Competing our way to better health

Reactions to the finale of the latest season of “The Biggest Loser” seem to fall into two general categories:

1) Rachel Frederickson, who shed more than half of her body weight to win the competition and take home $250,000, looks fabulous and deserved the prize for her hard work.

2) Rachel lost too much weight too rapidly and is a prime example of everything that’s toxic about how Americans view food behavior and entertainment.

Amid all the chatter, not to mention the snark, that has swirled around the show for the past several days, there’s one point that seems worthy of extended, thoughtful public discussion: What are the ethics of creating competition around people’s health?

Treating individual health as fodder for a contest is by no means confined to “The Biggest Loser.” Corporate and community initiatives abound that pit individuals and teams against each other to see who can lose the most weight, walk the most steps, exercise the most hours and so on. The popularity of “The Biggest Loser” has spawned imitation contests in workplaces, neighborhoods and even churches.

What’s the harm, as long as it helps motivate people to change their behavior? Well, not so fast.

The competitive approach may be successful for some, and it may inspire many on-the-fencers to become more engaged. For a story last year on corporate wellness trends, the Washington Post talked to an office worker from Maryland who joined a corporate fitness challenge and lost 42 pounds. “There’s sort of like a peer pressure and a competitiveness to it,” Sal Alvarez told the Post, adding that he found it very motivating.

Not everyone responds well to competition, however, and some people may even find it alienating, especially if they feel coerced to participate.

Although there are plenty of positive stories about how wellness challenges have helped people change their lives, there’s surprisingly little solid evidence of competition’s overall effectiveness as a health improvement strategy. More importantly, it’s not clear whether competition leads to behavior change that’s sustained after the contest is over.

Then there’s the matter of prizes. Are people motivated by the prospect of T-shirts, water bottles and gift cards? Do they need carrots to entice them to take action or is it better to emphasize good health as the reward? What if the carrot is really, really significant, such as the quarter of a million dollars dangled before the Biggest Loser contestants?

With that amount of money at stake, along with a chance to be on national TV and impress their family and friends, it shouldn’t be surprising that the participants in the show would become uber-competitive, possibly to the point of going overboard.

In a recent interview with People magazine, Rachel herself conceded that she “maybe” was “a little too enthusiastic in my training to get to the finale.”

Maybe competition is OK, as long as it helps people accomplish their health goals. Then again, maybe it exploits people’s vulnerabilities and propels them into doing something perhaps the wrong way or for the wrong reasons. Does the end justify the means? That’s the moral question that hasn’t really been answered.

‘The Biggest Loser’: inspiring or unhealthy?

Does “The Biggest Loser” empower people to lose weight and transform their lives, or does it promote unsafe, unrealistic methods for weight loss?

An online debate over the television reality show erupted last week at MedPage Today in response to a researcher’s study of the cultural assumptions behind “The Biggest Loser.”

Contestants on the show are taken to a ranch in California, where they work with trainers and nutrition specialists, undergo hours of exercise and compete in challenges to see who can drop the most pounds.

Natalie Ingraham, who is on the faculty at the University of California San Francisco, and her colleagues have been analyzing episodes of the popular show and the messages it sends about fatness and fitness. The study is still under way, but Ingraham shared some of the early findings during a panel discussion at a recent meeting of the American Public Health Association.

Among some of her preliminary conclusions: The show promotes unrealistic expectations about how much and how quickly people can lose weight. It rarely follows up with contestants afterwards to find out whether they maintained their weight loss.

More than this, though, “The Biggest Loser” suggests that people who are overweight can lose large amounts of weight, and that this is the ideal they should strive for, Ingraham said in her findings.

Her research prompted a response from none other than Bill Germanakos, the Season 4 winner of “The Biggest Loser” who now works as a health and wellness spokesman. Germanakos took exception with how the show was characterized, pointing out that participants have access behind the scenes to dietitians, psychologists and physicians specializing in weight loss.

Far from being stigmatizing, the show is inspirational, Germanakos said. “It shows obese people that are helpless and hopeless that there is HOPE and is meant to inspire and motivate those who thought they had tried everything.”

Sure, the show tends to dramatize people’s struggles for the sake of ratings, and the weight loss regimen it depicts doesn’t represent real-life conditions, other commenters agreed. But most said they found “The Biggest Loser” motivational. It’s “a great show that promotes healthy lifestyles,” a registered dietitian wrote.

Really? “Losing weight is hard, keeping it off is even more of a challenge as supported by research findings – most people gain back the weight they lose plus a few more pounds,” one commenter observed. She said she watched the show a few times and then quit. “Health is not about competing against each other, even in the spirit of being inspirational,” she wrote.

While the show may have helped some of the participants, the real issue “is not about the few, it is about the many,” someone else wrote. “These messages simply do not represent the reality for the majority. They continue the cycle of shame, blame, guilt, discrimination and abuse (by self and others).”

There in fact has been some ongoing debate about both the message and the methods of “The Biggest Loser,” although Ingraham appears to be one of the first to attempt to systematically analyze the show. Last year the St. Petersburg (Fla.) Times interviewed Kai Hibbard, who was the second-place winner in 2006 and who painted a less-than-inspirational picture of life behind the scenes. Contestants were dehydrated and often subjected to humiliation, Hibbard told a reporter. By the end of the show, her hair was falling out and her family was urging her to see a therapist. (Producers of “The Biggest Loser” said they’ve made changes in the show since then and they advocate “doing this the right way.”)

Psychologists also have criticized the show’s emphasis on weight loss as the sole measure of success, the implication being that overall physical and mental health don’t count and that if people don’t lose enough weight, they’re failures.

One of the most blunt assessments comes from Big Fat Blog, which questioned the entire premise of the show before it even went on the air:

This is substantial, and substantially harmful, reinforcing notions that all fat people are gluttonous over-consumers of junk food (all the temptation foods are junk, pastries and snack items) with no willpower unless something major ($1 million) is at stake, presenting the idea that a rigid regimen of forced exercise and a diet seemingly consisting of a lot of raw carrots, brown rice and grilled chicken breasts is the only (best?) way to lose weight, and that it is healthy to make a major change in activity and food intake levels all at once and any effort the body makes to resist those changes is entirely in the mind, indicative of a lack of will.

Add the coercive elements – the team and individual competition, the fact that team members lose challenges and therefore money and/or prizes and/or food privileges due to the behaviors of others — and this is just a gross violation; not just of the people who’ve been led (by a billion different factors) into believing that their bodies make them deserving of this treatment in order to win money but of all fat people, who are now given another set of false and dangerous media-created standards to either deny (the eating stereotypes) or live up to (the draconian diet/exercise ideas).

In the interests of full disclosure, I’ve never watched “The Biggest Loser” nor do I want to. Science still has a lot to learn about the mechanisms that govern weight and the complex ways these interact with psychology, environment and social behavior, and we oversimplify this at our peril. I’d like to think the definition of good health encompasses more than a single number on the scale. What do readers think?

Rating the weight-loss plans

In the world of diets, apparently not all are created equal. Consumer Reports recently evaluated seven of the most popular diet plans and picked a winner: Jenny Craig. The commercial program edged out Atkins, Ornish, Weight Watchers and Slim Fast as the most successful at helping people shed pounds.

The diet plan ratings, which were issued this week, inject some facts into the often confusing and hyped-up discussion about which diets work best for whom.

The Consumer Reports health team based its rankings on the published evidence from reputable medical journals: Were people able to stick with the diet? Did they lose weight? Was the diet supported by current science on nutrition and weight loss?

Jenny Craig, which combines counseling with a regimen of prepackaged, portion-controlled foods, rose to the top on the basis of a study, published last October in the Journal of the American Medical Association, that found participants achieved an average 8 percent weight loss over two years. The study involved 332 people. In what Consumer Reports called “a remarkable level of adherence,” the majority of the participants - 92 percent – stayed with the diet plan for the entire two years of the study.

Impressive as this might sound, it doesn’t necessarily mean people who want to lose weight should rush to sign up for Jenny Craig, Consumer Reports cautioned: “It’s obviously worth considering, but if you don’t like the idea of eating prepackaged meals, it might not be for you.”

In the long run, the best diet is the one you can live with, Kathleen Melanson, Ph.D., associate professor of nutrition and food sciences at the University of Rhode Island and director of the university’s Energy Balance Laboratory, told Consumer Reports. “If you’re forcing yourself on a diet you hate, it’s going to be really hard to stick with long term,” she said.

More food for thought from the Consumer Reports ratings:

- No matter what kind of diet you’re on, you won’t lose weight unless you burn more calories than you take in. But the evidence is beginning to show that some types of calories are more filling than others. Diet plan creators are increasingly incorporating this knowledge into how they design their menus – higher in protein, fiber, fruits and vegetables that fill people up and reduce hunger pangs without upping the calorie count.

- The evidence is growing that refined carbohydrates, such as those found in white bread and potatoes, contribute to weight gain and type 2 diabetes because of how they affect blood sugar and insulin levels.

- Fat appears to be less detrimental to health than commonly believed. Although it’s still “a subject of vigorous scientific debate,” saturated fat doesn’t seem to raise the risk of cardiovascular disease or stroke, according to Consumer Reports.

- Some studies suggest that dieters are better off if they replace the saturated fat in their diet with unsaturated fat rather than refined carbs.

- A dietary middle ground, suggested by Dr. Michael L. Dansinger, assistant professor of medicine at Tufts University and a weight-loss researcher: “a low-ish carbohydrate diet that’s high in vegetables and lean protein, including dairy; moderate in fruit; with nonsaturated fat from sources such as olive oil, nuts, avocados and fish.”

- Emotional support systems can make a difference. Jenny Craig offers both telephone and in-person counseling. Support group meetings also are one of the foundations of the Weight Watchers plan, which came in third in the Consumer Reports ratings, and the Ornish diet.

Update: As the ratings are further analyzed, some criticism and caveats have been emerging. The most notable objection: The study on which Consumer Reports based its rankings didn’t reflect diet conditions in the real world. Consumer Reports is defending its evaluation of the diet plans, pointing out that it was based on current science.

Is Jenny Craig really the best? It depends. For people who have difficulty with portion control or menu planning, or simply don’t like to cook, the prepackaged food may be an approach that works for them. Other people might have better success with a different strategy.

What the debate seems to underscore is that there’s no single approach that objectively works for everyone – and that losing weight, let alone sustaining weight loss over the long term, is extremely difficult for many of us.

Photo: Wikimedia Commons