From the Guidelines
Central obesity is a significant risk factor for cardiovascular disease, particularly in women, and should be managed through a comprehensive approach including lifestyle modifications and potentially medication, as evidenced by the most recent study in 2025 1. The recommended approach for managing central obesity includes both lifestyle modifications and potentially medication.
- Start with a comprehensive lifestyle intervention including caloric restriction (500-750 kcal/day deficit), increased physical activity (150 minutes of moderate-intensity exercise weekly), and a Mediterranean or DASH diet pattern rich in vegetables, fruits, whole grains, and lean proteins.
- For medication options, consider metformin 500mg daily initially, increasing to 1000mg twice daily as tolerated, which can improve insulin sensitivity, as supported by previous studies 1.
- GLP-1 receptor agonists like semaglutide (starting at 0.25mg weekly, gradually increasing to 2.4mg weekly) have shown significant efficacy for visceral fat reduction.
- For patients with comorbid conditions, medications should be tailored accordingly - SGLT2 inhibitors for those with diabetes or heart failure, and ACE inhibitors or ARBs for those with hypertension. Central obesity increases cardiometabolic risk through mechanisms including increased inflammatory cytokines, free fatty acid release, and altered adipokine production from visceral fat, which directly impacts insulin sensitivity and cardiovascular health, as highlighted in the study 1. Regular monitoring of waist circumference (target <40 inches for men, <35 inches for women) is essential to track progress, as suggested by the American Heart Association 1.
- The assessment of central distribution of fat is reasonable in patients by measuring waist and hip circumference and calculating waist-to-hip ratio, even if the BMI is within normal limits.
- Bariatric surgery may be considered for patients with a BMI >35 kg/m2 if lifestyle interventions have already been attempted without meaningful weight loss.
From the Research
Central Obesity Hypothesis
- Central obesity is associated with chronic low-grade inflammation and is a risk factor for cardiometabolic syndrome 2
- The Mediterranean diet pattern has a convincing evidence-base for improving cardiometabolic health, and may be effective in reducing central obesity 2
Lifestyle Modifications for Central Obesity
- Comprehensive lifestyle modification programs, including diet, physical activity, and behavior therapy, can induce significant weight loss and improve cardiovascular risk factors 3, 4, 5
- A moderately reduced-calorie diet, increased physical activity, and the use of behavior strategies can facilitate adherence to lifestyle modifications and achieve modest weight loss of 5% to 10% 4
- High levels of physical activity, continued patient-practitioner contact, and the long-term use of pharmacotherapy combined with lifestyle modification are associated with long-term weight control 3
Dietary Interventions for Central Obesity
- The Mediterranean diet has been shown to reduce central obesity in 13 out of 18 studies, with a significant reduction in waist circumference, waist-hip ratio, and visceral fat 2
- Energy restriction is often employed in Mediterranean diet interventions, but the diet may have a favorable effect on central obesity even without energy restriction 2
- Low carbohydrate diets are not significantly better than low fat diets for weight loss, and the most effective dietary approach may be a comprehensive lifestyle modification program 6
Treatment Options for Central Obesity
- Current treatments, including lifestyle, diet, and exercise, produce a weight loss of 5% to 7% on average 6
- Medications approved by the US Food and Drug Administration for long-term management of obesity can add about 5% to lifestyle approaches to weight loss, but may not be as effective as surgery 6
- A continuous treatment model across the lifespan may be necessary for the management of obesity, given its chronic nature 6