Associations of daily weight management-focused social support with weight loss, activity behaviors, and eating regulation in the context of metabolic and bariatric surgery.

Objective: Greater perceived social support (PSS) is associated with more favorable changes in weight loss, activity behaviors, and eating regulation after metabolic and bariatric surgery (MBS). However, studies have relied on generic, retrospective PSS measures, and stability of PSS levels and relations with weight loss and weight-related behaviors over time is unknown. Using smartphone-based Ecological Momentary Assessment, this study evaluated pre-to 1-year post-MBS changes in daily weight management-focused PSS and associations with weight loss, device-measured activity behaviors, and eating regulation before and during the initial year after MBS. Method: Adult MBS patients (n = 71) received (1) an accelerometer to measure daily moderate-to-vigorous intensity physical activity (MVPA) and sedentary time (ST) minutes/day, and (2) a smartphone to complete morning weight-focused PSS ratings and eating regulation (dietary restraint/disinhibition) ratings at four semi-random times daily for 10 days at pre- and 3, 6, and 12-month postoperative. Generalized linear mixed models analyzed the associations of PSS with total weight loss (%TWL) and activity/eating outcomes. Results: Participants on average reported relatively stable moderate-to-high PSS (3.98 on one to five scale) across assessments. Perceived social support was not related to %TWL, MVPA, or ST. Participants with higher PSS reported lower disinhibition and higher restraint than those with lower PSS (ps < 0.05); however, participants reported higher restraint on days that PSS was lower than their usual levels (p = 0.009). Conclusions: MBS patients on average had stable PSS levels across time. Higher PSS levels were associated with greater resistance to overeating cues (disinhibition) and cognitive control to restrict food intake (restraint) over time. Additionally, participants reported higher restraint when PSS levels were lower than usual. Overall, weight-focused PSS appeared to hold greater importance in relation to regulating eating behavior than engaging in activity behaviors or weight loss among MBS patients during the initial postoperative year. Clinical Trial Registration: NCT02777177.

Amputation Rates and Associated Social Determinants of Health in the Most Populous US Counties.

Importance: Social Determinants of Health (SDOH) have been found to be associated with health outcome disparities in patients with peripheral artery disease (PAD). However, the association of specific components of SDOH and amputation has not been well described. Objective: To evaluate whether individual components of SDOH and race are associated with amputation rates in the most populous counties of the US. Design, Setting, and Participants: In this population-based cross-sectional study of the 100 most populous US counties, hospital discharge rates for lower extremity amputation in 2017 were assessed using the Healthcare Cost and Utilization Project State Inpatient Database. Those data were matched with publicly available demographic, hospital, and SDOH data. Data were analyzed July 3, 2022, to March 5, 2023. Main outcome and Measures: Amputation rates were assessed across all counties. Counties were divided into quartiles based on amputation rates, and baseline characteristics were described. Unadjusted linear regression and multivariable regression analyses were performed to assess associations between county-level amputation and SDOH and demographic factors. Results: Amputation discharge data were available for 76 of the 100 most populous counties in the United States. Within these counties, 15.3% were African American, 8.6% were Asian, 24.0% were Hispanic, and 49.6% were non-Hispanic White; 13.4% of patients were 65 years or older. Amputation rates varied widely, from 5.5 per 100 000 in quartile 1 to 14.5 per 100 000 in quartile 4. Residents of quartile 4 (vs 1) counties were more likely to be African American (27.0% vs 7.9%, P < .001), have diabetes (10.6% vs 7.9%, P < .001), smoke (16.5% vs 12.5%, P < .001), be unemployed (5.8% vs 4.6%, P = .01), be in poverty (15.8% vs 10.0%, P < .001), be in a single-parent household (41.9% vs 28.6%, P < .001), experience food insecurity (16.6% vs 12.9%, P = .04), or be physically inactive (23.1% vs 17.1%, P < .001). In unadjusted linear regression, higher amputation rates were associated with the prevalence of several health problems, including mental distress (ß, 5.25 [95% CI, 3.66-6.85]; P < .001), diabetes (ß, 1.73 [95% CI, 1.33-2.15], P < .001), and physical distress (ß, 1.23 [95% CI, 0.86-1.61]; P < .001) and SDOHs, including unemployment (ß, 1.16 [95% CI, 0.59-1.73]; P = .03), physical inactivity (ß, 0.74 [95% CI, 0.57-0.90]; P < .001), smoking, (ß, 0.69 [95% CI, 0.46-0.92]; P = .002), higher homicide rate (ß, 0.61 [95% CI, 0.45-0.77]; P < .001), food insecurity (ß, 0.51 [95% CI, 0.30-0.72]; P = .04), and poverty (ß, 0.46 [95% CI, 0.32-0.60]; P < .001). Multivariable regression analysis found that county-level rates of physical distress (ß, 0.84 [95% CI, 0.16-1.53]; P = .03), Black and White racial segregation (ß, 0.12 [95% CI, 0.06-0.17]; P < .001), and population percentage of African American race (ß, 0.06 [95% CI, 0.00-0.12]; P = .03) were associated with amputation rate. Conclusions and Relevance: Social determinants of health provide a framework by which the associations of environmental factors with amputation rates can be quantified and potentially used to guide interventions at the local level.

Associations of weather and air pollution with objective physical activity and sedentary time before and after bariatric surgery: a secondary analysis of a prospective cohort study.

Background--: Most metabolic and bariatric surgery (MBS) patients perform too little moderate-to-vigorous intensity physical activity (MVPA) and too much sedentary time (ST). Identifying factors that influence MVPA and ST in MBS patients is necessary to inform the development of interventions to target these behaviors. Research has focused on individual-level factors and neglected those related to the physical environment (e.g., weather and pollution). These factors may be especially important considering rapid climate change and emerging data that suggest adverse effects of weather and pollution on physical activity are more severe in people with obesity. Objectives--: To examine the associations of weather (maximal, average and Wet Bulb Globe Temperatures), and air pollution indices (air quality index [AQI]) with daily physical activity (PA) of both light (LPA) and MVPA and ST before and after MBS. Methods--: Participants (n=77) wore an accelerometer at pre- and 3, 6, and 12-months post-MBS to assess LPA/MVPA/ST (min/d). These data were combined with participants' local (Boston, MA or Providence, RI, USA) daily weather and AQI data (extracted from federal weather and environmental websites). Results--: Multilevel generalized additive models showed inverted U-shaped associations between weather indices and MVPA (R2≥.63, p<.001), with a marked reduction in MVPA for daily maximal temperatures ≥20°C. Sensitivity analysis showed a less marked decrease of MVPA (min/d) during higher temperatures after versus before MBS. Both MVPA before and after MBS (R2=0.64, p<.001) and ST before MBS (R2=0.395; p≤.05) were negatively impacted by higher AQI levels. Discussion--: This study is the first to show that weather and air pollution indices are related to variability in activity behaviors, particularly MVPA, during pre- and post-MBS. Weather/environmental conditions should be considered in MVPA prescription/strategies for MBS patients, especially in the context of climate change.

Characterizing the Course of Loss of Control Eating and Prognostic Factors Following Bariatric Surgery: an Exploratory Analysis.

PURPOSE: Postoperative loss of control eating (LOCE) has detrimental associations with weight outcomes and mental health following bariatric surgery. However, little is known regarding LOCE course following surgery and preoperative factors that predict remittance, continuance, or development of LOCE. The present study aimed to characterize LOCE course in the year following surgery by identifying four groups: individuals with (1) postoperative de novo LOCE, (2) maintained LOCE (endorsed at pre- and post-surgery), (3) remitted LOCE (endorsed only at pre-surgery), and (4) those who never endorsed LOCE. Exploratory analyses examined group differences in baseline demographic and psychosocial factors. MATERIALS AND METHODS: A total of 61 adult bariatric surgery patients completed questionnaires and ecological momentary assessment at pre-surgery and 3-, 6-, and 12-month postoperative follow-ups. RESULTS: Results showed that 13 (21.3%) never endorsed LOCE prior to or after surgery, 12 (19.7%) developed LOCE after surgery, 7 (11.5%) evidenced remittance from LOCE after surgery, and 29 (47.5%) maintained LOCE prior to and after surgery. Relative to those who never endorsed LOCE, all groups who evidenced LOCE before and/or after surgery reported greater disinhibition; those who developed LOCE reported less planned eating; and those with maintained LOCE reported less satiety sensitivity and greater hedonic hunger. CONCLUSION: These findings highlight the importance of postoperative LOCE and need for longer-term follow-up studies. Results also suggest a need to examine the longer-term impact of satiety sensitivity and hedonic eating on LOCE maintenance, and the extent to which meal planning may buffer risk for de novo LOCE following surgery.

Real-time versus retrospective self-report assessment of loss-of-control eating in adults undergoing bariatric surgery.

OBJECTIVE: Loss-of-control (LOC) eating is common in adults undergoing bariatric surgery. Agreement between real-time and retrospective assessment methods is unclear. METHODS: Adults with severe obesity reported on LOC eating over the preceding 28 days via Eating Disorder Examination-Questionnaire (EDE-Q) items and in near real time over 10 days via ecological momentary assessment (EMA; involving daily repeated surveys delivered via smartphone in the natural environment), with both assessment forms completed before surgery and at 3, 6, and 12 months after surgery. Wilcoxon signed rank tests and generalized linear mixed models were used to compare participants' EDE-Q and EMA reports of subjectively and objectively large LOC episodes across time points. RESULTS: Participants reported subjectively large LOC episodes more frequently via EMA than EDE-Q across time points, although differences did not reach statistical significance (all p > 0.05). Conversely, objectively large LOC episodes were more frequently reported via EDE-Q than EMA, with differences reaching significance at 6 months post surgery only (p = 0.03). CONCLUSIONS: Agreement between real-time and retrospective assessments of LOC eating varied by episode size and time elapsed in the year following surgery. These findings should be considered when designing assessment batteries for bariatric surgery-seeking adults and when extrapolating research findings across studies with diverging methods of real-time versus retrospective self-report assessment of LOC eating in adults undergoing bariatric surgery.

Ecological momentary assessment of changes in eating behaviors, appetite, and other aspects of eating regulation in Roux-en-Y gastric bypass and sleeve gastrectomy patients.

Bariatric surgery can have profound impacts on eating behaviors and experiences, yet most prior research studying these changes has relied on retrospective self-report measures with limited precision and susceptibility to bias. This study used smartphone-based ecological momentary assessment (EMA) to evaluate the trajectory of change in eating behaviors, appetite, and other aspects of eating regulation in 71 Roux-en-Y gastric bypass and sleeve gastrectomy patients assessed preoperatively and at 3, 6, and 12-months postoperative. For some outcomes, results showed a consistent and similar pattern for SG and RYGB where consumption of sweet and high-fat foods and hunger, desire to eat, ability to eat right now, and satisfaction with amount eaten all improved from pre-to 6-months post-surgery with some degree of deterioration at 12-months post-surgery. By contrast, other variables, largely related to hedonic hunger and craving and desire for specific foods, showed less consistent patterns that differed by surgery type. While the findings suggest an overall pattern of improvement in eating patterns following bariatric surgery, they also highlight how a return to preoperative habits may begin as early as 6 months after surgery. Additional research is needed to understand mechanisms that promote changes in eating behavior after surgery, and how best to intervene to preserve beneficial effects.

Associations of physical activity and sedentary behavior with appetite sensations and eating regulation behaviors before and during the initial year following bariatric surgery.

Background: Bariatric surgery produces weight loss in part by impacting appetite and eating behavior. Research suggests physical activity (PA) assists with regulation of appetite and eating during non-surgical weight loss, although whether PA carries similar benefits in the context of bariatric surgery is unknown. Objective: Evaluate associations of moderate-to-vigorous intensity PA (MVPA) and sedentary time (ST) with appetite sensations (hunger [homeostatic/hedonic], satiety) and eating regulation behaviors (restraint, disinhibition) before and during the initial year following bariatric surgery. Method: Adult bariatric patients received an accelerometer to measure MVPA/ST and a smartphone to complete appetite/eating ratings at four semi-random times daily for 10 days at pre- and 3-, 6-, and 12-months post-surgery. Data were analyzed using generalized linear mixed models. Results: Higher MVPA levels related to more satiety across time (p = 0.045) and more restraint at 3-months post-surgery (p < 0.001). At pre-surgery, higher MVPA levels also related to more disinhibition (p's < 0.01), although participants reported more disinhibition on days they performed less MVPA than usual (p = 0.017). MVPA did not relate to hunger. Lower ST levels related to more hedonic hunger (p = 0.003), especially at 12-months post-surgery (p < 0.001), and participants reported more homeostatic hunger on days they accumulated more ST than usual (p = 0.044). Additionally, higher ST levels related to more disinhibition at 3-months post-surgery (p's < 0.01) and lower restraint at pre-surgery (p's < 0.05). ST did not relate to satiety. Conclusions: This study is the first to show that MVPA and ST each associate with appetite and eating regulation in daily life before and during post-surgical weight loss. Results, while preliminary and requiring experimental confirmation, highlight potential for targeting bariatric patients' activity behaviors to enhance modulation of appetite, control of food intake, and resistance to overeating.

Energy, Attentiveness, and Fatigue After Bariatric Surgery and Associations with Daily Physical Activity and Weight Loss: an Ecological Momentary Assessment Study.

PURPOSE: Energy and fatigue are thought to improve after bariatric surgery. Such improvements could be related to weight loss and/or increased engagement in day-to-day health behaviors, such as moderate-to-vigorous physical activity (MVPA). This study used ecological momentary assessment (EMA) to evaluate several aspects of energy/fatigue in real-time in patients' natural environment during the first year after surgery and assessed the associations of percent total weight loss (%TWL) and daily MVPA with daily energy/fatigue levels. METHODS: Patients (n = 71) undergoing Roux-en-Y gastric bypass or sleeve gastrectomy rated their energy, alertness and attentiveness (averaged to create an "attentiveness" rating), and tiredness and sleepiness (averaged to create a "fatigue" rating) via smartphone-based EMA at 4 semi-random times daily for 10 days at pre-surgery and 3-, 6-, and 12 months post-surgery. Daily MVPA minutes were assessed via accelerometry. Weight was measured in clinic. RESULTS: Energy ratings initially increased from pre- to post-surgery, before leveling off/decreasing by 12 months (p < 0.001). Attentiveness and fatigue ratings did not change over time. %TWL was unrelated to any ratings, while MVPA related to both energy and attentiveness but not fatigue. Participants reported more energy on days with more total MVPA min (p = 0.03) and greater attentiveness on days with more total (p < 0.001) and bouted (p = 0.02) MVPA. CONCLUSIONS: While more research is needed to confirm causality, results suggest that greater daily MVPA is associated with increased daily energy and attentiveness among bariatric surgery patients, independent of %TWL. Findings add to growing evidence of MVPA's potential benefits beyond energy expenditure in the context of bariatric surgery.

Ecological momentary assessment of gastrointestinal symptoms and risky eating behaviors in Roux-en-Y gastric bypass and sleeve gastrectomy patients.

BACKGROUND: Gastrointestinal symptoms (GIS) are common after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). However, little is known about frequencies of GIS and their co-occurrence with risky eating behaviors. OBJECTIVES: Compare RYGB and SG on GIS and risky eating behaviors, and test associations between GIS and behaviors. SETTING: Two university hospitals in Northeastern United States. METHODS: RYGB (n = 18) and SG (n = 53) patients completed smartphone-based ecological momentary assessment of GIS and risky eating behaviors at 4 semi-random times daily for 10 days preoperatively and at 3, 6, and 12 months postoperatively. Study objectives were evaluated using generalized linear mixed-effects models. RESULTS: All available data from each assessment were included in the analysis: participant attrition was 18%, 30%, and 38% at 3, 6, and 12 months. All GIS were reduced at 12 months postoperative. Bloating decreased consistently whereas cramping, dehydration, and dumping first increased at 3 to 6 months then decreased to 12 months. Diarrhea, nausea, reflux, and vomiting decreased to 12 months for RYGB, but first increased at 3 to 6 months then decreased to 12 months for SG. Consumption of carbonated and sugar-sweetened beverages, fatty meats, and sweets decreased to 6 months then rebounded at 12 months. Eating past the first sign of fullness, drinking liquids with meals, not starting meals with protein, and fried foods consumption decreased to 6 months and then rebounded for RYGB only at 12 months. Alcohol consumption did not change. Sweets consumption and eating past the first sign of fullness were most consistently associated with GIS for both RYGB and SG patients. CONCLUSION: GIS and risky eating behaviors improved postoperatively, although patterns of change were variable and occasionally differed between RYGB and SG. Pending replication, patients may benefit from intervention to limit risky behaviors that are tailored to their surgery type.

Risk factors for 30-day readmission and indication for ERCP following laparoscopic cholecystectomy: a retrospective NSQIP cohort study.

BACKGROUND: Laparoscopic cholecystectomy (LC) is one of the safest, most commonly performed surgical procedures, but postoperative complications including bile leak, retained stone, cholangitis, and gallstone pancreatitis following LC occur in up to 2.6% of cases and may require readmission with possible endoscopic retrograde cholangiopancreatography (ERCP) intervention. There is a paucity of literature on factors predictive of need for ERCP following LC. The goal of this study is to describe the prevalence and risk factors for readmission with indication for ERCP. METHODS: We queried the ACS/NSQIP 2012-2017 Participant User Files for patients who underwent LC. Patient demographics, comorbidities, operative characteristics, and postoperative outcomes were evaluated. Multivariate logistic regression was used to identify risk factors for readmission with indication for ERCP intervention. RESULTS: Of 275,570 patients, 11,010 (4.00%) were readmitted within the 30-day postoperative period. Among these, 930 (8.44%) were admitted with indication for ERCP intervention. On multivariate regression, readmissions were more likely in older patients, inpatients, and patients with baseline comorbidities, acute preoperative morbidity, and those discharged to care facilities. The use of intraoperative cholangiogram was associated with lower odds of readmission. Less than 10% of readmitted patients had an indication for ERCP. Those who were readmitted with an indication for ERCP were more likely to have undergone emergency surgery, experienced longer operative times, and had elevated preoperative LFTs or gallstone pancreatitis prior to surgery. The risk of 30-day mortality was significantly higher among patients who experienced any complications after their surgery (OR 13.03, 95% CI 10.57-16.07, p < 0.001). CONCLUSIONS: Older patients, patients with greater preoperative morbidity, and those discharged to care facilities were more likely to be readmitted for any reason following laparoscopic cholecystectomy, whereas patients with evidence of complicated gallstone disease were more likely to be readmitted with an indication for ERCP, even when controlling for the use of intraoperative cholangiogram. Initiatives aimed at reducing readmission with indication for ERCP should focus on these patient subgroups.

Prolonged sedentary time adversely relates to physical activity and obesity among preoperative bariatric surgery patients.

BACKGROUND: Bariatric surgery patients spend much of their waking time sedentary. Yet, little is known about their patterns of accumulation of sedentary time (ST) and whether more prolonged ST is associated with lower physical activity (PA), independent of total ST, or obesity severity. OBJECTIVES: To characterize variability in prolonged ST among bariatric patients preoperatively and assess the importance of a "prolonger" pattern in relation to PA and weight status. SETTING: Two university hospital clinics, United States. METHODS: Adult patients (n = 76) wore a wrist-based accelerometer for 10 days preoperatively. ST and time spent in light and moderate-to-vigorous PA was determined using validated thresholds. Percent of total ST accumulated in ≥30-consecutive ST minute bouts was calculated, and participants were trichotomized into low, medium, and high "prolongers" based on this value. The associations of prolonged ST with PA and obesity were examined. RESULTS: On average, participants accumulated a mean ± standard deviation of 10.5 ± 2.1 hours of ST per day, 30% of which was prolonged (prolonger groups: low = 7.2%-24.5%, medium = 24.5%-33.0%, and high = 34.0%-52.6% of ST in ≥30-min bouts). Adjusting for covariates including total ST, high prolongers had fewer light PA minutes per day (P < .01), and a greater percentage of prolonged ST related to lower likelihood of meeting the national guideline of ≥150 moderate-to-vigorous PA minutes per week (P = .012). High (versus low) prolongers had more severe obesity (P < .05). CONCLUSIONS: Accumulating a greater percentage of ST in prolonged bouts appears to be adversely related to PA and obesity severity among bariatric patients. Future research should determine whether interrupting prolonged ST with brief breaks can favorably modify PA and weight in this population.

Defining Global Benchmarks in Bariatric Surgery: A Retrospective Multicenter Analysis of Minimally Invasive Roux-en-Y Gastric Bypass and Sleeve Gastrectomy.

OBJECTIVE: To define "best possible" outcomes for bariatric surgery (BS)(Roux-en-Y gastric bypass [RYGB] and sleeve gastrectomy [SG]). BACKGROUND: Reference values for optimal surgical outcomes in well-defined low-risk bariatric patients have not been established so far. Consequently, outcome comparison across centers and over time is impeded by heterogeneity in case-mix. METHODS: Out of 39,424 elective BS performed in 19 high-volume academic centers from 3 continents between June 2012 and May 2017, we identified 4120 RYGB and 1457 SG low-risk cases defined by absence of previous abdominal surgery, concomitant procedures, diabetes mellitus, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, anticoagulation, BMI>50 kg/m and age>65 years. We chose clinically relevant endpoints covering the intra- and postoperative course. Complications were graded by severity using the comprehensive complication index. Benchmark values were defined as the 75th percentile of the participating centers' median values for respective quality indicators. RESULTS: Patients were mainly females (78%), aged 38±11 years, with a baseline BMI 40.8 ±â€Š5.8 kg/m. Over 90 days, 7.2% of RYGB and 6.2% of SG patients presented at least 1 complication and no patients died (mortality in nonbenchmark cases: 0.06%). The most frequent reasons for readmission after 90-days following both procedures were symptomatic cholelithiasis and abdominal pain of unknown origin. Benchmark values for both RYGB and SG at 90-days postoperatively were 5.5% Clavien-Dindo grade ≥IIIa complication rate, 5.5% readmission rate, and comprehensive complication index ≤33.73 in the subgroup of patients presenting at least 1 grade ≥II complication. CONCLUSION: Benchmark cutoffs targeting perioperative outcomes in BS offer a new tool in surgical quality-metrics and may be implemented in quality-improvement cycle.ClinicalTrials.gov Identifier NCT03440138.

Multi-sensor ecological momentary assessment of behavioral and psychosocial predictors of weight loss following bariatric surgery: study protocol for a multicenter prospective longitudinal evaluation.

BACKGROUND: Bariatric surgery is currently the most effective strategy for producing significant and durable weight loss. Yet, not all patients achieve initial weight loss success and some degree of weight regain is very common, sometimes as early as 1-2 years post-surgery. Suboptimal weight loss not fully explained by surgical, demographic, and medical factors has led to greater emphasis on patient behaviors evidenced by clinical guidelines for appropriate eating and physical activity. However, research to inform such guidelines has often relied on imprecise measures or not been specific to bariatric surgery. There is also little understanding of what psychosocial factors and environmental contexts impact outcomes. To address research gaps and measurement limitations, we designed a protocol that innovatively integrates multiple measurement tools to determine which behaviors, environmental contexts, and psychosocial factors are related to outcomes and explore how psychosocial factors/environmental contexts influence weight. This paper provides a detailed description of our study protocol with a focus on developing and deploying a multi-sensor assessment tool to meet our study aims. METHODS: This NIH-funded prospective cohort study evaluates behavioral, psychosocial, and environmental predictors of weight loss after bariatric surgery using a multi-sensor platform that integrates objective sensors and self-report information collected via smartphone in real-time in patients' natural environment. A target sample of 100 adult, bariatric surgery patients (ages 21-70) use this multi-sensor platform at preoperative baseline, as well as 3, 6, and 12 months postoperatively, to assess recommended behaviors (e.g., meal frequency, physical activity), psychosocial indicators with prior evidence of an association with surgical outcomes (e.g., mood/depression), and key environmental factors (e.g., type/quality of food environment). Weight also is measured at each assessment point. DISCUSSION: This project has the potential to build a more sophisticated and valid understanding of behavioral and psychosocial factors contributing to success and risk after bariatric surgery. This new understanding could directly contribute to improved (i.e., specific, consistent, and validated) guidelines for recommended pre- and postoperative behaviors, which could lead to improved surgical outcomes. These data will also inform behavioral, psychosocial, and environmental targets for adjunctive interventions to improve surgical outcomes. TRIAL REGISTRATION: Registered trial NCT02777177 on 5/19/2016.

Greater Adherence to Recommended Morning Physical Activity is Associated With Greater Total Intervention-Related Physical Activity Changes in Bariatric Surgery Patients.

BACKGROUND: This study examines whether performance of bout-related physical activity (PA) during morning hours is related to greater overall bout-related PA increases within a preoperative PA intervention for bariatric surgery (BS) patients. METHODS: Participants with severe obesity (n = 33; mean age = 45.6 ± 9.6 years; BMI = 45.7 ± 7.0 kg/m2) seeking BS were randomized to and completed 6 weeks of preoperative PA counseling (retention = 82.5%). Participants were encouraged to walk daily at a moderate intensity in bouts ≥ 10 minutes during morning hours to overcome time-related obstacles and establish a PA habit. Timing and amount of bout-related moderate-to-vigorous PA (MVPA) was assessed via objective monitor at pre- and postintervention. RESULTS: Greater proportion of bout-related MVPA performed during morning hours (4:00 AM-12:00 PM) at postintervention was associated with larger total increases in bout-related MVPA minutes/day (ß = .40, P = .03). At postintervention, a greater proportion of participants whose longest MVPA bouts occurred during morning hours (n = 11) achieved the public health guideline (ie, ≥150 bout-related MVPA minutes/week) versus those whose longest MVPA bouts occurred during nonmorning hours (n = 19; 63.6% vs. 26.3%, P = .04). CONCLUSIONS: Intervention-related increases in PA tended to be greatest when PA was performed in the morning. Morning exercise may be a viable strategy for promoting habitual PA in inactive BS patients.

Changes in enjoyment, self-efficacy, and motivation during a randomized trial to promote habitual physical activity adoption in bariatric surgery patients.

BACKGROUND: The Bari-Active trial found that a physical activity (PA) intervention (PAI), versus standard presurgical care control (SC), produced significant increases in daily bout-related moderate-to-vigorous PA (MVPA, in≥10-min bouts) preoperatively. The present study examined whether PAI also produces superior improvements in psychological and/or motivational processes that may be important for PA adoption. OBJECTIVES: Compare PAI and SC on baseline to postintervention changes in PA-related enjoyment, self-efficacy, and motivations, and examine whether greater bout-related MVPA changes are associated with greater improvements in these variables. SETTING: University hospital, United States. METHODS: Participants (87% female; body mass index = 45.0±6.5 kg/m(2)) were randomly assigned to 6 weeks of PAI (n = 40) or SC (n = 35). PAI received weekly counseling sessions to increase daily walking exercise. At baseline and postintervention, both groups completed 7-day objective PA monitoring and questionnaires to evaluate changes in bout-related MVPA and PA enjoyment, self-efficacy, and motivation. RESULTS: Retention was 84% at postintervention. Intent-to-treat analyses showed that PAI on average reported more favorable changes than SC in PA enjoyment, self-efficacy, amotivation (i.e., lack of PA motivation), and identified and intrinsic regulations (i.e., more autonomous PA motivations; P<.01). In PAI completers (n = 33), changes in bout-related MVPA and psychological/motivational variables were unrelated. CONCLUSION: PAI produced greater improvements in PA-related enjoyment, self-efficacy, and motivations than SC. The lack of association between objectively measured PA changes and psychological/motivational processes highlights the need for future research to identify which processes are most important for PA adoption and maintenance in bariatric surgery patients, and to determine whether the method used to measure PA affects the pattern of association.

Exercise improves quality of life in bariatric surgery candidates: results from the Bari-Active trial.

OBJECTIVE: To examine the impact of a pre-bariatric surgery physical activity intervention (PAI), designed to increase bout-related (≥10 min) moderate to vigorous PA (MVPA), on health-related quality of life (HRQoL). METHODS: Analyses included 75 adult participants (86.7% female; BMI = 45.0 ± 6.5 kg m(-2)) who were randomly assigned to 6 weeks of PAI (n = 40) or standard pre-surgical care (SC; n = 35). PAI received 6 individual weekly counseling sessions to increase walking exercise. Participants wore an objective PA monitor for 7 days and completed the SF-36 Health Survey at baseline and post-intervention to evaluate bout-related MVPA and HRQoL changes, respectively. RESULTS: PAI increased bout-related MVPA from baseline to post-intervention (4.4 ± 5.5 to 21.0 ± 21.4 min day(-1)) versus no change (7.9 ± 16.6 to 7.6 ± 11.5 min day(-1)) for SC (P = 0.001). PAI reported greater improvements than SC on all SF-36 physical and mental scales (P < 0.05), except role-emotional. In PAI, better baseline scores on the physical function and general health scales predicted greater bout-related MVPA increases (P < 0.05), and greater bout-related MVPA increases were associated with greater post-intervention improvements on the physical function, bodily pain, and general health scales (P < 0.05). CONCLUSIONS: Increasing PA preoperatively improves physical and mental HRQoL in bariatric surgery candidates. Future studies should examine whether this effect improves surgical safety, weight loss outcomes, and postoperative HRQoL.

Bari-Active: a randomized controlled trial of a preoperative intervention to increase physical activity in bariatric surgery patients.

BACKGROUND: Habitual physical activity (PA) may help to optimize bariatric surgery outcomes; however, objective PA measures show that most patients have low PA preoperatively and make only modest PA changes postoperatively. Patients require additional support to adopt habitual PA. The objective of this study was to test the efficacy of a preoperative PA intervention (PAI) versus standard presurgical care (SC) for increasing daily moderate-to-vigorous PA (MVPA) in bariatric surgery patients. METHODS: Outcomes analysis included 75 participants (86.7% women; 46.0±8.9 years; body mass index [BMI]=45.0±6.5 kg/m2) who were randomly assigned preoperatively to 6 weeks of PAI (n=40) or SC (n=35). PAI received weekly individual face-to-face sessions with tailored instruction in behavioral strategies (e.g., self-monitoring, goal-setting) to increase home-based walking exercise. The primary outcome, pre- to postintervention change in daily bout-related (≥10 min bouts) and total (≥1 min bouts) MVPA minutes, was assessed objectively via a multisensor monitor worn for 7 days at baseline- and postintervention. RESULTS: Retention was 84% at the postintervention primary endpoint. In intent-to-treat analyses with baseline value carried forward for missing data and adjusted for baseline MVPA, PAI achieved a mean increase of 16.6±20.6 min/d in bout-related MVPA (baseline: 4.4±5.5 to postintervention: 21.0±21.4 min/d) compared to no change (-0.3±12.7 min/d; baseline: 7.9±16.6 to postintervention: 7.6±11.5 min/d) for SC (P=.001). Similarly, PAI achieved a mean increase of 21.0±26.9 min/d in total MVPA (baseline: 30.9±21.2 to postintervention: 51.9±30.0 min/d), whereas SC demonstrated no change (-0.1±16.3 min/d; baseline: 33.7±33.2 to postintervention: 33.6±28.5 minutes/d) (P=.001). CONCLUSION: With behavioral intervention, patients can significantly increase MVPA before bariatric surgery compared to SC. Future studies should determine whether preoperative increases in PA can be maintained postoperatively and contribute to improved surgical outcomes.

Contraceptive use in women undergoing bariatric surgery.

INTRODUCTION: Contraceptive counselling in women undergoing bariatric surgery is crucial due to increased risk of foetal growth restriction postoperatively. We evaluate if women undergoing bariatric surgery are being counselled about and using contraception. METHODS: A 36-question survey was sent electronically to patients at the Miriam Hospital Bariatric Center in Providence, Rhode Island. RESULTS: Of the thirty-five women included in our study, 85.7% and 80% reported receiving contraceptive counselling and advice to avoid pregnancy in the 12-24 months following surgery, respectively. Only 65.7% were using contraception. More women using contraception reported receiving counselling (95.7% vs. 66.7%) and knew to avoid pregnancy postoperatively (82.6% vs. 75%) than women not using contraception. Contraceptive use declined over time following surgery. CONCLUSION: We have identified an important opportunity for healthcare providers to promote ongoing compliance with contraception for women undergoing bariatric surgery.

Self-reported and objectively measured sedentary behavior in bariatric surgery candidates.

BACKGROUND: Sedentary behavior (SB), independent of physical activity, represents a significant health risk. We previously used objective measures to demonstrate that bariatric surgery candidates engage in high levels of SB overall, but supplementing these measures with subjective reports would provide information about time allocated to different forms of SB. The aim of this study was to examine self-reported time spent performing specific types of SB and discrepancy between self-reported and objectively measured estimates of total sedentary time in bariatric surgery candidates. METHODS: A total of 52 bariatric surgery candidates (87% female; age = 46.2 ± 9.1 years; body mass index [BMI] = 45.3 ± 6.7) completed the 9-item Sedentary Behavior Questionnaire (SBQ) as a subjective measure of SB and wore the SenseWear Armband (SWA; SenseWear, Pittsburgh, PA) as an objective measure. Paired samples t tests and the intraclass correlation coefficient (ICC) assessed measurement discrepancy. RESULTS: Television-viewing was the most frequently performed type of SB (2.7 ± 1.6 hours per day), followed by paper/computer work (1.9 ± 1.8 hours per day), driving/riding in automobile (1.2 ± 1.1 hours per day), and sitting/talking on telephone (1.1 ± 1.2 hours per day). On average, the SBQ and SWA produced similar estimates of daily sedentary time (hours per day) at the group level (9.6 ± 4.8 versus 9.3 ± 1.9; mean difference = -.34 ± 4.6; P = .59), although agreement between the measures at the individual level was poor (mean absolute value of difference = 3.8 ± 2.8 hours per day; ICC = .22; P = .06). CONCLUSION: Television-viewing was the single SB in which participants most frequently engaged and thus may be an important modifiable target for reducing total sedentary time in bariatric surgery candidates. The SBQ and SWA can be used similarly to describe SB levels in this patient population at the group level; however, ability of these measures to produce comparable estimates of sedentary time for any individual patient is limited.