Introduction
Persons seeking metabolic and bariatric surgery (MBS) tend to spend most of their time in sedentary behaviors and perform low levels of physical activity (PA) [
1,
2]. Participation in regular PA can be challenging because of both obesity- (e.g., physical limitations, negative body image) and non-obesity-related barriers (e.g., time constraints, low financial resources, weather, lack of motivation, lacking social support) [
3,
4]. Several aspects including socio-demographic, biological, psychological, social, and environmental factors may influence the decision to perform PA and maintain it long-term [
5].
PA after MBS is important because it contributes to greater weight loss, helps maintain a lower weight, and can reduce risk of diseases and improve quality of life [
6‐
10]. World Health Organization (WHO) guidelines currently recommend at least 150–300 min/week of PA of moderate intensity, or 75–150 min/week of vigorous intensity, or an equivalent combination of both. The guidelines also state that sedentary time should be limited and replaced with PA of any intensity [
11].
Weight loss after MBS can facilitate participation in PA; however, the literature on PA after MBS is conflicting. A meta-analysis from 2019 found no increase in objectively measured PA within 6 months post-surgery but found significant improvement after 6 months [
12], while other studies report no increase [
13,
14].
Psychological factors are central to the decision to perform PA; the main PA mediators are enjoyment, self-efficacy, and social support. Self-efficacy is a person’s confidence in their ability to perform a particular behavior [
5]. Weight loss may affect PA mediators [
2,
15,
16], but further studies are needed to evaluate determinants of PA behavior in individuals who have undergone MBS. The aim of this study was to explore levels of PA and the main PA mediators before and after MBS.
Discussion
Light PA, total PA, steps/day, and self-reported PA all increased, but the results show generally low levels of higher PA intensities both before and after MBS. Sedentary time percentage of wear time increased significantly while mean sedentary time and MVPA (min/day) remained unchanged.
The PA mediator enjoyment, self-efficacy for exercise, and positive social support from family increased significantly post-surgery, in line with previous studies [
2,
15,
32]. Weight loss can improve physical functioning and reduce pain and thus makes it easier to perform PA [
12]. This may in turn enhance PA enjoyment, self-efficacy, and belief in own ability to perform PA. The effect size of the change in PA enjoyment was large (SRM = 0.84), which indicates that the positive experience of PA was considerably higher post-surgery. This is likely due to lower body weight and a reduction in obesity-related barriers to PA [
33]. However, the effect size of change for self-efficacy and social support from family was small (SRM = 0.39 and 0.29), suggesting that these changes were less important than the change in enjoyment. With improved PA mediators, we suggest that there is potential for an increase in MVPA; however, to achieve this, additional interventions are needed and should be offered to patients undergoing MBS.
The increase in mediators for PA indicates a positive change in the participants’ perception of PA, which can be a first step towards a change in behaviors. However, it did not lead to a significant change in MVPA at group level, which has also been shown in previous studies [
13,
14]. To accomplish an increase in higher intensities of PA, interventions should focus on habits. Habits develop when a behavior is repeated in a consistent context for an extended period of time [
34]. If the experience of performed PA is satisfactory, there is an enhanced tendency to repeat the action. Over time cognitive shortcuts develop—a new habit is formed [
35]. The challenge is to put habit theories into clinical practice to help individuals who have undergone MBS develop new PA habits.
The proportion of individuals meeting PA recommendations in a population may vary. A Swedish cohort study observed fivefold higher odds for high sedentary time and low MVPA in persons with BMI ≥ 35 compared to persons with BMI < 24.9 [
36]. Most participants (82%) in our study did not reach the recommended PA levels [
11]. On the group level, mean MVPA was 78.4 min/week pre-surgery and 104.3 min/week post-surgery. However, even if this change was not significant, the effect size suggests a small and possibly meaningful increase in MVPA. Almost 25% of participants increased their MVPA by at least 10 min/day. Additionally, 18% of the participants reached > 150 min of MVPA/week post-surgery, compared to 10% pre-surgery, which is consistent with a Norwegian study where 17.9% met the recommended MVPA level at 1-year post-surgery [
37]. This increase may have a positive effect on the individual’s health status if PA is regularly performed at this level. Furthermore, WHO guidelines on PA state that health benefits can occur even with PA levels below recommendations [
11].
Mean valid accelerometer wear time differed significantly pre- and post-surgery, and participants wore the accelerometer 30 min longer per day post-surgery. We do not know the reason for these differences, but a large weight loss may result in being out of bed for longer during the day. Another reason could be a better routine to wear the accelerometer at the follow-up. Longer wear time will likely result in longer sedentary time, as people in general spend more than half of their waking time sedentary [
36]. When considering percentage of wear time, our results show a significant reduction in sedentary time post-surgery, in contrast to using actual time, which gave a non-significant result. However, the effect size of change was in the small range (SRM = 0.31), and it is somewhat unclear if the change is of clinical significance. Time spent in LPA and MVPA is probably not affected as much by wear time as is sedentary time. The most relevant results in our study are therefore the increase in actual time spent in LPA and MVPA and the decrease in sedentary time as percentage of wear time.
Persons with obesity often report that they are not used to performing PA and do not identify as someone who practices PA [
32,
38], which can make it challenging to start or increase PA. Furthermore, non-obesity-related barriers to PA (e.g., lack of time, motivation, social support) may remain post-surgery [
33].
Findings in the current and previous studies indicate that MBS is not sufficient to change a person’s PA habits. There is a need for further research to understand what motivates patients post-MBS to decrease sedentary time and perform PA of higher intensities and how best to support them. Previous studies show that this objective can be difficult to achieve. Neither group-based educational programs of four to ten sessions, nor a motivational individual PA intervention for 6 months resulted in increased PA [
39‐
41]. An intervention focusing on mediators for PA, motivational theories, and how habits are formed may be more successful. Future research could test if internet-based cognitive behavioral therapy with additional support from health care professional could be appropriate for an intervention to increase PA after MBS. Although self-efficacy for exercise improved after MBS, the post-op scores are at a low level and additional treatment efforts may be directed specifically at improving self-efficacy.
Strengths and Limitations
The major strengths of this study include the longitudinal design with objective monitoring of PA with accelerometers, as well as the investigation of mediators for PA. It is one of few studies using validated measures of enjoyment, self-efficacy for exercise, and social support in relation to PA post-MBS.
The power calculation indicated a sample size of 100 participants to achieve a power of 94%. However, the SD of sedentary time was lower in our study (63.2 min/day) than in the study the power calculation was derived from (141.5 min/day), and the power in our study was as strong as in the power calculation.
A major limitation of our study is the large dropout rate. At follow-up, 67% of the participants completed the questionnaires, but only 56% had also valid accelerometer data. It was a challenge to measure PA in individuals in free-living conditions. Despite intensive monitoring, several accelerometers were not returned, resulting in complete follow-up measures from 50 participants. Therefore, the results need to be interpreted with some caution. A higher proportion of dropouts were operated with SG; otherwise, we found no significant differences between completers and dropouts.
Our study population of 90 participants represents almost 20% of all persons who underwent MBS at the university hospital during the study period. Due to organizational reasons and periods of lack of personnel at the surgery unit, only 147 of 455 operated patients were asked for consent to participate in the study. It is possible that persons who were not asked or declined participation were less physically active, which may have biased our results.
We assessed outcomes 12 to 18 months after MBS, and participants may have experienced the “honeymoon effect” with major weight loss and maximum motivation at this point of time. Effects also need to be evaluated in the longer term to determine whether the changes are sustainable over time.
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