One of my family's favorite show's is The Biggest Loser, although some viewers don't appreciate how it pushes people so hard to lose weight, the show probably inspires some overweight people to regain control of their lives. But one of the most frustrating parts of the show, at least for me, is its overwhelming emphasis on exercise, because when it comes to reaching a healthy weight, what you don't eat is much much more important. Last week I talked about the many ways exercise is awesome. This week I want to focus on one way it's not, weight loss. Sorry, but that's the topic of this week's Healthcare Triage.

(Intro)

Think about it this way. If an overweight man is consuming a thousand more calories than he's burning and wants to be in energy balance, he can do it by exercising. But exercise consumes far fewer calories than many people think.

30 minutes of jogging or swimming laps might burn off 350 calories. But many people, fat or fit, can't keep up a strenuous 30-minute exercise regimen, day in and day out. They might exercise a few times a week, if that. Or they could achieve the same calorie reduction by eliminating two 16 ounce sodas each day. Proclamations that people need to be more active are ubiquitous in the media. The importance of exercise for proper weight-management is reinforced when people bemoan the loss of gym class in schools as the cause of the obesity epidemic. Even Michelle Obama's Let's Move program places the focus on exercise as a critical component in combating excess weight and obesity.

There are any number of things wrong with this approach. The first is that it's just not true that Americans in general aren't listening to calls for more activity. From 2001 to 2009, the percentage of people who were sufficiently physically active increased, but so did the percentage of Americans who were obese. The former did not prevent the latter. Studies confirm this finding. A 2011 meta-analysis looked at the relationship between physical activity and fat mass in children, and found that being active is probably not the key determinant in whether a child is at an unhealthy weight. In the adult population, interventional studies have difficulty showing that a physically active person is less likely to gain excess weight than a sedentary person. Further, studies of energy balance, and there are many of them, show that total energy expenditure and physical activity levels in developing and industrialized countries are similar, making activity and exercise unlikely to be the cause of differing obesity rates. Moreover, exercise increase's one's appetite. After all, when you burn off calories being active, your body will often signal to you to replace them. Research confirms this.

A 2012 systematic review of studies that looked at how people complied with exercise programs showed that over time, people wound up burning less energy with exercise than predicted and also increasing their caloric intake. Other metabolic changes can negate the expected weight loss benefits of exercise over the long-term. When you lose weight, metabolism often slows. Many people believe that exercise can counter or even reverse that trend. Research, however, shows that the resting metabolic rate in all dieters slows significantly, regardless of whether they exercise. This is why weight-loss, which might seem easier when you start, becomes more difficult over time.

This isn't to say that exercise plays no role. There are many studies that show that adding exercise to diets can be beneficial. A 1999 review identified three key meta-analyses and other randomized controlled trials that found statistically significant, but overall small, increases in weight loss with exercise. A meta-analysis published just last year found that in the long term, behavioral weight management programs that combine exercise with diet can lead to more sustained weight loss (3-4 lbs) over a year than diet alone. Over a six month period, though, adding exercise made no difference. Another systematic review from last fall found similar results, with diet plus exercise performing better than diet alone, but without much of an absolute difference.

All of these interventions included dietary changes, and the added weight-loss benefit from activity was small. There are far too many people, though, who can manage to find an hour or more in their day to drive to the gym, exercise, and then clean up afterward, but who complain that there's just no time to cook or prepare a healthful meal at home. If they would spend just half the time they do exercising trying to make a difference in the kitchen, they'd most likely see much better results. Many people think of dieting as a drastic and rigid change, with a high risk of putting the pounds back on. What's more likely to succeed are gradual changes, made in a much more sustainable way. I also don't mean to make it sound as if weight loss with diet is easy and exercise is hard. They're both hard. The challenge of a slowing metabolism and the desire to eat more occurs in both cases, although dietary change still works better than exercise.

But I can't say this enough, and if you need a reminder, go watch last week's episode again. Exercise has a big upside for health beyond potential weight-loss. But that huge upside doesn't seem to apply necessarily to weight-loss. The data just don't support it. Unfortunately, exercise seems to excite us much more than eating right does. After all, as Sarah Green said to me when I was writing my column on this topic, The Biggest Loser would be a really boring show if it were shot after shot of contestants just not overeating.

Healthcare Triage is supported in part by viewers like you through patreon.com, a service that allows you to support the show through a monthly donation. We'd especially like to thank our honorary research associates, Cameron Alexander and Qadeem Salehmohamed. Thanks, Cameron and Qadeem! If you'd like to support the show, more information can be found at patreon.com/healthcaretriage.

(Endscreen)