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Coronal Image of a TOFI and a Normal Control

TOFI,[1][2] thin-outside-fat-inside is used to describe lean individuals with a disproportionate amount of fat (adipose tissue) stored within their abdomen. The figure to illustrate this shows two men, both aged 35 years, with a BMI of 25 kg/m2. Despite their similar size, the TOFI had 5.86 litres of internal fat, whilst the healthy control had only 1.65 litres.

Subjects defined as TOFI with body mass index (BMI) <25 kg/m2 have increased levels of many of the risk factors associated with the metabolic syndrome. This phenotype is a further refinement of the “metabolically-obese but normal-weight[3][4][5]” (MONW).

Subjects defined as TOFI have been described as being at higher risk of developing insulin resistance and type II diabetes due to the fact that they have reduced physical activity/VO2max, reduced insulin sensitivity and higher abdominal adiposity and a more atherogenic lipid profile. Another important characteristic observed in this cohort of subjects is elevated levels of liver fat.


To classify an individual as TOFI, it is essential to measure their internal fat content. The only way that this is possible is by using magnetic resonance Imaging (MRI) or CT scanning. The parameters of the MRI scanner are manipulated to show fat as bright (white) and lean tissue as dark.

Indirect methods such as waist circumference are not suitable as individuals with an identical waist circumference can have vastly different levels of internal fat.

Variation in visceral fat in men with the same waist circumference

The figure clearly shows that despite having an identical waist circumference (in this example all men had a waist of 84 cm), there is considerable variation in the amount of visceral fat (volumes shown on the image in litres) present.


This is difficult to establish in the general population since the necessary imaging examinations are time consuming and expensive, however in a recent research study it was estimated that 14% of the men and 12% of the women scanned with a BMI 20–25 kg/m2 were classified as TOFI[1].

Related phenotypes[edit]

Fat-Fit (FOTI) image

No less important than the TOFI are the metabolic opposites. The subjects have variously been described as being FOTI (fat outside, thin inside), the metabolically healthy obese (MHO)[6][7][8][9] or even the fit fat.[10][11] These subjects have little internal fat relative to their size and an example of this can be seen in the figure where MRI images taken at the level of the umbilicus are shown from a fat-fit (FOTI) and a fat-unfit (control) subject.

Society and culture[edit]

Since the first scientific observations that some lean subjects could have as much, if not more, body fat internally than overweight or obese individuals,[12] there has been considerable media and press interest in this area of research. The first article in the popular press appeared in 2006 in The Guardian,[13] followed by many other newspapers[14][15] and television documentaries.[16][17]


  1. ^ Thomas, E. Louise; Frost, Gary; Taylor-Robinson, Simon D.; Bell, Jimmy D. (2012). "Excess body fat in obese and normal-weight subjects". Nutrition Research Reviews. 25 (1): 150–161. PMID 22625426. doi:10.1017/S0954422412000054. 
  2. ^ Thomas, E. Louise; Parkinson, James R.; Frost, Gary S.; Goldstone, Anthony P.; Doré, Caroline J.; McCarthy, John P.; Collins, Adam L.; Fitzpatrick, Julie A.; Durighel, Giuliana; Taylor-Robinson, Simon D.; Bell, Jimmy D. (2011). "The Missing Risk: MRI and MRS Phenotyping of Abdominal Adiposity and Ectopic Fat". Obesity. 20 (1): 76–87. PMID 21660078. doi:10.1038/oby.2011.142. 
  3. ^ Ruderman Neil B.; Schneider, S. H.; Berchtold, P. (August 1981). "The "metabolically-obese," normal-weight individual". American Journal of Clinical Nutrition. 34 (8): 1617–1621. 
  4. ^ Conus, Florence; Rabasa-Lhoret, Rémi; Péronnet, François (2007). "Characteristics of metabolically obese normal-weight (MONW) subjects". Applied Physiology, Nutrition, and Metabolism. 32 (6): 4–12. PMID 17332780. doi:10.1139/H07-926. 
  5. ^ De Lorenzo, A.; Martinoli, R.; Vaia, F.; Di Renzo, L. (December 2006). "Normal weight obese (NWO) women: an evaluation of a candidate new syndrome". Nutrition, Metabolism & Cardiovascular Diseases. 16 (8): 513–523. PMID 17126766. doi:10.1016/j.numecd.2005.10.010. 
  6. ^ Stefan, Norbert; Kantartzis, Konstantinos; Machann, Jürgen; Schick, Fritz; Thamer, Claus; Rittig, Kilian; Balletshofer, Bernd; Machicao, Fausto; et al. (11 August 2008). "Identification and characterization of metabolically benign obesity in humans". Archives of Internal Medicine. 168 (15): 1609–1616. PMID 18695074. doi:10.1001/archinte.168.15.1609. 
  7. ^ Wildman, Rachel P.; Muntner, Paul; Reynolds, Kristi; McGinn, Aileen P.; Rajpathak, Swapnil; Wylie-Rosett, Judith; Sowers, MaryFran R. (11 August 2008). "The obese without cardiometabolic risk factor clustering and the normal weight with cardiometabolic risk factor clustering: prevalence and correlates of 2 phenotypes among the US population (NHANES 1999-2004)". Archives of Internal Medicine. 168 (15): 1617–1624. doi:10.1001/archinte.168.15.1617. 
  8. ^ McAuley, Paul A.; Blair, Steven N. (May 2011). "Obesity paradoxes". Journal of Sports Sciences. 29 (8): 773–782. PMID 21416445. doi:10.1080/02640414.2011.553965. 
  9. ^ Pataky, Z.; Makoundou, V.; Nilsson, P.; Gabriel, R. S.; Lalic, K.; Muscelli, E.; Casolaro, A.; Golay, A.; Bobbioni-Harsch, E. (September 2011). "Metabolic normality in overweight and obese subjects. Which parameters? Which risks?". International Journal of Obesity (Lond). 35 (9): 1208–1215. PMID 21206481. doi:10.1038/ijo.2010.264. 
  10. ^ Lee, Chong Do; Blair, Steven N.; Jackson, Andrew S. (March 1999). "Cardiorespiratory fitness, body composition, and all-cause and cardiovascular disease mortality in men". American Journal of Clinical Nutrition. 69 (3): 373–380. PMID 10075319. 
  11. ^ O'Donovan, G.; Thomas, E. L.; McCarthy, J. P.; Fitzpatrick, J.; Durighel, G.; Mehta, S.; Morin, S. X.; Goldstone, A. P.; Bell, J. D. (December 2009). "Fat distribution in men of different waist girth, fitness level and exercise habit". International Journal of Obesity (Lond). 33 (12): 1356–1362. PMID 19752873. doi:10.1038/ijo.2009.189. 
  12. ^ Thomas, E. Louise; Saeed, Nadeem; Hajnal, Joseph V.; Brynes, Audrey; Goldstone, Anthony P.; Frost, Gary; Bell, Jimmy D. (November 1998). "Magnetic resonance imaging of total body fat". Journal of Applied Physiology. 85 (5): 1778–1785. PMID 9804581. 
  13. ^ Revill, Jo (10 December 2006). "Are you a Tofi? (That's thin on the outside, fat inside)". Science. The Observer. Guardian. Retrieved 2013-04-23. 
  14. ^ Derbyshire, David (2006-12-11). "Get in touch with your inner fat". Telegraph. Retrieved 2013-04-23. 
  15. ^ Cheng, Maria (2007-05-10). "DIET: Thin people may be fat inside". Usatoday.Com. Retrieved 2013-04-23. 
  16. ^ "Jacques's MRI scan". The Men Who Made Us Fat. Episode 1. 2012-06-14. BBC. BBC Two. Retrieved 2013-04-23. 
  17. ^ "BBC News - Health Explained: What is fat?". BBC. 2010-09-01. Retrieved 2013-04-23.