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The age-related redistribution of adipose tissue within the body is perhaps more important than the total body fat gain. As shown in Fig. 2, the visceral/subcutaneous fat ratio at the abdominal level, as detected by computed tomography, increases with age in both normal-weight and overweight subjects [27]. Intra-abdominal fat (IAF) increases with age both quantitatively and proportionally more than peripheral fat mass [28-30], even in the absence of obesity. IAF gain apparently starts before the age of 20 years both in men and women, but the accumulation of IAF accelerates at the age of menopause in women [28-30]. DEXA in healthy subjects confirms that the ratio of upper- to lower-body fat increases linearly after 20 years of age in both genders [30]. Between the 20 and 70 years, it increases from 1.07 to 1.67 in men and from 0.81 to 1.21 in women [30]. Similarly, IAF area, measured at the L4 level by CT, increases linearly in obese subjects with advancing age, even without significant changes in

Fig. 2. Changes of the visceral/subcutaneous (V/S) fat ratio at the abdominal level by sex, age, and overweight, as detected by computed tomography

whole FM [29]. The cause of this centralisation of body fat is a combination of several age-related factors, such as changes in hormone levels and fatty-acid utilisation, less physical activity, and leptin resistance [31,32].

It is this increase in IAF that seems to cause insulin resistance, rather than aging per se [31,33]. Studies on patients with type II diabetes suggest that the metabolic link between increased IAF and insulin resistance is the greater availability and/or oxidation of free fatty acids [34-37]. Physical inactivity certainly enhances IAF accumulation and, more directly, insulin resistance [38, 39]. However, the significant independent effects of menopause and sarcopenia on insulin resistance remain to be established [31].

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