‘Skinny’ clients with poor fitness may have high levels of hidden visceral fat, putting them at greater risk of serious disease than you or they realise.

Written by: Rosemary Marchese

With so many of your clients approaching you to help them Skinny Fat Picshed the kilos it’s easy to find yourself focusing your fitness career on ‘that’ word – ‘obesity’. While there should certainly be an emphasis on reducing body fat levels, for some of your potential or actual clients there is a strong possibility that they have actually taken this too far.Introducing the ‘skinny-fat’ client, otherwise known as TOFI – thin on the outside, fat on the inside.

TOFI individuals appear ‘healthy‘ to society, and their thin,  waif-like  bodies are often celebrated. You seldom see overweight or obese people gracing the covers of magazines, unless they are being body-shamed. It’s the skinny female models, sometimes with protruding ribs, that win the million dollar contracts and rule the catwalk. And what do they do to earn these accolades? As fitness professionals we know only too well: they eat very little (despite what they tell the media).

While male TOFI clients do exist, it is predominantly a female issue. In the case of the catwalk models, for example, it’s the female ‘skinny’ model that tends to lead the show while the muscly, very fit male model is more highly regarded than the skinny, unfit male. So why is this apparently-aesthetic issue important?

TOFI is a tickingtime-bomb

Let’s look at a scenario of three 54-year-old people who have just suffered a heart attack. Who do you think is more likely to die? Person A that has a ‘normal’ body mass index (BMI) of 23, Person B who is overweight (BMI of 27), Person C who is obese (BMI of 30) or Person D who is underweight (BMI of 18)? If you guessed Person B and C then you won’t be alone, but you’re not necessarily right. In fact, Person A and D are more likely to die in the next few years after experiencing the heart attack. Shocked? Now, the explanation for why being a little overweight or perhaps obese (by BMI standards) could potentially be protective after a heart attack, otherwise known as the Obesity Paradox, is going to have to wait for another day (but, no, it doesn’t mean you should train your clients to become obese). Here, let’s look at why Person D, the TOFI client, could be much worse off than you realise.

The concept of the TOFI client  has really been brought to the fore by  Dr Carl Lavie, author of The Obesity Paradox: When Thinner Means Sicker and Heavier Means Healthier. Throughout his book, Lavie shows  how, over the past few decades, he has been challenging conventional medical wisdom – creating a few enemies and ruffling some feathers along the way. The more he looked into the research regarding diseases such as diabetes, heart disease and cancer, the more he found that the people who fared the worst were not just low in body fat, but were also low in muscle mass and cardio fitness. Lavie points out that it’s not just the presence of fat that is an issue for health, but also the lack of it. We focus so much on ‘fat loss’ that we tend to miss this population of people that are dying, or at least very sick, despite appearing healthy.

The scientific relationship between body fat and risk for illness and death is not well understood by most people, including doctors who were educated before more recent scientific findings became available. Lavie encourages us to look more closely and change our long-held convictions about fat as he stirs up debate about the value – or confusion – surrounding BMI.

The 30-second article

  • TOFI individuals are ‘thin on the outside, fat on the inside’
  • These clients may have inadequate nutrition, lack muscle and have poor cardiorespiratory fitness, leading to high levels of fat around their visceral organs
  • This ‘hidden’ fat puts them at higher risk of heart disease, type 2 diabetes, cancer, stroke and other conditions
  • By focusing so much of our attention on overweight clients, we often overlook TOFI clients and their health risks
  • You can help TOFI clients reduce their metabolic risks by prescribing moderate intensity exercise, and gradually introducing resistance training, HIIT and functional training, as well as directing them towards a healthy eating

How to recognise the TOFI client

So, who is the TOFI client? This is the client who focuses on weight loss or maintaining a ‘skinny’ frame through diet alone, such  as the bride who starves herself  before  the wedding. They can appear generally skinny (but not anorexic), but may have a little ‘pudge’ around their bellies and even under their chin. They tend to have very poor physical fitness. So, while they appear  to be a healthy weight or underweight by BMI standards, their body is ‘acting fat’ on the inside because they have excess fat around their   visceral   organs.  They   are lacking muscle and that muscle is what uses the energy and keeps visceral fat levels at bay.

Is TOFI a metabolic time-bomb?

Who cares if the TOFI client has fat around their visceral organs as long as they have a low BMI? You should care, and so should they. By focusing so much of our attention on overweight clients, we often overlook TOFI clients and their health risks. The fat around the visceral organs is the worst type of fat to have, because it enters the portal system of blood vessels and heads straight towards vital organs. Welcome heart disease, type 2 diabetes, cancer, stroke and more.

One of the many other reasons these clients suffer, without realising it, is the resultant increase in insulin resistance. We often associate insulin resistance with overweight and obesity, but this phenomenon occurs in TOFI people too. A lack of a sound exercise program, combined with too few calories consumed, can cause muscles to start to waste away, and it doesn’t take long before insulin resistance steps in. When insulin levels are high, other hormones can be thrown off balance, either by getting revved up or turned down. All of this leads to clients heading towards a biological cliff (disease), and once they fall off that cliff it’s very hard to recover them to normal metabolism.

TOFI clients are often unfit

The lack of physical activity of TOFI clients means they often lack fitness. The irony, however, is that many PTs avoid programming cardio for clients who are ‘too skinny’, opting instead to put them onto  a  resistance  training  program,  sometimes  coupled  with  a recommendation for a higher kilojoule eating plan.

While every client needs to be treated individually and their physical fitness assessed, it’s imperative that a lack of cardio respiratory fitness (CRF) is not missed. There has to be a focus on improving their CRF while increasing lean body mass, not just the latter.

The old notion that skinny people don’t need to do cardio really needs to be challenged. When physical activity is the key factor that leads to the use of glucose and other energy stores, including fat, it doesn’t make sense for clients with not-so-healthy visceral fat to avoid cardio exercise. We’re not talking marathon running here, but you  do need to assist them in improving their CRF.

FBM-CoverRosemary Marchese is a physiotherapist and fitness industry advisor with 20 years’ experience.She is the author of The Essential Guide to Fitness and The Fit Busy Mum: Seven habits for



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