How Do You Know if You’re Malnourished When Fat?

Published Categorised as Health

I was watching ABC’s Extreme Makeover: Weight Loss  Edition (link has annoying video with audio ad) last night and heard the medical specialist inform the 456-lb woman that she was malnourished. I wondered: how did they assess malnutrition? How do we know if we’re malnourished, even when fat? So I asked my resident nutrition guru. Here is his answer.

As I discovered when reading through research articles and perusing Judy Taylor’s medical records for my book Lifeliner, Judy underwent many kinds of analyses of her body composition and assessments of her nutritional state at the behest of her doctor, my resident nutrition guru. After years of conducting such tests and reading the literature, my resident nutrition guru, aka Jeej, realised that they do not predict outcomes well and  that the best way to assess a person’s nutritional status is through Subjective Global Assessment, a method that he developed and that independent scientific research supports. The Assessment involves four questions:

  1. Are the bowels normal?
  2. Does the person eat a normal diet?
  3. Is the person of normal weight and neither losing nor gaining?
  4. Does the person have normal energy?

If the answer is yes to all four questions, then the person is not malnourished. Doing blood tests and body scans will not give a superior or even as good an answer as this assessment, although scans and tests sure are sexier and feel like real medicine.

But, I asked, what does normal mean?

Normal Bowels

Normal bowels are ones without diseases like Crohn’s or without resections or do not have ostomies. In other words, a not normal bowel is a bowel with severe problems that muck up a person’s ability to absorb nutrients or even digest food. Spastic bowel (irritable bowel) or lactose intolerance, as painful as they are, are normal, in this sense anyway.

Normal Diet

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A normal diet includes all the food groups. One that skips fruits and vegetables is not normal. So eat them!

Normal Weight

It’s interesting watching old movies. Everyone is skinnier yet fatter. Women weren’t sticks; men weren’t pumped muscles. Yet they were healthy and energetic. I wondered: why do muscles look so different now, look plumper and more defined, when decades ago people had to be stronger because daily living required more physical work and some jobs required more strength or the same strength as they do now? Marbling. That was the answer I got.  Today, people have more  fat in their muscles, which plumps the muscles up. Think of top Alberta steak. It’s value comes from the fat that marbles the muscle so that during cooking, the fat liquifies and keeps the meat moist. Well, humans are nicely marbled too today, way more than in decades part, because of what they eat. Our diet has changed that much apparently.

I believe this change in the look of muscles and, concurrently, our average size, has changed our perception of what is normal. Some people think I look normal weight, but given my genetic heritage and my midriff circumference, I’m not. I’m too big. I bet when I reach my normal weight, I’ll be getting comments on how skinny I am. But if I was put back in time, I would fit right in with the general population.

Today, researchers consider that normal weight is best measured by stomach circumference. Men need to have stomachs <102 cm (40 in) in circumference and women <88cm (35 in), and the waist-hip ratio must also be <0.9 for men and <0.85 for women in order to be considered normal weight.

Although gaining weight is the central preoccupation and problem of North Americans, losing weight when not trying (i.e., with no change in diet, exercise, or lifestyle) is also not good, and going below a certain weight for your height leads to bad nutritional status too.

Normal Energy

Sometimes I wonder what is normal energy. Sometimes I feel like people of my parents’ generation had more energy than healthy people today do … or maybe that generation just didn’t whine about things but got on with it. In any case, you must differentiate between low energy caused by disease or injury and low energy caused by nutritional deficiencies. Many things can cause your energy levels to drop, like a chronic illness or recovering from an injury or surgery. It’s the unexplained changes from your normal energy levels that may signal malnutrition, assuming you’ve ruled out disease or syndromes.

So I asked: is it worth testing any nutrients? Yes. Three. Vitamin D. Iron. And Vitamin B12 in certain populations.

Vitamin D

This vitamin is important for bone strength and does affect energy levels. Briefly and simply, if you have too little Vitamin D, then your parathyroid hormone will shrink your bones, leading to osteoporosis. If you have too much, then the parathyroid will stop making bone, also not good. The levels of Vitamin D that lead to one or the other are not far apart. Tis a fine balance. Vitamin D supplementation will prevent the former from happening, but now that the Ontario provincial government is making people pay, how will you be able to afford a sufficient number of tests to know when you’re in balance and are keeping in balance? Well, there is one caveat: weight-bearing exercise or obesity, both of which stress the bones, will cause bone to continue to be created even if Vitamin D levels are high enough to shut off the parathyroid. If a person is using weight and gravity to stress the bones, then the real problem is in ensuring you’re taking enough supplementation to avoid a too-low level. However, there is now controversy over what that level is. Only time, unfortunately, will tell who is right.


We have known for decades that too little iron leads to anemia. Ferritin is a good indicator of iron deficiency, which is fairly common among young women. Too much iron will change your skin colour, among other problems. If you’re having energy problems, this is an obvious test to do.

Vitamin B12

Recent research shows that in the elderly — people older than about seventy years of age — low B12 can lead to cognitive decline. Apparently, the elderly metabolize this vitamin differently than the general adult population. I didn’t understand the science behind how eating normal amounts of B12 can lead to this decline in the over-seventy set, but suffice to say that researchers discovered that supplementing the diet with B12 in the elderly led to significant improvements in cognitive performance. In short, old people’s brains work better when given B12.

Vegetarians and vegans should also be tested for B12 as the best sources of this vitamin are from meat or lots of micro-organisms in water (I wouldn’t want to have the latter, my stomach less so!). The body stores this vitamin for five years, so if you’ve been eating a meat-free diet for that number of years or longer, then it’s probably time to be tested.


Please note: this is for informational purposes only and does not constitute advice of any sort nor can I give personalized advice. Also note that cholesterol and glucose tests are not involved in nutritional status and continue to be important tests regardless of nutritional status.

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