Keeping the Weight Off

Weight loss and maintenance of weight loss is difficult if not nearly impossible for most people.

A registry of individuals who have lost 30 pounds or more and maintained their weight loss over a year exists in the U.S. This research effort is known as the National Weight Control Registry. It currently has over 10,000.

I was looking at some of the published research results from this study. A paper published in 2012 used cluster analysis to identify sub-types of individuals with successful long-term weight loss.

The study identified four specific sub-types of successful dieters. The varied on a variety of historical, demographic and behavioral variables. However, I was impressed by the amount of exercise the participants documented.

Over 90% of the successful dieters burned an average of 2500 calories in a typical week of physical activity. Although calories burned by exercise varies by weight a typical weekly amount of exercise to burn 2500 calories per week would be:

• Walking 25 miles per week (six plus hours walking per week)
• Running 18 miles per week (three plus hours running per week)

These levels of physical activity are two to three times more than typical recommendations for physical activity in the general population.

This study suggests successful weight loss maintenance is hard work. Unless you are committed to and capable of this level of activity it may be nearly impossible to lose weight and keep the weight off.

Readers with more interest in this study can access the free full-text manuscript by clicking on the PMID link in the citation below.

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Photo of fireworks is a Moto G4 plus smartphone pic from my files.

Ogden, L., Stroebele, N., Wyatt, H., Catenacci, V., Peters, J., Stuht, J., Wing, R., & Hill, J. (2012). Cluster Analysis of the National Weight Control Registry to Identify Distinct Subgroups Maintaining Successful Weight Loss Obesity, 20 (10), 2039-2047 DOI: 10.1038/oby.2012.79

Which States Have Highest Obesity Rates?

In a previous post I examined the geographic variability of physical activity in the U.S. West coast states tended to have the highest rates of physical activity.

The CDC map of rates of obesity (BMI of 30 or greater) shows a similar pattern of distribution. States with higher physical activity rates show lower rates of obesity.

The five states with the highest prevalence of obesity in the general population are:

1. Mississippi 35.1%
1. West Virginia 35.1%
3. Arkansas 34.6%
4. Tennessee 33.7%
5. Kentucky 33.2%

States with the lowest rates of obesity.

1. Colorado 21.3%
2. Hawaii 21.8%
3 District of Columbia 22.9%
4. Massachusetts 23.6%
5. California 24.1%
5. Utah 24.1%

Data and chart are from the CDC website.

For more information see:

Nutrition, Physical Activity and Obesity Data, Trends and Maps web site. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity and Obesity, Atlanta, GA, 2015. Available athttp://www.cdc.gov/nccdphp/DNPAO/index.html.

Who Meets Physical Activity Goals?

The Center for Disease Control (CDC) in the U.S. recommends adults participate in a minimum of 150 minutes of moderate exercise or 75 minutes of intense exercise weekly.

There is significant geographic variability in percentage of adults meeting recommended levels of physical activity.

The chart in this post is generated from the CDC website and plots individual states and the rates for adults achieving the physical activity goal. Darker blue colors indicate greater physical activity. 

The 12 states with over 55% of adult meeting the physical activity goals include:
1. Washington
2. Oregon
3. California
4. Montana
5. Utah
6. Colorado
7. New Mexico
8. Alaska
9. Vermont
10. New Hampshire
11. Hawaii
12. District of Columbia

The 6 states with less than 45% of adults meeting the physical activity goals include:
1. Texas
2. Oklahoma (my state)
3. Arkansas
4. Mississippi
5. Tennessee
6. Indiana

The reasons for this significant variation between states is unclear. There appears to be some inverse correlation between state physical activity level rates and obesity rates.

More information about these patterns can be found in the citation below:

Nutrition, Physical Activity and Obesity Data, Trends and Maps web site. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity and Obesity, Atlanta, GA, 2015. Available at http://www.cdc.gov/nccdphp/DNPAO/index.html

Academic Performance in Adolescents: Behavioral Correlates

Galileo Bust in Galileo Museum, Florence (wryates photo)

There is a significant level of interest in the best behavioral activity balance in adolescents.

Adolescents currently live in an environment of expanding opportunities for spending time watching TV, surfing the internet and playing video games.

Understanding the best balance of study, exercise and time in front of a screen is an important topic.

Kristen Corder and colleagues recently examined adolescent behavioral activity patterns and performance on the General Certificate of Secondary Education (GCSE) exam in British adolescents.

They examined the amount of time adolescents spent in physical activity, screen-time (TV, internet, computer gaming) and non-screen time (reading/homework). These behavioral activity measures were then linked to the performance on the GCSE. The GCSE is taken by all British students at the end of Year 11 schooling, corresponding with an average age of 16 years.

The key finding from the study included the following:

• Physical activity levels did not correlate with academic performance
• Increasing amounts of screen time correlated with poorer academic performance with one extra hour linked to a 9.3 lower score
• Increased amounts of non-screen time (reading/homework) correlated with higher performance (one extra hour per day was associated with an increase of 23 points on the GCSE)

The study found that the benefit of hours spent doing homework peaked at 4 hours per day. Those spending less or more than 4 hours per day in study had lower GCSE exam scores.

Some studies of exercise in adolescents demonstrated increased academic performance with greater levels of exercise. This effect was not seen in the current study that used date from an activity monitor to measure physical activity. The authors note that physical activity should be promoted primarily for health benefits in adolescent age groups.

The implications of this study for parents is that a balanced activity schedule is important for adolescents. Providing support for at least 4 hours of study/reading per day appears optimal. Physical activity and screen time after completing optimal homework hours does not appear to have significant academic performance effects.

Individuals with more interest in this study can access the free full-text manuscript by clicking on the PMID link on the citation below.

Photo of Galileo bust from the Galileo Museum is from the author's files. 

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Corder K, Atkin AJ, Bamber DJ, Brage S, Dunn VJ, Ekelund U, Owens M, van Sluijs EM, & Goodyer IM (2015). Revising on the run or studying on the sofa: prospective associations between physical activity, sedentary behaviour, and exam results in British adolescents. The international journal of behavioral nutrition and physical activity, 12 (1) PMID: 26337325

Exercise in the Prevention of Alzheimer's Disease

Growing evidence links physical activity to improved cognitive outcome in elderly individuals.

Few studies have examined effects of exercise on those at highest risk for Alzheimer's disease.

J Carson Smith and colleagues recently published a prospective study of a cohort of older adults using structural magnetic resonance imaging.

The key elements of the design of their study included the following elements:
Participants: 97 adults between the ages of 65 and 89
Physical activity level: Frequency and intensity of leisure activity was assessed using the Stanford Brief Activity Survey
Alzheimer's risk status: Assessed using APOE genotype
Brain scanning protocol: Magnetic resonance imaging of brain using a 3T scanner at baseline and 18 months later. The brain hippocampal volume was identified as a key structure involved in APOE-related atrophy and memory decline
Statistical analysis: Participants were grouped in low and high physical activity groups and those with and without high-risk APOE Alzheimer's risk

The research team identified a statistically significant interaction between high-risk Alzheimer's participant and physical activity:

"Hippocampal volume decreased 3% in the High Risk/Low PA (physical activity) group whereas the volumetric changes in the remaining three groups were negligible."

The high-risk Alzheimer's group that participated in higher levels of physical activity appeared to have significant protection against hippocampal atrophy. To reach the higher levels of physical activity in the study they had to endorse one of the following levels:

• Brisk walking 15 minutes daily three or more days per week
• Jogging 15 minutes daily three or more days per week
• Swimming 15 minutes daily three or more days per week
• Moderately difficult chores 45 minutes daily three or more days per week
• Regular jogging, running, bicycling or swimming 30 minutes or more
• Playing sports such as handball or tennis an hour or more 

The authors examine the potential mechanisms for physical activity to reduce hippocampal atrophy in those with the high risk APOE genotype.

They note the beneficial effect of exercise may be through effects on cholinergic function, brain lipid metabolism or reduced neuroinflammation.

If this study is replicated it is an important finding with several implications.

One implication is that it may be one of the first research findings to support routine genetic testing for APOE and Alzheimer's risk. Those identified as high risk by APOE status could be targeted for aggressive behavioral interventions to increase physical activity along with increased surveillance of cognitive function.

Readers with more interest in this research can access the free full-text manuscript by clicking on the PMID link in the citation below.

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Photo of roseate spoonbill at sunset is from the author's files.

Smith JC, Nielson KA, Woodard JL, Seidenberg M, Durgerian S, Hazlett KE, Figueroa CM, Kandah CC, Kay CD, Matthews MA, & Rao SM (2014). Physical activity reduces hippocampal atrophy in elders at genetic risk for Alzheimer's disease. Frontiers in aging neuroscience, 6 PMID: 24795624

Getting Women with Fibromyalgia Moving

What is fibromyalgia and what exactly what does exercise have to do with the treatment and long-term outcome of the condition?  A recent study published in Medicine & Science in Sports & Exercise is helpful in understanding the relationship between fibromyalgia and exercise and how clinicians (and patients) might find better strategies for treatment.

Fibromyalgia is a clinically defined pain syndrome estimated to affect about 5 per cent of the general population with criteria for diagnosis defined by the American College of Rheumatology to include:

• Pain in all four quadrants of the body
• Pain along the spine
• Presence of 11 of 18 specific tender points

The 18 specific tender points (or trigger points) are outlined in the accompanying public domain figure from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and Wikipedia.

Women have higher prevalence rates for fibromyalgia.  The reason for this gender discrepancy in unknown as is the cause of the disorder.   Patients meeting criteria for this medical pain disorder commonly have significant cognitive and emotional symptoms as well.   Endorsement rates for problems with cognitive impairment (poor concentration, memory problems, psychomotor speed problems and diminished attention span) are common in fibromyalgia.  Additionally, rates of anxiety and mood symptoms and disorders appear high.  The cause for this association is also unknown.

Like many pain syndromes, exercise seems to be helpful in the long-term management of fibromyalgia.  Although a natural response to pain is to reduce activity, this physical withdrawal can be counterproductive to a good long-term outcome.  It is important for women with fibromyalgia and their physicians to assess and monitor response to exercise as a key component to treatment.

McLoughlin and a research team from the University of Iowa and the University of Wisconsin studied the relationship between self-reported exercise and actual exercise in a group of women with fibromyalgia and a group of women without fibromyalgia.  They utilized an accelerometer that was worn on the hip for 7 days to compare actual activity levels to what the women were reporting.   The key findings from the study were:

• Fibromyalgia subjects reported less physical activity (confirmed by accelerometer data) than controls
• Both those with fibromyalgia and controls reported higher levels of activity than could be validated by accelerometer data
• Self-report activity levels were poorly correlated with accelerometer activity in fibromyalgia but not controls
• High depression scores in fibromyalgia correlated with lower physical activity

For clinicians, the take home message here is you can’t rely only on your fibromyalgia patient’s self-report of exercise.  I think we will be seeing more use of devices such as accelerometers in clinical practice to get a more objective measure of physical activity.  Similar movement measurement capabilities (like those found in accelerometers) are available in the iPhone and iPod Touch.  Such tools may also be used to monitor change in activity with a new intervention, i.e. attending Jazzercise on a regular basis.  Targeting depression treatment in women with fibromyalgia may be one method to improve the chances of getting activity levels up.

The need for implementing activity programs is not limited to the medical illness of fibromyalgia.  Similar programs in obesity, heart disease, diabetes and lung disease are needed.  Collecting activity levels in these and other medical conditions may give clinicians additional insight into the effects of inactivity on disease progression.

Getting activity levels up in fibromyalgia can lead to significant improvement.  A recent trial of exercise in fibromyalgia by Fontaine and colleagues found regular activity reduced pain and reduced functional impairment.  This intervention paired education with a pedometer data that would be monitored by the research team.  When accountability is incorporated in exercise trials, compliance and benefits go up.

MCLOUGHLIN, M., COLBERT, L., STEGNER, A., & COOK, D. (2011). Are Women with Fibromyalgia Less Physically Active than Healthy Women? Medicine & Science in Sports & Exercise, 43 (5), 905-912 DOI: 10.1249/MSS.0b013e3181fca1ea

Fontaine KR, Conn L, & Clauw DJ (2010). Effects of lifestyle physical activity on perceived symptoms and physical function in adults with fibromyalgia: results of a randomized trial. Arthritis research & therapy, 12 (2) PMID: 20353551