August 2008 Issue

Behind the Scenes of The Biggest Loser
By Juliann Schaeffer
Today’s Dietitian
Vol. 10 No. 8 P. 42

They exercise and eat their way to dramatic weight loss—but just how do these Biggest Losers do it? Go backstage with Cheryl Forberg, RD, and Michael Dansinger, MD, and learn how to apply the show’s strategies to your own practice.

On NBC’s hit show The Biggest Loser, it pays to lose big. With five seasons under its belt (and a sixth set to premiere next month), contestants compete to see who can work out harder, eat better, and abstain from temptations longer to, ultimately, lose the most weight and win the $250,000 grand prize. The show has taken hold of much of America and the world, as it now airs in 90 countries, and at-home viewers cheer as their favorite contestants embrace healthier lifestyles.

Although much of the show concentrates on the exercise aspect of weight loss, two of The Biggest Loser’s medical experts, Cheryl Forberg, RD, and Michael Dansinger, MD, say they may be in the background, but they’re working hard to give contestants the nutrition tools necessary to build a healthy relationship with food.

Before the Workouts Begin
At The Biggest Loser, an emphasis on nutrition is evident even before contestants are officially chosen for the show. After a pool of thousands of applicants is narrowed down considerably, Forberg, who also sees patients in private practice in California, meets with would-be contestants for a “nutrition confessional.” In addition to finding out who has which bad eating habits, “I ask them what their current weight is, what their dream weight is, and when the last time was that they were at that weight,” she says.

“I also ask them if they are on any medications or supplements or if they have any health issues, and I talk about their history of different weight loss plans: what they’ve tried, what worked, and what didn’t,” says Forberg, who also has the hopeful contestants jot down their daily food intake in a food journal, which she then analyzes.

After contestants are officially selected, Forberg reviews the diet plan with everyone. As opposed to dictating what foods are to be eaten in what amounts at what hour, she gives contestants guidelines, with a calorie budget based on comprehensive testing to determine body composition.

What do these guidelines look like? The Biggest Loser plan for success is based on two main principles: The first relates to exercise and advises contestants that they must burn off more calories than they take in each day. The other principle, which is based on an eating strategy that Dansinger and Forberg developed, lists the recommended daily caloric intakes for weight loss. “I think the doctors on the medical expert team and myself each brought our own philosophies to the table when we wrote the diet, and we were all on a pretty similar wavelength,” says Forberg. “We came up with a macronutrient ratio of 45% carbohydrates, 30% protein, and 25% healthy fats.”

In the first days of the program, Forberg also gives contestants some much-needed nutrition education: instructions about portion size, weighing food, and food journaling. Still, since many contestants are brand new to much of what Forberg teaches, she says the education aspect “is ongoing because the food journaling is new to a lot of them, and it’s not always that easy.”

Food journaling is one of the program’s cardinal components, emphasizes Forberg, whose newly released book, Prevention Positively Ageless: A 28-Day Plan for a Younger, Slimmer, Sexier You, is based on the diet she helped create for the show. “I analyze their food journals every single day,” she says. “I have records of their food journals, and I make reports and share them with the trainers and the medical expert team,” making recommendations when she sees a contestant’s diet is missing a key nutrient.

Back to Diet Basics
In the diet guidelines, contestants are directed toward higher water, less starchy fruits and vegetables, with a daily recommended intake of at least 4 cups of fruits and vegetables. Whole grains, lean protein choices, and low-fat or nonfat dairy foods are also recommended, and cooking methods for preserving the greatest amounts of nutrients (such as steaming and grilling) are offered. Other guidelines include the following:

• Try to eat one raw vegetable each day, and eat a vegetable salad most days of the week.

• Savor fruits from different color groups to ensure a variety of nutrients.

• Try to choose packaged cereals with less than 5 grams of sugar and at least 5 grams of fiber per serving.

• Avoid processed meats, such as bologna, hot dogs, and sausage.

Forberg notes that because the food plan is so high in fiber and has a combination of macronutrients, “It’s a very satisfying food plan, so we don’t find people asking for more calories. If anything, they have trouble eating all of their calories. They’re coached on a regular, daily basis by the trainers if that’s a problem.”

Although Forberg has the most contact with contestants at the show’s onset, she says she continually reinforces nutritional guidance throughout “because it’s so much information at the beginning, especially for people who really didn’t know much about nutrition.”

Yet Forberg says that contestant after contestant, even after leaving the show, raves to her about the nutrition education’s lasting impact. “A lot of them say they’ve tried so many other plans and the reason this one really works is because there is so much education attached to it. For the first time, they really understand why they’re making these choices, and it makes it easier to stick with because they really understand it,” she says.

At-Home Help
Getting fit and healthy is no easy feat for anyone, but Dansinger says at-home viewers shouldn’t compare themselves to The Biggest Loser contestants—and shouldn’t get discouraged when their scale doesn’t show the same results. “On the show, contestants are able to adhere to lifestyle changes 100%, and they get huge results [because of that],” says Dansinger. “In the real world, people can’t spend all their waking hours devoted to lifestyle change.”

In reality, there is no Biggest Loser Campus for the vast majority of overweight and obese Americans who must fight the stressors of work, family, and habitual bad food patterns daily. And although Dansinger says there is no “big secret” behind many of The Biggest Loser’s dietary practices, he says nutrition professionals can still use some of the show’s tools to effect change from clients truly looking for a healthier way of life.

Communication: “I think the main point to take away from the show when considering what to do in the real world is that the weight loss is going to be proportional to the degree to which someone can adhere to lifestyle changes. What you put in is what you get out of it,” says Dansinger. “There’s a direct relationship. The people in the real world, in the clinic, can get the kind of results that people get on the show if only they [are] able to throw themselves into it full force.”

Although most clients are unable to devote even close to 100% of their time transitioning to better lifestyle habits, Dansinger says clients need to know that every bit of effort helps. “The number of hours spent on eating healthy food and exercising directly translates into the results,” he says of the basic principle of weight loss. “If someone’s going to exercise an hour a week and spend only an extra hour in the kitchen, then [clients need to know that’s] going to give smaller results than if they’re spending 10 hours a week exercising and in the kitchen preparing their food. That’s the main principle.”

Diet: Dansinger says the eating strategies used on the show, which likely resemble dietitians’ own dietary recommendations, can just as easily be used in the clinic. “The dietary recommendations are consistent with the standard recommendations, except we emphasize lean protein a little bit more and discourage refined grains much more extensively than the mainstream approach, [including] generous amounts of fruits and vegetables, low-fat proteins, moderate amounts of whole grains, and fats from healthy sources like vegetable oils, nuts, or fish,” he says.

Competition: While competition and teamwork are almost daily aspects of The Biggest Loser, this isn’t always feasible for clinics. “But whenever people can use that, that’s an important principle,” says Dansinger, adding that when the people giving the advice practice what they preach, it can do wonders. “[Trainers] Bob [Harper] and Jillian [Michaels] are good examples.”

Food journal: Dansinger says contestants continuously record what they eat, and he cannot emphasize the tool’s importance enough. “When someone has to write down [everything he or she is eating]—and that includes the calorie amount—it helps them see how to get the most for a certain calorie budget,” he says. “So if they have a certain target—let’s say it’s 1,600 calories a day—just by writing it down, it forces them to manage their calories. Secondly, when they’re eating foods that are off the plan, it helps them see exactly how many calories they’re eating when they go off and whether it’s worth it.”

He says food journals can also be used for troubleshooting when pounds aren’t dropping as fast as clients would like or expect. “For me, when someone’s not losing weight as expected, then their food journal is really valuable for me to troubleshoot what might be wrong,” he says. “Sometimes, their food record is perfect and there’s no weight loss, and that could mean that someone’s eating more calories than they believe or not recording everything that they’re eating. Or sometimes they’re doing a good job recording, and a clean food journal with no weight loss could suggest that someone might be putting on muscle weight or temporary fluid weight rather than a true problem.”

However, Dansinger says it’s wise for nutrition professionals to assume a 20% to 30% underreporting with clients’ journals. “Even the best recorders are probably underreporting by 20% or more for several reasons,” he says, noting hidden fats, inadvertent underestimating, and forgetting to write down a quick nibble or two as possible culprits. “It’s easy to forget a few nickels and dimes.”

Exercise: While Dansinger says it’s certainly not necessary for dietitians to team up with a personal trainer, he says it could benefit clients, as personal trainers bring an added layer of accountability to clients prone to putting workouts at the bottom of their priority list. “Anyone who connects with a personal trainer is going to benefit and will likely get more weight loss and build up more muscle. So any time I think that [a client] will go for it, I’ll encourage it,” he says.

Noting that trainers are in the best position to get the maximum tolerated exercise from clients, he says, “In general, it’s good for people to push themselves beyond what they believe they’re capable of achieving. It’s not human nature to push yourself to the limits, but a good trainer knows how to do that without going beyond the limits.”

Dansinger says he has clients shoot for a minimum of seven hours of exercise per week. “Almost everyone is capable of exercising seven hours a week, even if it’s just walking at a leisurely pace. But in most cases, people are capable of much more than that, especially after a few weeks or months of consistent effort,” he says.

Home environment: While Dansinger doesn’t currently offer home visits to his clients, he suggests nutrition professionals make the trip, if possible. “In principle, it would be nice if we could send the dietitian to someone’s home to give recommendations about what to change. If we could see what’s in the cupboards of some people, I think we’d be shocked,” he says. “On the show, they use this principle to a certain extent. Sometimes the trainers actually do go to their homes and help them get set up, including [assessing] exercise equipment in the home.”

Dansinger and Forberg agree: The Biggest Loser’s success may not be in the novel dietary components but the simultaneous application of the unique situation, nutrition education, and endless exercise. “What provides the accelerated weight loss on the show is the ability to put all of the different components together simultaneously, which is very unusual,” Dansinger says.

What’s not unusual is how the medical expert team works to address how contestants view food. “We really work as a team to not just address changing the food but the relationship with food,” Forberg says. “The bottom line is that the focus here is on the quality of the calories as much as the quantity.”

— Juliann Schaeffer is an editorial assistant at Today’s Dietitian.


Applying Biggest Loser Tools to a Practice Setting
Michael Dansinger, MD, weight loss and nutrition advisor for the hit show The Biggest Loser, also runs a weight loss clinic at Tufts-New England Medical Center in Boston, where he employs many of the show’s tools. He finds seeing patients weekly for three months and then once every other week works best. “I think that level of hands-on interaction is necessary in most cases. Monthly or every other month just isn’t nearly enough for most people to get good results,” he says.

Dansinger says his clients are often more motivated than most, desperate to avoid the consequences of chronic conditions. “Most of my patients have type 2 diabetes or are at high risk for type 2 diabetes,” he says. “They are a special group because many of these people are highly motivated or even desperate to lose weight in order to avoid diabetes medications or to discontinue diabetes medications or avoid insulin shots. So many people are willing to do whatever I ask them to do, and that’s a nice situation to be in.”

Dansinger has patients follow the same eating strategy used on the show, which is high in fruits and vegetables, lean protein, and nonfat or low-fat dairy. Much like on the show, he spends the first session with patients coaching and educating them about the eating plan and explaining food journaling, “and then we create a concrete plan,” he says, “[ie,] when they’re going to do their exercise, exactly what types of foods they might be eating for breakfast, lunch, dinner, and snacks. And then I see them a week later and a week later for three months. At each visit, we spend about 15 minutes reviewing their food journal and discussing ideas for meals and how to fine-tune the exercise plan. We discuss whether their effort matches their progress.”

Also like on the show, he gives patients a list of food categories to eat and those to avoid, along with a sample grocery list and 40 examples of meals. “But I wouldn’t tell them what to eat on a particular day of the week,” he says.

Dansinger compares weight loss counseling to swimming lessons. “The idea is you need a dozen or so times before you get the hang of it,” he explains. “You can’t just have one lesson—that’s just not going to be sufficient—and you can’t just read about it and know what to do. You need to have a back and forth exchange with someone to guide you and build on your initial success to the point that you’ve mastered it.”

Dansinger says patients usually get the hang of the eating and exercise strategy after roughly three months. “After that, they’ve pretty much heard everything that I have to say, but they still need the accountability,” he says. After three months of seeing a patient, he switches to sessions every other week until one year has passed.

“At that point it’s a matter of maintaining it, which is sometimes harder than taking the weight off in the first place,” he says. “And we liberalize the eating plan just slightly. During the weight loss phase, I’m asking people to follow the eating plan at 90% adherence level. To maintain, they can usually get away with about 80% or 85% adherence to the approved foods list. But we still aim for seven hours of exercise at the maximum tolerated level, and we still keep the food journals.”

— JS