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Thin on the outside, fat on the inside

by Dr Rangan Chatterjee   /  December 1, 2015

Is it possible to look skinny but be clinically obese? You might be surprised by the answer…

We all know that we have a big problem with obesity in this country. The World Health Organisation projects that by 2030 almost three quarters of men and two thirds of women will be overweight. This is clearly very worrying with serious consequences for people’s health as well as the nation’s finances.

In this blog, however, I want to draw your attention to an issue that can be just as serious – if not more! It’s the phenomenon of being thin on the outside but fat on the inside, often called ‘skinny fat’ or TOFI for short.

You’ve probably heard people boast, “I’m so lucky, I can eat whatever I want without putting on weight” but… is that really all that lucky?

In a word: no. Ironically, it may be these thin individuals with dangerous levels of visceral fat that need to worry the most about their health. These people can often carry on in cruise control with their lifestyle choices without knowing about the hidden dangers beneath their skin.


Remember Sandeep on the first episode of Doctor in the House? He had a relatively normal BMI but actually had alarming levels of visceral fat inside his body. This is the dangerous kind of fat that surrounds your organs such as your liver and heart.

This has been known in the medical profession for many years but more and more research keeps emerging that supports this.

A recent paper in the Annals of Internal Medicine reports that “Normal weight adults with central obesity (TOFIs) have worse long term survival rates than those with raised BMIs”.

One of the study authors, Dr.Lopez–Jimenez, says that the findings “suggest that persons with normal-weight central obesity (TOFI) may represent an important target population for lifestyle modification and other preventive strategies.”


People who are TOFI are often of normal weight. However, they have low levels of lean muscle, but excess amounts of visceral fat.

Excess levels of visceral fat is associated with Insulin Resistance, which can lead to type 2 diabetes and heart disease as well as many other related diseases.

Often you can recognise someone like this as they have an “apple” appearance – think of the classic “beer belly”. Beer does not contain any fat but is loaded with sugar and refined carbohydrates, key drivers of excess visceral fat.

On the first episode of Doctor in the House, I arranged for a specialist DEXA scan for Sandeep to look at his levels of visceral fat. Unfortunately this is not available on the NHS but a simple way to get similar information is to ask your practice nurse to take your waist and hip measurements.

From this, you can calculate your Waist to Hip ratio (WHR). Ideally, you want your waist to be smaller than your hips. Abdominal obesity is when your WHR is greater than or equal to 0.9 for a man and greater than or equal to 0.85 for a woman.


The treatment for TOFI is often very similar to that for obesity. That is because the goal is not only to be a normal body weight, it is to be healthy and lean as well.

At you might expect, diet plays a key role. When I work with my patients to become more healthy, any weight loss is always a great bonus. For me, that is never the goal! The goal is to concentrate on eating whole food in its natural unprocessed form as much as possible (you can read more about this in my free e-book.)

Strength training can also be very useful for those who are TOFI. It increases lean muscle as well as improving insulin sensitivity. Simple bodyweight exercises such as press ups, step ups and squats can be highly effective. If you feel you don’t have enough time, why not try my 5 minute kitchen workout.

As always, I love to read your comments and questions, so please get in touch via Facebook and Twitter if you’d like to chat.

— Dr Chatterjee


DISCLAIMER: The content in this blog is not intended to constitute or be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your doctor or other qualified health care provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read in this blog or on this website.

Dr. Rangan Chatterjee MbChB, BSc (Hons), MRCP, MRCGP