The pill, your periods, and sugar

Dear Doctor Ninja,

You know how there are sugar pills in contraceptive pills? Recently, I learned that it’s not necessarily unhealthy to have skipped periods. Does it mean I can skip the sugar pills and continue to take the non-sugar pills to stop periods altogether? My husband and I are not planning on children and I’ve always felt that having periods are kind of a pain.

What is the story?


Confused 40 Something

The history of the birth control pill is amazing. It’s not only a story about discovery, but also one of medicalization, society, religion, sex and marketing. Whole books have been written about all of this. But you’re not here to read a book; just some quick advice from a ninja in pyjamas.

The typical set of birth control pills comes in a “monthly” set. 28 pills. Twenty-one of those pills have hormones in them—usually a combination of some form of estrogen and progesterone, which are the hormones that are responsible for signaling ovulation (release of an egg from an ovary) as well as for signaling thickening of the lining of the uterus (the organ also known as “the womb”). Twenty-one pills with hormones, but 28 in a pack. So what’s up with the 7 remaining pills?

These are the “sugar pills”; they’re pills that have no hormones in them, though probably not much sugar.

Why are they there?

In order for the birth control pill to prevent pregnancy, it has to be taken every day. The daily dose of estrogen prevents ovulation. The dose of progesterone thins the lining of the uterus, making it difficult for a fertilized egg to implant there.

However, two competing stories about menstruation figure into why these sugar pills are there at all:

1) that not having a period causes build up of “bad things” (dating back to some cultural beliefs about the “uncleanliness” of menstrual blood); and

2) periods are also a signal that one is indeed, not pregnant.

In the time of the introduction of the birth control pill, both of these stories figured prominently in both the minds of the inventors as well as the public. In order for the birth control pill to be accepted by the public, and thus for it to be successful at the goal of preventing unwanted pregnancies, periods still needed to happen.

Today, women have much more choice when it comes to controlling this aspect of their body. It is, however, a choice under constant threat of being taken away, both from a policy/interest group point of view as well as an accessibility point of view (with regards to costs, but also the intersection between cost and ideas about the “rightness” of birth control in general).

While there is some risk in taking the birth control pill (most famously, blood clots), there does not seem to be any evidence to suggest that not having a period puts you at any higher risk than that. The risk of having a blood clot ranges from 0.03 to 0.09 percent (3-9 in 10 000 people taking the pill). That you are already taking a birth control pill suggests that you are at least okay with the baseline risk that comes with this. Not having a period does not make this number higher.

There are longer term options available on the market; ranging from having a period just four times a year, to not having one at all.

In the end, deciding which option is best for you depends on how much you think of a period as being a sign that you aren’t pregnant, and also the associations you have with having a period and feeling like “things are okay”. For some, this association is very strong, and never having a period can cause distress even though they know the current facts about risk.

The “sugar pills” were never about what we know; they’re about how we feel.

How much B could B12 be, if B12 could be 12?

Dear Doctor Ninja,

I recently had my annual physical where I told my physician about my endless battle with canker sores. To figure out what was going on we did some basic blood work and found out that I have a deficiency in Vitamin B12.

I’ve been taking over the counter B12 supplements for about 6 weeks now, but my canker sores are still just as prevalent as before. My question is really a few questions. How long does it take for oral, over the counter supplements to kick in to fix this kind of issue? Would the B12 shots be a better option for this? And finally, do supplements really fix this kind of issue to begin with, or is it just a way to cover up some low blood test results?


Cankered Out

There is one trial examining how effective vitamin B12 is at reducing both how long canker sores last as well as how often people get them. This study showed a dramatic reduction in both how long sores lasted as well as the number of sores per month, with an average starting rate of 27.6 sores per month down to 3.9 sores per month. In this study, the participants took 1000mcg of vitamin B12 every day before going to bed.

There was another study looking at whether a multivitamin would do the same thing, and showed that it didn’t, but the dose of vitamin B12 was at the recommended daily allowance level, which is about 2.4mcg.

Since it seems the lowest dose of vitamin B12 commonly sold is 1000mcg though, getting the dose doesn’t seem to be a problem.

The positive study looked at sores every month. The first major drop in the number of sores per month happened at the 2-month mark, with another major drop at the 5-6 month mark.

Participants who were taking the placebo also noticed a drop in the number of sores per month, which was similar to the B12 group at the 3-4 month mark, but nowhere near the B12 group at the 5-6 month mark.

Whether or not a B12 shot would be “better” would depend entirely on whether a shot would keep your levels of B12 high enough between injections comparable to taking 1000mcg in a pill or tablet. But injections haven’t been studied specifically for canker sores.

One thing to note is that people who had underlying diseases that are associated with canker sores (Behcet disease, rheumatoid arthritis, and lupus, for example) were not studied; so if you fall into any of these categories, these results would not apply.

People who had an existing B12 deficiency were also not studied, so in your case, WHY you were B12 deficient becomes an important aspect of whether or not this research would apply specifically to you. If you were deficient for purely dietary reasons, then adjusting your diet to be not-deficient and then supplementing ON TOP of that, would put you more into the category of the studied participants. However, if you were/are deficient for other reasons (e.g. an absorption problem), then addressing that particular issue might be necessary.

But even if you don’t fit strictly into the category, the question for most people in your circumstance might look more like this:

“If I take 1000mcg of vitamin B12 every day, could it hurt me?”

And the answer to that question is almost certainly, “No,” from a physical point of view. Financially, vitamin B12 is quite cheap, but I don’t know how strapped you are for cash. And then there’s the “mental” cost of remembering to take it every night (which you could do by putting it next to your toothbrush, if you brush your teeth every night).

The costs of taking vitamin B12 every night for 6 months appear pretty low, for a potential dramatic fix.

If you’re looking to really give this a shot, you would want to make sure that you’re getting 1000mcg per day; and probably stick to it for 6 months before deciding it’s not working.

The other question you might ask yourself is:

“If this works, am I prepared to take vitamin B12 every night possibly indefinitely?”

And that’s an answer only you know, depending on how annoying your canker sores are and whether you’re willing to pay the price to control them (if the B12 solution works).

The good news is that you have an end date to decide whether or not to stop. If there’s no real change within 6 months, then your results would be outside what we would expect to see. I wouldn’t waste any more time or money at that point and definitely wouldn’t pile another thing on top of it to see if they “work together” which can be a common trap people fall into for fear that they’re missing a critical component in a mix of solutions. In this case, the timeline is pretty clear.

Reference: Volkov I, Rudoy I, Freud T et al. Effectiveness of Vitamin B12 in Treating Recurrent Aphthous Stomatitis: A Randomized, Double-Blind, Placebo-Controlled Trial, J Am Board Fam Med January 2009, 22 (1) 9–16; DOI:

If someone says a salt exists, and everyone hears it, should you drink it?

Dear Doctor Ninja,

I’ve been reading about the benefits of celery juice and they seem miraculous. But there seems to be a lot of conflicting information about it. Some experts say that there isn’t any science behind it, while people who have actually tried celery juice say they feel a lot better. Should I start drinking celery juice?


V. Egetated

Every few years, juice from a previously un-juiced plant makes it way into the world in a major way. This year, it’s celery. A decade ago, it was cranberry. A few years ago, it was green leafy vegetables like kale and spinach (i.e. “green juice”)—beverages that seem quite standard in non-specialty stores like convenience stores today.

These waves of trends seem to tap into a common theme: Nature provides, but inefficiently, or inadequately. Juicing a plant removes or reduces its solid components, allowing you to fit more liquid parts of the plant (and the things dissolved in that liquid part) into your body at once. You could eat an orange, but to get a glass of orange juice requires two to four oranges. If you’ve ever eaten four oranges in a row, that’s a lot of orange for most people. If your goal in eating oranges is to get vitamin C, there’s about 50mg of vitamin C in one orange. Since vitamin C is water-soluble, most of the vitamin C in one orange can be extracted by juicing. When you consider that vitamin C supplements tend to come in 500mg servings, that’s 10 oranges, or 2.5 glasses of orange juice, or 1 single vitamin C tablet.

Whether you drink the juice or eat the plant/fruit depends on what you’re trying to get out of it.

In the case of celery juice, the proposed reason to juice celery is to get “cluster salts” out of the celery, which are the “active ingredient” that supposedly causes all the good things to happen.

The problem is that no one knows if cluster salts, as they’re being described by proponents of celery juice, exist. Or, if they do exist, what they are. And if they can’t tell us what they actually are, then there’s no way to develop a method to detect them. If I have a friend who may or may not be real, but I can’t describe them to anyone, no one will be able to tell whether my story about this friend is real or not because there’s no way to recognize this friend.

The lingering questions then cascade from here: If cluster salts exist, and they are good and presumably detectable, how many milligrams of cluster salts are in a head of celery? How many would be required to have the effect you’re looking for?

So, should you drink celery juice? It depends on whether you can answer the question of why you think drinking it will be good for you in terms of nutrient value; and whether that nutrient and reason can be shown to exist outside someone else’s dreams.


Dear Doctor Ninja,

I’m a trainer in California and one of my new clients is a trans-woman who has completed her surgical affirmation. She is dieting and wants to continue losing weight without gaining muscle and wants to “tone”. I’m wondering if any of the exercises we might use could mess up her hormones somehow, and in particular her testosterone?


H. Ormonal

The process of affirming one’s gender happens in stages, but I think the short answer to your question is no, none of the exercises you might use would “mess up” hormones, regardless of what stage your client could be in. If your client is following the WPATH (World Professional Association for Transgender Health) process, then she would have had to been taking estrogen for at least a year before her surgeries, and depending on which surgeries she decided to have, may have had her testes removed, thereby essentially removing testosterone from the picture moving forward.

However, all of this is relatively moot.

From an aesthetic point of view, it sounds like your client would like to look thinner and leaner. “Tone”, as most trainers know, is achieved through having some muscle bulk, so that the “thin” doesn’t look “bony”, or starved; but also through body fat loss as well, so the fullness that covers the bony bits doesn’t look “soft”, which appears more fat-like to the eye.

It seems like you have the fat-loss part down. Your client is already losing weight and would like to continue. But you’re worried about how to build muscle mass without over-building it and somehow the trans- part of this client has your mind spinning in directions that you wouldn’t have if this client had been cis-gendered.

The arguments that some women have against progressive resistance training is that they will look too bulky. And perhaps, in some people, this could be an issue. But given the effort it takes for most cis-men (with typical male testosterone levels) to put on muscle mass, it’s unlikely that your client (even if they’ve retained their testes) is going to radically change her appearance within a period of time that you couldn’t adjust things in time. Even with the increases in testosterone that are seen with resistance training in cis-men, the time it takes to build enough muscle mass to make an aesthetic difference is high for most people.

Given that we know muscle mass is built by progressively increasing workload, and is lost by inactivity or decreasing workload, the solution is to respond to changes as they appear. There has to be enough muscle mass to hide things like ribs and sharp shoulder angles. So your client can’t just diet/train down to “thin” if she also wants “toned”. At some point, that muscle mass might start to look bulky. And regardless of what hormones are at play, the fix at that point would be to dial down the workload.

I suspect this is the approach that you would use for a cis-woman. You already have the tools to bring this client success. Don’t let the trans part get in your way here.

Fizz, fizz, plop, plop?

Dear Doctor Ninja,

I’m a 27 year old woman who is trying to lose weight. I switched from regular soda to diet soda, but I’m worried about some news that the sweetener in the diet soda will make my gut health worse. I like the flavor of soda and the fizziness, and the diet soda keeps from from drinking the regular stuff, but I also worry, since gut health seems to be so important.


G. Utrot

Personally, I think the jury is still out on what artificial sweeteners do to the bacteria in your gut in terms of whether the changes that seem to have been reported have any impact on you. And while there are some diseases and conditions that are directly caused by problems with gut flora, they’re not generally ones that can be fixed through diet alone.

The answer to your question lies more in the realm of what it takes to dislodge your dieting sanity. If diet soda is what makes the difference between sticking to your diet and achieving weight loss, and if weight loss is your major goal, then I say, take the theoretical hit (and I do think it’s theoretical) and lose that weight. If diet soda is something that’s just, “nice to have” and you can stick to your diet whether you have it or not; AND the theoretical risk bothers you that much, then consider something else that might be just as refreshing or fizzy that might be sweetener-free.

There’s also the idea that switching is the first step to “quitting”, if that’s also a major goal. Tastes are changeable. You can condition yourself out of a soda habit, just as much as you can condition yourself into one. The benefit of a diet soda is that it allows you to quit or reduce on your own terms without having to worry about the calories. Not everyone can go from full-sugar soda to plain water in one giant step.

The decision you made the day you switched from regular soda to diet isn’t carved in stone. You can choose to taper off diet soda in favor of other non-caloric drinks when it feels time and you can do it as fast or gradually as you want; if ever.

Birth and Bias

Dear Doctor Ninja,

I’m a first time mother and I’m learning about all the pain management techniques, medications, and birth interventions. I can’t help but dread the process of delivery considering what mainstream media and fear-mongering mommy groups portray. So many women are traumatized by their birth experience and I feel that health care standards are too low. (For example, if 80% of women have perineal tears, why has nothing been invented or researched to decrease this statistic? Compare this to when a small portion of men reported slight negative symptoms for potential male contraceptives, clinical trials were halted immediately.)

At the same time, I have unwillingly curated the narrative that the health care system is highly patriarchal and practices have been established by men/male doctors without considering the comfort and verbal symptoms relayed by women. Several studies have cited that when women present verbal feedback about signs and symptoms, they have been neglected or sent for psychiatry treatment instead of having physical treatments. Interventions such as Vacuum Extraction, Forceps, Episiotomy seem highly aggressive with increased harm to mother AND baby.

Where do / How have birth intervention practices come about? Who are some thought leaders in the specialization? Is my narrative untrue or distorted? What can be done individually or nationally, to push the standard for better health care for women?


Feminist First Time Mother

First of all, congratulations on the coming new chapter of your life!

What I see in your letter is the fear of not being heard, and the fear of your needs being ignored, misunderstood, and the fear of being mistreated outright in a situation where you feel you have very little control. Pain is the great disabler–it changes what we want; how we see the world, and others; and our priorities. So, confronted with a scenario in which pain seems to be an inevitable, and predictable part of the event, you are wise to look ahead into the future from a place where pain doesn’t yet have quite this power over you.

There’s nothing distorted by your narrative. Tears happen. Traumatization happens. As with all things, childbirth carries risks that are unique to every mother. And yes, there are studies that have shown that women can be taken less seriously when they talk about pain. And interventions are used when the judgement of the physician deem the risk to be high enough to the mother or baby to use them. There isn’t a frame of reference in which these events don’t exist; and we would be wise not to ignore them.

But, regardless of where birth intervention practices come from, and who the so-called thought-leaders in obstetrics are, and what can be done to push for better healthcare for women (all topics of great significance and interest), the singular reality is this: You are going to have a baby. You, specifically. This baby, specifically. And with the attendance (if you’re choosing to have a hospital birth), of a specific physician or group of physicians, as well as the entire healthcare team that will be part of the process. AND hopefully, whoever you’ve chosen as your “helper”. You might feel that standards of care in general are quite low, but it’s the standards and quality of the specific care you’re going to receive that matter in this scenario.

When it comes down to you and this event, reassurance and trust are paramount, regardless of who is present and making decisions. What can you do specifically to push for better health care for yourself? Book that appointment with your doctor. The one who you’re hopefully seeing for pre-natal visits. Make it clear that you need a chunk of time and that it’s not a quickie visit. Be prepared with your questions; but remember, that this visit (or series of visits) is about your fears and worries, and not about getting clinical information. Redirect your doctor if they seem to be talking about specific procedures in a general and abstract kind of way, as opposed to addressing how and why you feel the way you do. Because doctors are human too; they have their own fears and worries. Being “cold and clinical” can be a default kind of place when the conversation becomes uncomfortable.

Find out if the location  you’re planning on giving birth has tours. If they don’t, ask if you can have one. Bring your helper with you. Find out whether you’re in a practice that has group call for deliveries. It’s okay to meet those other doctors too, depending on how big the call group is (otherwise, it might be a lot of appointments!)

Part of what doctors are paid to do is to listen to you tell them your worries and fears. The other part is to be good at all of the other skills that are needed to provide care in the best interest of their patients. But sometimes they forget that this is your first birth and not your 1000th. And it’s okay to remind them of that too.

As for what can be done about raising the quality of healthcare for women in general:

  1. Take your own experience forward, including this one, and consider the spaces in which you see room for improvement

  2. Get involved locally with patient advocacy groups and develop your own sense of the story through hearing the stories of others, both positive and negative. It’s only through hearing and seeing others that the question of an untrue or distorted narrative can be answered. Global practice is shaped by the critical mass of local ones.

Lollipops and Island Dreams

Dear Doctor Ninja,

I’m planning to continue my studies with a Master’s degree.

I really like to keep up with the latest research and I would love to contribute to my field as a researcher. I’m having trouble deciding which degree to pursue, if I should strive for a MSc within my field, or one in Research Methods. What should I base my decision on?

Is a coin flip ok?

PS: I hope it is not a very specific question.


Fiddy Fiddy

I really wish you had been more specific. But I’ll give you the best answer I can.

You don’t mention whether the kind of Masters you’re looking to pursue is a course-based program or a thesis-based program. A course-based Masters in Research Methods is actually quite abstract, since you’re not really doing as much design work. It’s like going to art school and learning about all the _things_ you need to use to draw, or sculpt, but never actually drawing or sculpting. A thesis-based Masters is going to have more practical components, but you can’t study Research Methods in a vacuum—they need to be applied to a field of some kind. In a thesis-based non-Research-Methods program, you can still learn a lot about Research Methods, depending on who your supervisor is, and what kinds of courses you take. It’s not really an either/or decision.

A coin flip is either totally okay, or not okay at all. If the coin flip reflects your overall ambivalence to either pathway, I would want to encourage you to do some soul searching as to why you want to do a Masters in the first place. While it is only 2 years of your life (hopefully, if you finish on time; and completion time IS important), every graduate student experiences “the dark times” in their degree where the original reason for going in the first place is what gets them through. If however, you feel some sort of strong pull that feels equal in both pathways, and see yourself equally “happy” (is there really such a thing in graduate school?) in both scenarios where you have convictions that will get you through those times that you just have to grit your teeth and push through, then flipping a coin is as good as any way to make this decision.


This question also sounds like these are pathways you are simply contemplating at this time. Both options are just potential pathways, not real ones. If you have two offers in your hands, that’s a different story. If you haven’t applied to either programs, then you are making a decision between two equally unreal outcomes. It’s like deciding whether you’d like to have a bag of lollipops or a small tropical island. If you don’t have either of them at your disposal, then you’re just making a decision about which one sounds better to you today. If, however, there’s a bag of lollipops and a deed to a small tropical island in front of you and you are in some sort of odd game show where you have to choose one, then go for the one that has now become more attractive, or flip that coin.

In short, you don’t need to make this decision today, because one or (and hopefully this isn’t the case) both of these options might not actually be available to you. If both options are available to you in a concrete kind of way, THEN, you may find that when things get really real, that you see the choices differently.

You can date both options at once until one becomes more attractive than the other—either because you get to choose between them, or because one dumps you first.

Push-ups and your pumper

Dear Doctor Ninja,

I’m a guy in his mid-30’s. I just heard about a study that says if you can do 40 push-ups that your risk of a heart attack is much lower. I can’t do 40 push-ups. If I train myself to do 40 push-ups, can I prevent a heart attack?


C. Hesturts

This study really made the headlines, Mr. Hesturts, didn’t it? Some of devil is in the details here—mostly having to do with “What is a push-up?”

Most people know what a push-up should look like. But for firefighters, the test that is performed has some pretty specific parts:

  1. your chin has to touch a 5-inch tall object (this seems pretty mean for tall people)

  2. your back has to be neutral (no sagging)

  3. you have to do them to an 80beats-per-minute metronome

  4. you have to do the push-ups within 2 minutes

But that’s not all, you also cannot:

  1. Do more than 3 incorrect push-ups

  2. Fail to maintain continuous motion with the metronome cadence

  3. Have any joint or muscular pain, or dizziness or unsteadiness or chest pain while you are doing the test.

So what does this all mean? Let’s break down what it really takes to do 40 push-ups:

To do ONE push-up, you have to have:

  1. the ability to stand or kneel

  2. the ability to get into push-up position (bend over, support weight with hands)

  3. the ability to keep your body straight

  4. the ability to lower yourself to the 5-inch object

  5. the ability to push back up

  6. the balance to support yourself on two hands and feet together

  7. the coordination to get down and up as well as to keep time with the metronome

To do FORTY push-ups, you have to have, in addition:

  1. muscular endurance in your chest, triceps, shoulders

  2. the ability to hold the rest of your body (some might call it your “core”) in a specific position

  3. sufficient strength to do one push-up

A push-up defined in this way isn’t a simple movement. In the end, this has more to do with exercise capability and the ability to exercise at all, than it does directly to do with heart health. Certainly the two are linked—the ability to exercise has to be satisfied before one can exercise and THEN exercise is linked with lower rates of heart attacks. But really, this study is one that compares people with higher-than-average exercise condition with people with much-lower-than-average exercise condition within a group of people (firefighters) who generally have better-than-average exercise condition.

What’s interesting is that we aren’t told of those men in the 0-10 push-up group, how many could do 0 push-ups vs any non-zero number. The kinds of things that would prevent you from doing a single push-up range from being extraordinarily weak, to a wide range of medical problems that are already linked with bad outcomes of all kinds, including heart attacks.

The other interesting number in this study is that of 1104 participants, the number of heart-related events was 37. In the general population, over 10 years, we would expect there to be about 55 first-time heart attacks (both fatal and non-fatal), so taking this into consideration, firefighters, no matter how many push-ups they can do seem to be at lower risk for heart-related events than the general population. However, amongst the firefighters who could only do 0-10 push-ups there were 8 heart-related events, which is almost 2 times higher than the general population rate which we would expect to be around 3 or 4.

The main message of this paper is that a push-up test doesn’t require a lot of fancy equipment (you need a 5-inch tall thing that will stand on its own, a metronome, and enough floor space to do a push-up without touching any walls) and that there might be a link between being able to do 40 push-ups and not being able to do 40 push-ups within 2 minutes and your first heart attack. Oddly, I think the floor space is more the barrier, given how tiny examination rooms are in doctors’ offices.

If you can’t do 40 push-ups now, then there’s going to be a certain amount of work that has to be done to get to 40. It might be a lot of work if your current number is less than 10 but more than 0. That work would be exercise. So can you prevent a heart attack if you train yourself to do 40 push-ups? Well, if exercise is linked with a lower risk of heart attacks, and you have to exercise enough to have a body that can do 40 push-ups, then yes, you’ll reap the rewards that come with that, because to get to 40 push-ups and stay there, you have to develop a habit of exercise.

Whether or not it will prevent a heart attack depends entirely if you were going to have one in the first place.

Disappointment, or error?

Dear Doctor Ninja,

I am a reasonably fit 57 year old male. Nearly three years ago, I had a DEXA scan that revealed I had about 500g of visceral fat. It didn’t seem critical that I lose it, but I thought it would definitely be good if I reduced it. Between the scan and November last year, I hiked 1000km over four separate hikes, rode my bicycle a lot, became a vegetarian and generally reduced drinking alcohol. In November last year, I started an intensive 12-week workout program, which included five weight-training workouts and one aerobic workout every week. I also didn’t have an alcoholic drink for 100 days. Then I had another DEXA scan. I felt sure that my visceral fat level would have dropped. Instead, it was 160g more, causing me to exclaim mutha-ninja! Would you have any advice on the best ways to reduce visceral fat?


Fujibayashi Nagato

First off, congratulations on making some great lifestyle changes that seem to be working for you!

Before I get into your question, I think it’s important to note a number of reasons why you might have been disappointed in your perceived lack of progress.

In an ideal situation, if you wanted to know how effective your 12-week program was going to be, you would have done a DEXA scan before you started. Since it’s been 3 years and a bit since your DEXA, we really don’t have a good idea of what your visceral fat has been doing. Were you possibly even higher than 660 grams 12 weeks ago?

The other consideration is the nature of the DEXA scan itself. Again, in an ideal situation, you would have a DEXA scan with the same scanner, as different scanners use different algorithms to calculate the various tissue masses. You didn’t mention if this was a whole-body DEXA scan or a single-level one, which can also affect things, particularly if your previous scan was one and your latest scan was the other.

Even measurements with the same machine carry measurement error though. Fat mass variation between scans of the same person (with no change in body composition) can be in the 150g range, which means that an increase of 160g of visceral fat from your previous scan 3 years ago could be due to just the variation in the machine, as opposed to an actual meaningful increase in visceral fat.

You can’t reduce your visceral fat to 0. The average amount of visceral fat in healthy 20-30 year old males likes somewhere in the 400g range. You’re not 20-30 years old anymore, so the average amount of visceral fat in a healthy 50-60 year old male is expected to be higher as visceral fat tends to increase as we age, even if our waistlines don’t.

Visceral fat is contrasted from the fat that sits under the skin (the fat you can pinch, also called subcutaneous fat). It’s the fat around your organs. Visceral fat plays an essential role in organ health as both a source of energy as well as padding; it’s only when visceral fat is in _excess_ that it becomes a problem. Its accumulation is directly related to fat accumulation in general. There’s no known effective way to directly target visceral fat without making changes in other fat stores.

Fat, in general, does not accumulate when there’s no difference between the energy you’re spending vs the energy you’re eating. So the best ways to prevent visceral fat accumulation, or to reduce it, are the same ways to lose fat in general, which come down to controlling the “energy in vs energy out” equation. While there are still many small controversies about which diet is best and whether there can be ways of trying to get around this energy balance requirement, it still seems to bear out that it’s the main linchpin of the matter. How you choose to manipulate energy balance (whether through vegetarianism, or carnivorism) depends mostly on the priorities you have on what, of many factors, play into whether you can stick to an eating style or not. “Diets” are mostly mind-tricks that we use to allow us to execute a habit of eating within energy balance—some people need different or stricter rules than others.