Diabetes : Dangerous Visceral Fat

By Edward M. Eveld, The Kansas City Star

Michelle Sullivan weighs more than she wishes she did. She knows the extra pounds aren't doing her any good. Sound familiar?

She also knows "extra pounds" is a euphemism. She's decided to get a no-nonsense assessment, a body scan that reveals the graphic details.

It's in her hand now, a colorful image wth her fat tissue lit up in eye-catching yellows.


"This is new to me," says Sullivan as she looks at the scan. "This makes it more real. Right now I'm feeling disappointed in myself."

The mirror already told her she doesn't look the way she wants, although her 6-foot stature helps in that regard. But the scan is telling her something more important than that.

Becky Captain, nurse practitioner at St. Luke's Cardio Health and Wellness Center, points out that the yellow color on the periphery of Sullivan's scan is subcutaneous fat, which everyone carries in varying degrees, the layers so evident in the mirror.

But there inside the abdomen is the yellow to be worried about, Captain says.

That's visceral fat, the kind that isn't benignly storing energy but actively producing enzymes that cause havoc in the body. Lethal fat.

Sullivan, a nurse at North Kansas City Hospital, looks disheartened. She feels healthy at 49, but she's on two kinds of blood pressure medicine, and at this moment she's reminded of a former patient of hers who at age 70 had been prescribed nearly three dozen medications.

"I don't want to that patient," she says.

St. Luke's began offering the body composition scanning last month. It shows patients their fat distribution and calculates their estimated "visceral adipose tissue," a measure of the fat mass concentrated in the abdomen.

The cardio center's staff hopes it will help patients gain a better understanding of their bodies and the serious health effects of the fat they're carrying.

For years it's been known that the tape measure and even the body mass index (BMI) formula tell you about size but not about fat. Methods to measure total body fat sometimes aren't very precise, and they don't provide specific information about abdominal fat.

Meanwhile, the dangers of visceral fat -- which grows inside the belly, pushes against organs and secretes harmful chemicals -- are becoming clearer. Such fat is linked to diabetes, heart disease, arthritis and other inflammatory diseases, even cancer.

"You deposit all this fat inside your belly, under your liver," says James O'Keefe, preventive cardiologist at St. Luke's. "If you deposit too much fat inside your belly, it lights the fires of inflammation."

Visceral fat emits immune system chemicals called cytokines, O'Keefe says. That's bad for insulin sensitivity and blood pressure, to name just two effects, increasing the risks of Type II diabetes and cardiovascular disease.

Besides the body scan image, with its disturbing splotches of abdominal yellow, an accompanying analysis provides a total body fat percentage, a fat mass index (comparing fat mass to height) and the visceral adipose tissue, or VAT, estimate. It compares these and other values to "young normals," healthy people ages 20 to 30, and to people in the same age group as the patient.

A VAT value higher than 100 is considered an "increased" health risk and calls for changes in diet and exercise. Higher than 160 is considered "high risk."

The scan costs $50, typically not covered by insurance. O'Keefe says the machine uses low-intensity radiation and is "very safe." It out-performs other fat-measuring methods, he says.

"It's the gold standard for telling us about body fat," he says.

During Sullivan's appointment, cardio wellness coordinator Keyona Gregory tells her to lie on her back with "robot arms" -- at her side with palms facing her body -- and her toes touching, penguin-like. During the six-minute scan, the table moves side to side in all four directions while the scanner arm passes over the patient.

The imaging machine is made by Hologic and used typically for bone density scans. St. Luke's officials believe they are the only ones in the area using it to analyze body composition.

Another patient, Richard, who asked that his last name not be used, is 64 and takes immunosuppressant medications to keep two ailments at bay, plaque psoriasis and ulcerative colitis.

Although Richard has been overweight for years, his cholesterol levels are excellent. He's been told he's "genetically gifted," one of the lucky few who escape some of the bad effects of unhealthy diets and being overweight.

But it was his dermatologist who suggested the body scan, suspecting that abdominal fat was contributing to his inflammatory diseases. Richard also worries about his long-term use of the immunosuppressant drugs, particularly that they might increase his risk of cancer.

After his scan, he meets with Captain and, as he looks at the image, learns that his VAT was 375.

"The visual makes a difference," he says. "I had thought of fat as being mostly on the outside. This is a revelation to me. Really the very idea of this visceral fat, that it's all around your organs, it doesn't take much to think that's bad."

Captain tells him that his diet needs to change and that he should begin with a straightforward goal: Each meal should consist of lean protein and "two colors," vegetables and fruits. She recommends follow-up scans in three months and six months.

"If we can get the visceral fat down, we believe we can reduce these auto-immune diseases," she says.

"I'm about to retire, and actually I feel pretty good right now," Richard says. "But I had a sense that I had traded on my good genes about as long as I could expect to."

He's right to be concerned. The scientific finger-pointing at visceral fat continues.

In an article published earlier this year in the journal Cancer Prevention Research, scientists found that when they removed belly fat from two groups of mice, through diet in one group and with surgery in a second group, the tumors were reduced.

The dieting mice lost fat all over, but the result was particularly remarkable for the mice that had surgery, said one of the authors, "because these mice were still obese, they just had very little abdominal fat."

Anyone with an apple shape -- bigger in the middle than above or below -- likely has visceral fat to lose. And people whose waist size in inches is more than half their height in inches should be alert to the problem, O'Keefe said.

Researchers have found, however, that some people considered overweight are "metabolically fit" -- more muscle, more subcutaneous fat, less belly fat -- and so are fairly healthy.

And some thin-appearing people, whose bodies naturally accumulate less subcutaneous fat, in fact carry excess visceral fat. A thin-looking St. Luke's doctor was surprised to score a VAT of 118, which is in the "increased risk" category.

After her scan, Sullivan learns her VAT is 271, and she has begun the work to change that. Captain suggested she get back to a walking routine of at least 10 minutes a day. Now she walks around her work complex every day, about a 15-minute trip.

She's already given up her morning Coke and now drinks flavored water, unsweetened tea and coffee. She wasn't a coffee drinker before.

"I've been trying to have a cup at about 10:30 in the morning," she said. "It makes me feel a little full."

Sullivan has a meeting this week with a dietitian. She wants to make healthier meals for herself but also satisfy her 17-year-old son.

"I'm not a big sweets eater, but I think I eat way more carbs than I realized," she said. "There are so many temptations it's not even funny."

Keep it simple

Visceral fat isn't forever. In fact, it submits fairly readily to healthy eating and exercise.

Becky Captain, St. Luke's nurse practitioner, tells clients to keep it simple: "On your plate at each meal should be a lean protein and at least two colors." The "colors," of course, are fruits and vegetables.

Because people eat too many carbohydrates and simple sugars, even that bowl of cereal in the morning needs to go, she says.

To get you started with the mindset change, here are breakfast recommendations from St. Luke's Cardio Health and Wellness Center.

--Apple, banana and/or celery slices with all-natural peanut butter.

--A half cup of nonfat cottage cheese with (not canned) berries, pears, pineapple, peaches and/or tomatoes.

--Meat leftovers from an earlier meal -- fish, chicken, turkeyor meat ending in "loins" and "rounds" -- with fruit and vegetable.

--An egg-white omelet (limit egg yolks to three to four a week) with fruit and vegetable.

--A handful of nuts -- walnuts, almonds, pecans -- with fruit and vegetable.

--A smoothie drink made with a half cup nonfat cottage cheese, half cup nonfat Greek yogurt and 1 cup of frozen fruits such as peaches, strawberries and raspberries.

Edward M. Eveld, The Star

Seeing yellow

For some people fighting their weight, a below-the-skin image might help. Michelle Sullivan's "body composition" scan graphically shows her fat in yellow. The emphasis here is not on the outer layer of yellow but on the yellow that shows up in the abdomen. That's visceral fat, which is linked to heart disease, diabetes and inflammatory diseases. St. Luke's Cardio Health and Wellness Center is offering the scans for $50, typically not covered by insurance.

To reach Edward M. Eveld, call 816-234-4442 or send email to eeveld@kcstar.com.

___ ©2013 The Kansas City Star (Kansas City, Mo.)

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