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The Truth About Belly Fat

July 29, 2015

Author: Lily Mazzarella
Belly fat:  it comes on stealthily, accumulating as we go about our fast-paced and stressful lives, perhaps not eating as well as we know we should, not exercising as much as we used to. It creeps up during hormonal transitions (puberty, postpartum, menopause & andropause), or after a long illness. And, seemingly suddenly we are stuck with it—for belly fat is notoriously difficult to lose.

Known technically as intra-abdominal fat or visceral adipose tissue (VAT), belly fat is distinct from the regular old fat on the rest of our bodies, and plays by its own rules.

While I’ve never been a proponent of dieting—and I believe there are many healthy weights—this is one kind of fat you want to reduce. Here’s why:

VAT puts you at risk for serious chronic conditions. It is associated with:

  • high cortisol levels (which contribute to depression, insomnia, and cognitive difficulties, among other woes)
  • altered intestinal permeability (“leaky gut”)
  • liver inflammation and fatty liver
  • increased risk of thyroid, breast and prostate cancer
  • cardiovascular disease
  • dyslipidemia
  • insulin resistance
  • Type II diabetes
  • systemic inflammation
  • leptin resistance and appetite dysregulation (leptin is a hormone secreted by fat cells that signals satiety to the brain)

Belly fat can increase your chance of mortality from unrelated conditions such as cancer. And in men, VAT is an independent predictor of all-cause mortality.

Given the dangers associated with belly fat, the ease with which it accumulates, and its frustrating resistance to our attempts at reduction, it is worth a deeper look into research on what it is, how we get it, what it responds to.

What exactly is VAT?

It looks like we’ve grown a new organ.

Visceral adipose tissue is fat that surrounds our internal organs. It differs in several ways from the fat that accumulates under the skin (subcutaneous fat) and in muscle tissue. Unlike the fat that deposits below the waist on thighs and buttocks (the classic “pear” body shape), VAT is highly metabolically active. It is formally understood to be an endocrine organ—that is, it sends out messenger molecules such as cytokines, adipokines, and hormones that have effects in distant tissues. It is distinctly pro-inflammatory—it secretes IL-6 and TNF, messengers which amplify systemic inflammation and are associated with multiple chronic diseases.

While in a research setting it can be measured directly by CT scan or MRI, waist circumference provides a reasonable approximation of VAT in your own home or doctor’s office.  An absolute waist circumference of greater than 35 inches for women, and 40 inches for men, is considered predictive for the presence of visceral fat, and at least a degree of insulin resistance.

What it’s not: 

  • the stuff you can pinch (that’s subcutaneous fat)
  • post-pregnancy weight or abdominal stretching
  • bloating (flat belly in the morning that distends over the course of the day)

There are many contributing factors to VAT.  Let’s look at the top 5.

1.  Genetics:  There are many genetic determinants of fat distribution. Some people are simply more belly fat-prone. And some sex differences: women tend to gain VAT more easily than men, though VAT may be more dangerous to men’s health. But epigenetic factors—that is, factors like diet, socioeconomic status, and lifestyle—play a huge role in gaining and losing VAT.

2.  Simple carbs and high insulin:   Insulin is our “pack it away for a rainy day” hormone. It is released by the pancreas when we eat, and it allows glucose to enter (and feed) our cells. When we consume a diet high in simple carbs (bread, pasta, chips, crackers, juice, soda), sugar, and fructose, we secrete even more insulin to keep pace with the high blood sugar that results from this intake. Two undesirable things occur:  first, the body puts as much of the sugary excess as it can into storage for a later date—which means fat. In the presence of high cortisol, this means visceral fat. The second is insulin resistance. In this case, the cell no longer respond efficiently to the effects of insulin, so that blood sugars remain high, and even MORE insulin needs to be secreted. A vicious cycle ensues: we now know that VAT causes insulin resistance. Poor quality fat and excess overall calorie intake (think fast food and Starbucks) is hallmark of the standard American diet, which of course also contribute to deposition of belly fat.

3.  Cortisol derangements:  It has long been known that high cortisol, the long-acting stress hormone released by our adrenal glands, is implicated in the deposition of fat around the middle. There are many contributing factors to chronically elevated cortisol, including depression, infection, poverty and socioeconomic hardship, marital strain, poor quality diet (high fructose corn syrup and trans fats), work stress, and trauma. Cortisol is released “on demand” when we encounter physiological or psychological stress, but also has a natural diurnal rhythm:  levels peak in the very early morning hours, and gradually diminish over the course of the day until they are at their lowest around 10 o’clock. Recently, in studies on adolescents with school-related stress, and adults with work stress, a heightened “CAR,” or cortisol awakening response (a sudden increase in cortisol levels in the 30-60 minutes after waking), was linked to increased deposits of visceral fat.

Unfortunately, cortisol also encourages “foraging behavior,” which in our times means rifling through the freezer for Dove bars and the cupboard for chips. Sweet and fat can quell the feedback loop of cortisol release, which can lead to self-medication in the form of a late night ice cream binge before sleep. Of course, eating inflammatory foods sets us up for further cortisol dysregulation.

4.  Sedentism:  By conservative estimates, the average American adolescent and adult spends 50-70% of waking life seated.  Our time spent in cars, at desks, and in front of screens is clearly contributing to the VAT health crisis. The authors of the scholarly article “Exercise, Abdominal Obesity, Skeletal Muscle, and Metabolic Risk: Evidence for a Dose Response” put it bluntly:  “Unfortunately, it is apparent that in sedentary middle-aged men and women, relatively short periods of physical inactivity lead to significant weight gain, substantial increases in visceral fat, and further metabolic deterioration.

I’ll paraphrase my teacher Simon Mills, the great British phytotherapist: In modern times, we take our stressors sitting down, and the results are catastrophic. Stress hormones are meant to mobilize us for action, and when we don’t move our bodies in kind, we reap only negative effects:  elevated blood sugars, metabolic derangements, inflammation, anxiety, tension, and agitation, and diminished memory and critical thinking.

5.  Gut/Liver inflammation:  Inflamed guts and livers, high stress, and high insulin and blood sugar levels contribute to deposition of our least favorite kind of fat. Different hormonal and inflammatory signals, along with excess energy intake in the form of simple carbs, encourages fat to deposit around the abdominal organs. This fat RESPONDS to hormonal signaling (which is why it persists), and in turn, signals out to the rest of the body—hormones, cytokines, etc.



how to lose belly fat

As my frustrated clients report, it doesn’t appear to respond to normal attempts at weight loss like calorie restriction. Here’s what it does respond to:


The effects of exercise on VAT are well-researched. Moderate to high intensity exercise, with or without a program of calorie restriction (aka dieting), results in substantial decreases in visceral fat. This looks like 30-45 minutes per day, 5 days per week of moderately strenuous exercise or interval training. That’s walking at a brisk enough pace to not be able to talk comfortably—walking like we might to cross an airport. In fact, it appears that we are more likely to lose VAT by exercising than dieting:  researchers found “preferential reductions in visceral adipose tissue with exercise-induced weight loss” compared with calorie restriction.

Keep in mind that these studies are often 4-12 months in duration. You might not see the effects of exercise on your belly fat right away. But it is happening! And meanwhile, you are reaping the myriad benefits of getting fit:  boosting your mood, cognition, sleep quality and libido, and improving your insulin sensitivity.

In my practice I see many people benefit from shaking up their exercise routine. Seasoned joggers do well alternating high-intensity sprints with walking, and incorporating weight training. Gym-goers who have been on the same circuit for 3 years might need a cardio blast several times per week. Nearly everyone benefits from gaining trained muscle mass.

And then there are high-cortisol over-exercisers, who actually need to take it down a few notches. If you’ve been doing the same kind of exercise for months or years and aren’t seeing changes in body shape, it may be time to mix it up. If you have injuries or chronic pain, or are very deconditioned, start slowly—and consider working with a physical therapist or professional trainer to get you set up on a safe exercise regimen.

Count sugars, not calories, and don’t go low-fat

One of the best ways to prevent and reverse VAT is to spend less time under the insulin curve. As discussed above, insulin is our “pack it away for a rainy day” hormone. And when blood sugars remain high over time, we secrete even more of it, and our cells become resistant to its effects. A vicious cycle ensues:  we now know that VAT causes (or worsens) insulin resistance. In order to get off this train, we need to dramatically reduce or eliminate simple carbohydrates and increase healthy complex carb (vegetable!), protein, and fat intake.

In fact, going “low-fat” may be counter-productive:  In a 2012 Johns Hopkins study, one group of volunteers ate a low-carb diet, while another consumed a low-fat diet with the exact same calorie content. On average, the low-carb dieters lost over 10 pounds more than the low-fat dieters. And the weight loss was “better quality,” meaning less lean tissue was lost. It also resulted in decreases in VAT and that improved arterial function in the low-carb volunteers.

A recent Japanese study confirmed these findings:  a 3-month “moderately low-carb” diet (aka, not Atkins-style), resulted in significant reductions of VAT independent of calorie restriction, especially in men.

To be clear:  by “low-carb” I mean a reduction in simple carbohydrates which have little or no real nutritional value, and tend to perpetuate cravings. Vegetables are carbohydrates. A plant-based diet that relies on vegetables instead of starchy carbs, accompanied by high-quality protein and fat, is one of the best things you can do for your health and VAT reduction.

Eat high-quality protein

Regular intake of high-quality protein (along with fat and plant fiber) helps keep your blood sugar stable—which prevents insulin spikes, and keeps your body from having to sound the adrenal alarm bell (adrenal hormones like cortisol work to raise plummeting blood sugar in the absence of food intake, or after a “crash”).  I suggest getting about 20-30 grams of protein for breakfast, and shifting away from a grain-based breakfast (goodbye, oatmeal!)—this adjustment has been life-changing for me, and for my clients with fatigue, anxiety, weight gain and unstable blood sugar. Getting protein throughout your day, and not skipping meals keeps your energy and mood on an even keel throughout the day. It can also prevent late-night simple carb/sugar cravings.

Tip:  if you can digest dairy, whey protein is particularly well-studied for its effects on VAT reduction. Be sure to go for the non-denatured, low-heat processed grass-fed stuff.

Eat plants

As an herbalist perhaps I am biased:  I know that plants will save us. Many plant constituents appear useful in VAT reduction, especially fiber, flavonoids and polyphenols. In two studies on adolescents, low fiber intake was associated with higher VAT and higher inflammatory markers; higher fiber intake corresponded to lower VAT and inflammation scores. In a study on obesity-prone rats, a diet enriched with flavonoid-rich tart cherry “significantly reduced body weight, abdominal fat, reduced blood lipids, reduced plasma inflammation, and reduced fasting glucose.”  Some of these findings have been reproduced in humans—and more studies are under way. Various polyphenol components of green tea and red wine (resveratrol) have been touted for their beneficial effects on metabolic risk factors and weight loss, and have been well-studied—in rats. While we need more human data, good sense and my years in clinical practice tell me the more plants someone eats, the more VAT they will lose, and the better they will feel.

Stress reduction & Sleep 

My insomniac and stressed out clients often cannot lose weight despite their best dietary and fitness efforts. I realize this one is tough. Tell certain people to get more sleep and stress less, and you might as well be telling them to fly, or breathe under water. Some people are battered and swamped by difficult life circumstances, others are stress-wired and worry-prone. Sleep issues are complex and multi-factorial (and often stress-related).

That said, there are many effective measures we can undertake to get out from under stress:  Cognitive-behavioral therapy, mindfulness meditation, and yoga are all good long-term stress modifiers. And if you needed any more encouragement to exercise, this is it:  upping your physical activity can help reduce your stress AND improve sleep.

Forgoing afternoon caffeine and sugar, using f.lux technology at night to protect your eyes from pineal gland-disrupting blue light, and going to bed a ½ hour earlier could go a long way in getting you more sleep over time. I use herbal adaptogens like Ashwagandha, Eleuthero, and Rhodiola to support my clients through unremitting stress, and to help reset sleep patterns.

Love your Liver & Gut

There is a special connection between the liver and belly fat—a relationship you want to interrupt. About 1 in 4 of American adults and 1 in 10 American children have fatty liver disease that is unrelated to alcohol use. The culprits? High dietary sugars, poor quality fats, and inflammation in the gut that lead to abnormal intestinal permeability. This allows proinflammatory LPS (bits of bacterial and fungal cell wall) to land at the liver, with inflammatory cascade ensuing. Fatty and inflamed livers are associated with VAT and insulin resistance—visceral fat may worsen or even cause fatty liver. I often suggest liver/gallbladder-focused “cleanses” (like the Spring Cleanse) to my clients concerned about VAT;  decongesting the liver jumpstarts metabolism and belly fat loss.



Get your thyroid checked   –  The links between thyroid health and visceral fat are not well-elucidated. However, from my clinical experience I can say that hypothyroidism will undermine your best attempts at VAT reduction. Ask your doctor for a complete thyroid panel—not just a TSH check.

Eschew the scale, measuring is better  –  As you increase your protein and your exercise, you will build muscle tissue—which weighs far more than fat! Your bones may become denser. All of which is great for your health, but will not reflect in a loss on the scale. When working with VAT, it is preferable to measure your waist at its widest point, and re-measure every 1-2 weeks as you begin your anti-inflammatory diet and exercise regimen. Interestingly, the World Health Organization and National Institutes of Health put the waist measurement site in slightly different places on the body. I tell people to measure ½ way between the top of the hip bone and the bottom of the ribcage.

Every little bit counts  –  don’t get discouraged. ANY reduction in visceral fat is a boon to your health. Even if your loss seems insignificant to you, it’s not. VAT is complex and self-perpetuating:  it can take time to give your body signals to do something different. Loss can be slower during periods of high stress, and menopause.

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