Cellulite is a common term used to describe superficial pockets of trapped fat, which cause uneven dimpling, “orange peel”, or cottage cheese skin. Practically all post-pubescent females display some degree of cellulite. There appears to be a hormonal component to its presentation. Common but not exclusive areas where cellulite is found, are the thighs, buttocks, and the abdomen. Cellulite is not related to being overweight; average and underweight people also get cellulite.

Liposuction, which extracts fat from under the skin, is not effective for cellulite reduction and may exacerbate the cosmetic problem. Dieting does not get rid of the dimpled appearance, but a balanced diet and exercise may help to reduce the fat content within the distorted cells, reducing their contribution to the dimpling.

Hormonal Factors

Hormones play a dominant role in the formation of cellulite. Estrogen is the most important hormone. It seems to initiate, and aggravate cellulite. Other hormones including insulin, the catecholamine, adrenaline and noradrenalin, thyroid hormones, and prolactin have all been shown to participate in the development of cellulite.

Predisposing factors

Several genetic factors have been shown to be necessary for cellulite to develop. Gender, race, biotype, a hormone receptorallele that determines the receptor number and sensitivity, distribution of subcutaneous fat, and predisposition to circulatory insufficiency have all been shown to contribute to cellulite.

Diet

Diet has been shown to affect the development and amount of cellulite. Excessive amounts of fat, carbohydrates, salt, alcohol or too little fiber can all contribute to an increased cellulite.

Lifestyle

Smoking, lack of exercise, tight clothes, high-heeled shoes, and sitting or standing in a single position of long periods have all been correlated with an increase in cellulite. A high stress lifestyle will cause an increase in the catecholamine hormones.

Cellulite Anatomy

Underneath the epidermis and dermis exists three fat layers. Cellulite develops in the most superficial of these layers, known as the hypodermis or subcutaneous fat layer. This layer is structurally unique from the others because its fat lobes are organized into chambers by surrounding strands of connective tissue. Hormones, not exercise and diet, primarily regulate fat storage and metabolism in the subcutaneous fat layer. The fat cells within the two reserve fat layers situated underneath the subcutaneous fat layer are dispersed in a loose network. Fat storage and metabolism in these layers is predicted by genetics and influenced by the two basic elements of lifestyle, diet and exercise. Most notably, these layers are not responsible for the formation of cellulite.

Male vs. Female

In women, the subcutaneous fat layer is organized into large vertical chambers where an abundance of fat can be stored. The chambers in men are arranged as small diagonal units, which not only store smaller quantities of fat but are also unlikely to result in cellulite formation.

How does Cellulite Develop?
“Edematous-fibrosclerotic panniculopathy” is a medical term used to describe cellulite. In the past decade, there has been extensive research to clarify the possible causes, and many authors agree on the following points:

• Adipose cells (fat cells) swell due to fat storage.
• Capillary walls become excessively permeable causing localized accumulation of fluid.
• Inadequate lymphatic drainage slows the removal of excess fluid.
• Adipose cells cluster and are bound by collagen fibers, which further impedes blood flow.
• Connective tissue strands stiffen, pulling down on their anchor points. 

The changes in blood flow, lymphatic drainage, fat, and connective tissue result in cellulite - a bumpy or dimpled appearance of the skin.

Factors involved in Cellulite

Hormones
Special importance is placed on hormonal factors (estrogen, folliculine, etc.), since cellulite develops mainly in women during periods of hormonal change, such as puberty, pregnancy, menopause, premenstrual syndrome, and the initial months on birth control pills. Hormones are responsible for regulating the changes in blood flow, lymphatic drainage, fat, and connective tissue, all of which play a role in the formation of cellulite.

Lifestyle: Diet and Exercise
Cellulite forms as a result of complex physiological changes to the subcutaneous fat layer, despite attempts to exercise regularly and follow a well-balanced diet. However, without a healthy lifestyle, the overall appearance of existing cellulite can worsen over time due to weight gain, poor nutrition, and inadequate water intake. 

Age
Aging results in a loss of thickness and tone of the connective tissue within the dermis and the superficial fat layer. The outcome is a more visible and flabby cellulite. 

Cellulite Profile

There are several ways to evaluate and classify cellulite.

1. The pinch test is a simple way to locate cellulite. Pinch the skin on your outer thigh between your index finger and your thumb, and look for dimpling. You can also try other regions of the body, namely the buttocks and abdomen.
2. The Nurnberger - Muller scale can be used to classify cellulite based on a four-stage process, beginning with normal skin and terminating with its most advanced stage.
3. Stage 0
   No dimpling when the subject is standing and lying. The pinch test reveals “folds and furrows”, but there is no mattress-like appearance.
4. Stage 1
   No dimpling while the subject is standing or lying, but the pinch test reveals the mattress-like appearance.
5. Stage 2
   Dimpling appears spontaneously when standing and not lying down.
6. Stage 3
   Dimpling is spontaneously positive standing and lying down.

Questionnaire
Determine your Cellulite Profile by answering the following questionnaire:

1. Do you have visible cellulite (no pinching needed)?
   Yes No
2. Is your cellulite painful when you pinch your skin?
   Yes No
3. Do you have cellulite in more than 1 area of your body?
   Yes No
4. Did you start noticing cellulite before the age of 25?
   Yes No
5. Do you suffer from marked premenstrual syndrome?
   Yes No
6. Do you have water retention?
   Yes No
7. Do you suffer from chronic constipation?
   Yes No
8. Has your weight fluctuated more than 5% in the last three years?
   Yes No
9. Are you taking any hormones?
   Yes No
10. Do you drink a lot of coffee, tea or alcoholic beverages
    on a daily basis?
    Yes No
11. Do you smoke?
    Yes No
12. Do you drink under 8 glasses of 8 ounces (2 liters) 
    of water per day?
    Yes No
13. Is your diet rich in saturated fats (meat and dairy) and/or
    high glycemic carbohydrates (pasta, rice, bread, etc)?
    Yes No
14. Do you prefer salty foods?
    Yes No
15. Have you gone over 3 months without regular exercise?
    Yes No

Total your score giving yourself 1 point per question answered YES. 

If your score is above 8, it is recommended that you make lifestyle changes to minimize further worsening of cellulite.

• Increase water intake to a minimum of 8 glasses of 8 ounces (2 liters) per day.
• Minimize consumption of coffee, tea and alcohol.
• For each serving of coffee, tea or alcoholic beverage, drink 2 glasses of water.
• Exercise regularly.
• Minimize consumption of saturated fat and carbohydrates.
• 75% of the food should consist of fruit, vegetables, and whole grains. The remaining 25% may consist of meat, fish, eggs, nuts, and whatever one likes best.