Shlomi (a pseudonym, as are all the names in this article) sits across from me with a troubled expression, gently smoothing his hands over the prominent mound beneath his chest that threatens to burst the buttons of his shirt. At 47, he is a busy banker and father of two teenagers, but more than anything, he is concerned about the "beer belly" he has been diligently nurturing in recent years. "I don't even like alcohol," he confesses, "but maybe it's all the cola? Even though I only drink the sugar-free version. Or is this bulge just another gift from my dad? He also passed on his baldness."
In contrast, Einat is preoccupied with her backside, which she claims has expanded like yeast dough on a warm day over the past few years. "You have to help me," she pleads despairingly. A 34-year-old teacher, a few months post-second childbirth, Einat is determined not to let the size of her derrière become part of her impressive resume. "I've already gone up three sizes in skinny jeans," she admits, "even though my waist is exactly the same as before the wedding."
So, what causes our fat to accumulate specifically in the belly, or in the buttocks and thighs? And does it have health implications? The answer, as with most things in medicine, is complex.
Body fat distribution in individuals with overweight or obesity is generally classified into two main types: apple and pear. The apple-shaped (also known as "android") distribution is primarily seen in men, where fat accumulates in the upper body, especially the abdomen, chest, and arms. In contrast, the pear-shaped (or "gynoid") distribution is more common among women of childbearing age, where fat tends to gather around the hips, buttocks and thighs. Shlomi and Einat are classic examples of these types.
Another important distinction is between subcutaneous fat (the visible fat) and visceral fat (the fat surrounding our internal organs, such as the liver, intestines and heart). Subcutaneous fat accounts for about 80% of the body's total fat, with the remaining 20% being visceral fat. Generally speaking, male, apple-shaped obesity is primarily visceral, whereas female, pear-shaped obesity is mainly subcutaneous. As the cliché goes, men, unlike women, tend to keep everything inside the belly.
This "fruit salad" of fat has significant health implications because male, visceral obesity is now recognized as increasing the risk of cardiovascular diseases and shortening life expectancy. It's no coincidence that metrics like waist circumference and waist-to-hip ratio, often unfavorable in patients with apple-shaped obesity, have become significant predictors of morbidity and mortality.
This existential threat mainly arises from the metabolic activity of the "bad adipocytokines" – a general term for various proteins produced and secreted by visceral fat tissue, negatively impacting our health. These substances contribute to the development of chronic inflammation and decreased insulin sensitivity, two mechanisms underlying diabetes, which often coexists with obesity.
"In recent years, growing evidence suggests that female fat, which tends to accumulate over the buttocks, hips, and thighs of young women, possesses health benefits and even reduces the risk of cardiovascular diseases."
On the other hand, female, subcutaneous fat distribution does not have such a negative reputation. On the contrary, there is increasing evidence that this type of fat, which accumulates over the buttocks, hips, and thighs of young women, possesses health benefits and even reduces the risk of cardiovascular diseases. "Blessed am I not made a woman," some of us admit at dawn. In this context, we might want to reconsider.
The gender factor is not the only one directing fat traffic in our bodies. Our chronological age, along with the hormonal changes it brings, are significant variables complicating our story further. As menopause approaches, a woman's estrogen levels plummet into the abyss. During this tumultuous period, in addition to hot flashes, insomnia and mood swings, a woman receives another generous gift from the Creator: a transition from pear-shaped to apple-shaped obesity.
The fat, which lovingly coated the thighs and buttocks and was even considered protective, suddenly migrates upward en route to the belly, becoming a risk factor. The physiological decline in testosterone levels among older men has a similar effect, thus exacerbating abdominal obesity and its associated risks.
It is important to note that, beyond gender, age and hormones, genetics also plays a significant role in regulating fat distribution in our bodies. More than 100 different genetic variants involved in this process have been identified, but as is often the case in this enigmatic field, much remains unknown.
Returning to Shlomi and Einat, I completely agreed with the despondent Shlomi that his "beer belly" is indeed concerning – not necessarily from an aesthetic standpoint, but certainly from a health perspective. After measuring his waist circumference, which surprisingly exceeded 40 inches, I referred him to a considerate dietitian, equipped him with a suitable exercise prescription, and we agreed to consider long-term medication in the future. As for the anxious Einat, I tried to comfort her with reassuring words, explaining at length that her condition is natural and even healthy, hoping she would one day come to terms with her blessed pear shape.