Basic and clinical aspects Bouchard,

George

A Bray,

and

Van

fat distribution13

S Hubbard

There is a substantial body of data showing that there is a U- or i-shaped relationship between relative body weight and excess mortality. Several recent studies suggested that variations in regional fat distribution may have a higher predictive value for future health risks and that this effect may be as strong as for hypercholesterolemia, hypertension, and smoking. For

three principal components ofbody fat are associated with the health outcomes. The first component is the total amount of body fat expressed as a percentage ofbody weight. The second component is the amount of subcutaneous truncal or abdominal fat (upper-body fat). The third component is the quantity of visceral fat located within the intraabdominal cavity. These components are partly correlated with one another but nonetheless exhibit a fairly high degree ofindependence. One of the

this

central

Introduction

reason,

a workshop

dealing

with

the

basic

and

clinical

as-

pects ofregional fat distribution was sponsored by the National Institutes of Health to examine the data relating to variations in fat distribution and its potential health risks. Gaps in knowledge about fat distribution were identified and recommendations

for

clinical

future applications

summary

about

regional

developed.

the general

and

for

proceedings.

fat distribution

morbidity

basic

This

report

sciences

nature

to

metabolic

as research

a

provide

of the relationship

selected

as well

and

represents

It is intended

and

mortality

both

an

between

characteristics, needs

for basic

and

scientists.

Session

Moderator of

National

Health.

Institute

eases, NIH; Center.

George

In his introductory workshop,

A:

Van

Digestive

Phillip

Formal

S Hubbard,

and

Kidney

National Diseases,

Presentations.’

of Diabetes

and

A Bray,

Pennington

Phillip

Digestive

and

Biomedical

remarks welcoming participants Gorden, Director of the National

In-

Gorden,

Kidney

Dis-

Research to this Institute

of Diabetes and Digestive and Kidney Diseases, posed a number ofquestions that he felt were focal points for the workshop. These included why differences in regional fat distribution are important and whether they are epiphenomena or bear a causal relationship

with which questions

to the

regional of why

metabolic

alterations

fat distribution differences

and

is associated.

in fat distribution

chronic

of what

Am J C/in Nutr

Statistics;

versity

of Goteborg.

workshop

ofeach risks.

ofthese

was

to delineate

three components

William

Sciences

Center,

measurements density through

H

Mueller,

Houston;

Lars

be estimated

techniques I

Summary

University

of

Sjostrom,

Uni-

of total body fat can be obtained underwater weighing and perhaps

by use of bioelectric impedance technology. body fat, as a fractional component of body

In addition,

total

composition, can with a high degree of reliability by using isotope measuring total body water or lean body mass as of a workshop

sponsored

by the National

Institutes

Health held on September 1 1- 13, 1989, at the Lister Hill Center, Bethesda, MD. The workshop was cosponsored by the National tute ofDiabetes and Digestive and Kidney Diseases; the National cer Institute; the National tional Institute on Aging;

Human

diseases

metabolic signals control this process, and of what importance are genetic and hormonal factors in these changes. The relationship between regional fat distribution and health has come clearly into focus within the last 10 y. Over that span of time, several prospective epidemiological studies strongly suggested that in addition to total body fat, the location of that fat plays an important role in the risks ofcardiovascular disease and in the risks ofdeveloping diabetes, hypertension, gallbladder disease, stroke, and overall mortality. It appears that at least 946

Health

Health

Development;

of NIH,

InstiCan-

Heart, Lung and Blood Institute; the Nathe National Institute of Child Health and

and the Division

ofNutrition

Research

Activity

Laboratory,

Laval

Coordi-

nation.

He also raised occur,

for

Texas

Accurate from body

Institute National

at the

Moderators sessions B, C, and D: John D Brunzell, University ofWashington; Francis E Johnston, University of Pennsylvania; F Xavier Pi-Sunyer, St Luke’s-Roosevelt Hospital Center. Formal presentations: Robert Kuczmarski, National Cen-

of problem

session and

identified

Session B: methods for measurement of regional fat distribution

ter

A: overview

of Diabetes

stitutes

relevant

were

of these

overview

clinical

research

challenges

more clearly the relationship of fat to health and metabolic

2

From the Physical

Ste-Foy, Quebec; the ana State University, and Obesity, Eating tional Institute of Bethesda, MD.

b990;52:946-50.

3

Requests

Nutrient bation

for reprints

Metabolism Programs,

Sciences

and a selected

and Obesity,

Westwood

Printed

for publication in USA.

bibliography

Eating

Building,

ofDiabetes and Digestive and Kidney Received May 25, 1990.

Accepted

University,

Pennington Biomedical Research Center, LouisiBaton Rouge, LA; and the Nutrient Metabolism Disorders and Energy Regulation Programs, NaDiabetes and Digestive and Kidney Diseases,

Disorders

Room

3A18B,

Diseases,

to VS Hubbard, and Energy National

Bethesda,

ReguInstitute

MD 20892.

May 30, 1990.

© 1990 American

Society

for Clinical

Nutrition

Downloaded from https://academic.oup.com/ajcn/article-abstract/52/5/946/4651156 by McMaster University user on 04 February 2019

Claude

of regional

REGIONAL estimated

from

total

body

potassium.

Subcutaneous

fat as well

as visceral fat can be measured with considerable using either computed tomography or magnetic aging.

Truncal

sessed

reasonably

and

abdominal well

or with ultrasound. waist, hip, or thigh central

versus

subcutaneous

with

a variety

Measurements can be useful

peripheral

accuracy resonance fat can

ofskinfold ofthe as an

FAT

by im-

also

be as-

measurements

circumference of the indirect estimation of

fat distribution.

One

obvious

need

for

from

large

From ceral

epidemiologic

multiscan

fat in males

studies.

tomography

is moderately

related

it is clear to total

body

ogy.

Improved

techniques but

from

ever, it was clear that visceral fat, truncal, of these

specific

Despite

in body the

and

truncal standing than

fat may

absolute

measurements

two

may thus be more of fat distribution

of any ratios.

least

biologically

For

the

laboratory

as the

drawbacks.

to Hispanics provide can

presentations:

gland

Research

Aging,

NIH;

Michael

Robert

Stern,

The

in

Formal

ratios methods

found

in the dis-

fat distribution in the database

the San Antonio are available

to have

in the females,

more

have apply

Heart

Study

for blacks.

body

Mexi-

fat that

tends

to

yet they have a lower overall mortaldiseases than do non-Hispanic is more

is less

common

frequently

in Mexican

observed.

The

regional

ter;

or skinas well

as

Claude

presentations:

MRC

Amendivergence

fat distribution

University

Greenwood,

Bouchard,

Laval

of Colorado

University

Health

ofCalifornia,

Beth Israel Medical University; Marielle

University;

Sciences

Cen-

Davis;

Marvin

Center; Rudolph L Rebuffe-Senve, Yale

University.

ofdeterminants Factors

gender,

composition

Andres,

M Malina,

fat distribution

from

diabetes

H Eckel,

tribution.

National

University ofTexas

Health

New

En-

Institute

on

of Texas,

Austin;

Sciences

Center

at San Antonio. Regional

differences

ofthe Mexican Americans from the risk patterns established in whites of Northern European decent is intriguing and warrants further research. In contrast, bbacks with upper-body obesity seem to be at a higher risk for morbidity than are the other ethnic groups, and the causes of this difference need urgent attention.

A variety

useful in underto health status

L Adams-Campbell,

Reubin

University

racial

level

of physical smoking ing age,

influence

affecting

of energy activity,

the

balance, and

and alcohol gender, total

a variety

tissue lipoprotein lipase, amount of subcutaneous by genetic visceral

fat,

lipase,

and

corticosteroid

age,

fat and its disfat

include

of the

of social

diet,

factors

gonadal

total

concentrations

includadipose-

also influence fat. Truncal

steroids,

gender,

and

body are the

age, level

including

of the same factors ofenergy balance,

and lipolytic activity truncal-abdominal causes,

For

body

body

composition

intake. Many body fat, level

roids.

total

percent

the fat is

adrenal

fat,

ste-

lipoprotein

important

de-

terminants.

Lucile

Institute;

were

hypertension

Three Formal

and

than

centrally located, from cardiovascular Although

cans,

data

information

Americans

influenced

for body

although

more

Kirschner, Newark Leibel, Rockefeller

changes

the surrogate measurements, it was recognized that there was a need for reference values accounting for age, gender, and ethnic differences.

Session C: normative data and regional fat distribution

ethnic

adipose tissue. Although black females are known to be more obese than white

the relationships ofthe obesity to regional been poorly defined. Similar limitations

be an

such and

set of circumference

important

of States

to

would

the use ofratios at

a considerable

which it is stable. For females the percent until after age 60-70 y and then declines.

Session D: factors determining and metabolic aberrations

standardization ofa conference

produce little or no change of visceral and subcutaneous

quantity

are also

tribution United

Robert

has

Although

for

fat distribution

standards

aging.

wherever

as a surrogate

the regional

ratio

to be

for measuring body fat now

be encouraged

to interpret

or abdominal fat the relationships

fold-thicknesses

standardized.

with

The interrelated nature of aging and body fat content, regional fat distribution, physical activity, and physical fitness is evident and future studies need to take these relationships into account. In addition to the effects ofgrowth, development, and aging,

whites. sites

might improve workshop, how-

measures

value,

difficult

fat or visceral The

collected From the

provide working ofthis workshop.

the

and

nearly age 60 y, after fat continues to rise

be more ity rate

when

of the sites

where international and the convening

the epidemiologic

ratios.

that

not been

should

to estimate

is an area important,

are

are

even

literature

have

in women

in epidemiol-

precise laboratory methods or abdominal fat and total

methods

ratios

precise

definition

data techniques.

waist-hip-circumferences These

effects

needed

of the

anthropometric

methods outcome

important

still

a clearer

techniques

However,

develop

less

are

a review

and

used when anthropometric the usefulness of these

components would appear

are they

measurements

methods

Use

and its diminished

is given

for anthropometric

more

fat than less this

It is apparent

possible.

In fe-

less at risk from the effects of visceral fat or have fat relative to males. Understanding the basis for

training

exist.

fat.

to total

most

vis-

are

Anthropometric proper

that

women

differential fat distribution is an important problem.

maturation,

amount of cross-sectional data about skinfold measurements and circumferences exist for childhood, there is a paucity of longitudinal data. Data on the longitudinal changes offat distribution from childhood to adulthood is an area of considerable importance where more information is needed. During adult life the percent body fat in males rises steadily from age 20 y until

there

computed

males the visceral fat increases less in relation it does in males. Current research suggest that somewhat visceral

ual

947

changes

during

growth,

during

sex-

ences the

hypotheses in regional

were

suggested

to account

fat distribution.

neuroendocrine

response

ond centers adipose-tissue

on

the effects metabolism

that

genetic

variations

nals

are

responsible

of gonadal in various the

involves

to various

in tissue for

One

forms

the

differ-

differences of stress.

in A see-

and adrenal steroids on depots. A third assumes

sensitivity

individuality

for

and

metabolic

in regional

sig-

fat distri-

Downloaded from https://academic.oup.com/ajcn/article-abstract/52/5/946/4651156 by McMaster University user on 04 February 2019

future development is for standardized procedures with which truncal and abdominal subcutaneous fat can be quantitated either from anthropometric measurements or by reducing the cost and increasing the availability of accurate instrumental techniques. Such techniques could be validated on a subsample

DISTRIBUTION

948

BOUCHARD

bution.

These

hypotheses

are obviously

not

mutually

exclusive

and they may all contribute to the variation in regional fat distribution. Genetic background plays a role in all three components. From studies on twins and other biological relatives vs relatives by adoption, body

fat,

it is possible the

to define

amount

of truncal

the or

heritability

of percent

abdominal

fat,

and

the

deposited

or lost

is striking

for the changes

in the truncal

ing.

These

variations

and

they

are highly

sensitivity

of fat

or abdominal

in visceral

in response

show

suggestive

region.

fat with a familial

of inherited

distribution

This

chronic

effect

overfeed-

concentration

differences

to alterations

in the

bal-

ance. These data also support the notion that the visceral fat is highly variable among individuals at given levels of total fatness or truneal fat. Regional fat distribution is also related to steroid hormone concentrations. In patients with Cushing’s disease (hyperadrenocorticism) there is increased central fat deposition, particularly visceral fat, associated with an increased activity of lipoprotein lipase in the abdominal fat cells. Corticosteroids can directly enhance the formation oflipoprotein bipase when added to fat cells in vitro. Testosterone on the other hand tends to decrease lipoprotein lipase in the abdominal adipose tissue cells

and

to increase

lipolysis.

However,

males

have

on the aver-

age larger fat cell sizes in abdominal and intraabdominal fat deposits. The production of several steroids is directly related to body fat. Estradiol production increases in both males and females as the degree of body fat increases. Testosterone production is higher in obese than in lean individuals but perhaps not in morbidly obese individuals. Women with truncal or abdominal fat have higher concentrations diob, free testosterone, and free estradiol mone-binding

globulin.

Moreover,

upper-body

creases the metabolic clearance dihydrotestosterone. The production production per-body ditional

rate

ofestradiol

obesity research

than

is needed

The

robe

of the

obesity

higher

in women

with

lower-body

to determine

whether

lute concentration of testosterone or estradiol the regional distribution of fat or the relative steroids.

gonadab

estrasex-horin-

rate for testosterone rate oftestosterone

is much

in women

of testosterone, and reduced

and

adrenal

and vs the with

obesity.

upAd-

it is the abso-

that influences levels of these hormones

in con-

trolling fat distribution still requires considerable research. Fat deposition also is determined by the relative balance between fatty acid availability mediated by lipoprotein lipase and fatty acid mobilization as assessed by lipolytic rates. Lipoprotein

lipase

cells and ofestrogens

activity

is increased

is also increased may

be less

by estrogens

in obese obvious

in the

vs lean subjects. in lean

women

gluteal

This than

Women

tend

to have

more

alpha-2

adrenergic

or stimulating

factors

involved?

Conversely,

are

there

inhibitory factors that could be depot specific thus preventing excessive fat accumulation in certain compartments of the body? These and other issues pertaining to adipose cell biology should be addressed. Differentiation ofadipocytes represents a mechanism by which the number or function of cells can be regulated. The study of fat-cell differentiation holds promise for better understanding the way in which adipose tissue mass is controlled in various depots. Candidate enzymes or other proteins and eventually candidate genes should be identified so that the genetic exploration of the regional fat distribution described at this workshop can be undertaken. In this context, the three components defined in this report could be useful in delineating the path from morphology to physiology to metabolic markers and finally to specific genes.

Session E: clinical consequences-effect distribution on mortality and morbidity

of regional

fat

Moderators sessions E and F: Richard L Atkinson, Hampton Veterans Affairs Medical Center; Jules Hirsch, Rockefeller University. Formalpresentations: Harland Austin, University ofAlabama at Birmingham; Per Bjorntorp, University of Goteborg; Jean-Pierre Despres, Laval University; Aaron R Folsom, University of Minnesota; Steven M Haffner, University of Texas Health Science Center at San Antonio; Millicent W Higgins,

National

Ahmed

Kissebah,

Landsberg,

Heart,

Lung

Medical

Harvard

Medical

Goteborg. The regional distribution on mortality and morbidity. cal

studies

demonstrate

and

Blood

College School;

of

Institute,

NIH;

Wisconsin;

Bo Larson,

Lewis

University

ofbody fat has considerable Six prospective longitudinal unequivocally

that,

of

effects elini-

whether

the

sub-

scapular skinfold, or the waist-to-hip

the ratio of subscapular to triceps skinfold, circumference ratio is used as an index of fat

fat

distribution,

is a clear

effect

abdominal

in obese

women in part because of the increased estradiol production rates ofthe latter. The relative predominance of beta- 1 and alpha-2 adrenergic receptors also influences the balance between lipolysis and fat synthesis.

tors in the gluteal region, which is the area of increased fat deposition in the typical gynoid or female fat pattern. Conversely, men with abdominal fat tend to have an increased number of alpha-2 adrenergic inhibitory receptors in abdominal adipose tissue. More information is needed about genetic and ethnic differences in regional fat distribution and age and gender should be systematically accounted for in these studies. Studies on the hormonal and molecular mechanisms controlling fat-cell number and fat-cell size and size distribution in various depots are clearly needed. In particular, the contribution of fat-cell number and size to the progressive enlargement of the truneal or abdominal fat deposits and the visceral fat stored should be defined. One important question is the relative importance of changes in the size offat cells vs an increase in their number in the enlargement oftruncal-abdominal fat or visceral fat stores. If fat-cell number is involved to a significant extent, are there growth

in the

energy

AL

recep-

tive

risk

there

or upper-body ofdeath

for vascular

and

robust

fat with diseases

association

overall reaches

of increased

mortality. ‘-2,

The a risk

relaequiv-

alent to that reported for hypercholesterolemia, hypertension, or smoking. The risk is also progressive with increasing upperbody fat. Four of the six studies only included men, one only included to women, and one included both sexes. More data are needed on the relationship of gender to the regional fat dis-

Downloaded from https://academic.oup.com/ajcn/article-abstract/52/5/946/4651156 by McMaster University user on 04 February 2019

amount visceral fat. About 25% ofthe variance in percent body fat is accounted for by genetic factors after adjustment for age and gender differences. Adjusting for total body fat produces a comparable genetic effect for truncal or abdominal fat. As yet no data exist on the heritability of the amount of visceral fat. During responses to overfeeding and negative energy balance caused by exercise, there are large individual differences in the changes in weight or fat mass and on the extent to which fat is

ET

REGIONAL

TABLE

1

Overview and

metabolic

each

alterations

ofthe

regional

associated

independent

fat distribution Percent

Variable

total fat

body

ly with

Truncal-abdominab subcutaneous

Visceral fat

fat

In obese

dium

components4

sympathetic

that

the overall

disease

observed

terpretations

++ ++

+

+

++

den

individuals

+

++

++

++

+

U

had

a much

+

+

++

+

+

++

scapular,

+

++

++

Heart

+

+

+

+

++

++

central fat distribution ever, when the effects

+

+

++

+

indicate All

the

studies

nantly

variation

positive

or negative

associa-

European

gender

men

fat distribution from

and

exist

descent

except

may

cardiovascular

women.

However,

for some

confounding

are

in

suggesting

in regional

investigation

currently

differences

of this

in Caucasians

for the Honolulu

other

in-

factors

biceps

largely

may

disease

was

unclear

whether

but

assessed

adiposity is known

disease

and

breast

cancer

patterns

on survival

once

the

Study.

of hyper-

in lipoprotein and insulin of some of these metabolic

metaboeffects

truncal

or abdomi-

nal fat, and visceral fat is presented in Table 1 . It appears that total body fat is the primary component associated with inplasma

creased

insulin

subcutaneous

and

total

increased lipoprotein

insulin resistance and (HDL) cholesterol.

enhances intolerance,

insulin and

portant

tribution thetic

resistance further

underlying

and nervous

hypothesis concentrations

even reduces

factor obesity system

is that and

triglycerides

truncal-abdominal

sympathetic that

further, HDL

both

in-

activity

may

fat dis-

be the sympaOne attractive

is modified are

fat

glucose One im-

ofregional

hypertension hyperinsulinemia. of these

with

in high-densityin visceral

exacerbates cholesterol.

in the relationship

with and

whereas

fat is associated a reduction An increase

in turn

in older

disease

cancer

socioeconomic

creased

NIDDM,

of

atheroscle-

studies varying adiposity esti-

and

fatter

women.

has

developed

should

be

known

to

be influenced by obesity. In four studies, the subjects with endometrial cancer had a higher BMI than did control noncancer

risk

fat, subcutaneous

It is also in the risk

of predomi-

Endometrial

lower

body

procedures.

the

investigated.

to be in the

in total

of

in which

covariate

as it is with

is higher

individuals

ofvariation

of

effect

More data are needed on this important interaction between the postmenopausal state and obesity, regional fat distribution, and the risk for breast cancer. The role of sex hormones in this phenomenon as well as the effects of differing fat distribution

studies

alterations summary

fat

An

as assessed by increased body mass index to be associated with the risk of developing

In Swedish

tension and with lism. A tentative

ofcentral

relationship. Heart

an increased

studies

breast cancer with a relative risk in prospective between 1 .5 and 2. The relationship of central mates

of

diabetes. Howconcentrations

latter.

no such

ultrasound

mortality,

with

are

Antonio

in the development

is an important

gallbladder hypertension.

San

Americans

the effect in the

be involved

through

insulin

the

ofdeveloping and insulin

analysis,

there

ratio In the Japanese increased sub-

in Mexican

eliminated

also

disease,

In

effect

on the risk of glucose

subjects.

associated

skinfolds.

was a clear

Studies in other ethnic groups as well as more studies on women are needed. The effects of age as a modifier of the risk from regional fat distribution needs to be explored. Longitudinal data on changes in adipose tissue distribution with age in both genders are urgently needed as are exploration of the biological and social correlates. Not only is central fat distribution associated with increased it is also

waist-to-hip-circumference

in multivariate was

developing rosis, and

disappeared

and

there

fat distribution

NE

in mortality

ofcontrol

for further

that

those

controlled

a higher

risk ofdeveloping diabetes. progressing to diabetes had

triceps

Study,

were

When the two prospective men and women con-

diseases

differences

need

with higher

Americans

+

+

in fat distribution,

lack

disturbances

++

on mortality. comparing

between

with

++

test.

and

be associated

+

+

the sex-related

then

and lipid metabowith a high level of

+

cardiovascular

explain

could

so-

concomi-

U U

gallbladder

for differences from

activity

enhance with

+

Total

mortality

may

system

+

(BMI)

trolled

tubule

+

+

its impact Gothenburg

activity

the renal

tant detrimental effects on blood pressure lism. A state ofinsulin resistance combined

distribution

t Oral glucose-tolerance

sympathetic

from

+

Positive or negative association; ++, stronger NE, no or marginal effect; U, effect unknown.

and from

subjects,

reabsorption

in plasma lipid transport. Truncal fat distribution plays an important role in the development ofnon-insulin-dependent diabetes mellitus (NIDDM). Three prospective trials documented this relationship. In Swe-

+,

tribution studies

949

by

fat involved

critical

with

Finally,

the

ofa

fat distribution,

aromatization

variety

disease

however,

did

not

risk of endometrial cancer in three of that it was the total quantity of body of steroids

ofthe fat distribution

regional

covariate

that

played

the

fat-distribution profile. appears to be an important

ofsocioeconomic

and

with

health-risk

factors.

truncal-abdominal

group,

to have

fat tend less education,

to have more sickness and absenteeism from work, to have a higher incidence of peptic ulcer that is more likely to bleed, to smoke

and

have

a higher

alcohol

intake,

to be

inactive,

and

to have shorter stature. This syndrome and its relationship to regional fat distribution requires more consideration. In contrast, lower-body obesity, or a gluteofemoral pattern of fat distribution (the gynoid type), appears to be relatively benign

in terms

it translates theless, and

mone

into

of impact obesity

contribute

increase

presentations: William

and

and

mortality,

in total

is associated

to important

F: interventions Research;

on morbidity

a significant

lower-body

could

Formal by

on regional

role independently

Session

insulin

affected

Studies

show an effect on the four studies, suggesting

is another

body

with

orthopedic

unless fat.

varicose

Noneveins

disorders.

implications

H Leon

Bradlow,

H Dietz,

New

Institute

England

for

Medical

HorCen-

Downloaded from https://academic.oup.com/ajcn/article-abstract/52/5/946/4651156 by McMaster University user on 04 February 2019

Systolic blood pressure Diastolic blood pressure Fasting plasma glucose Fastingplasmainsulin Glucose response to OGTTt Insulin response to OGTT Insulin secretion Hepatic extraction ofinsulin Hepatic glucose production Plasma triglycerides Plasma cholesterol Plasma HDL cholesterol HDL cholesterol/total cholesterol Plasma postheparin hepatic lipase Plasma postheparin lipoproteinlipase

4

DISTRIBUTION diet.

ofthe

obesity

tion;

FAT

950 ter;

BOUCHARD William

tute,

R Harlan,

NIH;

John

Schwartz,

National

H Himes,

Harborview

Heart,

Medical

Changes

in caloric very

tios.

A

reduction

change

in this

about little

Center;

ratio.

In overfeeding is larger

than

the

to affect

It has been

about

high

it appears

truncal

fat and

are associated ra-

a 0.00 1-0.003 tell us little

more

fat more

the results

that

even

were

lipid fat and/or

differences

though

slight,

readily

than

the

changes

fat

seen

fat.

exerin re-

improvement

metabolism is observed in subjects high visceral fat. Little is known

in this

regard.

by specific

drug

therapy.

such therapy would probably treatment with drugs.

It should

require

be recognized

long-term,

even

that

life-long,

Research

needs

and

visceral

longitudinal

considerable

achieved

lost.

in truncal

fat on the limbs

oftwo

Drug intervention was also discussed. It was recognized that although alterations of regional fat distribution induced by a safe drug treatment, particularly for the individuals in the highrisk category, would be desirable, considerable research was still needed before this could be available and applied to humans. The postulate was advanced that within specific subpopulations, biochemical or physiological interventions could be

importantly

fat is being

that the increase

in subcutaneous

from

studies

gender

activity

or subcutaneous

subcutaneous

gional fat distribution in plasma insulin and with

The

abdominal fat is deposited to a greater defat. Exercise, like diet-induced weight loss,

suggested

cise-training

in body

increase

Stern,

at San Antonio; Tremblay, Laval

is associated with these measurements

visceral

that subcutaneous gree than visceral seems

1 kg However,

studies

InstiRobert

in waist-to-hip-circumferences

changes

whether

Michael

Center Angelo

and physical

changes of

the absolute about

intake

small

Blood

AL

The briefly

main

research

summarized

methods, regional

technology, fat distribution

nisms

ofregional

specific

sites

any

of the

experimental nents.

needs

the workshop are 1) studies on and normative values; 2) relationship of to disease; 3) determinants and mecha-

under

identified

four

fat distribution; of fat distribution.

components

and statistical

during

major

and

headings:

4) intervention

It is essential

of obesity

controls

that

be undertaken

for the remaining

towards research with

on proper

compoB

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only

and

of Minnesota;

University of Texas Health Sciences Ann C Sullivan, Hoffman-LaRoche; University. with

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