More Emphasis on Lifestyle Improvements Needed After Bariatric Surgery, Study Finds

Crystal Johnson-Mann, MD, MPH

Despite showcasing improved adherence to healthy eating behaviors and physical activity recommendations, new research suggests more emphasis is needed on optimizing lifestyle changes post-bariatric surgery in individuals with severe obesity and metabolic disease.

An analysis of data from more than 4500 patients comparing lifestyle patterns among those who underwent bariatric surgery against those considered eligible for surgery, results of the study demonstrate undergoing surgery is associated with improvements in lifestyle patterns, but still fail to achieve the levels of adherence to healthy eating and physical activity seen among their counterparts with normal weight.

“Obesity is a chronic disease process and must be managed as one, like hypertension or diabetes,” said study investigator Crystal Johnson-Mann, MD, MPH, an assistant professor and a minimally invasive/bariatric surgeon in the division of gastrointestinal surgery at the University of Florida College of Medicine, in a statement. “Patients have the best outcomes from bariatric surgery when it is fully utilized as an adjunct to lifestyle/behavioral changes, such as changes in physical activity and diet. Not all patients postsurgery can be as physically active as desired due to ongoing neurologic, musculoskeletal or other factors, but physical activity should be highly encouraged in those who can engage in order to maximize the benefits of their metabolic surgery.”

Although the uptake of bariatric surgery has increased in recent years, few studies have explored how undergoing bariatric surgery might influence patient behaviors. To do so, investigators designed their study as a cross-sectional analysis of data from the National Health and Nutrition Examination Survey (NHANES) from survey cycles taking place from 2015-2018 to characterize differences in lifestyle behaviors among those with normal weight, those who received bariatric surgery, and those who were considered clinically eligible for bariatric surgery.

The investigators' initial search of NHANES data returned a sample of 11,848 participants aged 18 years or older. After categorizing patients into groups based on weight and whether or not they had undergone bariatric surgery as well as those with missing data, a cohort of 4659 participants were identified for inclusion. This cohort had a mean age of 46.1 (SD, 18.6) years, 58.8% were women, 12.7% were Black, and 3.7% reported having undergone any bariatric surgery. Among those who underwent bariatric surgery, the median time since surgery was 7 (IQR, 3-10) years.

The primary outcomes of interest for the study were self-reported measures to assess physical activity and eating behaviors. Measurements of physical activity included moderate-to-vigorous physical activity (MVPA), sedentary activity, and whether physical activity guidelines were met and eating behaviors were measured as total energy intake and Health Eating Index (HEI)-2015 diet scores.

In propensity score-weighted analyses, those who underwent bariatric surgery reported more time spent engaging in MVPA those eligible for surgery, with total reported MVPA per week at 147.9 minutes per week compared to 97.4 minutes per week, respectively. Compared to those of normal weight (45.6%; 95% CI, 13.8-32.4%), the percentage of patients achieving physical activity guidelines were nearly 2 times greater than those in the bariatric surgery (23.1%; 95% CI, 13.8-32.4%) and surgery-eligible group (20.3%; 95% CI, 15.6-25.1%).

Further analysis of HEI-2015 scores demonstrated HEI scores were greater for those with normal weight (54.4; 95% CI, 53.0-55.9) than those who underwent bariatric surgery (50.0; 95% CI, 47.2-52.9) or were eligible for the surgery (48.0; 95% CI, 46.0-50.0). Additionally, when assessing HEI components, mean scores were similar among those who received bariatric surgery and those considered clinically eligible for surgery. Investigators also noted daily total energy intake was lowest among those who underwent bariatric surgery (1746 kcal; 95% CI, 1554-1937), followed by those with normal weight (1943 kcal; 95% CI, 1873-2013) and those eligible for bariatric surgery (2040 kcal; 1953-2128).

“The provision of nutritional counseling and support to help patients make and maintain postsurgical changes in their dietary intake and physical activity is key to supporting long-term weight loss maintenance,” said senior investigator Kathryn Ross, PhD, MPH, an associate professor of clinical and health psychology in the College of Public Health and Health Professions, in the aforementioned statement. “Offering positive, nonjudgmental support while helping patients set realistic, achievable goals can also benefit postoperative patients trying to make changes in their eating and activity patterns.”

This study, “Assessment of Physical Activity and Healthy Eating Behaviors Among US Adults Receiving Bariatric Surgery,” was published in JAMA Network Open.