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The Weight Debate
Len Kravitz, Ph.D.

In a recent edition of Medicine & Science in Sports & Exercise some leading researchers (Jakicic et al. 2019, Gaesser et al., 2019) debated, in a point-counter-point combination of articles, whether the health risks of obesity have or have not been exaggerated. Our approach with this research column is the summarize several key points about obesity from these contrasting intellectual perspectives, and to provide the best practical application to the fitness professional. We will also discuss the evidence-based behavioral guidelines for treating obese populations.

Healthy Obesity is Attainable
Gaesser and Blair (2019) contend that we, as a field of researchers and practitioners, should focus more on improving health behaviors, and spend less time on weight loss strategies for those clients with BMI obesity classifications (i.e., BMI &Mac179; 30 km/m2). The researchers indicate they are not trying to minimize the risks of obesity, but to indicate there is a subpopulation of fit obese individuals, who are not adversely affected by their adiposity. Gaesser and Blair underscore research indicating that cardiorespiratory fitness is an important vital sign of health and a stronger predictor of mortality than obesity. In their conclusion, these Gaesser and Blair urge health care professionals to promote a healthier lifestyle, including physical activity and healthy diet, rather than trying to achieve a specific weight loss target. They suggest that the focus with obese individuals will be better served if we design programs primarily for enhancing fitness, as it is more important than programs directed toward combatting fatness.

Obesity is Related to All Causes of Chronic Disease and Mortality
Jakicic et al. (2019), in their counterpoint article, maintain that the health risks of obesity have not been exaggerated. The researchers cite studies showing that obese BMI levels are associated with cardiovascular disease mortality in men and women as well as all causes of mortality. The scientists continue their argument, referencing studies that show excess body weight is associated to several forms of cancer and type 2 diabetes. In regards to patients with cancer, Jakicic and colleagues note that research shows that a higher BMI is correlated with poorer survival and greater likelihood of reoccurrence of the cancer. In regards to type 2 diabetes, Jakicic et al. denote studies show that weight loss can reduce the risk of developing this disease, as well as reduce the medications needed to treat it. Several of the negative health consequences of obesity include a correlation with cardiovascular disease, type 2 diabetes, sleep disorders, low back pain, chronic pain in legs and feet, increased risk to several forms of cancer, reduced balance and mobility, and reduced health-related quality of life (Jakicic et al. 2019). Jakicic et al. propose that health care providers should target obesity similarly to other health risk factors (e.g., hypertension, hyperlipidemia, etc) in their programming.

Point-Counter Point: Both Sides Win
It is interesting to note that one overall outcome of this intellectual debate, on whether the health risks of obesity are exaggerated, further clarify the role of the fitness professional and health care provider. Clearly stated in both papers is the major premise that interventions that promote an OPTIMAL healthy lifestyle is best, as this will lead to the greatest possible health benefits for clients. Jakicic et al. (2019) state that fitness and health professionals should develop programing that improves major lifestyle behaviors such as sufficient physical activity, optimal nutrition, less sedentary behavior, no smoking, and compliance with prescription medication.

Behavioral Approaches to Treat Obesity
Lifestyle interventions that help clients lose 1-2 pounds per week, resulting in 5-10% weight loss by 6 months are genuine (Olson, Bond, and Wing, 2017). For optimal weight loss to occur, a kilocalorie deficit (approximately 500 to 1000 kilocalories/day) strategy in food consumption is necessary. Olson and colleagues suggest that for persons under 200 lbs of body weight a 1000-1500 kilocalorie dietary lifestyle is a sensible goal, whereas for clients over 200 lbs of body weight, a 1500-1800 kilocalorie approach is preferable. The researchers emphasize that the behavioral approach should be individualized for the client, as successful weight loss can be attained with a low carbohydrate or low fat approach, as long as there is some form of kilocalorie reduction.

According to Olson and colleagues, self-monitoring of body weight, food intake (including beverage consumption) and physical activity (i.e., pedometer app and exercise logs) is the best predictor of a successful behavioral approach to treat obesity. Self-monitoring serves as a cue to action for a client to recognize the effect of lifestyle on body weight and health outcomes. The researchers explain that another chief behavioral strategy is stimulus control. With stimulus control, a client is learning to reduce the cues that prompt eating and increase the cues that encourage healthy lifestyle choices. An example of this strategy is removing high calorie foods from the kitchen and replacing them with low calorie, healthy options. Other behavioral strategies to include in the behavioral treatment of obesity include goal setting (perhaps follow the S.M.A.R.T. principle: specific, manageable, attainable, realistic, and time-limited), and problem solving. With problem solving, a fitness professional may discuss an upcoming situation with a client (i.e., a party), which may make it tempting for the client to over eat (or over drink). With problem solving, the fitness professional and client can establish strategies to manage these foreseen difficult situations.

With physical activity and exercise for the treatment of obesity, steady progression is the key. Starting clients with 50 minutes per week of moderate intensity activity (e.g. brisk walking) is appropriate. Gradually progressing up to 200-250 minutes per week of exercise appears to be an optimal recommendation for maintenance of weight that is lost (Olson et al., 2017). Olson and colleagues (2017) also highlight that successful obesity interventions should have planned strategies that combat sedentary behavior (see July/August of IDEA Fitness Journal for ideas). The researchers highlight a successful weight loss program, besides having many clinical benefits, also has several psychological benefits, including reduced depressive feelings, lowered anxiety, increased self-esteem and improved body image.

Table 1. Chief Components of a Behavioral Weight Loss Program
Behavioral Strategies
Problem solving and goal setting
Self-monitoring (daily recording of diet, weight, physical activity and exercise)
Stimulus control (removing high calorie foods from the home)
Discuss strategies to increase adherence to the diet and activity goals

Calorie Restriction
Reduce fat and/or carbohydrate intake to achieve calorie goals
People >200 lbs: advise a 1500-1800 kcal/day diet
People <200 lbs: advise a 1000-1500 kcal/day diet
Individualized to produce a 500-1000 kilocalorie deficit

Physical Activity and Exercise
Begin with 10-minute sessions on 5 days of the week
Progressively increase to 30 minute sessions on 5 days in the week
Eventually increase to 200-250 minutes/week
Exercise at a somewhat hard intensity
Source: Adapted from Olson et al., 2017

Strategies for Preventing Weight Regain
Following successful weight loss, weight regain often occurs in the months subsequent to the intervention. Olson et al. (2017) suggest that our societal obesogenic environment contributes to this weight regain. An obesogenic environment includes environmental stimuli that promote physical inactivity (elevators, escalators, delivery services, computer games, television watching, etc.) and food/drink over consumption (e.g., super sizing and restaurant portion sizes). According to Olson et al., clients who maintain a lower calorie lifestyle, engage in regular physical activity and exercise, and self-monitor their weight are most likely to maintain their weight loss over time. The researchers summarize other research that concludes the strongest and most reliable predictor of long-term weight maintenance (after weight loss) is regular exercise.

Take-Home Thoughts
A great many clients seek out personal trainers in hopes to achieve new weight management goals. Evidence from this point-counter point debate suggests that if we reframe our client messaging to attaining optimal health, including sufficient physical activity, optimal nutrition, less sedentary behavior, no smoking, and compliance with prescription medication that clients results will be even much more meaningful.

Bio: Len Kravitz, PhD, CSCS, is the program coordinator of exercise science at the University of New Mexico, where he received the Outstanding Teacher of the Year and Presidential Award of Distinction. He just released his third book, HIIT Your Limit (Amazon).

Jakicic, J.M., Rogers, R.J., and Donnelly, J.E. (2019). The health risks of obesity have not been exaggerated. Medicine & Science in Sports & Exercise, 51(1), 222-225.
Gaesser, G.A. and Blair, S.N. (2019). The health risks of obesity have been exaggerated. Medicine & Science in Sports & Exercise, 51(1), 218-221.
Olson, K., Bond, D., Wing, R.R. (2017). Behavioral approaches to the treatment of obesity. Rhode Island Medical Journal, 100(2), 21-24.