An article written by Dr Edward Leatham, Consultant Cardiologist © 2025 E.Leatham
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With the Christmas and New Year festivities over, many people are counting the cost — both to their bank balance and their waistband.
January is traditionally a time when gym memberships swell, Dry January leads to a sharp drop in alcohol intake, and people take stock after the excesses of winter. A familiar combination of reduced energy expenditure, disrupted sleep, increased socialising, and greater intake of calorie-dense food and alcohol leads to measurable weight gain across many populations. What is increasingly clear is that much of this weight gain accumulates not just under the skin (subcutaneous fat), but deep within the abdomen as visceral adipose tissue (VAT)¹.
This makes January an ideal time to focus not only on how much weight is gained, but where it is gained — and why some fat is far more dangerous than others.
Subcutaneous vs visceral fat: why the location matters
Subcutaneous fat is the fat you can pinch. It sits beneath the skin and, while it can be frustrating cosmetically, is generally less metabolically harmful.
Visceral fat is different. VAT accumulates around internal organs such as the liver, pancreas, and intestines. It is hormonally active, inflammatory, and strongly linked to insulin resistance. In simple terms, VAT behaves less like stored energy and more like an endocrine organ, driving adverse metabolic signalling¹,².
This is why visceral fat is closely associated with cardiometabolic disease: higher blood pressure, higher triglycerides, lower HDL cholesterol, worsening glucose control, fatty liver disease, and increased cardiovascular risk¹,².
Crucially, VAT can rise without dramatic changes in body weight. Some individuals have a “normal” BMI but a high visceral fat burden — sometimes described as metabolically obese normal weight. BMI cannot detect fat distribution, and it is distribution that often determines risk.
Why we’re focusing on waist measurement this year
This year, we are encouraging everyone to pay closer attention to waist measurement. It is one of the most direct, simple, and accessible ways of estimating visceral fat risk outside a scanner.
While there are absolute waist circumference targets, the most useful and personalised measure is the waist-to-height ratio. Simply divide your waist circumference by your height. If the result is greater than 0.5, the likelihood is high that visceral adipose tissue is present and contributing to insulin resistance and early metabolic syndrome³.
Importantly, this risk can exist even in people whose weight or BMI appears “normal”. Waist measurement often reveals metabolic drift years before routine blood tests become abnormal.
The dual set-point hypothesis: why weight creeps up with age
An important concept that helps explain why many people struggle despite sustained effort is the dual intervention point (dual set-point) hypothesis. Rather than defending a single fixed weight, the body appears to operate within a biologically influenced range: a lower and an upper intervention point4,5.
Within this range, weight can drift in response to environment — food availability, stress, sleep disruption, and physical activity. However, as the lower boundary is approached, powerful biological mechanisms activate to resist further weight loss: appetite increases, resting energy expenditure falls, and weight regain becomes more likely⁴.
Critically, evidence suggests that this lower intervention point gradually rises with age, even in physically active and health-conscious individuals⁵. Loss of skeletal muscle, hormonal change, reduced spontaneous movement, and cumulative stress all contribute. This helps explain why maintaining a healthy waist at 50 or 60 often requires more deliberate strategy than it did at 30.
This reality has driven increasing interest in metabolic technologies and interventions designed not to fight biology, but to reset it. Building skeletal muscle mass raises basal metabolic rate and improves glucose disposal, while reducing visceral adipose tissue lowers insulin resistance and chronic inflammation. Together, these changes may help stabilise — or even modestly lower — the defended lower set point, while improving lipid patterns including reductions in small dense LDL (sdLDL) particles that frequently accompany visceral obesity and metabolic syndrome⁶,⁷.
The goal is not extreme leanness, but a stable, metabolically healthy state that the body is more willing to maintain.
Exercise: think long-term, not just January
Joining a gym is an excellent plan — but nothing beats a plan that is sustainable beyond the end of January.
In patients attending our visceral fat reduction and GLP-1 mimetic clinics, our consistent recommendation is slow and steady. Avoid starting anything that cannot be maintained long term — with the notable exception of the Christmas diet, which most of us are relieved to leave behind.
The forms of exercise that matter most as we age are those that build and preserve skeletal muscle. Resistance training and high-intensity interval training (HIIT) are particularly effective, improving insulin sensitivity and increasing metabolic capacity. Walking and gentle exercise remain valuable for cardiovascular and mental health, but on their own they do little to reverse age-related muscle loss.
Sarcopenia: the hidden driver of insulin resistance
From around the age of 30, adults lose approximately 5–10% of skeletal muscle mass per decade. This process — known as sarcopenia — is a major contributor to declining metabolic health⁸.
Skeletal muscle is the primary site of glucose disposal. As muscle mass falls, post-meal glucose spikes become larger, insulin demand increases, and excess energy is more readily stored as fat — particularly visceral fat. Sarcopenia may therefore be one of the most important drivers of middle-age spread, especially after periods of excess such as Christmas banquets.
Why the scales can mislead you
Bathroom scales are emotionally powerful but biologically misleading. As resistance training and adequate protein intake rebuild skeletal muscle, body weight may change very little — because muscle is denser than fat.
The waist measurement, however, tells a more meaningful story. When visceral fat is being lost, waist circumference typically reduces steadily, often on a weekly basis, even when the scales appear stubborn.
For this reason, we encourage patients to weigh less often and measure their waist more often, focusing on long-term trends rather than daily fluctuations.
VAT and small dense LDL: why visceral fat changes lipid risk
Not all LDL cholesterl particles carry the same risk. Individuals with visceral adiposity and insulin resistance often develop a lipid profile characterised by elevated triglycerides, lower HDL cholesterol, and an increased proportion of small dense LDL (sdLDL) particles — a pattern strongly associated with atherosclerotic cardiovascular disease⁶.
Visceral fat contributes to this pattern through hepatic insulin resistance, altered lipoprotein metabolism, and increased inflammatory signalling. Studies demonstrate that reducing intra-abdominal fat improves lipid metabolism and shifts LDL particle size toward a less atherogenic profile⁷.
This is one reason VAT reduction has benefits well beyond appearance — it directly targets the metabolic drivers of vascular disease.
Going further: measuring VAT and supporting N-of-1 recovery
For patients attending our VAT-reduction and GLP-1 clinics, we go further than simple anthropometrics.
Low-dose CT is used to quantify visceral adipose tissue and define a personalised, metabolically healthy target. Body composition scales track trends in skeletal muscle mass, visceral fat, and subcutaneous fat over time. In carbohydrate-sensitive individuals, glucose monitoring helps identify dietary triggers and guide food choices.
All data are captured in an N-of-1 diary, allowing patients to understand their own metabolic responses and build strategies that work long term.
Looking ahead to a healthier year
Over the coming year, our metabolic blog series will focus on practical strategies to reduce visceral adipose tissue, preserve skeletal muscle, and use modern metabolic tools effectively.
By shifting attention away from short-term weight loss and towards waist measurement, muscle preservation, and sustainable habits, we hope 2026 will be a healthier and more resilient year for many.
References
- Després J-P. Body fat distribution and risk of cardiovascular disease. Circulation. 2012;126:1301–1313.
https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.111.067264 - Neeland IJ, et al. Visceral and ectopic fat, atherosclerosis, and cardiometabolic disease. Nat Rev Cardiol. 2019;16:173–184.
https://www.nature.com/articles/s41569-018-0107-3 - Ashwell M, Gibson S. Waist-to-height ratio as an indicator of early health risk. Obes Rev. 2016;17:646–655.
https://pubmed.ncbi.nlm.nih.gov/27071953/ - Speakman JR, et al. Set points, settling points and alternative models of body weight regulation. Dis Model Mech. 2011;4:733–745.
https://pmc.ncbi.nlm.nih.gov/articles/PMC3209643/ - Speakman JR. Models of body weight regulation. Philos Trans R Soc B. 2023;378:20220231.
https://royalsocietypublishing.org/doi/10.1098/rstb.2022.0231 - Tchernof A, et al. The dense LDL phenotype and visceral obesity. Diabetes Care. 1996;19:629–637.
https://diabetesjournals.org/care/article/19/6/629/3331 - Purnell JQ, et al. Reduction of intra-abdominal fat improves lipid metabolism. J Clin Endocrinol Metab. 2000;85:977–982.
https://pubmed.ncbi.nlm.nih.gov/10720026/ - Cruz-Jentoft AJ, et al. Sarcopenia: revised European consensus. Age Ageing. 2019;48:16–31.
https://academic.oup.com/ageing/article/48/1/16/5126243
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