Body Size, Cardiometabolic Risk, and Educational Disparities in Mortality Among U.S. Adults, 1988-2019

Obesity remains a focal issue in population health, yet recent evidence finds many adults with obesity have favorable cardiometabolic health, sometimes better than their ‘healthy’ weight counterparts. While biomedical research frames this a function of random biological differences in the population, the co-occurrence of obesity with other morbidities is influenced by social factors, such as individuals’ socioeconomic status and the many resources it affords in mitigating the more harmful consequences of a high body weight. Consequently, this study examines profiles of body size and cardiometabolic health among U.S. adults, assessed using ten clinically-measured and self-reported indicators spanning obesity, hypertension, dyslipidemia, and hyperglycemia, and how they explain the educational gradient in mortality. Using latent class analysis and National Health and Nutrition Examination Survey data linked with mortality records (1988-2019; N=40,377 adults; 7,502 deaths), I identify six cardiometabolic health profiles that vary in their association with mortality and are unequally distributed based on individuals’ educational attainment. These differences in latent classes explain 8-14% of educational disparities in all-cause mortality, though mediation is as large as 30-40% for causes of death more closely associated with cardiometabolic health. Critically, this study shows how situating obesity among other indicators of cardiometabolic health helps avoid an overly narrow view of obesity as a population health risk, especially in explaining socioeconomic gradients in mortality. • Six metabolic phenotypes identified using comprehensive health indicators. • Classes mediate 8-14% all-cause mortality, but up to ∼40% for other causes. • Healthy obesity phenotype shows no independent all-cause survival disadvantage. • Educational gaps largest for diabetic and hypertensive phenotypes. • Results challenge obesity-centric explanations of health inequalities.