Background <p>Pericardial fat tissue has been proposed as an independent risk factor for cardiovascular disease. Given the limitations of imaging-based quantification in clinical practice, surrogate indices have been proposed as practical tools for estimating ectopic fat accumulation.</p> Objective <p>This study aimed to evaluate the factors associated with increased pericardial fat, estimated using the Dysfunctional Adiposity Index (DAI), a surrogate marker previously proposed for this purpose, in patients with type 2 diabetes without cardiovascular disease.</p> Methods <p>This retrospective cross-sectional study included patients with type 2 diabetes. The DAI was used as a surrogate marker to estimate pericardial fat volume. Binary logistic regression analysis was used to identify independent factors associated with increased pericardial fat.</p> Results <p>A total of 1479 patients with type 2 diabetes were included in the study. Of them, 67.5% had increased pericardial fat volume. The mean age of the subjects was 58.96 ± 14.39&#xa0;years, with a mean body mass index of 28.44 ± 6.11&#xa0;kg/m², a mean HbA1c of 7.74 ± 2.06%, and a median microalbuminuria of 11.06 (2.78–52.82) mg/24&#xa0;h. After multiple logistic regressions, a longer duration of type 2 diabetes, metformin use, higher fasting glucose, microalbuminuria, and LDL-C were positively associated with increased pericardial fat volume. In contrast, male sex and fibrate use were inversely associated.</p> Conclusion <p>A longer duration of type 2 diabetes, metformin use, higher fasting glucose, microalbuminuria, and LDL-C are associated with higher surrogate-estimated pericardial fat. These findings suggest that the DAI may provide insights into ectopic fat accumulation; however, further studies are needed before considering it a reliable non-invasive surrogate marker.</p>