Obesity has traditionally been linked with diabetes, high blood pressure, fatty liver disease and cardiovascular illness. Yet clinical practice presents a group of patients who appear to challenge this understanding. They have obesity based on body mass index, but their blood sugar, cholesterol and blood pressure remain within the normal range. This group is commonly described as having metabolically healthy obesity.

The question is whether this represents a genuinely low risk form of obesity or simply an early stage before metabolic disease appears.

The answer matters because obesity is increasing across India. The National Family Health Survey round 5 (2019-21) estimates that nearly one in every four Indian men or women is overweight or obese, with rates ranging from 8 percent to 50 percent across States and across both rural and urban populations. As the number of people living with obesity rises, so does the number who appear healthy during routine health examinations.

Looking Beyond Body Weight

Body mass index remains a useful screening tool, but it cannot distinguish between fat and muscle or identify where fat is stored. Two people with the same BMI may have very different metabolic profiles.

The location of body fat is often more informative than the amount of body fat. Fat stored around the liver, pancreas and abdominal organs behaves differently from fat stored under the skin. Visceral fat releases inflammatory substances, alters insulin sensitivity and contributes to metabolic disease. Subcutaneous fat has a much smaller effect on these processes.

This is especially true in the case of India. A nationwide study by the Indian Council of Medical Research published in The Lancet Diabetes and Endocrinology in 2023 estimated that one in every three Indian adults above 20 years of age, about 35 crore people, has abdominal obesity, while one in every four has generalised obesity. These findings suggest that fat distribution deserves as much attention as body weight.

A Healthy Report Today Does Not Predict Tomorrow

Some individuals with obesity have normal laboratory reports for several years. Their blood sugar remains controlled, blood pressure is normal and cholesterol levels are acceptable. This has led to the term metabolically healthy obesity.

However, long-term follow-up studies show that this state is often temporary. Many individuals who are metabolically healthy at one stage develop insulin resistance, fatty liver disease or cardiovascular risk factors later. Ageing, declining muscle mass, reduced physical activity and changes in diet all influence this transition.

For this reason, metabolic health should be viewed as a dynamic condition rather than a permanent label. A normal report today does not eliminate future risk.

Lifestyle Has a Strong Influence

Diet quality, physical activity and muscle mass largely determine whether metabolic health is maintained.

India has moved from calorie deficiency to calorie sufficiency, but this has not translated into better nutrition. According to the State of Food Security and Nutrition in the World Report (2024), nearly 78 crore people, or about 55 percent of India's population, cannot afford a healthy diet, while almost 40 percent do not get an adequate nutrient rich diet. Diets based on refined carbohydrates and ultra processed foods provide energy but do not help maintain metabolic health.

Physical activity is an issue too. The World Health Organisation estimates that 50 per cent of Indians do not meet recommended levels of physical activity. Reduced movement over time leads to reduced muscle mass, which slows down glucose utilisation. Even when body weight remains stable, metabolic risk begins to rise.

This helps explain why some people continue to appear metabolically healthy for years, while others develop diabetes or hypertension much earlier despite having a similar BMI.

Childhood Patterns Continue into Adult Life

Metabolic health is also shaped during childhood. India now has more than 14.4 million children living with obesity, the second highest number globally according to the GBD Obesity Collaborators published in the New England Journal of Medicine (2017). Childhood diets high in processed foods and low levels of physical activity influence insulin sensitivity and fat distribution well before adulthood.

These early changes affect future metabolic health. Adults who appear healthy despite obesity may already have biological changes that are not yet visible through routine testing.

The Need for Better Assessment

Managing obesity requires more than measuring height and weight. Waist circumference, waist to height ratio, fasting blood sugar, lipid profile and liver function tests provide a better picture of metabolic health. In some patients, imaging studies that estimate visceral fat offer additional information, particularly when there is a strong family history of diabetes or cardiovascular disease.

Regular monitoring is equally important. A person classified as metabolically healthy today may show significant changes a few years later. Periodic assessment allows these changes to be identified before complications develop.

A Label That Requires Caution

The term metabolically healthy obesity can be misleading if it creates the impression that obesity carries little risk. Current evidence does not support that conclusion.

Some individuals with obesity maintain normal metabolic markers for a period of time. That observation is clinically valid. At the same time, obesity remains associated with higher long-term risks, particularly when abdominal fat increases or physical activity declines.

The focus therefore should not be on deciding whether metabolically healthy obesity is real or a myth. The more relevant question is how long metabolic health can be maintained and what can be done to preserve it.

Routine screening, attention to waist circumference, preservation of muscle mass, regular physical activity and better diet quality remain the most reliable strategies. These measures benefit those with obesity regardless of whether current laboratory values appear normal.

Obesity should not be assessed by appearance alone, nor should a normal blood report be interpreted as permanent reassurance. Metabolic health changes over time, and clinical decisions should reflect that reality rather than a single snapshot.

(By Dr. Ashish Gautam, Principal Director, Robotic and Laparoscopic Surgery, Max Super Speciality Hospital, Patparganj, New Delhi)



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