Are You a Skinny Fat Person?

Mark Hyman, MD                                                                                                                
Posted: 08/26/2012 11:15 am EDT Updated: 10/26/2012 5:12 am EDT            

The common wisdom is that if you are overweight you are unhealthy, and if you are thin, you are healthy. But new research points to just how dangerous being skinny can be -- if you are a "skinny fat" person, that is.
 
The medical term for this is "MONW," or metabolically obese normal weight, which I prefer to refer to as being a skinny fat person. It means you are under lean but over fat -- not enough muscle and too much fat (especially belly fat). It seems it is better to be fat and fit than thin and out of shape.
While we know that 68 percent of the American population is overweight, and that most have diabesity -- being somewhere on the continuum of pre-diabetes to Type 2 diabetes -- the shocking news from a study published in the Journal of the American Medical Association is that nearly 1 in 4 skinny people have pre-diabetes and are "metabolically obese."
 
What's worse is that 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. Perhaps having that extra muscle on your body from having to carry around those extra pounds protects you.


Studies on teenagers found that 37 percent of the skinny kids had one or more signs of pre-diabetes such as high blood pressure, high blood sugar, or high cholesterol. Wait -- almost four out of 10 normal-weight kids are pre-diabetic?
  
It is bad enough that one-third of kids are overweight or obese in America, but now it appears that only about 20 percent of children in America are healthy. In other words, 8 out of 10 children in America are overweight or have pre-diabetes or Type 2 diabetes.
 
In my medical practice I see this all the time. Jim came in for a "wellness check up" and felt happy about his weight. His BMI (or body mass index) was 22 (normal is 18 to 24.)
He 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 he had a blood sugar of 117 mg/dl (pre-diabetes), triglycerides of 350 mg/dl, and an HDL of 35 mg/dl. His blood pressure was 148/96 mmHg (normal is less than 110/75 mmHg).

And when we measured his insulin levels after taking a sugar drink, they were sky high. Insulin is the real culprit here -- it is the fat storage hormone. It stores belly fat and leads to hormonal and metabolic changes that cause muscle loss and inflammation, furthering the vicious cycle of pre-diabetes or Type 2 diabetes -- whether you are skinny or fat.
He was shocked to find out he had severe pre-diabetes and was a ticking time bomb for a heart attack, stroke, and even cancer and dementia. I treated Jim exactly the same way as my patients with Type 2 diabetes.


Get the Right Tests


So how do you know if you are a skinny fat person? There are a few criteria you can use that can help you identify yourself as having diabesity or being "skinny fat," including family history of Type 2 diabetes or early onset of heart disease (heart attack in relative under 50 years old), or even looking down and see a little pot belly. And if you are of Asian or Indian descent, you can get diabesity at a much lower body weight.
There are some important blood tests that you should have your doctor do:

• Fasting blood sugar or glucose (normal less than 90 mg/dl)
• Triglycerides (normal less than 100 mg/dl)
• HDL (good cholesterol (normal greater than 60 mg/dl)
• Blood pressure (normal less than 120/80, ideal less than 115/75)

But there are a few special tests your doctor may not do that you should insist on that tell the true story and help to detect diabesity much earlier. They are:
1. An insulin response test (what most doctors call a glucose tolerance test but with the addition of insulin measurements) that will:

• Measure glucose (blood sugar) AND insulin levels while fasting and one and two hours after a 75-gram glucose drink (the equivalent of two sodas).
• Glucose should be less than 90 mg/dl fasting and never go above 120 mg/dl at one and two hours. Over 140 mg/dl is pre-diabetes, and over 200 mg/dl is Type 2 diabetes.


• Insulin should be less than 10 fasting and never go above 25 or 30 after the sugar drink. Many with diabesity and skinny fat people can have levels over 50, 100, or even 200.

2. NMR Lipid Particle Test (by LipoScience performed by LabCorp)

• This measures the size and number of cholesterol particles. You should have fewer than 1,000 total
• LDL particles and fewer than 500 small LDL particles.


• Most cholesterol tests just measure the total amount, like 200 mg/dl, but the particle test is MUCH better at predicting risk for heart disease.


• When you are a skinny fat person with diabesity you have too many particles, and they are the small, dense, dangerous kind.