June 2013 Issue

The Perils of Belly Fat — Dietitians Discuss the Health Consequences and Interventions That Can Hit Home With Male Patients
By Lori Zanteson
Today’s Dietitian
Vol. 15 No. 6 P. 36

Men who give their health low priority by neglecting to eat healthfully and exercise regularly put themselves at risk of becoming overweight or obese. When the weight accumulates around their belly, they’re especially vulnerable to developing chronic diseases down the road. And many men, unfortunately, are following this detrimental path.

“Men aren’t the best at health care,” says Chicago-based dietitian David Grotto, RD, LDN, founder of Nutrition Housecall, LLC and author of The Best Things You Can Eat. “They’re more likely to smoke, drink, and do drugs, and skipping meals is their No. 1 dieting approach.”

Manuel Villacorta, MS, RD, CSSD, author of Eating Free: The Carb-Friendly Way to Lose Inches, Embrace Your Hunger, and Keep Weight Off for Good, sees this trend among his male patients every day. He says many men don’t value the time it takes to eat nutritious meals because, in their minds, there’s no time. However, because many don’t like cook and would rather stop at fast-food restaurants, they develop poor eating habits that can lead to excessive belly fat, leaving them more vulnerable to cardiovascular disease (CVD), metabolic syndrome, certain cancers, and benign prostatic hyperplasia (BPH), an enlarged prostate.

Given these health consequences, nutrition professionals have the opportunity to learn how to better reach their male clients and help them implement strategies to lose the weight around their midsections, prevent disease, and live healthier lives.

Research Roundup
One of the biggest differences between the sexes is the way they perceive their weight. According to a 2012 study from the University of Illinois, men who are overweight or obese are more likely than women to underestimate their weight.1 Overestimating weight was associated with female gender and younger age, while underestimating was associated with male gender and older age, placing them at risk of obesity-related diseases.1 What raises the risk even further is the type of belly fat.

Abdominal fat falls into two categories: subcutaneous fat, found just below the skin, and the more consequential visceral fat, which surrounds the vital organs deep within the abdomen. Less obvious than subcutaneous fat, visceral fat, sometimes called “hidden fat,” is only visible with the use of CT scans or MRI, so even thin or normal-weight people can have it. Visceral fat causes excess fatty acids to drain into the liver and muscles, triggering changes in the body that can increase LDL cholesterol and triglycerides, and make insulin less effective in controlling blood sugar, leading to insulin resistance.

Cardiovascular Disease
Studies have long shown the association between abdominal obesity and CVD, which increases the risk of cardiac rhythm problems, heart attack, heart failure, stroke, and sudden death. A study published in the June 2007 issue of Critical Pathways in Cardiology found that excess visceral abdominal fat was associated with elevated triglycerides, reduced HDL cholesterol, elevated blood pressure, and increased fasting plasma glucose. The study suggested that addressing abdominal obesity and excess visceral fat can improve CVD factors.2

A Canadian study published in the June 2012 issue of Health Reports suggested that abdominal measurements, such as waist circumference, waist-to-hip ratio, and waist-to-height ratio, even among those who fall within a normal BMI category, can indicate CVD risk factors. In fact, among men in the normal and overweight BMI categories, waist-to-hip and waist-to-height ratios were associated with having at least two CVD risk factors.3

Independent of BMI and the amount of visceral fat is the ratio of visceral to subcutaneous belly fat, a unique CVD risk factor for some people. According to research published in 2012 in Diabetologia, a higher visceral-to-subcutaneous fat ratio, measured by CT scans, was associated with the most studied CVD risk factors, including blood pressure, insulin resistance, and elevated cholesterol blood levels.4

Type 2 Diabetes
Several studies support the link between visceral fat and the risk of developing type 2 diabetes, although these findings have been deemed controversial. A report published in the May 2008 issue of the American Journal of Clinical Nutrition cited studies that showed an association among belly fat, insulin resistance, and hyperglycemia. The studies found that visceral fat is increased in proportion to BMI, and releases excess free fatty acids associated with insulin resistance. Researchers in this study concluded that the accumulation of abdominal fat raises the risk of type 2 diabetes.5

Metabolic syndrome, defined as impaired glucose metabolism, central obesity, elevated blood pressure, and dyslipidemia, affects about 25% of the world’s population. In the United States, it’s most common in men, and incidence increases with age. Metabolic syndrome is known to raise the risk of both CVD and type 2 diabetes because of insulin resistance and abdominal obesity. A study published in January 2012 in Postgraduate Medicine found that weight loss and increased physical activity significantly improved all aspects of metabolic syndrome. In addition, researchers recommended dietary modifications, such as eating more fruits, vegetables, whole grains, monounsaturated fats, and low-fat dairy products, to benefit most patients.6

Overweight and obesity also have been associated with an increased risk of certain cancers, including colorectal and colon cancer. According to data published in March in Gut, men who are obese have a 30% to 70% increased risk of colon cancer. Colorectal cancer follows similar trends. Researchers indicated that abdominal visceral fat was of greater concern than subcutaneous fat and that obesity may be associated with worse cancer outcomes, such as recurrence or death.7

Prostate cancer, the second most common cancer among men, is linked with some components of metabolic syndrome, including obesity and belly fat.8 Moreover, abdominal fat has been linked with non-Hodgkin’s lymphoma.9

In addition to raising prostate cancer risk, belly fat may increase the risk of BPH. An enlarged prostate causes urinary tract symptoms, such as difficulty holding or releasing urine, as well as erectile dysfunction and loss of libido. It affects men beginning at about age 55, and the incidence increases as they get older.

Although it’s considered a common condition affecting aging men, studies have shown a higher incidence of BPH in those who are obese and have central obesity. A study published in the January 2006 issue of Obesity indicated that while both BMI and waist circumference were positively correlated with prostate size, belly fat was the only independent factor affecting prostate hyperplasia, suggesting that it’s an important risk factor of BPH.10

More recent research cited in the July 2009 issue of Current Urology Reports also names belly fat as a risk factor for BPH. According to the study, men without excess belly fat who engaged in physical activity, ate a low-fat diet, and consumed five or more servings of fruits and vegetables daily had a lower BPH risk.11

How Can Dietitians Help?
Alarming as the science is, the link between belly fat and chronic disease may not be the best motivator for a man to make the dietary and lifestyle changes needed to reduce his midsection. To encourage male clients to adopt more healthful lifestyles, it’s best to take a performance-based approach, Grotto says. “Guys don’t respond to a disease model,” he adds.

Men are most concerned about performance—sexual, mental, and physical—which can be affected by extra pounds around the waistline, he says. Rather than beginning a consultation by talking about the threat of disease, Grotto suggests asking male clients whether it’s difficult to get out of bed in the morning or stay up at night. “All [of this] can be attributed to belly fat,” Grotto explains. “[Discuss] practical things that happen on a daily basis rather than the obscure, which won’t resonate. Performance vs. disease makes a lot of sense.”

It’s less likely that a male client will discuss his sexual performance with a female dietitian, but since it’s a common concern, simply mention that belly fat is linked to sexual problems such as erectile dysfunction. Or, if that’s uncomfortable, use a bit of innuendo, Grotto suggests. He promotes the benefits of healthful dietary and lifestyle choices to his male patients with the phrase, “If it’s good for the heart, it’s good for other parts,” allowing them to make that connection on their own.

Villacorta talks about the gut right away with his male clients, telling them “rather than weight management, we’re going to do waist management. They actually like that because they always think weight loss is for women.”

After the first session, when his male clients realize they don’t have to follow a specific diet, Villacorta says, “They’re like wow, and they really open up to me,” and talk more about personal things, such as the importance of appearance and sexual performance.

As his clients get more comfortable, Villacorta provides strategies to motivate them—a critical initial step toward healthful, positive change. Most men think they have to eat salads to reach their weight loss goal, Villacorta says, so when he recommends they eat a burrito—albeit a healthful one—they’re shocked.

It’s important to “give them a meal plan that speaks to them, like a nice 5- or 6-oz piece of chicken or fish,” he explains. “That deck of card-sized protein doesn’t work for everybody, and men really don’t like to be hungry.”

But at the same time, most men don’t like to take the time to eat healthfully either, Villacorta says. “They believe eating gets in their way—no shopping, no cooking, no eating.”

During his sessions with clients, he stresses that eating should be a priority and uses a hands-on approach, such as stocking his office shelves with real-food products from local markets so he can show them exactly what to buy. “You can tell them how to look for high fiber, to read the label, but unless you show them, they’re not going to get it,” Villacorta says. When male clients leave his office, they have a shopping list and some even take pictures of the products with their phones. Making it simple takes away the overwhelming feeling of grocery shopping—something most men don’t do.

Villacorta also keeps menus on hand from his clients’ favorite restaurants. Together they review the menus to determine healthful food choices. This way “they continue to go to their favorite places, and they buy what they like. Otherwise, they have no clue. I give them meal plans they’re comfortable with and can live with. I show them it’s doable.”

Grotto also is a proponent of keeping real food in his office so he can counsel clients, but he goes one step further: He visits clients in their homes. Grotto goes through their pantries to determine which foods they enjoy and shows them which items to eat more or less of. Then he prepares a delicious dish for the family right in their kitchen. “Men are very tactile, very verbal,” he explains. “You have to paint the picture to provide the experience then and there.”

One of the biggest misconceptions men have about achieving a healthier weight is that the fun associated with eating will be taken away, Grotto says. Men don’t want to give up flavor, he says, so he shows them how to trade in the unhealthful versions of the foods they like for the more healthful ones that are just as satisfying. For example, he suggests clients choose lean cuts of meat to make chili or fry French fries in canola oil and eat them in smaller portions.

Grotto uses MyPlate when discussing portion sizes with men because they can see what filling one-half of their plate (make it a 9-inch plate) with fruits and vegetables looks like. This also helps men with the concept of eating until they’re satisfied rather than eating until they’re full. For men, fullness has been the main indicator of when to stop eating, but “we have to redefine what full is,” he says.

To reach male clients, it takes a great deal of follow up and repetition, Grotto continues. But if dietitians can communicate with men in such a way that convinces them that their RD understands their concerns and needs, they’ll be sure to get their male clients to strive toward a healthier weight and future.

— Lori Zanteson is a food, nutrition, and health writer based in southern California.


1. Andrade FC, Raffaelli M, Teran-Garcia M, Jerman JA, Garcia CA. Weight status misperception among Mexican young adults. Body Image. 2012;9(1):184-188.

2. Després JP. Cardiovascular disease under the influence of excess visceral fat. Crit Pathw Cardiol. 2007;6(2):51-59.

3. Shields M, Tremblay MS, Connor Gorber S, Janssen I. Abdominal obesity and cardiovascular disease risk factors within body mass index categories. Health Reports. 2012;23(2):7-15.

4. Kaess BM, Pedley A, Massaro JM, Murabito J, Hoffmann U, Fox CS. The ratio of visceral to subcutaneous fat, a metric of body fat distribution, is a unique correlate of cardiometabolic risk. Diabetologia. 2012;55(10):2622-2630.

5. Gastaldelli A. Abdominal fat: does it predict the development of type 2 diabetes? Am J Clin Nutr. 2008;87(5):1118-1119.

6. Prasad H, Ryan DA, Celzo MF, Stapleton D. Metabolic syndrome: definition and therapeutic implications. Postgrad Med. 2012;124(1):21-30.

7. Bardou M, Barkun AN, Martel M. Obesity and colorectal cancer. Gut. 2013;Epub ahead of print.

8. McGrowder DA, Jackson LA, Crawford TV. Prostate cancer and metabolic syndrome: is there a link? Asian Pac J Cancer Prev. 2012;13(1):1-13.

9. Chu DM, Wahlqvist ML, Lee MS, Chang HY. Central obesity predicts non-Hodgkin’s lymphoma mortality and overall obesity predicts leukemia mortality in adult Taiwanese. J Am Coll Nutr. 2011;30(5):310-319.

10. Lee S, Min HG, Choi SH, et al. Central obesity as a risk factor for prostatic hyperplasia. Obesity (Silver Spring). 2006;14(1):172-179.

11. Poon KS, McVary KT. Dietary patterns, supplement use, and the risk of benign prostatic hyperplasia. Curr Urol Rep. 2009;10(4):279-286.