What Body Fat Tells Us About Diabetes in Asia

Metabolic diseases like diabetes are on the rise globally, but in Asia, the challenge is especially urgent—and complex. In countries like Singapore, where Chinese, Malay and Indian people live side by side, it's become increasingly clear that diabetes doesn't affect everyone in the same way. In fact, studies have shown that diabetes is nearly four times as prevalent in Malay and Indian communities compared to Chinese.

“These are big differences in diabetes risk between Singapore's communities. If you were to put that in terms of a simple measure like height, it’s as though you are looking at a group that was four times taller” said Professor John Chambers, President’s Chair in Cardiovascular Epidemiology at the Lee Kong Chian School of Medicine (LKCMedicine), Nanyang Technological University (NTU), and Chief Scientific Officer of PRECISE. “It’s surprising, and important for us to understand, why groups of people living in Singapore have such different health outcomes.”

While the difference in health is clear, the reasons why are much less obvious. In recent years, visceral adiposity—fat stored deep within the abdomen and nestled against internal organs—has emerged as a key suspect. Unlike subcutaneous fat, which lies just under the skin and is linked more to long-term adaptations to cold environments, visceral fat is highly metabolically active and has been strongly linked to insulin resistance, high blood pressure and abnormal cholesterol levels.

Yet the common clinical measure of obesity, the body mass index (BMI), is a poor measure of visceral fat. As a result, BMI overlooks a pattern common in Asians—high visceral fat despite low body weight. This “thin outside, fat inside” profile is frequently seen in Asian type 2 diabetes patients, highlighting the need for more tailored, population-specific assessments.

A team of researchers led by Dr Theresia Mina, a Dean’s Postdoctoral Fellow at LKCMedicine, used dual X-ray absorptiometry (DEXA) to investigate the role of visceral fat and metabolic diseases in Singapore. Unlike BMI, which is a simple ratio of weight to height squared, DEXA scans can measure where fat is stored and distinguish between visceral and subcutaneous fat. Their results have been published in The Lancet Diabetes & Endocrinology. 

An Answer, and a New Question

As part of the Health for Life in Singapore (HELIOS) study, a preparatory study for our larger SG100K initiative, over 9,000 Singaporeans had their body composition assessed by DEXA and compared against key metabolic indicators such as insulin sensitivity, blood lipid levels and blood pressure. The researchers found that excess visceral fat strongly correlated with poor metabolic health and nearly fully explained the differences between triglyceride levels and blood pressure when comparing Chinese and Malay participants. However, it only partially explained the differences in diabetes status between Chinese and Indian participants. “Even when we took into account well-recognised risk factors such as body mass, body composition and visceral fat localisation, there remained substantial differences in risk of diabetes that are unexplained,” Prof Chambers said. 

This dual finding presents both clarity and mystery. On one hand, the study provides conclusive evidence that visceral fat is a major driver of metabolic dysfunction. On the other hand, it also raises a new question of what then explains the higher risk of diabetes in Indian populations compared to Chinese ones. “There is still an unsolved disease mechanism that urgently needs to be understood and a health inequity that demands a solution,” Prof Chambers said.

One possible mechanism that the team is currently investigating is epigenetics, where environmental factors influence the way genes are expressed rather than alter the genes themselves. “The hypothesis is that metabolic programming¾our early life trajectory, breastfeeding or not, patterns of nutrition or physical activity that were set up in early childhood¾these factors might account for the remaining differences we have observed,” said Prof Chambers. “What is nice about that is that if it is due to early life metabolic programming, then it is a fixable problem. We can identify these early life exposures that are putting people on different trajectories and it becomes a readily addressable public health issue, unlike genetics, which cannot be changed.”

Turning Diversity into Discovery

The study provides direction for both patient care and public health. Firstly, it underlines the need for more tailored public health strategies. “This paper shows that it is really important to appreciate the differences across ethnic groups—that there is different metabolic burden,” said Dr Mina. “One way to move forward would be to perhaps consider different cut-off values for different ethnic groups for health screening in Singapore as well as globally,” she added.

Another strength of the study, according to Prof Chambers, is its precision. “We can be pretty definite about the magnitude of these relationships, the importance of visceral fat as a contributor to metabolic problems in the Malay ethnic group, and also the extent to which it's contributory in Singaporeans of Indian descent,” he said. 

This study is just one of the early striking findings coming out of the HELIOS study, which is part of the SG100K study of 100,000 participants across Singapore’s multi-ethnic population, drawing from people from all walks of life and across the social, economic and health spectrum. By collecting deeply phenotyped, high-quality data representative of the diverse Singaporean population, SG100K has enabled researchers to detect patterns that would have otherwise remained hidden.

In the next phase, the study will be further enriched with electronic health care records and molecular data on metabolites, proteins and RNA species, in addition to the baseline genetic data. “So this study is just a first glimpse of the power of precision medicine,” Prof Chambers said.

But the ambition doesn’t stop there. The goal is to take the Asia-specific findings from the study and place them alongside international datasets in a larger global context, and in so doing understand the Singaporean data more deeply while also contributing to a truly global understanding of health. Ultimately, the work reflects a growing commitment to a more equitable and effective form of medicine—one that recognises diversity not as a complication, but as a key to understanding and solving complex health problems.