Commentary: ‘Skinny-fat’ Asians face a hidden risk for Type 2 diabetes

SINGAPORE: If you are one of the many Asians who have never struggled with weight and are considered within “normal” weight, you might still be told by your doctor that you are at high risk of developing Type 2 diabetes.
It can be surprising, then confusing, and especially frustrating. The term “skinny-fat” sounds like an oxymoron at best and body-shaming at worst, but it perfectly describes a significant risk factor for diabetes in Asians.
It describes an individual who may appear of normal weight, yet has low muscle mass and a high percentage of body fat. This sets the stage for insulin resistance.
It’s more common in Asians than we might realise and an alarming reality behind this is the hidden risk of diabetes.
Asians face a greater risk of diabetes despite not being obese. One in three Singaporeans is at risk of developing diabetes in their lifetime, while nearly one in 10 adults live with diabetes.
It can be dangerously misleading for Asians to view Type 2 diabetes as a disease only linked to excess weight, as is often portrayed outside of Asia. On the surface, this makes sense – more body fat can disrupt insulin sensitivity, making it harder for the body to manage blood sugar levels – so obesity can be a useful starting point to consider diabetes risk.
But studies show that Asians are more likely to develop diabetes at a lower body mass index (BMI) compared to other groups. And this is despite lower BMI thresholds: Obesity is defined as above or equal to 27.5 kg/m2 for Asians, and 30 kg/m2 for non-Asian adults.
While BMI has long been used to estimate the risk for diabetes and other metabolic conditions, it doesn’t always paint a complete picture.
One major reason is that Asians tend to have a different body fat distribution compared to non-Asians. Someone who looks slim may carry more visceral fat – the kind of fat stored around internal organs – which is much more harmful than subcutaneous fat – the kind you can pinch.
Visceral fat significantly increases insulin resistance. So an Asian with a “healthy” weight might still have enough visceral fat to interfere with normal glucose regulation, leading to a higher risk of Type 2 diabetes.
The medical community is increasingly moving away from relying solely on BMI as a health metric. A more holistic approach includes looking at other measurements such as waist circumference, body fat percentage and visceral fat levels to get a more comprehensive understanding of a person’s metabolic health.
Unfortunately, cultural habits and lifestyle choices play a big part of this problem.
In Singapore, only 71.1 per cent of Singaporean adults met the physical activity guidelines in 2021. Following these guidelines is crucial for maintaining healthy muscle mass and regulating blood sugar levels. Even well-meaning habits, like emphasising academic success, may come at the expense of adequate physical activity for kids, and can create conditions that lead to an increased risk later on in life.
Dietary patterns are another major factor contributing to the increased risk of diabetes in Asians: Rice and other refined carbohydrates such as breads and buns have been diet staples for generations.
In today’s context, where many have sedentary jobs and don’t generally engage in physically demanding activities outside of exercise, relying on these high glycemic index (GI) foods can be harmful. They cause rapid spikes in blood sugar levels, which, combined with a genetic predisposition to insulin resistance, can impair the body’s ability to manage insulin effectively.
The good news is that we can significantly reduce the risk of diabetes, even for those with genetic predisposition. The first step is recognising that being “slim” doesn’t always mean healthy.
Sounds easy, but it’s not that straightforward. Take the case of one of my patients: He looks outwardly fit, his BMI is normal and says he has been lean his whole life. He always believed he was in pretty good shape – until a health check-up.
It was a wake-up call. Surprisingly, his blood sugar levels were creeping up, while the body composition analysis showed that his body fat percentage was on the higher end.
Looking healthy on the outside or on the weighing scale didn’t necessarily mean that his metabolic health was in good shape.
Health assessments and personalised care that take into account factors like body or visceral fat and muscle mass can be more effective in predicting diabetes risk and empowering people to improve their health.
Next, it’s been said but always bears repeating: Lifestyle interventions, such as increasing physical activity, improving diet and managing stress, are incredibly effective in preventing diabetes.
If intense workouts are daunting, start with something as simple as brisk walking, swimming or yoga to get on the right track. Another of my patients started doing resistance training and lifting light weights to build muscle and reduce her visceral fat.
When it comes to diet, small but consistent changes can make a big difference. Reducing the intake of refined carbohydrates and replacing them with whole grains, legumes and non-starchy vegetables like broccoli can help stabilise blood sugar levels. Including lean protein in every meal further moderates glucose spikes and helps build muscle, supporting overall metabolic health.
We need to reframe the narrative around diabetes and weight, especially in Asian communities. Too often, people believe that only those who are visibly overweight are at risk for diabetes, leaving many who appear slim unaware that they too could be vulnerable.
In fact, someone who looks overweight can actually be metabolically healthy if they have good muscle mass, healthy fat distribution and stay active. Those who appear slim may be at higher risk due to factors like hidden visceral fat and lack of muscle mass.
Diabetes prevention isn’t just about losing weight – it’s about improving overall metabolic health. For many, it starts with realising that true health goes beyond appearances.
Dr Kyle Tan is a co-founder and consultant at NOVI Health.