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Obesity, Skinny – Fat & Disease

The Skinny on Skinny-Fat 

Excess adipose tissue around a male's belly is a form of obesity

English: Excess adipose tissue around a male’s mid-section. (Photo credit: Wikipedia)

This post picks up on a prior post (see “Belly Fat – the Enemy Within“) about the misleading nature of BMI (body mass Index) measurements. This includes press reports that encourage complacency among those with higher risks for disease than is currently perceived.

One study of older adults with normal BMIs found the following:

“Visceral adipose tissue (belly fat) was nearly 50% higher in men and women with metabolic syndrome. The association…was particularly noticeable in normal-weight and overweight men and women, but less so in the obese”.

This means that pot bellies are even more damaging in normal weight people than in the obese. This is likely because most such people are thin but lack sufficient muscle mass. They’re thin, but not fit.

This phenomenon of “skinny-fat” – pot bellies in those with normal BMIs – may be as great a health threat as overall obesity, especially in older people. Yet it remains far less recognized as a disease risk factor. Many still take false comfort in the idea of an “obesity paradox” – that excess fat actually protects them in their senior years.

A recent study, however, removed the internal biases and confounders in previous studies that supported this notion. As noted in “Old Age Offers No Protection from Obesity’s Death Grip“, the obesity “paradox was a mirage. As obese Americans grow older…their risk of death climbs “.

An earlier report on “skinny-fat” people at the physician website,, noted:

“Subcutaneous fat in the thighs of obese men and women was associated with a lower prevalence of metabolic syndrome, a finding that supports earlier clinical findings that the ‘apple’-shaped physique is linked more closely to cardiovascular and diabetes risk than the ‘pear’”.

This helps explain men’s higher risk for these diseases. Men are more likely to accumulate fat around the abdomen, while women are more prone to a “pear-shape” fat accumulation in the hips, thighs, and buttocks.

Much More Than Cosmetics

So while excess fat in the thighs and buttocks may offend your cosmetic sensibilities, it’s belly fat that’s the greater threat to your physical and fiscal health.

Animated map of obesity incidence by state (19...

Animated map of obesity incidence by state (1985-2006) (Photo credit: Wikipedia)

That’s because, as noted previously, visceral fat acts as an endocrine organ emitting pro-inflammatory cytokines that promote disease in nearby organs and throughout the body.

Fatty liver disease is an emerging epidemic linked to soaring obesity rates that can cause liver inflammation and damage leading to cirrhosis even among non-drinkers.

Fatty liver disease is found in 4 out of 5 obese patients. There’s more aggressive progression of the disease in America than in Europe due to higher rates of obesity in the U.S.[1]

Alcohol abuse, acetaminophen (Tylenol) overuse, and overuse of many other drugs processed by the liver (such as cholesterol-lowering statin drugs) can further compromise healthy liver function. These pose even greater risk for “skinny-fat” people.

Since the liver produces bile that aids in digestion and absorption of nutrients, this can also impair the benefits of even a nutritious diet.

The nutritional benefit of better digestion is one reason weight loss in the overweight and obese leads to improved health (see “Nutrition & Diet Are Your Best Medicine” for more on this).

Excess Fat Also Damages the Heart

Visceral fat can also be found beyond the abdomen – most notably around the heart. This is called “epicardial adipose tissue” and too much of it has been found to have the same inflammatory effects as visceral abdominal fat.

While epicardial fat serves an essential role in supplying local energy for the heart, greater epicardial fat thickness is found in obese people. One study of epicardial fat tissue found:

“In obese patients,…epicardial fat…secretes several proinflammatory cytokines and is infiltrated by macrophages…(and) may contribute locally to the pathogenesis of coronary atherosclerosis (plaque formation)”.

Another review of epicardial fat found…

A…strong direct correlation between epicardial fat and abdominal visceral (fat)..epicardial fat may be an important factor responsible for cardiovascular disease in obesity.”[2]

Reducing excess belly fat should be a primary goal of any weight loss program regardless of BMI level. Yet studies show fewer than 1 in 4 doctors measure patients’ waists.[3] These and other shortcomings of mainstream medical practice in America are discussed in-depth in Our Healthcare Sucks.

Fortunately, you can measure your own waist. But don’t fool yourself if wearing smaller-waisted pants well below the belt line is your chosen fashion statement.

Get out the measuring tape and measure your abdomen as described in the following interview of Dr. Oz by John Tesh. This may prove the best indication of your disease risk.

Obesity and Alzheimer’s 

Despite Dr. Oz’s suggestion that your waist should be no larger than half your height, many of the studies on obesity and disease use waist size alone. BMI, however, does take height into account. The study cited next considered both waist size alone and waist size combined with BMI to assess the effects of excess belly fat on the incidence of Alzheimer’s Disease.

Regardless of race, men with a waist over 40”and women over 35” (some studies suggest a cut-off point closer to 34”) and a BMI over 30 are at substantially increased risk for diabetes, heart disease, certain cancers, and have an up to 260% greater risk of Alzheimer’s Disease.[4] [5]

A study in the journal Neurology found people with “central obesity” in their 40’s had a much greater risk of developing Alzheimer’s Disease in their 70’s. This risk increased in proportion to BMI combined with excess belly fat, as shown in the following table:

Relative Risk of Alzheimer’s
Based on Central Obesity

            Obesity Category                 Increased Alzheimer’s Risk
         Top 20% Waist Size                              +172%
  Top 20% Waist Size & BMI >30                              +260%

Source: See footnote 4

Most people know, at least at some level, that obesity increases their risk of heart disease and diabetes. But few probably know of this greatly increased risk of Alzheimer’s.

Given the intense public fear of Alzheimer’s Disease, those with loved ones who are overweight – or with excess belly fat even at normal weight – can use this information to motivate behavioral changes to achieve healthy waist – loss.

Obesity and Stroke

While on the subject of the brain effects of excess belly fat, some studies have found only men with elevated BMIs are at increased risk for stroke.

The Nurses’ Health Study, however, found women were also at greater risk for stroke, especially those with larger waists.  This is supported by an increase in strokes in women ages 35 to 54 in federal NHANEs surveys from 0.5% in 1988-1994 to 2% in 1999-2004. This four-fold stroke increase among women is attributed to a corresponding increase in obesity.

Given these clear associations and causal relationships between excess belly fat and the leading causes of death and disability, it does no one a service to diminish the adverse health effects of excess body fat with media reports that maybe obesity isn’t such a threat after all (see “Weight Loss Fallacies and Fraudulent Science“).

We should instead be sounding the alarm to both the obese and a complacent population of “skinny-fat” men and women who are at greater risk for an early end than they realize.

Do you know someone who’s skinny-fat? Will this post cause you to reach out to alert them, without offending them, to their unwitting risk of a shortened and/or disabled future?

How will you go about doing so? Weigh in below with any suggestions you have for using this information without alienating someone you’re trying to help.

Or is that someone you?

Next: Obesity & Cancer

[1] Non-Alcoholic Fatty Liver Disease.

[2] Epicardial fat: properties, function and relationship to obesity. Obesity Reviews. 8(3):253-261. Sept. 2006.

[3]SYNERGIE: Lifestyle management reduces body fat distribution and metabolic syndrome risk factors. 4/28/08.

[4] Obesity and central obesity as risk factors for incident dementia and its subtypes: a systematic review. Obesity Reviews. 9, pp 204-218. (May 2008). Doi: 10.1111/j.1467-789X.2008.00473.x.

[5] Central obesity and increased risk of dementia more than three decades later Neurology 3/26/08;71:1057-64.

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