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Don’t be a TOFI be a SUMO

Ask yourself this question. If you had to choose between being thin without having to do any exercise, or doing lots of exercise but still have a high BMI, which would you choose? Silly question I know, undoubtedly most people will opt for the former. But after reading this blog see whether you have a different opinion.

We all know someone who seems to have no problems with their weight. No matter what they eat, or how little exercise they do, they are slim and in shape. You may even be this person. On the other hand, we may know people who seem on the larger side but are brilliant at a sport or fitter than you could ever hope to be. In fact, fitness and fatness aren’t as closely linked as we once thought. In addition, newer understanding about where we store fat may actually prove to be the most important factor.

People often change their lifestyle and exercise levels as a reactive measure. The classic example is putting weight on during the festive season, and then stepping up the exercise in the new year. However, science is increasingly telling us that there is actually very little correlation between our size and our overall health and fitness. Some studies suggest that the risk of cardiovascular disease is lower in individuals with a high BMI and good aerobic fitness, compared with individuals with normal BMI and poor fitness.

In addition to this, the way our body distributes fat can hold more significance in how damaging it is to our health. Fat that is more centrally placed (sometimes described as being apple shaped) is potentially much more harmful than more peripherally distributed fat. Central fat is often accompanied by fat around our organs (visceral fat) and within the abdominal cavity. You may have heard the term ‘fatty liver’ before. Ironically, it is possible to have large stores of visceral fat but low levels of fat below the skin (subcutaneous fat). This will give you the appearance of a TOFI, thin on the outside, fat on the inside.

Why does central obesity matter?

In medical terms, this type of obesity epidemic is called ‘central obesity’. There are very strong links with central obesity and developing the Metabolic Syndrome. The metabolic syndrome is a cluster of biochemical and physiological abnormalities that are associated with the development of cardiovascular disease, insulin resistance and type 2 diabetes. Not good news at all.

Are genetic factors important with central fat?

I often hear patients blame their genetics for being overweight, saying ‘big bones run in the family’. This may even affect their willingness to try and lose weight as they feel it is a battle they are destined to lose. When it comes to losing subcutaneous fat, for most people, there is no reason why it can’t be lost. There are however associated genetic traits that make this more difficult e.g. a large appetite, variations in metabolism. But very rarely are genetics the primary cause of obesity (Prader-Willi syndrome is one example of a rare genetic condition that makes you put on weight). In many cases, obesity is more to do with environmental factors, such as poor eating habits learned during childhood.

On the other hand, when it comes to central obesity some studies suggest that genetics play a much bigger role and the majority of inter-subject variance in central abdominal fat in non-obese individuals is due to genetic factors. There may also be a variation across different ethnic backgrounds. People of a South Asian origin have a more centralised distribution of body fat without necessarily developing generalised obesity and show raised obesity-related risk at lower waist circumference levels.

How do we measure internal fat?

If you wish to spend your hard earned money measuring your internal fat, a common technique used is bioelectrical impedance analysis (BIA) machine. You might find this machine at the gym or specialist sports clinics. This machine passes an electrical current through the body to calculate the percentage of body fat. Unfortunatley, there are lots of inaccuracies associated with this method. Dehydration, for example, affects BIA measurements as it causes an increase in the body’s electrical resistance. Also, the jury is out on how accurately it can differentiate between internal and subcutaneous fat. New medical imaging techniques using MRI and CT are now allowing us to measure internal fat accurately. But these techniques are still mainly used for research purposes only.

Can we reduce central obesity and internal fat?

Yes, you guessed it. Diet and exercise come to the rescue once again. However, to target central and visceral fatty deposits, we need to be smart about how we exercise. Some studies suggest that light aerobic exercise is relatively ineffective at targeting central obesity. In contrast, anaerobic, or high intensity exercise depletes our muscle glycogen stores and requires the mobilisation of our fat stores from within the body. There is some evidence to also suggest that early morning exercise before eating carbohydrates help us to deplete our glycogen stores and burn that internal fat. Diet also plays an important part in reducing visceral fat. This includes avoiding refined sugar and carbohydrates and increasing our fibre content.


Let’s look at the life of a sumo wrestler. They are the experts in high intensity exercise, or interval training as they perform explosive bouts of movement followed by short periods of rest. If you were to look at a sumos’ body composition by putting them through a MRI scanner, amazingly they would demonstrate very little internal fat. They would also have an extremely good anaerobic capacity and very high fitness levels. All this despite the fact that some wrestlers can reach a BMI of 50+ and consume over 6000 calories a day. Sumos also have large amounts of muscle mass which helps increase their metabolism burning those stores of fat around their organs. In contrast, our skinny friend who does no exercise may display very poor fitness, low muscle mass, and high levels of central obesity, despite appearing thin and healthy on the outside.

What does this mean for me?

The message I’m trying to get across from this blog is not to judge fitness on appearance. And also not to be complacent and think that just because you might not be overweight you should neglect your fitness. Not many of us will ever get the opportunity to formally measure our central fat stores, just like we won’t get the chance to measure the state of our arteries (and if ever you do, it’s probably a bit too late!). However, by incorporating high intensity interval sessions like a sumo wrestler does, we can improve our anaerobic threshold and burn our internal fat stores, reducing the risk of developing type 2 diabetes and cardiovascular disease. A good way to start doing this is by mixing up your running!

In summary, it is much better to treat our bodies with respect both on the inside and out, and not get obsessed with appearance and waistlines!

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    Orla Mulligan
    Administration and Social Media Manager
    Administration, LBSM

    Orla Mulligan is the administration and social media manager for LBSM. She has a strong background in sport having herself played netball at an elite standard for the U21s Northern Ireland team in the European Championships as well as the U21s competition for Saracen Mavericks.

    She understands youth sport pathways having herself played and training in the netball Kent regional pathway. She has a keen interest in most sports and a good understanding of how injury and illness can impact on the mind and body, as well as rehabilitation pathways.

    She looks forward to speaking and assisting LBSM patients and gives her best support to them during their treatment pathway.

    A day in the life of Orla involves communicating with patients via phone and email, managing and organising clinics, operations and media management.

    Outside of work, Orla is a gym enthusiast, enjoys tennis and still finds the time for an occasional game of netball.

    Maddie Tait
    BSc, MSc
    Associate, LBSM
    Musculoskeletal and Sports Podiatrist

    Maddie treats and manages complex foot and ankle injuries in London and Surrey.

    She is particularly interested in helping her patients improve their quality of life and achieve their personal goals, working closely with Foot and Ankle Consultants, Sports Medicine Doctors and Physiotherapists.

    Maddie has a sporting background herself having previously represented England in Hockey. She understands the demands of elite sport and the importance of physical and mental health. In her spare time, Maddie continues to enjoy an active lifestyle by running, cycling and attending a Pilates class.

    Having graduated from University of Brighton with a MSc (hons) in Podiatry, Maddie focused her career in Podiatric Sports Injuries and Biomechanics. Previously she completed a BSc (hons) in Sport Science at Loughborough University.

    A day in the life of Maddie involves consulting patients in clinic, performing gait and biomechanical assessments, measuring and fitting orthotics and braces. She also regularly teaches and presents at sports medicine and podiatry conferences.

    Outside of work, Maddie still finds time to play hockey and enjoys running and skiing.

    Mr Prakash Saha
    Consultant Partner, LBSM
    Consultant in Vascular Surgery

    Mr Prakash Saha is a Consultant Vascular Surgeon at LBSM. He takes pride in providing the best possible results for his patients by using the most appropriate non-surgical and surgical methods based on clinical evidence, patient results and satisfaction.

    He treats fit and active people suffering with a range of cardiovascular issues, from painful leg swelling associated with exercise to venous insufficiency, post-thrombotic syndrome and leg ulcers. He also treats people with arterial system problems including poor circulation, compression syndromes and aneurysms. He carries out both endovascular and open aortic repair and has some of the best outcomes in the country.

    Mr Saha studied medicine at the United Medical & Dental Schools at Guy’s and St. Thomas’ Hospitals before completing his higher surgical training in London and the South East. During this time, he was awarded the prestigious NIHR Clinical Lectureship in Vascular Surgery at St. Thomas’ Hospital, giving him comprehensive training in open and endovascular techniques for treating arterial and venous disease. Prakash completed his aortic surgery training at the St. George’s Vascular Institute before carrying out a specialist fellowship at the Royal Prince Alfred Hospital, Sydney.

    Mr Saha regularly lectures and runs workshops across the globe on the latest surgical techniques to treat vascular disease. He has also been awarded a number of research grants from the Royal College of Surgeons, the Circulation Foundation, the Wellcome Trust, the Academy of Medical Sciences, and the British Heart Foundation, which has led to over 80 publications and the development of innovative technologies to help treat patients. For this work, Prakash has received a number of prizes, including the Venous Forum prize from the Vascular Society of Great Britain and Ireland, an International Young Investigator Award, and an Early Career Investigator Award from the American Heart Association.

    A day in the life of Mr Saha involves seeing patients in clinic, operating in surgical theatre or lecturing at his university. He also regularly teaches and presents at vascular and sports medicine conferences.

    Mr Saha is an avid cyclist and tennis player (although yet to get a set of Dr Seth!). Outside of work, he spends time with his family who consists of 3 children and enjoys travelling.

    Dr Gajan Rajeswaran
    Consultant Partner, LBSM
    Consultant in Sports and Musculoskeletal Radiology

    Dr Gajan Rajeswaran is a Consultant Musculoskeletal Radiologist at LBSM, with an extensive background of working in elite sport. He is one of the most recognised radiologists in the sports medicine field. He provides top level imaging and medical diagnostic services for patients and athletes.

    Dr Gajan Rajeswaran completed his undergraduate medical training at Imperial College London and his radiology training at Chelsea & Westminster Hospital. He has obtained two post-CCT fellowships in musculoskeletal imaging. He was appointed as a consultant at Chelsea & Westminster Hospital in 2011.

    He has a passion for all sports having worked as a radiologist at the Glasgow Commonwealth Games and London World Athletic Championships and continues to support The Championships, Wimbledon. He also continues to work with a number of Premier League and Championship Football Clubs, Premier League Rugby Clubs, England Sevens Rugby, British Athletics and the Lawn Tennis Association.

    A day in the life of Dr Rajeswaran involves giving his expert opinion on investigations such as MRI and CT scans, x-rays and ultrasound. He also performs injection lists under ultrasound, CT and X-ray including spinal injections. He also regularly teaches and presents at sports medicine conferences.

    Dr Gajan Rajeswaran is an avid football fan and life-long fan of Tottenham Hotspur (for which he offers no apologies!). Outside of work, he spends time with his family and has a keen passion for photography.

    Dr Ajai Seth
    Medical Director, LBSM
    Consultant in Sport and Exercise Medicine

    Dr Ajai Seth is a Sport and Exercise Medicine Physician. He has dedicated his career to helping people with sport and exercise related injury and illness. He consults and treats everyone from the elite athlete to the weekend warrior.

    Dr Ajai Seth is part of the British Tennis Sports Physician team at the LTA and has also provided cover to elite athletes at Wimbledon Tennis, European Tour Golf, Premier League Football, British Athletics, and the Men’s England Football academies as part of the FA.

    He also prides himself for working in disability sport and is currently the Chief Medical Officer for Team GB Wheelchair Tennis which has taken him to the Olympics and Paralympics.

    Dr Ajai Seth is dedicated to education, training and research and is a Senior Lecturer in Sports Medicine at King’s College London where he lectures in all aspects of Sports Medicine and Science.

    He also has a passion for travel and Expedition Medicine, which has seen him accompany medical, scientific and charity expeditions all around the world. He also has vast experience in treating musculoskeletal injuries from children and adolescents to veteran exercisers, both male and female.

    Dr Seth also has positions in leading Sport Medicine organisations, including the non-executive board for the UK’s largest Sports Medicine charity, BASEM and Past President for the Royal Society of Medicine. 

    A day in the working life of Dr Seth involves consulting his patients in clinic, performing diagnostics and ultrasound guided injections. He also regularly lectures and tutors students and presents at sports medicine conferences internationally. He also spends part of the working week at the National Tennis Centre, LTA, supporting British Tennis players.

    Outside of work, Dr Seth enjoys playing club tennis, triathlon, golf, running and skiing (but will give any sport a go!). He enjoys keeping fit and active and good quality family time with his wife and three children.