**2.5 Characterization of metabolic profiles**

Although obesity, particularly visceral adiposity, is typically associated with metabolic dysfunction and cardiometabolic diseases, there are some obesity

**Figure 3.** *Obesity-related health risks and comorbidities [7, 24, 26].*

phenotypes that appear protected from some of the adverse metabolic effects of excess body fat [28]. Disease risk may not be uniform across all obese phenotypes.

The classification of an individual as "metabolically healthy" is not clearly defined, with 5 to more than 30 definitions documented across studies [28, 29]. In 2009, a harmonized definition for metabolic syndrome (MetS) was derived by The International Diabetes Federation Task Force on Epidemiology and Prevention, the National Heart, Lung, and Blood Institute, American Heart Association, World Heart Federation, International Atherosclerosis Society, and the International Association for the Study of Obesity [30]. According to this definition, participants who met ≥3 of the 5 abnormal criteria, excluding WC, were classified as having MetS and thus metabolically unhealthy and obese (MUO). These five components include high fasting blood glucose, high systolic and diastolic BP, elevated plasma triglyceride levels, low high-density lipoprotein cholesterol levels, and obesity (particularly central adiposity) [28, 30]. Obese participants who met 0, 1, or 2 of these criteria were classified as metabolically healthy but obese (MHO) [28, 31].

A classification of MHO should not be mistaken for metabolically unhealthy normal weight (MUN). These individuals are not phenotypically obese but share a metabolic profile similar to an overt obese person, including hyperinsulinemia, insulin resistance, and a predisposition to type 2 diabetes and premature CVD [32]. Studies suggest that MHO is a transient state and only a precursor to MUO [25, 33]. Data from longitudinal studies suggest that approximately 30% to nearly half of people with MHO transition back to MUO after 4 to 20 years of follow-up [28]. Indeed, in the absence of regular, systematic, and supervised diet and exercise programs, obese individuals with MHO profiles experience subsequent declines in cardiometabolic health [34].

Differences in metabolic profiles of those with MHO versus MUO could be due to phenotypic characteristics that lower risk of MetS, such as lower visceral adiposity, higher birth weight, adipose cell size characteristics, and genetic markers of adipose cells [35]. Alternatively, differentiation of these metabolic profiles has been attributed to variations in physical activity and cardiorespiratory fitness levels [28, 31], diet (e.g., lower intake of sugar, sugar-sweetened beverages, and saturated fat in MHO than MUO), and lower adiponectin concentrations in MUO than MHO [28].

Recent studies have suggested that MHO profiles may not indicate a lower risk for mortality, particularly when compared to metabolically healthy normal weight [33], and lifestyle interventions (e.g., weight management and physical activity) should continue to be recommended to reduce total mortality in all obese individuals [35].

#### **2.6 Other considerations of obesity**

Obesity has a profound impact on the cost of health care. Direct costs refer to money consumed to treat obesity-related health problems such as hospitalization, medical consultations in outpatient clinics, and obesity-related medications [36]. Obesity is associated with increases in annual health-care costs of 36% and medication costs of 77% compared with being of normal weight [37]. In 2014, a pooled estimate of annual medical costs attributable to obesity was \$1901 in USD (ranging from \$1239–\$2582), accounting for approximately \$150 billion nationally, with variations in costs primarily driven by age and severity of obesity-related comorbid condition [6].

There are long-term negative economic consequences and indirect costs of obesity. Indirect costs refer to lost productivity or costs to the economy outside of the health sector. Childhood obesity is associated with truancy from school, even after controlling for key covariates [37]. According to the National Longitudinal Survey on Youth 1979 data, higher BMI in late-teen years was associated with 3.5% lower hourly wages for men and women [38]. Obese adolescents were also more likely to

**83**

*Obesity Acceptance: Body Positivity and Clinical Risk Factors*

be the victim of bullying (e.g., name-calling, teasing, physical abuse) and isolation during adolescence [37], which can result in an economic cost associated with (untreated) mental and behavioral health. If obesity could be addressed in early life by reducing the number overweight and obese 16 and 17-year-olds by 1%, then the number of adults with obesity would reduce by 52,812, and lifetime medical costs

Obesity is also a matter of national security. The impact of obesity on the U.S. military has largely been unreported [39]. Since 2002, there has been a 61% rise among active duty forces, with obesity-related healthcare spending and costs to replace personnel unfit to serve exceeding \$1.5 billion USD [39]. The military is facing significant recruiting challenges, with nearly 25% of young adults and over 70% of citizens in most states ineligible to serve due to higher BMI [39]. Other obesity-related issues faced by the military include lost work among those in active duty totaling 656,000 days, violent intentions and behavior, food demand and insecurity, impaired responses to infectious diseases, and vulnerability to injury

Currently, there are no accepted standards for what constitutes a health-related threat to national security. Focusing only on the harms of obesity to the wellbeing of the population at large, not just to individuals with obesity, carries with it a risk of perpetuating weight stigmatization [40]. However, framing obesity as a national security threat has significant public health importance, provided importance is placed on gathering quantitative and qualitative data that characterizes the threat, and correlation and causation relationships are properly differentiated [40].

Over the last 40 years, the decline in mortality from CVD in the U.S. has been a public health success story. In the U.S., coronary heart disease as a leading cause of death has fallen 60% from its peak in the mid-1960s, with similar declines observed in nearly all regions of the world, especially in high-income countries [41]. However, if we place a narrower focus on racial/ethnic subgroups, or select populations from developing countries, we find that progress has not been equally shared [41, 42]. The sharp decline in mortality rates has been fueled by swift progress in prevention and treatment efforts. These efforts include rapid declines in cigarette smoking, improved methods for treating and controlling HTN, the use of statins to lower circulating cholesterol levels, and limiting or preventing infarction through the use of sophisticated methods [43]. Other factors have resulted in decreases in the rate of CVD despite increases in BMI, such as improved treatment or changes in other risks [26]. Clinical interventions have also proven effective in treating and controlling major risk factors of CVD, such as high systolic BP, cholesterol, and fasting plasma

The medical profession and social constructionists profess different concepts of illness. The medical model approaches disease as a biological condition, universal and unchanging, independent of time or place; in contrast, social constructionists

define illness as the social and cultural meaning of that condition [44].

*DOI: http://dx.doi.org/10.5772/intechopen.93540*

would decrease by \$586 million [37].

**3. Cardiometabolic research**

and death [40].

**3.1 Strides**

glucose [26].

**3.2 Setbacks**

*3.2.1 Medicalizing obesity*

#### *Obesity Acceptance: Body Positivity and Clinical Risk Factors DOI: http://dx.doi.org/10.5772/intechopen.93540*

be the victim of bullying (e.g., name-calling, teasing, physical abuse) and isolation during adolescence [37], which can result in an economic cost associated with (untreated) mental and behavioral health. If obesity could be addressed in early life by reducing the number overweight and obese 16 and 17-year-olds by 1%, then the number of adults with obesity would reduce by 52,812, and lifetime medical costs would decrease by \$586 million [37].

Obesity is also a matter of national security. The impact of obesity on the U.S. military has largely been unreported [39]. Since 2002, there has been a 61% rise among active duty forces, with obesity-related healthcare spending and costs to replace personnel unfit to serve exceeding \$1.5 billion USD [39]. The military is facing significant recruiting challenges, with nearly 25% of young adults and over 70% of citizens in most states ineligible to serve due to higher BMI [39]. Other obesity-related issues faced by the military include lost work among those in active duty totaling 656,000 days, violent intentions and behavior, food demand and insecurity, impaired responses to infectious diseases, and vulnerability to injury and death [40].

Currently, there are no accepted standards for what constitutes a health-related threat to national security. Focusing only on the harms of obesity to the wellbeing of the population at large, not just to individuals with obesity, carries with it a risk of perpetuating weight stigmatization [40]. However, framing obesity as a national security threat has significant public health importance, provided importance is placed on gathering quantitative and qualitative data that characterizes the threat, and correlation and causation relationships are properly differentiated [40].
