A Cup of Coffee – Is All Fat Created Equal?

Welcome back! Last week, we talked about the Lie that is Santa. Do we tell our children the truth? If you missed that blog and would like to catch up, click HERE.

This week, we are going to talk about fat. Did you know that there’s something called visceral fat? This is the fat that goes unseen in many people, yet it can be very dangerous.

What is it?

Visceral fat is fat that wraps around your abdominal organs deep inside your body. You can’t always feel it or see it. In fact, you may have a pretty flat tummy and still have visceral fat. That’s sometimes called TOFI, or “thin outside fat inside.” This is why it can be so deceiving.

Why is it dangerous?

There are two kinds of fat that we’ll discuss today. While we can agree that too much fat is never a good thing, the fat that lies just underneath your skin, which is called subcutaneous fat, is less of a concern than visceral fat.

Visceral fat is more likely to cause numerous serious medical issues, such as heart disease, Alzheimer’s, type 2 Diabetes, strokes, and high cholesterol. All of these conditions are more likely to be linked to too much fat in the trunk of your body.

It is also suspected that visceral fat creates certain proteins that inflame your body’s tissues and organs and narrow your blood vessels. This can create high blood pressure and other issues.

How do we know we have visceral fat?

There’s actually no way to know where and how much visceral fat is hidden in your body without expensive imaging tests. Most doctors will not order these tests just to check for this type of fat, so we need to rely on other means to measure for it.

Waist size. This is an easy way to get a rough estimate. Wrap a tape measure around your waist over your belly button. Try not to suck in your stomach. In women, 35 inches or more is a sign of visceral fat. In men, it’s 40 inches. NOTE: This is a crude tool, especially if you’re a very big person. And if you’re of Asian descent, the benchmark for visceral fat drops to 31.5 inches for women and 35.5 inches for men.

Body shape. Look in the mirror. If you’re an apple — a big trunk and slimmer legs — it often can mean more visceral fat. This body shape is more common among men. Women are more likely to be pears — with bigger hips and thighs.

Imaging tests. These pricey scans are the only way to check the exact amount of visceral fat you have. If your doctor orders a CT scan or an MRI test to check for another medical condition, they can also get a detailed picture of your visceral fat. If you’ve had an MRI or abdominal CT scan, ask your doctor to measure for this fat.

How do we remove it?

There is the old standby methods of exercise, eating healthy foods, and losing weight, with the hope that you will be targeting the visceral fat along with the subcutaneous fat. Every little bit helps, right? But could there be more to it?

I actually gain weight when I eat well and exercise!

I hear you. You’ve tried and tried. You’ve eaten all the right foods, exercised 30 minutes a day, five days a week, and you are GAINING weight. It’s a fact for many. And what about the thin people who still have way too much visceral fat? If it was all about diet and exercise, wouldn’t they be good to go? But they aren’t. So let’s explore why that may be.

It could be all about the hormones

Prevention posted an article in September of 2022 about this very subject.

“As we age, the body can become more insulin-resistant, driving your body to store fat instead of burning it off,” explains Sara Gottfried, M.D., author of The Hormone Cure and The Hormone Reset Diet. “Women also become more estrogen-dominant as we move into perimenopause and beyond. Estrogen dominance promotes insulin resistance, which causes belly fat build-up,” she says.

“Insulin resistance can have a knock-on effect on leptin. Leptin is the hormone that alerts your body when you’re full, but elevated insulin levels eventually lead to elevated leptin, as well,” she explains.

“Elevated leptin, despite what you may think, does not mean you are more likely to put down your fork and stop eating. Consistently elevated leptin levels can lead to a dysfunction of leptin receptors,” Dr. Gottfried says. These receptors stop sending signals to the brain to tell you to stop eating. As a result, you do the exact opposite of what leptin is designed to control, and you continue to eat, never receiving the signal to stop.

Dr. Gottfried says not to blame yourself for excess weight gain. “If you’re struggling to lose excess weight with no success, don’t blame it on a lack of willpower or self-discipline. Most likely your hormones have turned against you,” she says.

Stress can also be a player

Another major player in the hormonal belly fat game is cortisol. Often referred to as the stress hormone, cortisol levels increase when your body senses you’re overwhelmed and anxious, which can lead to stubborn weight gain. According to Jacqueline Montoya, M.D., a board-certified emergency medicine and critical care physician and owner of GreenMed M.D., this is because the body goes into fight or flight mode. “High levels of stress and anxiety can send the body into survival mode which increases our cortisol levels and signals the body to store more fat,” she explains.


Insomnia and exhaustion can be tell-tale signs that hormones are to blame for your weight gain. Lack of sleep causes fatigue, which leads to stress and insomnia. All these things will mess with your hormones, specifically your cortisol levels. “High cortisol can lead to decreased thyroid levels, which can cause central weight gain,” Dr. Montoya explains. “It can also decrease growth hormones, which are responsible for tissue building, muscle growth, and overall health.”

So what are the answers?

Aside from medical intervention, there are lifestyle changes you can make to break the cycle and reset your hormones.

“Making conscious day-to-day decisions about what you eat, the amount of exercise you get, how many hours you sleep, and how you handle stressful situations, is key to combatting hormonal imbalances,” Dr. Montoya says. Dr. Gottfried suggests overhauling what you eat. “I recommend 40 days of cutting out sugar, gluten, dairy, alcohol, and caffeine,” she says. “Aim to eat one pound of vegetables daily, such as cruciferous vegetables, along with anti-inflammatory protein. The goal is to reduce nutritional stress by cutting out highly reactive foods.”

In addition to changing your diet, Dr. Gottfried recommends intermittent fasting. She prefers the 16:8 method. Every day, there’s an eight-hour eating window and a 16-hour overnight fast. But you can decide on what period of time you’d like to fast, whether it’s morning or evening. She also advises doing HIIT workouts and getting at least seven to eight hours each night. “Poor quality of sleep wrecks havoc on your internal biochemistry and you are more likely to overeat when you are tired,” she says.

Why is this happening to me?

Some of this is a mystery, says Scott Keatley, R.D. a nutritionist and co-owner of Keatley Medical Nutrition Therapy. But, he says, “we believe that estrogen and testosterone are important for the differentiation of fat cells.” And, as estrogen levels drop in your body when you near menopause or actually go through it, the types of fat your body creates and where it goes on your body changes, he says.

“A decrease in estrogen levels is associated with the loss of subcutaneous fat—fat stored under the skin—and an increase in abdominal fat,” says women’s health expert Jennifer Wider, M.D. Your body also tends to have higher levels of cortisol, i.e. stress hormones around this time, Dr. Wider says—and that also can lead to more belly fat.

Take away points


  • Our body has different types of fat tissue.
  • Subcutaneous fat is just under our skin.
  • Visceral fat (visceral adipose tissue) is deep in our abdomen and surrounds our internal organs.
  • Visceral fat is ‘metabolically active’ – it produces hormones that alter sugar and fat metabolism and produces pro-inflammatory molecules.
  • Visceral fat is worse for our health than subcutaneous fat.

It’s now well established that higher amounts of visceral fat are linked to an increased risk of:

  • Insulin resistance
  • Type 2 diabetes
  • Heart disease
  • Dementia
  • Some forms of cancer (e.g. colorectal, breast cancer).

Carrying too much visceral fat causes poorer sensitivity to insulin (insulin resistance).

  • Excessive visceral fat causes poor insulin sensitivity/insulin resistance.
  • Visceral fat secretes pro-inflammatory molecules leading to inflammation.
  • People with higher amounts of visceral fat are at greater risk of cardiovascular and metabolic disease.
  • Visceral fat releases inflammatory cytokines that directly impair insulin signaling.
  • Visceral fat releases fat metabolites which accumulate in and impair the function of the liver.

Let’s talk about sex hormones, shall we?

Fitness Genes posted this blog by Dr. Haran Sivapalana about the topic at hand.

How do our sex hormones (e.g. testosterone, estrogen) affect visceral fat?

It’s a complicated picture, but the balance of your sex steroid hormones (including testosterone and estrogen) influences your pattern of fat deposition and can affect how much visceral fat you carry.

Consequently, an imbalance of your sex hormones can lead to a greater deposition of visceral fat. This, in turn, results in poorer insulin sensitivity.

Given their different reproductive physiology, the exact relationship between hormonal imbalances, visceral fat, and insulin sensitivity differs considerably between men and women.


Several studies suggest that, in men, low testosterone levels are associated with an increased amount of visceral fat.

More specifically, rather than low absolute levels of testosterone, visceral fat deposition in men likely arises from low levels of testosterone relative to estrogen. In other words, it’s a lower ratio of testosterone to estrogen that increases the risk of visceral fat gain.

Under this relationship, both reduced testosterone production and/or excessive estrogen production can lead to more visceral fat tissue. Check your Testosterone Level and Estrogen Production Traits for more information.


In contrast to men, higher levels of testosterone (and other androgens) seem to be associated with greater amounts of visceral fat in women.

Again, it is likely to be a high level of testosterone relative to estrogens, rather than absolute levels of testosterone, that causes visceral fat deposition in women. In scientific terms, we sometimes describe this imbalance of having high levels of androgens and testosterone relative to estrogens as having a greater degree of androgenicity.

On this note, studies suggest that post-menopausal women are more likely to experience an accumulation of visceral fat.

Circulating levels of estrogen (estradiol) drop off dramatically during menopause as the ovaries stop producing estrogen. Given that testosterone and androgen production remains fairly stable during the same period, the ratio of testosterone to estrogen increases. This then leads to greater visceral fat deposition.


  • Your balance of sex hormones affects fat metabolism and deposition.
  • An imbalance of sex hormones may lead to the accumulation of visceral fat.
  • In men, low levels of testosterone (relative to levels of estrogen) are linked to more visceral fat.
  • In women, high levels of testosterone (relative to levels of estrogen) are linked to more visceral fat.
  • By causing a build-up of visceral fat, an imbalance of sex hormones can worsen insulin sensitivity.

How does visceral fat affect our balance of sex hormones?

Unfortunately, too much visceral fat can also upset further upset your balance of sex hormones. In turn, this may lead to more visceral fat accumulation and further worsening of insulin sensitivity. It’s a prime example of a vicious cycle or feedback loop.

One reason for this vicious cycle is that visceral fat acts as a metabolically active, endocrine organ – it secretes various hormones and other molecules that can alter the metabolism of sex hormones.

For example, in men, estrogen production largely takes place in peripheral tissues – including visceral fat. Visceral fat contains an enzyme called aromatase, which converts testosterone into estrogen. Men who carry more visceral fat are therefore likely to have greater aromatase activity, and consequently, convert more testosterone into estrogen.

This has three simultaneous effects:

1) It decreases circulating testosterone levels.

2) It increases circulating estrogen levels.

3) It lowers the ratio of testosterone to estrogen.

All three of these may lead to the deposition of visceral fat and, thereby, poorer insulin sensitivity/insulin resistance.


  • Accumulating visceral fat leads to further disruption of your sex hormone balance.
  • This in turn worsens insulin sensitivity and causes further inflammation.

That’s a lot. Isn’t that a lot?

Yes, why yes it is. Hopefully, this will help you to better understand that losing weight after a certain age, isn’t that simple. Be gentle with yourself. There’s a lot involved and any serious attempt at weight loss should be overseen by your medical professional. Going it alone, especially if you’ve already tried unsuccessfully and, in fact, have gained weight, then that’s your sign. See your physician for a heart-to-heart, armed with good information so your discussion can be a productive one.

And…if you are blessed with a thin body, please don’t take it for granted that you are healthy. You can be in just as much trouble as your overweight friend, especially if you crave sugar over healthy foods. You should also consider an appointment with your PCP.


As always, this blog is not a replacement for sound medical advice. I am not a doctor. Please make an appointment to see your healthcare provider and put a good plan in place that works for you and the needs of your body.

That’s all I have for you this week, dear reader. I’ll see you back here next Wednesday to share another cup of coffee. Until then, be good to yourself and each other.

Mind, Body, Spirit…Osteopathic Doctors treat the whole person, not just the ailment. Is your PCP a DO? Would you like to learn more about Osteopathic Physicians? Click HERE!

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