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'The Biggest Loser' Highlights Failings of Exercise Guidelines

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Long-Term Data Are Needed

I think Dr. Robert Huizenga is correct that current exercise recommendations aren’t enough. For cardiovascular consequences of exercise, it’s clear that a minimum of 30 minutes a day of aerobic work is required. Most people shortcut the exercise.


Dr. Alan J. Garber

But I think we need to ascertain what fraction of the obese population is that motivated and, unfortunately, I suspect it’s not the majority. ... It’s a very intensive program. It requires a lot of mid-level practitioners and allied-level professionals to make this work. To do it well is expensive. It’s not cheaper than prescribing medicines and probably not cheaper than doing a modest bariatric surgical intervention either.

This level of obesity is a lifetime problem. ... We need a better idea about the durability of the effect and about the adverse consequences. He needs long-term follow-up data. In the short run he’s produced major benefits. The question is whether these patients are able to sustain the emotional commitment and the effort involved in doing this long-tem.

Also, since mobility and joint issues are common in obese individuals, does this increased level of exercise put people at risk for further joint disease? I don’t know what happens to the cartilage in their knees and hips. ... Are you setting people up for hip replacements in 10 years? We require long-term follow-up data for everything we do now. This type of intervention should be no different.

Dr. Alan J. Garber, professor in the departments of medicine, biochemistry, and molecular biology and molecular and cellular biology at Baylor College of Medicine, Houston. He is a consultant/advisory board member for Novo Nordisk, Daiichi Sankyo, Merck, Takeda, LipoScience, Boehringer Ingelheim, Sekris, and Lexicon.


 

FROM THE ANNUAL MEETING OF THE AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS

PHILADELPHIA – "The Biggest Loser," the popular reality TV show that features morbidly obese contestants competing to shed transformational amounts of weight, provides on a national stage proof of principle that aggressive exercise and lifestyle interventions can have a dramatic effect, reversing diabetes-related risk markers and hypertension.

The implication of the show’s staggeringly successful results are that national exercise guidelines set inadequately aggressive targets for morbidly obese patients, the show’s medical consultant Dr. Robert Huizenga said at the annual meeting of the American Association of Clinical Endocrinologists.

"I think if we get away from dumbed-down exercise recommendations, we can see a whole new paradigm of treating diabetes in this country," said Dr. Huizenga of the department of medicine at the University of California, Los Angeles.

The show’s 24-week regimen consists of approximately 4 hours of daily exercise, including 1 hour of intense resistance, 1 hour of intense aerobic activity, and 2 hours moderate aerobic activity (for example, walking), along with a caloric intake of at least 70% of estimated resting daily energy expenditure, explained Dr. Huizenga, who is also a former team physician to the L.A. Raiders football team.

Among the show’s latest 35 participants, at baseline, 17 had normal glucose tolerance, 12 had prediabetes, and 6 had type 2 diabetes. Those with prediabetes and diabetes were slightly older than those with normoglycemia (44.2 and 44.0 years, respectively, vs. 35.5 years), and had higher body mass indexes (48.1 and 48.6 vs. 44.5 kg/m2). They also were more likely to be taking antihypertensive medications (15 and 7, vs. 2).

During the course of the 24-week regimen participants increased their daily exercise from 0.3 hours to 3.7 hr/day, with a concomitant reduction in sedentary TV and computer time from 5.6 to 2.4 hr/day.

The average body weight at baseline body weight (143 kg) for the entire group, dropped by 5 kg at week 1, 20 kg at week 6, and 52 kg at week 29 (all P less than .0001, compared with baseline). From baseline to week 29, BMI dropped from 46 to 29 kg/m2, waist circumference from 142 to 102 cm, and percent of body fat from 49% to 29%. That weight loss at 7 months is greater than what is typical of Roux-en-Y gastric bypass at 1 year, Dr. Huizenga noted.

Systolic blood pressures dropped from 138 mmHg at baseline to 118 mmHg at week 29, and diastolic blood pressure from 90 mmHg to 74 mmHg (P less than .0001 for both). All participants were taken off their antihypertensive medications by week 2 and were consuming salt, Dr. Huizenga reported.

While LDL cholesterol levels did not change significantly, HDL cholesterol rose from 44 to 51 mg/dL (P = .0005) and triglycerides dropped from 127 to 67 mg/dL (P less than .0001).

Among the 12 contestants with prediabetes, hemoglobin A1c dropped from 5.6% to 5.1% at week 29 (P less than .005). The drop also was significant for the six participants with type 2 diabetes, from 6.9% to 5.2% (P less than .005). The three who had been taking metformin discontinued it at week 1. Concomitant significant reductions also were seen in fasting glucose, fasting insulin, and the homeostasis model assessment-estimated insulin resistance index, he said.

Serum adiponectin rose from 8.6 mcg/mL at baseline to 13.1 mcg /mL at week 29. C-reactive protein actually rose initially, from 6.9 mg/L at baseline to 9.7 mg/dL at week 1, but then subsequently dropped to 3.0 mg/L by week 29. The reason for the initial CRP increase isn’t entirely clear, but Dr. Harold Bays, medical director of the Louisville (Ky.) Metabolic and Atherosclerosis Research Center, postulated that the likely mechanism is adipocyte hypertrophy resulting from the acute exercise. As people become accustomed to exercise, adipocyte hypertrophy is reduced and CRP declines. Dr. Huizenga concurred with that explanation.

There have been no deaths among the 371 total Biggest Loser contestants, compared with the 1% to 10% death rate associated with Roux-en-Y gastric bypass, Dr. Huizenga noted.

"There’s an urgent need for development, implementation, and payer coverage of aggressive exercise–centric programs for prevention and remission/cure of type 2 diabetes, hypertension and their associated comorbidities," he concluded.

In response to an audience member’s question about how realistic it is to expect people to spend 3-4 hours a day exercising, Dr. Huizenga responded, "If somebody is faced with a potentially life-threatening lymphoma, they somehow find time for 3 hours of chemotherapy ... We have people spending 5-6 hours of nonproductive leisure time [a day] on computers and television. I believe we have the time, what we don’t have is priority in this country. We don’t have the proper education or motivation."

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