Bariatric Surgical Patient Care: Could we please begin with introductions from the group and a description of your individual roles within the bariatric field?
Dr. Schuh: My name is Leslie Schuh. I am an experimental psychologist, and I joined the bariatric center at St. Vincent Carmel Hospital 4 years ago as a research scientist. I previously worked studying other types of medical conditions where behavior is a big component in their etiology and treatment. As a research scientist, my role is to manage the research studies at our bariatric center.
Dr. Creel: This is Dave Creel, and I am a licensed clinical psychologist, a certified exercise specialist through the American College of Sports Medicine, and a registered dietitian. Most of my work is clinical work with our surgical and nonsurgical patients, as well as with our kids' program. I also collaborate on some research here at the center, primarily right now in the physical activity arena.
Dr. Jakicic: This is John Jakicic, and I chair the Department of Health and Physical Activity at University of Pittsburgh. I also direct our Physical Activity and Weight Management Research Center, which is mostly an applied clinical research center. We fund mostly NIH types of grants through this.
Our focus has been on behavior change related to physical activity and nutritional change. In past years, our work has been with nonsurgical patients, and then in more recent years, we have been doing more with surgical patients and the role of activity in pre- and postbariatric surgery.
Dr. Gomez: My name is Adrienne Gomez. I am a bariatric physician and a board certified family practitioner. I supervise a medical weight loss program at St. Vincent Carmel. I also see presurgical and postsurgical bariatric patients.
Dr. Hurst: This is Lori Hurst, and I am also board certified in family medicine and have practiced family medicine for 7 years while doing weight management workshops for my patients in my local community. I joined the bariatric center at St. Vincent Carmel in September of 2012. Now I work with Dr. Gomez in the nonsurgical weight management program, as well as with our pre- and postsurgical patients.
Bariatric Surgical Patient Care: How important is physical activity pre- and postbariatric surgery?
Dr. Schuh: Physical activity is important both pre- and postsurgery. Some of the research—and a lot of this research is really in its infancy—shows that, before surgery, those patients who have some level of physical activity tend to have fewer complications and tend to be those who are able to maintain more physical activity over the years after surgery.1,2 So it is maintained over a long period of time.
There is also some research showing that those who are more active are able to lose more weight and maintain more weight loss.3,4 A lot of this is retrospective. I think we need a lot more prospective studies, but we are getting there.
Dr. Jakicic: I tend to agree with the fact that some of this is in its infancy, and a lot of it has been cross-sectional, retrospective kinds of studies, though those data are pretty clear that—maybe not within the first 6 to 12 months postbariatric surgery—once you get beyond 12 months postbariatric surgery, physical activity becomes more and more important. It seems like those who are engaging in higher levels, or more consistent levels of physical activity, tend to do better long term, not necessarily losing more weight but not regaining the weight beyond that 1-year to possibly 2-year period of time.
Some of the work that we have done presurgery is interesting because recent data we have looked at suggest that engaging people in these interventions prior to surgery to try to get them to change behavior—the jury is still out on whether or not that has any effect postsurgery.
However, when we looked at our physical activity data, objectively measured, those who engaged in an intervention had modest increases in physical activity presurgery. Then, those who engaged in usual care, once they were cleared for surgery, actually showed decreases in physical activity.
So what we probably need to be careful about is, once a person is cleared for surgery, having them not adopt the idea of, “I am already pretty inactive, and now I can even become more inactive because here comes the Holy Grail.” I am just concerned that we do not let that happen.
Dr. Creel: I think one myth, if you will, in weight management is that exercise has been oversold for weight loss. People sometimes think that exercise is going to have this huge impact on weight management, on their weight loss.
When people then have surgery, a lot of times they lose so much weight, they feel so much better, and in the short run, they are maintaining that weight loss fairly well without much physical activity. We do not see that as much in nonsurgical patients. At least, it is not as exaggerated.
So one of the challenges is for us to be able to talk to patients about exercise as something separate from just managing weight, as something that is very beneficial to their health overall. It is beneficial to their cardiac health, to their joint health, and to all the other effects—sleep, depression, self-efficacy—all the things that we know exercise does in the short run, so that we are not putting all of our eggs in one basket for people who maybe think, “Well, I am maintaining my weight loss without activity.”
As John said, I think the further we get out from surgery, the more we are going to see that the more exercise people do, the better they do long term with their weight loss. However, I think we are going to see more people able to sustain their weight loss, or a significant portion of their weight loss, after bariatric surgery without as much exercise. There are some data that show that people who have lost and maintained weight loss through bariatric surgery exercise less than people who have lost and maintained weight loss without surgery.
The idea is that we need to talk to patients about all the health benefits of exercise because most of the people we see, they are really interested in improving their health and quality of life. You can lose a lot of weight and still feel tired and depressed, and have poor sleep or cardiovascular disease. Although exercise is not a cure all, it can have many positive benefits independent of weight loss.
Dr. Gomez: I would definitely echo what Dave [Creel] said about the health benefits of exercise. I think we need to put more emphasis when we are talking with patients on the health benefits of exercise, and not so much on the weight loss factor.
Second, it is important for us to talk to patients about exercise—whether they are nonsurgical patients, presurgical, or postsurgical—because it seems to be one of the more difficult things to incorporate into their lives. It seems to require the most effort. It seems we encounter more resistance with exercise than we do resistance to dietary changes. So it is going to require a little more discussion on our part, and a little more focus to get people to think about it and to become more active.
Dr. Jakicic: I agree with this issue of placing more emphasis on physical activity and exercise. From a small pilot study that we did not that long ago, when we surveyed people who had undergone bariatric surgery, we asked them what kind of counseling they received related to physical activity from their surgeon and their healthcare provider. The vast majority of them did not even recall physical activity being talked about after they had the surgery. And of those who did recall having it talked about, the vast majority of them were getting information that was not consistent with current public health guidelines. So I do think we have a lot of work to do here relative to helping to promote physical activity in this population.
Dr. Hurst: It would be wonderful if we had a very large study that showed absolutely without question that bariatric patients postoperatively should exercise and that they would have wonderful benefits for doing so that would show up on the scale. That would be nice, but really, I think educating patients on the overall health benefits they experience from physical activity in general is essential, but it would be wonderful to have some more data to show our patients.
One of the things that we do in each presurgical appointment is set activity goals. We are very committed to that here. A lot of patients do not have a requirement by their insurance company to participate in any kind of presurgical weight loss counseling, so that might account for some of the data showing that patients do not recall being educated about the importance of physical activity. That is one of the components of our presurgical program here that we discuss at every visit, whether we are meeting with patients for 3 months, 6 months, or even a year sometimes before their surgery.
Bariatric Surgical Patient Care:
Many of you in this discussion are engaged in the clinical trial, Promoting Physical Activity Among Bariatric Surgery Patients.
5
Could you discuss the study and what types of physical activity interventions you are using and what results are stemming from those interventions?
Dr. Schuh: First, I want to make sure to point out: this is an ongoing clinical trial, so anything that we say is going to be preliminary. Results might change. But we are currently in the midst of a clinical trial looking at patients in three groups—usual care at our center; receiving a pedometer so that they can have feedback to track their steps over time and set individual goals; and the third group receives exercise counseling in addition to that pedometer.
Patients begin the study 2 weeks to 1 month before surgery, and then we see them at 2, 4, and 6 months after surgery in pairs of visits.
At the first visit, they receive an accelerometer and wear that for 2 weeks, and then come back and return the accelerometer so we are able to get some objective measures of their activity over those different time points. We are also doing some self-report questionnaires as well.
Dr. Creel: As far as the counseling goes, there are nine contacts basically in that 7-month period of time. Really, we wanted to make this as much of a natural setting as we could, so we thought about how exercise counseling might be integrated into postoperative care. It is really more of a naturalistic type of setting versus having a setting where we are saying, “We want everyone to achieve this many minutes of exercise, or come to the center and exercise”—more of a counseling environment where we are collaboratively setting goals. We are looking at all of the resources they have in their area to do either indoor activity, outdoor activity, or group activity, their support network, and trying to promote physical activity in that manner.
If you look at treatment models, we are using more of a self-determination theory approach where there is a lot of autonomy. We are trying to relate physical activity to broader life goals, and we also educate them so that they feel competent to do the activity. We want them to get enough education that they feel comfortable doing physical activity, walking on a treadmill, using an elliptical trainer, doing some strength training if they want.
But the pedometer group, though, just really has a pedometer, and it is self-directed. At the initial meeting, we talk about how you use a pedometer, long-term goals and benefits of getting 10,000 steps per day. But after that, patients simply wear their pedometer, record their steps, and turn in their step journals. And then the usual care group just gets the usual information that we provide through our center.
Bariatric Surgical Patient Care:
Thank you for that overview. Dr. Jakicic, you brought up some interventions for physical activity that were done presurgery, and then they did not have so much of an effect postsurgery. Would you like to elaborate on that data?
Dr. Jakicic: I am aware of some studies that are being undertaken to examine the effect of a presurgical intervention for changing lifestyle behavior, and whether this assists in changing key behaviors postsurgery. The research that I am aware of has used a very strong behavioral program involving in-person contacts and so forth, very much modeled after some of the successful interventions like the Diabetes Prevention Program,
6
Look AHEAD,
7
and others. Based on what I have been given the opportunity to observe, it really seems to have a modest effect on additional weight initially. I think that is simply because the surgeries are just so powerful for weight loss. They are so powerful that if we are looking at that behavior, it is difficult. My sense is that this is also having very modest effects on physical activity initially postsurgery, since just because people can get up and go does not mean they will get up and go, which may mean that we need postsurgical interventions actually to get them going as well.
So we have to ask: What is our outcome? If weight is our outcome, that is going to be tricky for some of these presurgical behaviors to influence, at least initially, and we may need to examine the influence longer term. If something else is our outcome, well, then we have to make sure we are asking the right question. For example, there are some data that suggest that getting folks physically active initially after surgery does improve things at first like glucose control beyond what is occurring with the weight loss resulting from bariatric surgery, and this may be because the surgeries are so powerful.
I think that our health benefits are longer term. They are not these initial 3- to 6-month effects. They are 6, 12, 18 months out, when physical activity really starts to take a bigger role here. It does not mean we should not do it. It does not mean that we should not try to get patients engaged in these behaviors. But I think it depends on what our outcome is as to how we try to help sell this to participants.
Dr. Hurst: One question for Dr. Jakicic: In regards to the intervention that you mentioned preoperatively, how long was it? Was it a 3-month program, a 6-month program? And then postop, what was the time frame that you followed participants as far as their activity levels?
Dr. Jakicic: I am aware of interventions that were initially 3 to 6 months in duration, and then patients were also assessed postop through at least 1 year. I want to be clear that this does not mean that presurgical interventions are not helpful. I think it means that we have to figure out how to best use those presurgical interventions and link them to the things that are happening postsurgically to have the biggest impact.
Dr. Creel: I agree that the context changes so much from pre- to postop very quickly, and so what people are able to do, what they may enjoy, what they think they enjoy, it can all change very rapidly.
You could argue that if you promote preoperative exercise incorrectly that people may be turned off to it. Maybe they got hurt or it is just too difficult for them. Or maybe someone made fun of them, or they had a bad experience. So I think John [Jakicic] makes a good point that we really need to look at that transition—the changes that are going to occur after surgery—and how we individualize the treatment to help them postoperatively.
The other thing that is important, when I talk to people preoperatively, sometimes I will teach a class, and we talk a lot about all these medical aspects that they can improve. But it is important to realize these people are not just subjects, they are not just people who we are practicing medicine on. These are people who have lives, and they want to enjoy themselves.
I tell them, if you are driving a clunker and you get a new car, you probably want to drive it. It does not make sense to leave it in the garage. I think if we can promote this and say, “What can you not do prior to surgery that you want to do after surgery?” you start planting those seeds. “What do you want to be able to do with this new body and your improved health?” We want to set it up so that they look forward to doing these things, not like it is a pill they have to swallow after bariatric surgery to maintain their weight loss. So the way we frame it may be really important.
Dr. Jakicic: Let me just play off of that comment from Dave [Creel]. What we find, in surgical and nonsurgical patients alike, is that, of course, the scale moving really motivates them. But then they notice that they can start to get out of the chair a little easier. They can start to walk up the steps and it does not hurt so badly, or they are not as much out of breath.
These functional gains that they start to see can happen rather quickly, and they are measurable to that individual person on a day-by-day basis. We do not have to pull a blood sample to find out that something good is happening to them.
This can be very motiving to people. And that is what they tell us. They can start playing with their children and grandchildren; they can get on the floor and play with them, and so on. I think these outcomes are very motivating, and we need to think about those as health outcomes. Those are quality of life health outcomes that we have not emphasized enough when we are trying to sell physical activity, especially to this population that really has not been all that active prior to having surgery.
Dr. Hurst: I definitely agree with that. Usually when we are setting our activity goals preoperatively, the focus is on “What do you want to be able to do postoperatively?” “What are the things in your life that you have not been able to do because of the excess weight,” and “What are you hoping to do after experiencing significant weight loss?” That is part of the activity goal setting. But it is hard to measure.
I think the study participants with the accelerometers who are not necessarily showing much increased activity after surgery are a bit perplexing because you would think that because of their quality of life being so much better, you would see an increase in the activities of daily living. Activities such as playing with the grandkids and being able to clean the house more often and go up and down stairs more easily should reflect on their accelerometer activity. Patients are telling us postoperatively that they can do these things much more often and easily than they were able to do before the weight loss. So it is interesting to look at. But maybe, like John [Jakicic] said, finding out how to best measure the activity-based lifestyle changes is the key.
Dr. Jakicic: Right. And I think we may be missing some of these outcomes when we look at some of these even objective measures because the traditionalists want to know, “How many minutes of moderate to vigorous intensity physical activity are you getting?” When in fact what we may be getting initially are the things that are not “moderate to vigorous levels of physical activity.” The patients are just starting to actually get up and move around a little bit more. And that is a very winnable situation for us. So maybe it is how we are looking at the data, not that the data are not necessarily showing a positive effect.
Dr. Creel: I would piggyback on that. I think the way we define moderate and vigorous activity in this group of patients may be different than for other populations. One thing that we are seeing when we do treadmill tests and we compare perceived exertion to heart rate, patients are telling us it feels harder than we would expect based on some of the physiological measures.
So I think that John makes a good point, that the exercises may feel moderate to them but does not actually meet that moderate physical activity category. When they are at the upper end of moderate, they physically say, “It is too hard for me to do.” So we could be missing some things in these objective measures because a lot of these cut points were established studying people who were not as morbidly obese as our folks are.
Dr. Jakicic: I agree because the one thing is that these folks—especially those who are in the higher levels of obesity, the 40+BMI range—they may have a MET capacity at max of maybe 6 METs or maybe 5 METs. And a brisk walk for them that would elicit 4 METs is 80% of their max versus going out for what may be considered a slower walk by normal standards may actually be moderate for them, and we are missing it when we go to analyze it because we are using the standard cut points that people have tried to apply to everyone. So we actually may be getting more activity than we think; we are just missing it.
Someone earlier said we have a lot of work to do here. We do have a lot of work to do here because we cannot just treat the data and treat the patient as if they had a BMI of 25, and look at all the things we have looked at over time. We have to adapt some of those measures and techniques to this unique population.
Bariatric Surgical Patient Care: What types of measures are you using to determine whether bariatric surgery and improved physical activity levels result in improved physical fitness? Are there mechanisms available that can be adequately measured to see whether physical fitness has indeed improved?
Dr. Creel: People have done different things to measure improvements in fitness. For example, the 6-minute walk test, which looks at how much distance one can cover in that amount of time.
We chose to use a treadmill protocol, which is based on the person's level of fitness, and they go through that protocol, and we have some endpoints. At the end of the study, which is about 6.5 months postoperatively, we give them that exact same protocol, and we look at differences in heart rate and perceived exertion at their stopping point initially. Say they stopped at 6 minutes before; we look at that 6-minute time point.
And then we continue the protocol and see how much longer they can go until they get to a perceived exertion of 16 on a 6-to-20 Borg scale, or reach 70% of their max heart rate with the Karvonen formula, which is correlated to oxygen uptake.
So that is how we are doing it. We do not feel comfortable using the maximum treadmill test with this group of folks, and very few people have done that. So we are using submaximal, and we are comparing them to themselves pre- and postoperatively, and seeing how much longer they can go and how much easier they perceive it to be, and looking at both of those measures.
Dr. Jakicic: Agreed. Even back in the early ’90s, we saw some of this in the severely obese folks before surgery became as popular as it is today. But very low-calorie diets were very popular back then. And we found that using the traditional measures of VO2 max, these individuals who are severely obese do not hit the traditional physiological parameters for VO2 max. So using that as the criteria to measure fitness is probably not a great idea.
Adapting some of those to a submaximal level is probably an appropriate method that we can standardize across folks. And within research, using treadmill protocols and so on is very good. For clinical practice, I think it would be helpful if clinicians could figure out a way to have some sense of whether or not the patient's fitness is improving—that would be great.
Dr. Creel: It can be difficult because everyone improves fitness in terms of they just lose weight. So even if they have not increased their activity at all, they increase the time on the treadmill for the most part. They say it is easier.
So we are going to see that with our usual care folks, but we want to see if it is more pronounced in the people who are actually getting the counseling. And if the people who are doing more activity, the accelerometer counts are higher, if they are actually showing these metabolic improvements and these perceived improvements, how difficult the exercise actually is.
Bariatric Surgical Patient Care: Are you finding that people who are receiving more of the counseling and being shown how they are doing on the accelerometer are improving more so than the control group?
Dr. Schuh: Well, again with the caveat that the trial is still ongoing, we do seem to be seeing at least an inkling that the counseling group is performing more moderate activity than the usual care group. They may be doing a little bit better physically. We're anxious to collect data from more patients to see whether our results hold up.
Dr. Creel: I would just add that we have done approximately 2,000 surgeries since we began recruiting for our study. To date, a little more than 100 patients have enrolled in the study. So we are getting probably a group of folks who are interested in physical activity and the usual care folks may be more motivated to exercise on their own than the typical patient who did not volunteer for our study.
So in a perfect world, you would study people who were just the traditional bariatric surgery patients. But that is a little bit more challenging, when the majority of patients are not willing or able to participate, at least in our setting.
Bariatric Surgical Patient Care: How can some of the trends and themes we are discussing here transfer to clinicians? We have talked about looking at things like lifestyle improvement rather than just weight outcome. How can some of these ideas start to transfer to the clinic?
Dr. Gomez: It is important to talk to the patient preoperatively and address what it is they would like to accomplish after surgery—to get an idea of what the patient's definition of success would be regarding their physical activity and their abilities. Then we can see them after surgery and revisit those goals that they had. Hopefully, they will say, “This is what I wanted to see happen. This is the activity level I have been looking forward to,” and then you can have an ongoing conversation regarding physical activity as the months and years wear on and that honeymoon phase of surgery is over.
It is important not to lose sight of what makes each individual patient feel successful, and make sure that we, as clinicians, help them to achieve this.
Dr. Jakicic: We have done some surveys of nurses and other support staff who work primarily in bariatric surgery, and what we find is that maybe that is a good place to start. They can talk to the patient about getting out and getting active, but they are not really trained in behavioral strategies for helping a person to do that. They are not trained in strategies to overcome the barriers that are there. Even the surgeons are not, and so you have to rely on the other staff.
So clinically speaking, maybe a good place for us to be starting, in addition to just saying we need to talk about it, is making sure that the staff who work with these patients on a day-to-day basis have the adequate training to do the things that we think we need to do in order to make this most effective.
Dr. Creel: I agree. I think that two things can happen. We can have people doing counseling who do not really understand fitness very well, and so cannot give enough resources to provide necessary advice. And then we can have people who are highly trained in fitness that really are not that skilled in behavior modification. The patient loses out in both of those instances.
So whoever is talking about exercise with the patient needs to understand behavior change, and have some basic knowledge about resources that are available. The approach is so important. How are we conceptualizing this issue with lack of physical activity? Is it a time issue? Is it an expectation issue? Is it a long history of poor goal setting? What are some of the major factors that are getting in the way, and how do we work with the patient in a collaborative way to overcome it versus just giving out a prescription or trying to have them meet some standard which will frustrate them? You may get some results by being tough with the patient for the first time, but then you never see them again.
So I think there is a fine balance that needs to be reached. Having an interdisciplinary team of people who are all cross-trained is really important. Programs should try to employ exercise professionals who understand the patients very well, and specialize in bariatric care. Most programs have full-time dietitians; you need full-time physicians and psychologists. But sometimes we do not have trained staff for the exercise part.
Bariatric Surgical Patient Care: Could we go around the table and have a closing thought on what you would like to see in the future in the physical activity and bariatric surgery space?
Dr. Jakicic: This is a very important topic. The work with this particular type of patient is still in its infancy, and a lot of work still has to be done. One of the things we need to learn more about is if the presurgical intervention really helps the postsurgical intervention, and how. We need to know in what way do you do that best, and how long do you have to keep it going for, and those kinds of things.
One thing we did not talk about is the different types of surgery—gastric bypass is different from the sleeve, which is different from the band. And it is very possible that while the behaviors we are trying to get people to do are very different, one could potentially hypothesize that the dose of physical activity necessary to help someone metabolically and with weight and so on may be different if they have had their surgical procedure done by a bypass versus a band versus a sleeve. I think that is another area of research that we need to explore.
Dr. Schuh: John, I think you are absolutely right. There are so many questions we still need to answer, and I would like to see us answer them more through objectively measured, prospective studies. What is the best time to start an intervention, and how long does that intervention have to be? How can we tailor it to particular patients' needs? Are there different methods that are better for different patients? I think these are all still open questions.
Dr. Gomez: One of the most important things to me when discussing all of this is keeping in mind the parameters we are using. Bariatric surgery patients may require a completely different approach compared to the nonobese patient or when talking about physical fitness with someone who is already active.
I think it would be really exciting to have more studies specifically with bariatric surgery patients or morbidly obese patients because our way of thinking and our way of measuring outcomes may be completely different.
Dr. Hurst: In terms of surgical patients and our studies, we really do need to be finding the right objectives to measure. I think one of the issues has been the longevity of the studies. With patients who have struggled with their weight—as it goes with the saying, “Rome was not built in a day”—people do not get to where they are, to their BMI of 50, 60, and beyond, in a year or two. It is decades, many times, of habits, lifestyles, mindsets, and thought processes that contribute to where they are when they present to us. We have 3 to 6 months with them before surgery, and then we are measuring things pretty closely up to a year.
Then beyond that, it is tough. For most people, weight management is a lifelong journey. We have to really focus on the behavior and the thought processes. What have been their barriers? There are definitely some common themes, but it can be very different for each individual. And they may not knock down all those barriers for many months after their surgery.
So one of our goals is to track compliance and follow-up here at our center for a longer period of time. In regard to lifestyle interventions, it is hard to argue whether it is better preop or postop; both would be great, forever would be ideal. So we need to look at the time frame of our studies as well, and decide if we are measuring data at the best time.
At least from a theoretical standpoint, it would be reasonable to propose that the best time to intervene with activity counseling would be at the 9–12-month postop time frame because about the 12- to 18-month mark is where the honeymoon period is over, the weight loss is slowing down, and motivation can start to wane. Physical activity for weight loss may not be as important before that time because of the large daily calorie deficit from decreased intake. I would propose, then, that those who are more physically active from 1 year and beyond likely maintain a greater percentage of weight loss and are more physically fit compared to those patients who are sedentary. But I believe focusing on the behavioral aspect of physical activity after bariatric surgery is really the key, and having qualified staff to educate patients on how to develop and sustain new habits in this arena is necessary.
Dr. Creel: Two things come to mind as far as future research. One, I would love to see something similar to the National Weight Control Registry, in that we are studying folks who have lost weight and kept it off. I would love to see a registry of postoperative bariatric surgery patients who have adopted a consistent, active lifestyle, and I would love to study those folks and see what their progression was to get there. They have been active for 2 years pretty regularly. How did they get there? What are some strategies they use? What kind of stages did they go through, so that we can learn from those folks.
The other thing I would love to see is with our interventions, when they are effective with some folks and not effective with others, to hear from the patients to deconstruct these interventions to see what is effective for what people, and what is not effective for what people. We can learn so much from our patients, rather than just assuming that one approach works for everyone.
Bariatric Surgical Patient Care:
Thank you all for your thoughts on this important topic.
