Dr. Mark Hyman: Do You Have Skinny-Fat Syndrome?


“If I’m not overweight, do I need to become concerned about obesity and other health issues?” asks this week’s House Call. “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.

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 and if you are thin, you are healthy. Unfortunately, the reality isn’t so simple.

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 because 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, cancer and dementia.

You might be surprised how I addressed these conditions.

How Do You Know if You’re Skinny-Fat?

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)

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You might also ask your doctor for these two tests that help detect diabesity and other problems before they become problems:

1. An insulin response test that measures glucose (blood sugar) 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. 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. More than 140 mg/dl indicates pre-diabetes and more than 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.

2. 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. 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.

Curbing Skinny Fat Syndrome with these Strategies

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:

  • 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 the U.S. These pharmacological doses crash our metabolism, spike insulin levels and wreak all sorts of havoc.

  • 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.

  • Increase fiber intake. Load up on plenty of fiber-rich plant foods like non-starchy veggies, legumes, nuts, seeds and lower-sugar fruits like berries.

  • Exercise regularly. For skinny-fat syndrome, I particularly like strength training and high intensity interval training to build muscle and reverse insulin resistance.

  • Avoid artificial sweeteners. Check out my recent blog where I discussed the numerous dangers of these fake sugars.

  • Get good sleep. Sleep deprivation alters metabolism and increases cravings for carbs and sugar. Make time for eight hours of quality sleep every night. You can find 19 of my top sleep tips here.

  • 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. You can find these and other professional-quality supplements in my store.

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 in this blog and implement the eight strategies to reverse this health-robbing condition.

The smartest way I know to reverse skinny-fat syndrome is by following The Blood Sugar Solution 10-Day Detox Diet, which allows you to gain control of your health and lose dangerous “skinny fat” in just 10 days. You can also find tons of free information about controlling insulin levels and reversing diabesity on my blog page.


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