Why does fat accumulation in the middle (belly fat or central obesity) results in chronic disease?  Is there any type of food or other lifestyle that encourage fat accumulation in the middle?  And how can we avoid belly fat/central obesity to prevent chronic diseases? 

The metabolic syndrome, a cluster of risk factors, represents the gateway disease for many chronic conditions such as type 2 diabetes, heart disease, stroke, dementia, and cancer.  You need three of the following five risk factors to diagnose metabolic syndrome: central obesity, high blood pressure, high blood sugar, high triglyceride, and low HDL (the good guy cholesterol).

However, central obesity is the cornerstone in developing metabolic syndrome, without which other risk factors might not occur. 

Fat storage has been a blessing throughout human history; our ancestors stored excess energy as fat during the abundance of summer to ensure survival during the scarcity of the winter.  Again, women store fat around the hip area during childbearing age as a strategic reserve to meet high demands in pregnancy and lactation.

But this helpful survival trick has become harmful in modern life because high body fat increases the risk of chronic disease and could result in serious complications such as heart attack and stroke.

In this blog, we will discuss physiological fat storage that supports the body at times of scarcity and increasing demands and the pathological fat that increases the risk of chronic disease.

Let me emphasise a medical fact

It’s not obesity but central obesity that harnesses the development of the metabolic syndrome.  The metabolic syndrome is common among obese and slim people.  Studies have confirmed that 40% of thin people have metabolic syndrome.

“Outwardly healthy, he was nevertheless at risk”

Andy, a 45-year-old gentleman, was well, apart from mild symptoms of indigestion.  But he was very concerned about recent blood tests arranged by his GP that reported abnormal liver function and borderline sugar and cholesterol levels.  Andy has a family history of early death: his father died of a heart attack at the age of 46, and his mother died of liver cirrhosis in her 50s, although strangely, she did not drink alcohol.

Andy admitted his diet was high in carbohydrates, including cereals or oat porridge for breakfast, and commercial fruit juices, bread, pasta, rice, and potatoes.  He found it very difficult to do any exercise due to a busy job, working from home.  Being at home also made him more aware of his family’s daily tribulations, causing stress and distracting him from his work.  Therefore, he frequently worked very late, negatively impacting his sleep.  He does not drink alcohol but snacks regularly on crisps, rice crackers, cakes, and chocolate bars.  He is not on any medication that could cause liver damage.

On examination, his body weight was 75 kg, and his BMI was 24.5 (normal), waist 41.5, and hip 40, making his WHR (waist-hip ratio) very high at 1.05 (normal is less than 0.9 in men.)  This indicates fat accumulation in the abdomen, and further evaluation with an abdominal ultrasound scan confirmed fatty liver.

Body weight, body fat, body shape – which is the best indicator?

But one’s disease risk is not solely dependent on body weight or fat percentage.  Andy had a normal BMI, which is not an accurate predictor of disease.  Your BMI tells you if you have a weight problem, but it does not assess your risk of chronic disease.  According to BMI evaluation, athletes with high muscle mass and healthy obese people are wrongly categorised as abnormal.  One study confirmed that BMI is not helpful as 33% of men and 52% of women with a normal BMI had excess body fat.

In 1947, the French physician, Jean Vague, observed that central obesity led to diabetes, heart disease and gout.  This knowledge helped her colleagues improve diabetic control and lower high triglycerides and high cholesterol by advising their patients to follow a low-calorie and low carbs diet.

This has diverted the focus from how much fat the body contains (body weight and fat percentage) to where the fat is stored, body shape rather than body size.

Accumulation of fat in the abdomen (belly fat) alters the body shape.  An expansion in the waistline results in android (male type obesity) or apple body configuration.  The waist size and waist-hip ratio (WHR) are more helpful in predicting one’s disease risk.  A waist size over 80 cm in women or over 94 cm in men increases the risk of disease.

Potential areas to store fat in the abdomen

Modern imaging techniques such as computed tomography (CT) and magnetic resonance (MRI) make it possible to categorise fat in the abdomen into intra-abdominal and subcutaneous (under the skin) fat.  Helping our understanding of the health risk associated with belly fat.

Subcutaneous (under the skin but over abdominal muscles) fat is the physiological fat storage.  It can occur all over the body in healthy obese men or around the hips and thighs; in women, giving them a pear rather than an apple body shape.

Subcutaneous fat serves as a strategic energy reserve; it insulates the body and regulates body temperature; it acts as a cushion to protect abdominal organs and as an endocrine organ producing various hormones.

Intra-abdominal fat is divided into visceral and ectopic.  Visceral fat is the deposition of fat around abdominal organs, such as the omentum fat pad that protect the intestine, perinephric (around the kidneys), or ectopic fat within abdominal organs such as the liver and pancreas, resulting in the fatty liver or fatty pancreas.  Visceral and ectopic fat is harmful to health.

How belly fat increases the risk of chronic diseases

Visceral fat near the liver or its blood vessels can move quickly to be processed in the liver.  In a normal-weight person, the amount of fat reaching the liver at any time is within the liver’s metabolic capacity, having no adverse effect.  However, individuals with excess visceral fat continue sending large amounts of fat to the liver, leading to fat accumulation (fatty liver) and the development of non-alcoholic fatty liver disease (NAFLD).  In the long term, this leads to altered liver function, and more serious blood sugar dysregulation, as the liver becomes insulin resistant.  Excess fat in the body also leads to more fat being stored in muscles, rendering the muscles resistant to the action of insulin.

Muscles and the liver are the biggest consumers of glucose.  As both become insulin resistant, this raises insulin levels leading to high blood pressure and high blood glucose (two components of the metabolic syndrome.)

Since the two biggest consumers of glucose are shutting down, most of the glucose will be converted into the standard type of fat, triglyceride, raising its level (another metabolic syndrome risk factor.)

On the other hand, subcutaneous fat releases fat more slowly into the general circulation, reaching the liver in lower concentration and, therefore, less likely to cause damage.

The fat storage pattern in the abdomen also increases the risk of chronic diseases.  The fat tissue can accommodate extra fat by increasing the number of fat cells or their size.  Visceral adipose tissue tends to increase the cells’ size rather than build new cells.  increasing cells’ size triggers chronic low-grade inflammation, the hallmark of chronic diseases.

Belly fat also acts as an endocrine tissue to produce inflammatory chemicals like IL-6 and TNF alpha, which initiate and sustain low-grade inflammation to cause insulin resistance and increase the risk of chronic diseases such as diabetes and heart disease.

What controls fat distribution?

Oestrogen (the female hormone) promotes the accumulation of subcutaneous fat around the hips, buttocks, and thighs, resulting in a gynoid (also known as pear) body shape.  This healthy version of fat accumulation can be used during increased demand in pregnancy and lactation.  After menopause, the oestrogen level falls, and the fat storage pattern changes to become like men (android or apple shape.)

Testosterone (the male hormone) increases fat utilisation and decreases fat storage.  This explains why the body fat percentage is lower in men than women.  Age-related decline in testosterone results in men accumulating fat in the abdomen (visceral and focal).

Post-menopausal women and men store fat primarily within the abdominal cavity around or within the abdominal organs (viscera or ectopic), putting them at higher risk of chronic diseases.

Causes of central obesity

A high intake of energy-dense food – sugar, processed carbs (bread, rice, pasta, and pizza) – is well known to result in belly fat accumulation, particularly if combined with a sedentary lifestyle and low physical activity.  Also to blame is the excessive consumption of commercial fruit juice and soda, particularly those sweetened with high fructose corn syrup (HFCS).  There is also enough evidence to implicate fried food, saturated and trans-fat, red and processed meat.

Studies show that eating ultra-processed food is associated with central obesity rather than general obesity.  However, real and minimally processed food is linked with lower central obesity risk.  High-quality protein, including small oily fish and essential amino acids, are negatively affected by central obesity.

Alcohol consumption is very well known to cause belly fat accumulation.  “Beer belly” is, in fact, a medically sound term!  One study reported that an intake of over four litres of beer per week is associated with a higher degree of abdominal obesity, particularly amongst men.

Chronic stress, a common feature of modern life, stimulates the appetite of the affected person to eat highly processed, palatable food to excess, thus causing central obesity.

Fatty liver

Fatty liver occurs when fat builds up in the liver.  Mild fatty liver does not show any symptoms in the early stages.  It starts to cause significant effects when the liver fat content exceeds 5% of its weight.  The condition affects 30% of the population, but worryingly, 10% of children in the UK have mild fatty liver disease.

The condition is more reported among obese and overweight people.  It is commonly related to insulin resistance, raised blood sugar, high blood pressure, chronic kidney disease and type 2 diabetes, especially in those over 50.

Symptoms can include fatigue, fluctuations in energy, particularly feeling sleepy after a meal, a significant energy dip in the afternoon, Gynecomastia (man boobs), pain or discomfort in the right upper quadrant of the abdomen, and in the later stages, liver palms (red palms), prominent veins under the skin, jaundice (yellow discolouration of the skin and eyes), enlarged spleen and ankle oedema.

The condition progresses from simple inflammation of liver cells to liver damage and scarring.  With extensive scarring, it progresses to fibrosis and, later, the more serious liver cirrhosis.  The latter stages can be associated with high mortality.  Liver cirrhosis can be complicated by liver failure or eventually progress to liver cancer.

It can take years for fibrosis or cirrhosis to develop, so it is vital to make lifestyle changes to prevent the disease from getting worse.

Andy’s ultrasound scan confirmed fatty liver.  His routine blood tests showed high liver enzymes (ALT and GGT), borderline blood sugar, high triglyceride and high inflammatory marker (CRP).

Having fatty liver would imply having fatty muscles, which can also interfere with insulin signalling, negatively impacting muscle function.

Fatty pancreas

The pancreas lies in the upper abdomen behind the stomach.  It produces pancreatic digestive enzymes and insulin to control blood sugar all over the body.  The fatty pancreas is a common incidental ultrasound finding.  It occurs in patients with fatty liver who share other metabolic risk factors, such as central obesity, high blood pressure, high blood sugar and triglycerides.

Studies show that patients with fatty pancreas have more visceral than subcutaneous fat.  It can progress to pancreatic dysfunction with high blood sugar and type 2 diabetes.  They are also at risk of suffering pancreatitis and are prone to pancreatic cancer.

How to reverse central obesity

Losing weight through diet or a combination of diet and exercise was proven useful.  Visceral fat is usually burnt and lost early in the process.

Professor Taylor of Newcastle University reversed type 2 diabetes in patients with fatty liver and pancreas by putting them on a low-calorie diet.  A repeat of the MRI scans confirmed fat resolution in vital organs.  11 out of 13 patients maintained normal blood sugar levels one year after the clinical intervention.

You should replace processed food (bread, rice, pasta, and pizza) with real food – fruit and vegetables, beans and legumes, nuts and seeds.  Studies have demonstrated the benefit of the Mediterranean diet in reducing liver fat and improving insulin sensitivity.

Monounsaturated fatty acids in avocado, olive oil, nuts and seeds were found to promote fat loss.  The EGCG in green tea also reduces liver inflammation and fat content.

Remember, my friends; you have a CHOICE:

Citrus fruits, including lemon, lime, as well as bitter melon, stimulate liver flush to help improve liver function.

Healthy fats may be found in fish oil (omega 3), seeds and nuts, avocados, and olive oil.  Several studies showed that olive oil has a beneficial effect on the liver.

Onions: eating onions regularly can prevent NAFLD even in the presence of other risk factors such as obesity, high blood sugar, and cholesterol.

Intermittent fasting for 16 hours every 24 is great for encouraging the body to burn fat for energy; it is a micro-replica of our ancestors’ seasonal eating pattern

Choose organic chicken and small oily fish instead of red and processed meat, which is full of saturated fat.

Exercise is great, says medical literature, suggesting the benefit of good physical activity in reducing liver fat content.  This includes both endurance and resistance training, regardless of the exercise intensity.

Please, my friends, don’t be one of the millions who are heading for central obesity – and all its dangers.  Don’t wait until it’s too late.  You can do some initial body shape assessment yourself, and if you are in any doubt, please ask for my advice; I’ll be delighted to guide you through the process until you achieve your pressing health goals.

Please share your thoughts and ask any questions on this subject – in the Comment section below is always best so that I can respond most quickly – and please do subscribe to the newsletter so that you don’t miss further vital information.  Thank you!



Body fat distribution


Non-alcoholic fatty liver disease: Dr Robert Rountree shares


Fatty liver: what it is, and how to get rid of it


Non-alcoholic fatty liver disease


Genetic factors for fatty liver


Fatty pancreas: a possible risk factor for pancreatic cancer in animals and humans