Does Lifestyle Intervention After Gastric Bypass Surgery Prevent Weight Regain? A Randomized Clinical Trial

Positive Program Evaluation and Health Maintenance among Post-Metabolic and Bariatric Surgery Patients Following a 6-Week Pilot Program

PURPOSE

Despite lifestyle changes and medication therapies, weight loss is difficult to maintain. Metabolic and bariatric surgery (MBS) is an effective route for significant weight reduction. However, post-operation there are limited opportunities to support weight loss maintenance. The following study aimed to pilot test a 6-week, 6-session nutrition and support program for post-MBS surgery patients.

MATERIALS AND METHODS

A 6-week post-MBS pilot nutrition and support program was developed to test feasibility and acceptability. Participants completed a baseline survey that included demographics, weight changes, success post-surgery, and self-efficacy of leading a healthy lifestyle. Weight change, percent total weight loss, self-efficacy, and program evaluation measures were assessed.

RESULTS

Participants (n = 18) were recruited from a local MBS clinic, predominately female (88.9%), non-Hispanic white (94.4%), received sleeve gastrectomy surgery (100%), and were 2-3 years post-operation (44.4%). Eight of the 18 participants attended the in-person sessions, serving as the intervention group. Both weight loss over and behavioral variables remained stable for both groups across the 6 weeks with no significant differences from pre to post program (p > 0.05). For program evaluation, intervention participants "agreed" or "strongly agreed" with 10 of 11 program satisfaction measures.

CONCLUSION

Following the program, weight loss was maintained among both intervention and control groups. Intervention feedback indicated that the program's approach to provide nutrition education and support was successful and acceptable. Future enhancement of the intervention should include a broader multidisciplinary approach, longer intervention period, and intentional recruitment of participants with a weight regain.

Did the COVID-19 pandemic change the weight reduction in patients with obesity after bariatric surgery?

BACKGROUND

The COVID-19 pandemic has significantly impacted healthcare services worldwide, including bariatric surgery. There is a concern that the pandemic-induced stay-at-home orders and social restrictions may negatively affect weight reduction outcomes post-bariatric surgery. This study aimed to examine the impact of the COVID-19 on weight loss up to six months after three types of bariatric surgeries including One-Anastomosis Gastric Bypass (OAGB), RY Gastric Bypass (RYGB), and Sleeve Gastrectomy (SG) before and two time periods during the COVID-19 pandemic.

METHODS

We conducted a retrospective study using data from a comprehensive database of bariatric surgery patients in Iran. We recruited 882 patients who underwent bariatric surgery from the initiation of COVID-19 to 6 months before public vaccination (Time period 3); among them, 311 patients underwent surgery in the first six months of the pandemic (Time period 2). These patients were compared with 1368 ones in the control group who completed their 6 months follow-up before the pandemic. The study compared the BMI reduction, excess weight loss (EWL), and total weight loss (TWL) outcomes between these groups using Generalized Estimating Equations (GEE) with gamma distribution to adjust for factors that were unevenly distributed across the groups.

RESULTS

The age of participants in time periods 2 and 3 had a mean (standard deviation) of 38.97 (10.99) and 38.84 (10.71), respectively. In all groups, the majority of patients were females, accounting for 76.02%, 71.06%, and 75.74% for the control group and time periods 2 and 3, respectively. There was no significant difference between the groups in terms of weight reduction, as measured by BMI reduction, EWL, and TWL (related P values: 0.283, 0.465 and 0.169). Regression analysis indicated that higher baseline BMI values were associated with greater BMI reduction (0.04, 95% CI: 0.03-0.05), but this did not translate to higher EWL or TWL. Males showed greater BMI reduction (0.33, 95% CI: 0.18-0.49) and EWL (1.58, 95% CI: 0.79-2.37) than females, while females achieved higher TWL compared to males. Among different types of surgery, the OAGB resulted in more weight reduction among patients in the study.

CONCLUSION

In conclusion, our study reveals that bariatric surgery remains effective for weight reduction during the first 6 months of the pandemic in Iran. Implementation of pandemic protocols ensures comparable efficacy to non-pandemic times. However, caution is needed in generalizing results beyond our specific context due to study limitations. Further research is essential to comprehensively assess the pandemic's broader impact on bariatric surgery outcomes under varying conditions.

Role of the exercise professional in metabolic and bariatric surgery

Background

Physical activity (PA) is important for the long-term health and weight management of patients who undergo metabolic and bariatric surgery (MBS). However, the roles of exercise professionals in MBS settings have not been systematically determined.

Objectives

To investigate: (1) who are the professionals implementing PA programming in MBS clinical settings; and (2) what patient-centric tasks do they perform?

Setting

Clinical and academic exercise settings worldwide.

Methods

This multimethod study included a scoping review of PA programs in MBS described in the research literature. Data about job tasks were extracted and provided to 10 experts to sort into categories. Cluster analysis was utilized to find the hierarchical structure of tasks. A Delphi process was used to agree on a final model.

Results

The majority of PA professionals were exercise physiologists in the USA and physiotherapists or other types of exercise professionals elsewhere. Forty-three tasks were identified, the most reported being: supervision of exercise, fitness testing, and exercise prescription. Seven higher-order categories were determined: (1) Exercise-related health assessment, (2) Body composition and physical fitness assessment, (3) Lifestyle physical activity and sedentary behavior assessment, (4) Education, instruction, and prescription, (5) Exercise monitoring, (6) Behavioral counseling and psychosocial support, and (7) Dietary support. The following statements were rated an average of 9.0, classifying them as "imperative": 1) "Pre- and post-operative PA/exercise guidelines for MBS patients are needed", 2) "MBS programs need to include PA/exercise as part of multidisciplinary care".

Conclusions

The expert group reached a consensus on 7 major classifications of job tasks for the exercise professional. It is important for governing medical associations across the world to formally recognize experienced exercise professionals as playing pivotal roles in continuing, multidisciplinary care for MBS patients. These findings also provide evidence-based information in the effort to solidify these positions within the greater context of healthcare.

Weight loss maintenance after bariatric surgery

Metabolic and bariatric surgery (MBS) is an effective treatment for patients with morbid obesity and its comorbidities. However, many patients experience weight regain (WR) after achieving their nadir weight. Establishing the definition of WR is challenging as postoperative WR has various definitions. Risk factors for WR after MBS include anatomical, racial, hormonal, metabolic, behavioral, and psychological factors, and evaluating such factors preoperatively is necessary. Long-term regular follow-up and timely treatment by a multidisciplinary team are important because WR after surgery is multi-factorial. Although lifestyle interventions that focus on appropriate dietary education, physical activity education or interventions, and behavioral psychological interventions are suggested, more well-designed studies are needed because studies evaluating intervention methods and the effectiveness of WR prevention are lacking. Anti-obesity drugs can be used to prevent and manage patients with WR after MBS; however, more research is needed to determine the timing, duration, and type of anti-obesity drugs used to prevent WR.

Weight Regain After Bariatric Surgery: Scope of the Problem, Causes, Prevention, and Treatment

PURPOSE OF REVIEW

Although bariatric surgery is the most effective treatment of severe obesity, a proportion of patients experience clinically significant weight regain (WR) with further out from surgery. The purpose of this review is to summarize the prevalence, predictors, and causes of weight regain.

RECENT FINDINGS

Estimating the prevalence of WR is limited by a lack of consensus on its definition. While anatomic failures such as dilated gastric fundus after sleeve gastrectomy and gastro-gastric fistula after Roux-en-Y gastric bypass can lead to WR, the most common causes appear to be dysregulated/maladaptive eating behaviors, lifestyle factors, and physiological compensatory mechanisms. To date, dietary, supportive, behavioral, and exercise interventions have not demonstrated a clinically meaningful impact on WR, and there is limited evidence for pharmacotherapy. Future studies should be aimed at better defining WR to begin to understand the etiologies. Additionally, there is a need for non-surgical interventions with demonstrated efficacy in rigorous randomized controlled trials for the prevention and reversal of WR after bariatric surgery.

Despite regression of healthy lifestyle habits, weight loss after bariatric surgery is not affected during the COVID-19 pandemic

BACKGROUND

The coronavirus pandemic has caused a worldwide health crisis. Bariatric patients require extensive pre- and post-operative follow-up, which may be less feasible during public health social distancing mandates. We assessed the impact of the pandemic on the behaviors and weight loss outcomes of our pre- and post-operative bariatric patients.

METHODS

A retrospective review of a prospectively maintained database identified patients who underwent either sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) at a single institution between March 2018 and May 2020. A cohort undergoing surgery within 12 months before the pandemic as well as a cohort undergoing a medically supervised diet prior to surgery was surveyed regarding pre- and post-COVID-19 lifestyle habits. Excess weight loss (EWL) outcomes from a group of pre-COVID surgical patients were compared to that of a group of post-COVID surgical patients. Primary outcome was whether the lockdown changed 1-year weight loss outcomes. Secondary outcome was whether patient lifestyle behaviors were changed during the pandemic.

RESULTS

There was no difference in 1-year EWL between pre- and post-COVID SG patients (51.7% versus 55.9%, p = 0.35), or between pre- and post-COVID RYGB patients (88.9% versus 80.4%, p = 0.42). Pre-stay-at-home order, 91.8% endorsed physical activity compared to 80.3% post-stay-at-home order (p = 0.0025). Mean physical activity decreased from 4.2 h/week to 2.7 h/week after the stay-at-home order (p < 0.0001). Additionally, 41.3% reported worsened dietary habits post-stay-at-home order.

CONCLUSION

The COVID-19 pandemic has greatly impacted the behaviors of bariatric surgery patients. Despite deterioration of lifestyle habits, 1-year weight loss outcomes after bariatric surgery remained the same before and after the instatement of social distancing measures. In the short term, the biological effect of metabolic procedures may mask the effects of suboptimal diet and physical activity, but more studies are necessary to better assess the impact of COVID-19 on outcomes after bariatric surgery.

The impact of exercise on prevention of sarcopenia after bariatric surgery: The study protocol of the EXPOBAR randomized controlled trial

Introduction

Bariatric surgery is one of the treatments for severe obesity, with proven efficacy in reducing weight and diseases associated with obesity. Weight loss associated with bariatric surgery is greatly associated with a significant reduction of skeletal muscle and bone mineral mass, which leads us to induce that after bariatric surgery, patients incur an increased risk of sarcopenia. The need for prophylactic programs that prevent sarcopenia in bariatric surgery patients seems to be one of the crucial points for the long-term surgical success of bariatric and metabolic surgery. The aim of this randomized clinical trial will be to study the effects of a 16-week supervised exercise intervention program on the prevention of sarcopenia, in patients undergoing bariatric surgery. As a secondary purpose, it is also intended to characterize metabolic risk factors, physical fitness, and quality of life in post-bariatric surgery patients.

Method

A total of 45 patients on the waiting list for bariatric surgery and who have subsequently perfurgery, will be include on EXPOBAR (EXercise POst BARiatric) and randomized into 2 groups, experimental and control. The intervention starts one month after surgery, for a total of 16 weeks. Parameters of body composition, metabolic risk, quality of life, physical activity, physical fitness, and sedentary behavior will be determined. For each participant, outcomes are measured at five different time points: before the surgery, before the exercise program, after the exercise program, six and twelve months after de exercise program.

Results

This study will provide the effects of a physical exercise on sarcopenia, in patients after bariatric surgery.

Trial registration

The trial was registered at Clinicaltrials.gov NCT03497546.

A systematic review of interventions to increase physical activity and reduce sedentary behaviour following bariatric surgery

Background

Objectives

Eligibility

Study appraisal and synthesis methods

Results

Limitations

Conclusion and implications of key findings

Systematic review registration number

Diet and physical activity are associated with suboptimal weight loss and weight regain 10-15 years after Roux-en-Y gastric bypass: A cross-sectional study

INTRODUCTION

Suboptimal weight loss (SWL) after bariatric surgery affects approximately 30% of the patients in the long-term. Diet and physical activity (PA) are likely to modulate long term weight loss outcomes after Roux-en-Y gastric bypass (RYGB).

OBJECTIVES

To compare food habits and PA levels between those experiencing SWL and optimal weight loss (OWL), and between those experiencing weight regain (WR) and no weight regain (NWR), 10-15 years after RYGB, in addition to a pre-operative control group.

METHODS

Participants were recruited from the Bariatric Surgery Observation Study (BAROBS), ≥ 10 y after RYGB. Food intake was assessed by a Food Frequency Questionnaire (FFQ) and PA levels with Sensewear armbands.

RESULTS

75 participants (79% females) were recruited. Excess weight loss (EWL) was 17 ± 19% and 87 ± 22% in the SWL and OWL groups, respectively and WR was 31 ± 15% and 1 ± 11% in the WR and NWR groups, respectively (P < 0.001 for both). The OWL group reported a lower energy intake (P = 0.012) than the control group. The control group reported a higher intake of milk, cream and cheese than both SWL group (P = 0.008) and OWL group (P < 0.001). The SWL group reported a higher intake of processed meat products than the OWL group, while the OWL group reported a lower intake of sauces than both the SWL and the control groups (P < 0.001 and P = 0.005, respectively). The OWL group reported a lower intake of cakes, sugar and sweets than both SWL group (P = 0.035) and control group (P = 0.021). The WR group reported a lower PA duration (P = 0.046) compared with the NWR group. EWL was positively, and WR negatively, correlated with average PA duration.

CONCLUSION

A high intake of energy-dense foods and low PA is associated with poor weight loss outcomes, namely SWL and WR, 10-15 years after RYGB.

Potential Mechanisms for How Long-Term Physical Activity May Reduce Insulin Resistance

Insulin became available for the treatment of patients with diabetes 100 years ago, and soon thereafter it became evident that the biological response to its actions differed markedly between individuals. This prompted extensive research into insulin action and resistance (IR), resulting in the universally agreed fact that IR is a core finding in patients with type 2 diabetes mellitus (T2DM). T2DM is the most prevalent form of diabetes, reaching epidemic proportions worldwide. Physical activity (PA) has the potential of improving IR and is, therefore, a cornerstone in the prevention and treatment of T2DM. Whereas most research has focused on the acute effects of PA, less is known about the effects of long-term PA on IR. Here, we describe a model of potential mechanisms behind reduced IR after long-term PA to guide further mechanistic investigations and to tailor PA interventions in the therapy of T2DM. The development of such interventions requires knowledge of normal glucose metabolism, and we briefly summarize an integrated physiological perspective on IR. We then describe the effects of long-term PA on signaling molecules involved in cellular responses to insulin, tissue-specific functions, and whole-body IR.

Factors Related to Weight Loss Maintenance in the Medium-Long Term after Bariatric Surgery: A Review

Despite bariatric surgery being the most effective treatment for obesity, some individuals do not respond adequately, especially in the long term. Identifying the predictors of correct weight maintenance in the medium (from 1 to 3 years after surgery) and long term (from 3 years and above) is of vital importance to reduce failure after bariatric surgery; therefore, we summarize the evidence about certain factors, among which we highlight surgical technique, psychological factors, physical activity, adherence to diet, gastrointestinal hormones or neurological factors related to appetite control. We conducted a search in PubMed focused on the last five years (2015–2021). Main findings are as follows: despite Roux-en-Y gastric bypass being more effective in the long term, sleeve gastrectomy shows a more beneficial effectiveness–complications balance; pre-surgical psychological and behavioral evaluation along with post-surgical treatment improve long-term surgical outcomes; physical activity programs after bariatric surgery, in addition to continuous and comprehensive care interventions regarding diet habits, improve weight loss maintenance, but it is necessary to improve adherence; the impact of bariatric surgery on the gut–brain axis seems to influence weight maintenance. In conclusion, although interesting findings exist, the evidence is contradictory in some places, and long-term clinical trials are necessary to draw more robust conclusions.

Behavioral weight management interventions in metabolic and bariatric surgery: A systematic review and meta-analysis investigating optimal delivery timing

Metabolic and bariatric surgery (MBS) yields unprecedented clinical outcomes, though variability is high in weight change and health benefits. Behavioral weight management (BWM) interventions may optimize MBS outcomes. However, there is a lack of an evidence base to inform their use in practice, particularly regarding optimal delivery timing. This paper evaluated the efficacy of BWM conducted pre- versus post- versus pre- and post-MBS. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and included pre- and/or post-operative BWM interventions in adults reporting anthropometric and/or body composition data. Thirty-six studies (2,919 participants) were included. Post-operative BWM yielded greater decreases in weight (standardized mean difference [SMD] = -0.41; 95% confidence interval [CI]: -0.766 to -0.049, p < 0.05; I² = 93.5%) and body mass index (SMD = -0.60; 95% CI: -0.913 to -0.289, p < 0.001; I² = 87.8%) relative to comparators. There was no effect of BWM delivered pre- or joint pre- and post-operatively. The risk of selection and performance bias was generally high. Delivering BWM after MBS appears to confer the most benefits on weight, though there was high variability in study characteristics and risk of bias across trials. This provides insight into the type of support that should be considered post-operatively.