Your weight is “normal.” So why are you at higher risk for heart attack, stroke and diabetes?
Here’s why—and what to do…

Normal-weight obesity (NWO) may sound like an oxymoron, but that doesn’t make it any less harmful.

Obesity (or, in many cases, simply being overweight) is a well-established risk factor for a slew of health problems, including hypertension, elevated cholesterol and high blood sugar—which, in turn, increase your odds of having a heart attack, stroke, type 2 diabetes and other serious medical conditions.

The grim link between excessive body weight and poor health is why scientists have carefully defined who  is overweight and who isn’t, creating three main categories—normal weight, overweight and obesity—based on a formula called the body mass index, or BMI.

Here’s the rub: Your BMI (see graphic on page 12) can be normal, but you can still have the same weight-relatedhealth risks as a person with obesity—something knownas normal-weight obesity, or NWO. 

For important insights on this commonly overlooked phenomenon, Bottom Line Health spoke with John A. Batsis, MD, a noted authority on NWO…

Understanding body weight labels 

NWO occurs when a person has excess body fat that the BMI fails to take fully into account. The type of fat found in NWO is almost always excess abdominal fat, commonly called “central obesity” or “visceral fat” because it surrounds the viscera, or the internal organs of the abdominal cavity. 

There are varying estimates on the extent of this problem in the US, but a scientific paper published in Nutrition Reviews stated that 30 million Americans have NWO. 

A risky type of fat

The scientific evidence linking NWO to poor health is very strong…

• Metabolic syndrome, cardiovascular disease and diabetes. Metabolic syndrome is a cluster of conditions—including hypertension, high blood sugar, elevated cholesterol or triglycerides and central obesity—that increases your risk for heart disease, stroke and type 2 diabetes. In a study published in European Heart Journal, people with NWO were four times more likely to have metabolic syndrome than those without NWO.

• Functional decline. As one ages, function—the ability to get out of bed, walk, do everyday activities and take care of yourself—is paramount. As function declines, risk increases for frailty, falls, fractures…and placement in a nursing home. When researchers at ­Dartmouth-Hitchcock Medical Center analyzed six years of health data for nearly 4,500 adults age 60 and older, they found that women with NWO had a much greater decline in function than women with a normal BMI and waist circumference.

• Premature death. Among more than 7,000 patients age 65 and older with heart disease, those with NWO were 29% more likely to die during a 7.1-year period than those without NWO, according to a study published in Mayo Clinic Proceedings. In research published in Annals of Internal Medicine, men with NWO were twice as likely to die over a 14-year period as men who were overweight or obese.

Why would NWO be even more harmful than obesity alone? The main reason is that the component of central obesity that characterizes NWO is particularly inflammatory—and inflammation drives chronic disease, such as heart disease, diabetes, cancer, kidney disease, fatty liver disease, autoimmune disease and neurodegenerative ­disorders such as Parkinson’s disease. 

Do you have NWO?

NWO is common, but most people don’t know they have it because primary care physicians rarely diagnose it. NWO can be identified by determining your BMI and measuring your waist circumference.* If your BMI is “normal”—­between 18.5 and 24.9—but your waist circumference is greater than 40 inches (for men) or more than 34.6 inches (for women), you have NWO. 

That may sound like an easy determination, but measuring waist circumference accurately is not that simple. Ideally, a nurse or other trained health professional should do it. But you also can measure your waist circumference by using a cloth tape measure and following these steps (note: this method may not be 100% accurate)…

Put the tape measure at the top of your hip bone. Loop the tape measure around your waist, level with your ­belly button and level all the way around your body, front and back.

Important: Make sure the tape measure is snug but not too tight…breathe easily while measuring—and don’t hold your breath…take the measurement right after you exhale.

How to prevent or reverse NWO

If you have NWO or are concerned about belly fat, you can reverse the condition—or prevent it. My advice…

Diet. Follow a nutritionally balanced, evidence-based weight-loss and weight-maintenance diet, such as a Mediterranean-style diet or the DASH (Dietary Approaches to Stop Hypertension) diet. Both plans emphasize fruits and vegetables, whole grains, beans, poultry, fish and low-fat dairy products, with a minimum of lean, red meat and avoidance of fried foods, refined carbohydrates and processed foods. 

Important: When losing weight, it’s important to lose fat, not muscle. To do that, you need to consume enoughmuscle-building protein—typically a daily protein intake of 15% to 25% of total calories. Good protein sources include chicken, meat and nuts.

Caution: Avoid very low-calorie diets for weight loss, which in older adults can cause imbalances in fluids and electrolytes (calcium, magnesium, potassium and sodium). Never consume less than 1,200 calories daily unless your doctor recommends this and you are under medical supervision.

Exercise. Aim for 150 minutes of ­moderate-to-vigorous exercise every week. Examples: Walking for moderate exercise…and jogging for vigorous exercise. Ideally, your routine should also include resistance-training two to three times weekly, along with stretching and balance training.

Take vitamin D. This nutrient is crucial for maintaining muscle mass and strength. Ask your doctor to test your blood level, which should be no lower than 30 ng/mL. If your level is low, your doctor can recommend a supplement dosage tailored to your needs and recheck your vitamin D levels in about eight weeks.

Set and monitor goals. Making and sustaining behavioral changes is difficult, but it can be done. You must decide what you’re going to do…track your progress with a daily diary…and adjust your routine to stay on track.