The Evolution of Abdominal Visceral Obesity Assessment: What is New?

Written by: Andri Dauni, Dr. Noraidaitulakma Abdullah @ Muda
Date published: 12 April 2020


       The prevalence of overweight and obesity had increased substantially over the past decade in many countries including Malaysia and projected to increase 57.8 % (3.3 billion people) in 2030. Many epidemiologic studies indicate that overweight and obesity are important risk factors for premature death, diabetes, heart disease and cancer. They are globally known as public health burden and became clinically important because of their costs and effects [16,21,32,37,45,47]. In 2002, Malaysia become Asia’s fattest country with the highest prevalence of overweight and obesity in the Asian Region and approximately half of the population were overweight or obese [14,30]. The Malaysian Cohort project also indicated the increase of the prevalence of obesity in parallel with NHMS 2015 report (increased from 14% to 17.7% from 2006 to 2015) [18,28,29,30].

      Obesity is defined as abnormal body fat due to energy imbalance between calories consumed and calories expended which can cause negative impact on health.  This is as a result of unhealthy lifestyle such as over intake of high calorie foods that contain much of fat and lack of physical activity due to mass change in work form condition, transportation modes and drastically uncontrolled urbanization [3,31,46,48]. Classification of human body fat tissue can be divided into two unique compartments with different metabolic characteristic called subcutaneous adipose tissue (or subcutaneous fat) and visceral adipose tissue (or visceral fat). Excess of visceral fat also known as Abdominal Visceral Obesity. Researchers had put more interest in visceral fat because of its association with various medical problems [10,39]. Compared to subcutaneous fat which stored just under our skin, visceral fat was stored within the abdominal cavity which blanketed many vital internal organs such as intestines, liver and pancreas (Figure 1A). With this location and through various studies, researchers found out that excess of visceral fat was highly correlated with metabolic risk factors [3]. Study in the past also proved that abnormal visceral fat was highly associated with hypertension, hypercholesterolemia, diabetes, obesity, cardiovascular disease, cancer, stroke, prostate enlargement and depression [13,14,19,20,24,27,33,41]. Visceral fat was considered as the predominant risk factor for metabolic syndrome [44]. Visceral fat can be eliminated by performing certain level of physical activity [50].

      The classical procedure in measuring this visceral fat is by using body mass index (BMI), Waist Circumference (WC) and Waist Hip Ratio (WHR). Body Mass Index (BMI) is a person’s weight in kilograms divided by the square of height in meters (kg/m2) [3,31,46]. This methodology is still continuing to be used until today because of simplicity, cost effective, none invasive procedure, no radiation involves and can be used for large population [2,4]. However, these  methodology limited on fat distribution information and unable to distinguish between subcutaneous fat and visceral fat masses [6,16,26,38]. Meanwhile, Computed Tomography (CT) scan, Magnetic Resonance Imaging (MRI) and Dual Energy X-ray Absorptiometry (DEXA) have been used widely as a goal standard to measure visceral fat but are not suitable for large population because of cost and simplicity factors [9,19,43]. In 2005, a new simple method using Bioelectrical Impedance Analysis (BIA) had been developed to measure visceral fat [43]. With an advancing in technology, a machine based on BIA called InBody have been used to measure visceral fat area. This newly method had been considered as a more convenient substitute method for measuring the visceral fat than CT scan [34,36]. It is safe, non-invasive, cost effective, fast and simple operation, suitable for large population and has high validity and reliability. InBody 720 is a type of InBody analyzer that has been used widely in research for body composition [23].

Figure 1. (A) Two different type of human body fat tissues – visceral fat and subcuteneous fat; (B) The Malaysian Cohort project participant performing the body composition analysis using the InBody 720 analyzer; (C) Result output from InBody 720 analyzer shows the measured visceral fat area.


      In Malaysia, only certain studies specifically focus on the measurement of visceral fat and its correlation to health problem. Instead, most of the previous studies paid attention more towards obesity and abdominal obesity (using waist circumference or waist hip ratio) in correlation to metabolic syndrome and disease [13,30]. Hence, the Malaysian Cohort Project had taken the early intiative to apply InBody 720 analyzer (Biospace Co. Ltd., Seoul, Republic of Korea) in research specifically to determine the body composition of the cohort participant including visceral fat area (Figure 1B & Figure 1C) [18]. It is always important to study visceral fat. First and foremost, as mentioned previously, excessive visceral fat is strongly associated with metabolic risk factors [9,10,35]. Local study conducted in a rural village in Tawang, Bachok reported that visceral fat showed significant association to blood pressure [14]. Early finding in 2002 reported that  Asian have higher visceral fat distribution than Caucasian although with lower BMI. Again, studies in 2007 and 2011 also found the similar finding which indicated South Asians have higher amounts of body fat despite having similar or lower BMI [8,22,25]. Among Asian, Indian has higher visceral fat compared to Malay and Chinese [7,22]. Recent study also showed that even individual with normal BMI can suffer from metabolic complications commonly found in obese people [40,42]. Further study can be implemented to elucidate this phenomenal.

      Initially, the clasification of visceral fat area determined by this InBody 720 analyzer used in The Malaysian Cohort project followed the cut off point developed by Japan in 2005. It stated that the high visceral fat area (VFA) or ≥ 100 cm2 showed a higher prevalence of metabolic disorders than normal visceral fat area (VFA) or < 100 cm2 [43]. However, The Malaysian Cohort project will be creating a new cut off point for this clasiffication because it is unapplicable to Malaysian population in correlation to metabolic syandrome. The new cut off point will be developed by using ROC curve analysis and metabolic syandrome will be based on the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP-III) (Jama 2001). Different country have created their own cut off point. Table 1 shows the prevalence of abnormal visceral fat area and cut off point in different countries. One international body composition journal predicted that visceral fat will be increasing over 200% in men and 400% in women between the 3rd and 7th decades [17]. 

Table 1. Visceral fat area (VFA) in general population


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