But it was the excess weight less visible to the untrained eye that may have been hurting him more.

"I found out I was borderline diabetic," he says. "I'm Native American, and diabetes is an epidemic on our reservation. I knew I needed to start paying attention to my health." advertisement 
 
 

Sanderson, 41, a Pima, lives in Apache Junction. Relatives on the Gila River Reservation have lost limbs to the disease. His grandmother lost her life.

The belly fat contributing to his extra pounds, especially the visceral fat that accumulates around the organs inside the belly, has been associated with increased risk of diabetes, heart disease and other conditions.

"People with an apple shape - extra weight in the middle and upper body - are much more likely than people with a pear shape to have insulin resistance and the infamous metabolic syndrome," says Chandler physician Scott Rigden, who is Sanderson's doctor.

Insulin resistance, sometimes called pre-diabetes, is the inability of the body to use insulin efficiently. It's a marker of metabolic syndrome, a cluster of health risk factors. Other characteristics of the syndrome are elevated blood pressure, cholesterol and triglycerides, and low levels of the healthy HDL cholesterol.

Physician Pamela Peeke, author of Fit to Live: The 5-Point Plan to Become Lean, Strong & Fearless for Life (Rodale, 2007, $26.95 hardcover), calls visceral belly fat "toxic fat."

Subcutaneous fat, the jiggly stuff that's easy to see and pinch, collects under the skin and on top of the abdominal muscle wall. For most people, that kind of fat is more harmful to appearance and self-regard than to health.

"But excessive fat deep inside the belly, the visceral fat, that's a problem," says Peeke, clinical assistant professor of medicine at the University of Maryland. "It's highly associated with colon and other forms of cancer, like uterine and ovarian cancers."

Visceral belly fat overwhelms the ability of the liver to function, she says. Thus impaired, the liver is unable to process cholesterol efficiently and stave off heart disease or to process insulin and fight type 2 diabetes.

"All of a sudden," Peeke says, "it's not so much how fat you are. It's where the fat is at."

Fat cells in the abdomen don't sit there passively. They are active units of life, capable of creating metabolic changes that can produce estrogen even after a woman has gone through menopause or that can contribute to sleep apnea.

Paska Permana, a research health scientist at the Carl T. Hayden VA Medical Center in Phoenix, is studying the role of inflammation in fat tissue, including inflamed tissue's possible connections to obesity and insulin resistance.

Researchers know, for example, that visceral fat cells break down more easily than subcutaneous fat cells into fatty acids that circulate in the bloodstream, she says. At high levels, the free fatty acids can impair the body's sensitivity to insulin.

Permana says even thin people have - and require - moderate amounts of abdominal fat.

"It's thought that at least a little bit of visceral fat is needed to cushion the organs," she says.

But statistics illustrate the urgency of controlling belly fat and other potential contributors to diseases such as diabetes, she says. In the United States, an estimated 50 million people have insulin resistance and 21 million have the full-blown disease.

Genetics may be partly to blame for the accumulation of belly fat, Permana says.

Aging is another culprit, especially during menopause and its male counterpart, a state UM physician Peeke calls "manopause."

"As you coast through your 40s and 50s," Peeke says, "the sex hormones begin to decline, and that makes it easier for men and women to put on extra fat deep inside the belly."

Poor lifestyle choices and chronic stress also contribute, and these are areas over which you have some control. Stress increases the adrenal glands' secretion of cortisol, a hormone linked to the production of abdominal fat.

"If you're not exercising and you're eating crap," Peeke says, "you're going to put on weight. And if you're in your 40s, it's more likely to end up around your belly."

Exercises that target the middle appear to have less impact on belly-fat-related problems than does overall cardiovascular conditioning, says Rigden, the Chandler doctor.

"There's all kinds of folklore that if you do enough crunches, that's the key," Rigden says. "But when you do aerobics, or cardio exercise, you're rhythmically using your largest muscles and that pushes insulin (from the abdominal fat and bloodstream) into the muscles. That seems to help the most to turn around insulin resistance."

He advises patients like Sanderson to spend 75 percent of their workout time on aerobics and the rest doing resistance and floor exercises.

Sanderson, who has lost about 80 pounds since learning he was pre-diabetic, does aerobics five days a week, adding weight training to his routine three of those days.

The gym where he works out is upstairs at a multigenerational recreation center, he says, "and the first time I started walking up those stairs, I thought, 'Oh, no. I'm not going to be able to do this.' "

He made it, and he keeps going back, even though he's still the biggest guy there. He's got about 150 pounds to go, but his blood pressure and blood glucose levels are coming down, the knee pain is gone and he's sleeping well.

On non-gym days, he tries to walk at the park or hike with friends and his daughters, Marissa, 18, and Tara, 15.

The girls split their time between Sanderson and his ex-wife. On the five days a week they're with Dad, they eat dinner together as often as possible, with Marissa and Tara sometimes sampling his "caveman diet" - lean protein, lots of vegetables, some fruit and limited grains.

Both girls are active in sports and naturally fit, and that makes Dad happy.

"Diabetes and dialysis, after everything I've seen, those are the worst things you'd ever want to hear," Sanderson says.

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