Why normal BMI does not always mean good metabolic health?

You may appear slim and feel well, yet be at risk of diabetes, fatty liver and heart diseases due to unrecognised metabolic dysfunction.

In clinical practice, individuals with normal BMI and normal blood sugar show early insulin resistance, excess visceral fat, cholesterol or fatty liver. Normal weight does not equal healthy metabolism — a distinction critical for long-term health.

Dr. Aijaz Ilmi is Senior Consultant & Head, Preventive Health, Metabolic & Corporate Wellness, Pacific OneHealth, Lajpat Nagar, New Delhi. (Pacific OneHealth)

The hidden epidemic beneath normal weight

India faces a metabolic crisis beyond obesity. A 2025 analysis of ~18,900 adults from the ICMR-INDIAB survey reported 83% had at least one metabolic risk factor — diabetes, prediabetes, dyslipidaemia, obesity or hypertension — indicating vulnerability is not limited to the visibly overweight.

Many Indians develop metabolic abnormalities at modest body weights, partly due to abdominal fat accumulation and lower muscle mass. While useful, BMI is an incomplete measure. Weight shows how much we weigh, not how well our metabolism functions.

Visceral fat: The fat you cannot always see

Subcutaneous fat differs from visceral fat, which accumulates deep in the abdomen around the liver, pancreas and intestines.

Excess visceral fat is metabolically active — it promotes inflammation, disrupts insulin signalling, and increases risk of type 2 diabetes, fatty liver and cardiovascular disease, even when weight and clothing size remain stable.

Muscle loss is equally critical. Skeletal muscle is a site for glucose disposal; reduced muscle mass and physical inactivity impair metabolic resilience without weight gain. Metabolic health depends on fat reduction, muscle preservation and insulin sensitivity.

Insulin resistance: The problem before the diagnosis

Insulin resistance is often the earliest disturbance in metabolic health. When cells become less responsive to insulin — which moves glucose into cells — the pancreas compensates by producing more insulin.

Consequently, fasting glucose and HbA1c can remain normal for years, creating false reassurance while compensatory hyperinsulinemia and other metabolic abnormalities develop. Eventually, compensation may fail, leading to prediabetes and diabetes.

Fasting insulin is not a universal screening test; it may provide insight in selected individuals but needs cautious interpretation. Normal blood sugar does not always mean optimal metabolic health.

Fatty liver: A silent metabolic warning

Fatty liver, now termed metabolic dysfunction-associated steatotic liver disease (MASLD), is a frequently overlooked marker of metabolic dysfunction, not solely linked to alcohol or obesity.

It is closely associated with insulin resistance, abdominal adiposity, elevated triglycerides and overall cardiometabolic risk.

A 2026 study in The Lancet Regional Health – Southeast Asia of 7,764 participants from the CSIR Phenome India cohort reported an age-adjusted MASLD prevalence of 38.9% in the study population — not India's national prevalence, but highlighting liver health as integral to metabolic health.

MASLD often remains silent for years, with normal liver enzymes even in significant disease. Fat accumulation in the liver signals broader metabolic imbalance.

Beyond cholesterol and sugar: Connecting the dots

Conventional care often evaluates metabolic risks in isolation — blood sugar for diabetes, cholesterol for cardiac risk, liver enzymes for liver disease, blood pressure separately — but metabolism does not operate in silos.

Insulin resistance, visceral adiposity, dyslipidaemia, hypertension, fatty liver and chronic low-grade inflammation share interconnected biological pathways.

A comprehensive assessment should look at the overall pattern, including waist circumference, blood pressure, fasting glucose, HbA1c, lipid profile and liver health, with ApoB, lipoprotein(a) or insulin-resistance measures when indicated, for integrated interpretation and earlier risk identification.

The metabolic reset: Changing the biology, not just the weight

Metabolic dysfunction is often modifiable, especially when recognised early.

Pacific OneHealth, the Total Wellness Programme and The Metabolic Reset Plan focus on identifying underlying metabolic disturbances and addressing them through individualised, evidence-based interventions — beyond calorie counting or rapid weight loss.

Key components include improving dietary quality, ensuring adequate protein and fibre, reducing refined carbohydrates and sugary beverages, preserving muscle through resistance training, improving sleep, managing stress, and adding medical treatment where necessary.

Even modest lifestyle changes can improve insulin sensitivity, blood pressure, triglycerides and liver fat. The goal is to reduce abdominal fat, improve strength and activity, and achieve a healthier metabolic system.

Prevention must begin before the diagnosis

Modern medicine treats established disease, but the next frontier is identifying biological dysfunction before progression to diabetes, cardiovascular disease or advanced liver disease.

This requires shifting from a disease-centred model to an integrated approach combining prevention, early risk assessment, lifestyle medicine and specialist care.

At Pacific OneHealth, this idea guides preventive and metabolic healthcare — looking beyond isolated symptoms and lab values to understand the whole person. Prevention aims not just to add years to life, but to add healthier, more functional years.

The question we should really be asking

Body weight tells only part of the story. A person may be slim yet insulin resistant, have normal blood sugar but excess visceral fat, or feel well while fatty liver develops silently.

Not all normal-weight people are unhealthy; appearance alone cannot determine metabolic health. The focus should be to understand "How healthy is my metabolism—and what can I do today to protect it?"

Many problems remain invisible, and metabolic disease is addressed before receiving a diagnosis.

Pacific OneHealth Hospitals is a specialist-led model, bridging the healthcare "missing middle" between neighbourhood clinics and tertiary hospitals through technology-enabled Centres of Excellence.

Its ecosystem integrates preventive health, internal medicine, metabolic health and diagnostics, connecting screening with clinical evaluation, care and ongoing management.

The approach emphasises understanding the individual, listening to concerns, making medical information accessible, and delivering evidence-based, coordinated care.

Metabolic disruption often occurs without visible weight gain or symptoms. Early risk recognition enables timely intervention before complications.

The article is written by Dr. Aijaz Ilmi is Senior Consultant & Head,Preventive Health, Metabolic & Corporate Wellness, Pacific OneHealth, Lajpat Nagar, New Delhi.

Pacific OneHealth hospital has a total 3 branches in New Delhi, one in Lajpat Nagar, one in Dwarka and one in Karol Bagh.

For more information, please visit: www.pacificonehealth.com

Note to the Reader: This article is part of Hindustan Times' paid consumer connect initiative and is independently created by the brand. Hindustan Times assumes no editorial responsibility for the content.

The information does not constitute medical/health advice. Readers are strongly advised to consult a registered medical practitioner.