What Are You Growing Around Your Middle?
A patient of mine named his ranch Belly Acres, which may be one of the finest pieces of Western real-estate branding I’ve ever encountered. The name conjures up cattle leaning contentedly against fence posts, a tractor that starts on the third try, and a rancher whose belt buckle has not been visible since the Reagan administration.
But Belly Acres also happens to be a surprisingly good name for one of the most important pieces of real estate in human health: the territory between our ribs and our belt.
Most of us acquire a little property there eventually. A few extra pounds arrive during the holidays, establish residency and apparently discover there are no zoning restrictions. One subdivision becomes another. Before long, Belly Acres has expanded beyond the original homestead.
Unfortunately, when it comes to abdominal fat, location matters. And the most troublesome acreage isn’t necessarily the part hanging over your belt.
Location, Location, Inflammation
There are two major kinds of abdominal fat worth knowing about.
Subcutaneous fat lies underneath the skin. It is the soft stuff you can grab with your hand and curse at in the mirror.
Visceral fat lives deeper inside the abdomen, surrounding organs such as the liver and intestines. You generally can’t pinch it because it is tucked behind the abdominal wall, quietly conducting business. And business is good.
For years we thought body fat was essentially a storage shed for excess calories. Eat more energy than you need and the body parks the leftovers in adipose tissue for later. This is certainly one of fat’s jobs, and from an evolutionary standpoint it is brilliant. When dinner occasionally disappeared for three days, having a few thousand calories stored around the hips could be the difference between survival and becoming an interesting archaeological specimen.
But adipose tissue isn’t merely storage.
It is biologically active tissue that communicates with the rest of the body through hormones, inflammatory mediators and other signaling molecules. Visceral fat in particular is associated with insulin resistance, fatty liver disease, abnormal lipids, hypertension, cardiovascular disease and type 2 diabetes.
Belly Acres, it turns out, has its own communications department and they send a lot of memos.
The Fat That Talks Back
As fat cells enlarge, particularly in visceral depots, the biological neighborhood begins to change. Adipocytes become stressed and dysfunctional. Immune cells, including macrophages, accumulate within adipose tissue. Inflammatory signaling increases. The normal production of helpful adipokines such as adiponectin can decline while the metabolic effects of excess circulating fatty acids become increasingly troublesome.
Some of those fatty acids travel directly toward the liver through the portal circulation.
The liver, which was already busy processing dinner, medications, alcohol, hormones and whatever supplement somebody on the internet convinced you to take, now receives a steady delivery of additional fat. Eventually it begins storing some. Welcome to fatty liver.
At the same time, muscle and liver become less responsive to insulin. The pancreas compensates by making more of it. For quite a while, blood glucose may remain perfectly normal because the pancreas is working overtime.
This is an important point. A normal fasting glucose does not necessarily mean that everything at Belly Acres is peaceful. Insulin resistance and compensatory high insulin levels can precede abnormal glucose by years. The glucose looks fine. The pancreas is sweating through its shirt.
When the Ranch Outgrows the Fence
Eventually the metabolic consequences begin appearing on routine laboratory work. Triglycerides may rise. HDL may fall. Blood pressure creeps upward. Fasting glucose increases. Hemoglobin A1c wanders into the prediabetic range. Liver enzymes may rise as hepatic fat accumulates.
None of these problems necessarily travel alone. They often arrive together because they are different manifestations of the same underlying metabolic disturbance.
We call the familiar cluster metabolic syndrome: abdominal obesity, elevated blood pressure, abnormal glucose, high triglycerides and low HDL cholesterol.
Modern medicine sometimes has a peculiar talent for turning one interconnected physiological problem into five separate diseases requiring five separate prescriptions. One pill for the blood pressure. One for the glucose. One for the triglycerides. Another for something the first pill did.
The medications may be entirely appropriate, but somewhere underneath the pharmaceutical committee meeting there may still be one very important question, “What’s happening at Belly Acres?”
The Bathroom Scale Is a Terrible Surveyor
This is where body weight becomes misleading.
Body Mass Index, or BMI, is useful when studying populations, but it can be remarkably crude when applied to an individual. It knows your height and weight and almost nothing else about you.
BMI cannot tell whether those 190 pounds belong to someone who deadlifts twice his body weight or someone whose principal resistance exercise is opening the refrigerator.
More importantly, two people with identical BMIs can have dramatically different amounts of visceral fat.
That is why waist circumference can provide information the bathroom scale misses. An even simpler measurement gaining considerable attention is the waist-to-height ratio. The rule of thumb is wonderfully uncomplicated. Try to keep your waist circumference below half your height.
For the waist measurement: find the bottom of your lowest rib and the top of your hip bone, and measure halfway between those two points. It’s roughly in line with your belly button.
A six-foot person, for example, would ideally have a waist below about 36 inches. It isn’t a perfect diagnostic tool, and body composition, ethnicity, age and sex all matter, but it provides a surprisingly useful snapshot of central adiposity.
Sometimes a tape measure tells you something the $4,000 laboratory panel forgot to mention.
The Liver Next Door
One of the first neighbors affected by an expanding Belly Acres is the liver.
Metabolic dysfunction-associated steatotic liver disease, what many of us spent years calling nonalcoholic fatty liver disease, is now extraordinarily common. Excess energy, insulin resistance and increased fatty-acid delivery encourage fat to accumulate within liver cells.
The liver can tolerate this for quite some time. Until it doesn’t.
In susceptible people, simple fatty liver can progress toward inflammation, fibrosis and eventually cirrhosis. Long before that happens, however, fatty liver is often waving a metabolic flag telling us that energy storage and insulin signaling are no longer working particularly well.
The liver isn’t an innocent bystander living next door to Belly Acres. It shares the irrigation ditch.
How to Sell Off a Few Acres
Fortunately, visceral fat is metabolically responsive. We do not have to wait for a pharmaceutical bulldozer to arrive.
Exercise is one of the best tools we have. Aerobic activity can reduce visceral fat and improve insulin sensitivity, sometimes even without dramatic changes on the scale. Resistance training adds another advantage by building muscle, the largest glucose-disposal organ in the body and one of our most valuable metabolic assets as we age.
Muscle is expensive tissue. It needs energy. It stores glucose. It improves physical function. It protects bone. It gives carbohydrates somewhere useful to go. If visceral fat is undesirable metabolic real estate, muscle is prime commercial property.
Food matters too, although there is no single magical Belly Acres diet. The common denominator is remarkably boring: fewer ultra-processed foods and refined carbohydrates, adequate protein, plenty of vegetables and fiber, whole fruits, legumes, nuts, healthy fats and foods that still vaguely resemble something that once grew, flew, ran, swam or had roots.
Sleep belongs on the list as well. Chronic sleep deprivation alters appetite regulation, insulin sensitivity and stress hormones in ways that make weight regulation considerably harder. Excess alcohol can add calories, worsen sleep and contribute directly to liver fat. Chronic stress can make the entire enterprise more difficult.
None of this is terribly exotic. That’s probably why nobody has become a billionaire selling it.
You Can Lose Fat Without Losing Much Weight
One of the most encouraging aspects of improving metabolic health is that the bathroom scale may substantially underestimate your progress.
Imagine someone who begins resistance training, increases protein intake, cleans up the diet and starts walking every day. Over six months he loses ten pounds of fat but gains six pounds of muscle.
The scale announces, “Congratulations, you’re down four pounds.” The scale is an idiot.
That person may have substantially reduced visceral fat, improved insulin sensitivity, lowered triglycerides, increased strength, improved bone health and changed their metabolic trajectory while barely changing the number on the scale.
This is why the goal shouldn’t simply be weight loss. The goal is better body composition and better metabolic health. We want less dysfunctional visceral fat and more functional muscle.
In ranching terms, we’re not trying to make the property smaller. We’re improving how the land is being used.
Keep an Eye on the Property
Your body needs fat. Adipose tissue stores energy, cushions organs, participates in hormone signaling and has been keeping human beings alive through famines and hard winters since long before anyone invented DoorDash.
The problem is not body fat itself. The problem is when the storage system begins exceeding its comfortable capacity and excess energy starts spilling into places where it doesn’t belong – around the abdominal organs, inside the liver and eventually into muscle and other tissues.
That’s when Belly Acres stops being a charming little homestead and starts becoming a management problem.
Fortunately, the property can be improved.
Build muscle. Walk more. Occasionally breathe hard enough that conversation becomes inconvenient. Eat mostly real food. Get enough protein and fiber. Sleep. Don’t drink your liver into early retirement. And every now and then, take a tape measure and walk the fence line. The bathroom scale can come along if it wants. Just don’t put it in charge.
When it comes to Belly Acres, a little property is part of being human. But more acreage isn’t always more valuable.
Author
Scott Rollins, MD, is Board Certified with the American Board of Family Practice and the American Board of Anti-Aging and Regenerative Medicine. He specializes in bioidentical hormone replacement for men and women, thyroid and adrenal disorders, fibromyalgia and other complex medical conditions. He is founder and medical director of the Integrative Medicine Center of Western Colorado (www.imcwc.com) and Bellezza Laser Aesthetics (www.bellezzalaser.com). Call (970) 245-6911 for an appointment or more information.
