Written and medically reviewed by Dr. Daniel Chong. Last reviewed 2026-08-30. 13 min read
Two numbers, and the gap between them
Let me start with two figures from the National Health and Morbidity Survey 2023. About 21.8 per cent of Malaysian adults are obese by body mass index. About 54.5 per cent have abdominal obesity, measured by waist circumference.
More than half of us carry too much around the middle, while only about one in five would be flagged by the number most people actually check. That gap is the entire subject of this article, and it is why a man can step off a scale reasonably satisfied and still be walking around with the thing that matters most.
It is also why the most common conversation I have in clinic starts with a patient saying some version of: I am not fat, I just have a bit of a tummy.
I hear it most from two groups. Executives working long desk-bound days across George Town and the Bayan Lepas corridor, and expatriates who moved to Penang a few years ago and cannot quite account for what has happened to their waistline since.
Not all fat is the same fat
Subcutaneous fat sits under the skin. It is the fat you can pinch. Metabolically it is relatively well behaved, and it is, in a real sense, where fat is supposed to go.
Visceral fat sits inside the abdominal cavity, wrapped around and between the organs. You cannot pinch it. It is what makes a firm, protruding abdomen rather than a soft one, and it is why some men have a belly that feels solid rather than squishy.
There is a third category worth knowing: ectopic fat, stored where it does not belong at all. Inside the liver, in the pancreas, in and around muscle, around the heart. Fatty liver disease is the most common example and it is now extremely common in Malaysia.
Why visceral fat is the dangerous one. Two reasons, and the second explains everything.
First, it is not inert storage. It is an active endocrine organ, secreting inflammatory signalling molecules and reducing production of protective ones. The result is low-grade systemic inflammation that interferes with insulin signalling throughout the body.
Second, and this is the crucial anatomy: visceral fat drains directly into the liver. Blood leaving the abdominal organs travels through the portal vein to the liver before reaching the rest of the circulation. So the free fatty acids and inflammatory molecules it releases arrive at the liver first, and at high concentration.
The liver responds by becoming resistant to insulin, producing more glucose than it should, and manufacturing more triglyceride-rich particles. That gives the pattern I see constantly on blood results: raised triglycerides, low HDL, a rising fasting glucose, and often a mildly raised liver enzyme dismissed as nothing for years.
Subcutaneous fat on the thighs drains into the general circulation. Visceral fat drains into the liver. Same fat, different plumbing, completely different consequences.
Visceral fat is the strongest modifiable driver of insulin resistance, which sits underneath type 2 diabetes, high blood pressure, the atherogenic lipid pattern, fatty liver disease, obstructive sleep apnoea and cardiovascular disease. These cluster together in the same people because they share a root cause, not because of bad luck.
The encouraging part, and I will come back to it, is that visceral fat is also the fat that responds first.
Why this hits Asian men particularly hard
This is the part I wish were more widely understood, because it changes how you should read your own numbers.
We carry more fat, and more of it visceral, at the same BMI. Body mass index was developed and validated largely in European populations. At the same BMI, Asian populations tend to carry a higher proportion of body fat, and a higher proportion of that fat sits in the visceral compartment.
This is why the World Health Organization, after an expert consultation on Asian populations, recognised that cardiometabolic risk rises at lower BMI values in Asian groups, with additional public health action points suggested at around 23 and 27.5 rather than the familiar 25 and 30.
| Asian populations | European populations | |
|---|---|---|
| BMI action points | around 23 and 27.5 | 25 and 30 |
| Waist, men | 90cm and above | Considerably higher |
| Waist, women | 80cm and above | Considerably higher |
| Waist-to-height | Under 0.5, and it adjusts automatically for build | |
Ninety centimetres is about thirty-five and a half inches. A great many men reading this are wearing a 34 inch trouser and assuming that settles the matter. Trouser sizing and waist circumference are not the same measurement, and the trouser is usually the more flattering of the two.
The storage capacity explanation. The most useful way to think about this is as a storage problem. Your subcutaneous depot has a capacity. While there is room in it, surplus energy goes there, and that is comparatively safe. Once it is full, the surplus has to go somewhere else, and it goes into the visceral compartment and then into the organs themselves.
The evidence suggests Asian populations have a lower subcutaneous storage capacity relative to body size. The tank is smaller, so it fills sooner, and spillover begins at a lower body weight. That is the mechanism behind the phenomenon sometimes called thin outside, fat inside: a normal BMI, a normal-looking body, and a metabolic profile that looks nothing like it.
Men store centrally by default. Male fat distribution is androgen-driven and preferentially central. Women store more in the hips and thighs, which is metabolically protective, until menopause shifts the pattern.
Here is a nuance worth being accurate about, because it cuts against the usual assumption. In Malaysian national data, obesity defined by BMI is actually more common in women than in men. The male problem is not that men are heavier. It is that men put what they do have in the worst possible place, and that a man's belly can therefore carry more metabolic risk than a woman's higher BMI.
Less muscle to work with. Skeletal muscle is where most of the glucose you eat is disposed of. Less muscle means less capacity to clear glucose, which means more circulating insulin, which promotes further fat storage. A man who has been slowly losing muscle since his thirties and gaining a centimetre or two of waist each year is running both sides of that equation in the wrong direction.
Our diet pattern, honestly
I want to write this without moralising, because Malaysian food is genuinely one of the best things about living here and I have no interest in telling anyone to give it up. But there are specific features of how we eat that feed visceral fat efficiently.
Refined carbohydrate at nearly every meal. White rice or refined wheat forms the base of most meals, often three times a day, frequently in generous portions and frequently with limited protein or vegetables alongside. A high, repeated glycaemic load drives insulin, and insulin drives storage.
Sugar in liquid form, all day. This is the one I raise most often. Teh tarik, kopi with condensed and evaporated milk, bandung, sweetened bottled drinks. Liquid sugar produces a rapid glucose rise, provides essentially no satiety, and is consumed almost unconsciously because it counts as a drink rather than as food. Three sweet drinks a day is common and it is a substantial daily sugar load.
Refined carbohydrate combined with fat. Nasi lemak, roti canai, char kuey teow, mee goreng, nasi kandar. These are delicious specifically because the combination is delicious, and that combination is also the most efficient possible vehicle for surplus energy.
Very low fibre and vegetable intake. The national survey figures are stark. Adequate fruit intake sits somewhere around 7 to 14 per cent depending on age group. Fibre slows glucose absorption, improves satiety and has a specific association with reduced visceral fat accumulation. Most of us are getting a fraction of what we need.
Late eating. Supper is a social institution, twenty-four hour outlets are everywhere, and eating a substantial meal late shifts the whole metabolic day. It also degrades sleep.
Eating out as the default. Portion sizes, oil quantity and sugar content are all outside your control when someone else cooks nearly every meal. This is not a criticism of hawker food, which can be eaten well. It is an observation that it removes the levers.
Alcohol, where relevant. Roughly one in ten Malaysian adults drinks, and among those who do, national data suggests around half drink to excess in a session. Alcohol contributes energy, promotes central fat deposition and adds directly to liver fat.
Our activity pattern
The national survey puts physical inactivity at close to 30 per cent of adults, and that figure understates the problem, because the definition of active is a fairly low bar.
The climate. It is hot and humid essentially always. Outdoor activity in the middle of the day is genuinely unpleasant, and that is a real constraint rather than an excuse.
The built environment. Most Malaysian urban development is car-dependent. Pavements are intermittent, distances are designed for driving, and incidental daily movement, the walking people in more walkable cities do without thinking about it, is largely absent from our lives.
Resistance training is rare. This is the one that matters most and gets the least attention. Muscle is the primary site of glucose disposal, and building it changes your metabolic capacity rather than just burning calories on the day. Most Malaysian men who do exercise choose walking, badminton or football, all of which are good, none of which build much muscle.
Two Penang patterns I see every week
The expatriate who gained eight kilos
This one is so consistent it is almost a syndrome. Someone relocates to Penang for work or retires here under MM2H, and within two or three years the waist has grown by several inches, often without a corresponding change on the scale at first.
The reasons are structural rather than personal. Incidental movement disappears, because anyone arriving from a European or East Asian city has come from a life of walking to transport, walking at lunch, walking to shops, and the heat and car-dependent layout remove all of it. That is easily several thousand steps a day, gone quietly.
Eating out becomes the default. Domestic help, inexpensive and excellent food everywhere, and no particular reason to cook. The social calendar changes, running on dinners, drinks and weekend gatherings. The old routine did not travel: the gym membership, the running club, the cycling group rarely survive relocation.
And crucially, the annual company screening stopped. A great many people had a yearly medical at home and simply have not had one since arriving. Five years can pass without anyone looking at a blood result.
One technical point for non-Asian patients. The lower waist threshold of 90cm applies to Asian populations. If you are of European origin, the conventional thresholds are higher, so do not assume the Malaysian figure is your figure. But if you are of South or East Asian descent, including those born and raised elsewhere, the lower threshold does apply to you. This is a common source of false reassurance in expat health screening, and it is worth ten seconds of clarification rather than five years of assumption.
The executive who has a screening every year and is still surprised
The second group is more frustrating, because these are people who have been doing the responsible thing.
Corporate and executive health screening packages in Malaysia are widely available and reasonably priced, and most check height, weight, BMI, blood pressure, fasting glucose and a standard lipid panel. That is genuinely useful, and it is also not enough to see this problem coming.
What the standard package usually does not include: a properly measured waist circumference, body composition with lean mass reported separately, fasting insulin so that insulin resistance can be identified years before glucose starts to drift, and liver fibrosis assessment when enzymes are mildly raised.
So the report comes back green, the BMI sits at 24, and nobody mentions that the waist is 94cm and the triglyceride to HDL ratio has been quietly worsening for four years.
The working pattern does not help either. Client dinners and business entertaining as a professional obligation. Regional travel. Long meetings and longer commutes. Plant and shift schedules in the Bayan Lepas free trade zone, where rotating hours disrupt sleep and eating in ways that independently drive insulin resistance. Evening exercise repeatedly displaced by work that genuinely could not wait.
None of that is a character failing. It is a schedule, and schedules can be worked with, but only once somebody has measured the right things.
How we actually assess this
You cannot manage what you have not measured, and the scale measures the wrong thing.
Waist circumference, measured properly, with a tape at the right level and at the end of a normal breath out, not held in. Against 90cm for men.
Waist-to-height ratio. Divide your waist by your height in the same units. Keeping it under 0.5 is a simple, well-validated target that adjusts automatically for build. It is the single most useful number most people are not tracking.
Body composition analysis, which separates fat mass and lean mass and gives an estimate of visceral fat specifically. Crucially, this lets us track whether you are losing fat or losing muscle, which the scale cannot distinguish.
Blood work: HbA1c and fasting glucose, fasting insulin so insulin resistance can be assessed rather than inferred, a full lipid profile with attention to triglycerides and HDL, liver enzymes, and liver fibrosis scoring where fatty liver is suspected. Blood pressure at every visit.
Screening for obstructive sleep apnoea, which is both a consequence of central adiposity and a driver of it, and which is substantially underdiagnosed here. We have written separately on why snoring is screened before anything else is offered.
There is no blood test that measures visceral fat directly. What blood tests show you is what it is doing.
How we manage it
The plan is not exotic. It is specific, sequenced, and measured.
Nutrition, adapted to how you actually eat. The aim is not a Western diet plan handed to someone who eats Malaysian food. Reduce the glycaemic load rather than eliminating rice: half the usual portion, more vegetables, protein at every meal. Protein matters disproportionately because it supports the muscle we are trying to protect and does more for satiety than anything else. Address liquid sugar first, because it is the highest-yield single change available to most patients and it costs nothing. Kurang manis is a start. Kosong is better. Increase fibre deliberately, since it will not happen by accident. Shift the largest meal earlier and reduce late-night eating. Our dietitians have written on hitting protein targets on hawker food.
Training, with resistance work as non-negotiable. Two to three resistance sessions weekly, progressively loaded. This is the intervention that changes your metabolic capacity rather than simply spending energy. Aerobic work alongside, and given the climate, indoors or early morning is realistic rather than aspirational. And ordinary daily movement, which in a car-dependent city has to be deliberately engineered back in.
Sleep. Short and poor sleep drive insulin resistance and appetite dysregulation directly. The 2023 national survey found insufficient sleep in around 39 per cent of urban adults and above 40 per cent in those aged forty to fifty-nine. If someone has significant central adiposity, snoring and daytime sleepiness, sleep apnoea needs investigating before we conclude that willpower is the issue.
Managing what is already there. Blood pressure, lipids and glucose are treated on their own merits alongside the underlying work, not deferred until the waist improves.
Medication, where it is indicated. GLP-1 receptor agonists are prescription medicines with real trial evidence in defined populations: people with obesity or overweight plus a weight-related condition, people with type 2 diabetes, and in the cardiovascular outcome data, people with established cardiovascular disease. They are effective, and the reduction in visceral and liver fat with meaningful weight loss is genuine.
They are also not a first move for everyone with a belly, not a substitute for the work above, and they require assessment before prescribing and monitoring during it. We have written separately about what a supervised programme actually involves.
The single most important thing to get right if you use one: a substantial proportion of the weight lost on these medications is lean tissue. Losing muscle while chasing a smaller waist works directly against the metabolic goal, since muscle is where glucose is disposed of. Protein intake and resistance training are not optional add-ons to this treatment. They are what make it worth doing.
What to expect
Visceral fat responds first, and that is genuinely good news. Because it is metabolically active and richly supplied with blood, it is mobilised earlier than subcutaneous fat. In practice, blood markers frequently improve before the mirror does, and considerably before anyone comments on your appearance.
This matters psychologically, because many men give up at week six having decided nothing is happening, when in fact quite a lot has.
Realistic timelines. Blood markers begin shifting within eight to twelve weeks. Meaningful waist change over three to six months. Body composition should be measured rather than guessed, at baseline and every three months.
A modest change does more than you would expect. Even a five to ten per cent reduction in body weight produces disproportionate improvement in visceral and liver fat and in the metabolic markers that follow. You do not need a transformation to substantially change your risk.
Track the waist and the tape, not just the scale. If you are training properly, the scale may move slowly while your waist and your blood results move well. That is exactly the outcome we want, and it is invisible to a bathroom scale.
The short version
More than half of Malaysian adults now have abdominal obesity, and the number that most people check will not tell them whether they are among them.
If you are a man in your thirties, forties or fifties with a waist over 90cm, a normal-ish BMI and a set of blood results nobody has looked at properly, you are the person this article was written for. The good news is that this is one of the most modifiable risks in medicine, that visceral fat is the first fat to go, and that a modest change makes a disproportionate difference.
The first step is measurement. Not the scale.
References
- National Health and Morbidity Survey 2023, Ministry of Health Malaysia
- NHMS 2023 reporting, CodeBlue, Galen Centre
- Prevalence and Associated Factors of Physical Inactivity Among Malaysian Adults, NHMS 2023
- WHO expert consultation on appropriate BMI for Asian populations
Frequently asked questions
Because BMI cannot see where fat is stored, and Asian populations tend to carry more visceral fat at any given BMI. A normal BMI with a waist over 90cm is a recognised pattern with real metabolic risk attached.
Not directly. Spot reduction does not work. However, visceral fat is preferentially mobilised when overall fat falls, so it tends to go earlier than the fat you can pinch, which is why the waist often improves faster than expected.
With a tape measure, on bare skin, at the end of a normal breath out, without pulling it tight and without holding your stomach in. Not at the level your trousers happen to sit. Compare it against 90cm, and also divide it by your height and aim to stay under 0.5.
It can be. Most cases remain stable, but a proportion progress to inflammation and scarring. It is common in Malaysia, closely tied to visceral fat, and worth assessing rather than ignoring when liver enzymes are raised.
It depends on your ancestry rather than your address. The 90cm figure is for Asian populations. If you are of European origin the conventional thresholds are higher. If you are of South or East Asian descent, wherever you were born, the lower threshold applies. Worth clarifying at your assessment.
Standard corporate packages check BMI, blood pressure, fasting glucose and lipids, all useful. They usually do not include a measured waist, body composition with lean mass, fasting insulin or liver fibrosis assessment, which are the things that identify this pattern years earlier. A normal package result and a 94cm waist can coexist comfortably.
Not on its own. Quantity, frequency and what accompanies it are the problem. Adding protein and vegetables and reducing the portion changes the glycaemic impact of the same meal considerably.
Blood markers within roughly three months, visible waist change over three to six. Visceral fat generally moves before appearance does.
This article is general information and does not replace individual medical advice. Suitability and outcomes vary between individuals and no result can be guaranteed. Medicines referred to are named for education only and are not advertised; prescription medicines are prescribed only after individual assessment by a doctor. Devices used are registered with the Medical Device Authority.