Written by Dr. Kamen Ng. Reviewed by Dr. Daniel Chong. Last reviewed 2026-09-03. 10 min read
Patients rarely come to see me about their metabolism
They come about acne that started in their late twenties and will not settle. About hair appearing on the chin and jawline. About a patch of skin at the back of the neck that has turned darker and slightly velvety, which they assume is dirt or friction. About stubborn weight around the middle that has not responded to anything they have tried.
These are aesthetic concerns, and they are entirely legitimate ones. But a reasonable amount of the time, they are also the first visible sign of something happening underneath. My job in that consultation is to treat what brought the patient in, and to notice what they did not come in for.
The thing these conditions have in common
Prediabetes, fatty liver and polycystic ovary syndrome sound unrelated. One concerns blood sugar, one the liver, one periods and fertility. In practice they frequently share a single driver: insulin resistance.
Insulin moves glucose from the bloodstream into your cells. When cells stop responding well, the pancreas simply makes more of it. Blood sugar can look perfectly normal for years while insulin levels climb quietly in the background. That excess insulin is not neutral, and where it causes trouble depends largely on the individual.
In the bloodstream, the compensation eventually falls short and glucose starts to drift upwards. That is prediabetes.
In the liver, high insulin promotes fat storage in liver cells. Fat accumulates where it should not be and inflammation follows. This is metabolic dysfunction-associated steatotic liver disease, or MASLD, which you may have previously heard called non-alcoholic fatty liver disease.
In the ovaries, high insulin increases androgen production and disrupts the signalling that governs ovulation. Cycles become irregular. Acne, unwanted hair growth and difficulty conceiving can follow. This is a central mechanism in PCOS, and it is why the woman sitting in front of me about her skin may in fact be describing a metabolic condition.
Why I take this seriously in an aesthetic consultation
When the National Health and Morbidity Survey asked Malaysian adults why they had not been screened for diabetes, high blood pressure or high cholesterol in the past year, the two most common reasons given were that they felt healthy and that they had no symptoms.
That is exactly the difficulty. Around 15.6 per cent of Malaysian adults live with diabetes, and roughly two in five of them do not know it. Among adults aged 18 to 29, more than eight in ten are unaware. These conditions are silent by design in their early stages.
Fatty liver is often found by accident, on a scan ordered for something else, or through a mildly raised liver enzyme. Untreated, it can progress from simple fat accumulation to inflammation and then to scarring, usually without the patient feeling unwell along the way.
PCOS is frequently discussed as a fertility issue, which understates it considerably. It carries a meaningfully increased long-term risk of type 2 diabetes, cardiovascular disease and fatty liver. A woman diagnosed at 25 is managing a lifelong metabolic condition, not simply an irregular cycle.
So when a patient asks me about persistent adult acne or new facial hair, I would rather ask about her periods than not.
How much change is actually required
This is where I usually see relief on a patient's face, because the answer is smaller than most people assume.
| Condition | Weight change | What the evidence shows |
|---|---|---|
| Prediabetes | About 7 per cent | Combined with around 150 minutes of activity a week, substantially reduced progression to type 2 diabetes in the Diabetes Prevention Program |
| Fatty liver | 10 per cent or more | 90 per cent had resolution of steatohepatitis, 45 per cent showed regression of fibrosis |
| Fatty liver | 5 per cent or more | 58 per cent had resolution. Below 5 per cent, considerably lower |
| PCOS | 5 to 10 per cent | International guidance points to improvement in cycle regularity, ovulation and androgen levels |
I would add the caveat the fatty liver authors themselves make, because it matters. Fewer than one in ten patients in that study actually reached the 10 per cent mark through lifestyle change alone, and around seven in ten lost less than 5 per cent. The biology is encouraging. Achieving it without structured support is the difficult part, which is rather the point of supervising this properly.
Individual responses vary considerably and none of these figures are promises. But for a woman of 70kg, we are talking about roughly 4 to 7kg. That is a manageable target rather than a transformation, and sustained modest change tends to serve patients better than rapid change that does not hold.
Why I do not rely on the scale
This is where a lot of false reassurance comes from, so it is worth being precise.
The Malaysian Clinical Practice Guidelines classify body mass index using Asian cut-offs, which sit lower than the international scale most people are familiar with. Normal is 18.5 to 22.9. Overweight, or pre-obese, begins at 23.0 and runs to 27.4. Obesity begins at 27.5.
That matters because most online calculators, fitness apps and imported health charts still use the international scale, where normal extends to 24.9. A patient with a BMI of 23 or 24 will often be told by an app that she is in the healthy range. Under the guidelines her own doctors work to, she is already overweight, with an increased risk of comorbidities. She has not been reassured. She has been misinformed.
Even within the genuinely normal band the scale has limits. Lean fatty liver is well recognised. It is entirely possible to have a BMI of 21 or 22, be slim by any visual assessment, and have a liver carrying substantial fat.
Waist circumference is usually more informative. As a general guide for Asian populations, approximately 90cm in men and 80cm in women is the point at which visceral fat becomes a concern. Body composition analysis, which distinguishes fat mass from muscle mass, adds another layer again. My colleague has written in more detail on why the waist matters more than the scale.
What changes things, from the diet side
Local conversations about diet tend to fixate on rice. That is too narrow. In my experience the changes that matter most are these.
Sweetened drinks. Teh tarik, kopi peng, bubble tea, canned drinks and fruit juices deliver a large glucose load with no fibre and little satiety. For many patients this single category accounts for a substantial portion of daily sugar. It is often the highest-yield change available and among the easiest to sustain.
Refined carbohydrate portions, rather than carbohydrate itself. White rice, roti canai, mee goreng and kuih raise blood glucose sharply, particularly in large servings eaten without protein or vegetables. Reducing portion size and adding protein and vegetables to the same meal changes the glucose response without asking anyone to give up the food they grew up with.
Enough protein. Losing weight while under-eating protein means losing muscle alongside fat. Muscle is where most glucose is disposed of, so losing it worsens the very problem you are trying to solve. This is a large part of why crash diets tend to leave people worse off. Our dietitians have written on hitting protein targets on Malaysian food.
Fibre. Vegetables, legumes and whole grains slow glucose absorption and improve fullness. Most of my patients are nowhere near adequate intake.
Fructose and ultra-processed food. High fructose intake is directly implicated in liver fat accumulation.
Alcohol. MASLD is defined as non-alcohol-related, but alcohol adds a separate burden to a liver already under strain.
The lifestyle factors patients tend to overlook
Resistance training. Cardio is useful, but muscle is metabolically active tissue and the primary site of glucose disposal. Building and keeping it improves insulin sensitivity independently of weight loss. Two or three sessions a week is a sensible starting point.
Everyday movement. One in three Malaysian adults is not physically active. Walking after meals, taking stairs and sitting less all have measurable effects.
Sleep. Consistently short or poor sleep worsens insulin sensitivity and increases appetite. A patient sleeping five hours a night is working against herself regardless of what she eats.
Chronic stress. Sustained cortisol elevation encourages visceral fat storage and worsens insulin resistance.
Weight cycling. Repeated rounds of rapid loss and regain erode muscle mass and often leave patients metabolically worse off than when they began. It is one of the main reasons I favour a slower, supervised approach.
When to see a doctor
Consider a metabolic assessment if you are over 35, or over 30 with a family history of type 2 diabetes; have a waist above roughly 90cm in men or 80cm in women; have had gestational diabetes or delivered a large baby; have been told you have fatty liver on any scan, however incidental; have a raised liver enzyme; have high blood pressure or an abnormal cholesterol profile; or have PCOS or suspect you may.
Please arrange an appointment sooner if you notice:
Periods consistently more than 35 days apart, or fewer than eight cycles a year. New or worsening acne, unwanted facial or body hair, or thinning at the scalp. Difficulty conceiving after twelve months of trying, or six months if you are over 35. Darkened, velvety skin at the neck, armpits or groin, known as acanthosis nigricans, which is a visible marker of insulin resistance. Persistent fatigue, increased thirst, frequent urination or blurred vision. Or unexplained weight loss, which should be reviewed promptly.
The purpose of seeing a doctor early is not to be told to eat less. It is to establish where you actually stand. That usually means fasting glucose and HbA1c, a lipid profile and liver enzymes, and where indicated a liver ultrasound, fasting insulin or hormonal testing. Body composition analysis provides context that weight alone cannot.
From there a plan can be built around what your results show. For some patients that means nutrition and training. For others, additional medical treatment may be appropriate, which is properly a conversation with your doctor rather than a decision made from an article.
What I would want you to take from this
The acne, the hair growth, the darkened patch of skin at your neck are worth treating in their own right. I treat them. But they are sometimes a message from somewhere deeper, and I would be doing you a disservice if I addressed only what is visible.
You will most likely feel entirely well throughout all of this. That is precisely why screening exists.
References
- Vilar-Gómez E, Martinez-Perez Y, Calzadilla-Bertot L, et al. Weight loss through lifestyle modification significantly reduces features of nonalcoholic steatohepatitis. Gastroenterology. 2015;149(2):367-378.e5
- Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. New England Journal of Medicine. 2002;346(6):393-403
- Ministry of Health Malaysia and Malaysian Endocrine and Metabolic Society. Clinical Practice Guidelines: Management of Obesity, 2023
- Institute for Public Health, Ministry of Health Malaysia. National Health and Morbidity Survey 2023
- WHO Expert Consultation. Appropriate body-mass index for Asian populations. The Lancet. 2004;363(9403):157-163
Frequently asked questions
Sometimes, yes. Darkened, velvety skin at the neck, armpits or groin, known as acanthosis nigricans, is a recognised visible marker of insulin resistance. Persistent adult acne, new facial or body hair and scalp thinning can also point to an underlying hormonal or metabolic cause, particularly in women.
The Malaysian Clinical Practice Guidelines use Asian cut-offs, which sit lower than the international scale. Normal is 18.5 to 22.9. Overweight, or pre-obese, runs from 23.0 to 27.4. Obesity begins at 27.5. Most fitness apps still use the international scale where normal extends to 24.9, so a BMI of 23 or 24 will often be reported as healthy when your own doctors would classify it as overweight.
The evidence is dose-dependent. In a 2015 study of 293 patients with biopsy-proven steatohepatitis, 90 per cent of those losing 10 per cent or more of body weight had resolution, and 45 per cent showed regression of fibrosis. At 5 per cent or more, 58 per cent had resolution. Worth noting that fewer than one in ten patients reached 10 per cent through lifestyle change alone, which is rather the argument for supervising it properly.
Yes. Lean fatty liver is well recognised. It is entirely possible to have a BMI of 21 or 22, look slim by any visual assessment, and have a liver carrying substantial fat. This is one reason the scale alone is a poor screening tool.
No, and describing it that way understates it considerably. PCOS carries a meaningfully increased long-term risk of type 2 diabetes, cardiovascular disease and fatty liver. A woman diagnosed at 25 is managing a lifelong metabolic condition, not simply an irregular cycle.
International guidance points to 5 to 10 per cent as the range at which many women see improvement in cycle regularity, ovulation and androgen levels. For a woman of 70kg that is roughly 4 to 7kg: a manageable target rather than a transformation.
Fasting glucose and HbA1c, a lipid profile and liver enzymes as a baseline. Where indicated, a liver ultrasound, fasting insulin, or hormonal testing. Body composition analysis adds context that weight alone cannot, because it distinguishes fat mass from muscle.
That is precisely why screening exists. When Malaysian adults were asked why they had not been screened, the two most common answers were that they felt healthy and had no symptoms. These conditions are silent by design in their early stages, and among adults aged 18 to 29 with diabetes, more than eight in ten are unaware of it.
This article is general information and does not replace individual medical advice. Treatment plans are individualised and require examination. Prices quoted are starting prices published at the time of writing; the pricing page is the current source. Outcomes vary between individuals and no result can be guaranteed.