Curious Cook: TOFI, FOFI and metabolic syndrome

The growth in fast food diets since the 1960s is strongly correlated with metabolic syndrome. —FOODIE FACTOR/Pexels

Much of the world is suffering from a slow-burning pandemic called Metabolic Syndrome, which is resulting in millions of cases of Non-Communicable Diseases (NCD). A NCD is defined as a disease which cannot be spread via any viral and/or bacterial vector from a sufferer. An example NCD is diabetes which afflicted 11.3% (37.3 million) of the entire population of the USA in 2019, with a staggering 38% (96 million) of the population additionally judged to be pre-diabetic.

The statistics have not improved since then, with cases expected to rise to around 55 million confirmed diabetics in the USA by 2030. Some 75% of the total healthcare costs in the USA are now related to metabolic syndrome in some manner. These sobering statistics are dwarfed by China, which has more than 141 million diabetics currently (10% of population), with an estimated 365 million people (26% of the population) who are pre-diabetic.

Analysed by age and race, diabetes can be even more worrying, especially if one is older and Asian. The USA incidence of diabetes is 29.2% for people aged 65 or more, and 16.7% for people of Asian heritage regardless of age. Only black people have a marginally higher incidence rate of 17.4%, and the general data suggests diabetes is a disease which disproportionately affects low to middle income people in most countries. This is an important point to note as this observation is also relevant for metabolic syndrome, as explained later.

Note that before the 1960s, the incidence of diabetes was less than 1% in the USA and the rate was even lower in China. Tracking the surge in diabetes by time and correlating various factors over the years is useful in determining the probable causes of both diabetes and metabolic syndrome.

What is it anyway?

So, what is metabolic syndrome? Clinically, the definition is somewhat vague, being defined as a group of metabolic disorders which aggravate the risks of cardiovascular disease, stroke, and type 2 diabetes. There are no wonderful outcomes from having metabolic syndrome, even though many sufferers may not even be aware of it, at least in the early stages.

Modern processed food can contain significant amounts of proteins from animals which have been treated with antimicrobials. — PHOTOMIX COMPANY/PexelsModern processed food can contain significant amounts of proteins from animals which have been treated with antimicrobials. — PHOTOMIX COMPANY/Pexels

The externally verifiable symptoms are easy to spot, such as a waistline of 102 cm or more for men and 89 cm or more for women. Also, a blood pressure of 130/85 mmHg or higher is another common indication, and a urine strip test should be able to detect “glycosuria” (presence of excess glucose in urine).

If any of the above symptoms are present, a blood test may be useful to check for triglyceride levels of 150 mg/dL or higher, and low HDL cholesterol levels of 40 mg/dL or below in men and 50 mg/dL or less in women. If two or more of the above conditions are present, then the probability of having metabolic syndrome would be uncomfortably high and an urgent dietary review may be required, though one should always also consider a medical examination.

No magic cure

There are treatments for the symptoms of metabolic syndrome, but there are currently no drugs which can cure it. That is because metabolic syndrome is very often a condition caused by persistent (often daily) bad dietary habits over an extended period.

And because metabolically bad foods are usually the most common and least expensive meals available to most people, the path of least resistance in economic terms will inevitably lead to more cases of metabolic syndrome every year. And indeed, the growth in the volumes of processed/fast foods in public diets from the 1960s onwards is strongly correlated with metabolic syndrome over time.What bad foods anyway?

Studies have established that metabolic syndrome occurs when the human body processes foods which damage the liver and/or the Human Gut Microbiota (HGM, the microbial flora in human intestines). It is easy to demonise many foods, especially modern processed foods, but there are good reasons for this, and the criticisms are valid. However, the explanations are complicated, but it is worth understanding a couple of the lesser-known aspects of metabolic syndrome.

Sugar, fat and liver

So, we start with fat, or rather, fat caused by sugars. Overconsumption of sugar results in the body converting the energy in sugars into fats. The human body is designed to store fat in cells called ‘adipocytes’, layers of which make up fatty tissue.

There are two main areas reserved in the body for such cells: (i) subcutaneous adipose tissue (SAT, fat between the skin and muscles), and (ii) visceral adipose tissue (VAT, fat that surrounds organs in the abdominal cavity). Fat cells outside these areas is known as ‘ectopic fat’, such as the fat found in many human livers today.

Fructose induces the creation of twice as much liver fat as sucrose. — MALI MAEDER/PexelsFructose induces the creation of twice as much liver fat as sucrose. — MALI MAEDER/Pexels

To put the issue of fats into context, human health can be compromised with over 10 kilos of SAT, or more than 2.5 kilos of VAT, or only just over 136 grams of liver fat. Of all the fats, excess liver fat is probably the most reliable indicator of metabolic syndrome.

That is because the liver is not designed to store fats, and neither are muscles. These tissues are designed to hold relatively small amounts of glycogen, a form of glucose used to provide the body with small reserves of energy. Too much glucose in the diet gets converted into fats and some excess fats finally get stored as ectopic fat, such as unhealthy, excess liver fatty tissue, a certain sign of metabolic syndrome.

Making matters worse is the use of refined fructose to sweeten foods. Fructose is the main sugar in most fruits, but modern food processing can include a lot of fructose as it is cheaper (and sweeter) than normal table sugar (sucrose). Due to the difference in digestive pathways, fructose induces the creation of twice as much liver fat as sucrose as fructose can only be processed in the liver.

Excess ectopic fat in the liver is also known as Non-Alcoholic Fatty Liver Disease (NAFLD). Over 100 million Americans suffer from it along with up to 30% of the world’s population. A 2019 Malaysian study found 48.3% of men surveyed had NAFLD. Severe cases of NAFLD can lead to impaired insulin processing, which can result in Type 2 diabetes.


This brings up the issue of TOFI (Thin Outside, Fat Inside). A subset of the population can appear thin on the outside but have a high amount of ectopic fats in their bodies. This may be due to idiosyncratic processing of normal sugars/fats, or overconsumption of fructose (but not sucrose or fats). In effect, TOFI people may be suffering from severe metabolic syndrome without presenting the usual external symptoms, ie, people who are FOFI (Fat Outside, Fat Inside).

The HGM, again

Modern processed foods are generally low in proper fibre, even those with “added fibre”. The food industry normally uses the word ‘fibre’ as a marketing aid, not an indication of nutrition. Most “added fibre” is derived from ground-up/processed wood cellulose (usually just called ‘fibre’ or coded as E460 to E469 on food labels).

A subset of the population can appear thin outside but can have ectopic fats inside. — ASAD PHOTO MALDIVES/PexelsA subset of the population can appear thin outside but can have ectopic fats inside. — ASAD PHOTO MALDIVES/Pexels

The omission of soluble fibre in processed foods can lead to an imbalanced HGM, as soluble fibre is important for metabolism by the gut into short-chain fatty acids such as butyrate, a compound which helps to balance the HGM, regulate the immune system, controls inflammation and protects the intestines.

Modern processed foods can also contain significant amounts of proteins from animals which have been treated with antimicrobials, and these drugs can destroy healthy gut bacteria, as do plant-based ingredients treated with pesticides/herbicides.

There are many benefits of a properly functioning HGM. Around 30% of our ingested nutrients are metabolised there, and if the HGM does not get the nutrients required, it sends signals to our brains to prompt eating more foods in search of the missing nutrients. However, this does not always result in proper nutrition when consuming processed/fast foods, which then directly or indirectly leads to metabolic syndrome.

An aside about diabetes

Diabetes is a disease known for around three thousand years, and ancient Indians tested for diabetes using ants to detect sugar in urine. They called this condition madhumeda or “honey urine”. The term ‘diabetes’ was coined in the third century by Apollonius of Memphis in Greece, and ancient doctors rarely encountered it. ‘Diabetes mellitus’ is translated as ‘passing through of honey’.

It is curious to note that there was a plausible treatment for diabetes in the first half of the last century, but the planned high-fat, low-carbohydrate diet never became mainstream because it was hijacked by the discovery of insulin in 1921. The irony is that recent research now appears to vindicate such a diet, which can work well when managed with insulin in the initial stages.

Before insulin, there were various “treatments” for diabetes, mostly not based on any science, though many of them relied on lowering consumption of carbohydrates, or simply starvation. One diet required the consumption of rancid meats and fats, while the French in 1841 proposed low-carb vegetables, and men (and only men) were also allowed a bottle of red wine a day.

However, insulin removed the restrictions on diets and allowed people to carry on eating high-carb foods and sugar as before. The rationale is that diabetes should not prevent the consumption of any kinds of food. The less mentioned outcome, of course, is such a strategy ensures that diabetes becomes a life-long condition as there are no attempts to cure it or treat the underlying causes.

And even with insulin, it is a dubious approach as uncontrolled diets can provoke the build-up of ectopic fats. What may be more disturbing was that diabetics were encouraged to consume fructose as this sugar bypasses normal digestive processes and thus does not raise blood glucose levels, but at the risk of creating more ectopic fat in the liver.

The views expressed here are entirely the writer’s own.

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