Maintaining Weight Loss: Who is the biggest loser?
There is a lot to consider when examining the impact of changing lifestyle in the short or long term with the goal of losing weight. In my answer I will compare the findings of the longitudinal study of TBL against similar clinical trials that assess the success of long term weight loss and its attbutation to changes in basic metabolic rate (BMR).
This question focuses on the use of the TV show “The Biggest Loser” (TBL) which debut in October 2004. In the show, obese, contestants compete to win a significant cash prize by losing the highest percentage of weight relative to their initial weight (Wikipedia, 2016).
TBL: Weight loss regimen: Risks and Criticism
First, to fully understand what is happening to the bodies and minds of the contestants in TBL prior to finishing the show, I will explore some of the criticisms of TBL over its broadcast history. The show starts with a disclaimer, which states:
“Our contestants were supervised by doctors while participating in the
show, and their diet and exercise regimen was tailored to their
medical status and their specific needs. Consult with your own doctor
before embarking on any diet or exercise program.”
Despite this claim of supervision by a certified medical professional, all contestants are required to sign a waiver which states:
"…no warranty, representation or guarantee has been made as to the
qualifications or credentials of the medical professionals who examine
me or perform any procedures on me in connection with my participation
in the series, or their ability to diagnose medical conditions that
may affect my fitness to participate in the series". (Pitney, 2010)
The exploitative nature of the show is attacked by Dr Charles Bruant (Edward, 2016), director of the Michigan Metabolomics and Obesity Center, who states:
"I’m waiting for the first person to have a heart attack. I have had
some patients who want to [follow the show's regimen], and I counsel
them against it. I think the show is so exploitative. They are taking
poor people who have severe weight problems whose real focus is trying
to win the quarter-million dollars." (Edward, 2016)
Dr. Bruant’s asserts that the mental strain placed on the contestants due to the 'competition' aspect of the show leads to significant mental trauma is reaffirmed by information supplied by the contestants themselves.
Ryan C. Benson, the winner of the program’s first season (Wikipedia, 2016), publicly admitted that "[I] dropped some of the weight by fasting and dehydrating myself to the point that I was urinating blood". Since the show completed, Benson has regained almost all of his weight (Edward, 2016).
In 2009, Kai Hibbard (runner-up from the third season) told The New York Times that "contestants would drink as little water as possible in the 24 hours before a weigh-in" and would "work out in as much clothing as possible" when the cameras were off. She further stated that two weeks after the show ended, she had regained about 31 pounds, mostly from staying hydrated (Edward, 2016).
Next, In a June 2010 interview, Hibbard (another contestant) said, "I do still struggle [with an eating disorder]. I do. My husband says I’m still afraid of food... I’m still pretty messed up from the show.” (Poretsky, 2016).
It is clear that TBL is a harmful show for those competing and this has had a significant effect on their mental health, this trauma culminates just before they move into a self-lead period sustaining their weight loss. It is clear that, for some contestants, the psychological trauma of taking part in the competition has directly affected their ability to sustain a healthy weight in the long term but this is not true for all those involved.
The triggers for many weight gain relapses are known to be linked to depression spirals from self-image hate. Food is treated as a comfort for these people who are disgusted when they see themselves leading to a compulsion to eat to feel emotionally 'better'. An examination of the psychology of the show (Domoff SE, et al., 2012) concluded that Participants in The Biggest Loser competition had significantly higher levels of dislike of overweight individuals and more strongly believed that weight is controllable after the exposure which could lead to future depression and faster rebound to original weight.
TBL: Longitudinal Study
In 2016, the results of a long term study by the US National Institute of Health (NIH) were released which documented the weight gain and loss of contestants in Episode 8 (in which Danny Cahill achieved the show's record-setting loss). The study found that most of the 16 contestants involved regained their weight, and in some cases, gained more, than before they entered the contest. (Kolata, 2016).
The New York Times article continues to assert the reasoning behind the general trend of TBL contestants to regain lost weight as being primarily linked to a slowing metabolism, meaning they burn fewer calories at rest then expected for a person of their current size.
The article continues to explain how dieting affects metabolism:
Researchers knew that just about anyone who deliberately loses weight
— even if they start at a normal weight or even underweight — will
have a slower metabolism when the diet ends. So they were not
surprised to see that “The Biggest Loser” contestants had slow
metabolisms when the show ended.
However, rather than the metabolisms of the contestants recovering to
match that of someone of their current size, they instead plummeted as
if their bodies were fighting to put the weight back on. In one
extreme case Mr. Cahill who gained 100lbs since the show has to eat
800 calories less than a man of his current size to maintain his
weight. (Kolata, 2016)
The article continues, quoting Dr. Michael Schwartz, an obesity and diabetes researcher who is a professor of medicine at the University of Washington:
“The key point is that you can be on TV, you can lose enormous amounts
of weight, you can go on for six years, but you can’t get away from a
basic biological reality,” ... “As long as you are below your initial
weight, your body is going to try to get you back.” (Kolata, 2016)
Next, Dr. David Ludwig, the director of the New Balance Foundation Obesity Prevention Center at Boston Children’s Hospital, who was not involved in the show is quoted:
“This is a subset of the most successful [dieters]"...“If they don’t
show a return to normal in metabolism, what hope is there for the rest
of us?”…“that shouldn’t be interpreted to mean we are doomed to battle
our biology or remain fat. It means we need to explore other
approaches.” (Kolata, 2016)
The article concludes that for the vast majority of TBL contestants, all of them have a significant fight with their metabolism following the show.
The shock-and-awe tactics of the show to strip the weight off fast could be potentially causing a substantial deficit in leptin levels for a sustained period, and that lead to a higher baseline hunger level. The article (Kolata, 2016) supports this theory somewhat, referencing a one-year study similar to TBL format funded by Australia’s National Health and Medical Research Council (Sumithran, Prendergast, Delbridge, Purcell, Shulkes, Kriketos and Proietto, 2011), Dr. Joseph Proietto of the University of Melbourne and his colleagues recruited 50 overweight people who agreed to consume just 550 calories a day for eight or nine weeks. They lost an average of nearly 30 pounds, but over the next year the weight was regained. Dr. Proietto and his colleagues looked at leptin and four other hormones that satiate people. Levels of most of them fell in their study subjects. They also looked at a hormone that makes people want to eat. Its level rose.
“What was surprising was what a coordinated effect it is,”...“The body
puts multiple mechanisms in place to get you back to your weight. The
only way to maintain weight loss is to be hungry all the time. We
desperately need agents that will suppress hunger and that are safe
with long-term use.” (Sumithran, Prendergast, Delbridge, Purcell,
Shulkes, Kriketos and Proietto, 2011)
In the aforementioned article (Kolata, 2016), Dr. Hall, an expert on metabolism at the National Institute of Diabetes and Digestive and Kidney Diseases, is quoted for stating that the researchers involved in the show knew “[the contestants] will have a slower metabolism when the diet ends”.
Following the show, Dr. Hall released an article that fully details the magnitude of dietary restriction and exercise intervention that the contestants experience. The findings of “Diet versus exercise in “the biggest loser” weight loss competition” (Hall, 2013) concurs with many of the points previously discussed here with respect to the contestants maintaining and continuing to attempt a diet that was known to not sustainable in the long term. Using simulation, Dr. Hall showed that the weight loss that contestants craved could be achieved by less drastic methods, thought the time needed to achieve and maintain their goals successfully would be in the domain of years and not months as was suggested by the competition.
Other Relevant Studies
Those who are successful at maintaining weight lost often experience positive associations with their new, lower weight. On TBL it is clear that negative associations with food can and have developed which might raise the probability of longer term relapse. The psychological symptoms for those who have been successful at long term maintenance of weight loss (Klem et al., 1998) are those of positive general mood and self-confidence, with many involved in the study stating that is was easier to keep the weight off. In this study, it was entirely down to those involved to decide how much weight they wanted to lose and at what rate.
Next, the body takes many years to respond to the change needs it has placed upon it. A recent study (Wing and Hill, 2001) found that the period that it takes for your body to adapt to new diet and exercise regimes is longer that that expected; the chances of long term success of keeping weight lost off also greatly increase after keeping weight off for more than 2 years due to continued adherence to diet and exercise strategies, low levels of depression and dis-inhibition, and medical triggers. This may go some way to explaining the reasons for relapse when the average cycle time for a diet and sustain is 1 year.
A study of resting metabolic rate (RMR) by the National Weight Control Registry (Wyatt, 1999) of those who have reduced their weight concluded that in at least some reduced-obese individuals there does not seem to be a permanent obligatory reduction in RMR beyond the expected reduction for a reduced lean mass through rapid dieting. This is supported by additional analyses of resting metabolic rates among formerly obese subjects (Astrup, 1999); this analysis concludes that formerly obese subjects had a 3-5% lower mean relative RMR than control subjects; the difference could be explained by a low RMR being more frequent among the formerly obese subjects than among the control subjects. Whether the cause of the low RMR is genetic or acquired, the existence of a low RMR is likely to contribute to the high rate of weight regain in formerly obese persons.
The metabolic rate is known to scale with body mass, which can be broken down into fat-free-mass and fat mass. Studies (Weinsier, Schutz and Bracco, 1992; Cunningham JJ, 1991; Fukagawa et al., 1996) agree that changes to the amount of fat-free-mass a person has directly affects their metabolism but the level which other factors affect metabolism: fat mass (FM), gender, age and hormone levels (Leptin, triiodothyrionine (T3), and thyroxine (T4)) is still not completely understood. A study by the American Society for Clinical Nutrition (Johnstone et al., 2005) investigated the effects of these secondary factors, concluding that both FFM and FM are significant contributors to the basal metabolic rate. However, it also found that leptin, gender and T3 levels are not statistically significant in determining the BMR.
One important factor to consider is the research conducted as part of the Minnesota Starvation Experiment (Keys and Drummond, 1950). A follow up study published in the American Journal for Clinical Nutrition re-created the MSE but in an improved environment, utilising the Biosphere facility to investigate if the findings of the MSE, that during starvation the body drastically changes its metabolism, were accurate. The results of this study (Weyer et al., 2000) were that six months after exit and return to a normal diet, body weight had increased to pre-entry levels; however, adjusted metabolism was still significantly lower than in control subjects.
The study by Weyer et al. concluded that in lean humans metabolism adaptively decreases to account for “Starvation Mode” and in response to sustained (>5 years) energy restriction. On average, those involved in the biosphere study lost 15% of body mass on a nutritionally rich diet which points to fat-mass (FM) being lost and not significantly lowered levels of fat-free-mass (FFM). However, it is also worth noting that the average change described to BMR was 180kcal, broken down by the study to indicate that the reduction attributed to changes in FM and FFM were equal to those attributed from a reduction in fidgeting. (~60kcal ea.)
Effect of Exercise on Changing Metabolism
Strength training has shown, especially for men, to contribute to a rapid improvement in RMR (resting metabolic rate) (LEMMER et al., 2001). An earlier study of 50-65-yr-old men also agrees with these findings that the BMR can be improved with resistance exercise (Pratley, 1994). A 2001 review concludes that “More recent research demonstrates that resistance training may positively affect risk factors such as … resting metabolic rate … which are associated with diabetes, heart disease, and cancer” (Winett and Carpinelli, 2001). In addition to the findings that resistance exercise improves RMR, cardiovascular training has shown to be effective at maintaining weight loss (Pollock et al., 1998).
However, other analysis of TBL show indicate that exercise alone would not have a significant impact on RMR compared to that of changes to diet, an analysis of the show simulated that exercise alone was predicted to decrease RMR by only 1% versus baseline whereas dietary changes alone was predicted to suppress RMR by 25%.
Examining "The Biggest Loser" (TBL) it is clear that the contestants are taking part in a weight loss exercise program that makes it harder to maintain long term. The detrimental physiological and physical impact on the contestant’s bodies sets them up for long term failure. This matches the 6 month re-test data that was gathered on the RMR and weight of those who took part.
Studies have found that by completing a doctor-recommended weight loss regime that is driven by the individual (as observed in the national weight control registry) that sustained weight loss/lost is more likely to prevail. Pairing a sensible weight-loss/maintenance program with resistance exercise can help the body in bringing the BMR back to normal levels for a person’s build following a diet, provided that there has not been significant fat-free mass (FFM) lost.
TBL's target market is those who subscribe to the “all-or-nothing” principle of dieting that became popular after the millennium. With contestants providing entertainment through their extreme ‘journey’ viewers are sucked in to watching the show. One can assume If the weight loss was 0.5kg per week with 1 hour of exercise per day, instead of its current format, many would not tune in.
TBL feeds the growing trend of “fad diets” which promise huge results in very little time, often misrepresenting facts to sell a product or service to appeal to modern expectations of immediate gratification.
For real, sustainable long-term weight loss the conclusion is a simple one. Sensible weight loss targets combined with a mild 10-20% calorific deficit and regular varied exercise will lead to sustained weight loss; post-diet, balancing exercise and diet will lead to an easy weight sustain.
Astrup, A. (1999). Meta-analysis of resting metabolic rate in formerly obese subjects. American Journal of Clinical Nutrition, [online] 69(6), pp.1117-1122. Available at: http://www.ncbi.nlm.nih.gov/pubmed/10357728 [Accessed 18 May 2016].
Biology of Human Starvation. (1952). Nature, 170(4318), pp.177-177.
Cunningham JJ, J. (1991). Body composition as a determinant of energy expenditure: a synthetic review and a proposed general prediction equation. American Journal of Clinical Nutrition, 54, pp.963-969.
Edward, W. (2016). "On ‘The Biggest Loser,’ Health Can Take Back Seat". The New York Times. [online] Available at: http://www.gainesville.com/article/20091125/ZNYT01/911253011/1109/SPORTS?p=2&tc=pg [Accessed 18 May 2016].
Fukagawa, N., Bandini, L., Dietz, W. and Young, J. (1996). Effect of Age on Body Water and Resting Metabolic Rate. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 51A(2), pp.M71-M73.
Hall, K. (2013). Diet versus exercise in “the biggest loser” weight loss competition. Obesity, 21(5), pp.957-959.
Johnstone, A., Murison, S., Duncan, J., Rance, L. and Speakman, J. (2005). Factors influencing variation in basal metabolic rate include fat-free mass, fat mass, age, and circulating thyroxine but not sex, circulating leptin, or triiodothyronine. American Society for Clinical Nutrition, 82(5), pp.941-948.
Keys, A. and Drummond, J. (1950). The biology of human starvation. Minneapolis, Minn.: Univ. of Minnesota Pr. [usw.].
Klem, M., Wing, R., McGuire, M., Seagle, H. and Hill, J. (1998). Psychological symptoms in individuals successful at long-term maintenance of weight loss. Health Psychology, 17(4), pp.336-345.
Kolata, G. (2016). After ‘The Biggest Loser,’ Their Bodies Fought to Regain Weight. The New York Times. [online] Available at: http://www.nytimes.com/2016/05/02/health/biggest-loser-weight-loss.html?_r=0 [Accessed 18 May 2016].
LEMMER, J., IVEY, F., RYAN, A., MARTEL, G., HURLBUT, D., METTER, J., FOZARD, J., FLEG, J. and HURLEY, B. (2001). Effect of strength training on resting metabolic rate and physical activity: age and gender comparisons. Medicine and Science in Sports and Exercise, 33(4), pp.532-541.
Pitney, N. (2010). "Biggest Loser: Contestants Admit Dangerous Practices, Can't Speak Out". [online] The Huffington Post. Available at: http://www.huffingtonpost.com/2009/11/25/biggest-loser-contestants_n_370538.html [Accessed 18 May 2016].
Pollock, M., Gaesser, G., Butcher, J., Despr??s, J., Dishman, R., Franklin, B. and Garber, C. (1998). ACSM Position Stand: The Recommended Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory and Muscular Fitness, and Flexibility in Healthy Adults. Medicine & Science in Sports & Exercise, 30(6), pp.975-991.
Poretsky, G. (2016). "Bigger Loser Finalist Says Show Gave Her An Eating Disorder". [online] Jezebel.com. Available at: http://jezebel.com/5564997/bigger-loser-finalist-says-show-gave-her-an-eating-disorder [Accessed 18 May 2016].
Pratley, R. (1994). "Strength training increases resting metabolic rate and norepinephrine levels in healthy 50-to 65-yr-old men.". Journal of Applied Physiology, [online] 76(1), pp.133-137. Available at: http://www.ncbi.nlm.nih.gov/pubmed/8175496 [Accessed 18 May 2016].
Sumithran, P., Prendergast, L., Delbridge, E., Purcell, K., Shulkes, A., Kriketos, A. and Proietto, J. (2011). Long-Term Persistence of Hormonal Adaptations to Weight Loss. New England Journal of Medicine, 365(17), pp.1597-1604.
Weinsier, R., Schutz, Y. and Bracco, D. (1992). Reexamination of the relationship of resting metabolic rate to fat-free mass and to the metabolically active components of fat-free mass in humans. Americal Journal of Clinical Nutrition, 55, pp.790-794.
Weyer, C., Walford, R., Harper, I., Milner, M., MacCallum, T., Tataranni, P. and Ravissin, E. (2000). Energy metabolism after 2 y of energy restriction: the biosphere 2 experiment. American Journal for Clinical Nutrition, [online] 72(4), pp.946-953. Available at: https://www.ncbi.nlm.nih.gov/pubmed/11010936 [Accessed 19 May 2016].
Wikipedia. (2016). The Biggest Loser (season 1). [online] Available at: https://en.wikipedia.org/wiki/The_Biggest_Loser_(season_1) [Accessed 18 May 2016].
Wikipedia. (2016). The Biggest Loser (U.S. TV series). [online] Available at: https://en.wikipedia.org/wiki/The_Biggest_Loser_%28U.S._TV_series%29 [Accessed 18 May 2016].
Winett, R. and Carpinelli, R. (2001). Potential Health-Related Benefits of Resistance Training. Preventive Medicine, 33(5), pp.503-513.
Wing, R. and Hill, J. (2001). SUCCESSFUL WEIGHT LOSS MAINTENANCE. Annu. Rev. Nutr., 21(1), pp.323-341.
Wyatt, H. (1999). Resting energy expenditure in reduced-obese subjects in the National Weight Control Registry. The American journal of clinical nutrition, [online] 69(6), pp.1189-1193. Available at: http://ajcn.nutrition.org/content/69/6/1189.long [Accessed 18 May 2016].