ALL BELLIES ARE NOT THE SAME
At a community forum on altered fat syndromes a patient commented, "Lipodystrophy sucks!" With his obvious belly, it appeared he was talking from firsthand experience. "But wait," I said. "Not all bellies are the same. Let's check it out." I made my way to him, and we did a quick, belly-focused physical examination. Squeezing around his belly button, I found I could grab a roll of fat that seemed to account for most of the addition to his midriff. "At first glance," I told him, "I would say that you might not be of a victim of abnormal fat accumulation and need to make an appointment to talk about your diet and exercise."

You can certainly tell if you are losing fat under your skin, especially in the face or legs. You can also tell if a fat pad appears on your upper back-usually near your neck. But it appears there is little consensus on what defines abnormal fat accumulation in the abdominal area. Studies have sought to quantify the incidence of these physical changes that can occur in people who are surviving with chronic disease and are perpetually on medications, but with complicating factors such as insulin resistance or diabetes, the studies do not always seem to be talking about the same thing. Bellies come in two main varieties: the ones you can pinch (caused by subcutaneous fat) and the ones you cannot (caused by visceral fat or fluid accumulation). It makes sense that we should not guess about whether a condition exists when we have the means to test for it.

Three studies presented this year at the 13th International Conference on AIDS attempted to define alterations in belly fat with currently standardized methods. One study of 73 men and women showed that measuring the waist and comparing it to a hip measure (waist-to-hip ratio) did not identify patients with altered fat deposits as opposed to those with normal subcutaneous fat accumulation. Computed tomography scans, however, could be used to differentiate the two types of belly fat.

In another study magnetic resonance imaging was compared to other measures in 48 patients and seven controls. This group reported that multiple waist measures that show an increase best predicted internally deposited belly fat and that changes in abdominal fat folds (accomplished with caliper pinches) predicted normal subcutaneous belly fat gain. From this data we can start to investigate the use of some simple body measures (anthropometry) to identify and define belly types.

The next step is to see which measures help us to find the problem we are looking for. Standard body measures were used in a study of 56 men and women in England to differentiate between normal and abnormal fat gain and loss. Unfortunately, there were no measures around the belly! The authors' conclusions suggested a need for "alternate standardized clinical anthropometric approaches" to provide a means of "simple monitoring of prevalence, severity, and progression" of changes in fat deposits. It is apparent that we will need to standardize some belly-specific measures.

While the researchers argue out the definition, you can do something a little more definitive to identify and quantify the type of belly growth you may experience. If your midriff has grown and you cannot account for most of that by grabbing a large roll of fat between your fingers, you may have had abnormal changes in fat. You will need to make sure your health care team does not miss this problem and can differentiate between normal and abnormal belly gain. Also, if the belly gain is not just fat directly under the skin, you should talk with your doctor about making sure that the protrusion is from fat and not from fluid (abdominal fluid accumulation, known as ascites, may be present in severe liver or kidney disease).

Once you identify the nature of your belly growth, you can better decide if it is a diet and exercise problem or if you have altered metabolic processes in need of addressing.

Fields-Gardner is the director of services for The Cutting Edge, an HIV nutrition company in the Chicago area. She is a member of the International AIDS Society and the American Dietetic Association's Dietetic Practice Group on HIV and AIDS. She has written a book on HIV medications and a clinicians' guide to nutritional management of HIV.