Most prominent difference between African-American and white respondents in perceptions and attitudes about ADHD
\r\n\tWith the discovery of more unconventional heavier crude and alternative hydrocarbon sources, primary upgrading or cracking of the oil into lighter liquid fuel is critical. With increasing concern for environmental sustainability, the regulations on fuel specifications are becoming more stringent. Processing and treating crude oil into a cleaner oil with better quality is equally important. Hence, there has been a relentless and continuous effort to develop new crude upgrading and treating technologies, such as various catalytic systems for more economical and better system performance, as well as cleaner and higher-quality oil.
\r\n\r\n\tThis edited book aims to provide the reader with an overview of the state-of-the-art technologies of crude oil downstream processing which include the primary and secondary upgrading or treating processes covering desulfurization, denitrogenation, demetallation, and evidence-based developments in this area.
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The Center for Disease Control and Prevention lists the African American males as leading other racial groups and gender in the diagnosis of learning and behavioral disorders, incarceration rates, new HIV infections, homicide and poverty. Although the reason for these observations are quite complex and multidimensional, some of the comorbidities found in untreated African Americans patients with ADHD include conduct disorder, oppositional defiant disorder, depression, anxiety disorders, learning disabilities, and alcohol or drug addiction. In addition, even though African American males living in poverty are most likely to be referred to mental health agencies for mental health services, they are the least likely to receive mental health services. In 2006, the number of children in the United States aged between 5 and 7 who were diagnosed with ADHD was 4.5 million. In the last decades the number of children diagnosed with ADHD who are on psychotropic medication continues to rise steadily. However, the impact of this steady rise has been skewed and not evenly distributed by ethnicity, socioeconomic status and gender as minorities (African Americans and Hispanics) are most often diagnosed or misdiagnosed. The incidence of ADHD appears to be similar in African-Americans and White populations. ADHD is diagnosed in 4.1% of all children with the greatest prevalence among Caucasian children (5.1%). However, when the prevalence of ADHD among male children are considered by race, African American children and adolescents are disproportionately diagnosed with ADHD, with an estimated prevalence rate of 5.65%, 4.3% for Hispanics, 3% for Whites; and 1.77% for females of all races. The prevalence of ADHD in African-Americans is most likely similar to that in the general population (3-5%); nevertheless, minority children have lower likelihood of receiving a diagnosis of ADHD and of receiving any treatment. Reasons for this disparity are multifaceted and diverse and have not been fully elucidated. Among some of the identifiable barriers that attempt to explain these disparities are family-driven (parent, patient, and family) and Policy-driven (healthcare system and physician bias) obstacles.
The primary goals of treatment of ADHD are to decrease disruptive behaviors, enhance academic performance, improve interpersonal relationships with peers, family and friends, improve self-esteem, and promote independence. There are difficulties inherent in the diagnosis of ADHD. These include absence of specific diagnostic tests, the lack of specificity of symptoms, inability to observe symptoms that may not be present in an office setting, low rate of concordance in symptom-reporting among various informants (i.e. parents, teachers and parents) and a lack of a standard evaluative process. Although medical professionals may use different diagnostic routes to diagnose ADHD, most agree that the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) is the basis for an appropriate diagnostic process. Others have suggested the use of multiple methods of assessment which are culturally-sensitive and, which involves several people with varying degrees of relationship to the child to be the most effective way to reduce the bias associated with diagnosis. Whaley & Geller observed that the use of informal interviews and methods of assessment seem to increase the bias towards more diagnosis of ADHD towards African Americans. In recent years, following extensive research in this subject by major medical organizations such as the American Academy of Pediatrics (AAP) and the American Academy of Child and Adolescent Psychiatry (AACAP), guidelines have been published to assist physicians in making the diagnosis of ADHD. Efforts must be made to identify these barriers of the diagnosis and treatment of ADHD, awareness among healthcare providers, and the African-American and other Minority communities. The objective of this chapter is to examine the disparities in the diagnosis and treatment of ADHD in the minority groups in America, especially the African-American community, the factors associated with disparities and the impacts of these disparities. The strategies and interventions to address the issue will also be outlined.
Perceptions of ADHD-related symptoms among parents of African American children appear to differ in important ways from those of parents of White children. African American families from low to middle class incomes, compared with Whites, tend to view behavioral and emotional difficulties as problems of and for families, institutions and communities rather than as constituting individual psychopathology. It is not uncommon for African-American parents to perceive many of the symptoms and behaviors associated with ADHD to be variants of normal behavior and not in need of professional intervention. When compared with parents from other ethnic backgrounds, many African-American parents are not well-informed about the symptoms and treatment of ADHD. Indeed, studies suggest that African-American parents may be even more uninformed about ADHD, its causes, diagnosis and treatment than are parents form other ethnic and racial backgrounds. Bussing and colleagues (1998) conducted a study that sought to identify the differences in ADHD knowledge between 224 African-American parents and 262 White parents. They reported that only 69% of African-American parents compared with 95% of White parents had ever heard about ADHD (p<0.01), and that 36% of African-Americans knew “a lot”, “some” or “a little” about ADHD, compared with 70% of White parents (p<0.01). In addition, as reported by African-American parents, only 18% of them received information about ADHD from their physician, compared with 29% of White parents (p<0.01). Equally important, the study found the effects of ethnicity on ADHD familiarity were independent of other covariates, such as socioeconomic status. Furthermore, the lack of knowledge about ADHD among the African-American community has been described as a “vicious cycle” that may be caused when members of this community seek medical advice from other individuals within their own ethnic background who are equally uninformed about ADHD.
ADHD in African-American children is associated with comorbid disruptive behavior; mood and anxiety disorders. However, African-American families may not attribute the symptoms of ADHD to the disorder itself and are less aware than White families about the etiology of ADHD. For example, sugar intake has been reported as a common explanation for the symptoms of ADHD among members of the African-America community. ADHD symptoms in African-Americans are frequently missed or incorrectly diagnosed and comorbid disorders go unattended. African-American parents feel more uneasy than White parents about treating their children with pharmacologic interventions. Dos and other investigators evaluated parental perceptions of stimulant medication for the treatment of ADHD; they demonstrated that significant numbers of non-whites parents (63%) than white parents (29%) thought that counseling was the best choice of treatment, whereas 59% of white parents of white parents preferred medication over counseling compared with 36% of non-white parents. In addition, 16% of non-whites compared with 5% of white parents believed that the use of stimulants would lead to drug abuse. School officials are more likely to assign African-American children to special education classes (which is the only educational resource employed to address many black children with ADHD), although many of the symptoms they display may be resolved with proper treatment that would allow them to remain in their regular classes. Between 1980 and 1990, black children were placed in special education at more than twice the rate of whites.
African-American parents (57%) are more likely to believe that their children’s race or ethnicity and fears of being “labeled” remain one of the important factors preventing acceptance of the diagnosis and treatment of children with ADHD. Many parents fear the perceived social stigma of ADHD diagnosis, and some fear overdiagnosis and misdiagnosis. The stigma of ADHD and lack of information about ADHD were found to be significant barriers to treatment of ADHD among African Americans [Table 1]. In their survey study, Omolara and colleagues (2007) found evidence of racial concerns about the stigma of ADHD diagnosis among African American participants. While some believe that a diagnosis of ADHD “gives children a label for the rest of their lives’, others viewed that medicalization as a form of social control with historical roots.
In addition, pressures from family and friends to refrain from seeking treatment, fear of jeopardizing future employment or ability to serve in the military, concerns that parental skills will be questioned, and fear of the unknown are other factors that have been described by patient and families and these are thought to impact the diagnosis and treatment of ADHD. The African-American population fear of the unknown may be related in part to the consequences of the Tuskegee Experiment, which caused many in the community to lose trust in the field of medical research. However, African American health professionals were even found to be less likely to diagnose ADHD or prescribe stimulant medication treatment due to their social and culturally constructed views of the disorder.
It has also been demonstrated from studies that a substantial proportion of children from all races who are at a high risk for ADHD drop out of care, and that adolescent perceived stigma about ADHD is influential, above and beyond the perspectives of parents.
\n\t\t\t\t | \n\t\t
Most prominent difference between African-American and white respondents in perceptions and attitudes about ADHD
A substantial number of obstacles to the successful diagnosis and successful treatment of ADHD overall are related to limitations in the diagnosis and treatment of ADHD in African-American patients. While some of these barriers are easier to remove, others may prove more difficult. Some of these barriers are race or ethnicity-related, while others may be attributable to limited access to healthcare or insurance coverage, low socioeconomic status of African-American patients and a dearth of culturally-competent mental healthcare providers. Bussing et al. (2003) found that African American children were less than half as likely to be assessed, diagnosed, and treated for ADHD as Caucasians. Their research survey among African American parents to determine common barriers to help seeking for their children with symptoms of ADHD found that across race, the most commonly cited barriers are system barriers, no perceived need and negative expectations of treatment outcomes.
It has been reported that during clinician-patient encounter, negative social stereotypes are known to shape behaviors and influence decisions made by healthcare providers. Race and ethnicity is known to adversely influence the medical care provided for other medical conditions. Minority patients with ADHD are likely to be affected by this practice as well. Historically, there has been a disproportionate pattern of diagnosis among minority populations in the category of disability. While some of this pattern of diagnosis may be related to minorities being disproportionately exposed to risk factors and psychosocial stressors and are more likely to be economically disadvantaged, the commonly used instruments of assessment which could provide misleading or invalid results when used alone to assess patients from various cultural backgrounds may explain the this phenomenon. Frequently, the quality of healthcare delivered is compromised when healthcare providers are culturally insensitive to patients. There are important cultural differences among individuals of diverse ethnic backgrounds pertaining to their attitudes and beliefs of illness, choice of care, access to care, and degree of trust toward authority figures or institutions and tolerances for certain behaviors. Investigators may have to use culturally sensitive diagnostic tools to assist them in uncovering important aspects about ADHD that may be unique to the African-American population.
Humans have the inclination to perceive or label other people or things based on their initial impressions or due to harboring elements of discrimination and stigma. Healthcare workers and physicians who care for mental health patients are not exonerated from this attribute. Eack and colleagues (2008) reported that African-Americans were three times more likely as whites to receive a diagnosis of schizophrenia based on the physician perception of the truthfulness, suspicion of symptom denial, poor insight or “uncooperativeness” of their African-American patients. Without a good understanding of cultural nuances that may provide clues about other possible diagnoses and the stigma associated with a diagnosis of mental illness among the Black community, white physicians may view black patients with suspicion which may color or affect their clinical judgment. Interestingly, the same study reported that this disparity did not appear to affect other US minority groups, such as Hispanics.
Conscious (Explicit) or unconscious (Implicit) bias or prejudices held by healthcare providers and sometimes racially-motivated discrimination by mental healthcare personnel can cause the cross-cultural diagnosis of ADHD to be challenging. In addition, biases expressed by the evaluators, interviewers or the researcher may influence the outcomes of scoring the behavioral expressions of African-American children. Depending on this held biases or cultural expectations of what constitutes “normal behaviors”, non-African American evaluators may rate American-American children with higher levels of hyperactive or disruptive behaviors even when the behavior is normal within the context of cultural expectations. It is not uncommon for parents and patients of ethnic minorities to report discrimination in receiving health care. Gingerich and colleagues (1998) reviewed several comparative studies in the 1970 which used teachers’ ratings to compare the prevalence of hyperactivity, a component of ADHD among ethnic minorities and white children. They reported one large study conducted using 1700 elementary school children from rural and urban Texan locations in which African-American children were rated as more hyperactive than expected based on their representative population when compared with schools located in white, middle-class neighborhoods where they found that the frequency of hyperactivity was consistent across all ethnic groups. The biases held by health care workers or mental health service providers can result in either under or over-diagnosis of ADHD in African-American children.
This factor may prevent the optimal care of Africa-American children with ADHD. More minority clinicians are needed to alleviate the intercultural issues of trust and communications that often arise. In 1985, out of the 30,000 Psychiatrists registered to practice in American, only about 600 were Black (Bell, Fayen & Mattox, 1998). In spite of the efforts and progress made in promoting diversity of healthcare professionals among the physician workforce, the concern about a lack of diversity continues to be an impediment to access and care, especially in the minority populations. Thus, despite some initial progress, African Americans, Latinos/Hispanics, and Native Americans continue to be underrepresented in the U.S. physician workforce. The American Medical Association Council on Medical Education Report 7 (2007) put the total number of US physicians involved in patient care in 2006 as 723,118. When categorized into Race/Ethnicity, 71.4% of these physicians were white, 15.8% were Asian, 6.4% were Hispanic, and 4.5% were Black/African-Americans. The American Medical Association report in 2012 puts the total number of Black physicians in the workforce at 3.5%, indicating a decline (Table 2). Complicating access to care, most of these physicians set up their practices in urban areas to the detriment of rural communities.
African-American families are less likely than their white counterparts to have access to the healthcare system. This may partly be due to the lower socioeconomic class and higher poverty levels among African-Americans. African-Americans tend to lack insurance coverage for psychiatric or psychological evaluations, behavior modification programs, school consultations, parent management training, and other specialized program. Substantial costs barriers exist resulting in out-of-pocket costs. Pastor and Reuben reported a significantly wide and long-standing gap in the rate of the diagnosis of ADHD based on the type of health insurance coverage. They reported that those with Medicaid insurance are most likely to be diagnosed with ADHD, followed by those with private insurance coverage, while those without insurance ended at a distant third. Even when they have insurance, the capitation imposed by the State Mental Health Services further makes access to care very difficult or inadequate, especially, for African Americans and other minority populations. Low income African American caregivers are often frustrated and feel helpless while trying to navigate the maze of the care system. There is no funded special education category specifically for ADHD. This limited access to healthcare system will contribute to less diagnosis of ADHD
\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t
White | \n\t\t\t519,840 | \n\t\t\t54.5 | \n\t\t
Black | \n\t\t\t33,781 | \n\t\t\t3.5 | \n\t\t
Hispanic | \n\t\t\t46,507 | \n\t\t\t4.9 | \n\t\t
Asian | \n\t\t\t116,412 | \n\t\t\t12.2 | \n\t\t
American Native/Alaska Native | \n\t\t\t1,594 | \n\t\t\t.16 | \n\t\t
Other | \n\t\t\t13,019 | \n\t\t\t1.3 | \n\t\t
Unknown | \n\t\t\t223,071 | \n\t\t\t23.4 | \n\t\t
Source: Physician Characteristics and Distribution in the US, 2010 Edition. American Medical Association.
Total physicians by race/ethnicity – 2008
(Total physicians = 954,224)
Comorbidities associated with ADHD include Conduct Disorders, Opposition Defiant Disorders (ODD), Depressive Disorders, Anxiety disorders, Learning disabilities and Alcohol and Drug addiction. Samuel and colleagues (1999) stated that African-American children with ADHD have higher levels of comorbid psychopathology (Opposition Defiant Disorder, Severe Major Depression, Bipolar Depression, and Separation Anxiety) than in African-American controls. They also reported that when compared to their Caucasian counterparts, African-American youths have a tendency to be more resistant or unable to seek treatment, only doing so when their symptoms are more severe. This may be responsible for a broader spectrum of the severity of ADHD symptoms in African-American youths. Epstein (2005) attributed the exhibition of more ADHD symptoms in African-American youths to fact that they are exposed to more ADHD-related risk factors. This concept was supported by Stein and colleagues (2002) who reported that African-American youth may be exposed to these risk factors at higher rates other than other youth, which may account for the higher prevalence of ADHD in African-Americans. In the general population, some of the risk factors associated with the development of ADHD and related pathology include low socioeconomic status (SES), juvenile detainee status, prenatal marijuana exposure and exposure to environmental toxins. Lead, one of the most thoroughly studied environmental toxins, is linked to impaired attention, hyperactivity, and aggression even at low levels of exposure. Bazargan and colleagues (2005) found that African-Americans living in Public Housing reportedly have higher incidence of ADHD than in the general population as a whole (19%) as compared to the pooled rate of 5%. The increased exposure resulted from paints used in housing before 1950s which contained a high percentage of lead. Other risk factors attributable to higher incidence of ADHD in African-Americans include low socioeconomic status, lack of access to healthcare (Kendall & Hatton, 2002) and high incidence of low birth weight (Breslau & Chilcoat, 2000). The higher incidence and symptomatology of ADHD in African-Americans has its consequences some of which will be further elucidated.
There appears to be an epidemic of incarceration, especially of African-American males in the United States of America. Compared to the rest of the industrialized world, America has the highest rate of incarceration, currently at about 738 per 100,000. The Justice Department reports that there are about 2.3 million inmates incarcerated in America. In 2010, Dick and Sharon Kyle, a pair of citizen journalists and information activists reported (www.LAProgressive.com) in an article titled “More Black Men in Prison than Were Enslaved II” that by race, Black males continued to be incarcerated at an extraordinary rate. They pointed out that Black males make up 35.4 percent of the jail and prison population, even though they make up less than 10 percent of the overall U.S population. They also observed that four percent of U.S. black males were in jail or prison in 2009, compared to 1.7 percent of Hispanic males and 0.7 percent of white males. This translated to black males being locked up at almost six times the rate of their white counterparts.
Black and colleagues (2010) reported that although Attention Deficit/Hyperactivity Disorder (ADHD) is associated with comorbid psychiatric diagnoses and antisocial behavior that contribute to criminality, yet studies of ADHD in offenders are few. Out of the 319 offenders they evaluated using the Mini International Neuropsychiatric Interview and Medical Outcome Health Survey; ADHD was present in 68 (21.3%) subjects. Offenders with ADHD were more likely to report problems with emotional and social functioning and to have a higher suicide risk scores. Other psychopathologies identified in offenders with ADHD include higher rates of mood, anxiety, psychotic and somatoform disorders. They are also more likely to have antisocial and borderline personality disorders. To reduce the impact of ADHD on the rate of incarceration of African-American youth, they recommended that Prison Administrators be trained to recognize the symptoms of ADHD and recommend offenders for further intensive screening rather than commitment to prisons first.
Source: www.prisonerhealth.org
Source: Justice Policy Institute Report: The Punishing Decade, & U.S. bureau of Justice Statistics Bulletin. NCJ219416. Prisoners in 2006.
Records show that many American youth are caught up in our juvenile justice system. Significant proportions of the arrests are due to either possession of or use of substances, particularly marijuana and crack cocaine. The United States Department of Justice puts the estimate of yearly arrest of juveniles at 2.5 million with approximately over a 100,000 youth under the age of 18 years incarcerated daily. Minority youth in the African-America and Hispanic population are overrepresented, accounting for more than 60% of juvenile offenders in the juvenile justice system. Interestingly, many of these detained youth have psychiatric disorders and are housed in detention facilities that lack mental health services, thereby compounding the problem.
Individuals with substance abuse disorders exhibit hyperactivity, inattention and impulsivity which are core symptoms of ADHD. These symptoms may promote antisocial behaviors which may contribute or exacerbate substance use or abuse. Conversely, substance use could worsen the symptoms of ADHD.
Studies of substance abusers and delinquents revealed a higher prevalence of ADHD comorbidity. ADHD is associated with an earlier onset of psychoactive substance use disorders, independent of psychiatric comorbidities. Retz et al. (2007) stated that children with ADHD show higher levels of substance use disorder comorbidity, particularly when it is associated with social maladaptation and antisocial behavior. Addicted delinquents with ADHD showed worse social environment and a higher degree of psychopathology, including internalizing and externalizing behaviors, when compared to addicted delinquents without ADHD. Retz and coworkers (2007) systematically examined 129 young male prison inmates for ADHD and substance use disorder. They found that 64.3% showed harmful alcohol consumption and 67.4% fulfilled DSM-IV criteria for any drug abuse or dependence. Further analysis showed that 28.8% of the participants had a diagnosis of ADHD combined type and 52.1% showed ADHD residual type. The outcome of these results should suggest adequate therapeutic interventions for addicted young prison inmates, considering the ADHD comorbidity, which is associated with additional psychopathology and social problems.
The core symptoms of ADHD, hyperactivity, inattention and impulsivity, are associated with poor developments in several areas of normal functioning. This may be reflected in African-American children with ADHD as poor academic achievements and comportment at school. Biederman and other investigators found that while hyperactivity declines over the course of the disorder, inattention symptoms persist into adulthood. Currie and Stabile, (2006) stated that this persistence of the inattention component of ADHD may be associated with numerous functional deficits, including educational failure. ADHD symptoms affect social functioning, interactions with teachers, peers, siblings and overall quality of life. Non-African-American teachers are more likely to rate African-American children as more hyperactive and disruptive in class than children from other ethnic backgrounds. The Office of Special Education Report (2005) revealed that although African-American children represent only 15% of the US population in 2001, they were overrepresented in specific learning disabilities (18%), mental retardation (34%) and are more likely to be emotionally disturbed (28%). The National Center for Education Statistics (2001) documented that African-American males make up the majority of students described as “emotionally disturbed” and are more likely to be suspended, expelled from school or subjected to corporal punishment than their white or female peers. In addition to living in extreme poverty and other social dysfunctions, it has been suggested that ADHD may be contributory to the high rates of school drop-out among African-American youth
There is evidence that ADHD places a substantial economic burden on patients, their families and third-party payers. Pelham and his colleagues (2007) projected that the economic impact of education and medical services for children diagnosed with ADHD as at 2005 was conservatively estimated at $36-$52 billion per year, which makes ADHD an important economic and social issue. It is also true that most African-American families live in poverty and are less likely to be insured or have access to mental health services. ADHD leads to increased costs in healthcare and other domains, which is likely to have economic implications for African-American families, their children with ADHD diagnosis and the society in general. Das and colleagues documented a correlation between ADHD, employment status and financial stress in middle-age individuals with ADHD. They also reported significant impairment in health, personal and social domains in their study group.
The economic implications of ADHD on African-America families may include the costs related to common psychiatric and medical comorbidities of ADHD, the indirect costs associated with work loss among adults with ADHD, the costs of managing accidents among individuals with ADHD and the costs associated with the legal issues engendered by the criminality and deviant behaviors among individuals with ADHD. Chow and colleagues (2003) reported that the economic difficulties imposed on African-Americans due to poverty and lack of health insurance makes it more likely that African-Americans resort to the use of emergency services when they receive mental health care.
A comparative study on self-reported risky sexual behaviors was conducted by Flory and colleagues (2006) in young adults (ages 18 to 26) with and without childhood attention deficit/hyperactivity disorder diagnosis. Among the participants were 175 males with a Pittsburg Longitudinal Study (PALS) diagnosis of childhood ADHD. The controls were 111 demographically similar males without childhood ADHD diagnosis. The conclusion drawn from this study is that childhood ADHD predicted earlier initiation of sexual activity and intercourse, more sexual partners, more casual sex, and more partner pregnancies. Although they pointed out that childhood conduct problems did contribute significantly to risky sexual behaviors among participants with ADHD, they also observed an independent contribution of ADHD, which suggested that the characteristic deficits of the disorder or other associated features may be useful childhood markers of later vulnerability. White and colleagues (2012) reported that ADHD symptoms were associated with greater sexual victimization during adolescence and engagement in risky sexual behaviors. The same study also found a strong association between ADHD symptoms, sexual victimization as well as risky sexual behaviors which is stronger for black women than their white counterparts. Risky sexual behaviors result in increased incidence of Sexually Transmitted Diseases (STDs), HIV/AIDS and unplanned teen pregnancies among African-American youth. Currently, The Center for Disease Control and Prevention (CDC) ranks African-American males as leading other races and gender groups in incarceration rates, new HIV infections, homicide deaths, poverty rates, and diagnosed learning disorders. In addition, the 2011 CDC Report on “African Americans and sexually Transmitted Diseases” showed that STDs take an especially heavy toll on African Americans, particularly young African American women and men. Although African Americans represent just 14 percent of the U.S. population, yet they account for approximately half of all reported chlamydia and syphilis cases and almost three-quarters of all reported gonorrhea cases.
Das and colleagues reported that inattention symptoms associated with ADHD significantly affects multiple life domains in mid-life. Marriages, spousal relationships, social interactions and health-related quality of life are all negatively impacted by ADHD symptoms. The families of children with ADHD have to contend with a greater number of behavioral, developmental and educational disturbances which often requires that more time, commitment, logistics and energy be spent. ADHD can put a strain on family relationships, especially for partners that have different views on discipline and parenting styles. The stress may be elevated if either parent feels they are bearing the burden of dealing with the child with ADHD, like taking time off to deal with behavioral problems, school attendance, medical consultations or meeting as part of ADHD management. Parents can feel overwhelmed or find it challenging to cope with their child’s disruptive behaviors. Parents may feel socially isolated if they start avoiding social events or family gatherings in hope of avoiding behavioral problems associated with their child’s diagnosis. The child with ADHD may unintentionally hurt other kids or their siblings during plays or damage property, thereby causing strained relationships. Spousal relationships may be strained. There is the danger of both or either parents spending so much time on the child with ADHD that they do not spend enough time cementing their relationship as couples. This may lead to domestic conflicts, violence and sometimes divorce. The level of attention paid by parents to the child with ADHD may engender sibling jealousy and rival with the family
A number of strategies and interventions have been suggested to improve outcomes and reduce the impact of ADHD in African-Americans. These should be targeted at early diagnosis and treatment of ADHD, increasing awareness about ADHD, removing the stigma of mental illness, elimination of healthcare disparities, enabling access to healthcare and teaching the benefits of ADHD treatment. The importance of early diagnosis and prompt treatment cannot be overemphasized. Instead of using one-size-fits-all or the traditional diagnostic parameters, clinicians should incorporate ethnically-sensitive structured parent questionnaires or rating scales to aid in the diagnosis of ADHD in African American children. It is also suggested that care be tailored to suit the needs of African-American children with ADHD and their care-givers. This may engender more corporation and acceptance of a diagnosis of ADHD in their children and compliance with treatment programs. It is important to have an integrated health care system where patients and their families can have greater access to culturally sensitive materials or programs that will educate them about the symptoms of ADHD and the benefits of proper treatment that will improve behaviors. Parents, caregivers and mental health counselors should be involved in all the stages of diagnosis and treatment planning of African-American children with ADHD. This strategy will enable them to become partners in their own care and secure their cooperation as much as possible. This will also decrease the rate of discontinuity of care since management of ADHD of ADHD requires adherence to treatment regimens and medical appointments.
Odom and colleagues evaluated and demonstrated the usefulness of increasing awareness of ADHD through educational intervention in mothers, predominantly African Americans and reported increase in parental confidence and satisfaction among those who were taught about ADHD; since these qualities are needed in coping with this chronic illness. Same education and training should be provided to teachers who serve the African American populations.
As earlier stated, clinicians may consider using ethnically sensitive, structured questionnaires or rating scales to aid in the diagnosis of ADHD in African Americans. Obtaining a thorough medical history, conducting a thorough physical examination and utilization of guidelines on the diagnosis and evaluation of ADHD is imperative rather than relying too heavily on questionnaires for the diagnosis of ADHD.
Substantial strides at improving outcomes can be made by clinicians and healthcare providers by initiating pilot programs that will track the efficacy of a longitudinal care model whereby primary care physicians will collaborate with mental healthcare professionals. Furthermore, schools, primary care providers and service agents should be incorporated into this collaborative effort to monitor symptoms of ADHD and the response to treatment since a successful management of ADHD is contingent on cooperation and open communication among these caretakers. It is very important that adequate numbers of minority healthcare providers be accessible in schools, clinics and hospitals to address the potential issues of cross-cultural bias and mistrust. Thus, healthcare organizations must recruit and retain a diverse staff whose demographic characteristics are representative of the service area
Healthcare institutions must consider ways of offering improved access to medical services and raising the level of awareness in the community. For example, community events, churches and day care centers could be used to disseminate information and teach about ADHD in order to raise awareness regarding the importance of treatment and to lessen fears of stigmatization in the community.
It is important that care be tailored to suit the needs of various ethnic groups, such the African American community. Culturally competent medical care ensures that all patients will receive care that is compatible with their cultural beliefs and practices. The need to increase cultural competence in healthcare is described in detail in “Healthy People 2010”, which is a statement of national health objectives that are designed to identify the most significant preventable threats to health and to establish national goals to reduce these threats. The criminal code of sentencing and guidelines for African-Americans with a diagnosis of ADHD needs to be reviewed with a view to the elimination of the zero tolerance policy. Instead of confining African American youths to the prison In conclusion, healthcare providers must be diligent in their commitment to reduce or remove barriers to the proper diagnosis and treatment of ADHD in African Americans. There is the need to increase awareness in the African American community regarding the symptoms of ADHD and its treatment, and to improve cultural awareness and sensitivity towards African-American patients among clinicians to reduce the challenges involved in the cross-cultural diagnosis.
Obesity is a chronic disease with risk factors that include positive energy balance, resulting primarily from ”obesogenic” changes that include economic growth, abundance, inexpensive and nutrient-poor food, industrialization, and sedentary lifestyles [1]. Comorbidities and sequelae associated with obesity include hypertension (HTN), inflammation, dyslipidemia, infertility, certain cancers, heart attack, stroke, type 2 diabetes, and obstructive sleep apnea [1, 2]. Weight stigmatization and its associated mental and behavioral consequences, economic burden, and premature death are also associated with obesity.
Historically, obesity went hand in hand with a poor sense of self-perception. Most people are aware of how they look, and whether poor or positive, have an opinion about their body image. Social media influencers, pressure from societal norms, and media images, as well as friends and family, all have an impact on body image. Over the past decade, the body positivity movement has undoubtedly gone mainstream. Often synonymous with this movement is fat acceptance, a movement focused on the demarginalization of the overweight or obese (OW/obese) population. Also mentioned in discussions of fat acceptance and fat rights activism is Health at Every Size® (HAES) as a public health approach to obesity. Yet, the acceptance of overweight and obesity in the absence of prevention or weight reduction threatens to undermine the decades-long progress made toward mitigating risk for cardiovascular disease (CVD).
Positive body image is indeed a necessary component of overall health and an important factor in determining one’s ability to reach weight loss goals. An imperative complement to these movements, however, is adequate health literacy, or an ability to read, comprehend, and use information in a manner that promotes and maintains good health [3]. It is only with proper knowledge of what constitutes a clinical definition of “normal” weight versus higher weights associated with increased CVD risk, coupled with mindful weight management, regular exercise, monitoring blood pressure (BP), and maintenance of blood sugar, that will continue progress toward reducing CVD risk.
Over the past 40 years, there has been a sharp rise in worldwide obesity with prevalence nearly tripling since 1975 [4]. According to the World Health Organization (WHO), overweight and obesity are defined as having abnormal or excessive fat accumulation that may impair health [4]. Studies show the global obesity epidemic is worsening. In 2016, nearly 2 billion adults over 18 years worldwide were overweight and of these, over 650 million were obese [4].
Prevalence of obesity and severe obesity in the U.S. continue to rise [5]. Currently, the rates of obesity exceed 30% in most sex and adult age groups, whereas its prevalence has reached 17% among children and adolescents, defined as a BMI exceeding the 95th percentile [6]. In 2017–2018, it was estimated that 42.4% of U.S. adults aged 20 and over were obese (Figure 1) and 9.2% were severely obese [7] (Figure 2), and these may be underestimated. In a study comparing rates of obesity diagnosis to national rates of obesity based on BMI data from the Behavioral Risk Factor Surveillance System, the authors found that obesity is largely underdiagnosed and undertreated in clinical settings [8].
Prevalence of obesity among adults aged 20 and over, by sex and age: United States, 2017–2018. Notes: Estimates for adults aged 20 and over were age-adjusted by the direct method to the 2000 U.S. Census population using the age groups 20–39, 40–59, and 60 and over. Crude estimates are 42.5% for total, 43.0% for men, and 42.1% for women.
Age-adjusted prevalence of severe obesity among adults aged 20 and over, by sex, age, and race and Hispanic origin: United States, 2017–2018. 1Significantly different from men. 2Significantly different from adults aged 20-39. 3Significantly different from adults ages 40-59. 4Significantly different from all other race and Hispanic-origin groups. Notes: Estimates for adults aged 20 and over were age-adjusted by the direct method to the 2000 U.S. Census population using the age groups 20–39, 40–59, and 60 and over. Crude estimates are 9.0% for total, 6.8% for men, and 11.1% for women.
Over the past 20 years, mean weight, waist circumference (WC), and BMI among U.S. adults over aged 20 increased across all age groups for non-Hispanic white and Mexican-American men and women, and for non-Hispanic black women [9]. Men had more obesity among those aged 20–39 and 40–59 than women in the same respective age groups, and less obesity among those 60 and over compared to women of the same age group [7]. However, none of the reported differences were significant. On the contrary, during this same time period, women reportedly had a higher overall prevalence of severe obesity than men, with significant differences in age groups race/ethnicity, and sex [7] (Figure 2).
BMI is a useful inexpensive tool that has long been used to assess overweight, obesity, and risk for diseases that occur resulting from excess body fat. The internationally accepted standard cut-off points for defining a healthy or unhealthy weight is when body mass index (BMI) is 25 kg/m2. The prevailing BMI classifications are underweight (BMI < 18.5 kg/m2), normal weight (BMI of 18.5–24.9 kg/m2), overweight (BMI of 25.0–29.9 kg/m2), obesityClass I (BMI of 30.0–34.9 kg/m2), obesityClass II (BMI of 35.0–39.9 kg/m2), and extreme obesityClass III (BMI ≥ 40.0 kg/m2) [5].
BMI is not without its limitations, often overestimating body fat in individuals with more muscle tissue, while underestimating body fat in individuals who have lost muscle [10]. Another challenge with using BMI as an adiposity metric is that it is unable to estimate percent body fat nor can it differentiate fat distribution for a given BMI, which can vary across age groups, sex, and race/ethnicity [11, 12, 13]. Results from some epidemiological investigations have even justified implementing adjustments to the cut-off values for classifying obesity and elevated WC among racial/ethnic populations [5, 14]. Lastly, using BMI percentile cutoffs to determine obesity and morbid obesity becomes especially problematic among children as it fails to consider large head size and high torso-to-leg ratio in the pediatric population [15]. The variation of high BMIz values, due to sex and age, make it very difficult to interpret the high BMIz levels (and changes in these levels) among children with severe obesity, possibly leading to incorrect conclusions [16]. Despite its limitations, BMI is used in most clinical settings and is correlated to more direct measures of body fat, such as underwater weighing and dual energy X-ray absorptiometry [17].
When predicting cardiometabolic disease, many studies demonstrate the use of WC, a measure of visceral adipose tissue and commonly used to calculate waist-to-hip ratio, as a preferred approach over BMI for estimating body fat [5, 18]. A WC ≥ 102 cm in men and ≥ 88 cm in women can be an indicator of increased risk for type 2 diabetes, HTN, and CVD, even among individuals with normal weight [19]. Other studies have suggested a combination of adiposity metrics more efficiently identifies all CVD risk factors [20], while some have found the use of either BMI or WC as the index of adiposity identifying the same persons, with equal utility [21].
Many sophisticated direct volumetric techniques are available for body composition assessment that vary in sensitivity and specificity. For example, some more expensive methods include tracer dilution, bioelectrical impedance plethysmography, densitometry, dual-energy X-ray absorptiometry (DEXA), and air displacement plethysmography [22]. Still, other tools that can better visualize and quantify tissues, organs, muscle, and adipose tissue include imaging techniques such as nuclear magnetic resonance and computed tomography [14, 22]. However, in most clinical settings, BMI along with other simple, non-invasive anthropometric measures are used.
On a physiological level, obesity is the result of an energy imbalance between calories consumed and the calories expended, creating an energy surplus and a state of positive energy balance resulting in excess body weight [1]. Obesity also arises from poor health behaviors (e.g., poor sleep habits, diet, physical activity), genetic and epigenetic factors, gut microbiota, and a failure of health care professionals to advise people with obesity on appropriate courses of action for weight reduction [13, 23, 24]. Other “obesogenic” environmental drivers of obesity include marketing of inexpensive nutrient-poor foods, sedentary places of employment, industrialization, mechanized transportation, and urbanization [1].
An indirect driver of increasing BMI is the increasing trend in mean body weight without corresponding increases in height over time. According to the National Health Statistics Report, there is a rising trend in BMI with no significant change in height, with even slight decreases in height among some racial/ethnic groups [9]. For example, among all men, mean height significantly increased from 1999 to 2000 (175.6 cm) to 2003 to 2004 (176.6 cm) and subsequently decreased until 2015–2016 (175.4 cm) [9]. Among all male racial/ethnic groups, only non-Hispanic black men experienced a significant decrease in mean height from 1999 to 2000 (176.0 cm) to 2015 to 2016 (175.5 cm). In contrast, among all women, no significant linear trends were observed over the same time period or for any racial/ethnic subgroup [9].
It is widely recognized that cardiovascular risk and metabolic complications are due to a constellation of obesity, physical inactivity, and primary HTN [25]. Compared to those with a healthy or normal weight, people with obesity are at especially increased risk for many adverse health outcomes, including high BP, higher levels of low-density lipoprotein cholesterol, lower levels of high-density lipoprotein (HDL) cholesterol, type 2 diabetes, stroke, sleep apnea, and poor quality of life [7, 24, 26] (Figure 3). Obesity has also been linked to cancers of the esophagus, colon and rectum, liver, gallbladder and biliary tract, pancreas, breast, uterus, ovary, kidney, and thyroid. [26]. Individuals with severe obesity are further susceptible to obesity-related complications, such as coronary heart disease and end-stage renal disease [7].
Obesity-related health risks and comorbidities [
A systematic evaluation of the health effects of high BMI revealed that in 2015, excess body weight accounted for about 4 million deaths worldwide, with an additional 120 million disability-adjusted life-years [26]. Higher BMI classified as overweight and not obese is also associated with mortality. Over one-third of global deaths and disability-adjusted life-years were related to BMI classified as overweight (less than 30 kg/m2) [26].
In a U.S. study using National Health and Nutrition Examination Survey data examining the prevalence of 11 common chronic conditions, obesity experienced the largest significantly increased trend of any condition over the past 25 years (1998–2014) [27]. Due to its pervasiveness and its detrimental impact on morbidity and mortality, obesity is included as a chronic condition in multimorbidity models rather than as a control factor [27].
Although obesity, particularly visceral adiposity, is typically associated with metabolic dysfunction and cardiometabolic diseases, there are some obesity 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].
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 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].
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 glucose [26].
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].
The idea of obesity as a social and cultural construct has contributed to its shift from being viewed as a comorbidity that ultimately leads to more complex diseases to its own treatment as a chronic disease with a complex etiology. In 2013, the American Medical Association officially recognized obesity as a complex chronic or non-communicable disease requiring medical attention [5, 13, 45]. The medicalization of obesity has presented a setback in the progress toward combating obesity and its resulting morbidities. Treating obesity as a health outcome rather than a comorbid condition leading to a chronic disease influences policies to focus on medical solutions (e.g., gastric bypass surgeries or pharmacological treatment of obesity-related comorbidities) rather than social and environmental factors as primary drivers of obesity, such as health illiteracy, the role of nutrition-deficient product promotion by the food industry, or healthy food access in areas with high rates of OW/obesity [44]. Other observers have raised similar concerns, not only emphasizing medicalization’s overexpansion of medicine’s domain, but also proclaiming it to be a mechanism by which the pharmaceutical industry can increase markets [46]. These medical policy changes will thus further contribute to rising health care costs. The Food and Drug Administration similarly expresses concern that proposed obesity drugs themselves increase cardiovascular or other risks and may require changes to clinical research protocols [46]. By treating the medical and social narratives of obesity as mutually exclusive, we may indeed see a resurgence of CVD in the near future.
The concept of health, illness, and disease are defined differently based on various factors in society. A medical practitioner may define health in very different terms than social or cultural definitions. However, all modern concepts of health recognize health as more than the absence of disease, pointing toward a greater capacity of the individual for self-realization and self-fulfillment [47].
According to the WHO, health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity [48]. Other definitions of health can be found in three main models that include social, biomedical, and functional aspects. The social model places its focus on the social determinants of health and illness and argues that the way society is structurally organized affects the etiology of health and illness [49]. It highlights changes that need to be made by society, including health disparities by social class, occupation, race/ethnicity, gender, and income, in order to make the population healthier [49]. The biomedical model of health, currently dominant in medical practice, focuses on biological determinants playing a key role in explaining disease as a condition, primarily caused by external (e.g., physical, chemical, and microbiologic factors) or internal (e.g., vascular, immunologic, and metabolic) factors [50]. In this model, the physical or biological aspects of disease and illness serves as the focal endpoint and is associated with the diagnosis, cure, and treatment of disease. Lastly, functional medicine model focuses more on the dynamic functional processes that result in a person’s disease and less with disease as the endpoint [51].
There are skeptics, primarily influenced by the social model of health, who assert the obesity epidemic, and even the idea of health itself, is socially constructed. Holland et al. view obesity as a construct propagated by scientific discourse, which functions within a context of social surveillance and bio-power, even though they acknowledge obesity rates as “social facts” and being obese as a reality [52]. The Association for Size Diversity and Health, an international professional organization and strong proponent of the HAES® movement, asserts that, “health exists on a continuum that varies with time and circumstance for each individual. Health should be conceived as a resource or capacity available to all regardless of health condition or ability level, and not as an outcome or objective of living [53].”
Natalie Boero characterizes the obesity epidemic as a “postmodern epidemic,” or “epidemics in which unevenly medicalized phenomena lacking a clear pathological basis get cast in the language and moral panic of “traditional” epidemics [54].” The “postmodern” and constructed labels given to the obesity epidemic are said to be justified due to there being no known discrete cause of obesity, having been attributed to a wide range of factors, from genetic predisposition, to socioeconomic factors (e.g., food quality/scarcity), to the built environment. Adding to this argument is the idea that obesity research tends to conflate overweight and obesity, largely attributable to a critical reliance on a fluid metric (due to its changing categories) to diagnose health [54] and issues with participant selection in study populations [55].
The constructionist view of obesity, largely endorsed by sociologists and members of fat activism, and those that treat obesity as a biomedical fact and health risk, undoubtedly occupy two poles of obesity scholarship. Both hold influence on how the public views and treats OW/obesity. Yet, how can we continue our public health campaign of reducing obesity while avoiding what members of the fat acceptance movement label as “fat shaming”? Is there still a platform wherein OW/obesity and its health ramifications can be publicly discussed from a biomedical perspective while also avoiding weight stigmatization? Until these questions are addressed, the contention between these two groups will remain and the growing popularity of body positivity and fat activism, without regard for the health risks that accompany obesity, will render the public health message of the health advantages of preventing or treating obesity largely ignored.
Body image involves a person’s perceptions, thoughts, behaviors, and feelings regarding his or her appearance. There are several aspects of body image that can be explored: perceptual, attitudinal, and psychological [56]. Perceptual body image investigates the accuracy of body size estimations relative to its actual size. Attitudinal body image assesses an overall subjective satisfaction of the body, personal feelings and beliefs about the body, and avoidance of exposure of the body to others [56]. Finally, psychological measures combine one or more of these components. In all aspects, body image is a subjective concept and experience.
Any aspect of body image an individual has of his or her body is pivotally determined by interactions within obesogenic environments [57], (social) media [58], fitness imagery [59], and sociocultural experiences [59, 60, 61]. For example, in a study examining the impact of different forms of inspirational fitness (“fitspiration”) images on women’s image of their bodies, the authors found that exposure to “fitspiration” images led to decreased body satisfaction and increased negative mood over time [59].
Body image satisfaction also exhibits elasticity and can change throughout developmental periods. For example, adolescents display body image elasticity as they undergo the significant physical and psychological changes of puberty [56]. Other examples of groups who may pay special attention to body-related imagery and display sensitivity to media cues are pregnant women, bodybuilders, athletes, and people with eating disorders. Research suggests there are also qualitative differences in body image that vary between men and women, by age group, sexual orientation, and race/ethnicity [56, 62].
Western societies, particularly those with affluence in the twenty-first century, have generally associated thinness with happiness, success, youthfulness, and social acceptance [56]. Most citizens of the Western world view fatness as a negative that is to be avoided. There has been a cultural prejudice and stigma toward those with overweight or obesity [60]. However, weight stigmatization has itself become a public health concern due to the associated psychological and physical health consequences to OW/obese individuals. The psychological and social stigmata associated with being OW/obese often makes this population vulnerable to discrimination in their personal and work lives [5]. Often blamed for their weight, the OW/obese are labeled as lazy, weak-willed, out of control, and lacking motivation [2, 56, 60]. The prevailing message in the media is that the cause and cure for obesity lies within the individual [60]. In a study examining obesity perception among policymakers from over 10 developed countries, over 90% saw lack of personal motivation as having a “strong” or “very strong” impact on obesity [23].
Nevertheless, weight stigmatization has been a long-standing approach to reducing obesity. However, it has not proven to be a motivator for weight loss [60]. There are studies that show stigmatizing weight is counterproductive. Individuals who experience weight stigma or perceived weight discrimination are at increased risk for anxiety, depression, bulimia, body dissatisfaction, low self-esteem and other psychological disorders [24]. Other findings have shown that even after controlling for key covariates such as BMI, age, and sex, these psychological outcomes remain, indicating that overweight perception rather than obesity is associated with psychological distress [63].
Weight stigma perpetuates unhealthy behaviors, including increased eating, reduced self-regulation, and avoidance of exercise [64]. Further, chronic stress resulting from weight stigma contributes to the development and/or pathophysiology of obesity, independent of adiposity [64]. Stress has been found to induce high levels of cortisol (an obesogenic hormone), leading to increased activity of the sympathetic nervous system (SNS) and release of corticotrophin-releasing hormone. Chronically elevated SNS activity could deregulate hypothalamic-pituitary-adrenal axis activity, thus further contributing to the etiology of obesity [65].
Reducing obesity rates has become a target for public health action, due to the link between obesity and a range of chronic diseases and premature mortality. However, critics of this view suggest that obesity has been primarily framed within a medical narrative, thus generating greater social anxiety and fears of “fatness” [66]. Some argue that dominant medical narratives are responsible for the discourse circulating around the idea of fatness as a pathology and a moral failing [66], further asserting that all the statistics on fat people being unhealthy are baseless due to the failure of society to delineate between fat and fat stigma [67]. The supposed bias of physicians has increasingly come under scrutiny. Physicians are said to notoriously view fat patients as noncompliant, or unwilling to follow their directions [67]. Some medical and allied health professionals have been overtly labeled “fat phobic” and showing weight bias. Weight bias is defined as having a widespread stereotypical and prejudicial attitude, assumption, belief, or judgment toward fat people [68, 69]. Studies show widespread weight bias among medical professionals [70], medical students and physician assistants [71], and exercise and nutrition professionals [72], with no clearly defined approach to reduce these biases among students and professionals across various health disciplines [69]. There have even been reports of obese women avoiding routine gynecological exams, despite having higher rates of gynecological cancers than nonobese women, due to weight stigmatization and the corresponding negative attitudes of health care professionals toward overweight people [44]. The obesity problem we are facing is only exacerbated when participants express reluctance to address weight concerns with their health care providers for fear they will not be taken seriously [70], or avoid seeing their primary care physician or specialist entirely.
There has been a growing awareness of the psychosocial harms of weight stigmatization and fat shaming. Our culture is moving more toward body positivity, self-empowerment, inclusivity, and encouraging individuals to take pride in and accept their bodies, despite having BMI’s that classify them as clinically OW/obese. Popularized through Instagram, with over 11 million posts tagged with #bodypositive, 4 million for #bodypositivity, and more than 1 million for #bopo [73]. Indeed, an internet search of body positivity will yield more than 112 million results [73]. Body positivity aims to challenge dominant body image ideals, promote acceptance and respect of all bodies, irrespective of shape, size, and features, focusing more on appreciating the functionality and health of the body rather than only its appearance [73] (Figure 4).
A group of women at a fitness facility stretch to hold a child’s pose with their hands all reaching in to form a circle. Body positivity promotes strength and fitness coming in many forms, no matter the body shape or size (photo by: Sarah Pflug. Available from:
Positive body image is indeed a key factor in determining one’s ability to reach weight loss goals. However, setting positive weight loss goals is an assumption in traditional approaches to weight loss [74]. Other assumptions include 1) the notion that adiposity increases risk of morbidity and mortality, 2) maintaining weight loss can be achieved through proper diet and exercise, which will prolong life, 3) obese individuals can improve health only through weight loss, 4) and finally, the high economic burden on the health care system incurred by obesity-related costs can be mitigated by obesity treatment and prevention [74].
Many people who pursue weight-loss programs are seemingly motivated to lose weight to be normal, wear smaller clothes, and avoid weight stigmatization and discrimination rather than by the dangers of obesity or its associated health risks [54]. OW/obese individuals are now being more positively represented in the media, movies, and even in arenas where they have historically been absent or ignored, such as in the fitness and fashion industries, or as role models in music and entertainment. However, visual normalization of larger bodies, that is, more habitual visual exposure to people with excess weight, may further contribute to the higher prevalence of overweight and obesity, particularly among those with lower levels of education and income [75].
Established in 1969, the National Association to Advance Fat Acceptance (NAAFA) is a fat-rights organization congealed out of early protests of fat activists (Figure 5). Established as a support movement, the organization protests discrimination in the workplace and lack of fat acceptance in society [76]. The organization is dedicated to protecting the rights and improving the quality of life for fat people [77].
The National Association to Advance Fat Acceptance (NAAFA) is an all-volunteer, multigenerational fat-rights organization seeking to change the narrative around fatness, fight for fat-rights, and increase respect for all people, regardless of body type or size. Available from:
Fat acceptance and body positivity have become synonymous terms of late. Arguing that the former term is rooted in the latter term, some claim that fat acceptance is threatening to destroy the body positive movement. They contend that those originally intended to benefit from body positivity were individuals like cancer survivors who have suffered physical disfigurement, people with physical disabilities, and members of underrepresented racial/ethnic groups frequently ignored by the media. These individuals have no control over primarily physical factors that have set them apart.
Parallels have been drawn between fatness and smoking (i.e. an unhealthy and deadly condition brought on by behaviors, but difficult to change once the behavior is set in motion) [78]. It follows that those with no apparent medical reason for OW/obesity (e.g., medications, Cushing’s syndrome, polycystic ovary syndrome), on some level, choose to be OW/obese. Conversely, there are those that believe the idea that fat is permanently changeable to be a myth, citing studies that report participants gaining more weight than originally lost within three years of ending a diet [67].
Culture, society, (social) media, and reality TV have all influenced obesity perception, outpacing influential and well-established clinical definitions and medical advice warning of the cardiometabolic risks of obesity. For example, the terms “fat,” “curvy,” “plus-sized,” and “full-figured” are more frequently used among plus-size fashion bloggers, reclaiming the use of the word “fat,” and lessening the weight stigma around obesity [79]. OW/obese people can now be found on the glossy covers of magazines and amassing followers on social media outlets such as blog sites, Instagram, YouTube, TikTok, Tumblr, Twitter, and other online spaces. Under the guise of glamor and glitz, OW/obese social media and reality TV influencers advertise “fit, fabulous, and fat” lifestyles, which only serve to contradict public health messaging discouraging unhealthy lifestyles. While fat activists and the fat acceptance movement are working to reduce weight stigmatization, their influence on the public, particularly those with central adiposity, can potentially undermine the recognition of being overweight and its health consequences [75].
Civil lawmakers are also shifting the narrative to more acceptance and inclusivity as it relates to OW/obese perception. Antidiscrimination law theorizes unfairness based on government classifications of a group of people who are singled out and burdened without sufficiently good reason or in employment decisions based on protected traits outlined in Title VII of the 1964 Civil Rights Act. Fat advocates have become familiar with the difficulty of seeking legal arguments for fat rights protection under Title VII while also arguing that obesity is a medicalized impairment and disability [78].
Like the fat acceptance movement, HAES® is a weight-neutral approach that advocates the idea that health can be achieved and sustained, independent of weight status. The HAES® approach advocates intuitive eating, which involves listening to and acting on internal hunger and satiety cues and preferences. A HAES® approach attempts to addresses weight bias and stigma in individuals living with obesity, and is touted as a promising public health approach instead of focusing on weight status as an ultimate health outcome [74]. Proponents of HAES® assert that the long-term sustainability of traditional medical or behaviorally based interventions (e.g., pharmacological, surgical, and behavioral) for obesity has been disappointing. HAES® is emerging as standard practice in the eating disorders field [80] whose principles are professed by an array of civil rights groups and international professional organizations dedicated to promoting fat acceptance and fighting weight discrimination [80].
There is evidence supporting the notion of fit at every size. Higher fitness levels among the MHO are associated with fewer metabolic complications and lower prevalence of MetS at any age and across different weight status groups [31]. However, as previously mentioned, MHO has been shown to be a transient state to MUO [25, 33].
It is important to emphasize that health is a continuum on which every person lies, with one end of the spectrum representing morbidity/mortality and the other health and vitality. There is a size threshold, albeit non-discrete, over which a person crosses over into a state of increased risk of, or overt illness. Established comorbidities and sequelae frequently accompany sustained obesity, despite practicing intuitive eating, that reduce quality of life, not the least of which include increased risk of musculoskeletal pathology [81], arthritis/joint pain, respiratory conditions/diseases (e.g., sleep apnea, asthma), depression/anxiety, inability to participate in certain activities, and physical disability [1]. Additionally, the association between intuitive eating and diet quality remains unclear in epidemiologic literature. Nevertheless, HAES® holds value in its deemphasis on restrictive dieting, which has been associated with increased psychological stress, increased cortisol levels, and subsequent weight gain [65].
Despite years of empirical medical and comprehensive epidemiological research, many fat activists take pride in maintaining higher BMI and embracing their size, all while holding in contempt any efforts to increase health and wellness. Permeating through activism, academia, fashion, and even sports, the HAES® approach appears to promote not only acceptance, but pride in the esthetic of the fat body. Members of this movement seek to bring people of larger size back from the margins of society, fiercely labeling those who oppose their ideas as “body-shamers” and “fat phobic” perpetuators of societal norms.
While the OW/obese may find intuitive eating and HAES® approaches successful, there still remains a tremendous (mental) health care cost of obesity-related illnesses. These costs are a real economic impact to society. Years of medical and scientific research has provided irrefutable evidence of the deadly cost of condoning preventable OW/obesity and unhealthy lifestyles of over 650 million OW/obese worldwide. Simultaneously, the medical and public health community must not use the campaign to reduce fat as justification for prejudice and oppression. OW/obese individuals have a right to make their own choices; but health literacy and knowledge of the correct information and use of that information to make informed health decisions is of utmost public health concern.
At the primary level of prevention, modifying health behaviors, such as incorporating healthy eating and fitness habits into everyday lifestyles, can reduce metabolic risk factors (e.g., cholesterol levels, blood sugar levels, and BP) [25, 82]. The benefits of both reducing sedentary behavior together with increasing physical activity, especially in the elderly, is associated with a reduced risk for type 2 diabetes, compared with those physically inactive [82]. Lowering body fat, even if from obesity to overweight, can result in a reduction in metabolic abnormalities and lower levels of systemic inflammation, and lower BP [25]. The Look AHEAD study examined the effects of an intensive lifestyle intervention and found that lifestyle interventions can produce long term weight loss and improvement in fitness and sustained beneficial effects on CVD risk factors [83].
While self-acceptance and positive self-perception are certainly noble attributes, scientific knowledge of well-established risks of clinical obesity, particularly excess central body fat, cannot go unheeded. Health literacy, in combination with body positivity, may prevent reversal of the strides made in the reduction of CVD.
Health literacy is the degree to which individuals are able to access, understand, and use or process basic health information and services, thereby promoting good health for themselves, their families, and their communities [3]. Insufficient health literacy has been associated with poorer outcomes prior to and following coronary events, excess body weight, higher morbidity and mortality rates, healthcare use, and costs [84, 85] (Figure 6). Increasing health literacy will contribute to greater ability to read food labels, determine energy content, and make better food choices complementary to a healthy, physically active lifestyle. Health literacy should be evaluated as part of secondary prevention programs aiming to reduce CVD risk, such as dropout rates in cardiac rehabilitation [84].
Adverse health risks for patients with low health literacy (source: Centers for Disease Control and Prevention (CDC), Center for Preparedness and Response. Available from:
With the power to fundamentally change the way the population regards obesity and its health risks, health literacy has the potential to profoundly reduce barriers to health delivery, reduce health care costs, and improve overall health status.
Social media is a crowded space that is filled with competing health messages. These platforms play a principal role in attempting to change health behavior and prevent or improve CVD health outcomes. Social media messages have influenced the health care decision making among patients, not all of whom always check the authenticity of information received. For example, in a study exploring the impact of health-related information sharing and the influence of social media on people’s online health information-seeking behavior, the authors found that social media users received health information (80–90%), and admitted to starting (47%), and stopping medication (42%) after reading messages received on a social media platform [86]. Taking this into account, public health practitioners must focus their resources on platforms to counter sociological agendas. For example, most tenets of fat acceptance, body positivity (independent of weight status), and HAES® openly contradict health guidelines that are based on years of medical research. They must increase the amount of available information on CVD health, reinforce its salience as a CVD risk factor and public health problem, attract the attention of the OW/obese population, and offer practical solutions [87].
Medical advice must be translated into lay terms, adjusting for multiple levels of health literacy. Messages must include health incentives that are relatable to their audience. A successful public health campaign will include communication that is sensitive to the body positivity movement, one that encourages self-acceptance, and supports the mental health of this population. Incorporating elements from the social, biomedical, and functional models of health may elucidate why reducing body fat is beneficial for cardiometabolic health.
In clinical settings, it is imperative that medical professionals, including physician assistants [71] and exercise and nutrition professionals [72], increase their awareness of their own weight bias, as well as that of their colleagues. Creating a welcoming setting where the OW/obese do not feel stigmatized will open more opportunities for doctor-patient educational discourse on the health benefits of reducing body weight, restructure how they are clinically monitored, and reduce bias while profiling their CVD risk.
The biomedical model has been the dominant approach in medicine. However, in its organ-oriented approach and its failing to take psychosocial aspects of disease into account, its efficacy in the advent of chronic disease prevalence has become questionable [50]. There is an increasing recognition of the influential role of culture and society in our perception of health and healthy behaviors. Rather than medical practitioners taking the historic biomedical model approach to obesity in clinical settings, a more effective approach will be to incorporate ideas from the social model (e.g., screening for social and environmental contributors to obesity), together with concepts from the functional model (e.g., examining functional health of the OW/obese). Building bridges across models will advance our prevention efforts and holistic treatment in this population.
Obesity is still a pervasive problem, confirming its intractability. Obesity is a well-known risk factor for CVD, which is still a leading cause of morbidity and mortality in the U.S. and most developed countries. Yet, strides have been made in reducing CVD mortality rates. Over the last 40 years, we have seen a decline in mortality from CVD in the U.S. and many regions of the world. In response, there have been major setbacks to this progress, namely the fat acceptance and body positivity movements. Principally rooted within sociological frameworks, these movements appear inattentive to the established adverse health risks of maintaining an OW/obese status; nor do they promote efforts to modify health behaviors that reduce obesity and thus decrease risk of type 2 diabetes and CVD. Yet these emerging views are gaining momentum, revealing key changes in trends in fat identity and fat acceptance. These trends have key public health implications with a direct impact on a generation who daily engages with social media influencers who promote such messages. The parallel trend of the body positivity movement, in the absence of weight status consideration, threatens to reverse decades of progress made toward reducing coronary heart disease and its comorbidities.
The urgency of reducing obesity as a public health message continues. The body positivity and fat activism communities must reconcile with medical and public health professionals to equally address both the mental health benefits of self-acceptance and positive body image, while also bearing in mind the short- and long-term health advantages of preventing or treating obesity. Both groups must weigh in and not compete to win on framing the narrative of obesity. The future of cardiovascular health relies upon this collaboration.
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However, persistent land use, monoculture, and intensified production processes have led to soil diseases. This, along with abiotic stress, and mainly salinity of soil and waters, water stress, and suboptimal temperatures, can lead to physiological disorders emerging in peppers, e.g., cracking and Blossom end rot, which induce plant senescence, and lower not only in yields, but also in product quality. Salinity and water shortage are the two main environmental problems that crops face in the Mediterranean Region. One way of overcoming stresses from an ecological or integrated crop management viewpoint is to use grafted plants as an adaptation strategy. Initially, grafting technology has expanded in Solanaceae and Cucurbitacea species to overcome biotic stress. Nowadays, grafts are being used as several approaches to cushion the impact of climate change on agricultural systems. 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Forest fires are a great menace to ecologically healthy grown forests and protection of the environment. This problem has been the research interest for years, and there are a number of solutions available to resolve this problem. In this chapter, a summary is given for all the technologies that have been used for forest fire detection with explanation of what parameters these systems looking for to understand the fire behaviour.",book:{id:"6304",slug:"forest-fire",title:"Forest Fire",fullTitle:"Forest Fire"},signatures:"Ahmad AA Alkhatib",authors:[{id:"215875",title:"Dr.",name:"Ahmad",middleName:null,surname:"Alkhatib",slug:"ahmad-alkhatib",fullName:"Ahmad Alkhatib"}]}],onlineFirstChaptersFilter:{topicId:"34",limit:6,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:87,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:98,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:27,numberOfPublishedChapters:287,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:9,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:139,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:129,numberOfOpenTopics:0,numberOfUpcomingTopics:2,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!1},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:107,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:10,numberOfPublishedChapters:103,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:12,numberOfOpenTopics:2,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:0,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!1},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:10,numberOfOpenTopics:4,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. 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A dynamic career research platform which is based on the thematic areas of comparative vertebrate physiology, stress endocrinology, reproductive endocrinology, animal health and welfare, and conservation biology. \nEdward has supervised 40 research students and published over 60 peer reviewed research.",institutionString:null,institution:{name:"University of Queensland",institutionURL:null,country:{name:"Australia"}}},editorTwo:null,editorThree:null},{id:"20",title:"Animal Nutrition",coverUrl:"https://cdn.intechopen.com/series_topics/covers/20.jpg",isOpenForSubmission:!0,editor:{id:"175967",title:"Dr.",name:"Manuel",middleName:null,surname:"Gonzalez Ronquillo",slug:"manuel-gonzalez-ronquillo",fullName:"Manuel Gonzalez Ronquillo",profilePictureURL:"https://mts.intechopen.com/storage/users/175967/images/system/175967.png",biography:"Dr. Manuel González Ronquillo obtained his doctorate degree from the University of Zaragoza, Spain, in 2001. 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She obtained her Ph.D. in Veterinary Sciences from the University of Trás-os-Montes e Alto Douro, Portugal. After almost 32 years of teaching at the University of Trás-os-Montes and Alto Douro, she recently moved to the University of Évora, Department of Veterinary Medicine, where she teaches in the field of Animal Reproduction and Clinics. Her primary research areas include the molecular markers of the endometrial cycle and the embryo–maternal interaction, including oxidative stress and the reproductive physiology and disorders of sexual development, besides the molecular determinants of male and female fertility. She often supervises students preparing their master's or doctoral theses. 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His research interest focuses on computational chemistry and molecular modeling of diverse systems of pharmacological, food, and alternative energy interests by resorting to DFT and Conceptual DFT. He has authored a coauthored more than 255 peer-reviewed papers, 32 book chapters, and 2 edited books. He has delivered speeches at many international and domestic conferences. He serves as a reviewer for more than eighty international journals, books, and research proposals as well as an editor for special issues of renowned scientific journals.",institutionString:"Centro de Investigación en Materiales Avanzados",institution:{name:"Centro de Investigación en Materiales Avanzados",country:{name:"Mexico"}}},{id:"76477",title:"Prof.",name:"Mirza",middleName:null,surname:"Hasanuzzaman",slug:"mirza-hasanuzzaman",fullName:"Mirza Hasanuzzaman",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/76477/images/system/76477.png",biography:"Dr. Mirza Hasanuzzaman is a Professor of Agronomy at Sher-e-Bangla Agricultural University, Bangladesh. He received his Ph.D. in Plant Stress Physiology and Antioxidant Metabolism from Ehime University, Japan, with a scholarship from the Japanese Government (MEXT). Later, he completed his postdoctoral research at the Center of Molecular Biosciences, University of the Ryukyus, Japan, as a recipient of the Japan Society for the Promotion of Science (JSPS) postdoctoral fellowship. He was also the recipient of the Australian Government Endeavour Research Fellowship for postdoctoral research as an adjunct senior researcher at the University of Tasmania, Australia. Dr. Hasanuzzaman’s current work is focused on the physiological and molecular mechanisms of environmental stress tolerance. Dr. Hasanuzzaman has published more than 150 articles in peer-reviewed journals. He has edited ten books and written more than forty book chapters on important aspects of plant physiology, plant stress tolerance, and crop production. According to Scopus, Dr. Hasanuzzaman’s publications have received more than 10,500 citations with an h-index of 53. He has been named a Highly Cited Researcher by Clarivate. He is an editor and reviewer for more than fifty peer-reviewed international journals and was a recipient of the “Publons Peer Review Award” in 2017, 2018, and 2019. He has been honored by different authorities for his outstanding performance in various fields like research and education, and he has received the World Academy of Science Young Scientist Award (2014) and the University Grants Commission (UGC) Award 2018. He is a fellow of the Bangladesh Academy of Sciences (BAS) and the Royal Society of Biology.",institutionString:"Sher-e-Bangla Agricultural University",institution:{name:"Sher-e-Bangla Agricultural University",country:{name:"Bangladesh"}}},{id:"187859",title:"Prof.",name:"Kusal",middleName:"K.",surname:"Das",slug:"kusal-das",fullName:"Kusal Das",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSBDeQAO/Profile_Picture_1623411145568",biography:"Kusal K. Das is a Distinguished Chair Professor of Physiology, Shri B. M. Patil Medical College and Director, Centre for Advanced Medical Research (CAMR), BLDE (Deemed to be University), Vijayapur, Karnataka, India. Dr. Das did his M.S. and Ph.D. in Human Physiology from the University of Calcutta, Kolkata. His area of research is focused on understanding of molecular mechanisms of heavy metal activated low oxygen sensing pathways in vascular pathophysiology. He has invented a new method of estimation of serum vitamin E. His expertise in critical experimental protocols on vascular functions in experimental animals was well documented by his quality of publications. He was a Visiting Professor of Medicine at University of Leeds, United Kingdom (2014-2016) and Tulane University, New Orleans, USA (2017). For his immense contribution in medical research Ministry of Science and Technology, Government of India conferred him 'G.P. Chatterjee Memorial Research Prize-2019” and he is also the recipient of 'Dr.Raja Ramanna State Scientist Award 2015” by Government of Karnataka. He is a Fellow of the Royal Society of Biology (FRSB), London and Honorary Fellow of Karnataka Science and Technology Academy, Department of Science and Technology, Government of Karnataka.",institutionString:"BLDE (Deemed to be University), India",institution:null},{id:"243660",title:"Dr.",name:"Mallanagouda Shivanagouda",middleName:null,surname:"Biradar",slug:"mallanagouda-shivanagouda-biradar",fullName:"Mallanagouda Shivanagouda Biradar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/243660/images/system/243660.jpeg",biography:"M. S. Biradar is Vice Chancellor and Professor of Medicine of\nBLDE (Deemed to be University), Vijayapura, Karnataka, India.\nHe obtained his MD with a gold medal in General Medicine and\nhas devoted himself to medical teaching, research, and administrations. He has also immensely contributed to medical research\non vascular medicine, which is reflected by his numerous publications including books and book chapters. Professor Biradar was\nalso Visiting Professor at Tulane University School of Medicine, New Orleans, USA.",institutionString:"BLDE (Deemed to be University)",institution:{name:"BLDE University",country:{name:"India"}}},{id:"289796",title:"Dr.",name:"Swastika",middleName:null,surname:"Das",slug:"swastika-das",fullName:"Swastika Das",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/289796/images/system/289796.jpeg",biography:"Swastika N. Das is Professor of Chemistry at the V. P. Dr. P. G.\nHalakatti College of Engineering and Technology, BLDE (Deemed\nto be University), Vijayapura, Karnataka, India. She obtained an\nMSc, MPhil, and PhD in Chemistry from Sambalpur University,\nOdisha, India. Her areas of research interest are medicinal chemistry, chemical kinetics, and free radical chemistry. She is a member\nof the investigators who invented a new modified method of estimation of serum vitamin E. She has authored numerous publications including book\nchapters and is a mentor of doctoral curriculum at her university.",institutionString:"BLDEA’s V.P.Dr.P.G.Halakatti College of Engineering & Technology",institution:{name:"BLDE University",country:{name:"India"}}},{id:"248459",title:"Dr.",name:"Akikazu",middleName:null,surname:"Takada",slug:"akikazu-takada",fullName:"Akikazu Takada",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/248459/images/system/248459.png",biography:"Akikazu Takada was born in Japan, 1935. After graduation from\nKeio University School of Medicine and finishing his post-graduate studies, he worked at Roswell Park Memorial Institute NY,\nUSA. He then took a professorship at Hamamatsu University\nSchool of Medicine. In thrombosis studies, he found the SK\npotentiator that enhances plasminogen activation by streptokinase. He is very much interested in simultaneous measurements\nof fatty acids, amino acids, and tryptophan degradation products. By using fatty\nacid analyses, he indicated that plasma levels of trans-fatty acids of old men were\nfar higher in the US than Japanese men. . He also showed that eicosapentaenoic acid\n(EPA) and docosahexaenoic acid (DHA) levels are higher, and arachidonic acid\nlevels are lower in Japanese than US people. By using simultaneous LC/MS analyses\nof plasma levels of tryptophan metabolites, he recently found that plasma levels of\nserotonin, kynurenine, or 5-HIAA were higher in patients of mono- and bipolar\ndepression, which are significantly different from observations reported before. In\nview of recent reports that plasma tryptophan metabolites are mainly produced by\nmicrobiota. He is now working on the relationships between microbiota and depression or autism.",institutionString:"Hamamatsu University School of Medicine",institution:{name:"Hamamatsu University School of Medicine",country:{name:"Japan"}}},{id:"137240",title:"Prof.",name:"Mohammed",middleName:null,surname:"Khalid",slug:"mohammed-khalid",fullName:"Mohammed Khalid",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/137240/images/system/137240.png",biography:"Mohammed Khalid received his B.S. degree in chemistry in 2000 and Ph.D. degree in physical chemistry in 2007 from the University of Khartoum, Sudan. He moved to School of Chemistry, Faculty of Science, University of Sydney, Australia in 2009 and joined Dr. Ron Clarke as a postdoctoral fellow where he worked on the interaction of ATP with the phosphoenzyme of the Na+/K+-ATPase and dual mechanisms of allosteric acceleration of the Na+/K+-ATPase by ATP; then he went back to Department of Chemistry, University of Khartoum as an assistant professor, and in 2014 he was promoted as an associate professor. In 2011, he joined the staff of Department of Chemistry at Taif University, Saudi Arabia, where he is currently an assistant professor. His research interests include the following: P-Type ATPase enzyme kinetics and mechanisms, kinetics and mechanisms of redox reactions, autocatalytic reactions, computational enzyme kinetics, allosteric acceleration of P-type ATPases by ATP, exploring of allosteric sites of ATPases, and interaction of ATP with ATPases located in cell membranes.",institutionString:"Taif University",institution:{name:"Taif University",country:{name:"Saudi Arabia"}}},{id:"63810",title:"Prof.",name:"Jorge",middleName:null,surname:"Morales-Montor",slug:"jorge-morales-montor",fullName:"Jorge Morales-Montor",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/63810/images/system/63810.png",biography:"Dr. Jorge Morales-Montor was recognized with the Lola and Igo Flisser PUIS Award for best graduate thesis at the national level in the field of parasitology. He received a fellowship from the Fogarty Foundation to perform postdoctoral research stay at the University of Georgia. He has 153 journal articles to his credit. He has also edited several books and published more than fifty-five book chapters. He is a member of the Mexican Academy of Sciences, Latin American Academy of Sciences, and the National Academy of Medicine. He has received more than thirty-five awards and has supervised numerous bachelor’s, master’s, and Ph.D. students. Dr. Morales-Montor is the past president of the Mexican Society of Parasitology.",institutionString:"National Autonomous University of Mexico",institution:{name:"National Autonomous University of Mexico",country:{name:"Mexico"}}},{id:"217215",title:"Dr.",name:"Palash",middleName:null,surname:"Mandal",slug:"palash-mandal",fullName:"Palash Mandal",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/217215/images/system/217215.jpeg",biography:null,institutionString:"Charusat University",institution:null},{id:"49739",title:"Dr.",name:"Leszek",middleName:null,surname:"Szablewski",slug:"leszek-szablewski",fullName:"Leszek Szablewski",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/49739/images/system/49739.jpg",biography:"Leszek Szablewski is a professor of medical sciences. He received his M.S. in the Faculty of Biology from the University of Warsaw and his PhD degree from the Institute of Experimental Biology Polish Academy of Sciences. He habilitated in the Medical University of Warsaw, and he obtained his degree of Professor from the President of Poland. Professor Szablewski is the Head of Chair and Department of General Biology and Parasitology, Medical University of Warsaw. Professor Szablewski has published over 80 peer-reviewed papers in journals such as Journal of Alzheimer’s Disease, Biochim. Biophys. Acta Reviews of Cancer, Biol. Chem., J. Biomed. Sci., and Diabetes/Metabol. Res. Rev, Endocrine. He is the author of two books and four book chapters. He has edited four books, written 15 scripts for students, is the ad hoc reviewer of over 30 peer-reviewed journals, and editorial member of peer-reviewed journals. Prof. Szablewski’s research focuses on cell physiology, genetics, and pathophysiology. He works on the damage caused by lack of glucose homeostasis and changes in the expression and/or function of glucose transporters due to various diseases. He has given lectures, seminars, and exercises for students at the Medical University.",institutionString:"Medical University of Warsaw",institution:{name:"Medical University of Warsaw",country:{name:"Poland"}}},{id:"173123",title:"Dr.",name:"Maitham",middleName:null,surname:"Khajah",slug:"maitham-khajah",fullName:"Maitham Khajah",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/173123/images/system/173123.jpeg",biography:"Dr. Maitham A. Khajah received his degree in Pharmacy from Faculty of Pharmacy, Kuwait University, in 2003 and obtained his PhD degree in December 2009 from the University of Calgary, Canada (Gastrointestinal Science and Immunology). Since January 2010 he has been assistant professor in Kuwait University, Faculty of Pharmacy, Department of Pharmacology and Therapeutics. His research interest are molecular targets for the treatment of inflammatory bowel disease (IBD) and the mechanisms responsible for immune cell chemotaxis. He cosupervised many students for the MSc Molecular Biology Program, College of Graduate Studies, Kuwait University. Ever since joining Kuwait University in 2010, he got various grants as PI and Co-I. He was awarded the Best Young Researcher Award by Kuwait University, Research Sector, for the Year 2013–2014. He was a member in the organizing committee for three conferences organized by Kuwait University, Faculty of Pharmacy, as cochair and a member in the scientific committee (the 3rd, 4th, and 5th Kuwait International Pharmacy Conference).",institutionString:"Kuwait University",institution:{name:"Kuwait University",country:{name:"Kuwait"}}},{id:"195136",title:"Dr.",name:"Aya",middleName:null,surname:"Adel",slug:"aya-adel",fullName:"Aya Adel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/195136/images/system/195136.jpg",biography:"Dr. Adel works as an Assistant Lecturer in the unit of Phoniatrics, Department of Otolaryngology, Ain Shams University in Cairo, Egypt. Dr. Adel is especially interested in joint attention and its impairment in autism spectrum disorder",institutionString:"Ain Shams University",institution:{name:"Ain Shams University",country:{name:"Egypt"}}},{id:"94911",title:"Dr.",name:"Boulenouar",middleName:null,surname:"Mesraoua",slug:"boulenouar-mesraoua",fullName:"Boulenouar Mesraoua",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94911/images/system/94911.png",biography:"Dr Boulenouar Mesraoua is the Associate Professor of Clinical Neurology at Weill Cornell Medical College-Qatar and a Consultant Neurologist at Hamad Medical Corporation at the Neuroscience Department; He graduated as a Medical Doctor from the University of Oran, Algeria; he then moved to Belgium, the City of Liege, for a Residency in Internal Medicine and Neurology at Liege University; after getting the Belgian Board of Neurology (with high marks), he went to the National Hospital for Nervous Diseases, Queen Square, London, United Kingdom for a fellowship in Clinical Neurophysiology, under Pr Willison ; Dr Mesraoua had also further training in Epilepsy and Continuous EEG Monitoring for two years (from 2001-2003) in the Neurophysiology department of Zurich University, Switzerland, under late Pr Hans Gregor Wieser ,an internationally known epileptologist expert. \n\nDr B. Mesraoua is the Director of the Neurology Fellowship Program at the Neurology Section and an active member of the newly created Comprehensive Epilepsy Program at Hamad General Hospital, Doha, Qatar; he is also Assistant Director of the Residency Program at the Qatar Medical School. \nDr B. Mesraoua's main interests are Epilepsy, Multiple Sclerosis, and Clinical Neurology; He is the Chairman and the Organizer of the well known Qatar Epilepsy Symposium, he is running yearly for the past 14 years and which is considered a landmark in the Gulf region; He has also started last year , together with other epileptologists from Qatar, the region and elsewhere, a yearly International Epilepsy School Course, which was attended by many neurologists from the Area.\n\nInternationally, Dr Mesraoua is an active and elected member of the Commission on Eastern Mediterranean Region (EMR ) , a regional branch of the International League Against Epilepsy (ILAE), where he represents the Middle East and North Africa(MENA ) and where he holds the position of chief of the Epilepsy Epidemiology Section; Dr Mesraoua is a member of the American Academy of Neurology, the Europeen Academy of Neurology and the American Epilepsy Society.\n\nDr Mesraoua's main objectives are to encourage frequent gathering of the epileptologists/neurologists from the MENA region and the rest of the world, promote Epilepsy Teaching in the MENA Region, and encourage multicenter studies involving neurologists and epileptologists in the MENA region, particularly epilepsy epidemiological studies. \n\nDr. Mesraoua is the recipient of two research Grants, as the Lead Principal Investigator (750.000 USD and 250.000 USD) from the Qatar National Research Fund (QNRF) and the Hamad Hospital Internal Research Grant (IRGC), on the following topics : “Continuous EEG Monitoring in the ICU “ and on “Alpha-lactoalbumin , proof of concept in the treatment of epilepsy” .Dr Mesraoua is a reviewer for the journal \"seizures\" (Europeen Epilepsy Journal ) as well as dove journals ; Dr Mesraoua is the author and co-author of many peer reviewed publications and four book chapters in the field of Epilepsy and Clinical Neurology",institutionString:"Weill Cornell Medical College in Qatar",institution:{name:"Weill Cornell Medical College in Qatar",country:{name:"Qatar"}}},{id:"282429",title:"Prof.",name:"Covanis",middleName:null,surname:"Athanasios",slug:"covanis-athanasios",fullName:"Covanis Athanasios",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/282429/images/system/282429.jpg",biography:null,institutionString:"Neurology-Neurophysiology Department of the Children Hospital Agia Sophia",institution:null},{id:"190980",title:"Prof.",name:"Marwa",middleName:null,surname:"Mahmoud Saleh",slug:"marwa-mahmoud-saleh",fullName:"Marwa Mahmoud Saleh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/190980/images/system/190980.jpg",biography:"Professor Marwa Mahmoud Saleh is a doctor of medicine and currently works in the unit of Phoniatrics, Department of Otolaryngology, Ain Shams University in Cairo, Egypt. She got her doctoral degree in 1991 and her doctoral thesis was accomplished in the University of Iowa, United States. Her publications covered a multitude of topics as videokymography, cochlear implants, stuttering, and dysphagia. She has lectured Egyptian phonology for many years. Her recent research interest is joint attention in autism.",institutionString:"Ain Shams University",institution:{name:"Ain Shams University",country:{name:"Egypt"}}},{id:"259190",title:"Dr.",name:"Syed Ali Raza",middleName:null,surname:"Naqvi",slug:"syed-ali-raza-naqvi",fullName:"Syed Ali Raza Naqvi",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259190/images/system/259190.png",biography:"Dr. Naqvi is a radioanalytical chemist and is working as an associate professor of analytical chemistry in the Department of Chemistry, Government College University, Faisalabad, Pakistan. Advance separation techniques, nuclear analytical techniques and radiopharmaceutical analysis are the main courses that he is teaching to graduate and post-graduate students. In the research area, he is focusing on the development of organic- and biomolecule-based radiopharmaceuticals for diagnosis and therapy of infectious and cancerous diseases. Under the supervision of Dr. Naqvi, three students have completed their Ph.D. degrees and 41 students have completed their MS degrees. He has completed three research projects and is currently working on 2 projects entitled “Radiolabeling of fluoroquinolone derivatives for the diagnosis of deep-seated bacterial infections” and “Radiolabeled minigastrin peptides for diagnosis and therapy of NETs”. He has published about 100 research articles in international reputed journals and 7 book chapters. Pakistan Institute of Nuclear Science & Technology (PINSTECH) Islamabad, Punjab Institute of Nuclear Medicine (PINM), Faisalabad and Institute of Nuclear Medicine and Radiology (INOR) Abbottabad are the main collaborating institutes.",institutionString:"Government College University",institution:{name:"Government College University, Faisalabad",country:{name:"Pakistan"}}},{id:"58390",title:"Dr.",name:"Gyula",middleName:null,surname:"Mozsik",slug:"gyula-mozsik",fullName:"Gyula Mozsik",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/58390/images/system/58390.png",biography:"Gyula Mózsik MD, Ph.D., ScD (med), is an emeritus professor of Medicine at the First Department of Medicine, Univesity of Pécs, Hungary. He was head of this department from 1993 to 2003. His specializations are medicine, gastroenterology, clinical pharmacology, clinical nutrition, and dietetics. His research fields are biochemical pharmacological examinations in the human gastrointestinal (GI) mucosa, mechanisms of retinoids, drugs, capsaicin-sensitive afferent nerves, and innovative pharmacological, pharmaceutical, and nutritional (dietary) research in humans. He has published about 360 peer-reviewed papers, 197 book chapters, 692 abstracts, 19 monographs, and has edited 37 books. He has given about 1120 regular and review lectures. He has organized thirty-eight national and international congresses and symposia. He is the founder of the International Conference on Ulcer Research (ICUR); International Union of Pharmacology, Gastrointestinal Section (IUPHAR-GI); Brain-Gut Society symposiums, and gastrointestinal cytoprotective symposiums. He received the Andre Robert Award from IUPHAR-GI in 2014. Fifteen of his students have been appointed as full professors in Egypt, Cuba, and Hungary.",institutionString:"University of Pécs",institution:{name:"University of Pecs",country:{name:"Hungary"}}},{id:"277367",title:"M.Sc.",name:"Daniel",middleName:"Martin",surname:"Márquez López",slug:"daniel-marquez-lopez",fullName:"Daniel Márquez López",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/277367/images/7909_n.jpg",biography:"Msc Daniel Martin Márquez López has a bachelor degree in Industrial Chemical Engineering, a Master of science degree in the same área and he is a PhD candidate for the Instituto Politécnico Nacional. His Works are realted to the Green chemistry field, biolubricants, biodiesel, transesterification reactions for biodiesel production and the manipulation of oils for therapeutic purposes.",institutionString:null,institution:{name:"Instituto Politécnico Nacional",country:{name:"Mexico"}}},{id:"196544",title:"Prof.",name:"Angel",middleName:null,surname:"Catala",slug:"angel-catala",fullName:"Angel Catala",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/196544/images/system/196544.jpg",biography:"Angel Catalá studied chemistry at Universidad Nacional de La Plata, Argentina, where he received a Ph.D. in Chemistry (Biological Branch) in 1965. From 1964 to 1974, he worked as an Assistant in Biochemistry at the School of Medicine at the same university. From 1974 to 1976, he was a fellow of the National Institutes of Health (NIH) at the University of Connecticut, Health Center, USA. From 1985 to 2004, he served as a Full Professor of Biochemistry at the Universidad Nacional de La Plata. He is a member of the National Research Council (CONICET), Argentina, and the Argentine Society for Biochemistry and Molecular Biology (SAIB). His laboratory has been interested for many years in the lipid peroxidation of biological membranes from various tissues and different species. Dr. Catalá has directed twelve doctoral theses, published more than 100 papers in peer-reviewed journals, several chapters in books, and edited twelve books. He received awards at the 40th International Conference Biochemistry of Lipids 1999 in Dijon, France. He is the winner of the Bimbo Pan-American Nutrition, Food Science and Technology Award 2006 and 2012, South America, Human Nutrition, Professional Category. In 2006, he won the Bernardo Houssay award in pharmacology, in recognition of his meritorious works of research. Dr. Catalá belongs to the editorial board of several journals including Journal of Lipids; International Review of Biophysical Chemistry; Frontiers in Membrane Physiology and Biophysics; World Journal of Experimental Medicine and Biochemistry Research International; World Journal of Biological Chemistry, Diabetes, and the Pancreas; International Journal of Chronic Diseases & Therapy; and International Journal of Nutrition. He is the co-editor of The Open Biology Journal and associate editor for Oxidative Medicine and Cellular Longevity.",institutionString:"Universidad Nacional de La Plata",institution:{name:"National University of La Plata",country:{name:"Argentina"}}},{id:"186585",title:"Dr.",name:"Francisco Javier",middleName:null,surname:"Martin-Romero",slug:"francisco-javier-martin-romero",fullName:"Francisco Javier Martin-Romero",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSB3HQAW/Profile_Picture_1631258137641",biography:"Francisco Javier Martín-Romero (Javier) is a Professor of Biochemistry and Molecular Biology at the University of Extremadura, Spain. He is also a group leader at the Biomarkers Institute of Molecular Pathology. Javier received his Ph.D. in 1998 in Biochemistry and Biophysics. At the National Cancer Institute (National Institute of Health, Bethesda, MD) he worked as a research associate on the molecular biology of selenium and its role in health and disease. After postdoctoral collaborations with Carlos Gutierrez-Merino (University of Extremadura, Spain) and Dario Alessi (University of Dundee, UK), he established his own laboratory in 2008. 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