Fitness II Target levels (aerobic)

How much do you need to work out? It's an interesting question. The short answer from Thomas and Wing (2009) is 1 hour a day of walking, or 200 minutes a week. Looking a little deeper, the 1 hour of walking is based off a finding that in the National Weight Control Registry, the average woman burns 2545 calories a week through exercise and the average man burns 3293. (Wing & Phelan 2005).

It's true that over 3/4 of the NWCR maintainers walk as their primary form of exercise, but most use more than one form of exercise, and cycling and weights were used by over 20% of respondents. I think rather than set the perhaps daunting goal of dedicating an hour a day to walking, it's better to encourage people to consider a variety of exercises that meet the calorie goal, and multiple modes of exercise are in keeping with the survey findings.

Hopefully you are using a fitness tracker. They are available on Sparkpeople, fitbit, myfitnesspal, and a number of other websites generally on a free basis with ads. Motion sensing video game consoles and smartphone apps are other means to track fitness.

The 200 minutes figure comes from Jakicic (2003), and looking closer at that study I saw that the 200 minutes were only required to be in bouts of 10 minutes at a time. There is ongoing debate about this, with some people saying aerobic exercise needs to happen in 20 minute bouts, but the total amount of work being done was what most predictive of successful weight management in this study. 200 minutes, which was the maximum exercise "dose" prescribed in this study, was also associated with greater cardiovascular fitness. Would ever more fitness prove even better? For me, I think 45 minutes a day is the longest I'd be interested in working out, though participation in dance, sports, and leisure activities are certainly possibilities, but there's only so much time I can put into working out at this stage in my life.

Another key predictor the NWCR has identified in their maintainers is that they watch much less TV than the average American, and Thomas and Wing (2009) theorize that this gives them more time for exercise, monitoring food intake and other weight related strategies. The average amount of TV watched by an NWCR maintainer was 6 to 10 hours vs. the national average of 28 hours. I'm already in the lower range, though I also will march in place while watching TV, especially during commercial breaks. It does not burn as many calories as actual walking (according to my tracking device), but it beats sitting down.

Finally, it is important to remember that the vast majority of calories we burn are not from working out, but from our metabolism. For myself (at 160 and 67.5 inches) I might burn 450 calories in a day exercising, but I burn over 1700 calories in the same day just keeping my temperature at 98.6 and breathing, eating, and my various less intense activities. The thing is, if I weren't exercising, this larger proportion of calorie burn would start to diminish. There is a post exercise boost to the metabolism that can extend for many hours after exercise.(Knab et al. 2011) Exercise is also necessary to preserve and build lean body mass, which is the topic for the third Fitness installment.

Action Step: Find out how many calories you burn (based on your weight) walking briskly for one hour. This can be done on one of the nutrition trackers mentioned above. If you are interested in other forms of exercise, you can also look into how much time it would take to burn that number of calories in the other exercise. Weight training is a different story, which will be covered in the next installment.

References:
Thomas and Wing, 2009. Maintenance of Long-Term Weight Loss
http://www.rimed.org/medhealthri/2009-02/2009-02-53.pdf
Wing and Phelan, 2005. Long-Term Weight Loss Maintenance http://ajcn.nutrition.org/content/82/1/222S.long Jakicic et al. 2003. Effect of exercise duration and intensity on weight loss in overweight, sedentary women: a randomized trial. http://jama.jamanetwork.com/article.aspx?articleid=197256 Knab et al. 2011. A 45-Minute Vigorous Exercise Bout Increases Metabolic Rate for 14 Hours http://www.ncbi.nlm.nih.gov/pubmed/21311363

Attitude II Disinhibited Eating

Thus far we have focused on the attributes of successful maintainers, but it is also important to look at factors of people who have not succeeded at managing their weight. One of the behaviors to look out for is known as Disinhibited Eating, or difficulty controlling overeating (Thomas and Wing, 2009) or "A measure of periodic loss of control over eating." (Wing and Phelan 2005)

These findings came from a tool called the Three Factor Eating Questionnaire. Looking into the Questionnaire and how it can measure someone's disinhibited eating, I came across a couple of interesting studies. Keskitalo et al. 2008 was a twin study that found that uncontrolled eating and emotional eating were distinct behaviors, though it is not uncommon in my experience for them to be comorbid. They found that while BMI was not itself genetic between identical twins, it was correlated with the eating behaviors which showed a strong genetic link. Perhaps more interesting, they found that uncontrolled eating was associated with a liking of salty, fatty foods and emotional eating was associated with a liking of sweet, fatty foods.

De Lauzon et al. 2004 explored a modified eating questionnaire, and I was finally able to get a glimpse of what was on the questionnaire. I can certainly understand the concern of the public getting too familiar with these tools, so I'll just post a link to the abstract. My impression of the difference between uncontrolled eating and emotional eating was that emotional eating involved eating to sooth agitated moods. Uncontrolled eating involved the inability to stop eating and desire to eat (called hunger in the questionnaire) despite being full, just having eaten, or for no reason besides the allure of a food or situation. This study concluded that in clinical practice so much focus goes into what people eat, when the eating behaviors are what really could use modification.

Looking at uncontrolled eating, I think one issue it describes is confounding hunger, appetite, craving and a third type I'll call externally motivated eating. This includes eating because other people are eating and eating because an item is scarce or coveted. The other large issue is the inability to stop eating.

Unfortunately, animal studies indicate that fatty diets defeat the insulin moderated hunger controls in the brain. (cite) Many diets these days focus on the elimination of carbs because they stimulate insulin release, but there are other diets that lead to insulin resistance including high fat and high calorie. Thomas and Wing (2009) notes that diets of maintainers contain more fat now than they used to, which they speculate is due to low carb diets.

Getting back to emotional eating, a possible strategy for this would be finding alternate ways to sooth negative moods besides eating. We will look further at emotional regulation in the next Attitude segment.

Action steps: If you are an overeater, do you think you are more of an uncontrolled eater or an emotional eater, or both? Do you recognize the difference between physical hunger, appetite, craving, externally motivated hunger, and eating for comfort?

References:
De Lauzon et al. 2004, The Three-Factor Eating Questionnaire R-18 is Able to Distinguish among Different Eating Patterns in a General Population (Abstract)
http://www.ncbi.nlm.nih.gov/pubmed/15333731

Keskitalo et al. 2008, The Three-Factor Eating Questionnaire, body mass index, and responses to sweet and salty fatty foods: a twin study of genetic and environmental associations
http://ajcn.nutrition.org/content/88/2/263.full

Nutrition II Avoiding trigger situations

Avoiding situations that encourage overeating
Eating out:
Buffets, family style, pizza
Fast food (value combos, upsizing)
Eating out in general is decreased among NWCR maintainers
Dessert
At home:
Leftovers/sharing
Tasting during food prep
Seconds
Trigger foods
Eating directly out of the package
Conditions that stimulate overeating are individual. Choose a few from this list, or come up with some we may have overlooked.

Self Monitoring II: Cognitive Restraint

In the segment on Disinhibition, we learned about a Three Factor Eating Questionnaire. Two of the factors were Uncontrolled Eating and Emotional Eating, while the third is Cognitive Restraint. Successful NWCR maintainers scored high on measures of Cognitive restraint. This means that before they ate something, they evaluated it using one or more parameters, such as portion size, types of food and eating less than they might be inclined to with the object of weight management in mind. In this area, it is important to note that the average maintainer response was elevated, but not extreme. "Registry members scored high on this measure (mean of 7.1), with levels similar to those seen in patients who have recently completed a treatment program for obesity, although not as high as eating-disordered patients. These findings suggest that successful weight loss maintainers continue to act like recently successful weight losers for many years after their weight loss." (Wing and Phelan, 2005) Of course it's difficult to quantify how much concern over food is too much. Since reaching goal, it's likely you've run into situations where someone might have remarked you're too worried about food. If you have such a concern, http://www.nationaleatingdisorders.org/ has an anonymous and simple online screening tool. Thomas and Wing (2009) reported that NWCR maintainers eat an average of 1385 cal/day with the observation that over half of those surveyed were still trying to lose weight. Wing and Phelan (2005) elaborates that the tool used for this estimate is often 20-30% low: "Thus, registry members are probably eating closer to 1800 kcal/d. However, even with this adjustment, it is apparent that registry members maintain their weight loss by continuing to eat a low-calorie, low-fat diet."

Fitness III: Lean mass and metabolism

"Myths, Presumptions and Facts about Obesity" appeared a January 2013 issue of the New England Journal of medicine. Among the presumptions, which means ideas that are widely circulated but have not been confirmed or denied by academic research, is that "weigth cycling is associated with increased mortality". Weight cycling, aka yo yo dieting, refers to repeated weight loss and regain. When we lose weight, we are trying to lose fat but as I learned in analyzing my own numbers, we also lose quite a bit of lean mass. If my own figures are accurate(based on caliper measurement of bodyfat %) 20-30% of my weight loss was lean mass while I was exercising daily. I shudder to think what happened when I was just dieting. It's probable that of 46 pounds I lost in 2012, as much as 15 were lean mass. Let's hope some of that was skin. There are a couple of ways the amount of calories you burn in a day can be calculated. The Harris Benedict equation takes your height and age into account along with your age. It assumes your metabolism and lean mass decrease as you age. Whereas the Katch McArdle equation goes simply off lean body mass (which is 100% minus bodyfat%) What all this means is that part of the reason exercise is so important to weight maintenance is because you have probably lost a lot of your lean mass as you attained your goal weight. Getting back to the presumption about yo yo dieting, there is a sense that weight loss somehow damages the metabolism. This was addressed in an NWCR study that found the decreased caloric needs of maintainers were consistent with known the known factors of calorie equations such as age and lean mass. (Wyatt et al. 1999) While only 20% of NWCR maintainers lifted weights, it was the third most prevalent exercise used (Thomas and Wing 2009). My experience was that when I began eating a maintenance diet, my strength training became much more effective, whereas while I was losing weight progress in my strength program was miniscule. So the action step for this segment is to think about the role of building lean mass in your fitness program. Do you do strength training either weights or other kinds of resistance training? Have you tried increasing intensity since reaching goal, and what have you found? Resources: Wyatt et al. 1999, Reduced Energy Expenditure in reduced-obese subjects in the National Weight Control Registry http://www.ncbi.nlm.nih.gov/pubmed/10357738?dopt=Abstract A blog post by a bariatric doctor that discusses the points of Myths, presumptions and facts about obesity (the full article is not available to the public). http://www.weightymatters.ca/2013/01/the-new-england-journals-obesity.html

Attitude III Emotional Regulation

post under construction You may have heard the addage "happiness is a choice" and if you've had a mood disorder or known someone in the grip of one, it becomes clear that in many situations choosing happiness is easier said than done. "these findings suggest that negative affect and tendencies to uncontrolled eating may be associated with problems in the long term maintenance of weight loss. Behavioral weight control programs teach participants to identify and try to change negative thoughts and to plan ahead to prevent lapses from becoming relapses. Those individuals who practice these skills may be better able to deal effectively with periods of overeating or slips from the program" (Wing et al. 2008) Wing et al. 2008 Maintaining large weight losses http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2677901/#S18title McGuire et al. 1999 What predicts weight regain in a group of successful weight losers http://www.ncbi.nlm.nih.gov/pubmed/10357738?dopt=Abstract

Nutrition III Dietary Consistency

Post under construction Weekends and holidays Dietary consistency In addition to how a person eats day to day, the consistency of eating habits throughout the week and across special occasions is also predictive of success. Wing and Phelan (2005) outlines that 59% of the Registry participants ate the same on weekends as during the week. 45% ate the same on vacations and holidays as during the rest of the year. Maintainers who practice these behaviors were 1.5 times more likely to maintain their weight beyond the second year (by the +/- 5 lbs. definition).