You Could Have Diabetes While at a Healthy Weight: Here’s How

with Yeyi Zhu, PhD, Assiamira Ferrara, MD, PhD, and Unjali Gujral, MPH, PhD

Most often we associate having diabetes with overweight or obesity; however, there’s a surprising twist to the diabetes story–you may at risk even if you are at a healthy weight, or even underweight. Although hard to believe, it appears particularly true if you are in a racial or ethnic group other than Caucasian.1,2

You can develop diabetes even if you are at a healthy weight.If you are Hispanic, Asian, or Hawaiian, you are at increased risk of developing diabetes, even if you are thin. Be sure to have your blood sugar checked regularly. Photo: fstop123@iStock

Diabetes ranks as one of the most common chronic diseases in the United States, with at least 12% of the population likely to develop diabetes.2 The numbers do not give a full picture of the rising rate of diabetes. What does this mean for you?

According to data gathered by Kaiser Permanente, a California-based managed care medical organization, a startling new discovery has been made regarding risk of diabetes–even if you are at a healthy weight but you are biracial or fall into one of four racial/ethnic categories other than White, you may have a higher risk of developing T2D.3

Why Might Non-White Adults Develop Diabetes While at a Healthy Weight?

Hoping to tease out an explanation for this unexpected relationship between obesity and ethnicity in diabetes, the researchers looked at the prevalence of diabetes and prediabetes among different racial groups in various ranges of body weight. Using records from three integrated healthcare organizations, they evaluated medical records of more than 4.9 million patients who met established criteria.

The racial makeup of the study group was diverse:

  • 50% White
  • 21.6% Hispanic/Latino
  • 12.7% Asian
  • 9.5% Pacific Islander/Hawaiian
  • 0.5% American Indian/Alaskan Native
  • 4.3% multiracial or undeclared

The rates of diabetes increased across all races as both age and body mass index (BMI) increased, which was as expected. Now for the plot twist–Compared to their white counterparts, individuals from all other races were more likely to be develop diabetic across all body weight ranges. More stunning, the risk of diabetes was more pronounced among individuals who were underweight, at a healthy weight, or slightly overweight than anyone who reached the level of obesity,3 according to study measures.

The risk of developing prediabetes, similarly, rose with increasing age and body weight. Yet, among individuals who are Hispanic, Asian, or a Hawaiian/Pacific Islander, the chance of developing diabetes at lower ranges of body weight was significantly higher. These findings suggest that something other than body mass index must be behind the development of diabetes in these racial groups.

Being At a Good Weight May Not Be Enough for You to Avoid Diabetes

“Our research identified a group of people at risk who don’t get as much attention for diabetes: those who are underweight,” says Yeyi Zhu, PhD, a research scientist with the Kaiser Permanente, and the study lead author. “In particular, we found significant differences in diabetes prevalence among underweight men, from 7.3% in Whites to more than double that, or16.8%, in American Indians/Alaskan Natives.”

So while many individuals who are overweight may be screened by the doctor, as a matter of course, if you fall into one of the high risk minority groups, you might want to ask your healthcare provider to check your blood sugar, to evaluate your risk of  prediabetes and diabetes, even if you are in a healthy body weight range, or BMI. This is particularly true as you get older, says Dr. Assiamira Ferrara, MD, PhD, a senior research scientist at Kaiser Permanente.

The study has important implications to both providers and patients, says Unjali Gujral, MPH, PhD, assistant professor with the Emory Global Diabetes Research Center in Atlanta, Georgia. “From a provider standpoint, the US Preventive Services Task Force for Diabetes Screening currently recommends using overweight/obesity as the main screening criteria in all adults ages 40-70 years. Clearly, continuing to do so will likely lead us to miss a substantial number of racial/ethnic minorities at risk of diabetes.”

Previous work has suggested a BMI cut-off point of 23 kg/m2 for Asian populations. “However, it seems likely that a much lower body weight cut-point may need to be established to assure that we are identifying more high risk individuals in other race/ethnic groups,” Dr. Gujral tells EndocrineWeb.

In addition, there isn’t a lot of data about the most appropriate approach to treatment for those who are not overweight. “While the first-line pharmaceutical treatment for type 2 diabetes is currently metformin, which targets insulin resistance, this may not work in non-overweight individuals; instead, may be a more prudent strategy for these individuals may be to introduce treatments aimed at promoting the preservation and recovery of β-cells, which secrete insulin. But much more research is needed in this aspect,” she says.

We’ve been lead to believe that if our weight is under control, there would be no reason to think we should worry about having diabetes. But Dr. Gujral says that the evidence is strong enough to suggest we rethink this. She adds: “People should still be mindful that you are eating a healthy diet and getting regular physical activity—at all weights, and you should consider getting screened for diabetes even when you have a low BMI, particularly if you have a family history of the disease.”

How to Explain the Discrepancy between Body Weight and Risk of Type 2 Diabetes

Why those who avoid being overweight may be at increased risk for diabetes isn’t fully understood, says Dr. Zhu. “Body composition and factors such as physiology and susceptibility to impaired insulin secretion may play a role. In previous studies, for instance, researchers have found that Asians have a higher visceral fat than Whites at a similar body mass index. Having a higher percentages of visceral fat [eg, adipose fat surrounding internal organs] are associated with having an abnormal glucose metabolism.”

To gain a clearer understanding of the factors which may prompt diabetes, we’ll need to look more closely at body composition, genetics, and other lifestyle factors that may contribute to disparities in this chronic disease burden, Dr. Zhu says.

In addition, Dr. Gujral believes that there are likely to be different mechanisms and causes in distinct populations, and with that, differences in the effectiveness of the current screening tools for those whose diabetes stems from causes other than overweight.

“What we hypothesize at this point is that individuals with ancestry from regions of the world that historically had less access to food may have evolved to metabolize energy differently,” say Dr. Gujral. “These minority groups, therefore, may have innate susceptibility to poor insulin production, and may have higher levels of ectopic fat that settles around the organs such as the liver—these differences may contribute to increased diabetes risk. Since these factors likely vary by race and ethnicity, a lot more additional research is needed to truly understand the reasons behind this,” so we can improve detection and treatments.

Steps You Can Take to Reduce the Chance of Developing Diabetes

The experts advice remains the same for now: evaluate your lifestyle and adjust your food choices and activity level, regardless of your weight.

“Focus beyond your weight, to be sure you are doing whatever you can to promote good overall health,” Dr. Gujral tells EndocrineWeb. “This can be practiced by eating a diet high in fiber-rich foods including more vegetables, having limited lean meats, and avoiding saturated fats and added sugars.”

She adds: “Also keep hydrated (ie, drink plenty of water), get adequate sleep, and it is important to aim for at least 150 minutes a week of mild to moderate physical activity. This should be something sustainable and enjoyable whether it is hiking, playing tennis, running, or simply walking around the block.”

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