You’re not in your 20s or 30s anymore and you know regular health checks are important. So you go to your GP. During the appointment they measure your waist. They might also check your weight. Looking concerned, they recommend some lifestyle changes.

GPs and health professionals commonly measure waist circumference as a vital sign for health. This is a better indicator than body mass index (BMI) of the amount of intra-abdominal fat. This is the really risky fat around and within the organs that can drive heart disease and metabolic disorders such as type 2 diabetes.

Men are at greatly increased risk of health issues if their waist circumference is greater than 102 centimetres. Women are considered to be at greater risk with a waist circumference of 88 centimetres or more. More than two-thirds of Australian adults have waist measurements that put them at an increased risk of disease. An even better indicator is waist circumference divided by height or waist-to-height ratio.

But we know people (especially women) have a propensity to gain weight around their middle during midlife, which can be very hard to control. Are they doomed to ill health? It turns out that, although such measurements are important, they are not the whole story when it comes to your risk of disease and death.

How much is too much?

Having a waist circumference to height ratio larger than 0.5 is associated with greater risk of chronic disease as well as premature death and this applies in adults of any age. A healthy waist-to-height ratio is between 0.4 to 0.49. A ratio of 0.6 or more places a person at the highest risk of disease.

Some experts recommend waist circumference be routinely measured in patients during health appointments. This can kick off a discussion about their risk of chronic diseases and how they might address this.

Excessive body fat and the associated health problems manifest more strongly during midlife. A range of social, personal and physiological factors come together to make it more difficult to control waist circumference as we age. Metabolism tends to slow down mainly due to decreasing muscle mass because people do less vigorous physical activity, in particular resistance exercise.

For women, hormone levels begin changing in mid-life and this also stimulates increased fat levels particularly around the abdomen. At the same time, this life phase (often involving job responsibilities, parenting and caring for ageing parents) is when elevated stress can lead to increased cortisol which causes fat gain in the abdominal region.

Midlife can also bring poorer sleep patterns. These contribute to fat gain with disruption to the hormones that control appetite.

Finally, your family history and genetics can make you predisposed to gaining more abdominal fat.

Why the waist?

This intra-abdominal or visceral fat is much more metabolically active (it has a greater impact on body organs and systems) than the fat under the skin (subcutaneous fat).

Visceral fat surrounds and infiltrates major organs such as the liver, pancreas and intestines, releasing a variety of chemicals (hormones, inflammatory signals, and fatty acids). These affect inflammation, lipid metabolism, cholesterol levels and insulin resistance, contributing to the development of chronic illnesses.

The issue is particularly evident during menopause. In addition to the direct effects of hormone changes, declining levels of oestrogen change brain function, mood and motivation. These psychological alterations can result in reduced physical activity and increased eating – often of comfort foods high in sugar and fat.

But these outcomes are not inevitable. Diet, exercise and managing mental health can limit visceral fat gains in mid-life. And importantly, the waist circumference (and ratio to height) is just one measure of human health. There are so many other aspects of body composition, exercise and diet. These can have much larger influence on a person’s health.

Muscle matters

The quantity and quality of skeletal muscle (attached to bones to produce movement) a person has makes a big difference to their heart, lung, metabolic, immune, neurological and mental health as well as their physical function.

On current evidence, it is equally or more important for health and longevity to have higher muscle mass and better cardiorespiratory (aerobic) fitness than waist circumference within the healthy range.

So, if a person does have an excessive waist circumference, but they are also sedentary and have less muscle mass and aerobic fitness, then the recommendation would be to focus on an appropriate exercise program. The fitness deficits should be addressed as priority rather than worry about fat loss.

Conversely, a person with low visceral fat levels is not necessarily fit and healthy and may have quite poor aerobic fitness, muscle mass, and strength. The research evidence is that these vital signs of health – how strong a person is, the quality of their diet and how well their heart, circulation and lungs are working – are more predictive of risk of disease and death than how thin or fat a person is.

For example, a 2017 Dutch study followed overweight and obese people for 15 years and found people who were very physically active had no increased heart disease risk than “normal weight” participants.

Getting moving is important advice

Physical activity has many benefits. Exercise can counter a lot of the negative behavioural and physiological changes that are occurring during midlife including for people going through menopause.

And regular exercise reduces the tendency to use food and drink to help manage what can be a quite difficult time in life.

Measuring your waist circumference and monitoring your weight remains important. If the measures exceed the values listed above, then it is certainly a good idea to make some changes. Exercise is effective for fat loss and in particular decreasing visceral fat with greater effectiveness when combined with dietary restriction of energy intake. Importantly, any fat loss program – whether through drugs, diet or surgery – is also a muscle loss program unless resistance exercise is part of the program. Talking about your overall health with a doctor is a great place to start.

Accredited exercise physiologists and accredited practising dietitians are the most appropriate allied health professionals to assess your physical structure, fitness and diet and work with you to get a plan in place to improve your health, fitness and reduce your current and future health risks.

Rob Newton, Professor of Exercise Medicine, Edith Cowan University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

One of the most common feelings associated with persisting pain is fatigue and this fatigue can become overwhelming. People with chronic pain can report being drained of energy and motivation to engage with others or the world around them.

In fact, a study from the United Kingdom on people with long-term health conditions found pain and fatigue are the two biggest barriers to an active and meaningful life.

But why is long-term pain so exhausting? One clue is the nature of pain and its powerful effect on our thoughts and behaviours.

Short-term pain can protect you

Modern ways of thinking about pain emphasise its protective effect – the way it grabs your attention and compels you to change your behaviour to keep a body part safe.

Try this. Slowly pinch your skin. As you increase the pressure, you’ll notice the feeling changes until, at some point, it becomes painful. It is the pain that stops you squeezing harder, right? In this way, pain protects us.

When we are injured, tissue damage or inflammation makes our pain system become more sensitive. This pain stops us from mechanically loading the damaged tissue while it heals. For instance, the pain of a broken leg or a cut under our foot means we avoid walking on it.

The concept that “pain protects us and promotes healing” is one of the most important things people who were in chronic pain tell us they learned that helped them recover.

But long-term pain can overprotect you

In the short term, pain does a terrific job of protecting us and the longer our pain system is active, the more protective it becomes.

But persistent pain can overprotect us and prevent recovery. People in pain have called this “pain system hypersensitivity”. Think of this as your pain system being on red alert. And this is where exhaustion comes in.

When pain becomes a daily experience, triggered or amplified by a widening range of activities, contexts and cues, it becomes a constant drain on one’s resources. Going about life with pain requires substantial and constant effort, and this makes us fatigued.

About 80% of us are lucky enough to not know what it is like to have pain, day in day out, for months or years. But take a moment to imagine what it would be like.

Imagine having to concentrate hard, to muster energy and use distraction techniques, just to go about your everyday tasks, let alone to complete work, caring or other duties.

Whenever you are in pain, you are faced with a choice of whether, and how, to act on it. Constantly making this choice requires thought, effort and strategy.

Mentioning your pain, or explaining its impact on each moment, task or activity, is also tiring and difficult to get across when no-one else can see or feel your pain. For those who do listen, it can become tedious, draining or worrying.

No wonder pain is exhausting

In chronic pain, it’s not just the pain system on red alert. Increased inflammation throughout the body (the immune system on red alert), disrupted output of the hormone cortisol (the endocrine system on red alert), and stiff and guarded movements (the motor system on red alert) also go hand in hand with chronic pain.

Each of these adds to fatigue and exhaustion. So learning how to manage and resolve chronic pain often includes learning how to best manage the over-activation of these systems.

Loss of sleep is also a factor in both fatigue and pain. Pain causes disruptions to sleep, and loss of sleep contributes to pain.

In other words, chronic pain is seldom “just” pain. No wonder being in long-term pain can become all-consuming and exhausting.

What actually works?

People with chronic pain are stigmatised, dismissed and misunderstood, which can lead to them not getting the care they need. Ongoing pain may prevent people working, limit their socialising and impact their relationships. This can lead to a descending spiral of social, personal and economic disadvantage.

So we need better access to evidence-based care, with high-quality education for people with chronic pain.

There is good news here though. Modern care for chronic pain, which is grounded in first gaining a modern understanding of the underlying biology of chronic pain, helps.

The key seems to be recognising, and accepting, that a hypersensitive pain system is a key player in chronic pain. This makes a quick fix highly unlikely but a program of gradual change – perhaps over months or even years – promising.

Understanding how pain works, how persisting pain becomes overprotective, how our brains and bodies adapt to training, and then learning new skills and strategies to gradually retrain both brain and body, offers scientifically based hope; there’s strong supportive evidence from clinical trials.

Every bit of support helps

The best treatments we have for chronic pain take effort, patience, persistence, courage and often a good coach. All that is a pretty overwhelming proposition for someone already exhausted.

So, if you are in the 80% of the population without chronic pain, spare a thought for what’s required and support your colleague, friend, partner, child or parent as they take on the journey.

More information about chronic pain is available from Pain Revolution.

Michael Henry, Physiotherapist and PhD candidate, Body in Mind Research Group, University of South Australia and Lorimer Moseley, Professor of Clinical Neurosciences and Foundation Chair in Physiotherapy, University of South Australia

This article is republished from The Conversation under a Creative Commons license. Read the original article.