Surgery for Obesity and Related Diseases ] (2014) 00–00
Editorial comment
Comment on: Patterns of physical activity and sedentary behavior after bariatric surgery: an observational study Increasing physical activity (PA) is considered an essential goal within the context of bariatric surgery given that higher PA levels could assist with enhancing and maintaining postoperative outcomes [1]. Conversely, decreasing sedentary behaviors (SB), a group of behaviors characterized by very low energy expenditure and a sitting or reclining posture [2], may also be an important target for adjunctive preoperative and postoperative behavioral interventions [3–4]. Substantial evidence suggests that greater time spent performing SB, such as watching television and computer use, can negatively impact weight, cardiometabolic health, and life expectancy, independent of PA [5–7]. Efforts to generate more precise estimates of PA and SB levels constitute a growing focus of behavioral research in the field of bariatric surgery [1,8]. Although numerous studies during the past decade have produced findings suggesting that patients become habitually active postoperatively [9], the validity of these findings are questionable given that they are derived from retrospective selfreport questionnaires [8]. This measurement method involves considerable potential for inaccuracy given tendencies of patients to forget past PA behavior, respond in a manner to obtain praise and/or avoid criticism, and possibly confuse postoperative improvements in physical mobility with greater time spent being active [1,8,10]. More recent research that has used objective monitors to obtain real-time estimates of daily PA presents a vastly different picture regarding bariatric surgery patients’ preoperative and postoperative PA behavior. Although patients generally increase their PA postoperatively, the increases are markedly smaller than self-reported increases and show that most patients remain insufficiently active [1,10–11]. These contrasting findings highlight the importance of using objective monitors to obtain a more sophisticated understanding of patients’ PA and SB patterns and inform development of appropriate interventions and guidelines to modify these behaviors and optimize surgical outcomes. The study by Chapman et al. [12] is the first to objectively assess time spent in SB during the postoperative period and provide a detailed analysis of the patterns in which SB and PA are accumulated. The authors assessed time spent in PA and
SB via the SenseWear Armband (Body Media, Inc., Pittsburgh, PA) and step count via the StepWatch 3 Activity Monitor (Orthocare Innovations, Seattle, WA) during a 7-day period in 40 participants (75% female, 46 ⫾ 16 years old, BMI of 36.0 ⫾ 9.0 kg/m2) who were 14.0 ⫾ 8.0 months postgastric banding (LAGB) or sleeve gastrectomy (SG). Median values showed that participants spent the largest proportion (72%) of daily waking hours in SB, and 22%, 5%, and 0% of time in light-, moderate-, and vigorous-intensity PA, respectively. Additionally, the findings showed that greater time spent in SB and light PA was associated with higher and lower current weight, respectively. Although the study was cross-sectional, informal comparison with 2 previous preoperative studies [13,14] that used the identical monitor and intensity thresholds suggests that patients may substitute a small amount of sedentary time for light PA but do not make changes in moderate or vigorous PA postoperatively. The authors also showed that participants accumulated nearly half of time spent in SB in uninterrupted bouts of at least 30 minutes in duration. This finding is particularly concerning given that longer uninterrupted bouts of time spent in SB are associated with higher BMI and other cardiometabolic risk factors, independent of total time spent in SB [6]. Consequently, failure to change such patterns of SB accumulation could potentially undermine weight loss and other surgical outcomes. Additionally, findings revealed that participants rarely performed PA of any intensity in bouts Z10 minutes in duration, as per national guidelines [15]. Although all participants performed at least a single Z10-minute bout of light PA, only 58% and 18% of participants performed a least a single bout of moderate and vigorous PA, respectively. These findings largely confirm those from previous studies suggesting that bariatric surgery, despite producing substantial weight loss, resolution of co-morbidities, and improvements in physical function, yields little if any effect on patients’ participation in PA for sustained periods of time [10,11]. As recent studies suggest, barriers to postoperative adoption of habitual PA may be largely a function of psychosocial factors, such as low exercise motivation and self-efficacy, perceived lack of time, body image concerns, and social stigma [16–19].
1550-7289/14/$ – see front matter r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved. http://dx.doi.org/10.1016/j.soard.2013.10.015
2
D. S. Bond / Surgery for Obesity and Related Diseases ] (2014) 00–00
Clearly, more research on identifying and understanding PA barriers in the bariatric patient population and developing interventions that can effectively alleviate such barriers is highly warranted. Finally, the authors found that participants took approximately 9,100 steps per day, which is encouraging given that this average was similar to the step count reported in a local population sample and near the 10,000 steps per day “active” threshold. However, on closer inspection, only 39% of participants met the threshold, similar to a previous study [11]. Moreover, based on the data from the StepWatch activity monitor, it appears that this higher step count is largely due to time spent in short PA bouts of a light intensity. Although these minimal changes in PA and SB patterns may contribute to overall energy expenditure, larger reductions in SB and increased engagement in PA of longer duration and higher intensity is likely needed to achieve optimal weight maintenance and long-term resolution of co-morbidities. In conclusion, the study by Chapman et al. advances research on PA and SB in the field of bariatric surgery by using objective measures to provide greater insight regarding the amount of time that postoperative patients spend in SB as well as the manner in which patients accumulate SB and PA. One of the limitations of this study is the crosssectional design and the inability to determine whether the amount and patterns of SB and PA performed after surgery differ from before surgery. However, examination of the current findings in light of recent preoperative and longitudinal studies involving use of objective monitors supports the notion that patients experience considerable difficulty in changing these behaviors postoperatively and require additional intervention [1,10–11,17]. The data presented by Chapman et al. suggest that interventions and guidelines should be geared toward both increasing engagement in sustained periods of PA, particularly that of a moderate-to-vigorous intensity, and interrupting prolonged periods of SB with activity breaks. Future studies are needed to determine the most acceptable frequency and duration of breaks from SB and if both naturally occurring and intervention-produced changes in PA and SB patterns contribute to improved weight loss and other surgical outcomes. Dale S. Bond, Ph.D. Department of Psychiatry and Human Behavior Brown Alpert Medical School The Miriam Hospital/Weight Control and Diabetes Research Center Providence, Rhode Island
References 1 King WC, Bond DS. The importance of preoperative and postoperative physical activity counseling in bariatric surgery. Exerc Sport Sci Rev 2013;41:26–35. 2 Sedentary Behavior Research Network. Letter to the editor: standardized use of the terms “sedentary” and “sedentary behaviours.”. Appl Physiol Nutr Metab 2012;37:540–2. 3 Bond DS, Thomas JG, Unick JL, Raynor HA, Vithiananthan S, Wing RR. Self-reported and objectively-measured sedentary behavior in bariatric surgery candidates. Surg Obes Relat Dis 2013;9:123–8. 4 Vatier C, Henegar C, Ciangura C, Poitou-Bernert C, et al. Dynamic relationship between sedentary behavior, physical activity, and body composition after bariatric surgery. Obes Surg 2012;22:1251–6. 5 Mozaffarian D, Hao T, Rimm EB, Willett WC, Hu FB. Changes in diet and lifestyle and long-term weight gain in women and men. N Engl J Med 2011;364:2392–404. 6 Healy GN, Matthews CE, Dunstan DW, Winkler EA, Owen N. Sedentary time and cardio-metabolic biomarkers in US adults: NHANES 2003–06. Eur Heart J 2011;32:590–7. 7 Matthews CE, George SM, Moore SC, et al. Amount of time spent in sedentary behaviors and cause-specific mortality in US adults. Am J Clin Nutr 2012;95:437–45. 8 Thomas JG, Bond DS, Sarwer DB, Wing RR. Technology for behavioral assessment and intervention in bariatric surgery. Surg Obes Relat Dis 2011;7:548–57. 9 Jacobi D, Ciangura C, Couet C, Oppert JM. Physical activity and weight loss following bariatric surgery. Obes Rev 2011;12:366–77. 10 Bond DS, Jakicic JM, Unick JL, et al. Pre- to postoperative physical activity changes in bariatric surgery patients: self-report vs. objective measures. Obesity (Silver Spring) 2010;18:2395–7. 11 King WC, Hsu JY, Belle SH, et al. Pre- to postoperative changes in physical activity: report from the longitudinal assessment of bariatric surgery-2 (LABS-2). Surg Obes Relat Dis 2012;8:522–32. 12 Chapman N, Hill K, Taylor S, et al. Patterns of physical activity and sedentary behaviour following bariatric surgery: an observational study. Surg Obes Relat Dis 2013. (XX:XX–XX). 13 Bond DS, Unick JL, Jakicic JM, et al. Objective assessment of time spent being sedentary in bariatric surgery candidates. Obes Surg 2011;21:811–4. 14 Unick JL, Bond DS, Jakicic JM, et al. Comparison of two objective monitors for assessing physical activity and sedentary behaviors in bariatric surgery patients. Obes Surg 2012;22:347–52. 15 Haskell WL, Lee IM, Pate RR, et al. Physical activity and public health: updated recommendations for adults from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc 2007;39:1423–34. 16 Peacock JC, Sloan SS, Cripps B. A qualitative analysis of bariatric patients’ post-surgical barriers to exercise. Obes Surg 2013 Oct 4. [Epub ahead of print]. 17 Bond DS, Thomas JG, Ryder BA, Vithiananthan S, Pohl D, Wing RR. Ecological momentary assessment of the relationship between intention and physical activity in bariatric surgery patients. Int J Behav Med 2013;20:82–7. 18 Wouters EJ, Larsen JK, Zijlstra HA, van Ramshorst B, Geenen R. Physical activity after surgery for severe obesity: the role of exercise cognitions. Obes Surg 2011;21:1894–9. 19 Baillot A, Asselin M, Comeau E, Méziat-Burdin A, Langlois MF. Impact of excess skin from massive weight loss on the practice of physical activity in women. Obes Surg 2013;23:1826–34.
Editorial comment
Comment on: Patterns of physical activity and sedentary behavior after bariatric surgery: an observational study Increasing physical activity (PA) is considered an essential goal within the context of bariatric surgery given that higher PA levels could assist with enhancing and maintaining postoperative outcomes [1]. Conversely, decreasing sedentary behaviors (SB), a group of behaviors characterized by very low energy expenditure and a sitting or reclining posture [2], may also be an important target for adjunctive preoperative and postoperative behavioral interventions [3–4]. Substantial evidence suggests that greater time spent performing SB, such as watching television and computer use, can negatively impact weight, cardiometabolic health, and life expectancy, independent of PA [5–7]. Efforts to generate more precise estimates of PA and SB levels constitute a growing focus of behavioral research in the field of bariatric surgery [1,8]. Although numerous studies during the past decade have produced findings suggesting that patients become habitually active postoperatively [9], the validity of these findings are questionable given that they are derived from retrospective selfreport questionnaires [8]. This measurement method involves considerable potential for inaccuracy given tendencies of patients to forget past PA behavior, respond in a manner to obtain praise and/or avoid criticism, and possibly confuse postoperative improvements in physical mobility with greater time spent being active [1,8,10]. More recent research that has used objective monitors to obtain real-time estimates of daily PA presents a vastly different picture regarding bariatric surgery patients’ preoperative and postoperative PA behavior. Although patients generally increase their PA postoperatively, the increases are markedly smaller than self-reported increases and show that most patients remain insufficiently active [1,10–11]. These contrasting findings highlight the importance of using objective monitors to obtain a more sophisticated understanding of patients’ PA and SB patterns and inform development of appropriate interventions and guidelines to modify these behaviors and optimize surgical outcomes. The study by Chapman et al. [12] is the first to objectively assess time spent in SB during the postoperative period and provide a detailed analysis of the patterns in which SB and PA are accumulated. The authors assessed time spent in PA and
SB via the SenseWear Armband (Body Media, Inc., Pittsburgh, PA) and step count via the StepWatch 3 Activity Monitor (Orthocare Innovations, Seattle, WA) during a 7-day period in 40 participants (75% female, 46 ⫾ 16 years old, BMI of 36.0 ⫾ 9.0 kg/m2) who were 14.0 ⫾ 8.0 months postgastric banding (LAGB) or sleeve gastrectomy (SG). Median values showed that participants spent the largest proportion (72%) of daily waking hours in SB, and 22%, 5%, and 0% of time in light-, moderate-, and vigorous-intensity PA, respectively. Additionally, the findings showed that greater time spent in SB and light PA was associated with higher and lower current weight, respectively. Although the study was cross-sectional, informal comparison with 2 previous preoperative studies [13,14] that used the identical monitor and intensity thresholds suggests that patients may substitute a small amount of sedentary time for light PA but do not make changes in moderate or vigorous PA postoperatively. The authors also showed that participants accumulated nearly half of time spent in SB in uninterrupted bouts of at least 30 minutes in duration. This finding is particularly concerning given that longer uninterrupted bouts of time spent in SB are associated with higher BMI and other cardiometabolic risk factors, independent of total time spent in SB [6]. Consequently, failure to change such patterns of SB accumulation could potentially undermine weight loss and other surgical outcomes. Additionally, findings revealed that participants rarely performed PA of any intensity in bouts Z10 minutes in duration, as per national guidelines [15]. Although all participants performed at least a single Z10-minute bout of light PA, only 58% and 18% of participants performed a least a single bout of moderate and vigorous PA, respectively. These findings largely confirm those from previous studies suggesting that bariatric surgery, despite producing substantial weight loss, resolution of co-morbidities, and improvements in physical function, yields little if any effect on patients’ participation in PA for sustained periods of time [10,11]. As recent studies suggest, barriers to postoperative adoption of habitual PA may be largely a function of psychosocial factors, such as low exercise motivation and self-efficacy, perceived lack of time, body image concerns, and social stigma [16–19].
1550-7289/14/$ – see front matter r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved. http://dx.doi.org/10.1016/j.soard.2013.10.015
2
D. S. Bond / Surgery for Obesity and Related Diseases ] (2014) 00–00
Clearly, more research on identifying and understanding PA barriers in the bariatric patient population and developing interventions that can effectively alleviate such barriers is highly warranted. Finally, the authors found that participants took approximately 9,100 steps per day, which is encouraging given that this average was similar to the step count reported in a local population sample and near the 10,000 steps per day “active” threshold. However, on closer inspection, only 39% of participants met the threshold, similar to a previous study [11]. Moreover, based on the data from the StepWatch activity monitor, it appears that this higher step count is largely due to time spent in short PA bouts of a light intensity. Although these minimal changes in PA and SB patterns may contribute to overall energy expenditure, larger reductions in SB and increased engagement in PA of longer duration and higher intensity is likely needed to achieve optimal weight maintenance and long-term resolution of co-morbidities. In conclusion, the study by Chapman et al. advances research on PA and SB in the field of bariatric surgery by using objective measures to provide greater insight regarding the amount of time that postoperative patients spend in SB as well as the manner in which patients accumulate SB and PA. One of the limitations of this study is the crosssectional design and the inability to determine whether the amount and patterns of SB and PA performed after surgery differ from before surgery. However, examination of the current findings in light of recent preoperative and longitudinal studies involving use of objective monitors supports the notion that patients experience considerable difficulty in changing these behaviors postoperatively and require additional intervention [1,10–11,17]. The data presented by Chapman et al. suggest that interventions and guidelines should be geared toward both increasing engagement in sustained periods of PA, particularly that of a moderate-to-vigorous intensity, and interrupting prolonged periods of SB with activity breaks. Future studies are needed to determine the most acceptable frequency and duration of breaks from SB and if both naturally occurring and intervention-produced changes in PA and SB patterns contribute to improved weight loss and other surgical outcomes. Dale S. Bond, Ph.D. Department of Psychiatry and Human Behavior Brown Alpert Medical School The Miriam Hospital/Weight Control and Diabetes Research Center Providence, Rhode Island
References 1 King WC, Bond DS. The importance of preoperative and postoperative physical activity counseling in bariatric surgery. Exerc Sport Sci Rev 2013;41:26–35. 2 Sedentary Behavior Research Network. Letter to the editor: standardized use of the terms “sedentary” and “sedentary behaviours.”. Appl Physiol Nutr Metab 2012;37:540–2. 3 Bond DS, Thomas JG, Unick JL, Raynor HA, Vithiananthan S, Wing RR. Self-reported and objectively-measured sedentary behavior in bariatric surgery candidates. Surg Obes Relat Dis 2013;9:123–8. 4 Vatier C, Henegar C, Ciangura C, Poitou-Bernert C, et al. Dynamic relationship between sedentary behavior, physical activity, and body composition after bariatric surgery. Obes Surg 2012;22:1251–6. 5 Mozaffarian D, Hao T, Rimm EB, Willett WC, Hu FB. Changes in diet and lifestyle and long-term weight gain in women and men. N Engl J Med 2011;364:2392–404. 6 Healy GN, Matthews CE, Dunstan DW, Winkler EA, Owen N. Sedentary time and cardio-metabolic biomarkers in US adults: NHANES 2003–06. Eur Heart J 2011;32:590–7. 7 Matthews CE, George SM, Moore SC, et al. Amount of time spent in sedentary behaviors and cause-specific mortality in US adults. Am J Clin Nutr 2012;95:437–45. 8 Thomas JG, Bond DS, Sarwer DB, Wing RR. Technology for behavioral assessment and intervention in bariatric surgery. Surg Obes Relat Dis 2011;7:548–57. 9 Jacobi D, Ciangura C, Couet C, Oppert JM. Physical activity and weight loss following bariatric surgery. Obes Rev 2011;12:366–77. 10 Bond DS, Jakicic JM, Unick JL, et al. Pre- to postoperative physical activity changes in bariatric surgery patients: self-report vs. objective measures. Obesity (Silver Spring) 2010;18:2395–7. 11 King WC, Hsu JY, Belle SH, et al. Pre- to postoperative changes in physical activity: report from the longitudinal assessment of bariatric surgery-2 (LABS-2). Surg Obes Relat Dis 2012;8:522–32. 12 Chapman N, Hill K, Taylor S, et al. Patterns of physical activity and sedentary behaviour following bariatric surgery: an observational study. Surg Obes Relat Dis 2013. (XX:XX–XX). 13 Bond DS, Unick JL, Jakicic JM, et al. Objective assessment of time spent being sedentary in bariatric surgery candidates. Obes Surg 2011;21:811–4. 14 Unick JL, Bond DS, Jakicic JM, et al. Comparison of two objective monitors for assessing physical activity and sedentary behaviors in bariatric surgery patients. Obes Surg 2012;22:347–52. 15 Haskell WL, Lee IM, Pate RR, et al. Physical activity and public health: updated recommendations for adults from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc 2007;39:1423–34. 16 Peacock JC, Sloan SS, Cripps B. A qualitative analysis of bariatric patients’ post-surgical barriers to exercise. Obes Surg 2013 Oct 4. [Epub ahead of print]. 17 Bond DS, Thomas JG, Ryder BA, Vithiananthan S, Pohl D, Wing RR. Ecological momentary assessment of the relationship between intention and physical activity in bariatric surgery patients. Int J Behav Med 2013;20:82–7. 18 Wouters EJ, Larsen JK, Zijlstra HA, van Ramshorst B, Geenen R. Physical activity after surgery for severe obesity: the role of exercise cognitions. Obes Surg 2011;21:1894–9. 19 Baillot A, Asselin M, Comeau E, Méziat-Burdin A, Langlois MF. Impact of excess skin from massive weight loss on the practice of physical activity in women. Obes Surg 2013;23:1826–34.
