Should we reconsider the benefits of exercise and weight loss?

Diet and exercise: they were supposed to be the answer to all that ails America’s obesity and health care cost problem.

Signs of this Utopian vision are everywhere.  From entire government departments encouraging healthy lifestyles through fitness, sports and nutrition, government websites that encourage “healthy lifestyles,” and entire community efforts to partner with health care organizations to fight obesity with the hope of cutting health care costs.

What if, believe it or not, when it comes to people with Type II diabetes, diet and exercise don’t affect the incidence of heart attack, stroke, or hospital admission for angina or even the incidence of death?

Suddenly, all health care cost savings bets are off.  Suddenly, we have to re-tool, re-think our approach, understand and appreciate the limitation of lifestyle interventions to alter peoples’ medical destiny.  Suddenly we have to come to grips with a the reality that weight loss and exercise won’t affect outcomes in certain patients.  Suddenly, there is a sad reality that patients might note be able to affect their insurance premiums by enrolling in diet and exercise classes after all.

These thoughts are so disruptive to our most basic “healthy lifestyle” mantra that few can fathom such a situation.  Nor would any members of the ever-beauty-and-weight-conscious main stream media be likely to report such a finding if it came to pass.

And yet, that is exactly what has happened.

The Look AHEAD trial studied 5145 adults with type 2 diabetes who had a body mass index (BMI) > 25.  The purpose of the study was to compare the incidence of  nonfatal myocardial infarction (heart attack), nonfatal stroke, death, or hospitalization for angina between diabetics who received a rigourous weight loss and exercise program with education to just an educational approach alone.   Interestingly, the study failed to show any effect of weight loss and exercise over simple education about the disease in the incidence of these “macrovascular” endpoints.  In fact, the study was stopped early.

So disturbing were these findings to our basic understanding of disease prevention that the principle investigator recently appeared on Medscape in print and in video format to reassure the physician community:  “I can tell you from the outset that we were successful.”

And yet, they were not: they did not affect the incidence of stroke, heart attack, death, or admission to a hospital for angina in overweight Type II diabetic patients one bit, even after 11 years of trying.

You see, it is uncomfortable to sit with the reality that exercise and fitness might not be as helpful as we had hoped at altering certain health care outcomes.  So we ignore these trials.  We don’t report them in main stream media because we don’t like to feel uncomfortable with the realization that there’s much we still don’t know or understand about exercise and weight loss at affecting health outcomes in medicine.

Yet there is so much to learn from trials like this because they fly in the face of conventional wisdom.

Maybe we should stop pouring money into fitness rooms and health clubs and promote other intellectual or spiritual pursuits instead.   Maybe we should reconsider the benefits of exercise and weight loss as psychologic more than physical.  Maybe we should de-fund all those government programs set up to promote exercise and fitness as our path to health care cost-savings.

Or at the very least, we should just eat some humble pie, stop fooling ourselves, and understand the limitations of lifestyle interventions like weight loss and exercise to improve medical outcomes or to reduce health care costs in America.

Wes Fisher is a cardiologist who blogs at Dr. Wes.

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  • civisisus

    Maybe we should all agree that any poster who uses the dog-whistle “main stream media” in a post should be kicked in the reproductive organs before being allowed to post again on any internet ever.

  • doitbetter

    You could write it all off and quit. Or you could look to outliers outside the medical community who are doing big things with lifestyle coaching, exercise and new information and having success. Lots and lots of folks have had incredible change in their lives, through exercise and food consumption changes, through whole food nutrition, weightlifting, crossfit, paleo, and OPT. But the medical and research science is behind where these pioneers are advancing. Look to the people who ARE succeeding.

  • Jonathan Marcus

    Let me get this straight. You looked at one study and you give up. Sad.

    As a family doctor I can count a quite a number of patients who’s life and health were transformed by changing their diet and exercise patterns… for the long term. I’ve seen diabetic patients normalize their blood sugar and come off medication. I agree with doitbetter when he/ she says to look at those who are successful…. and ask why and how.

  • Dustin Salzedo

    I’ve been in the weeds going through the study protocol, and…the nutritional composition included commercial processed liquid diet “food” w/ macros C/P/F 55/15/30 and <10% sat. This would leave a whole lot of n-6 fats in the diet and not much in the way of n-3. It also doesn't state how much added sugar and fructose is in this diet. I think this is a major limitation in the study and may be a significant factor in the outcomes. It also may be that once patients tip over into DMII, there is irreversible vascular damage and endocrine perturbations. I don't think this study's outcomes translate into failure, but rather, that a whole foods diet eaten in a socially and culturally pleasurable and acceptable way and devoid of highly processed food products will lead to different outcomes. One maor difference is that when severe calorie restriction is used in diets using highly processed foods and lots of carbs, satiety is rarely achieved, and dieters tend to rebound with overeating once the restriction is lifted. With a paleo focus, satiety is usually achieved without intentionally restricting calories and without food cravings, and so the maintenance phase of eating this way doesn't change.

    It also may be time to give crowd-sourced studies a second look. They appear to have utility. As doitbetter commented below, there are many people following a paleo/antiinflammatory style diet who are reporting long-lasting significant improvements in chronic diseases, and they are also reporting that their diets are easily maintained while eating this way.

  • Alison Curtis

    I don’t buy this. If you are looking at the benefits of the standard american diet even a so called Healthy standard american diet, the shortcomings are numerous. I beg you to go look at Dean Ornish’s works or those of the gentlemen featured on ” Forks Over Knives”. Reversing Heart Disease and diabetes CAN BE DONE. We are just DOING It WRONG. A plant based diet can take care of it.

  • Kathleen Summers MD

    The average BMI was 35 and the sustained weight loss was 5%. If you weighed 300 pounds and were “successful” in the program, then you still weighed 285 pounds after 11 years. And you’re surprised they didn’t see a big difference in events?

    The patients were already well controlled with BP and blood sugar medications prior to the start of the study, and the control group, even though they weren’t getting intensive guidance, also lost weight and took better care of themselves (they knew they were in a study after all). That makes a comparison between the two arms messy and about how much weight was lost with a program versus how much weight was lost on their own. Both groups actually had relatively low event rates.

    What this study really says – again – is that it’s hard to get people to change their lives significantly – enough to drop large amounts of weight to seriously impact obesity-related diseases..It doesn’t really saying anything about whether adopting habits that return you to a normal weight will “normalize” your health.

    The real question is not whether a healthy diet and exercise really work (they do – this is one study that doesn’t properly address the issue), but how do we as clinicians, friends, and family members motivate each other to embrace a positive lifestyle change that returns our population back to a healthy weight?

  • Doreen Mohammed

    Maybe it’s more important (and of course ideal, but not completely impossible) to focus on preventing such diseases [diabetes, heart disease, hypertension] as much as possible in the first place, rather than allowing such diseases to manifest and then using preventive measures to calm them down? On top of that, lifestyle changes DO make a difference even after one gets such ailments…

  • John Wickenden

    The question is are your newly-made athletes increasing their mortality or just feeling better?
    I cycle and swim and so on and while the mood benefits and good sleep would be enough reward I tend to assume automatically it’s “good” for me. But medicine (and every other -ology) is full of communal assumptions and from what Christopher Ryan says your Stone Age friends…..I mean the original ones….. had a whole lot of time for sitting around. The corollary would be of course that our genes are designed to survive well in slouching mode. 
    So let’s see the “exercise works” evidence mentioned in comments……high quality meta-evidence only, of course.
    John Wickenden. Chiangmai, Thailand.

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