I’m certain that you have noticed that humans, especially overweight humans, come in a wide variety of shapes and sizes. We all know that excess body fat is not a good thing for health, nor for self esteem. But where fat is distributed on the body plays a big role in whether excess fat increases risk for conditions such as type 2 diabetes, coronary disease, stroke, cancer, cognitive decline, dementia, and premature death—or whether it is only a cosmetic issue and a challenge to weight-bearing joints but not for all the common chronic conditions mentioned.

The most common measure of body composition used in clinical studies is body mass index, or BMI, that divides weight by height. (There is no need to calculate, as there are online calculators, such as this one from the CDC, in which you just plug in your numbers.) For example, let’s take Jane, a 5-foot, 5-inch tall woman weighing 160 pounds who has a BMI of 26.2 that falls in the overweight range. Conventional definitions of BMI tell us that normal or desirable is a BMI of 18.5–24.9, overweight is 25.0 – 29.9, obesity is 30.0 and greater. But what if Jane has a flat abdomen but wide hips and large thighs and arms with fat flaps that hang off when she raises her arms? Of, what if she has skinny arms and legs but a protuberant abdomen? These are completely different situations, but both can occur at the same BMI.

There is therefore a fundamental flaw in BMI and similar calculations (such as the waist-hip ratio): they assume that body fat is uniformly distributed throughout the body, which is simply not true. Specifically, if fat is concentrated in the abdomen and encircles abdominal organs such as small and large intestines, liver, pancreas, kidneys, etc., i.e., abdominal, “visceral,” fat, this distribution of fat carries far greater implications for health. In fact, body fat outside of so-called visceral fat is, for the most part, harmless. There is some evidence that non-visceral, “subcutaneous,” fat, i.e., the fat beneath the skin in the hips, thighs, buttocks, arms, etc., is modestly beneficial outside of some effects such as stress on weight-bearing joints like hips and knees.

It means that BMI is a poor measure of health. A much better predictor? A simple measure of waist circumference, i.e., the measurement of your waist just at the top of your hip bone (iliac crest, the top of the pelvic bone) taken at end-expiration (after exhaling). Conventional advice dictates that you are in trouble due to visceral abdominal fat if, as a female your waist size is 35 inches or more, as a male 40 inches or more. But, as with so many other measures in conventional healthcare advice, these are cutoffs meant to tell you whether pharmaceuticals or other maneuvers should be introduced. Anyone reading this, of course, rejects this kind of thinking, recognizing that pharmaceuticals are largely unnecessary in life and the pharmaceutical industry is a cancer on society. There is no cutoff on waist circumference at which healthy or unhealthy effects occur, as it is a continuum that differs based on genetics and other factors. Waist circumference can only serve as a starting point that needs to be explored through measures such as fasting glucose, fasting insulin, triglycerides, blood pressure, C-reactive protein—measures that reflect insulin resistance, since abdominal visceral fat is a major determinant of insulin resistance. The greater your waist circumference, the more it reflects fat surrounding abdominal organs, the more your liver, heart, muscles, brain and other organs do not respond to insulin and your pancreas overproduces insulin to compensate. The fasting insulin level of someone with a small waist and responsive to insulin? 1,2, 3, or 4 micro units/L. The fasting insulin of someone with too much visceral abdominal fat and is insulin resistant? 50, 90, 130 micro units/L—not a little bit worse, but 10, 20, 100-times worse. This is the phenomenon that drives risk for modern diseases—even at a “normal” BMI.

Here’s another problem: No conventional weight loss strategy—pharmaceuticals, bariatric procedures such as gastric bypass or lap-band, or low-calorie or low-fat diets—selectively targets the worst fat, i.e., abdominal visceral fat. At best, there is as much loss of visceral fat as subcutaneous fat (as achieved, for instance, by GLP-1 agonists such as Ozempic, Trulicity, or Wegovy, all injections and at a cost of around $1000 per month). Most efforts, in fact, including calorie reduction or low-fat diets (that, by the way, cause numerous health problems, contrary to conventional dietary advice) target loss of subcutaneous fat over visceral fat—yes, you lose weight, but you do not necessarily regain control over health.

To make matters worse, most conventional weight loss efforts mean that, for every 10 pounds lost, 3 pounds are muscle. This is another problem, because loss of muscle leads to health problems that include loss of metabolic rate (a reduced metabolic rate means that it is easier to regain weight, even if you limit calories), gradual loss of flexibility and ability to confidently navigate the world, increased potential for bone-thinning and fracture, lower testosterone in males, and greater difficulty in losing weight in future. Many people, of course, yo-yo-diet: lose weight, regain weight, lose weight, regain weight. The weight regained is nearly all fat, meaning that each successive cycle of weight loss-weight regain is muscle lost, fat regained. For this reason, it becomes harder and harder to lose weight, easier and easier to regain weight.

The solution: address insulin resistance, the process that causes weight gain and blocks weight loss. The conventional “solution”? Prescribe drugs that increase insulin release or have effects such as cause your kidneys to urinate insulin, but ignore the underlying causes. Our solution? Address the factors in life that cause insulin resistance. It means not eating foods that trigger blood glucose and insulin: wheat, grains, and sugars. Address nutrients deficient in modern lifestyles: vitamin D, magnesium, omega-3 fatty acids, iodine. Consider adding other nutrients largely absent from modern life: collagen, hyaluronic acid, both of which not only yield smoother skin and healthier joints, but also reduce insulin resistance. Address your disrupted microbiome that lacks healthy species such as Lactobacillus reuteri and Lactobacillus gasseri and Faecalibacterium prausnitizii and push fecal microbes like E. coli and Klebsiella out of the 24-feet of small intestine and back into the colon where they belong. That is how you lose visceral fat.