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This post was updated on December 1, 2018for accuracy and comprehensiveness. It was originally published on December 26, 2016.

If you have been following this blog for a while, you are aware that body composition analysis is being used by many fitness experts, coaches, and healthcare professionals, and is essential if you truly want to get a handle on becoming fit.

But now might be the perfect time to emphasize the actual health risks and benefits associated with various body compositions, especially as we enter into 2019, with all those New Year’s resolutions fresh on our minds.

One thing we can safely do in 2019 is dump our reliance and our attention on the body mass index (BMI) as a means to measure our health.

The limitations of using the BMI to guide clinical and fitness decisions have been well documented, and it may be time to just say goodbye to BMI altogether when it comes to making decisions concerning a single individual, as outlined previously in this blog or as highlighted by many others.

Not having specific detailed insights into your personal body composition may lead to critical errors in assumptions, understanding, and recommendations, which can hinder your ability to reach your fitness goal. In fact, in some cases, it may even result in serious misdiagnosis, inappropriate treatments, and certainly missed opportunities.

We all know that besides our appearance, there is a long list of diseases that are obviously associated with obesity, which seems (and we will address this in a minute) to be the thing that is a the top of our minds this time of year. The list is long, but certainly includes heart disease, hypertension, cancer, joint problems, dementia, and diabetes.

But what about other abnormalities of body composition, like having too little muscle mass –  so-called “skinny fat” – when there is both sarcopenia (lack of muscle) and the sometimes less obvious visceral fat that can collect around the middle even for people whose BMI is normal (18-25)?

These are definite concerns that impact everyone, which is why a knowledge of your body composition is important for your health in 2019 and beyond.

The Elephant in the Room

Source: CDC

With so many different ailments related to body composition, let’s just spend a bit of time looking at one, if not the biggest, problem facing you and our nation today: diabetes.

In the September 8, 2015 edition of JAMA: the Journal of the American Medical Association, it was estimated that 52.3 % of the entire US population in 2012 had either diabetes (14.3%) or so-called prediabetes (38.0%).

But if that is not bad enough, a UCLA study in 2016 reported that in California, 55% of the state either have diabetes (9%) or have pre or undiagnosed diabetes (46.0%).  This is a true epidemic.

If you are just looking at the risks and causes of diabetes in those who are overweight or obese, you just might miss many opportunities to prevent, treat, or even reverse diabetes. A reliance on traditional metrics like the BMI and body weight could leave you in the dark.

Think about it this way: The use of the BMI assumes that the human body is composed of one homogeneous mass, when in fact, different tissue types (fat, muscle, etc) have significantly different mass, different volume, and different functions and impacts, not just on our appearance, but also on our metabolic health as well.

Let’s look at a group of people with normal BMIs.  Per gram, fat (which is what we seem to always be focusing on)  is about 14% larger than muscle by volume.

To visualize the implication, look at the images below of six actual men, all of whom are 5 feet 9 inches tall and 172 pounds. Many might be envious of their 25.4 BMI and most physicians, as they glance at their EMR computer screens, would congratulate and applaud. But looking at the actual patient or their scans via modern technology is instantly revealing.

Source: Body Labs

You may notice that Person 2 has a total volume of 76.8 L and visually appears much different than Person 5, who has a volume of 81.3 L.  Person 5 takes up roughly 6% more volume. Where is that extra 6% coming from? Body fat.

Notice particularly the difference in the midsection, where the abnormal accumulation of visceral fat occurs in metabolic syndrome, or what is becoming known as adiposity disease.

But what if we could learn what the actual body composition is for each of these men? What if we knew just how much muscle they had and how it is distributed?  What if we could determine how much fat a person carries around, and where that fat was located?  How might that knowledge change how one approaches attaining their fitness goals in 2019?

Maybe more importantly: How might that knowledge affect how one might approach or treat a person who was recently diagnosed with this ever so common disease, diabetes?

These questions are no longer just theoretical with the advent of state of the art tools to determine individual body composition in the gym or in the modern exam room in real time.

A Recent Clinical Example: Diabetes Reversed with A Better Body Composition

So let’s look at a recent clinical example highlighting how 21st century body composition analysis (BIA) can be used in day-to-day clinical practice to rapidly identify,  address, and in this case, ultimately reverse type II diabetes.

As you’ll see, diabetes can potentially develop over time undetected when poor body composition goes unreported.

A case study 

“Vihaan” (not his real name) got some bad news, and it was not at all what he expected.  He knew that something was wrong because he was not feeling right and that he seemed to be much more tired than usual.

A successful entrepreneur, his company was taking off, and his young family was growing and doing well.  But he was not.  It seemed like all of a sudden he began to be thirsty – really thirsty.  And then, came the never ending trips to the men’s room.

At 42, seemingly in good health and not at all “overweight”, he found out that he was diabetic, with a blood sugar of 265 mg/dl. Vihaan was shocked, he landed in his ophthalmologist’s office for the required eye examination, taking two diabetes medications, and beginning to get the blood sugar under control.  But he was not at all happy about it and really wanted to know if his eyes were affected by diabetes and what if anything, he might do to get to the root of the problem.

The fear associated with newly diagnosed diabetes is great, especially the fear of losing vision.   

Patients are often very motivated – maybe the most motivated they will ever be – to take action to avoid going blind. Nothing gets their attention like the thought of blindness, unless it the diagnosis of possibly cancer (a topic for a future post).  It is a golden opportunity to affect change in behavior, often the very behavior that has caused the problem in the first place.

After a careful eye examination, it was determined that, thankfully, he had no evidence of diabetic retinopathy, the potentially blinding condition that destroys the circulation to the eye.

It is often the first sign of damage due to diabetes and reflects the changes that are happening throughout the body, especially in the kidney, heart, brain, and peripheral nerves.

Excessive glucose in the circulation damages the delicate capillaries resulting in their eventual loss and destruction. This leaves the surrounding tissue starving for oxygen and nutrition.

Even though Vihaan’s eyes were unharmed for the time being,  the question remained: Why was this active young man in the prime of his life diabetic?  His weight was normal for his height: that is, his BMI was less than 25.  Sure, South Asians are known to get diabetes more readily and often at lower BMI’s but why now, and what could be done?

After a short discussion about the underlying drivers of diabetes, Vihaan was eager to learn more.  He was offered the opportunity to have a body composition analysis performed using the InBody 570 device.

In about three minutes the following print out was in the hands of both he and his physician.  Two significant things quickly became evident:

  1. Though his BMI was 24.6, his percent body fat was significantly elevated at 34%.  His BMI could be considered “great”, but he was metabolically in trouble.
  2. Vihaan’s muscle mass was significantly low in all four limbs and in his trunk as well. Here’s what was disguising Vihaan’s “normal” body weight and contributing to his high body fat percentage: low muscle mass.

A picture is worth a thousand words, and viewing and interacting with your data visually speaks volumes.

For Vihaan and his doctor, the data spoke volumes.  Now, they were in the realm of “show me” medicine, not just “tell me”.  Vihaan was now interacting with his own actionable data, generated in real time.

A conversation followed and the patient was now engaged in his own care with a plan to address both his severe lack of muscle and the obesity in his trunk.

Sarcopenia and Obesity in Type II Diabetes

Without body composition analysis, the degree of Vihaan’s sarcopenia would not have been appreciated, and neither would the 28 pounds of fat he was carrying in his trunk.

Doing a quick calculation of his Skeletal Muscle Index (absolute muscle mass/m2) revealed he was 8.931, approaching the severe range of sarcopenia.

Vihaan’s case might be extreme, but it’s hardly uncommon.

Much research has been done to reveal the association of increased visceral adipose tissue (VAT), the fat that is located in the midsection in and around your organs such as the liver and intestines, and diabetes.  Work has also shown that specifically in South Asians, the visceral fat explains much of the increased incidence of diabetes, particularly in males, compared with other ethnic groups, even at BMI levels of 25 or less.

However, disruption of skeletal muscle function has been shown to be the primary defect in type two diabetes as reported by DeFronzo in 2009. Reduction in insulin sensitivity can be documented as early as ten years before clinical diabetes is manifest, though the exact cause remains a matter of intense investigation.

Until recently, it has not be practical to obtain detailed measurements of both fat mass and muscle mass in the busy office setting.

However, low muscle mass, or sarcopenia,  is now being appreciated also as factor in the development of diabetes.  Muscle tissue is responsible the disposal of 80% of the glucose from a given meal.  With less muscle tissue, more glucose remains in the circulation and thus raises blood sugar levels.

Not only is low muscle mass a problem, but so is poor muscle quality.  When muscle mass is reduced, the muscle’s ability to produce energy by burning fats and glucose is also reduced.  This appears to be the result of reductions in the number and metabolic activity of the mitochondria, the powerhouse of the cells.

Having fewer and poorly functioning mitochondria can then lead to inflammation which has been shown to be a factor in insulin resistance and thus type II diabetes.

A happy ending

Vihaan’s story had a very happy ending, as he was able to follow a plan of weight training, consistent aerobic exercise, and a higher protein and lower carbohydrate diet.  In less than a year, he was off all diabetes medication and has effectively reversed his diabetes.

Though every case is different and certainly not every patient is likely to be able to reverse diabetes as Vihaan’s did, addressing both his obesity and low levels of muscle mass worked powerfully together turn his situation around.

So what might have been a more typical alternate scenario? This 42-year-old gentleman was placed on two diabetes medications and had he not taken charge of his diet and exercise, he would likely have been on some sort of medication for the remainder of his life.

Instead, through body composition analysis, he became empowered, and his unique individual metabolic profile was identified in mere minutes when he was most ready and willing to take action.  The clinical encounter had been leveraged; the fear of blindness may well have been his lever to achieve profound behavior change.

As you look into the New Year

So as you stand at the threshold of a new year and think about your health and fitness goals, remember that relying on your BMI or your body weight alone can fool you.

Without a proper understanding of your personal body composition, you may just head off in the wrong direction or miss out on important opportunities to make major improvements.

Seek out ways to discover your body fat percentage and lean body mass and use this knowledge to your advantage in the coming weeks and months to help you live a healthier life. Your future you will thank you for it!


Michael Mong, M.D., is board certified in Ophthalmology and a Diplomate of the American Board of Obesity Medicine. He has a special interest in the prevention and reversal of pre-diabetes, diabetes, and Alzheimer’s disease, as well as Functional Medicine. You can connect with him on Linkedin. 

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