Tag Archives: stress

The Skinny on “Skinny Fat” (Normal-Weight Obesity)

16 Nov

Tim Skwiat, MEd, CSCS, Pn2

There’s a common misconception that body weight is a reliable and accurate depiction of health. However, the number on a scale says very little about one’s level of fitness, body fatness, fat storage patterns, and levels of lean body mass.

Typically, an “ideal” or “normal” weight is calculated as a ratio of body weight to height. The most commonly used tool is called the Body Mass Index (BMI), which is a person’s weight (in kilograms) divided by his/her height (in meters) squared (i.e., kg/m2). Using this ratio, the BMI separates folks into the following categories:

  • Underweight (BMI < 18.5)
  • Normal weight (BMI 18.5 – 24.9)
  • Overweight (BMI 25 – 29.9)
  • Obese (BMI > 30)

Hence, the notion of “normal” weight is born, but as mentioned above, there are many limitations associated with the BMI and using this avenue to assess health and fitness. Along those lines, recent research suggests that where folks store body fat—even if they fit into the “normal weight” category—may drastically increase their risk of disease and death.

In a study published in the journal Annals of Internal Medicine, a group of researchers led by Dr. Francisco Lopez-Jimenez, director of preventive cardiology at the Mayo Clinic, examined 14 years worth of data including over 15,000 study participants to determine the potential connection between “normal-weight obesity” and the risk of cardiovascular disease and death. They found that folks who are “normal weight” but store an excessive amount of fat in their mid-sections were more than twice as likely to die from cardiovascular disease compared to “obese” people whose body fat was more equally distributed throughout their bodies.1

It’s not like obese folks have a reduced risk of morbidity and mortality either. In fact, as you might imagine, traditionally defined obesity is a substantial, independent risk factor for cardiovascular disease, and it’s associated with diabetes, high blood pressure, sleep apnea, and a host of metabolic issues.2 This research suggests that “normal-weight obesity” appears to be even worse than that.

To put the increased risk of disease and death into perspective, Dr. Lopez-Jimenez said, “Being normal weight with mid-section obesity is comparable to smoking a half to a full pack of cigarettes daily.”

While the effect of “normal-weight obesity” on mortality has gained a significant amount of attention, it shouldn’t come as a complete shock. Previous research has shown that abdominal obesity is associated with a “constellation of metabolic abnormalities,” including:3,4

  • High triglycerides
  • Low levels of “good” cholesterol (i.e., HDL)
  • High levels of apolipoprotein B (which is considered a better predictor of cardiovascular risk than the more commonly used LDL5)
  • Small, dense LDL and HDL particles (small, dense particles are considered more detrimental than large, fluffy particles6)
  • Unhealthy levels of inflammation
  • Insulin resistance
  • Poor carbohydrate tolerance and metabolism
  • Leptin resistance

A number of important lessons and practical applications can be gleaned from this research and information. For one, it’s possible to be “normal weight” and “metabolically obese,” which Dr. Lopez-Jiminez and colleagues4 have defined as having:

  • Normal BMI
  • High visceral fat
  • High body fat percentage
  • Low muscle mass
  • Reduced insulin sensitivity
  • High blood sugar
  • High triglycerides
  • Reduced HDL cholesterol

Secondly, using a ratio of body weight to height (i.e., BMI) can be a relatively poor indicator of health and fitness. With that in mind, it’s important to use other measurements to determine health risk. While body composition testing (i.e., ratio of fat to lean mass) is arguably the most accurate means to discern health status, using waist circumference and waist-hip ratios may be alternative options.7–9

In general, women who have a waist circumference greater than 35 inches and men whose waist measurement is 40 inches or more are considered to have “central obesity” and be at “substantially increased” risk for cardiovascular disease and metabolic complications. With that said, according to the World Health Organization (WHO), women with a waist circumference greater than 31.5 inches and men with a waist circumference greater than 37 inches are at an “increased” risk for metabolic complications.10

Some research suggests that waist-hip ratio may be an even better predictor of health risk than waist circumference. According to the WHO and other professional health organizations, abdominal obesity is defined as a waist–hip ratio of 0.85 for females and 0.9 or more for men, and folks that fit into these categories are considered to be at “substantially increased” health risk because of their fat distribution.10,11

There appears to be a number of factors that contribute to excessive storage of belly fat. While genetics play a role, there are several modifiable lifestyle and behavioral factors, well within your control, that can be addressed to prevent the accumulation of and/or reduce the amount of existing visceral fat.

Exercise. A sedentary lifestyle, an overall lack of physical activity, and low levels of fitness are associated with abdominal obesity. As mentioned above, it should be noted that “normal-weight obesity” is typically associated with lower levels of muscle mass. This is often described as being “skinny fat.”

Fortunately, a number a studies have examined the impact of exercise on visceral fat, and while the exact amount (i.e., volume) and intensity is still be investigated, a substantial body of evidence suggests that a combination of resistance training and aerobic conditioning (including moderate and intense cardiovascular activity) may be optimal to reduce/attenuate abdominal obesity.12–15 The additional advantage to including resistance training is that it is the primary means by which to increase muscle mass, and it is also very effective at improving carbohydrate tolerance and insulin sensitivity.16,17

According to the American College of Sports Medicine (ACSM), a combination of moderate- to high-intensity exercise performed for a total of at least 250 minutes per week (i.e., 5 – 6 days of 45 – 60 minutes of exercise) is associated with significant weight loss.18

Nutrition. Not surprisingly, nutrition behaviors and food intake appear to have a direct impact on central obesity, and what’s more, studies that combine regular physical activity with diet interventions (i.e., resistance and/or aerobic exercise PLUS a reduced-calorie diet) result in even more significant reductions in visceral fat than either individually.12,19 As cited above, poor insulin sensitivity and carbohydrate tolerance coincide with excessive abdominal obesity, and there’s evidence to suggest that diets rich in refined carbohydrates (e.g., sugar-sweetened beverages) may selectively promote the storage of belly fat.20,21 In addition, excessive consumption of saturated fats also appears to be linked to visceral fat storage.22

Perhaps overtly obvious, long-term energy excess (i.e., overconsumption of calories) also leads to increases in overall body fatness and increases in abdominal obesity, and along those lines, research suggests that reduced-calorie diets (regardless of macronutrient composition) are effective at decreasing abdominal obesity.23,24 With that said, there is evidence that higher-protein (i.e., > 0.5 grams of protein per pound of body weight per day), “controlled carbohydrate” (i.e., <40% of calories from carbohydrate) reduced-calorie diets may be more effective at reducing visceral fat.25–28

Stress management. Excessive stress or the inability to cope with stress may also be a contributing factor to central obesity. You may be familiar with the “stress hormone” cortisol, which appears to have a direct connection to fat accumulation, and in particular, abdominal fat. Studies have shown that folks with high waist-hip ratios tend to have poor coping skills and secrete more cortisol when faced with a stressful situation. This suggests a relationship between cortisol and abdominal fat accumulation, and additional studies have identified a similar association between cortisol concentrations, coping skills, chronic stress, and excess belly fat.29,30

There are a number of potential explanations for the stress-cortisol-visceral fat connection. For instance, the enzyme (HSD) that “activates” cortisol from its inactive form (i.e., cortisone) is more prevalent in visceral fat than subcutaneous fat tissue.31 What’s more, visceral fat tissue has greater blood flow and four times as many cortisol receptors (compared to subcutaneous).30

It’s worth noting that there are a number of factors that can contribute to the stress equation—and subsequently, influence the release of cortisol—including psychosocial stressors, food intake, sleep quality and quantity, exercise, and more. Thus, it’s a good idea to examine your overall “stress web” to identify how various domains (e.g., physical, mental, emotional, environmental, financial, spiritual) may contribute to your overall stress levels (i.e., allostatic load).

While stress management can be tricky, yoga, meditation, mindful breathing (i.e., deep belly breathing), healthy levels of physical activity, optimizing sleep, purposeful relaxation, managing finances, and cultivating healthy relationships can all contribute to maintaining healthy stress levels. What’s more, there are certain herbs called adaptogens (e.g., Rhodiola Rosea; Relora®, which is a combination of Magnolia bark extract and Phellodendron bark extract) that may be helpful in reducing cortisol, improving stress levels, and promoting resilience.32,33 Also, phosphatidylserine may blunt cortisol release, reduce stress, and help promote an optimal hormonal status.34

Supplementation. In addition to the suggestions above, there may be additional nutrients that have a beneficial impact on central obesity. Of course, any dietary supplement that can promote a negative energy balance (e.g., increase energy expenditure, reduce calorie intake) has the potential to reduce visceral fat. There is also some evidence that supplementation with conjugated linoleic acids, fatty acids found in small amounts in dairy and meat, may preferentially reduce abdominal fat (i.e., waist circumference) in populations with central obesity.35,36

Take-Home Points

  • Using one’s body weight (and therefore, the scale) as the primary end point for assessing health and fitness may be unreliable and inaccurate.
  • “Skinny fat” (i.e., normal-weight obesity), which is characterized by a relatively high body fat percentage, excess visceral fat, and low levels of muscle mass, may put one at significantly greater health risk than folks who are “fat and fit” (i.e., metabolically healthy but overweight/obese).
  • While using the scale is one way to assess progress, consider using other measurements (e.g., body composition testing, circumference measurements, waist-hip ratios) to paint a more comprehensive picture of levels of body fat, fat storage patterns, and levels of lean body mass.
  • In addition to some factors that may be out of your control (i.e., genetics), there are a number of behavioral factors, well within in your control, that you can modify to reduce visceral fat or attenuate the risk of developing it in the first place.
  • Consider your current physical activity patterns, nutrition behaviors, and stress management tactics and how those areas may be playing a role in your health and fitness. If you could work on just one of those areas, which would it be? More specifically, what’s one thing that you might consider doing more of in one of these domains?



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  17. Hansen E, Landstad BJ, Gundersen KT, Torjesen PA, Svebak S. Insulin sensitivity after maximal and endurance resistance training. J Strength Cond Res Natl Strength Cond Assoc. 2012;26(2):327-334. doi:10.1519/JSC.0b013e318220e70f.
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  24. Bradley U, Spence M, Courtney CH, et al. Low-Fat Versus Low-Carbohydrate Weight Reduction Diets: Effects on Weight Loss, Insulin Resistance, and Cardiovascular Risk: A Randomized Control Trial. Diabetes. 2009;58(12):2741-2748. doi:10.2337/db09-0098.
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  27. Due A, Toubro S, Skov AR, Astrup A. Effect of normal-fat diets, either medium or high in protein, on body weight in overweight subjects: a randomised 1-year trial. Int J Obes Relat Metab Disord J Int Assoc Study Obes. 2004;28(10):1283-1290. doi:10.1038/sj.ijo.0802767.
  28. Noakes M, Keogh JB, Foster PR, Clifton PM. Effect of an energy-restricted, high-protein, low-fat diet relative to a conventional high-carbohydrate, low-fat diet on weight loss, body composition, nutritional status, and markers of cardiovascular health in obese women. Am J Clin Nutr. 2005;81(6):1298-1306.
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  30. Epel ES, McEwen B, Seeman T, et al. Stress and body shape: stress-induced cortisol secretion is consistently greater among women with central fat. Psychosom Med. 2000;62(5):623-632.
  31. Morris KL, Zemel MB. 1,25-dihydroxyvitamin D3 modulation of adipocyte glucocorticoid function. Obes Res. 2005;13(4):670-677. doi:10.1038/oby.2005.75.
  32. Olsson EM, von Schéele B, Panossian AG. A randomised, double-blind, placebo-controlled, parallel-group study of the standardised extract shr-5 of the roots of Rhodiola rosea in the treatment of subjects with stress-related fatigue. Planta Med. 2009;75(2):105-112. doi:10.1055/s-0028-1088346.
  33. Talbott SM, Talbott JA, Pugh M. Effect of Magnolia officinalis and Phellodendron amurense (Relora®) on cortisol and psychological mood state in moderately stressed subjects. J Int Soc Sports Nutr. 2013;10(1):37. doi:10.1186/1550-2783-10-37.
  34. Starks MA, Starks SL, Kingsley M, Purpura M, Jäger R. The effects of phosphatidylserine on endocrine response to moderate intensity exercise. J Int Soc Sports Nutr. 2008;5(1):11. doi:10.1186/1550-2783-5-11.
  35. Risérus U, Berglund L, Vessby B. Conjugated linoleic acid (CLA) reduced abdominal adipose tissue in obese middle-aged men with signs of the metabolic syndrome: a randomised controlled trial. Int J Obes Relat Metab Disord J Int Assoc Study Obes. 2001;25(8):1129-1135. doi:10.1038/sj.ijo.0801659.
  36. Risérus U, Arner P, Brismar K, Vessby B. Treatment with dietary trans10cis12 conjugated linoleic acid causes isomer-specific insulin resistance in obese men with the metabolic syndrome. Diabetes Care. 2002;25(9):1516-1521.

Energy Leaks: Fixing Your Flat Tires

31 Jul

Energy Leaks: Fixing Your Flat Tires

Tim Skwiat, MEd, CSCS, Pn1

“The bird that learns to fly must also learn to land. She flies far but never forgets her nesting place. She travels far, yet understands her boundaries. One who flits about seeking peace forgets to look in her own tree.” – Haven Trevino

As I was filling up one of my car tires with air over the weekend, I got to thinking about the concept of energy leaks. You see, there’s a nail in one of my tires, which is causing a slow air leak, and I have to fill it up every so often—about once or twice a week—to avoid a complete flat, damaging the wheel, etc. Of course, I could just hire a mechanic to patch up the tire, and I wouldn’t have to worry about it…but I’m “too busy” for that.

Putting this into perspective, I realized that this is a major energy leak, which I’m addressing reactively, that is having a fairly significant negative impact and much further reaching implications than I give it credit.

Sure, it only costs a dollar to fill the tire up with air, but after three or four weeks (it’s actually been a few months), that adds up. What if I don’t have proper change? What if the air machine at the gas station where I stopped is out of service? How is this affecting fuel efficiency? Clearly, there are time and financial resources being drained.

What about the additional anxiety it causes? While I don’t think about it when I’m working, I’m concerned about a potential blowout when I’m driving on the highway. What about the incessantly annoying blinking light telling me that my air pressure is low? Duh.

Obviously, a simple leaky tire isn’t so simple: It’s an energy leak that’s rearing its ugly head on my resources. While I shared some examples of how this problem was specifically draining my energy (literally), the tire leaking air itself is a figurative metaphor for the energy leaks—both big and small—that we incur daily.

All of this got me thinking about how energy leaks may be impacting my sustainability, effectiveness, and efficiency. In addition, it is a good reminder how important it is to take a more proactive approach.


Although somewhat abstract, energy is ubiquitous, yet our energy capacity is finite. That is, we only have a limited amount of energy, although we have many different “buckets” in which we invest it. Thought of differently, proper energy provision affects and is impacted by our environment, relationships, finances, health and fitness, mental and emotional health, and much more.

In this way, stressful thoughts and feelings, incomplete tasks and to-dos, negative relationships, etc., can all be energy leaks that have a negative impact on the achievement of our goals and visions.

In his book Stress Management Through Ancient Wisdom And Modern Science, Umesh Sharma lists the following categories as potential “energy leaks“:

  • Unfinished business (e.g., conflicts with family, friends, co-workers; financial debts; overdue assignments; incomplete projects at home or work; incomplete tasks/to-dos)
  • Physical environment (e.g., is your home/work environment congruent with your beliefs, intentions, etc.; is there clutter everywhere you look; is your form of transportation clean and in good condition)
  • Support systems (e.g., do you give and receive energy from your spouse, friends, and family in a healthy way; do you know where to get help and how to ask for it when needed)
  • Physical health (e.g., do you eat in a way that optimizes your health, fitness, and vitality; do you get routine physical exams; do you exercise regularly; do you get enough sleep; do you rely on drugs/substances to “give” you energy)
  • Mental/emotional/spiritual health (e.g., do you owe an apology; do you practice mindfulness; do you meditate; do you challenge yourself mentally; are you interested and engaged in your line of work)


We are all prone to energy leaks, but the most important factor may be identifying them and addressing them proactively. It may be challenging to plug some of these energy drains and some—like that “thank you” note you haven’t written—may seem superficial. However, these are all tied back to you and are zapping your energy.

What are some of your energy leaks? I encourage you to identify yours, and once you do, you can start explore ways you can close them. At the same time, you may think about your “energy gains,” or those things, activities, people, etc., which bring you great energy. Ultimately, “fixing your flat tires” will leave you feeling more energized and healthy, and you’ll be ready to focus on the big things that matter most.


Stress management can be tricky, but things like yoga, meditation, mindful breathing, physical activity, managing finances, and healthy relationships can all contribute to healthy stress levels. While herbalists have known this for centuries, more and more research suggests that certain herbs (i.e., adaptogens) may be helpful in combating cortisol and improving stress levels.

As a matter of fact, scientists recently found that daily supplementation with a combination of Magnolia bark extract and Phellodendron bark extract (i.e., Relora®) reduces cortisol exposure and perceived daily stress, while improving a variety of mood state parameters, including lower fatigue and higher vigor, which suggests “an effective natural approach to modulating the detrimental health effects of chronic stress in moderately stressed adults.”

Thus, while you’re prioritizing and learning how to best manage your stress, you may be able to at least put a “patch” on the leaks and lessen the damage.

[Author’s Note: I wrote a portion of this as I was waiting for my tire to be repaired.]



Talbott SM et al. Effect of Magnolia officinalis and Phellodendron amurense (Relora®) on cortisol and psychological mood state in moderately stressed subjects. J Int Soc Sports Nutr. 2013 Aug 7;10(1):37.

Thirthalli J et al. Cortisol and antidepressant effects of yoga. Indian J Psychiatry. Jul 2013; 55(Suppl 3): S405–S408.

Turakitwanakan W et al. Effects of mindfulness meditation on serum cortisol of medical students. J Med Assoc Thai. 2013 Jan;96 Suppl 1:S90-5.