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1.  The relationship between DXA-based and anthropometric measures of visceral fat and morbidity in women 
Excess accumulation of visceral fat is a prominent risk factor for cardiovascular and metabolic morbidity. While computed tomography (CT) is the gold standard to measure visceral adiposity, this is often not possible for large studies - thus valid, but less expensive and intrusive proxy measures of visceral fat are required such as dual-energy X-ray absorptiometry (DXA). Study aims were to a) identify a valid DXA-based measure of visceral adipose tissue (VAT), b) estimate VAT heritability and c) assess visceral fat association with morbidity in relation to body fat distribution.
A validation sample of 54 females measured for detailed body fat composition - assessed using CT, DXA and anthropometry – was used to evaluate previously published predictive models of CT-measured visceral fat. Based upon a validated model, we realised an out-of-sample estimate of abdominal VAT area for a study sample of 3457 female volunteer twins and estimated VAT area heritability using a classical twin study design. Regression and residuals analyses were used to assess the relationship between adiposity and morbidity.
Published models applied to the validation sample explained >80% of the variance in CT-measured visceral fat. While CT visceral fat was best estimated using a linear regression for waist circumference, CT body cavity area and total abdominal fat (R2 = 0.91), anthropometric measures alone predicted VAT almost equally well (CT body cavity area and waist circumference, R2 = 0.86). Narrow sense VAT area heritability for the study sample was estimated to be 58% (95% CI: 51-66%) with a shared familial component of 24% (17-30%). VAT area is strongly associated with type 2 diabetes (T2D), hypertension (HT), subclinical atherosclerosis and liver function tests. In particular, VAT area is associated with T2D, HT and liver function (alanine transaminase) independent of DXA total abdominal fat and body mass index (BMI).
DXA and anthropometric measures can be utilised to derive estimates of visceral fat as a reliable alternative to CT. Visceral fat is heritable and appears to mediate the association between body adiposity and morbidity. This observation is consistent with hypotheses that suggest excess visceral adiposity is causally related to cardiovascular and metabolic disease.
PMCID: PMC3769144  PMID: 23552273
Visceral fat; Adiposity; DXA; Type 2 diabetes; Hypertension; Subclinical atherosclerosis; Liver function
2.  Relationship of adiposity to bone volumetric density and microstructure in men and women across the adult lifespan 
Bone  2013;55(1):119-125.
Recent evidence suggests that adipose tissue may negatively impact bone health, challenging the traditional paradigm that increased fat mass, through mechanical loading or endogenous estrogen production, is beneficial to the skeleton. We hypothesized that it is primarily the visceral compartment of body fat that is detrimental to bone metabolism, resulting in impaired bone density and architecture. In an age-stratified population sample of 218 women and 291 men (age 20–97 years), we assessed visceral (VAT) and subcutaneous (SAT) adipose tissue areas at the L2–L3 interspace level by single slice quantitative computed tomography (QCT) and measured total body fat mass (TBF) by dual-energy X-ray absorptiometry. We then correlated these findings with volumetric bone mineral density (vBMD) at the femoral neck (FN) and lumbar spine (LS) assessed by central QCT, and with vBMD and microstructural parameters at the ultradistal radius (UDR) by high resolution peripheral QCT (HRpQCT). In unadjusted analyses in postmenopausal women, TBF and SAT were positively correlated with total, trabecular, and cortical vBMD at the FN, LS, and UDR and with trabecular microstructure at the UDR. By contrast, VAT was not correlated with vBMD at the FN or LS but was positively correlated with UDR total and trabecular vBMD but not cortical vBMD. Adjustment for age or for bioavailable estradiol and testosterone levels reduced these correlations, while adjustment for body weight eliminated most positive associations. Assessment of the VAT/SAT ratio, however, demonstrated a negative relationship with vBMD at the FN and LS in postmenopausal women, a relationship eliminated when adjusted for age. Correlations between skeletal parameters and adipose measurements in pre-menopausal women and older men were weaker and mostly non-significant. In younger men, VAT was negatively associated with vBMD, cortical thickness, and trabecular microstructure at the UDR, and with LS vBMD and FN cortical vBMD. These associations generally remained after adjustment, with some negative associations (e.g. UDR cortical area) being accentuated. Similar results were found when the VAT/SAT ratio was correlated with FN vBMD in younger men; in contrast, VAT/SAT was positively correlated with FN vBMD in older men and this relationship was strengthened by age-adjustment. Together, our data suggest that adiposity has associations with bone that are age-, gender-, menopausal status-, adipose depot-, and bone compartment-specific. These novel observations warrant further investigations to establish any causal relationships.
PMCID: PMC3650114  PMID: 23428401
adipose tissue; visceral; subcutaneous; bone mineral density; bone microarchitecture
3.  Ethnic-Specific Differences in Vitamin D Status Is Associated with Adiposity 
PLoS ONE  2012;7(8):e43159.
Low circulating 25 hydroxyvitamin D [25(OH)D] concentrations are common in obesity (BMI ≥30 kg/m2) and a negative relationship with body fat distribution has recently been reported. Ethnic-specific differences in body fat distribution have been described with South Asians are reported to have greater visceral adipose tissue (VAT), which could influence circulating 25(OH)D concentrations. The objective of this study is to investigate the relationship between plasma 25(OH)D, adiposity, and body fat distribution in Europeans and South Asians.
Methods/Principal Findings
187 Europeans and 192 South Asians were assessed for demographics, anthropometrics, and plasma 25(OH)D concentrations. Subcutaneous adipose tissue (SAT) and VAT were quantified by CT scan, and percent body fat by DEXA. Data were assessed by general linear models. South Asians had lower (P<0.001) plasma 25(OH)D concentrations and higher VAT (P = 0.04) than Europeans. Plasma 25(OH)D concentrations were negatively (P<0.05) associated with BMI, waist circumference, percent body fat, total adipose tissue, VAT, and SAT in unadjusted models and negatively (P<0.05) associated with VAT, SAT, and percent body fat after adjusting for BMI, ethnicity, age, and season of blood collection in males and females. When percent body fat, VAT, and SAT were included in the same model, only VAT remained negatively (P<0.05) associated with plasma 25(OH)D concentrations. Ethnicity remained significant in all models (P<0.001).
Compared to other adipose tissue compartments, VAT may have a distinct role in determining plasma 25(OH)D concentrations, which may account for the lower levels in South Asians.
PMCID: PMC3430647  PMID: 22952641
4.  Distribution of Abdominal Obesity and Fitness Level in Overweight and Obese Korean Adults 
Background. Abdominal obesity and its relative distribution are known to differ in association with metabolic characteristics and cardiorespiratory fitness. This study aimed to determine an association between fitness level and abdominal adiposity in overweight and obese adults. Methods. 228 overweight and obese individuals were classified as either cardiorespiratory unfit or fit based on their recovery heart rate. Visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), the visceral-to-subcutaneous adipose tissue ratio (VAT/SAT ratio), and cardiometabolic characteristics were analyzed to examine the relationship between recovery heart rate and abdominal adiposity components. Results. After adjustments for age and sex, significant relationships of recovery heart rate and VAT, SAT, and VAT/SAT ratio were found; however, SAT was not significantly associated after further adjustment for body mass index (BMI) (r = 0.045, P = 0.499), whereas VAT (r = 0.232, P < 0.001) and VAT/SAT ratio (r = 0.214, P = 0.001) remained associated. Through stepwise multiple regression analyses after adjustment for age, sex, BMI, lifestyle factors, mean blood pressure, fasting glucose, HOMA-IR, lipid profiles, and hsCRP, recovery heart rate was identified as an independent variable associated with VAT (β = 0.204, P < 0.001) and VAT/SAT ratio (β = 0.163, P = 0.008) but not with SAT (β = 0.097, P = 0.111). Conclusions. Cardiorespiratory fitness level is independently associated with VAT and the VAT/SAT ratio but not with SAT in overweight and obese adults.
PMCID: PMC3958687  PMID: 24723950
5.  Visceral adipose tissue: relationships between single slice areas at different locations and obesity-related health risks 
Visceral adipose tissue (VAT) is widely recognized as conveying the highest health risk in humans among the currently measurable adipose tissue compartments. A recent study indicated that the traditionally measured VAT area at L4–L5 is not the VAT area with the highest correlation with total VAT volume. At present, it is unknown whether the area with the highest correlation is also the most strongly associated with obesity-related health risk.
The study aim was to establish which VAT slice area(s) are most strongly associated with obesity-related health risk indicators.
The subjects were a convenience sample of healthy adults who completed whole-body magnetic resonance imaging (MRI) scans. The correlations, with appropriate adjustments, were examined between individual MRI slice VAT areas and fasting serum/plasma triglycerides (TG), high-density lipoprotein cholesterol (HDL), glucose, insulin and blood pressure.
The sample consisted of 283 healthy men (age (mean±s.d.) 41.9±15.8 years; BMI, 26.0±3.2 kg/m2; VAT, 2.7±1.8 L) and 411 women (age, 48.1±18.7 years; BMI 27.0±5.4 kg/m2; VAT, 1.7±1.2 L). After adjusting for age, race, menopause status, scan position and specific blood analysis laboratory, VAT area at L4–L5 had lower correlations with most metabolic risk factors including serum/plasma TG, HDL, glucose, insulin and blood pressure than VAT volume in both men and women. The VAT areas 10 and 15 cm above L4–L5 in men had higher or equal correlations with health risk measures than VAT volume. In women, the VAT area 5 cm above or below L4–L5 and total VAT volume had similar correlations with health risk measures.
An appropriately selected single slice VAT area is an equally reliable phenotypic marker of obesity-related health risk as total VAT volume. However, in both men and women the VAT slice area at the traditional L4–L5 level is not the best marker of obesity-related health risk.
PMCID: PMC3166348  PMID: 17060927
metabolic syndrome; magnetic resonance imaging; computed tomography; body composition; abdominal obesity
6.  Genome-Wide Association for Abdominal Subcutaneous and Visceral Adipose Reveals a Novel Locus for Visceral Fat in Women 
PLoS Genetics  2012;8(5):e1002695.
Body fat distribution, particularly centralized obesity, is associated with metabolic risk above and beyond total adiposity. We performed genome-wide association of abdominal adipose depots quantified using computed tomography (CT) to uncover novel loci for body fat distribution among participants of European ancestry. Subcutaneous and visceral fat were quantified in 5,560 women and 4,997 men from 4 population-based studies. Genome-wide genotyping was performed using standard arrays and imputed to ∼2.5 million Hapmap SNPs. Each study performed a genome-wide association analysis of subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), VAT adjusted for body mass index, and VAT/SAT ratio (a metric of the propensity to store fat viscerally as compared to subcutaneously) in the overall sample and in women and men separately. A weighted z-score meta-analysis was conducted. For the VAT/SAT ratio, our most significant p-value was rs11118316 at LYPLAL1 gene (p = 3.1×10E-09), previously identified in association with waist–hip ratio. For SAT, the most significant SNP was in the FTO gene (p = 5.9×10E-08). Given the known gender differences in body fat distribution, we performed sex-specific analyses. Our most significant finding was for VAT in women, rs1659258 near THNSL2 (p = 1.6×10-08), but not men (p = 0.75). Validation of this SNP in the GIANT consortium data demonstrated a similar sex-specific pattern, with observed significance in women (p = 0.006) but not men (p = 0.24) for BMI and waist circumference (p = 0.04 [women], p = 0.49 [men]). Finally, we interrogated our data for the 14 recently published loci for body fat distribution (measured by waist–hip ratio adjusted for BMI); associations were observed at 7 of these loci. In contrast, we observed associations at only 7/32 loci previously identified in association with BMI; the majority of overlap was observed with SAT. Genome-wide association for visceral and subcutaneous fat revealed a SNP for VAT in women. More refined phenotypes for body composition and fat distribution can detect new loci not previously uncovered in large-scale GWAS of anthropometric traits.
Author Summary
Body fat distribution, particularly centralized obesity, is associated with metabolic risk above and beyond total adiposity. We performed genome-wide association of abdominal adipose depots quantified using computed tomography (CT) to uncover novel loci for body fat distribution among participants of European ancestry. We quantified subcutaneous and visceral fat in more than 10,000 women and men who also had genome-wide association data available. Given the known gender differences in body fat distribution, we performed sex-specific analyses. Our most significant finding was for VAT in women, near the THNSL2 gene. These findings were not observed in men. We also interrogated our data for the 14 recently published loci for body fat distribution (measured by waist–hip ratio adjusted for BMI); associations were observed for 7 of these loci, most notably for VAT/SAT ratio. We conclude that genome-wide association for visceral and subcutaneous fat revealed a SNP for VAT in women. More refined phenotypes for body composition and fat distribution can detect new loci not uncovered in large-scale GWAS of anthropometric traits.
PMCID: PMC3349734  PMID: 22589738
American journal of hypertension  2008;21(8):910-916.
We examined the relationship between visceral adipose tissue (VAT), independent of overall adiposity, and prevalent hypertension among adults enrolled in the Insulin Resistance Atherosclerosis (IRAS) Family Study. We also examined the role of insulin sensitivity (SI) upon hypertension. This was a cross-sectional epidemiological study in which African-American and Hispanic-American families were recruited from three clinical sites. The main outcome measure was prevalent hypertension, as defined by standardized protocol.
The relationship between VAT and prevalent hypertension was examined in adjusted marginal models among 1,582 participants. All continuous variables were standardized.
A significant VAT by gender interaction prompted separate analyses for VAT according to gender. Further adjustment for SI was performed to determine its potential role in the VAT-hypertension relationship. The mean age (SD) of the sample was 41.3 (13.8) years, with a mean BMI (SD) of 28.7 (6.0) kg/m2. Women comprised 58.5% of the sample (N = 925), and Hispanic-Americans comprised 69.2% of the sample (N=1095). One in five participants (21.2%) had prevalent hypertension. In women, VAT was significantly associated with hypertension, independent of BMI (OR = 1. 49 p= 0.006). African-American women demonstrated increased odds of prevalent hypertension compared to Hispanic-American women (OR = 3.08, p <0.001). Among men, VAT was not associated with hypertension independent of BMI, and BMI explained a significant amount of the variation in hypertension.
A significant relationship may exist between VAT and hypertension among women, but not men. The relationship between VAT and hypertension in women was not associated with insulin resistance.
PMCID: PMC2551313  PMID: 18566594
visceral adipose tissue; body mass index; hypertension; insulin sensitivity; gender; African-Americans; Hispanic-Americans
8.  Visceral adipose tissue, but not waist circumference is a better measure of metabolic risk in Singaporean Chinese and Indian men 
Nutrition & Diabetes  2012;2(8):e38-.
Visceral adipose tissue (VAT) is an independent risk factor in cardiometabolic diseases and is commonly measured by computed tomography (CT). It is measured clinically by waist circumference (WC). The L4/5 intervertebral space VAT (L4/5 VAT) is traditionally used to represent total VAT volume. We set out to determine (1) the level of intervertebral space on CT that best approximates the total VAT volume; (2) compare the association between WC and VAT in Singaporean Chinese and Indian; and (3) examine the correlation between VAT and cardiometabolic risk factors.
A total of 60 Chinese and 60 Asian Indian men older than 60 years were recruited. Their medical history was taken and anthropometry was measured. Fasting glucose, insulin, lipids, adipokines and inflammatory markers were measured. Insulin resistance was evaluated by homeostasis model assessment-insulin resistance. VAT was determined by CT. Total VAT volume was calculated in 22 patients from VAT areas at seven intervertebral levels. The optimal VAT area most representative of total VAT volume was determined and used for all patients to approximate total VAT volume.
The VAT area at L2/3 intervertebral space (L2/3 VAT) correlated almost perfectly with VAT volume (R2=0.974 and 0.946 for Chinese and Indians, respectively). Subjects from the two races had similar height, weight, body mass index (BMI), WC and L2/3 VAT but more Indian men had hypertension, hyperlipidemia and type 2 diabetes mellitus. WC was correlated with the L2/3 VAT area in both Chinese (r=0.484, P<0.001) and Indian subjects (r=0.366, P=0.004) without racial difference (P=0.2 for interaction term). L2/3 VAT also correlated better with cardiometabolic risk factors, adipokines and C-reactive protein than WC, BMI or L4/5 VAT.
The L2-L3 intervertebral space was the best anatomic level for a single-slice CT cross-sectional area measurement of VAT to approximate total body visceral adipose volume in this population of Chinese and Asian Indian men older than 60 years. L2/3 VAT was better correlated with multiple cardiovascular risk factors, adipokines and inflammatory marker than either L4/5 VAT, WC or BMI.
PMCID: PMC3432182  PMID: 23448802
visceral adipose tissue; waist circumference; metabolic syndrome; Chinese; Asian Indian; Singapore
9.  Sagittal Abdominal Diameter and Visceral Adiposity 
Obesity surgery  2013;23(7):874-881.
In the context of increasing obesity prevalence, the relationship between large visceral adipose tissue (VAT) volumes and type 2 diabetes mellitus (T2DM) is unclear. In a clinical sample of severely obese women (mean body mass index [BMI], 46 kg/m2) with fasting normoglycemia (n=40) or dysglycemia (impaired fasting glucose+diabetes; n=20), we sought to determine the usefulness of anthropometric correlates of VAT and associations with dysglycemia.
VAT volume was estimated using multi-slice computer tomography; anthropometric surrogates included sagittal abdominal diameter (SAD), waist circumference (WC) and BMI. Insulin sensitivity (Si), and beta-cell dysfunction, measured by insulin secretion (AIRg) and the disposition index (DI), were determined by frequently sampled intravenous glucose tolerance test.
Compared to fasting normoglycemic women, individuals with dysglycemia had greater VAT (P<0.001) and SAD (P=0.04), but BMI, total adiposity and Si were similar. VAT was inversely associated with AIRg and DI after controlling for ancestry, Si, and total adiposity (standardized beta, −0.32 and −0.34, both P<0.05). In addition, SAD (beta=0.41, P=0.02) was found to be a better estimate of VAT volume than WC (beta=0.32, P=0.08) after controlling for covariates. Receiver operating characteristic analysis showed that VAT volume, followed by SAD, outperformed WC and BMI in identifying dysglycemic participants.
Increasing VAT is associated with beta-cell dysfunction and dysglycemia in very obese women. In the presence of severe obesity, SAD is a simple surrogate of VAT, and an indicator of glucose dysregulation.
PMCID: PMC3750719  PMID: 23408092
Obesity; Type 2 diabetes; Waist circumference; Anthropometry; Intra-abdominal fat; Insulin resistance; Sagittal abdominal diameter
10.  Fatty Liver, Abdominal Visceral Fat and Cardiometabolic Risk Factors: the Jackson Heart Study 
To examine whether fatty liver, and abdominal visceral adipose tissue (VAT) are jointly associated with cardiometabolic abnormalities.
Methods and Results
African American participants were from the Jackson Heart Study (n=2882, 65% women) who underwent computed tomography. Fatty liver was measured by liver attenuation in Hounsfield Units (LA) and VAT was quantified volumetrically. Cross-sectional associations between LA, VAT, and cardiometabolic risk factors were assessed using linear and logistic regression, and their joint associations were further examined in 4 subgroups - (High-LA/Low-VAT [n=1704], Low-LA/Low-VAT [n=422], High-LA/High-VAT [n=436] and Low-LA/High-VAT [n=320]). Both LA and VAT were associated with most cardiometabolic traits (all p<0.0001), which persisted after additional adjustment for each other (LA, p < 0.01-0.0001 and VAT, p<0.0001). In bootstrap analyses, the regression coefficient of VAT was significantly greater than LA for triglycerides, HDL-C, impaired glucose and metabolic syndrome (MetS) (p range 0.009-0.0001). The interaction between LA and VAT was significant for HDL-C (p=0.002), impaired glucose (p=0.003) and MetS (p=0.04). Among 4 subgroups, participants with higher VAT and lower LA had higher prevalence of cardiometabolic traits than those with each condition alone.
Both fatty liver and VAT are independent correlates of cardiometabolic risk, but the associations are stronger for VAT than for fatty liver.
PMCID: PMC3228266  PMID: 21885852
Jackson Heart Study; Intrahepatic fat; abdominal adiposity and cardiometabolic risk factors
11.  Gender differences in the association of visceral and subcutaneous adiposity with adiponectin in African Americans: the Jackson Heart Study 
Adiponectin, paradoxically reduced in obesity and with lower levels in African Americans (AA), modulates several cardiometabolic risk factors. Because abdominal visceral adipose tissue (VAT), known to be reduced in AA, and subcutaneous adipose tissue (SAT) compartments may confer differential metabolic risk profiles, we investigated the associations of VAT and SAT with serum adiponectin, separately by gender, with the hypothesis that VAT is more strongly inversely associated with adiponectin than SAT.
Participants from the Jackson Heart Study, an ongoing cohort of AA (n = 2,799; 64% women; mean age, 55 ± 11 years) underwent computer tomography assessment of SAT and VAT volumes, and had stored serum specimens analyzed for adiponectin levels. These levels were examined by gender in relation to increments of VAT and SAT.
Compared to women, men had significantly lower mean levels of adiponectin (3.9 ± 3.0 μg/mL vs. 6.0 ± 4.4 μg/mL; p < 0.01) and mean volume of SAT (1,721 ± 803 cm3 vs. 2,668 ± 968 cm3; p < 0.01) but significantly higher mean volume of VAT (884 ± 416 cm3 vs. 801 ± 363 cm3; p < 0.01). Among women, a one standard deviation increment in VAT was inversely associated with adiponectin (β = − 0.13; p < 0.0001) after controlling for age, systolic blood pressure, fasting plasma glucose, high-density lipoprotein cholesterol, triglycerides, education, pack-years of smoking and daily intake of alcohol. The statistically significant inverse association of VAT and adiponectin persisted after additionally adjusting for SAT, body mass index (BMI) and waist circumference (WC), suggesting that VAT provides significant information above and beyond BMI and WC. Among men, after the same multivariable adjustment, there was a direct association of SAT and adiponectin (β = 0.18; p = 0.002) that persisted when controlling for BMI and WC, supporting a beneficial effect of SAT. Insulin resistance mediated the association of SAT with adiponectin in women.
In African Americans, abdominal visceral adipose tissue had an inverse association with serum adiponectin concentrations only among women. Abdominal subcutaneous adipose tissue appeared as a protective fat depot in men.
PMCID: PMC3586352  PMID: 23433085
12.  Associations of Visceral and Liver Fat with the Metabolic Syndrome across the Spectrum of Obesity: The AGES–Reykjavik Study 
Obesity (Silver Spring, Md.)  2010;19(6):1265-1271.
Visceral adipose tissue (VAT) is a key pathogenic fat depot in the metabolic syndrome (MetS), but liver fat (LF) may also play an important role. We evaluated associations of VAT and LF with MetS in normal weight, overweight, and obese men and women (BMI <25, 25-29.9, and ≥30 kg/m2, respectively). This analysis included 2495 participants from the AGES-Reykjavik Study with computed tomography measurements for VAT and LF. MetS was defined by ≥3 of the following: larger abdominal circumference, hypertension, elevated TG, low HDL, impaired fasting glucose, and microalbuminuria. We estimated the odds of MetS per 1-SD increase in VAT and LF, adjusting for key covariates. VAT was associated with an increased odds of MetS in normal weight, overweight, and obese women (OR=2.78, 1.63, and 1.43, respectively; all P<0.01) that diminished in magnitude with increasing BMI (VAT*BMI class interaction P<0.001). In men, VAT was related to MetS only among the overweight (OR=1.69, P<0.01). LF was associated with MetS in the overweight and obese groups in women (OR=1.38 and 1.45; both P<0.001) and in men (OR=1.38, P=0.01; and OR=1.27, P=0.10), but not in the normal weight groups. These BMI-specific relationships persisted when both fat depots were included in the model. VAT and LF were associated with MetS independently of each other, and these relationships were modified by BMI class such that, VAT was the more important depot at lower levels of obesity and LF at higher levels. Importantly, fatty liver may be a novel metabolic risk factor in overweight and obese individuals.
PMCID: PMC3081537  PMID: 21183935
13.  Dual-Energy X-Ray Performs as Well as Clinical Computed Tomography for the Measurement of Visceral Fat 
Obesity (Silver Spring, Md.)  2012;20(5):1109-1114.
Visceral adipose tissue (VAT) is associated with adverse health effects including cardiovascular disease and type 2 diabetes. We developed a dual-energy X-ray absorptiometry (DXA) measurement of visceral adipose tissue (DXA-VAT) as a low cost and low radiation alternative to computed tomography (CT). DXA-VAT was compared to VAT assessed using CT by an expert reader (E-VAT). In addition, the same CT slice was also read by a clinical radiographer (C-VAT) and a best-fit anthropomorphic and demographic VAT model (A-VAT) was developed. Whole body DXA, CT at L4–L5, and anthropometry were measured on 272 black and white South African women (age 29 ± 8 years, BMI 28 ± 7 kg/m2, waist circumference (WC) 89 ± 16 cm). Approximately one-half of the dataset (n = 141) was randomly selected and used as a training set for the development of DXA-VAT and A-VAT, which were then used to estimate VAT on the remaining 131 women in a blinded fashion. DXA-VAT (r = 0.93, standard error of the estimate (SEE) = 16 cm2) and C-VAT (r = 0.93, SEE = 16 cm2) were strongly correlated to E-VAT. These correlations with E-VAT were significantly stronger (P < 0.001) than the correlations of individual anthropometry measurements and the A-VAT model (WC + age, r = 0.79, SEE = 27 cm2). The inclusion of anthropometric and demographic measurements did not substantially improve the correlation between DXA-VAT and E-VAT. DXA-VAT performed as well as a clinical read of VAT from a CT scan and better than anthropomorphic and demographic models.
PMCID: PMC3343346  PMID: 22240726
14.  VAT=TAAT-SAAT: Innovative Anthropometric Model to Predict Visceral Adipose Tissue Without Resort to CT-Scan or DXA 
Obesity (Silver Spring, Md.)  2012;21(1):E41-E50.
To investigate whether a combination of a selected but limited number of anthropometric measurements predicts visceral adipose tissue (VAT) better than other anthropometric measurements, without resort to medical imaging.
Abdominal anthropometric measurements are total abdominal adipose tissue indicators and global measures of VAT and SAAT (subcutaneous abdominal adipose tissue). Therefore, subtracting the anthropometric measurement the more correlated possible with SAAT while being the least correlated possible with VAT, from the most correlated abdominal anthropometric measurement with VAT while being highly correlated with TAAT, may better predict VAT.
Design and Methods
BMI participants' range was from 16.3 to 52.9 kg m−2. Anthropometric and abdominal adipose tissues data by computed tomography (CT-Scan) were available in 253 patients (18-78 years) (CHU Nord, Marseille) and used to develop the anthropometric VAT prediction models.
Subtraction of proximal thigh circumference from waist circumference, adjusted to age and/or BMI, predicts better VAT (Women: VAT = 2.15 × Waist C − 3.63 × Proximal Thigh C + 1.46 × Age + 6.22 × BMI − 92.713; R2 = 0.836. Men: VAT = 6 × Waist C − 4.41 × proximal thigh C + 1.19 × Age − 213.65; R2 = 0.803) than the best single anthropometric measurement or the association of two anthropometric measurements highly correlated with VAT. Both multivariate models showed no collinearity problem. Selected models demonstrate high sensitivity (97.7% in women, 100% in men). Similar predictive abilities were observed in the validation sample (Women: R2 = 76%; Men: R2 = 70%). Bland and Altman method showed no systematic estimation error of VAT.
Validated in a large range of age and BMI, our results suggest the usefulness of the anthropometric selected models to predict VAT in Europides (South of France).
PMCID: PMC3618381  PMID: 23404678
15.  Effects of Growth Hormone and Pioglitazone in Viscerally Obese Adults with Impaired Glucose Tolerance: A Factorial Clinical Trial 
PLoS Clinical Trials  2007;2(5):e21.
Recombinant human growth hormone (GH) and pioglitazone (PIO) in abdominally obese adults with impaired glucose tolerance were evaluated under the hypothesis that the combination attenuates GH-induced increases in glucose concentrations, reduces visceral adipose tissue (VAT), and improves insulin sensitivity over time.
Randomized, double-blind, placebo-controlled, 2 × 2 factorial design.
Veterans Affairs Palo Alto Health Care System, Palo Alto, California, United States.
62 abdominally obese adults aged 40–75 with impaired glucose tolerance.
GH (8 μg/kg/d, or placebo) and pioglitazone (30 mg/d, or placebo) for 40 wk.
Outcome Measures:
Baseline and after 40 wk of treatment, VAT content was quantified by CT scan, glucose tolerance was assessed using a 75-g oral glucose tolerance test, and insulin sensitivity was measured using steady-state plasma glucose levels obtained during insulin suppression test.
Baseline: body mass index (BMI), plasma glucose, and visceral fat content were similar. 40 wk: visceral fat area declined 23.9 ± 7.4 cm2 in GH group, mean difference from placebo: −28.1 cm2 (95% CI −49.9 to −6.3 cm2; p = 0.02). Insulin resistance declined 52 ± 11.8 mg/dl with PIO, mean difference from placebo of −58.8 mg/dl (95% CI −99.7 to −18.0 mg/dl; p = 0.01). VAT and SSPG declined with GH and PIO combined, mean differences from placebo of −31.4 cm2 (95% CI −56.5 cm2 to −6.3 cm2; p = 0.02) and −55.3 mg/dl (95% CI −103.9 to −6.7 mg/dl; p = 0.02), respectively. Fasting plasma glucose increased transiently in GH group. No significant changes in BMI were observed.
Addition of PIO to GH attenuated the short-term diabetogenic effect of GH; the drug combination reduced VAT and insulin resistance over time. GH plus PIO may have added benefit on body composition and insulin sensitivity in the metabolic syndrome.
Editorial Commentary
Background: People who are overweight are at higher risk of developing type 2 diabetes, particularly if they have impaired glucose tolerance (IGT). When an individual has IGT, their cells are not able to respond properly to insulin in the blood, which means that blood sugar levels can remain high, and fat cells do not take up fatty acids from blood at the rate they should. The term prediabetes is often used to refer to these linked characteristics. However, if such individuals are able to lose weight they can reduce their chances of becoming diabetic in the future. In particular, loss of a particular type of fat, the visceral fat (packed in around the internal organs, as opposed to fat immediately under the skin), is thought to be beneficial for people at risk of developing type 2 diabetes. Some researchers have suggested that giving human growth hormone (GH) to people who are overweight might help reduce their levels of visceral fat. At the same time, drugs known as thiazolidinediones are currently used, in combination with other drugs, diet, and exercise, as a treatment for type 2 diabetes. The researchers carrying out this study wanted to find out whether combining treatment with human GH and a thiazolidinedione, pioglitazone (PIO), would reduce levels of visceral fat and improve glucose metabolism in overweight adults with IGT. The researchers specifically planned to compare the changes in these primary outcomes amongst people receiving both human GH and PIO for 40 weeks with the changes in individuals receiving placebo only; additional comparisons were also done for individuals receiving either drug alone, as compared to placebo.
What this trial shows: A total of 76 participants were randomized and received the treatment allocated to them, but only 62 participants were included in the final analyses due to losses to follow-up. The primary outcomes being compared at baseline and after 40 weeks of treatment were the change in visceral fat levels and change in individuals' sensitivity to insulin. Individuals receiving GH experienced a drop in visceral fat area over the 40 weeks of the trial, as compared to placebo, whilst PIO alone did not seem to have an effect on visceral fat area. Individuals receiving both GH and PIO, however, also showed a decrease in visceral fat area. When examining the effect on insulin resistance, GH alone did not seem to have an effect on the ability to respond to insulin. However, administration of PIO alone did bring about a decrease in insulin resistance levels, as compared to placebo, and individuals receiving both GH and PIO together also experienced a drop in insulin resistance. The trial was not designed to detect statistically significant differences in side effects between the groups studied, but some side effects, such as build-up of fluid in the limbs and joint stiffness, seemed to be more common in the groups receiving drug treatment than in the placebo group.
Strengths and limitations: Although the trial was small, enough participants were recruited to detect statistically significant changes in the primary outcomes. Strengths of the trial include the use of appropriate techniques to conceal the randomization sequence from investigators recruiting participants into the trial and blinding of both participants and investigators to the treatments that an individual would receive. However, one limitation includes the fact that the likelihood of developing diabetes was not directly measured as an outcome in this trial, and it is therefore not possible to conclude from these results that administration of GH, PIO, or both combined, will help prevent diabetes amongst overweight people with IGT. Finally, this trial compared the drug interventions directly with placebo and not with behavioral interventions such as diet and exercise, which are normally recommended for the prevention of diabetes amongst overweight people. It would be important to further investigate the efficacy, harms, and costs of these drugs directly against nondrug interventions before making any recommendations about their clinical use.
Contribution to the evidence: Other studies have shown that PIO administration has beneficial effects on insulin sensitivity in people with type 2 diabetes. This study adds evidence confirming that PIO is likely to have similar effects in people who are not diabetic but who are overweight and who have IGT. The study also adds data regarding the effect of PIO and GH combined in such populations; giving both drugs together seemed to have beneficial effects on visceral fat area and insulin sensitivity, as compared to placebo.
PMCID: PMC1865086  PMID: 17479164
16.  Associations between Accelerometer-derived Physical Activity and Regional Adiposity in Young Men and Women 
Obesity (Silver Spring, Md.)  2013;21(6):1299-1305.
Empirical evidence supports an inverse relationship between physical activity (PA) and adiposity, but studies using detailed measures of both are scarce. We described the relationship between regional adiposity and accelerometer-derived PA in men and women.
Design and Methods
Cross-sectional analysis included 253 participants from a weight loss study limited to ages 20–45 years and BMI 25–39.9 kg/m2. PA data were collected with accelerometers and expressed as total accelerometer counts and average amount of time per day accumulated in different intensity levels (sedentary, light-, and moderate- to vigorous- intensity PA (MVPA)). Accumulation of time spent above 100 counts was expressed as total active time. Computed tomography (CT) was used to measure abdominal and adipose tissue (AT). Multivariate linear regression analyses were used to assess the relationship between regional adiposity (dependent variable) and the various PA levels (independent variable), and were executed separately for men and women, adjusting for wear time, age, race, education, and BMI.
Among males light activity was inversely associated with total AT (β=−0.19; p=0.02) as well as visceral AT (VAT) (β=−0.30; p=0.03). Among females sedentary time was positively associated with VAT (β=0.11; p=0.04) and total active time was inversely associated with VAT (β=−0.12; p=0.04).
Findings from this study suggest that PA intensity level may influence regional adiposity differently in men and women. Additional research is needed in larger samples to clarify the difference in these associations by sex, create recommendations for the frequency, duration and intensity of PA needed to target fat deposits, and determine if these recommendations should differ by sex.
PMCID: PMC3716839  PMID: 23408709
17.  Visceral adiposity and its anatomical distribution as predictors of the metabolic syndrome and cardiometabolic risk factor levels 
Despite the recognition that central obesity plays a critical role in chronic disease, few large-scale imaging studies have documented human variation in abdominal adipose tissue patterning.
We aimed to compare the associations between abdominal subcutaneous adipose tissue (ASAT) and visceral abdominal tissue (VAT), which were measured at different locations across the abdomen, and the presence of the metabolic syndrome (MS; National Cholesterol Education Program Adult Treatment Panel III definition) and individual cardiometabolic risk factors.
This study included 713 non-Hispanic whites aged 18–86 y, in whom VAT and ASAT were assessed by using multiple-image magnetic resonance imaging. The anatomical position of the magnetic resonance image containing the maximum VAT area for each subject was used as a measure of VAT patterning. Multivariate linear and logistic regression analyses were used to examine the relation of VAT, ASAT, and VAT patterning to cardiometabolic risk.
VAT mass was a stronger predictor of the MS than was ASAT mass, but ASAT mass (and other measures of subcutaneous adiposity) had signification interactions with VAT mass, whereby elevated ASAT reduced the probability of MS among men with high VAT (P = 0.0008). There was variation across image locations in the association of VAT area with the MS in men, and magnetic resonance images located 4–8 cm above L4–L5 provided the strongest correlations between VAT area and cardiometabolic risk factors. Subjects whose maximum VAT area was higher in the abdomen had higher LDL-cholesterol concentrations (R2 = 0.07, P = 0.0001), independent of age and adiposity.
Further studies are needed to confirm the effects of VAT patterning on cardiometabolic risk.
PMCID: PMC2801427  PMID: 18996861
Human genetics  2008;125(2):153-162.
The SOCS3 gene product participates in the feedback inhibition of a range of cytokine signals. Most notably, SOCS3 inhibits the functioning of leptin and downstream steps in insulin signaling after being expressed by terminal transcription factors, such as STAT3 and c-fos. The SOCS3 gene is located in the chromosome region 17q24–17q25, previously linked to body mass index (BMI), visceral adipose tissue (VAT), and waist circumference (WAIST) in Hispanic families in the Insulin Resistance Atherosclerosis Family Study (IRASFS). A high density map of 1536 single nucleotide polymorphisms (SNPs) was constructed to cover a portion of the 17q linkage interval in DNA samples from 1425 Hispanic subjects from 90 extended families in IRASFS. Analysis of this dense SNP map data revealed evidence of association of rs9914220 (located 10 kb 5’ of the SOCS3 gene) with BMI, VAT, and WAIST (P-value ranging from 0 003 to 0.017). Using a tagging SNP approach, rs9914220 and 22 additional SOCS3 SNPs were genotyped for genetic association analysis with measures of adiposity and glucose homeostasis. The adiposity phenotypes utilized in association analyses included BMI, WAIST, waist to hip ratio (WHR), subcutaneous adipose tissue (SAT), VAT, and visceral to subcutaneous ratio (VSR). Linkage disequilibrium (LD) calculations revealed three haplotype blocks near SOCS3. Haplotype Block 1 (5’ of SOCS3) contained SNPs consistently associated with BMI, WAIST, WHR, and VAT (P-values ranging from 2.00x10−4 to .036). Haplotype Block 3 contained single-SNPs that were associated with most adiposity traits except for VSR (P-values ranging from 0.002 to 0.047). When trait associated SNPs were included in linkage analyses as covariates, a reduction of VAT LOD score from 1.26 to .76 above the SOCS3 locus (110 cM) was observed. Multi-SNP haplotype testing using the quantitative pedigree disequilibrium test (QPDT) was broadly consistent with the single-SNP associations. In conclusion, these results support a role for SOCS3 genetic variants in human obesity.
PMCID: PMC2804661  PMID: 19083014
Suppressor of Cytokine Signalling 3; Genetic Association; Single Nucleotide Polymorphisms; Obesity/Glucose Homeostasis Traits
19.  Thoracic Periaortic and Visceral Adipose Tissue and Their Cross-sectional Associations with Measures of Vascular Function 
Obesity (Silver Spring, Md.)  2013;21(7):1496-1503.
Perivascular fat may have a local adverse effect on the vasculature. We evaluated whether thoracic periaortic adipose tissue (TAT), a type of perivascular fat, and visceral adipose tissue (VAT) are associated with vascular function.
Design and Methods
TAT and VAT were quantified in Framingham Heart Study participants using multidetector computed tomography; vascular function was assessed using brachial artery vasodilator function, peripheral arterial tone and arterial tonometry (n= 2735, 48% women, mean age 50 years, mean BMI 27.7 kg/m2). Using multiple linear regression, we examined relations between TAT, VAT, and vascular measures while adjusting for cardiovascular risk factors.
Mean TAT and VAT volumes were 13.2 and 1763 cm3. TAT and VAT were associated with multiple vascular function measures after multivariable adjustment. After BMI adjustment, TAT and VAT remained negatively associated with peripheral arterial tone and inverse carotid femoral pulse wave velocity (p<0.02); TAT was negatively associated with hyperemic mean flow velocity (p=0.03). Associations of TAT with vascular function were attenuated after VAT adjustment (all p>0.06).
Thoracic periaortic and visceral fat are associated with microvascular function and large artery stiffness after BMI adjustment. These findings support the growing recognition of associations between ectopic fat and vascular function.
PMCID: PMC3742564  PMID: 23754461
obesity; vascular function; arterial stiffness; perivascular adipose tissue; visceral adipose tissue
20.  Reduced cortical thickness associated with visceral fat and BMI 
NeuroImage : Clinical  2014;6:307-311.
Structural brain imaging studies have shown that obesity is associated with widespread reductions in gray matter (GM) volume. Although the body mass index (BMI) is an easily accessible anthropometric measure, substantial health problems are more related to specific body fat compartments, like visceral adipose tissue (VAT). We investigated cortical thickness measures in a group of 72 healthy subjects (BMI range 20–35 kg/m2, age range 19–50 years). Multiple regression analyses were performed using VAT and BMI as predictors and age, gender, total surface area and education as confounds. BMI and VAT were independently associated with reductions in cortical thickness in clusters comprising the left lateral occipital area, the left inferior temporal cortex, and the left precentral and inferior parietal area, while the right insula, the left fusiform gyrus and the right inferior temporal area showed a negative correlation with VAT only. In addition, we could show significant reductions in cortical thickness with increasing VAT adjusted for BMI in the left temporal cortex. We were able to detect widespread cortical thinning in a young to middle-aged population related to BMI and VAT; these findings show close resemblance to studies focusing on GM volume differences in diabetic patients. This may point to the influence of VAT related adverse effects, like low-grade inflammation, as a potentially harmful factor on brain integrity already in individuals at risk of developing diabetes, metabolic syndromes and arteriosclerosis.
•We investigated cortical thickness in healthy adults.•Body mass index (BMI) and visceral adipose tissue (VAT) were used as predictors.•BMI and VAT were independently associated with cortical thickness.•Cortical thinning was observed in the temporal cortex with increasing VAT.•Our findings show close resemblance to GM volume differences in diabetic patients.
PMCID: PMC4215386  PMID: 25379443
Obesity; Cortical thickness; MR imaging; Visceral adipose tissue
21.  Commonality versus specificity among adiposity traits in normal-weight and moderately overweight adults 
Many adiposity traits have been related to health complications and premature death. These adiposity traits are intercorrelated but their underlying structure has not been extensively investigated. We report on the degree of commonality and specificity among multiple adiposity traits in normal-weight and moderately overweight adult males and females (mean body mass index (BMI) = 22.9 kg m−2, s.d. = 2.4).
A total of 75 healthy participants were assessed for a panel of adiposity traits including leg, arm, trunk, total fat masses and visceral adipose tissue (VAT) derived from dual energy X-ray absorptiometry (DXA), hepatic and muscle lipids from proton magnetic resonance spectroscopy, fat cell volume from an abdominal subcutaneous adipose tissue biopsy (n = 36) and conventional anthropometry (BMI and waist girth). Spearman’s correlations were calculated and were subjected to factor analysis.
Arm, leg, trunk and total fat masses correlated positively (r = 0.78–0.95) with each other. VAT correlated weakly with fat mass indicators (r = 0.24–0.31). Intrahepatic lipids (IHL) correlated weakly with all fat mass traits (r = 0.09–0.34), whereas correlations between DXA depots and intramyocellular lipids (IMCL) were inconsequential. The four DXA fat mass measures, VAT, IHL and IMCL depots segregated as four independent factors that accounted for 96% of the overall adiposity variance. BMI and waist girth were moderately correlated with the arm, leg, trunk and total fat and weakly with VAT, IHL and IMCL.
Adiposity traits share a substantial degree of commonality, but there is considerable specificity across the adiposity variance space. For instance, VAT, IHL and IMCL are typically poorly correlated with each other and are poorly to weakly associated with the other adiposity traits. The same is true for BMI and waist girth, commonly used anthropometric indicators of adiposity. These results do not support the view that it will be possible to identify adequate anthropometric indicators of visceral, hepatic and muscle lipid content in normal-weight and moderately overweight individuals.
PMCID: PMC4086512  PMID: 23949614
adiposity; hepatic fat; myocellular fat; visceral adipose tissue; common variants
22.  Adverse Associations between Visceral Adiposity, Brain Structure, and Cognitive Performance in Healthy Elderly 
The link between central adiposity and cognition has been established by indirect measures such as body mass index (BMI) or waist–hip ratio. Magnetic resonance imaging (MRI) quantification of central abdominal fat has been linked to elevated risk of cardiovascular and cerebro-vascular disease. However it is not known how quantification of visceral fat correlates with cognitive performance and measures of brain structure. We filled this gap by characterizing the relationships between MRI measures of abdominal adiposity, brain morphometry, and cognition, in healthy elderly. Methods: A total of 184 healthy community dwelling elderly subjects without cognitive impairment participated in this study. Anthropometric and biochemical markers of cardiovascular risk, neuropsychological measurements as well as MRI of the brain and abdomen fat were obtained. Abdominal images were segmented into subcutaneous adipose tissue and visceral adipose tissue (VAT) adipose tissue compartments. Brain MRI measures were analyzed quantitatively to determine total brain volume, hippocampal volume, ventricular volume, and cortical thickness. Results: VAT showed negative association with verbal memory (r = 0.21, p = 0.005) and attention (r = 0.18, p = 0.01). Higher VAT was associated with lower hippocampal volume (F = 5.39, p = 0.02) and larger ventricular volume (F = 6.07, p = 0.02). The participants in the upper quartile of VAT had the lowest hippocampal volume even after adjusting for age, gender, hypertension, and BMI (b = −0.28, p = 0.005). There was a significant age by VAT interaction for cortical thickness in the left prefrontal region. Conclusion: In healthy older adults, elevated VAT is associated with negative effects on cognition, and brain morphometry.
PMCID: PMC3171695  PMID: 21949507
cognitive aging; visceral adiposity; hippocampus; neuropsychological assessment; MRI
23.  Maturity-Associated Variation in Total and Depot-Specific Body Fat in Children and Adolescents 
This study considered the association between sexual maturation and adiposity in children and adolescents, and examined the contribution of sexual maturation to ethnic differences in total and depot-specific body fat.
The sample included 382 White and African American 5–18-year-olds. Body mass index (BMI), waist circumference (WC) and sexual maturity status (breast/genital and pubic hair stage) were assessed in a clinical setting. Total body fat (TBF) was measured by dual-energy X-ray absorptiometry and abdominal subcutaneous (SAT) and visceral adipose tissue (VAT) were measured by magnetic resonance imaging. Analysis of covariance adjusted for age was used to examine the association between sexual maturity status and adiposity, and linear regression adjusted for age was used to examine the influence of sexual maturation on ethnic differences in adiposity. Analysis of VAT also controlled for TBF. Significance was accepted at P<0.05.
Breast/genital stage was significantly associated with BMI, WC, TBF, and SAT in girls of both ethnic groups and in White boys. Breast stage was associated with VAT. Stage of pubic hair was significantly associated with TBF and VAT in White girls only. In girls, sexual maturation attenuated the ethnic effects on BMI and WC, but the ethnic effect in VAT persisted. In boys, sexual maturation did not attenuate ethnic differences on VAT and did not predict WC or SAT. Sexual maturity status independently explained variance in adiposity in girls only.
Sexual maturity status is an important determinant of pediatric adiposity and attenuates ethnic differences in girls’ adiposity.
PMCID: PMC3947527  PMID: 23564417
24.  Racial differences between African-American and white women in insulin resistance and visceral adiposity are associated with differences in apoCIII containing apoAI and apoB lipoproteins 
Nutrition & Metabolism  2014;11(1):56.
African-Americans have higher HDL, less visceral adipose tissue (VAT) and lower triglyceride (TG) and apoCIII concentrations than whites, despite being more insulin-resistant. We studied in African-American and white women the influences of insulin resistance and VAT on the apoAI concentrations of two HDL subspecies, one that contains apoCIII that is associated with increased risk of coronary heart disease (CHD) and one that does not have apoCIII that is associated with decreased CHD; and on the apoCIII concentrations of HDL and of the apoB lipoproteins.
The participants were 32 women (14 African-Americans, 18 white) of similar age (39 ± 12 vs. 42 ± 11y). Mean BMI was 34 kg/m2 in the African-Americans compared to 30 in the whites. A standard diet (33% fat, 52% carbohydrate, 15% protein) was provided for 7 days followed by a test meal (40% fat, 40% carbohydrate, 20% protein) on Day 8. Insulin sensitivity index (SI) was calculated from the minimal model.
After controlling for SI, African-Americans have a higher mean apoAI level in HDL with apoCIII compared with whites (12.9 ± 2.8 and 10.9 ± 2.9 mg/dL, respectively, P = 0.05). SI was associated with higher apoAI in HDL with apoCIII, whereas VAT was not associated with this HDL subspecies. This pattern of results was reversed for apoCIII concentrations in apoB lipoproteins. After adjusting for SI, African-Americans had lower apoCIII in apoB lipoproteins. SI was associated with lower apoCIII in total apoB lipoproteins, whereas VAT was associated with higher apoCIII in all the apoB lipoproteins. Additional adjustment for VAT tended to reduce the difference in apoCIII between the groups.
African-American women have a higher HDL with apoCIII level than whites when controlled for insulin sensitivity. African-Americans have lower insulin sensitivity. Insulin sensitivity is associated with higher levels of HDL with apoCIII. ApoCIII levels in VLDL are lower in African-American women than whites, also affected by insulin sensitivity which is associated with low apoCIII in VLDL. VAT has a strong association with apoCIII in apoB lipoproteins but not with apoAI in HDL with apoCIII.
Trial registration Identifier: NCT00484861
PMCID: PMC4280695  PMID: 25553059
ApoAI; ApoCIII; HDL; ApoB lipoproteins; Visceral adipose tissue; Insulin resistance; African-Americans; Coronary heart disease
25.  Visceral obesity in normal-weight patients suffering from chronic schizophrenia 
BMC Psychiatry  2014;14:35.
BMI (body mass index) can be misleading regarding the level of adiposity in a normal-weight individual. Recently, a bioelectrical impedance analysis (BIA) method was developed that can measure body composition variables. The main objectives of this study were to use BIA to compare the body composition variables between chronic non-diabetic schizophrenic patients with normal weight and healthy individuals. The secondary objective was to compare the nutritional pattern of schizophrenia patients with that of matched healthy subjects, and to identify possible relationships between the content of different components of their diet and visceral adiposity.
The subjects were 52 normal-weight patients (33 males and 19 females) diagnosed with schizophrenia based on the DSM-IV and 45 (23 males and 22 females) BMI- matched controls. The patients had been receiving atypical or typical antipsychotic agents for at least one year before enrollment into the study but continuously for 3 months preceding the study and were psychiatrically stable. Body fat (kg), percent (%) body fat, fat-free mass, VAT (visceral adipose tissue) and SAT (subcutaneous adipose tissue) were measured using the bioelectrical impedance analysis (BIA) method. Daily food rations (DFR) were quantitatively evaluated by a 24-h dietary recall method covering 3 days preceding the examination.
In normal-weight patients schizophrenia was significantly linked with higher VAT, VAT/SAT ratio and lower fat- free mass. Men had over 5 times and women over 2 times as much VAT as BMI matched groups. In women with schizophrenia and in their controls, the amount of magnesium, niacin and vitamin B6 in their diet inversely correlated with VAT, while in men lower zinc and vitamin C intake was related to higher visceral adiposity.
Our study has shown that normal-weight patients with chronic schizophrenia have higher levels of visceral fat (VAT) than controls but similar volume of subcutaneous adipose tissue (SAT). Although no clear conclusion can be made regarding cause-and-effect relationships between the dietary content of food served to our patients and visceral obesity, we suggest that schizophrenia diet should be further investigated as a possible factor related to this type of obesity.
PMCID: PMC3922935  PMID: 24506972
Schizophrenia; Normal weight; Body composition; Bioelectrical impedance

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