This article first appeared in the Winter 2019 issue of NewBeauty. Click here to subscribe.
Many of us notice an increase in our waistlines as we get older, even if we aren’t gaining weight. Researchers have found that we should be paying closer attention to the hard-to-lose fat around our midsections.
FACTS ON FAT
Get a group of women together to talk about common health and wellness issues, and the pursuit of a flatter, tighter tummy will surely come up. Whether we’ve had children or just never got rid of that pesky Freshman 15, many of us have had our own personal struggle with hard-to-lose fat. If it seems like a totally relatable issue, it’s because it is: According to the Centers for Disease Control and Prevention (CDC), women’s waist measurements have increased in the last 20 years from an average of 36.3 to 38.6 inches. The CDC also states that more than two in three women in the United States are considered overweight or obese. Those numbers point to an increase in women with tummies that put them at a higher risk for obesity-related diseases. Now, researchers are looking at more than just BMIs to assess health risks—they’re also factoring in our waistlines.
A recent study published in the Journal of the American Medical Association’s Network Open used data from the Women’s Health Initiative to track the health of more than 156,000 post-menopausal women between the ages of 50 and 79 over the span of 20 years. Assistant professor of epidemiology at the University of Iowa, Wai Bao, MD, PhD, said he and his team linked mortality rates to the respondents’ BMIs, as well as their central obesity, or the excess accumulation of fat around their midsection, which was measured by their waist circumference. “What we discovered was that women who were considered normal weight with a BMI of 18.4 to 24.9, but who also had central obesity, or a waist circumference of more than 34.6 inches, were a third more likely to die within a 20-year period than normal-weight women without central obesity.” This higher risk was almost identical to the risks observed among women who are considered obese—with a BMI of 30 or higher—who also had central obesity. The takeaway: being what we call “skinny fat” can be deadly.
DEEP AND DANGEROUS
So, why is belly fat so hard to lose? First, not all belly fat is created—nor can it be treated—equally. There are two types of fat found inside our stomachs. “Visceral fat is the fat that is stored within the abdominal cavity, deep into the abdominal muscles and around our organs,” says San Diego plastic surgeon Joseph Grzeskiewicz, MD. Visceral fat, commonly called the dangerous fat, cannot be pinched or felt because it is located behind the abdominal wall. “When we see a large belly, there can be an excess of visceral, or inside fat. The difficult thing about this type of fat is that there really is no way to remove it surgically—the only way to reduce it is through diet and exercise,” he says. We sometimes refer to visceral fat as active fat because it can actively increase the risk of long-term, life-threatening problems like heart attacks, heart disease, cancer, stroke and Type 2 diabetes.
If you can poke it, pinch it or jiggle it, then it’s the other type of fat found on our bodies called subcutaneous fat. We refer to this fat as outside fat because it accumulates outside the abdominal wall and underneath the skin. La Jolla, CA plastic surgeon Hector Salazar-Reyes, MD explains, “Subcutaneous fat under the skin is fat you can pinch with your fingers. As it accumulates, we have a tougher time losing it because the fat in our stomachs is not as metabolically active as the fat that we have on our extremities.”
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Thankfully, we only have to worry about the fat cells we were born with. “Fat only hypertrophies, meaning the fat cells we have at birth are the only ones we ever get,” says Dr. Salazar-Reyes. “The number of cells remains the same, but the cell size can get bigger.” When we’ve exhausted every effort to rid our bodies of those fat cells with diet and exercise, we have several options to help us reshape our waistlines by eliminating the fat doctors can actually get to—that soft, jiggly subcutaneous fat.
SUCK IT UP
To remove some of those over-nourished fat cells, surgeons use a cannula during liposuction to suck out the fat in a targeted area. “Once the fat cells are sucked out and removed from the body, they disappear and never come back,” Dr. Salazar-Reyes says. Today’s liposuction techniques focus on body sculpting to carve and mold the abdomen into a streamlined contour. “After removing the deep fat compartment, we can manipulate the remaining superficial fat to better show the patient’s muscles and give them very nice, well-defined six-pack.”
“There are also modalities such as radio frequency, ultrasound and some laser liposuction devices that claim to also cause more contraction and shrinkage of tissues,” explains Dr. Grzeskiewicz, “but they can add to the risks of the procedure, too, including burns.”
Liposuction can remove abdominal fat, but it won’t address excess or loose tissue from skin that’s been stretched by an extra fatty layer. A patient in good health who is close to her ideal body weight or fat percentage is a good candidate for a tummy tuck. This entails general anesthesia, removal of excess skin and fat, and at times, surgical tightening of the muscles of the abdominal wall. “Many women who believe they have belly fat may just be loose in their core,” says Las Vegas plastic surgeon Mary C. Herte, MD. “When they stand up, their abdominal contents fall forward, creating a Buddha belly, but when they lie down, their stomachs look flat. This is best treated by a tummy tuck with repair of the separated abdominal muscles to create an internal corset.” However, Eugene, OR plastic surgeon Mark Jewell, MD cautions, “over-tightening of the abdominal muscles in patients with large amounts of visceral fat and only a thin layer of subcutaneous fat can impair breathing.”
FREEZE OR BURN
Nonsurgical fat-reduction treatments, whether using hot or cold energy, work to disrupt fat cells, which are later expelled from the body through the lymphatic system (the dead fat cells slowly leave our bodies through our urine and sweat). The actual death cycle of the fat cell can take several months, making patience a real virtue with cutting-edge treatments like WarmSculpting by SculpSure, UltraShape, Vanquish and CoolSculpting.
Procedures like WarmSculpting and Vanquish use radio frequency to heat up fat cells; UltraShape uses ultrasound energy. The difference between these treatments and CoolSculpting is that they use controlled heat, whereas CoolSculpting uses cryolipolysis, or controlled cooling. “We apply cold to freeze the fat in a targeted area,” Dr. Herte says. “The destroyed fat cells are naturally eliminated over the next few weeks. Typically, multiple applications of the device are required over multiple sessions, but the upside is that there are no restrictions after the procedure. This is perfect for anyone whose schedule does not allow time off for recovery.”
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Magnetic muscle stimulation (MMS), a new category in tummy-toning treatments, help to jump-start muscle building faster than we ever can on our own in the gym. Boasting the power to give ab muscles a workout equivalent to 20,000 sit-ups or more in a 30-minute span, these new state-of-the-art devices— Emsculpt was FDA-approved last year, and CoolTone just received FDA-clearance this summer—claim to easily create muscle definition where fat once resided. The end result: a leaner, more toned tummy.
“High-intensity electromagnetic muscle stimulating technology has been in the rehab space for years, it was even used to prep astronauts back in the ’60s,” says Delray Beach, FL dermatologist Dr. Janet Allenby. “Now we are using the technology for body contouring with devices that build and tone muscle, reshaping problem body areas. Both Emsculpt and CoolTone deliver electromagnetic energy through the skin, directly to the muscle. The energy is basically talking to the neurons that tell the muscle to contract.”
These muscle-toning options are making it easier for women with a small amount of stubborn fat to fight the battle of the bulge without going under the knife. “Usually, we start with four to six treatments to a targeted muscle group, such as the abs, butt or thighs,” says Dr. Allenby. “Each treatment is telling your body that you’re getting ready for a higher intensity event and is prepping your muscles for a more explosive future response, which creates more muscles. Just like in traditional exercising, it may take several weeks before you see your desired tone develop, but you should feel improvement of your strength far quicker.” Dr. Allenby foresees a future where we look at MMS treatments as a supplement to, not a replacement for, an active lifestyle: “I recommend one maintenance treatment every six weeks to keep the muscles nice and tight.”
Despite the myriad of options to fight belly fat, the old adage remains true: Six-packs are made in the kitchen. “Someone with undisciplined dietary habits, but an intense exercise routine, will probably still accumulate more fat than someone who performs only modest exercise, but has a very clean, disciplined diet,” says Dr. Grzeskiewicz. “I find that the worst influence for development and retention of belly fat is a high-carbohydrate diet. For many patients, restricting carbohydrate intake is the only way to lose fat in this area.”
And while belly-busting treatments continue to grow, researchers have just tapped the surface of studying the link between waist circumference and disease. Dr. Bao says women need to know that their waist sizes are just as important as their BMIs, even if they’re meeting all of the health guidelines on paper. “With our study, we hope to inspire others to replicate our findings and eventually influence changes to the national health guidelines. For a woman with a normal BMI, a doctor may never take her waist circumference into consideration when assessing her overall health. All of these factors should be considered when evaluating a person’s risk for diseases related to increased body fat.”
TREATMENT OPTIONS: Surgical procedures include liposuction and a tummy tuck. Noninvasive options include nonsurgical fat reduction and magnetic muscle stimulation (MMS).
AVERAGE TREATMENT COST: Procedure costs can range from $3,000–$15,000 for liposuction; $5,000–$15,000 for a tummy tuck; $1,000–$2,000 per area for nonsurgical fat reduction; and MMS treatments average $1,000 a session per area.
BEST FOR: Healthy patients who are close to their ideal body weight with a BMI of 30 or lower.
LONGEVITY: For fat-reduction procedures like liposuction and nonsurgical fat reduction, “once we destroy or remove a fat cell, it can never come back,” says Dr. Salazar-Reyes.