Normal weight individuals who develop type 2 diabetes: the personal fat threshold

Abstract

Type 2 diabetes (T2DM) is frequently regarded as a disease of obesity and its occurrence in individuals of normal body mass index (BMI) is often regarded as indicating a non-obesity-related subtype. However, the evidence for such a distinct, common subtype is lacking. The United Kingdom Prospective Diabetes Study (UKPDS) cohort of people diagnosed with T2DM in the 1970s and 1980s had a median BMI of only 28 kg/m2. UKPDS data form the basis of current understanding of the condition even though one in three of those studied had a BMI of less than 25 kg/m2. BMI, though, is a population measure and not a rigid personal guide. Weight loss is considered de rigueur for treating obese diabetic individuals, but it is not usually considered for those deemed to have a normal BMI. Given the new evidence that early T2DM can be reversed to normal glucose tolerance by substantial weight loss, it is important to explain why non-overweight people respond to this intervention as well as obese individuals. We hypothesize that each individual has a personal fat threshold (PFT) which, if exceeded, makes likely the development of T2DM. Subsequent weight loss to take the individual below their level of susceptibility should allow return to normal glucose control. Crucially, the hypothesized PFT is independent of BMI. It allows both understanding of development of T2DM in the non-obese and remission of diabetes after substantial weight loss in people who remain obese by definition. To illustrate this concept, we present the distribution curve of BMI at diagnosis for the UKPDS cohort, together with a diagram explaining individual behaviour within the population. The concept of PFT is of practical benefit in explaining the onset of diabetes and its logical management to the non-obese majority of people with T2DM.