In my day to day endocrinology practice one of the first complaints I hear from people, no matter what the medical problem, is about weight. Almost always, it is either because they are gaining or unable to lose it. When I began my medical practice 40 years ago, this was also the case. What is it about weight that prevents more progress from being made? Could it be because in nature having adequate amounts of stored fat on the body eg belly fat, is essential for survival in the same way having gasoline in the fuel tank of a car is needed to keep it going? Not to mention the role of fat as an insulator against the cold. Imagine trying to live through a winter without clothes, the way primitive humans did? Being covered in fat was literally a lifesaver. The more we know about the role of fat (adipose) in our lives the better we are equipped to live with (and without) it.
It’s tempting to think that all fat is built the same, but this is not true.
There are actually three types of fat; white, brown, and beige fat, and they are distributed in different parts of the body in different proportions, as either visceral fat (inside the body and organs) or subcutaneous fat (under the skin).
White fat is the fat most people are familiar with – over 73.2% of all Americans carry too much and are classed as either overweight or obese (CDC, 2017 to 2018). While some white fat is absolutely essential for a healthy metabolism, every body has its limits.
Brown fat is found mainly in babies and plays a key role in providing energy and keeping us warm. Adults retain a small percentage of brown fat around their necks and shoulders.
Beige, or brite fat, is similar to brown fat and is optimized for burning fat rather than storing it, unlike white fat.
As we can see, white fat is the ‘bad stuff,’ and is the type of fat that many of us worry about.
Visceral and Subcutaneous Fat
Fat is distributed as either visceral or subcutaneous fat, and there is a big difference between the two.
Subcutaneous Fat
Subcutaneous fat is stored under the skin in the limbs and extremities; arms, belly, thighs, and buttocks. When you pinch your arm or leg, you’re likely feeling a layer of subcutaneous fat distributed under the skin. Made up of mostly white fat, some subcutaneous fat is essential for hormonal function, as well as keeping warm.
While people with different body compositions will likely carry different percentages of subcutaneous fat, everyone has their limits. Subcutaneous fat is not totally harmless, but it poses fewer risks than visceral fat.
Visceral Fat
Visceral fat is stored primarily around and inside the abdomen. Yes – fat is more than skin deep and is stored inside of us as well as under our skin.
Whilst excess subcutaneous fat is still unhealthy, many recent and reputable studies such as this large-scale meta-analysis of 2.5 million participants suggest that visceral fat poses a much greater health risk than subcutaneous fat.
The increased health risk of visceral fat is linked to its proximity to the vital organs.
The closer fat is to the stomach and abdomen, the greater the chance is that it penetrates under the skin, wrapping itself around the liver, heart, kidneys, pancreas, and other organs. A study conducted by the University of Chicago and published in 2016 also found that visceral fat behaves differently from subcutaneous fat and resists fat burning (lipolysis). This also explains why abdominal fat is seen as ‘stubborn fat’ that is hard to lose.
Around 59% of all US adults were abdominally obese in 2015 to 2016, representing a massive increase from around 47% in 1999 to 2000 (CDC, 2016).
Visceral fat poses a much greater risk than subcutaneous fat in developing in the following conditions:
Heart disease
Type 2 diabetes
Insulin resistance
High blood pressure
High cholesterol
Certain types of cancer, such as stomach cancer, bowel cancer, pancreatic cancer and liver cancer
How to Measure Visceral Fat
Traditionally, BMI (body mass index) has been the go-to yardstick for measuring body fat. Today, many health authorities encourage the use of both BMI and abdominal fat measurements. The measurement of waist circumference is a popular method to assess abdominal fat. It’s possible to have a healthy BMI and high waist measurement, and vice-versa.
Take your shoes off and stand with your feet together.
With a bare stomach, relax and exhale all air from your diaphragm.
Use a fabric tape measure to measure your waist circumference at the naval.
Record the measurement.
Be aware that this measurement is likely not the same as what many consider to be their ‘waist’ measure (i.e. the measurement they use to fit trousers).
Men
Women
Low Risk
37 inches and below
31.5 inches and below
Medium Risk
37.1 to 39.9 inches
31.6 to 34.9 inches
High Risk
40 inches and above
35 inches and above
Does Abdominal or Visceral Fat Increase With Age?
The short answer is yes, it does. The plight of the so-called beer belly or middle-age spread is real!
This study published in the International Journal of Body Composition Research found that visceral fat increased by over 200% in men and 400% in women between the age of 30 and 70.
Why?
As we age, our metabolism changes and slows down, but the ‘middle-age spread’ is also linked to changes in behavior and diet.
To briefly summarize, aging reduces our percentage of lean muscle mass, which lowers our metabolic rate. Additionally, whilst it’s perhaps natural to indulge a little more as we get older, it’s easy to eat more and exercise less. That gives your body every excuse to pile on that abdominal fat!
Abdominal Fat and Menopause
Studies have shown that estrogen plays a major role in body fat distribution, hence why women experience a much greater change in visceral fat with age due to menopause accompanied by the loss of estrogen (400% vs 200% in men between the ages of 30 and 70).
Multiple studies, including this one published in the Journal of Menopausal Medicine, have also found that estrogen replacement therapy (ERT) can mitigate some of this weight gain. However, estrogen replacement is not without its risks and is unsuitable for many.
Namely, ERT can increase the risk of blood clots leading to strokes and embolisms and cause headaches, swelling, or edema. ERT is also often linked to an increased risk of breast and ovarian cancer. It is worth mentioning however, studies reviewed by Breastcancer.org show that the risk is only significant after using ERT 10 years or more (in the case of estrogen-only therapy). Combination HRT which includes both estrogen and progesterone poses a much greater risk.
As such, ERT is certainly not a ‘silver bullet’ for treating menopause-related abdominal weight gain.
Part 2 of this article will be published in 2 weeks at this website www.metabolism.com
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The mission of the The Thyroid Project is to encourage sharing of information and experience between the public and the medical community about the treatment of hypothyroidism (low thyroid function). For at least the past few decades there is a growing awareness of “something missing†in the way suffers of hypothyroidism are treated for their disease.
Too many patients, as documented in an on-line study of 12,000 individuals conducted by the American Thyroid Association published in June 2018, (https://doi.org/10.1089/thy.2017.0681) , complain of persistent symptoms of hypothyroidism despite what their doctors believe is successful treatment with levothyroxine (brands include Synthroid, Unithroid, Tirosent, Levoxl). We believe something needs to be done to resolve this conflict between patients and their doctors.
Diabetes can be defined simply as elevated blood sugar levels. What exactly is high blood sugar and when should someone be concerned about their level? Does having prediabetes mean diabetes is around the corner? Metabolism.com tackles this tricky but important topic in this comprehensive review.
By Gary M. Pepper, M.D. Ozempic, Rybelsus, Trulicity, Wegovy, Saxenda are the central players in the weight loss craze sweeping across the globe. Metabolisim.com has been monitoring this phenomenon from its beginnings in 2008 with its report “Lizard Spit Reduces Blood Sugar and Appetite”, regarding the first drug in this class, Byetta (exenatide). Caught In the middle of the current chaos are the medical experts who treat diabetes and have been prescribing these medications for more than a decade. Here is a brief commentary from one such board certified endocrinologist; “I started treating Type 2 diabetics with GLP-1 agonists more than 10 years ago. In some respects, these medications have revolutionized the treatment of diabetes by lowering blood sugar effectively and promoting weight loss at the same time, a unique combination of benefits. Not everyone benefits from these drugs to the same degree unfortunately, and I have seen lots of patients experience unacceptable side effects from them. Nothing though, has prepared me for what is happening now. Too often, I find myself confronting someone who expects me to prescribe one of these drugs just so they can lose weight. Sadly, one extreme example was someone who, despite battling a life threatening medical condition, was insistent on getting a prescription. At the same time my diabetic patients are scrambling to find a place to buy their medications if they can even afford it. It is disheartening, to say the least, and I dread the negative interactions with some of my patients I now face almost daily.”
Off- Label Use
The FDA is the U.S. government’s department tasked with evaluating and approving drugs for specific medical conditions. When a new medication is approved for treating a medical condition by the FDA the agency will, at the same time, set strict guidelines for exactly which patients may use the newly approved drug. When a medication is used “off-label” it means that these limitations are being overridden by the provider for a potential benefit which outweighs the drugs risks. It is a general misconception that off-label means illegal; it does not. This practice has been going on for ages and more than 20% of prescriptions in the United States are prescribed off-label. A common example is the use of beta-blockers (approved for heart problems) for the treatment of performance anxiety.
GLP-1 agonist drugs, as discussed recently by metabolism.com. were originally approved for the treatment of Type 2 diabetes in adults. In the past few years most of these same medications have gained unprecedented popularity for their “off-label” weight loss benefit. Of the 5 GLP-1 agents presently in U.S. pharmacies only Wegovy (semaglutide) and Saxenda (liraglutide) are FDA approved for treating obesity. Of these two, Wegovy is the newer and had been much more popular that its sister drug Saxenda, probably due to being dosed only once weekly compared to daily for Saxenda and less likely to cause side effects. Due to Wegovy’s soaring popularity, its manufacturer, Novo Nordisk, increased the price of Wegovy two times since its initial release.
by Gary M. Pepper, M.D. and Sam Jeans, MSc The global anti-obesity drug market, in 2021was valued at over $2 billion. Within one year this figure had skyrocketed to $8 billion and is expected to climb to nearly $ 20 billion by 2027. This astounding growth is a reflection of soaring obesity rates, and the arrival of a new class of weight loss medication fueling a craze both in the USA and across the world.
The FDA and global health regulators, until very recently, had maintained a very tight ship when it comes to treating obesity with medication, placing the emphasis on diet and exercise rather than weight loss drugs. Since the 80s, anti-obesity drugs continued to be controversial, and a more stringent FDA implemented ongoing safety trials along with other precautions. There is some speculation that a shift in attitude toward approval of weight loss medication by the FDA , is underway
Weight loss drug controversies are far from over and, in fact, may soon rival the amphetamine crisis of the 70’s. For that reason, metabolism.com has felt it important to provide our guide to weight loss drug issues, past and present.
Anti-Obesity Drugs Timeline
Prescription drugs for lifestyle diseases such as obesity were marketed heavily throughout the 1950s to the 1970s. Amphetamines entered the public domain after the Second World War where they were used extensively in the military.
In the 50s, walk-in clinics prescribed diet pills with other medications almost at random, with or without genuine concern for one’s weight. These brightly colored pills became known as “rainbow pills”.
In the 1960s and 1970s, the so-called “rainbow pill diet” of pills was finally coming to an end as the FDA began to systematically ban many of the drugs involved. A high-profile expose by investigative journalist Susanna Mcbee, published in Life magazine, brought attention to this new modern public health crisis.
The rainbow pill diet combined amphetamines, laxatives, thyroid hormones, and even diuretics to produce extreme weight loss, combined with benzodiazepines, barbiturates, and steroids to reduce side effects, and antidepressants to suppress medication-induced insomnia and anxiety.
In 1968, rainbow pills were linked to over 60 deaths, with numerous accounts of their devastating impact surfacing in the news and media. Within just two months, 48 million pills were seized and destroyed. Nevertheless, amphetamine-based diet pills remained extremely popular throughout the 1970s. In 1978, some 3.3 million prescriptions for amphetamines were written each year, with some 50 million pills a year ending up in the black market.
In 1979, the FDA banned amphetamines as a weight loss aid, but that is hardly the end of the USA’s love affair with obesity medication.
Here’s a brief timeline of recent anti-obesity drugs:
