CW: Did you hear any real world messages from the Biggest Loser science?

There are a few things that endurance sports enthusiasts understand well: the importance of hard work, dedication and the need to push through discomfort.

In fact, I would submit that these requirements act not as deterrents but as draws. Take triathlon as a case and point: if it was easy and safe, and perhaps less ‘Iron,’ who would want to do it? We endurance folks advocate for suffering.

So with this as a backdrop, what should a bike-racing heart doctor from one of America’s unhealthiest states think about the most recent bru-ha-ha about scientific findings from the Biggest Loser?

In case you haven’t heard, the medical director of the Biggest Loser, Dr. Robert Huizenga, presented an abstract at the 2012 meeting of the American Association of Clinical Endocrinologists in which he chronicled the miraculous resolution of poor health measures in selected contestants on the Biggest Loser. (Ed. Note: Endocrinologists are hormone and diabetes specialists)

The Presentation:

Dr. Huizenga presented health records on 35 (59%) contestants from the Biggest Loser (May 2011-March 2012). Normally, I tell you about the intro and methods before the results.

In this case I will start with the remarkable results:

He found that contestants enjoyed breath-taking improvements in common measures of health. The Biggest Loser regimen “virtually reversed” diagnostic criteria for pre-diabetes, diabetes and hypertension. This occurred quickly (5 weeks) and despite stopping medicines.

These findings led to far-reaching conclusions: (I’ll quote from the press release.)

  • Dr. Huizenga believes that the study indicates that this type of program should be the first choice for anyone who is morbidly obese (Body Mass Index over 40) and who wants to lose weight and restore their health and well-being.
  • “We backed into a better mousetrap. It’s very gratifying to see this weight loss formula of intensive exercise actually also lead to a reversal of disease conditions,” Dr. Huizenga concludes. “It’s not easy, but it also isn’t invasive surgery with all of its inherent potential risks.”

Like many pseudo-science studies, the problems come in the Methods section. For starters, Biggest Loser contestants are incented by money and potential fame. This makes them an unrealistic sample of normal obese patients. Secondly, contestants follow a very atypical and not easily repeated exercise program, including four hours of exercise per day. You’ve seen the show—said exercise often involves a great deal of intensity.

Of course, no normal person can or should exercise that much. Nor is it useful to hold up selected financially motivated contestants as normal obese patients. And most glaring is the lack of long-term follow-up. These short-term gains may be just that: short-term.

My take:

That said, I’m far less inflamed than the very well spoken physician blogger, Yoni Freedhoff, author of Weighty Matters. Dr. Freedhoff says Dr. Huizenga’s motives bring to mind two of science’s bed bugs—cognitive dissonance and conformation bias. He calls for the abstract presenter to undergo fumigation. Gosh, that kind of inflammation makes me worry that Dr. Freedhoff is at risk for AF.

Let’s put a slightly less inflamed spin on the ridiculous study. I see it as a proof of concept. I realize there are plenty of studies showing exercise helps diabetes and high blood pressure, but this one really says it. Though I do not condone the means, it is striking what can be done when the body and mind decide to do it. In just a few weeks, without medicines, these patients were able to eliminate two disastrous diseases. Leave aside the motivation and lack of long-term follow-up, Dr. Huizenga showed the most hopeless of obesity patients reversed their illness. They did it. Let me repeat: THEY did it themselves!

This leads me to another Mandrola-ism. I believe good health can start with a sprint. People, me included, frequently fly off the handle when they start exercising or dieting. Some are even silly enough to try an Ironman. I did a half-marathon with basketball sneakers and one-week of prep. In many cases, some of these health sprinters start feeling the side effects of their goal-chasing. They feel less winded, their clothes become baggy and people start to say nice things like, “you look younger.” Then they flip. In an optimist’s world, they find balance and start on a road to a healthy life. Some of the infected then became vectors of good health. They spread the word and before you know it, your hood feels like Boulder Colorado. (Okay, that’s a stretch.)

My good friend and dean of the Academy of Masters of the Obvious, Bob Bobrow, once wrote me a treatise on what’s wrong with the Biggest Loser approach to life, happiness and health. He captures the essence of the problem:

We don’t believe that you can just exercise, just play, and be healthy and happy and wise. We don’t believe that you can do what comes naturally, go with the flow, enjoy the ride and be successful. You have to push it, bear down, bust a gut.

And there has to be an end game. A goal. A finish line. We don’t exercise to exercise. We exercise to lose weight, look sexy. We exercise for rock-hard abs and buns.

His recommendations are clear:

Sustained weight loss and good health and even a happy life don’t come from gutting it out. A healthy weight and a healthy you are side effects of a healthy, sub-threshold lifestyle. They aren‘t the end result of short bouts of sprinting followed by long periods of doing nothing. There’s no stopping in life, except for death. If there’s competitive analogy, good health is an ultra-marathon, not a sprint. So be the tortoise not the hare. Plug along at your pace. Find your limits and operate within them. Push them, but occasionally, but not as a rule. Enjoy your exercise. Don’t gut it out. Work within your limits, under your threshold, whatever they may be.

Forget about goals, pounds lost, laps run, weight lifted. To steal back a pilfered phrase, “Just do it.” You will enjoy yourself, and the results you want will just happen.

Mr. Bobrow’s recommendations are often recanted when asking healthy ninety-year-olds how they have lived so well and so long.

Hmm?

JMM

P.S. Let’s do a few words on the over-achieving Dr. Huizenga. (Disclosures are always important.) A son of a nuclear physicist and Harvard and Michigan graduate, Dr. H is an associate professor of clinical medicine at UCLA. His experience as the LA Raiders team doctor inspired him to write his first book, You’re OK, It’s Just a Bruise—A Doctor’s Sideline Secrets about Pro-Football’s Most Outrageous Team. This book was notable because it was at least partly adapted to the movie Any Given Sunday. As an athlete himself, Dr. Huizenga’s interests have been in the effects of extreme exercise on obesity.

Addendum: My friend Chris Kaiser from MedpageToday has this detailed report on the abstract.

14 comments

  1. Omitted from the press release is that, of the study participants, only 6 had diabetes and 12 had prediabetes. So it’s only a small pilot study, in terms of hyperglycemia.

    A prominent Internet meme of the last few years is that the old calories in/calories out theory of weight loss is failed or otherwise not applicable. The Biggest Loser program proves the ongoing validity of this Energy Balance Equation, even if it’s hard to apply in the real world.

    -Steve

  2. Interesting observations, Dr. John! Speaking of “the most hopeless of obesity patients reversing their illness”, have you seen this yet? http://www.youtube.com/watch?v=qX9FSZJu448&feature=youtu.be

    I experienced a strange urge to toss aside my crutches (that is, if I had them!) and start running again after watching this.

    The interesting difference between Arthur, the hero of this little film, and the average schmuck seems to be this motivation you cite in the Biggest Loser folks. Had Arthur not been quite so personally motivated (sans cash and TV fame), he may well have ended up as one of Dr. Freedhof’s bariatric surgery clients instead.
    regards,
    C.

  3. Thanks for the shout out.

    Also worth noting if we’re talking about the real world. There are literally hundreds of thousands of applicants each season. The selection process is rigorous. These folks were the cream of the crop in terms of having the right mental, physical and medical makeup to succeed.

    But I do think your mildly muted applause is premature. Losing’s no trick, all you have to do is suffer. Really what this study proves is that money and fame are great motivators to suffer.

    What they weigh at the end of the show has no consequence on the medical management of obesity – it’s what they weigh and their health a few years later.

    If he publishes a study suggesting remarkable results then, I’ll happily eat my big plate of crow.

  4. Great read Dr J. Thanks.

    See you on the road … if I could just keep up.

  5. On incentives – like the lottery, a single relatively small incentive can collectively prod a larger group people to invest far more in time and money than makes sense to reach a goal.

    Do we need an X-prize for personal health?
    http://nextbigfuture.com/2011/06/x-prize-director-describes-incentive.html

    A side note – mentally note up the amount of time, sweat, and money in the swim bike transition area for evidence of how a small prize can make otherwise sane people do nonsensical things that might just turn out to be good for them!

  6. Dr. John McDougall, MD, who recommends a low fat plant based diet writes the following on his website concerning type 2 diabetes:
    “In Adult Diabetes: Change in diet will allow 75% of these patients to stop taking all insulin, and more than 95% to stop taking all diabetic pills. (The few who continue to need medication should be treated with small doses of insulin.) Insulin adjustments are made as usual, with the aid of urine-sugar and blood-sugar tests, under a doctor’s supervision.”

    I don’t have diabetes (my 83 year old mother has type 2 diabetes and she takes a small amount of insulin. She eats a standard American diet and has struggled with her weight for most of her life.

    I am not diabetic (was never was) but my glucose levels have decreased after switching to Dr. McDougall’s diet and losing weight (from over 280 pounds 20 years ago to 170 pounds this morning). My last two fasting glucose levels were in the low 70’s but for years the fasting levels had been in the high 90’s. Last month, I had a postprandial glucose tolerance test done just to make sure that my glucose was not spiking after I ate breakfast (a very high fiber whole grain only meal with the most calories I eat in a day). The 2 hour after breakfast level was lower than the fasting glucose level of 72. I am not sure what that means but it certainly didn’t spike up. (I also exercise more since retiring 3 years ago — about 3 hours gardening each day and 35 minutes on my bicycle.

    Thank you for your blog postings — I have learned much and I appreciate your approach to medical care.

    1. Your welcome. Thanks for sharing your personal experiences. Again, these vignettes provide learning chances, which is indeed the point.

    2. +1 to the power of a plant-based diet, whether McDougall, Esselstyn, or Engine 2 Diet.

      Great post, John.

  7. I think Dr H is bold to present TBL work in a peer-reviewed conference and try to gain interest among physicians: and I say, more power to him.

    There’s no question that this isn’t an objective study: every type of bias you can think of is present. There’s also no question that it has inspired millions of viewers and readers to try to make a difference in their own lives. Which is much more than most physicians have chosen to do with lifestyle advice.

    Physicians are not trained to give advice about nutrition, diet and exercise: they’re not compensated for such, per se; and they expect it to fail.

    Although I have some quibbles about what they’re feeding the contestants, TBL is free with basic TV, and expects it to succeed. That’s tremendous.

    We could learn a lot from them…and many cities and employers already have, and are emulating this model in their own wellness programs.

    1. Thank you for this insightful comment. These are are all excellent points. My favorite is the notion that we can learn from these cases.

  8. Follow up on the Biggest Losers’ contestants would be fascinating. Over the weekend I watched (while standing a lot) “Weight of a Nation”. They talked about how a person in a weight reduced state must eat less and exercise more that a same sized person who was never overweight. The person who lost weight will have to do this forever. The theory was that with less leptin being released, the brain believes the body is starving, and institutes energy saving measures. There is an article
    http://www.drsharma.ca/obesitywhy-is-it-so-hard-to-maintain-a-reduced-body-weight.html
    which captures the bulk of what the program said. If true, it’s really a bummer for people who have lost weight.

  9. “contestants are incented by money and potential fame”

    Would also point out that Dr. Huizenga has an inherent conflict of interest in that he is medical director for the series.

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