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Posted on Wednesday September 24, 2025 in Metabolic Health
An article written by Dr Edward Leatham, Consultant Cardiologist
Tags: VAT, GLP-1, Inflammation, Diet, CKD, search website using Tags to find related stories.
Many people are described as “healthy despite being overweight” – but is that the full picture?
At our cardiology clinic, we often see patients with irregular heart rhythms, breathlessness, or fatigue. They may have a high body mass index (BMI) but normal blood pressure, cholesterol, and glucose levels. Some are told they have “metabolically healthy obesity” – a term that suggests low metabolic risk despite extra weight.
However, recent research shows that this state may be temporary – and that the location and type of body fat may be a better predictor of long-term health than BMI or weight alone¹⁻².
This fat lies just beneath the skin. It is most obvious on the belly, thighs, arms or hips and is what gives the body its visible shape.
While excessive amounts can cause discomfort and increase load on joints and the lungs, subcutaneous fat is often considered less dangerous from a metabolic point of view – especially when stored in the hips and thighs. It can act as a safe storage depot, helping to prevent fat from building up in more harmful locations.
Visceral adipose tissue (VAT) is stored deep in the abdomen, wrapped around the liver, intestines, pancreas and other organs. This internal fat is metabolically active and is strongly linked with:
People with high visceral fat often have normal body weight or appearance, but elevated health risks. You cannot always see this fat, and it is not picked up by the bathroom scale.
A simple way to estimate visceral fat is by measuring waist circumference.
If your waist is more than half your height, this may indicate unhealthy levels of VAT – even if your BMI is in the “healthy” range.
At Surrey Cardiovascular Clinic, when waist-to-height ratio exceeds 0.5, we may offer a low-dose CT scan to directly measure visceral fat volume. This helps us understand whether your primary health burden is:
Some patients with low BMI but low skeletal muscle mass have unhealthy visceral fat levels. Others with obesity may have low VAT and be metabolically well. This is why VAT measurement helps guide the right treatment priorities for your specific fat profile.
Skeletal muscle plays an important role in metabolic health and physical function.
A person with low muscle mass – especially if physically inactive – may appear lean but still have:
You do not need a referral to access a DEXA scan, which is a safe, low-radiation test that provides:
This test can be very helpful in building a tailored weight and health improvement plan, especially if symptoms like fatigue or breathlessness are out of proportion to BMI.
Even if fat is stored subcutaneously and not causing metabolic dysfunction, it still increases mechanical load on the heart and lungs.
Each additional kilogram of fat tissue requires blood flow, oxygen, and support from the cardiovascular system. This raises cardiac output (how much blood your heart needs to pump), even when you are at rest.
If you have atrial fibrillation, a condition where the heart beats irregularly, this extra demand can worsen:
People with AF or borderline heart function often notice that even modest weight loss improves their ability to breathe, exercise, and sleep better – even if blood tests are normal².
Some people with obesity have normal:
These individuals are often described as having “metabolically healthy obesity” (MHO). But this is often a temporary state.
Studies show that:
So while someone may start in a low-risk zone, weight gain, ageing, or inactivity can trigger a switch to high-risk status within a few years.
Another important tool in personalising treatment is continuous glucose monitoring (CGM).
Many high-VAT individuals show signs of a carbohydrate-sensitive phenotype, where certain starchy or sugary foods cause exaggerated blood sugar spikes – even without diabetes⁵.
Using CGM, we can:
Patients with a carbohydrate-sensitive profile often benefit from starting with a low-carbohydrate or low-glycaemic diet, which can improve:
You can read more about this approach in our companion blog on CGM and VAT [insert link to CGM blog].
If you have high VAT or show signs of metabolic dysfunction, the first line of treatment involves lifestyle strategies that specifically target VAT:
However, for those with persistently high VAT or higher cardiovascular risk, GLP-1 receptor agonists (such as semaglutide or liraglutide) may be appropriate⁶.
These medications can:
At our clinic, we assess your VATI (visceral adipose tissue index) alongside your clinical picture to guide when and if pharmacological support is appropriate.
If you are breathless, struggling with atrial fibrillation, or concerned about your long-term health, we can help assess your body fat, glucose profile, and metabolic risk.
We offer:
Let us help you go beyond the bathroom scale – and build a plan for better long-term health.
Let me know if you would like this blog converted to a PDF handout with clinic branding, or repurposed into a CGM/VAT patient explainer, waiting room slide, or email follow-up template.
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