabolic abnormalities, such as diabetes mellitus, hypertension, dyslipidemia, and central obesity, are significant contributors to the global burden of non-communicable diseases. Tuberculosis (TB) patients may be at increased risk of these conditions due to chronic inflammation, nutritional depletion, and anti-TB drug effects; however, locally grounded comparative evidence from resource-limited settings such as northwest Ethiopia remains scarce. This study aimed to assess the prevalence and determinants of metabolic abnormalities among TB patients in Gondar Town, Ethiopia.</p> Methods <p>An Institution -based comparative cross-sectional study was conducted from March to May 2024 at three health institutions in Gondar Town. A total of 260 participants 130 confirmed TB patients and 130 individually age- and sex-matched TB-negative controls confirmed by sputum smear microscopy were enrolled using simple random sampling with proportional allocation across facilities. Study Participants data were collected through structured questionnaire, anthropometric and clinical examinations, and laboratory analysis. Normality of continuous variables was assessed using the Kolmogorov-Smirnov test, and supported by histograms and Q-Q plots. Independent t-test and one-way ANOVA with Bonferroni post-hoc test was used for continuous variable comparisons across TB-positive with HIV, TB-positive without HIV, and TB-negative control groups. Chi-square and Fisher’s exact tests were used for categorical between-group comparisons Logistic regression analysis was performed on the pooled sample, to identify independent determinants of metabolic abnormalities; statistical significance was set at <i>p</i> &lt; 0.05 in multivariable analysis.</p> Results <p>The overall prevalence of metabolic abnormalities was higher among TB patients compared to TB-negative controls. Nearly half of the TB patients 48.46% (95% CI 39.92–57.08) had at least one metabolic abnormality compared to TB-negative controls 43.85% (95% CI 35.50–52.54). Among TB patients, the prevalence of diabetes mellitus, hypertension, dyslipidemia, and central obesity were 18.46% (95% CI 12.62–26.14), 6.92% (95% CI 3.62–12.83), 29.23% (95% CI 22.00–37.68), and 6.15% (95% CI 3.00–11.88), respectively. In contrast, the magnitudes were 10.00% (95% CI 5.86–16.53), 3.85% (1.59–8.96), 20.00% (13.94–27.83), and 9.23% (95% CI 5.29–15.61) among TB-negative controls. On multivariable logistic regression analysis, advanced age, sex, alcohol drinking habit were the predictor variables significantly associated (<i>p</i> &lt; 0.05) with metabolic abnormalities among study participants.</p> Conclusion and recommendation <p>This study provides the first institution-based comparative estimate of metabolic abnormality burden among TB patients in Gondar Town, northwest Ethiopia. The overall prevalence of composite metabolic abnormality was 48.46% among TB patients and 43.85% among controls a difference that did not reach statistical significance (<i>p</i> = 0.455). Similarly, between-group differences in the categorical prevalence of individual conditions including hypertension, hyperglycemia, overall dyslipidemia, and central obesity did not reach statistical significance. However, TB patients exhibited statistically significant differences in key continuous biochemical parameters compared to controls including significantly higher mean triglycerides, LDL-cholesterol, and fasting blood glucose, and significantly lower mean HDL-cholesterol and BMI. Patients aged 45 years and above, female patients, and heavy alcohol consumers represent high-risk subgroups who should be prioritized for targeted metabolic screening. These findings provide locally grounded evidence to support the integration of lipid profile and fasting blood glucose testing into routine TB treatment follow-up within the Ethiopian national TB program, particularly at referral-level facilities in northwest Ethiopia.</p> Clinical trial number <p>Not applicable.</p>