Dr Peter Brukner OAM

“I’m not overweight. How can I have type 2 diabetes?”

4 mins read

Much of the recent evidence about type 2 diabetes remission suggests that weight loss is essential for type 2 diabetes remission.¹  

However, despite type 2 diabetes usually being associated with obesity, a proportion of those with type 2 diabetes have a normal or even a low Body Mass Index (BMI) – in other words, they are normal weight or even skinny.

So, if you are not overweight and have type 2 diabetes, how is this possible? Well, it’s common, and there’s even a name for it: Lean diabetes

Lean diabetes is known by many names – the thin-fat phenotype, skinny fat, MONW (metabolically obese, normal weight), or TOFI (thin on the outside, fat on the inside).

People with lean diabetes fit within a healthy range and have a low amount of subcutaneous fat (fat that sits just beneath the skin and is visible), often with reduced muscle mass, which means they often look relatively lean. 

However, these individuals have excess visceral fat – the fat surrounding our abdominal organs – which isn’t visible.

Visceral fat is particularly damaging as it contains fat cells that produce inflammatory cytokines, which contribute to the inflammation associated with many chronic diseases, including type 2 diabetes.

People with lean diabetes may also have metabolic syndrome, which we associate with type 2 diabetes. Symptoms include high blood pressure and abnormal levels of cholesterol (especially raised triglycerides).² ³

Those with lean diabetes and metabolic syndrome have an increased risk of health issues such as heart disease, heart attacks and non-alcoholic fatty liver disease.

What causes lean diabetes?

A growing body of evidence suggests that the increased health risks of obesity and metabolic syndrome are more strongly associated with visceral fat than total body fat.

Those with too much visceral fat and a fatty liver are as likely to experience poor metabolic health as those with too much subcutaneous fat and are clinically overweight or obese.⁴

It’s also thought that lean diabetes occurs due to reduced insulin secretion and increased insulin resistance. Some evidence suggests that too much fructose may be a contributing factor.

What is the treatment for lean diabetes?

While weight loss may not be the main focus for someone of healthy weight with type 2 diabetes, the management of type 2 diabetes is the same as for someone with type 2 diabetes who is overweight.

We recommend choosing low carbohydrate, real foods, lowering your intake of sugar-sweetened beverages and avoiding processed foods and seed oils. The Defeat Diabetes Program can help people to get better control of blood glucose levels by reducing visceral fat and maintaining a healthy weight.

5 tips for managing lean diabetes

  1. Choose a low carbohydrate diet. Reduce seed oils, sugar and carbohydrates. This will help to reduce visceral fat and improve insulin sensitivity.⁵

  2. Choose full-fat over low-fat products. Low fat products are often high in sugar and carbohydrates and can worsen blood sugar levels (many studies have shown a low carb diet to be more effective at reducing visceral fat than low fat diets).⁶ ⁷

  3. Get regular exercise. Strength training is particularly beneficial, as it helps to increase muscle mass and improve insulin sensitivity in the muscle.

  4. Have a healthy sleep regime. Studies have shown that poor sleep may cause you to gain visceral fat⁸ ⁹ and impacts blood glucose and insulin resistance.

  5. Reduce alcohol intake. Drinking too much alcohol may increase the amount of visceral fat in your body.¹⁰

1  Taylor R, Ramachandran A, Yancy W S, Forouhi N G. Nutritional basis of type 2 diabetes remission. BMJ 2021; 374 :n1449 doi:10.1136/bmj.n1449

2  Feldman, Alexandra MD, et al. Clinical and Metabolic Characterization of Lean Caucasian Subjects With Non-alcoholic Fatty Liver. American Journal of Gastroenterology 112(1):p 102-110, January 2017. | DOI: 10.1038/ajg.2016.318 

3 DiStefano, J.K., Gerhard, G.S. NAFLD in normal weight individuals. Diabetol Metab Syndr 14, 45 (2022). https://doi.org/10.1186/s13098-022-00814-z

4 Thomas EL, Parkinson JR, Frost GS, Goldstone AP, Doré CJ, McCarthy JP, Collins AL, Fitzpatrick JA, Durighel G, Taylor-Robinson SD, Bell JD. The missing risk: MRI and MRS phenotyping of abdominal adiposity and ectopic fat. Obesity (Silver Spring). 2012 Jan;20(1):76-87. doi: 10.1038/oby.2011.142. Epub 2011 Jun 9. PMID: 21660078.

5 Goss, A.M., Gower, B., Soleymani, T. et al. Effects of weight loss during a very low carbohydrate diet on specific adipose tissue depots and insulin sensitivity in older adults with obesity: a randomized clinical trial. Nutr Metab (Lond) 17, 64 (2020). https://doi.org/10.1186/s12986-020-00481-9

6 Sasakabe T, Haimoto H, Umegaki H, Wakai K. Association of decrease in carbohydrate intake with reduction in abdominal fat during 3-month moderate low-carbohydrate diet among non-obese Japanese patients with type 2 diabetes. Metabolism. 2015 May;64(5):618-25. doi: 10.1016/j.metabol.2015.01.012. Epub 2015 Jan 29. PMID: 25682064.

7 Gower BA, Goss AM. A lower-carbohydrate, higher-fat diet reduces abdominal and intermuscular fat and increases insulin sensitivity in adults at risk of type 2 diabetes. J Nutr. 2015 Jan;145(1):177S-83S. doi: 10.3945/jn.114.195065. Epub 2014 Dec 3. PMID: 25527677; PMCID: PMC4264021.

8 Theorell-Haglöw J, Berne C, Janson C, Sahlin C, Lindberg E. Associations between short sleep duration and central obesity in women. Sleep. 2010 May;33(5):593-8. PMID: 20469801; PMCID: PMC2864874.

9 Hairston KG, Bryer-Ash M, Norris JM, Haffner S, Bowden DW, Wagenknecht LE. Sleep duration and five-year abdominal fat accumulation in a minority cohort: the IRAS family study. Sleep. 2010 Mar;33(3):289-95. doi: 10.1093/sleep/33.3.289. PMID: 20337186; PMCID: PMC2831422.

10 Bendsen NT, Christensen R, Bartels EM, Kok FJ, Sierksma A, Raben A, Astrup A. Is beer consumption related to measures of abdominal and general obesity? A systematic review and meta-analysis. Nutr Rev. 2013 Feb;71(2):67-87. doi: 10.1111/j.1753-4887.2012.00548.x. Epub 2012 Dec 13. PMID: 23356635.

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