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Subcutaneous fat localization

Subcutaneous fat localization

a T1-weighted image shows a subcutaneous Skbcutaneous Beta-carotene supplement with inhomogeneous high to intermediate Subcutaneous fat localization intensity arrow. Localizafion reality, locailzation Beta-carotene supplement certain localizatipn of weight Fasting and cancer prevention, a new steady-state equilibrium is attained. Fat in the lower body, as in thighs and buttocks, is subcutaneous and is not consistently spaced tissue, whereas fat in the abdomen is mostly visceral and semi-fluid. Therefore, these data suggest that LPL is central to the development of abdominal visceral obesity Superficial Liposuction.


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Subcutaneous fat localization -

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Reprints and permissions. Camastra, S. Role of anatomical location, cellular phenotype and perfusion of adipose tissue in intermediary metabolism: A narrative review. Rev Endocr Metab Disord 23 , 43—50 Download citation. Accepted : 22 December Published : 15 January Issue Date : February Anyone you share the following link with will be able to read this content:.

Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative. Download PDF. Abstract It is well-established that adipose tissue accumulation is associated with insulin resistance through multiple mechanisms. Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F, McQueen M, Budaj A, Pais P, Varigos J, Lisheng L.

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Download PDF Original Article Open Access 14 Sep Thus it was effective in predicting aberrations in glucose and insulin levels and also showed a strong correlation between plasma lipids and blood pressure WHR predicted subsequent diabetes in men 13 and coronary heart disease in both men and women 8 , 9 and was more predictive of these endpoints than either the BMI or a more complex procedure using the sum of multiple skinfold thicknesses.

Its effects are independent of the overall level of obesity. However, Pouliot et al. Thus, according to their data, the WHR determines the regional distribution of adipose tissue, which is relatively independent of the degree of obesity and appears less closely related to the amount of abdominal visceral adipose tissue.

In this study 38 , other simple anthropometric indexes were evaluated that appeared to be superior to the WHR in providing assessment of visceral obesity, waist circumference, and abdominal sagittal diameter to be discussed below. Similar conclusions were reached by Sjöström et al.

Waist circumference. For example, the waist circumference is correctly measured at the level of the umbilicus, but in many obese individuals, the umbilicus may be directed downward because of the excessive curvatures of the abdominal wall.

Waist circumference measured at the midpoint between the lower border of the rib cage and the iliac crest has been reported to be more closely correlated with the level of abdominal visceral adipose tissue and associated metabolic variables than the WHR in both sexes 38 , 42 , 44 , According to Pouliot et al.

The threshold value is similar in men and women in that for a given waist circumference, men and women had comparable levels of abdominal visceral adipose tissue. Thus, waist circumference, a convenient and simple measurement unrelated to height 46 and correlated with BMI and WHR 47 , determines the extension of abdominal obesity, which appears closely linked to abdominal visceral adipose tissue deposition.

Furthermore, while changes in waist girth reflect changes in risk factors for cardiovascular disease 48 and other forms of chronic disease, the risks vary in different populations; therefore, globally applicable cut-off points cannot be developed.

For example, abdominal fatness has been shown to be less strongly associated with risk factors for cardiovascular disease and type 2 diabetes in black women than in white women Risk factors such as total and HDL cholesterol were correlated with subcutaneous and abdominal fat areas by CT as well as their sum in healthy nonobese Asian Indians.

On the other hand, while there was an association of visceral adiposity with insulin secretion during an oral glucose test in men, such was not found in women In addition, it has been reported that visceral obesity is strongly related to coronary heart disease risk factors in nonobese Japanese-American men Also, people of South Asian Indian, Pakistani, and Bangladeshi descent living in urban societies have a higher incidence of obesity complications than other ethnic groups These complications are seen to be associated with abdominal fat distribution, which is markedly higher for a given level of BMI than in Europeans.

Finally, although women have an almost equivalent absolute risk of coronary heart disease CHD to men at the same WHR 53 , 54 , they show increases in relative risk of CHD at lower waist circumferences than men. Thus, there is a need to develop sex-specific waist circumference cut-off points appropriate for different populations.

The studies by Ferland et al. Therefore, the waist circumference, and the abdominal sagittal diameter as will be discussed below , are the anthropometric indexes preferred over the WHR to estimate the amount of abdominal visceral fat and related cardiovascular risk profile.

Using the equations for prediction, multiscan CT was used to determined visceral adipose tissue volume from the waist circumference in a sample of 17 males and 10 females with different degrees of obesity Again, it was concluded that the WHR is a suboptimal predictor of visceral adipose tissue volume.

Abdominal sagittal diameter. The sagittal diameter is measured with a ruler as the vertical distance from the horizontal spirit level to the examination table after a normal expiration Kvist et al.

The correlation of the sagittal diameter with visceral fat volume was 0. The correlations between the waist circumference and visceral fat were, respectively, 0. These correlations are considerably higher than those observed between anthropometric variables and the visceral fat area measured at the level of the umbilicus in obese men and women Ferland et al.

Desprès et al. Busetto et al. It is very likely, therefore, that the range of fatness in subjects studied greatly influences the magnitude of the correlations and perhaps also the comparison between the sagittal diameter and the waist circumference with regard to their utility in predicting intraabdominal fat.

In addition, the distinction between studies that used only visceral fat area and those that calculated visceral fat volume from multiple scans may be important to make Ross et al. A study from the Canadian group 38 conducted in a large group of males and females evaluated systematically the three anthropometric indexes and their association with abdominal visceral adipose and subcutaneous areas measured by CT between the fourth and fifth lumbar vertebrae and metabolic profile.

As seen in Table 1 , there was a strong association between waist girth and body fat mass, the slope of the regression line being steeper in women data not shown. With relation to the abdominal visceral fat area, for a given waist circumference, men and women had similar levels and the slopes of the regression lines were not different between genders.

Essentially similar results were observed with the abdominal sagittal diameter. However, in contrast with waist circumference, the slopes of regression of abdominal sagittal diameter to abdominal visceral fat area were significantly different between genders and were steeper in men data not shown.

Finally, it can be seen that the WHR was less strongly correlated with total body fat mass and abdominal visceral and subcutaneous areas than the other indexes. This study demonstrated that most of the variance in waist girth and abdominal sagittal diameter can be explained by variations in body fat mass and in abdominal visceral and subcutaneous adipose tissue areas 0.

With relation to the metabolic variables related to cardiovascular risk plasma triglycerides and high-density lipoprotein cholesterol levels, fasting and postglucose glucose and insulin levels , in women, the waist circumference and the abdominal sagittal diameter were more closely related to the metabolic variables than the WHR, whereas such differences were not apparent in men.

They concluded that waist circumference values above approximately cm, abdominal sagittal diameter values greater than 25 cm, and WHR values greater than 0.

Correlations r values between the anthropometric indexes and body fat mass, abdominal visceral, and abdominal subcutaneous fat areas in 81 men and 70 women. Correlations between sagittal diameter and waist circumference are usually quite high [ e.

Although the sagittal supine diameter can be studied with relatively good precision 61 , it is clear that this measurement requires appropriate equipment and skilled personnel. Since most people are measuring the WHR as an indicator of visceral fat, the focus should be switched to the waist girth alone without affecting the ranking of individuals with respect to visceral fat when based on the waist circumference compared with the sagittal diameter Computed tomography CT.

CT can be considered the gold standard not only for adipose tissue evaluation but also for multicompartment body measurement 61 , The reported error for the determination of total adipose tissue volume after performing 28 scans is 0.

The subcompartments of adipose tissue volume, visceral and subcutaneous adipose tissue, can be accurately measured with errors of 1. In eight nonobese Swedish males evaluated by the multiscan CT technique, the volume of visceral abdominal adipose tissue in the intraperitoneal and retroperitoneal compartments was found to be 1.

Using a multislice magnetic resonance protocol, Abate et al. In effect, in 13 lean males, Abate et al. If only one scan is used to measure the visceral adipose tissue area, a strictly defined longitudinal level is very important since the average visceral adipose tissue area shifts if there is a change in position, even of a few centimeters.

This, according to Sjöström et al. Instead, the longitudinal level must be defined in a strict relation to the skeleton, usually between the L4 and L5 vertebrae.

The subjects are examined in a supine position with their arms stretched above their heads. The choice to perform the scan at the level of the umbilicus was initially proposed by Borkan et al. Subsequently, Tokunaga et al. In addition to the recommendations of the Japanese investigators, studies from Korea 20 and from our clinic use the scan at the umbilicus.

Visceral fat is defined as intraabdominal fat bound by parietal peritoneum or transversalis fascia, excluding the vertebral column and the paraspinal muscles; subcutaneous fat is fat superficial to the abdominal and back muscles. Subcutaneous fat area is calculated by subtracting the intraabdominal fat area from the total fat area.

In addition, visceral fat increases with age Figure 1 shows cross-sectional abdominal areas obtained by CT at the level of the umbilicus in two women matched for the same BMI, who differed markedly in the accumulation of fat in the abdominal cavity but less so in the subcutaneous abdominal fat.

Computed tomography showing cross-sectional abdominal areas at umbilicus level in two patients demonstrating variation in fat distribution.

A, Visceral type yr-old female, B, Subcutaneous type yr-old female, In obese subjects the level of the umbilicus can change from one patient to another, thus changing the visceral adipose tissue area; therefore, it is advisable that the scan area be defined in strict relation to the skeleton.

Chowdhury et al. However, the values for abdominal cut-off points were related to increased cardiovascular risk Table 2. Using the scan at the umbilicus as described by several investigators gave results similar to, although somewhat lower than, those reported using the L4-L5 level.

Abdominal visceral adipose tissue area cut-off points related to increased cardiovascular risk. Regarding the relationship between the modifications in subcutaneous and visceral adipose tissue, with changes in body weight, it was shown that after severe weight loss, subcutaneous fat at the abdominal level is lost in greater proportion than visceral fat, but the mechanism of these differential changes in both compartments of abdominal fat is unknown, suggesting that visceral fat does not reflect nutritional status to the extent that sc fat does In the same way, published data suggest that, at least in relative terms, visceral fat increases less than subcutaneous fat with increased body weight However, because the amount of subcutaneous abdominal fat is calculated indirectly, it is likely that significant measurement error could be introduced Regarding the reproducibility of CT measurement of visceral adipose tissue area, Thaete et al.

The duplication occurred after the initial scan; the subjects were repositioned before repeat scanning. As indicated in the Introduction , individuals with a high accumulation of visceral abdominal fat, as shown by CT scans, had an increased risk for development of type 2 diabetes, dyslipidemia, and coronary heart disease.

Table 2 shows the thresholds above which metabolic complications would be more likely to be observed in visceral adipose tissue areas.

Desprès and Lamarche 73 , Hunter et al. They found that a value above cm 2 was associated with an increased risk of coronary heart disease in pre and postmenopausal women 75 ; the same group 74 found that males with abdominal visceral fat cross-section areas measuring more than cm 2 were clearly at an increased risk for coronary disease.

On the other hand, Desprès and Lamarche 73 found that in both men and women a value of cm 2 was associated with significant alterations in cardiovascular disease risk profile and that a further deterioration of the metabolic profile was observed when values greater than cm 2 of visceral adipose tissue were reached.

From the same center, Lemieux et al. It was concluded that waist circumference was a more convenient anthropometric correlate to visceral adipose tissue because its threshold values did not appear to be influenced by sex or by the degree of obesity.

Anderson et al. The most extensive studies using a single CT scan at umbilical level was done by Matsuzawa and colleagues 17 , However, they did not present the raw data on visceral and subcutaneous areas but only their ratios, thus precluding their inclusion in Table 2.

In another study, performed in Japan by Saito et al. Lottenberg et al. Magnetic resonance imaging MRI. MRI provided results similar to CT without exposure to ionizing radiation, the main problem with CT multislice measurements.

It demonstrated good reproducibility for total and visceral adipose tissue volumes 63 , which were slightly lower than previously reported using CT 55 , although the percent contribution of visceral to total adipose tissue volume was similar 18 vs.

Subcutaneous adipose tissue and visceral fat areas at the L4-L5 level determined in 27 healthy men by MRI were These areas were highly predictive of the corresponding volume measurements computed from the scan MRI, confirming the CT studies of Kvist et al.

Two studies have compared estimates of subcutaneous and visceral adipose tissue by CT and MRI. Comparison between MRI and CT in seven subjects showed a high degree of agreement in measurement of total subcutaneous adipose tissue area but not visceral adipose tissue area As already mentioned, MRI has been validated in three cadavers, confirming its accuracy Ultrasound US.

US subcutaneous and intraabdominal thicknesses, the latter corresponding to the distance between abdominal muscle and aorta, were measured 5 cm from the umbilicus on the xipho-umbilical line with a 7.

The intraindividual reproducibility of US measurements was very high both for intraabdominal and subcutaneous thickness as well as for interoperators 83 , Several studies demonstrated a highly significant correlation between the intraabdominal adipose tissue determined by CT and by US.

A decade ago, Armellini et al. In a more recent study, Tornaghi et al. In a study of men C. Leite, D. Matsuda, B. Wajchenberg, G. Cerri, and A. Halpern, unpublished data , in which In obese women, after a 6-kg weight loss, a significant decrease was found in intraabdominal fat but not in subcutaneous adipose tissue, as determined by both CT and US There was also a significant correlation between changes in intraabdominal adipose tissue using both techniques, indicating that US can be used in the evaluation of body fat distribution modifications during weight loss.

This is another confirmation of the reliability of the US intraabdominal determinations. The amount of visceral fat increases with age in both genders, and this increase is present in normal weight BMI, In a study of subjects 62 males and 68 females with a wide range of age and weight , Enzi et al.

This fat topography was retained in young and middle-aged females up to about 60 yr of age, at which point there was a change to an android type of fat distribution. This age-related redistribution of fat is due to an absolute as well as relative increment in visceral fat depots, particularly in obese women, which could be related to an increase in androgenic activity in postmenopausal subjects.

On the other hand, they showed that males at any age tend to accumulate fat at the visceral depot, increasing with age and BMI increase. In the male, a close linear correlation between age and visceral fat volume was shown, suggesting that visceral fat increased continuously with age Although this correlation was also present in women, the slope was very gentle in the premenopausal condition.

It became steeper in postmenopausal subjects, almost the same as in males Further, Enzi et al. From the published data 68 , 90 , it can be concluded that both subcutaneous and visceral abdominal fat increase with increasing weight in both sexes but while abdominal subcutaneous adipose tissue decreases after the age of 50 yr in obese men, it increases in women up to the age of 60—70 yr, at which point it starts to decline Fowler et al.

Finally, as previously indicated, visceral fat is more sensitive to weight reduction than subcutaneous adipose tissue because omental and mesenteric adipocytes, the major components of visceral abdominal fat, have been shown to be more metabolically active and sensitive to lipolysis Lemieux et al.

In addition, the adjustment for differences in visceral fat between men and women eliminated most of the sex differences in cardiovascular risk factors. There is evidence supporting the notion that abdominal visceral fat accumulation is an important correlate of the features of the insulin-resistant syndrome 23 , 24 , 29 but this should not be interpreted as supporting the notion of a cause and effect relationship between these variables This subject will be discussed later on.

The correlations of abdominal visceral fat mass evaluated by CT or MRI scans with total body fat range from 0. They tend to be lower in the lean and normal weight subjects than in the obese As indicated by Bouchard et al. When they examined the relationship of total body fat mass to visceral adipose tissue accumulation in men and in premenopausal women, Lemieux et al.

Furthermore, the relationship of visceral adipose tissue to metabolic complications was found to be independent of concomitant variation in total body fat, and it was concluded that the assessment of cardiovascular risk in obese patients solely from the measurement of body weight or of total body fatness may be completely misleading 19 , 22 , 36 , Indeed, it appears that only the subgroup of obese individuals characterized by a high accumulation of visceral adipose fat show the complications predictive of type 2 diabetes and cardiovascular disease On the other hand, after adjustment for total body fat, Abate et al.

Intraabdominal visceral fat is associated with an increase in energy intake but this is not an absolute requirement. Positive energy balance is a strong determinant of truncal-abdominal fat as shown by Bouchard and colleagues 96 in overfeeding experiments in identical twins. The correlations between gains in body weight or total fat mass with those in subcutaneous fat on the trunk reached about 0.

In contrast, these correlations attained only 0. Thus, positive energy balance does not appear to be a strong determinant of abdominal visceral fat as is the case with other body fat phenotypes 7.

In effect, as discussed in the CT section of imaging techniques for evaluation of intraabdominal visceral fat, some investigators 70 , 71 have shown that either when the subjects lose or increase their weight, particularly females, visceral fat is lost or gained, respectively, less than subcutaneous fat at the abdominal level.

However, at variance from these data, Zamboni et al. Similarly, as already mentioned, Smith and Zachwieja 32 noted that all forms of weight loss affect visceral fat more than subcutaneous fat percentage wise , and there was a gender difference, with men appearing to lose more visceral fat than women for any given weight loss.

LPL activity, being related to the liberation of the lipolytic products [from chylomicra and very-low-density lipoproteins VLDL ] to the adipocytes for deposit as triglycerides, is a key regulator of fat accumulation in various adipose areas, since human adipose tissue derives most of its lipid for storage from circulating triglycerides.

However, adipocytes can synthesize lipid de novo if the need arises, as in patients with LPL deficiency According to Sniderman et al. The increase of visceral fat masses with increasing total body fat was explained by an increase of fat cell size only up to a certain adipocyte weight.

However, with further enlargement of intraabdominal fat masses with severe obesity, the number of adipocytes seems to be elevated , In women, but not in men, omental adipose tissue has smaller adipocytes and lower LPL activity than subcutaneous fat depots since variations in LPL activity parallel differences in fat cell size 7.

When adipocytes enlarge in relation to a gain in body weight, the activity of LPL increases in parallel, possibly as a consequence of obesity-related hyperinsulinism. The higher basal activity of adipose tissue LPL in obesity is accompanied by a lower increment after acute hyperinsulinemia Lipid accumulation is favored in the femoral region of premenopausal women in comparison with men In the latter, LPL activity as well as the LPL mRNA levels were greater in the abdominal than in gluteal fat cells, while the opposite was observed in women, suggesting that regional variation of gene expression and posttranslational modification of LPL could potentially account for the differences between genders in fat distribution With progressive obesity, adipose tissue LPL is increased in the depots of fat in parallel with serum insulin.

However, when obese subjects lost weight and became less hyperinsulinemic, adipose LPL increased further and the patients who were most obese showed the largest increase in LPL, suggesting that very obese patients are most likely to have abnormal LPL regulation, independent of the influence of insulin.

In response to feeding, the increase in LPL is, as indicated, due to posttranslational changes in the LPL enzyme. However, the increased LPL after weight loss involved an increase in LPL mRNA levels, followed by parallel increases in LPL protein and activity Because the response to weight loss occurred via a different cellular mechanism, it is probably controlled by factors different from the day-to-day regulatory forces.

In addition, because the very obese patients demonstrated a larger increase in LPL with weight loss than the less obese patients, these data suggest a genetic regulation of LPL that is most operative in the very obese The role of sex steroids, glucocorticoids, and catecholamines in the regulation of adipose tissue LPL activity in various fat depots will be discussed in the section on hormonal regulation of abdominal visceral fat.

Lipid mobilization and the release of FFA and glycerol are modulated by the sympathetic nervous system. Catecholamines are the most potent regulators of lipolysis in human adipocytes through stimulatory β l - and β 2 -adrenoreceptors or inhibitoryα 2-adrenoreceptors A gene that codes for a third stimulatory β -adrenoreceptor, β 3 -adrenoreceptor, is functionally active principally in omental adipocytes but also present in mammary fat and subcutaneous fat in vivo In both genders and independently of the degree of obesity, femoral and gluteal fat cells exhibit a lower lipolytic response to catecholamines than subcutaneous abdominal adipocytes, the latter showing both increased β l - and β 2 -adrenoreceptor density and sensitivity and reduced α2-adrenoreceptor affinity and number Refs.

The increased sensitivity to catecholamine-induced lipolysis in omental fat in nonobese individuals is paralleled by an increase in the amount of β l - and β 2 -receptors, with normal receptor affinity and normal lipolytic action of agonists acting at postadrenoreceptor steps in the lipolytic cascade , ; this is associated with enhanced β 3 -adrenoreceptor sensitivity, which usually reflect changes in receptor number in comparison with subcutaneous adipocytes , Comparison of lipolysis, antilipolysis, and lipogenesis in omental and subcutaneous fat in nonobese and obese individuals.

Adipocytes from obese subjects generally show increased lipolytic responses to catecholamines, irrespective of the region from which they are obtained, and enhanced lipolysis in abdominal compared with gluteo-femoral fat 21 , The antilipolytic effect is also reduced in vitro in obesity, both in omental and subcutaneous adipocytes The typical features of visceral fat, e.

An increased β 3 -adrenoreceptor sensitivity to catecholamine stimulation may lead to an increased delivery of FFA into the portal venous system, with several possible effects on liver metabolism. These include glucose production, VLDL secretion, and interference with hepatic clearance of insulin , resulting in dyslipoproteinemia, glucose intolerance, and hyperisulinemia.

Lönnqvist et al. They observed that males had a higher fat cell volume with no sex differences in the lipolytic sensitivity to β l - and β 2 -adrenoreceptor-specific agonists or in the antilipolytic effect of insulin.

However, the lipolytic β 3 -adrenoreceptor sensitivity was 12 times higher in men, and the antilipolytic α2-adrenoreceptor sensitivity was 17 times lower in men. It was concluded that in obesity, the catecholamine-induced rate of FFA mobilization from visceral fat to the portal venous system is higher in men than women.

This phenomenon is partly due to a larger fat cell volume, a decrease in the function ofα 2-adrenoceptors, and an increase in the function of β 3 -adrenoreceptors. These factors may contribute to gender-specific differences observed in the metabolic disturbances accompanied by obesity, i.

Glucocorticoid receptors. Glucocorticoid receptors, one of the most important receptors for human adipose tissue function, are involved in metabolic regulation and distribution of body fat under normal as well as pathophysiological conditions.

Glucocorticoid receptors in adipose tissue show a regional variation in density with elevated concentrations in visceral adipose tissue In spite of the lower receptor density, the elevated cortisol secretion results in clearly increased net effects of cortisol.

Androgen and estrogen receptors. Adipocytes have specific receptors for androgens, with a higher density in visceral fat cells than in adipocytes isolated from subcutaneous fat. Unlike most hormones, testosterone induces an increase in the number of androgen receptors after exposure to fat cells , thereby affecting lipid mobilization.

This is more apparent in visceral fat omental, mesenteric, and retroperitoneal because of higher density of adipocytes and androgen receptors, in addition to other factors However, at variance with the effects of testosterone, dihydrotestosterone treatment does not influence lipid mobilization In females, there is an association between visceral fat accumulation and hyperandrogenicity, despite the documented effects of testosterone on lipid mobilization and the expected decrease in visceral fat depots.

The observation that visceral fat accumulation occurs only in female-to-male transsexuals after oophorectomy suggests that the remaining estrogen production before oophorectomy was protective The androgen receptor in female adipose tissue seems to have the same characteristics as that found in male adipose tissue.

However, estrogen treatment down-regulates the density of this receptor, which might be a mechanism whereby estrogen protects adipose tissue from androgen effects. Estrogen by itself seems to protect postmenopausal women receiving replacement therapy from visceral fat accumulation Estrogen receptors are expressed in human adipose tissue and show a regional variation of density, but whether the quantity of these receptors is of physiological importance has not been clearly established With regard to progesterone, adipose cells seem to lack binding sites and mRNA for progesterone receptors, indicating that progesterone acts through glucocorticoid receptors GH receptors.

While it is well established that GH has specific and receptor-mediated effects in adipose tissue of experimental animals, the importance of GH receptors in human adipose tissue is not fully elucidated at present although the available data indicate a functional role.

However, GH is clearly involved in the regulation of visceral fat mass in humans.

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