For decades, we’ve been taught to think about weight as a number.
Step on the scale. Calculate your BMI. Compare it with a chart.
And if the number falls within the “normal” range, we assume everything is fine.
But two people can have the exact same BMI and very different metabolic health.
They can have different amounts of muscle. Different amounts of body fat. And importantly, they can store that fat in very different places.
That’s why when I talk with patients about weight—especially in midlife—I’m interested in much more than the number on the scale.
Where we carry fat matters, too.
And the fat we accumulate around our internal organs, known as visceral fat, deserves particular attention.
Not because we should be afraid of body fat.
But because understanding body composition gives us information that weight alone simply can’t provide.
Not All Body Fat Is the Same
We all need body fat.
It stores energy, helps regulate hormones, cushions organs, and performs many other essential functions.
But fat isn’t stored uniformly throughout the body.
Subcutaneous fat is the fat located beneath the skin. It’s the fat you can typically pinch around your abdomen, thighs, hips, or arms.
Visceral fat sits deeper inside the abdominal cavity, surrounding organs such as the liver and intestines.
That distinction matters because visceral fat behaves differently metabolically.
Higher amounts of visceral fat have been associated with insulin resistance, type 2 diabetes, cardiovascular disease, abnormal lipid levels, and other cardiometabolic concerns.
So when we’re evaluating someone’s metabolic health, knowing their total weight only tells us part of the story.
You Can Have a “Normal” BMI and Still Carry Metabolic Risk
This is one of the limitations of BMI.
BMI is calculated using height and weight.
That’s it.
It doesn’t know how much muscle you have.
It doesn’t know your body fat percentage.
And it doesn’t know where you’re storing that fat.
Someone with significant muscle mass may have a higher BMI despite having relatively low body fat. Someone else may fall comfortably within a “normal” BMI range while having lower muscle mass and proportionally more body fat, including visceral fat.
That’s why I don’t think BMI should be treated as a complete assessment of someone’s health.
It can be useful information.
It just isn’t the whole picture.
A “normal” weight doesn’t automatically mean optimal metabolic health. And a higher weight doesn’t tell me everything I need to know about someone’s health either.
Context matters.
Midlife Can Change Where Women Store Fat
This becomes particularly relevant for women during perimenopause and menopause.
I hear some version of this frequently:
“My weight hasn’t changed that much, but my body has.”
Or:
“I’ve never carried weight around my middle before.”
There’s physiology behind that observation.
As women move through the menopausal transition, hormonal changes can contribute to shifts in body composition and fat distribution. Fat may increasingly accumulate around the abdomen rather than the hips and thighs.
At the same time, we’re getting older.
Muscle can decline with age. Activity may change. Sleep can become more difficult. Stress may increase. Insulin sensitivity and other aspects of metabolic health can shift.
This is why I try not to blame every midlife change on hormones.
Menopause matters.
But it exists within a much bigger picture that includes aging, genetics, nutrition, movement, sleep, stress, medications, medical conditions, and lifestyle.
The useful question isn’t simply, “Is this menopause?”
It’s:
What is happening in your body, and what can we actually do about it?
Visceral Fat Is Metabolically Active
One reason visceral fat gets so much attention is that it isn’t simply passive energy storage.
Visceral adipose tissue is metabolically active and is associated with inflammatory and hormonal signaling that can influence the rest of the body.
Higher visceral adiposity is closely connected with insulin resistance.
Normally, insulin helps move glucose from the bloodstream into cells where it can be used or stored. When tissues become less responsive to insulin, the body has to work harder to maintain normal blood sugar.
And importantly, this process can begin before someone meets the diagnostic criteria for diabetes.
That’s part of why I’m interested in looking at patterns earlier.
What is happening with blood glucose?
Triglycerides?
HDL and LDL cholesterol?
Blood pressure?
Waist circumference?
Body composition and visceral fat on DEXA?
Muscle mass?
Family history?
Sleep?
Activity?
One isolated measurement rarely gives us the entire answer.
Together, they can tell a much more useful story.
The Scale May Not Show You What’s Changing
This is another reason I like body composition data.
Imagine a woman whose weight has stayed relatively stable for five years.
The scale suggests nothing has changed.
But during those five years, she has gradually lost muscle and gained fat.
Her weight is identical.
Her body composition isn’t.
That’s a very different health picture.
The opposite can happen, too.
Someone begins resistance training, improves her nutrition, gains muscle, and loses fat. Her weight barely moves.
If the scale were our only measure of success, we might conclude that nothing is working.
Meanwhile, her body may be moving in exactly the direction we want.
Weight is data. It isn’t the verdict.
This Is Where Body Composition Can Be Helpful
At Nova Wellness, we use DEXA as our gold-standard body composition assessment. It gives us a detailed look at body fat distribution, including visceral fat, as well as lean mass and bone density.
We also use InBody analysis to track changes between DEXA scans. It gives us a convenient way to follow trends in skeletal muscle mass and body fat over time without repeating a DEXA every few months.
And you don’t necessarily need sophisticated testing to start paying attention to abdominal fat.
At home, a simple tape measure can provide useful information. Waist circumference isn’t the same as directly measuring visceral fat, but it’s an accessible way to track central adiposity and changes over time.
I find all three particularly useful when we’re working on medical weight management because they answer different questions.
If someone loses weight, I want to know more than how many pounds disappeared.
What happened to muscle?
What happened to fat?
What happened to visceral fat?
Is the overall body composition moving in a healthier direction?
Because the goal isn’t simply to become smaller.
It’s to improve health while preserving the tissue we’re going to need as we age.
So, How Do We Reduce Visceral Fat?
This is where the conversation becomes refreshingly unglamorous.
There isn’t one supplement, food, exercise, or “belly fat” strategy that selectively melts visceral fat.
And you can’t spot-reduce fat by doing hundreds of abdominal exercises.
What does matter is improving the larger metabolic environment.
That means returning to some of the same fundamentals that show up again and again in preventive and longevity medicine.
Move More—and Exercise Intentionally
Physical activity matters.
Walking is an excellent place to start, particularly for someone who has been sedentary.
But I also want patients to think beyond simply getting their steps.
Cardiovascular exercise helps improve fitness and metabolic health. Depending on the individual, incorporating periods of greater intensity may also be appropriate.
And then there’s resistance training.
I consider that essential for many adults in midlife.
Why?
Because we’re not simply trying to lose fat.
We’re trying to preserve or build muscle while we do it.
Muscle plays an important role in glucose metabolism, physical function, bone health, and long-term independence.
If your weight-loss strategy reduces fat but also significantly reduces muscle, I’m not satisfied simply because the scale went down.
Protein and Food Quality Matter
Nutrition doesn’t need to become an exercise in perfection.
But it does need to support the goal.
Adequate protein becomes particularly important when we’re trying to preserve muscle, especially during weight loss and as we get older.
I also care about the overall quality of someone’s diet: fiber, plants, minimally processed foods, appropriate portions, and an eating pattern that supports metabolic health without becoming unnecessarily restrictive.
There isn’t one perfect diet for everyone.
Some patients need to think more carefully about glucose regulation. Others need help getting enough protein. Some need a strategy they can realistically maintain while traveling, working, parenting, or navigating menopause.
That’s why individualized nutrition matters more to me than following whichever diet happens to be trending.
Don’t Ignore Sleep
Sleep is one of the most underestimated pieces of metabolic health.
Poor sleep can influence appetite, food choices, insulin sensitivity, energy, recovery, and our ability to exercise consistently.
And in midlife women, sleep problems can have multiple causes.
Hot flashes and night sweats.
Stress.
Alcohol.
Sleep apnea.
Anxiety.
Changes in schedule.
Other medical issues.
Telling someone to “sleep more” isn’t enough if we haven’t figured out why she isn’t sleeping.
Sometimes improving metabolic health means looking well beyond food and exercise.
Medical Weight Management Should Be About Health
This is why I think the conversation around medical weight management needs to change.
Weight is relevant.
But weight loss itself isn’t the endpoint.
I’m interested in improving the factors that influence long-term health.
Can we reduce excess body fat while protecting muscle?
Can we improve metabolic health?
Can we increase strength and cardiovascular fitness?
Can we improve nutrition without creating a relationship with food that is impossible to sustain?
Can we address sleep, menopause, and other factors that may be making progress harder?
Can we create a plan that someone can realistically continue?
That’s a much more meaningful definition of success than reaching an arbitrary number on the scale.
Sometimes the Right Plan Requires Looking Deeper
If someone is struggling with increasing abdominal fat or changing metabolic markers, the answer isn’t always “eat less and exercise more.”
Sometimes we need to understand what’s happening more comprehensively.
That might mean looking at family history, medications, menopause status, sleep, nutrition, exercise, body composition, and appropriate metabolic or cardiovascular markers.
Not everyone needs every test.
I’ve said this before, and I’ll keep saying it: more data isn’t automatically better medicine.
Testing is useful when it helps us answer a clinical question or changes what we do.
The goal isn’t to find something wrong.
It’s to understand the individual well enough to create a better plan.
Stop Letting the Scale Tell the Whole Story
I understand why the scale has become such a powerful measure.
It’s easy.
It’s inexpensive.
And it gives us a number we can track.
But easy to measure doesn’t mean most important.
If you’re in midlife and your body is changing, I want you thinking beyond pounds.
Think about your muscle.
Your waist.
Your strength.
Your cardiovascular fitness.
Your blood pressure.
Your metabolic health.
Your sleep.
Your nutrition.
And yes, when appropriate, your body composition.
Because the goal isn’t to occupy less space.
The goal is to build a body that is metabolically healthier, physically stronger, and capable of carrying you through the decades ahead.