Hormonal
In upper body obesity, the failure of subcutaneous fat to suppress free fatty acid (FFA) release in response to insulin/meal ingestion is the primary driver of elevated systemic FFA concentrations, which in turn cause insulin resistance in muscle, pancreas, and liver.
If you have upper body obesity, your subcutaneous fat cells are failing to listen to insulin, leaking fatty acids into your blood even after you eat. This leak causes insulin resistance in your muscles and liver. Simply removing subcutaneous fat surgically won't fix this; you must reduce fat cell size through caloric deficit and exercise to restore the fat's ability to store fat properly.
The most consistent finding with regards to adipose tissue lipolysis is that of much greater FFA release during hyperinsulinemia in upper body/visceral obesity compared with the nonobese or lower body obese state... The excess postprandial FFA release results in elevated postprandial FFA concentrations... By definition, this implies that adipocytes in upper body obesity are resistant to the antilipolytic effects of insulin.
Why this rating
Based on multiple human tracer studies (Meek, Guo, Jensen) comparing obese vs lean phenotypes, though it is a review of mechanisms rather than a single RCT.
Source
Role of Body Fat Distribution and the Metabolic Complications of Obesity
Michael D. Jensen · The Journal of Clinical Endocrinology & Metabolism · 2008
DOI 10.1210/jc.2008-1585
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