A Case of “Skinny” Fat Woman

History of Present Illness:

• Patient is a 31 year old woman of Chinese ethnicity, 5’4”, weight 127lb, BMI = 22 (low risk), percent body fat = 36.9% (High; healthy body fat range = 18% - 28%).
• She presents with the goal of improving her general health. She recently went on a hiking trip with friends and could not keep up, which made her realize that she was not as healthy as she thought
• she was.
• Her father died of a heart attack at the age of 51 and she also voiced concern that she may also be at risk of a heart attack since he was also thin and a non-smoker.
• She reports that since the age of 17, she has been concerned about her appearance.
• She restricts her diet to low-fat and diet foods to keep her weight below 130lb (she is 5’4”).
• She maintains a light tan (she uses tanning beds every other week).
• She colours her hair and wears makeup daily (she works at the L’Oréal cosmetic counter in a department store)
• For exercise, she walks to work and back (approximately 1 mile each way).
• She likes her job and has a “great” social life. She is, however, now quite anxious about her physical health.

Review of Systems (pertinent only):

• Fatigue without daily coffee
• Irritability and light-headedness if she doesn’t eat every 3 hours
• Past Medical History: Non-contributory
• Father: deceased from myocardial infarction – age 51.
• Mother: history of melanoma this year (one melanoma on inner thigh, treated with surgery only) – age 57
• No siblings.
• Yasmin oral contraceptive x 12 years (started at age 19)
• Supplements: None

Typical Daily Diet:

• B: bagel with cream cheese, coffee latte
• L: Cheese and crackers or peanut butter and apple, diet coke
• D: Eats out (usually Chipotle or pub food). Typical dinners:
• burger with fries or Chef salad with Ranch dressing or burrito bowl
• Alcohol: 1 -2 beers or glasses of wine most nights with dinner
• Snacks: occasional cookie or small buttered popcorn from movie theatre near where she works
• She notes, “I don’t like to diet, but I watch what I eat. Eating is very social for me – I am usually out with friends for dinner.”
• Activity: Walks 1 mile to and from work (2 mi total). Takes her just under 20 minutes to walk each way.
• Sleep: 7 hours most nights

• Patient appears to be normal weight for height, waist circumference of 28” (optimal <35)
• Tanned skin with multiple nevi
• Poor muscle tone with thin arms and legs
• Vitals: bp: 128/76 p: 72

Lab tests of note:

• Fasting blood glucose =90 (70-100mg/dL)
• TSH 2.46 (0.5 – 6 uU/mL)

Lipids:

• Total Cholesterol 198 (<200 mg/dL)
• HDL-C 38 (40-50mg/dL)
• LDL-C 100 (<129 mmol/L)
• Triglycerides 160 (normal <150 mg/dL)

Assessment Considerations:

• Nutrition focused physical that includes assessment of skin
• Comprehensive metabolic panel
• Lipid panel
• Organic Acids panel

Insights, Tips and Perspectives:

• Have patient keep food records that show what she planned on eating and what she actually ate
• Work with health coach for more assistance and support with recipes and grocery shopping
• Have patient get connected with either onsite or online support group to assist with behaviour modification compliance

Management Considerations:

• Whole foods based, calorie and carbohydrate controlled, low glycaemic index, Work to help her understand “healthy eating” vs. a low-fat diet anti-inflammatory, Mediterranean style diet
• Medical food for detox support (i.e UltraClear Renew)
• EFAs – 2-3 grams daily

Add 1-2 more days of 30 min cardio on empty stomach