Is it healthier to carry extra weight around your middle or lower down, around your hips?

In other words, are you apple- or pear-shaped?

It’s a bit of a trick question since doctors say that extra fat is unhealthy no matter where it is deposited.

Nonetheless, an article published today in the Annals of Internal Medicine concludes that people of normal weight who have a “spare tire” around their middle – “apple-shaped” – have a greater mortality risk than those who are overweight or obese but have a “pear-shaped” fat distribution.

Earlier studies have also shown links between abdominal fat and the risks for cardiovascular and metabolic disease, and overall mortality.

Fat Midsection

But in this study, a group of researchers led by Dr. Francisco Lopez-Jimenez, a specialist in cardiovascular diseases at the Mayo Clinic, took the data one step further.

The team scrutinized information from the Third National Health and Nutrition Examination Survey. They compared the total and cardiovascular mortality risks for persons with different combinations of body mass index (BMI) and waist-to-hip ratios.

They concluded that normal-weight adults with mid-body obesity have the worst long-term survival compared with any group, regardless of BMI.

In fact, the researchers said, a person of normal weight with so-called “central obesity” had twice the mortality rate of people who are overweight or obese based on BMI only.

They suggested that people with belly fat are a population that could be targeted for lifestyle modification and other preventative strategies.

Read More: Doctors Begin to Treat Obesity »

Losing That Belly Fat

Dr. Samuel Klein is the director of the Center for Human Nutrition at Washington University School of Medicine in St. Louis, Missouri. His response to the study?

“You’ve got to lose weight,” he simply stated.

In an interview with Healthline, Klein admitted that this advice might seem like mission impossible. His suggestion is to think small.

“If you do a series of mini-moves, the prospect isn’t so daunting. Even a 5 percent loss [of excess body weight] is good,” he said.

Klein knows that losing weight is not as difficult as keeping it off.

“You have to maintain a lifestyle change. The key is perseverance,” he said. “You can never really relax because it’s so easy to gain [the weight] back.”

Our bodies were built that way for survival, he explained. So, it’s no surprise to him that nearly of people in the United States are either overweight or obese.

“Obesity is a chronic disease,” Klein said. “Managing obesity is handcuffed by lack of training [for doctors], and by the fact that none of the medications that are available in general are covered by insurance. People don’t get the medications they could use.”

Klein believes patients should be equipped with better tools than a sheet of paper with diet advice.

“We need a system to develop a better program, with handouts, frequent follow-ups, monitoring, accountability, and referrals to experts in the area,” he said.

Not only are individuals affected, he said, but obesity is also a major public health problem, causing a number of expensive and serious diseases.

He urges a shift in how we think about weight loss.

“It’s a lifestyle, not a diet,” Klein said. “It’s a series of small achievable steps, not setting goals that are unrealistic.”

Read More: It’s Our Culture That Causes People to Be Overweight »

More Than Diet Guidelines

For Linda Bacon, Ph.D., a teacher and researcher into food issues, the question is not what to do about body fat, but why fat is the designated bad guy.

Bacon, the author of “Health at Every Size: The Surprising Truth About Your Weight,” wants to shift the focus from weight to well-being.

“I don’t think it’s valuable for people to believe you have to lose weight in order to get healthy,” she told Healthline in an interview. “In fact, weight plays little role in health, much less than socioeconomic status.”

Poorer people die younger, no matter what shape their bodies are, Bacon said. They have less access to medical care, fewer recreational opportunities, and less fresh food.

“Socioeconomic status has an effect on health, both independent of behavior and because of behavior,” said Bacon, who is also an associate nutritionist at the University of California at Davis. “It’s always challenging to make good choices. But even when they make the same choices [as wealthier people], they have a worse effect.”

She points to stress as a possible culprit. Cortisol is a hormone released by the adrenal glands in response to stress in the body. One of its effects is to cause the body to store more fat in the abdomen.

From a public health perspective, it would be better to look at social inequity than weight loss, Bacon said.

“Our best bet is to shift our focus. Weight is not the real issue,” she said.

As for those apples and pears, Bacon would probably suggest eating them.

Read More: Experts Say Obesity Is Biologically ‘Stamped In’ »