The skinny on belly fat — and how to get rid of it.
Are you intrigued by those Internet ads claiming to know "the secret to shedding belly fat" or "the one trick to losing belly fat"? Do you send away for the latest exercise DVDs because they promise you washboard abs? Have you tried dietary supplements or weight loss pills to whittle your waist?
If so, you're not alone. Americans spend countless hours and billions of dollars trying anything and everything to attain a flat stomach. But is there really a magic bullet — a fast and easy way to shed stubborn belly fat — as so many ads and commercials claim?
We talked to two experts from Rush, Rasa Kazlauskaite, MD, an endocrinologist with the Rush University Prevention Center, and Sheila Dugan, MD, a physical medicine and rehabilitation specialist, to find out why belly fat is more than just a cosmetic issue.
Q: First of all, what is belly fat?
Dugan: Well, there are different types of fat. Fat can accumulate just underneath the skin, which is called subcutaneous fat. That's the looser fat that lets you "pinch an inch."
There's also intramuscular fat within the skeletal muscles. And then there's visceral fat, which is packed between your abdominal organs (stomach, liver, kidneys, etc.), what we refer to as intra-abdominal or belly fat.
Just to clarify, we're not talking about just having a little fat below the belly button — that pouch some women get. We're also not talking about fat around the hips. Visceral fat affects the abdominal area; it causes a person to have a thicker waistline or pot belly.
Having too much fat is always bad, but when you’re talking about cardiovascular health, visceral fat is far worse than subcutaneous fat; research has shown a very strong correlation between belly fat and serious health problems — including heart disease, high blood pressure and diabetes. It's become pretty clear that belly fat is a big culprit.
So why do we get this belly fat? Our bodies are actually designed to store fat; we're very good at it. Back when humans were hunter-gatherers, we needed the ability to store fat so we could then burn it during the winter months when food was scarce, like bears when they hibernate.
Now that food is plentiful in our environment all the time and it's not feast or famine, we don't need to be so efficient at storing fat.
But the basic design of our bodies hasn't changed over time, so now we're eating all the time and, as a result, storing all the time. If you're consuming more calories than you're expending, fat will develop. Depending on a variety of factors, it can start to build up predominantly around the belly, even if other parts of the body, such as the arms and legs, remain thinner.
Q: What are those factors that can lead to belly fat?
Kazlauskaite: Normally, there's supposed to be some fat in the belly, the same way there's supposed to be some fat under the skin, around the heart, blood vessels and tendons, and in the bone marrow. This fat is thought to be protective, so if people exercise and diet and lose too much fat, that can be bad too.
But when people become overweight and accumulate extra fat, then the fat distribution matters. What seems to influence fat distribution most are genetics, gender and age. Those are the factors we cannot change.
But then we also know that with stress, with overeating and with physical inactivity, belly fat can accumulate out of proportion to the other areas where fat is supposed to be deposited.
Dr. Dugan and I were part of a recent study that showed that excess energy intake (meaning extra calories) through eating is a very important factor in belly fat gain, along with physical activity and stress. Those are all factors we can change.
Q: Is there really 'one trick' or 'one secret' to losing belly fat, as so many ads claim?
Kazlauskaite: When ads claim a "one trick" solution, you should remember that their main objective is to sell their product rather than to help you. Good marketing means one message, because it is hard to follow too many things at once. So they focus on one fad, and that tickles your curiosity and you click on the link to go their website.
Typically, however, there are many things you may need to improve to lose belly fat. I would say start by focusing on changing or improving one thing. Then, once you conquer that first objective, you can move on to the next thing, and so on.
One good place to start improving your food choices is to eliminate sugary drinks — and not just soda, but juices. Sugar increases belly fat and fiber reduces belly fat; thus when you're juicing fruits, you're removing the fiber, leaving pure sugar. So one quick fix, a very concrete fix, would be eliminating sugary drinks.
Recent studies have shown that sugar overuse is very widespread. Even kids who are growing and need energy should be consuming less than 14 tsp. of sugar per day, and right now, the average kid consumes around 40 tsp. a day, which is far too much. That 40 tsp. includes not just table sugar that we sprinkle on foods, but sugar hidden in foods and drinks.
Replacing sugary beverages with water will help dramatically cut down your sugar intake, and then once you've taken that step, you can figure out how to cut down on foods that are high in sugar.
The next "trick" would be to start your meal, especially your largest meal, with seasoned vegetables, be it vegetable soup or the half-plate of vegetables on your entrée plate (remember that vegetables should always comprise half of your plate). Eating the vegetables first will leave less room for other foods that aren't as healthy, because vegetable fiber is filling.
Fruit is not a substitute for vegetables, but if you have a sweet tooth and need put that final accent to your meal, eat an apple or berries.
Dugan: I would say committing to physical activity, to a physical lifestyle, is the single most important thing people can do to prevent the buildup of belly fat and get rid of existing belly fat.
I was principal investigator of a study at Rush back in 2007 that showed higher levels of physical activity were associated with lower intra-abdominal fat levels in both white and black women.
There has to be a balance between energy in and energy out, or food intake and physical activity.
Moderate-intensity physical activity, I would say, is the "magic pill" because the health benefits go beyond keeping your waistline trim: Not only can it reduce your risk of cancer, stroke, diabetes and heart attacks, but studies have shown that physical activity can significantly improve the moods of patients with major depressive disorders.
Long ago, Hipppocrates said, "walking is man’s best medicine," and even with all the advances in medicine in the centuries since, that statement still holds true. In both men and women, the first fat you lose when you exercise is visceral fat.
Q: How much physical activity do you need to start losing belly fat?
Kazlauskaite: The recommendation is 150 minutes per week or more of moderate physical activity. By moderate physical activity, we mean you are going at a pace where you can carry on a conversation, but you still break a sweat and raise your heart rate. You should push yourself but not be out of breath.
The best if you "accumulate" physical activity is at least three or four sessions per week. You don't have to do a lot at one time, but you have to continue your activity at least 10 minutes at a time to get maximal benefit. And more physical activity is better.
So I strongly recommend having an active hobby, and if you don't already have one, develop one. Get engaged in some kind of sport, whether it's a group activity or something you can do alone. Essentially, if an activity is pleasant to you, you'll continue to do it.
Dugan: That's really important, because if your leisure time involves sitting around on the sofa or in a chair, you might actually be offsetting the positive health effects of exercising even if you're working out regularly.
There was a study that showed people who sit eight to nine hours a day, even if they exercise the recommended 150 minutes per week, do not get the same benefits of exercising as people who are more active throughout the day.
If you have to sit most of the day for your job, try taking small breaks throughout the day to walk around; use your lunch hour to take a longer walk; take the stairs instead of the elevator, if possible; or do stretching exercises at your desk. Just do your best to move around as much as you can.
Kazlauskaite: Unfortunately, the general understanding of rest is relaxing in front of TV or dining out — and these things are what we call "passive rest." But really, our rest should consist of sleep, and our leisure time should consist of fun physical activity, which is active rest.
Statistics suggest that out of 900 months in his life, the average man in the U.S. spends approximately 198 months watching TV, five months complaining about his boss, and five months waiting on hold.
I thought that was a fascinating statistic. Think of the other things you could do with those 208 months of life. You can definitely find activities that are better for your health and will help keep the belly fat away.
Here's something else most people probably don't know: Fidgeting is good for you. It's considered a nonexercise physical activity, and it's an important way to burn energy. You get more health benefits if, in addition to exercising, you are a more fidgety, more active person the rest of the day. This means gesturing while you're talking, tapping your foot, just moving around.
Q: But can't you simply reduce belly fat by doing a lot of sit-ups or other exercises that target the abdominal area?
Dugan: Unfortunately, sit-ups and crunches can't eliminate visceral fat directly. You can't reduce fat from specific parts of your body by exercising that body part; our bodies simply don't work that way.
With sit-ups or other abdominal exercises, you're toning the abdominal muscles but not burning this intra-abdominal fat. The key, really, is to lower your overall body fat with moderate intensity physical activity and a healthy diet; when you reduce your total body fat, you'll also be reducing your belly fat.
However, while sit-ups can't "target" belly fat, what they can do is help you burn calories, strengthen your core and develop more muscle. Because muscle is more metabolically active than fat, the more muscle you have, the more calories you'll burn when you're at rest.
And burning those extra calories can help you achieve and maintain a healthier weight in conjunction with regular cardiovascular exercise and a healthy diet. So if you want to do abdominal exercises, make them part of your fitness routine. Just don't treat them as a substitute for the recommended 150 minutes of weekly moderate intensity physical activity.
Q: You said earlier that exercise is a magic pill, but what about actual pills — weight loss drugs or supplements? Can't those help melt away the belly fat?
Kazlauskaite: So far, there is not one single drug that is approved by the Federal Drug Administration for the reduction of belly fat. The fact is that supplements claiming "one trick solution" to belly fat are not strictly regulated, and a lot of the claims made in the ads are not backed up by research.
But marketing does miracles. Therefore the supplement industry is a multibillion-dollar industry because people think if it's shown on TV or featured in a magazine, it must be good.
The bottom line is that when it comes to belly fat, the solution is not in drugs or supplements. Enjoying a healthy lifestyle should be the focus, and while that's not as simple as swallowing a pill, the benefits will last a lifetime.
Q: You also mentioned that stress is one of the factors that contributes to belly fat build-up. What is the connection between stress and belly fat?
Dugan: This is a rapidly growing area of research. We're really starting to learn a lot more about the role stress plays in disease, including heart disease and diabetes.
As part of a study here at Rush, the WISH Study, in 2009 we found a strong correlation between depression and visceral fat, particularly among overweight and obese women. The results were the same even when the analysis adjusted for other variables that might explain the accumulation of visceral fat, such as the level of physical activity.
It’s been speculated that depression triggers the accumulation of visceral fat by means of certain chemical changes in the body — like the production of cortisol, which is a stress hormone — but we’re still trying to pinpoint the exact mechanism.
Kazlauskaite: That finding is in line with research findings that depression, anxiety and tension — all markers of stress — are associated with belly fat accumulation.
It’s not just that you tend to eat more when you’re stressed, it’s also what you eat. Typically, when you’re stressed you reach for what most people call comfort foods and what scientists and behavioral experts call “reward foods”: salty, sweet and creamy foods.
But another significant factor is what Dr. Dugan mentioned, the stress hormone response. Cortisol, in particular, seems to influence fat accumulation around the belly. We know that not only from research studies, but also from noticing that people with adrenal gland tumors, which cause cortisol overproduction, tend to have more belly fat and thinner arms and legs. So we can see that in nature, the stress hormone cortisol can drive abnormal fat distribution.
Dugan: That's why reducing stress is crucial to both preventing the buildup of belly fat and to losing existing belly fat.
Stress is essentially an imbalance between demands and resources. To help achieve more of a balance, I recommend carving out some time every day for an activity that will help you destress, whether it’s yoga or going for a walk or gardening or getting a massage. It doesn’t have to be a lot of time; even 30 minutes or an hour will be beneficial.
Adults, especially women, are often taking care of so many other people that they neglect to take care of themselves. But if you’re constantly putting yourself last, ignoring your own needs, the stress can get the better of you, and one of the things that can happen is you end up with more belly fat, which can lead to health problems that cause you even more stress.
Q: How does gender influence belly fat distribution?
Kazlauskaite: When we talk about women and fat distribution, the normal female pattern would be in the shape of a pear. When we talk of the normal male body shape, we talk about an apple. What we mean is that women tend to have wider hips than waist, or an hourglass figure. Men tend to have a straighter body shape, and when they accumulate fat, it tends to be in the mid-section area, so they get a protruding stomach.
This is reflected in the fact that when we look at the diagnostic markers for metabolic syndrome, men are allowed to have a wider waist: a woman’s waist should be under 35 inches, but men are allowed a waist girth of up to 40 inches.
Of course, a lot of men don’t realize how wide their waist really is. When we measure the waist and I tell a man, your waist is 45 or 50 inches, they say I’m measuring in the wrong place, because they think their waist is where the pants waist is. But they're wearing their pants under their belly, and so they think their waist is a lot smaller than it is because their pants still fit.
Q: We've been hearing a lot about metabolic syndrome lately. What is it, and why should people be concerned about it?
Dugan: Metabolic syndrome refers to a group of markers, or risk factors, that raise your risk for heart disease, diabetes, stroke and other health problems. In fact, people with metabolic syndrome are twice as likely to develop heart disease and five times as likely to become diabetics. So there’s clearly good reason to be concerned.
As for what those markers are, having a large waist — that apple body shape — is one, although as Dr. Kazlauskaite pointed out, men are allowed to have a slightly larger waistline than women. The other four are high levels of triglycerides (a type of fat found in the blood); low HDL, or “good,” cholesterol; high blood pressure; and a high fasting blood sugar level.
If you have three of these five markers, you're considered to have metabolic syndrome and should talk to your doctor about how to reduce your risk factors, including reducing your belly fat. You don’t want to wait until you develop diabetes or heart disease to take action.
Q: Is it true that visceral fat in women tends to increase during menopause?
Dugan: Yes. It's an interesting phenomenon, really. When that delicate balance of estrogen to testosterone shifts toward testosterone during the menopausal transition, the distribution of fat also shifts and women tend to accumulate more belly fat.
In men, we know that when their testosterone decreases naturally as they age, they tend to accumulate belly fat, but in women it isn’t really about having more testosterone, it’s about upsetting the estrogen-testosterone balance.
We used to think estrogen protected premenopausal women against cardiovascular disease and that the increased cardiovascular risk after menopause was related only to the loss of estrogen’s protective effect. But now we know that it’s actually the change in hormonal balance that’s largely responsible for visceral fat.
So if you’re a woman in your 30s or early 40s and you aren’t already eating healthy and exercising regularly, you should get started now and work hard to maintain these healthy behaviors throughout the menopausal transition.
Kazlauskaite: It’s also important to note that in both men and women, shifts in hormonal balance that cause belly fat to accumulate are also associated with decreased sex drive and decreased fertility.
Sometimes I remind men: The more inches around the waist, the less action below the waist. To have good erections you have to have perfect circulation, and since belly fat increases inflammation in the blood vessels and restricts blood flow, men’s erections may not be as good.
What also happens when a man is obese is that the brain starts suppressing the stimulation of testosterone, which is associated not only with erectile dysfunction but with decreased fertility.
In women, suppression of reproductive hormones might manifest as irregular menstruation, polycystic ovary syndrome and infertility. That’s why doctors often advise women who are obese to lose weight before trying to get pregnant.