It appears to be common belief that only overweight individuals are at risk for type 2 diabetes mellitus (T2DM). This is a widespread misconception. While it’s true that obesity is a risk factor, it’s essential to realize that even thin (or “skinny”) people can develop this chronic condition. In this article, we will explore the connection between body fat distribution and T2DM risk, shedding light on the concepts of Metabolically Healthy Obesity (MHO), Metabolically Obese Normal Weight (MONW), and Thin on the Outside, Fat on the Inside (TOFI). Can there be such a thing as being “skinny-fat”?
The Hidden Truth: Body Fat Distribution Matters
It is important to remember that T2DM doesn’t solely depend on outward appearances but rather on how the body regulates insulin and blood sugar. Hence, it is essential to recognize that individuals with a slender physique can also be vulnerable to developing diabetes, and this risk is shaped by more than just a numerical value on the body mass index (BMI).
MHO: Metabolically Healthy Obesity
Metabolically Healthy Obesity, or MHO, is a term that challenges the traditional view that all obese individuals are at high risk for metabolic diseases such as T2DM. MHO individuals have a high BMI, which is typically associated with obesity, but they maintain a surprising degree of metabolic health. They exhibit normal insulin sensitivity, blood pressure, and have favorable lipid profiles, including high levels of HDL (the “good” cholesterol) and low levels of plasma triglycerides. This sub-phenotype has been observed in people with BMIs well above 40 kg/m². A prime example of this sub-group of individuals is Sumo wrestlers.
However, it’s important to note that there is some debate in the medical community about the existence of true MHO individuals, as they may still present with subtle metabolic abnormalities, particularly related to inflammatory markers. Nonetheless, the concept of MHO challenges the notion that high BMI inevitably equates to poor metabolic health.
MONW: Metabolically Obese Normal Weight
On the other side of the spectrum, we have Metabolically Obese Normal Weight (MONW) individuals. These individuals may appear lean with a BMI under 25 kg/m², but they carry metabolic profiles typically associated with obesity. They often exhibit reduced insulin sensitivity, lower levels of HDL cholesterol, and elevated blood pressure.
What distinguishes MONW individuals is their unique pattern of adipose tissue distribution. Advanced imaging techniques like MRI have revealed that they can have a disproportionate deposition of visceral adipose tissue, particularly around the abdomen. This type of fat distribution significantly increases their risk of developing insulin resistance and, ultimately, T2DM.
TOFI: Thin on the Outside, Fat on the Inside
TOFI, or Thin on the Outside, Fat on the Inside, is a sub-phenotype that challenges our preconceived notions of health based on outward appearance. These individuals may look lean, even though they harbor a significant amount of hidden fat. Their body composition includes not only visceral fat but also ectopic fat deposits in the liver, muscles, and even the pancreas.
Elevated intra-hepatocellular lipid (IHCL) is a common feature in many TOFI individuals, and this is an independent risk factor for insulin resistance. They are often found among those who strive to maintain a “normal weight” through diet and minimal physical activity. Despite their lean appearance, TOFI individuals may have a heightened risk of developing T2DM due to their unique fat distribution and metabolism.
Key Takeaways
Understanding that thin people can also be at risk for T2DM due to factors such as MHO, MONW, and TOFI is vital for both healthcare professionals and the general public. It’s time to look beyond body weight and potentially consider the distribution of adipose tissue when evaluating diabetes risk. By promoting healthy lifestyle choices and a more comprehensive view of health, we can reduce the risk of diabetes and its associated complications for a healthier future.
BMI: body mass index; IHCL: intra-hepatocellular lipid; MHO: metabolically healthy obesity; MONW: metabolically obese, normal weight; T2DM: type 2 diabetes mellitus; TOFI: thin on the outside, fat on the inside
Link to the full article: https://www.physoc.org/magazine-articles/body-fat-our-own-janus/
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