By Austin Ulrich, PharmD, BCACP
Consultant Pharmacist, Ulrich Medical Writing LLC, Greensboro, NC
SYNOPSIS: Patients who underwent bariatric surgery reported more physical activity and less energy intake than those who were eligible for, but did not undergo, bariatric surgery; however, physical activity still did not reach recommended levels.
SOURCE: Hong YR, Yadav S, Suk R, et al. Assessment of physical activity and healthy eating behaviors among US adults receiving bariatric surgery. JAMA Netw Open 2022;5:e2217380.
Obesity is increasingly recognized as a complex yet treatable disease, given its effects on cardiovascular and metabolic health, as well as availability of treatments aimed to lower body weight.1 In the United States, the prevalence of obesity is rising, with up to 42% of patients classified as obese as of 2017-2018.2 Furthermore, the BMI for approximately 9% of U.S. adults is ≥ 40 kg/m2, the classification for severe obesity.2 Obesity accounts for a substantial proportion of individual health burden and healthcare spending, with an estimated $260 billion spent in the United States on aggregate medical costs attributed to obesity.3
Bariatric surgery is an effective intervention for weight loss and demonstrates substantial improvements in glycemic control and cardiovascular risk in patients with type 2 diabetes.4 Bariatric surgery encompasses a variety of procedures, including vertical sleeve gastrectomy and Roux-en-Y gastric bypass, two of the most common procedures in the United States.4 The criteria for bariatric surgery are based on body weight and comorbidities; patients with a BMI measurement ≥ 40 kg/m2 or 35 kg/m2 to 39.9 kg/m2 with comorbidities are recommended candidates for surgery.4,5 Appropriate nutrition and physical activity are essential components of post-bariatric surgery care. Patients should be engaged in maintaining better metabolic status associated with weight loss from bariatric surgery.4 Continuation of physical activity and dietary behavioral changes are necessary for long-term retention of health benefits from bariatric surgery.6,7
Hong et al sought to determine the physical activity levels and eating patterns for individuals after they had undergone bariatric surgery, those who were eligible for the procedure, and people with normal body weight. The authors used data from the National Health and Nutrition Examination Survey collected from 2015-2018. Individuals in the study sample were classified into three groups: normal weight (i.e., a BMI in the range of 18.5 kg/m2 to 24.9 kg/m2), post-bariatric surgery (self-reported), and eligible for bariatric surgery, but no reported procedure (American Society for Metabolic and Bariatric Surgery-recommended criteria; BMI measurement ≥ 40 kg/m2 or BMI ≥ 35 kg/m2 with at least one obesity-related comorbidity).5
In total, 4,659 participants were selected. Adults who reported undergoing bariatric surgery comprised 3.7% of the population. A median of seven years had passed since the surgery. Participants who underwent bariatric surgery were more likely to be older, female, and white vs. individuals eligible for bariatric surgery. Additionally, those who underwent bariatric surgery were more likely to report mobility limitations, more chronic conditions, and fair or poor general health. The application of propensity score-weighting helped mitigate most between-group differences, except for general health status, diabetes, and hypertension.
Based on the propensity score-matched analysis, participants who were post-bariatric surgery spent more time engaging in moderate-to-vigorous physical activity per week than those eligible for surgery (147.9 minutes per week vs. 97.4 minutes per week). No differences were observed for sedentary activity. Participants with normal body weight recorded a significantly higher Healthy Eating Index-2015 score than those who were post-bariatric surgery and those who were eligible for bariatric surgery (54.4 vs. 50.0; P = 0.01 compared to 48.0; P < 0.001). Total energy intake was lowest in those who underwent bariatric surgery, followed by participants with normal weight, then participants eligible for bariatric surgery (i.e., 1,746 kcal per day, 1,943 kcal per day, and 2,040 kcal per day, respectively).
The authors concluded patients who underwent bariatric surgery engaged in more physical activity and their energy intake was lower than those eligible for surgery. However, physical activity did not reach recommended levels post-bariatric surgery, indicating opportunity for improvement in this population.
COMMENTARY
The results of this study highlight the importance of engaging patients in post-bariatric surgery self-care to maintain surgical weight reduction and better health outcomes. The recommended level for adults, based on the U.S. Department of Health and Human Services guidelines, is 150 minutes to 300 minutes per week of moderate-to-vigorous physical activity.8 Although the group of patients in this study who underwent bariatric surgery reported physical activity levels close to this target, these individuals, as well as patients eligible for bariatric surgery, can improve activity levels to achieve national targets. Bariatric surgery continues to represent an important option for durable weight loss and improvement of type 2 diabetes.4 Primary care clinicians play an important role in recommending patients for bariatric surgery and longitudinal care post-procedure. Clinicians should continue encouraging patients who undergo bariatric surgery to adhere to recommended levels of physical activity and nutrition to maintain health benefits from bariatric surgery.
REFERENCES
1. Rubino F, Nathan DM, Eckel RH, et al. Metabolic surgery in the treatment algorithm for type 2 diabetes: A joint statement by International Diabetes Organizations. Diabetes Care 2016;39:861-877.
2. Hales C, Carroll M, Fryar C, Ogden C. Prevalence of obesity and severe obesity among adults: United States, 2017-2018. NCHS Data Brief, no 360. February 2020.
3. Cawley J, Biener A, Meyerhoefer C, et al. Direct medical costs of obesity in the United States and the most populous states. J Manag Care Spec Pharm 2021;27:354-366.
4. American Diabetes Association Professional Practice Committee. 8. Obesity and weight management for the prevention and treatment of type 2 diabetes: Standards of medical care in diabetes — 2022. Diabetes Care 2022;45:S113-S124.
5. American Society for Metabolic and Bariatric Surgery. Bariatric surgery guidelines and recommendations. June 2012.
6. Coen PM, Carnero EA, Goodpaster BH. Exercise and bariatric surgery: An effective therapeutic strategy. Exerc Sport Sci Rev 2018;46:262-270.
7. Kanerva N, Larsson I, Peltonen M, et al. Changes in total energy intake and macronutrient composition after bariatric surgery predict long-term weight outcome: Findings from the Swedish Obese Subjects (SOS) study. Am J Clin Nutr 2017;106:136-145.
8. U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans. 2nd edition. 2018.
Patients who underwent bariatric surgery reported more physical activity and less energy intake than those who were eligible for, but did not undergo, bariatric surgery; however, physical activity still did not reach recommended levels.
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