Why “Skinny Fat” Can Be Worse than Obesity - Dr. Mark Hyman

Why “Skinny Fat” Can Be Worse than Obesity

We have a big fat problem. America is a fat nation, and we are failing to solve our big fat problem. Failing big-time. Almost 70 percent of Americans are overweight. The latest study from the Centers for Disease Control and Prevention (CDC) shows about 35 percent of Americans are obese.

It comes as no surprise, then, that one in two Americans has what I call diabesity— the spectrum of imbalance ranging from mild insulin resistance to pre-diabetes to full-blown type 2 diabetes. The scariest part is that 90 percent of those suffering from this serious health condition don’t even know it.

Our diabesity epidemic aside, being overweight or obese can increase your risk for numerous problems including stroke, some cancers, heart disease, and depression. It can also seriously diminish quality of life.

What many people don’t realize is that we can suffer all these problems – diabesity and all its detrimental health consequences – even if we’re normal weight or underweight.

In fact, about one-quarter of the remaining 30 percent of those who don’t fall into the overweight or obese categories are what I call “skinny fat,” and the ramifications can be even more devastating than being overweight or obese.

The “TOFI” Epidemic

While the word “diabesity” is made up of the concepts of obesity and diabetes, even those who aren’t overweight can have this problem. These are the “skinny fat” people. They are “underlean” (not enough muscle) instead of “overweight” and have a little extra weight around the middle, or “belly fat.”

Scientists have a word for this phenomenon: Thin on the outside, fat on the inside, or TOFI. Dr. Jimmy Bell coined this acronym to describe people who are thin but unhealthy.

These skinny-fat people have a low body mass index (BMI) but very little muscle. They maintain a normal weight while suffering all the consequences of diabesity on the inside.

You might know someone who falls into the TOFI category. They eat whatever they want and stay thin, and you might even envy their ability to devour a piece of chocolate cake and not worry about their weight.

They might do some brisk walking or yoga, but they rarely engage in muscle-building exercise. Even though they are average or below weight, TOFIs often lack muscle tone. They often look tired, haggard, and even pale.

While they may not be technically overweight and may even look skinny on the outside, TOFIs have the metabolic features of a pre-diabetic obese person: Low muscle mass, inflammation, high triglycerides, low good cholesterol, high blood sugar, and high blood pressure.

If you’re overweight or obese, you’re well aware of the repercussions. Unfortunately, TOFIs often aren’t aware they can suffer the same consequences, which ultimately makes “skinny fat” more dangerous than being overweight.

“TOFIs probably need to worry more about their health than others, because the fat deposits they carry are hidden in the white fat that lies around their vital organs, streaked through their underused muscles, and wrapped around the heart,” writes Jo Revill in The Guardian. “It is this fat that sends out the chemical signals which eventually lead to insulin resistance, diabetes and heart conditions, rather than the fat lying in dimples underneath the skin.”

I’ve mentioned how most overweight people already have “pre-diabetes” and have significant risks of disease and death, yet they just don’t know it. Well, TOFIs fall squarely into that category, too.

A few extra pounds of belly weight, while remaining otherwise lean, can signify you are a TOFI. So can lab tests. You might be of normal weight, but have high triglycerides, low HDL, small LDL particles, and high blood sugar and insulin – all  “TOFI” signs.

Unfortunately, unless a person is overweight or obese, doctors might choose to ignore these warning signs that ultimately become big red flags for diabesity, heart disease, cancer, and much more.

Currently there are no national screening recommendations, no treatment guidelines, no approved medications, and no reimbursement to health care providers for diagnosing and treating anything other than full-blown diabetes.

If you fall outside that category, where you are pre-diabetic or otherwise heading down the diabesity highway – and a lot of people do, including TOFIs – then doctors usually do not express concern.

Think about that. Doctors are not expected, trained, nor paid to diagnose and treat the single biggest chronic disease in America, which, along with smoking, causes nearly all the major health care burdens of the twenty-first century, including heart disease, stroke, dementia, and even cancer.

Confessions of a Former TOFI 

Full disclosure: I was once a TOFI.

I used to eat Grape Nuts and ice cream for breakfast. I invented Oreo cookie ice cream. When I was a kid in the 1970s, I would come home from school and get a giant bowl of vanilla ice cream and a bag of Oreo cookies. I would take one whole row of Oreos from the package. I would carefully scrape off the white sugary part in the middle and sprinkle it on top of the ice cream. Then, I would crumble the cookie part into the ice cream and stir it all up until it was a creamy, delectable delight. Yum!

When I was 18, I became a vegetarian and thought giant cookies made with whole wheat flour, chocolate chips, honey, and nuts were a health food. Every night, I would slather mounds of honey over peanut butter on a big slice of bread.

That was the low-fat 80s, when honey, maple syrup and sugar were health foods. After all, they were low fat. Our own government was encouraging us to eat 8 to 11 servings of rice, cereal, bread, and pasta every day.

Cereal? Really? Most cereals are 75 percent sugar. That’s not breakfast. It’s dessert, even the whole-grain ones.

As my friend, Harvard professor David Ludwig, MD, PhD said once, “If you eat a bowl of corn flakes without the sugar or a bowl of sugar without the corn flakes, below the neck, they are the same thing. Your metabolism can’t tell the difference.”

As an adult, I continued my love affair with sugar and carbs. I made my own bread and pizza dough and ate pasta most nights. And of course, I was never without my Chunky Monkey and mint chocolate chip ice cream every night. I made waffles and pancakes regularly for my kids (and I ate them, too!). They were drenched in maple syrup, of course.

I constantly craved sugar and carbs. I didn’t realize that they had hijacked my taste buds, brain chemistry, hormones, and metabolism. I didn’t realize that I was a food addict. And I was not alone. The average American eats 146 pounds of flour and 152 pounds of sugar per person, per year. When combined, that’s almost one whole pound a day for every man, woman, and child in.

Here’s the thing. I was never really overweight (except about 10 pounds or so), but I noticed that my body was changing, that I was getting a bit flabby. I realized I had TOFI. I was skinny fat with love handles. Yikes!

Aesthetics aside, I also got chronic fatigue syndrome. It was sugar (and a few other things) that threw my body into a tailspin. Every night, before I went to work in the emergency room, I would eat a giant chocolate chip cookie and a half pint of Häagen-Dazs Vanilla Swiss Almond ice cream.

Then, everything crashed. I had rashes from yeast overgrowth under my eyes and itching in places I would rather not mention. My stomach was bloated, and I couldn’t digest food. My muscles ached, and I had brain fog. I had FLC Syndrome. I felt like crap.

I realized that the “healthy” low-fat, high-carb diet I was on was making me sick and making me TOFI.

If you’re a former TOFI, you know exactly what I’m talking about. And if you’re a current TOFI, don’t despair. I’m here to help you turn things around.

Overcoming TOFI Starts with Your Diet

Whether you are overweight or underweight, the consequences can become perilous. But there is hope. The right foods can help you attain and maintain a normal weight. The “prescription” for a TOFI is very similar to someone who is overweight, since the end goal is the same: Become lean and healthy, and maintain an ideal weight.

To do that, you’ll want to focus on real, whole foods. Every meal should contain copious non-starchy vegetables, four to six ounces of lean protein, and gluten-free grains (such as quinoa, black rice, and buckwheat) in their whole-kernel form.

Also include nutrient-dense starchy vegetables such as sweet potatoes and winter squash; low-glycemic fruit such as apples, pears, berries, or pomegranate; and beans and legumes. 

Healthy fats become one of the easiest ways to normalize your weight, have glowing skin, and feel better. Have one serving of a healthy fat (e.g., ¼ avocado or 1 tablespoon extra virgin olive oil, walnut oil, sesame oil, extra virgin coconut butter, or nut or seed butter – such as almond or cashew) with each meal.

Never skip meals, especially breakfast. If getting the day’s most important meal becomes a herculean challenge, consider some of my easy-to-prepare recipes.

For more information to overcome TOFI and maintain a healthy weight, see my book The Blood Sugar Solution. And, if sugar holds your health hostage and you want to forever break free from its grip, then I recommend doing my Blood Sugar Solution 10-Day Detox Diet, which will help you seamlessly transition into The Blood Sugar Solution.

Strength Training: The Secret Weapon Against TOFI 

Although some people are obviously overweight and you expect them to have a higher level of fat, others are what we call “skinny fat people” because they look skinny but have very little muscle.

That’s because it’s the ratio of fat to muscle that makes the biggest impact on health and metabolic balance, and a person’s outward appearance can be deceiving in this regard.

Suppose you lose 10 ounces of muscle a year. Even if you gain 10 ounces of fat per year during this time, the numbers on the scale may not change significantly and your clothes may not fit differently. In other words, at age 70 you could end up the same weight you were when you were age 20 but become twice as fat because your muscle tissue was replaced with fat!

We call this “metabolic obesity” or “skinny fat syndrome.” It has the same dangerous consequences for your health as being obese. As you lose muscle, you lose mitochondria and your metabolism slows down.

With age comes muscle loss. Strength training helps increase muscle size and strength. Strength training also boosts energy-producing mitochondria and metabolic rate so you burn more calories at rest or sleep.

Strength training can also help reverse or prevent diabesity. One study published in the journal Medicine and Science in Sports and Exercise found a twice-per-week 16-week resistance training program significantly increased insulin sensitivity in overweight Latino adolescent males.

Another study in the International Journal of Medical Sciences involving Hispanic adults 55 or older with type 2 diabetes found 16 weeks of strength training resulted in improved muscle quality, skeletal muscle fiber hypertrophy, accompanied by changes in biochemical markers known to contribute to whole-body insulin sensitivity.

It’s a win-win: Do strength training and you look better, feel better, reverse TOFI, and with that, reduce your risk for diabesity and other problems.

If strength training interests you – and as a TOFI, it should – find something you like and then vary it. By simply using your own body weight for training, stair climbing, push-ups, or squats can be a great start.

Finding a gym and using weights is another way to build muscle. If you have never lifted weights, be sure to get some help from the fitness trainer in the gym to learn proper technique and form to avoid injury.

Ideally, you want to build up to two sets of 8 to 10 repetitions of an exercise using a weight that leads to muscle fatigue for each major muscle group. A 20-minute routine two to three times a week can cover all the bases.

Who doesn’t have 40 to 60 minutes a week to invest in health and boosting brainpower?

7 Additional Strategies to Become TOFI-Free

As I mentioned above, many of the same solutions I provide for people with diabesity also apply to TOFIs. The basic idea involves giving your body the key components it requires so you stay lean and healthy, without being over- or underweight. Diet and exercise aside, these seven strategies can help you overcome TOFI and become your healthiest self.

  1. Address food sensitivities. Besides making you fat, food sensitivities can create miserable symptoms and contribute to inflammation, setting the stage for numerous symptoms including fatigue, headaches, and generally feeling like crap. Besides sugary and added-sugar products, you’ll want to eliminate all gluten and flour-based products (including gluten-free goods) and dairy. Too many people, trying to eat healthy, are eating too much gluten-free junk food like cookies, cakes, and other processed food. Just because a food is gluten-free doesn’t mean it’s healthy. Gluten-free cookies and cake are still cookies and cake! Vegetables, fruits, beans, nuts and seeds, and lean animal protein are all gluten-free— stick with those.
  2. Reduce stress. Stress can wreak total havoc on your health and happiness. Before your meals or any other time you need to mentally unwind, try my Take-Five Breathing Break. My UltraCalm CD can help you unwind after a long day. So can a hot bath, which relaxes your muscles and reduces tension physically and psychically. By adding one to two cups of Epsom salts (magnesium sulfate), ½ to one cup of baking soda (sodium bicarbonate), and 10 drops of lavender oil to your bath, you will gain the benefits of magnesium absorbed through your skin, the alkaline-balancing effects of the baking soda, and the cortisol-lowering effects of lavender, all of which help with sleep.
  3. Track your results. Tracking your food intake every day, along with your exercise, sleep, symptoms, and “numbers” (including weight, waist size, and lab test results) can hold you accountable to your health goals. Recognizing how you feel and what you experience as you alter your food intake and start to exercise more is like “innercise,” building the self-awareness needed to strengthen your ability to create high-level wellness and wholeness.
  4. Take 20 minutes every evening to write about your day. Try to write without stopping. If you don’t know what to write, just say, “I don’t know what to write,” until something comes to you.
  5. Stay hydrated. Drinking clean, fresh, pure water — six to eight glasses a day— has many benefits. Often we think we are hungry when we are thirsty, or we are tired when we are really dehydrated.
  6. Get seven to eight hours sleep. Lack of sleep or poor sleep damages your metabolism, causes cravings for sugar and carbs, makes you eat more, and drives up your risk of heart disease, diabetes, and early death. Getting enough sleep and sleeping well are essential for health and an easy way to maintain blood sugar balance and a healthy weight. You want to prepare for sleep. Take a “holiday” during the two hours before bed. Creating a sleep ritual can guide your body into a deep, healing night’s rest. Create a special set of things you do each night before bed to help ready your system for sleep. Visit this blog for more strategies to get a great night’s sleep.
  7. Take my foundation supplements. Studies show among its benefits, taking a high-quality multivitamin can reduce inflammation and fill in the nutrient gaps you’re probably not getting in your diet. I also recommend combining a diet that includes wild-caught fish regularly with omega 3 supplements. See this blog for a complete list of basic nutrient recommendations.

If you’ve ever known a TOFI, did you ever think that just because that person wasn’t overweight or obese that they were healthy? What changed your mind? Share your thoughts below or on my Facebook page.

Wishing you health and happiness,
Mark Hyman, MD
Mark Hyman, MD


Mark Hyman, MD

Mark Hyman, MD is the Founder and Director of The UltraWellness Center, the Head of Strategy and Innovation of Cleveland Clinic's Center for Functional Medicine, and a 13-time New York Times Bestselling author.

If you are looking for personalized medical support, we highly recommend contacting Dr. Hyman’s UltraWellness Center in Lenox, Massachusetts today.


If you are looking for personalized medical support, we highly recommend contacting Dr. Hyman’s UltraWellness Center in Lenox, Massachusetts today.

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