Hospital scales downplay deadly belly fat in diabetic patients

Nearly a quarter of adults attending diabetes clinics in Malawi’s top three hospitals carry dangerous abdominal fat levels that weighing scales fail to detect, a new study reveals.

The findings, published this month in the international journal Diseases, are based on a study of 1 356 men and women with Type 2 diabetes at Mzuzu, Kamuzu and Zomba central hospitals between November 2024 and January 2025.

A tape measure locates where fat piles up in the body

The researchers examined how two measurements of excess weight vary—body mass index (BMI), which measures weight and height to determine whether one is overweight or obese and waist-to-height ratio, which gauges whether a person has too much fat in the abdomen, also called central obesity.

However, the weight-for-height measurements do not tell clinical staff where the fat is concentrated in the body.

While BMI classified 61 percent of patients as overweight, the ratio, measured by a simple tape measure and height board, put the figure at 80.1 percent.

A weighing scale does not detect fat build-up, which kills diabetic adults

Crucially, 23.7 percent of patients — 322 people — had central obesity by waist measurement despite boasting a normal BMI.

“Those patients would have been recorded as a healthy weight had the diabetes clinic relied on the scale alone,” says lead author Alexander Thomas Mboma. “A patient can step off the scale with a perfectly acceptable BMI and still be carrying the fat that does the damage.”

The Doctor of Philosophy (PhD) candidate at Taipei Medical University in China conducted the study with Professor Alexander Kalimbira, a nutritionist from Lilongwe University of Agriculture and Natural Resources in Lilongwe.

Other co-authors are Elias Peter Mwakilama of the University of Malawi and Sub-Saharan Health and Research Institute, Duc Minh Cap of Haiphong University of Medicine and Pharmacy in China and Taipei’s Tuyen Van Duong and Rong-Hong Hsieh.

The researchers warn that ‘belly fat’ increases the risk of heart disease, high blood pressure, kidney failure and poor blood sugar control.

“A tape measure costs almost nothing and our data suggest it is telling clinicians something the scale is not,” Mboma explains.

The findings show that only 4.5 percent of patients were found overweight by BMI without also having central obesity, while 56.3 percent met both definitions.

Older patients and women carried the heaviest burden due to physical inactivity and frequent eating, including late in the evening.

Women had roughly twice the odds of BMI-defined obesity compared with men. They showed markedly higher odds of central obesity in both measurements.

Those aged 50 and above had higher central obesity than younger women on all three waist-based measures—consistent with the shift in body fat that accompanies menopause.

Patients below physical activity levels recommended by the World Health Organization had about twice the risk of obesity based on the weight-for-height test.

Central obesity by waist-to-height ratio ranged from 71.6 percent at Kamuzu Central Hospital in Lilongwe to 88.3 percent at Zomba Central Hospital.

This suggests that a single national figure for obesity among diabetes patients would hide substantial regional differences.“We are not asking for new equipment or laboratory tests. Many clinics already take height and waist circumference [measurements]. What we are proposing is that the waist-to-height ratio be recorded and acted on alongside BMI and older patients and women be prioritised for counselling on diet and physical activity,” Mboma says.

The study did not measure patients’ blood pressure, cholesterol or other clinical endpoints, which help clinicians predict which patients could develop complications.

The study drew on patients attending routine outpatient diabetes clinics in regional hospitals. As such, the results may not represent most diabetic Malawians managed in district hospitals and community health centres or those not attending care at all.

Professor Kalimbira, who supervised the work in Malawi, said the waist-to-height ratio is one simple way of finding the location of the fat.

“Too much fat in the abdominal region, widely known as ‘kukula mimba’, increases the risk of complications among people with diabetes as they fail to manage their high sugar levels even when on medication or dietary interventions.”

However, he decried low access to diabetes information and checkups increases the danger of dying without knowing their status.

Public health scholar Alison J Price’s study published in The Lancet in 2018 showed that 41 percent of people found with Type 2 diabetes in Lilongwe and Karonga districts were undiagnosed before. However, the findings showed that two in every five diabetic people on medication could not control the disease, raising the risk of complications and death.

“The results are particularly useful in clinical settings, where healthcare workers should not depend on BMI alone to make decisions, as that would miss individuals who need counselling regarding their body fat status, which is a risk factor for complications and early death,” Kalimbira warns.

The research, approved by Malawi’s National Health Sciences Research Committee, received no external funding.

They recommend that the tape measure and a height board should be added to routine assessments to capture serious risks skipped by BMI calculations. “Where priority is required because of multiple constraints at the point of service delivery, older and female patients should be prioritised with screening and lifestyle support,” Kalimbira states.

While nutrition and activity counselling remains central to diabetes care, the nutritionist advises diabetes patients to live active lives, avoid eating too frequently and desist from taking dinner or other foods late in the evening.

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