Dear Dr. Hyman,
“If I’m not overweight, do I need to become concerned about obesity and other health issues?
Even though I drink soda and eat whatever I want, I don’t gain weight.
Should I be worried?"
The short answer is yes, and here’s why.
One study published in the Journal of the American Medical Association found nearly one in four skinny people have pre-diabetes and are “metabolically obese.” In other words, about 25 percent of the population fit the skinny fat syndrome, also known as thin on the outside, fat on the inside (TOFI).
Skinny fat means just what it sounds like: You look thin but inside you’re fat. You’ve got organ fat (the more dangerous type of fat) coating your liver, kidneys, and other organs. You are under-lean but over-fat, meaning not enough muscle and too much fat (especially belly fat).
Most people assume if you’re overweight, you’re unhealthy; if you are thin, you are healthy. Unfortunately, the reality isn’t so simple.
Skinny fat might be worse than overweight!
Yes, America has a big fat problem: almost 70 percent are overweight and many have diabesity, a condition I define as anywhere on the continuum between pre-diabetes and type 2 diabetes.
Even though it might sound crazy, being skinny fat might become more dangerous than being overweight.
Let’s say you go to your annual doctor visit and you are overweight or obese. He or she will probably run blood tests, become concerned about type 2 diabetes, and ask you to lose some weight.
If you arrive thin, your doctor might not conduct those blood tests or otherwise acknowledge underlying issues. He or she might assume things are normal rather than checking under the hood for pre-diabetes and other problems that pave the way for detrimental repercussions.
That’s unfortunate, since if you are a skinny fat person and get diagnosed with diabetes, you have twice the risk of death than if you are overweight when diagnosed with diabetes. People who are thin but have pre-diabetes and high sugar also increase their risk for heart disease and early death.
In my medical practice, I see skinny fat syndrome all the time. Jim provides an excellent example. He came in for a “wellness checkup” and felt happy about his weight. His body mass index (BMI) was 22, which seemed within the normal range.
Jim never seemed to gain weight and felt he could “tolerate” a diet that included lots of bread, pasta, and sugar. He liked his two sodas a day and a few glasses of wine at night. He walked but didn’t do much vigorous exercise or weight training.
When we looked under the hood, we found Jim’s blood sugar was 117 mg/dl (pre-diabetes). His triglycerides were 350 mg/dl and his HDL was 35 mg/dl. His blood pressure was 148/96 mmHg. (Normal is less than 110/75 mmHg.)
When we measured his insulin levels after taking a sugar drink, they were sky high.
The culprit for many of these elevated numbers was inulin, the fat-storage hormone. Insulin stores belly fat and leads to hormonal and metabolic changes that cause muscle loss and inflammation, furthering the vicious cycle of pre-diabetes or worse, developing type 2 diabetes whether you are skinny or fat.
Jim understandably expressed shock that he had severe pre-diabetes and was a ticking time bomb for a heart attack, stroke, and even cancer and dementia.
You might be surprised how I addressed these conditions.
Am I “Skinny Fat”? Here’s how to know…
Signs of skinny fat syndrome include family history of type 2 diabetes, early onset of heart disease, or even having a little potbelly.
But signs can also be subtler, and I would rather you test than guess. That is why I strongly recommend blood tests to reveal skinny fat syndrome.
Ask your doctor to do these tests (ideal ranges are in parenthesis):
- Fasting blood sugar or glucose (normal less than 90 mg/dl)
- Triglycerides (normal less than 100 mg/dl)
- HDL – the good cholesterol (normal greater than 60 mg/dl)
- Blood pressure (normal less than 120/80, ideal less than 115/75)
You might also ask your doctor for these two tests that help detect diabesity and other problems before they become problems:
- An insulin response test that measures glucose (glicemia) AND insulin levels. This test is conducted in two steps: first, levels are checked after fasting; then levels are checked at one- and two-hour intervals after consuming a 75-gram glucose drink –the equivalent of two sodas.
Here’s what to look for:
Glucose should be less than 90 mg/dl after fasting and should never go above 120 mg/dl at the one- and two-hour marks.
Over 140 mg/dl indicates pre-diabetes and over 200 mg/dl indicates type 2 diabetes.
Insulin should be less than 10 after fasting and should never go above 25 or 30 after the sugar drink. Many with diabesity and skinny fat syndrome can have levels of over 50, 100, or even 200.
- NMR Lipid Particle (from Labcorp) or Cardio IQ Test (from Quest).This is the 21st-century cholesterol test that proves far more accurate at predicting heart disease and other factors than the traditional test which looks at total cholesterol levels. This measures the size and number of cholesterol particles.
Here’s what to look for:
You should have less than 1000 total LDL particles and less than 500 small LDL particles (the small, dense, dangerous kind). When you are a skinny fat person with diabesity, you have too many LDL and these are destructive and can cause leaky gut.
8 tips to reverse “Skinny Fat Syndrome”
Earlier, I discussed Jim, my skinny fat patient who was shocked to find he had diabesity. I worked with Jim and numerous other skinny fat patients with the exact same strategies as someone who is overweight, because both paths lead to diabesity and all its repercussions.
The solution requires getting blood sugar and insulin levels under control. These eight strategies always help:
1. Cut out refined sugar
We eat an average of 152 pounds of sugar and 146 pounds of flour (which convert to sugar) per person, per year in America. These pharmacological doses crash our metabolism, spike insulin levels, and wreak all sorts of havoc.
2. Eat MORE fat!
Healthy fat will cut your cravings. Olive oil, avocados, coconut butter, fish fat, and grass-fed lamb or beef all have good fats that boost your health while normalizing insulin and other hormones.
3. Increase fiber intake
Load up on plenty of fiber-rich plant foods like non-starchy veggies, legumbres, nuts and seeds, and lower-sugar fruits like berries.
4. Exercise regularly
For skinny fat syndrome, I particularly like strength training and high intensity interval training (HIIT) to build muscle and reverse insulin resistance.
5. Don’t drink your calories
That includes energy drinks, fruit juices, and alcohol. One recent study found sugar-sweetened beverages account for 184,000 deaths every year.
6. Avoid artificial sweeteners
Check out my blog where I discussed the numerous dangers of these fake sugars.
7. Get good sleep
Sleep deprivation alters metabolism and increases cravings for carbs and sugar. Make time for 8 hours of quality sleep every night.
8. Supplement smartly
Supplements help to maintain the optimal amounts of nutrients you need to optimize metabolism, help burn calories, and balance blood sugar. We get a lot of these from our healthy food choices; however, I always recommend a basic protocol to ensure optimal levels. At the very least, you should be taking a good multivitamin, fish oil (EPA/DHA,) and vitamin D.
If you suspect you’re skinny fat, don’t just assume everything is okay. Go to your doctor and check under the hood. Don’t be complacent simply because you are not overweight. Ask for the tests I mention here and implement the eight strategies to reverse this health-robbing condition.
Mark Hyman, MD, believes that we all deserve a life of vitality—and that we have the potential to create it for ourselves. That’s why he is dedicated to tackling the root causes of chronic disease by harnessing the power of Functional Medicine to transform healthcare. Dr. Hyman and his team work every day to empower people, organizations, and communities to heal their bodies and minds, and improve our social and economic resilience.
Dr. Hyman is a practicing family physician, a nine-time #1 New York Times bestselling author, and an internationally recognized leader, speaker, educator, and advocate in his field.
He is the Director the Cleveland Clinic Center for Functional Medicine. He is also the founder and medical director of The UltraWellness Center, chairman of the board of the Institute for Functional Medicine, a medical editor of The Huffington Post, and was a regular medical contributor on many television shows including CBS This Morning, Today Show, Good Morning America, CNN, and The View, Katie and The Dr. Oz Show.
Dr. Hyman works with individuals and organizations, as well as policy makers and influencers. He has testified before both the White House Commission on Complementary and Alternative Medicine and the Senate Working Group on Health Care Reform on Functional Medicine. He has consulted with the Surgeon General on diabetes prevention, and participated in the 2009 White House Forum on Prevention and Wellness.
Senator Tom Harkin of Iowa nominated Dr. Hyman for the President’s Advisory Group on Prevention, Health Promotion, and Integrative and Public Health. In addition, Dr. Hyman has worked with President Clinton, presenting at the Clinton Foundation’s Health Matters, Achieving Wellness in Every Generation conference and the Clinton Global Initiative, as well as with the World Economic Forum on global health issues.
He is the winner of the Linus Pauling Award, The Nantucket Project Award, and was inducted in the Books for Better Life Hall of Fame, and the Christian Book of the Year Award for The Daniel Plan.
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