Physical activity and quality of life in women treated with Roux-en-Y gastric bypass surgery : a randomized controlled trial and qualitative interviews

Introduction: Bariatric surgery is the most effective method for weight loss and long-term weight loss maintenance, but requires several changes in health behaviors. In Sweden, Roux-en-Y Gastric Bypass (RYGB) is the most common bariatric surgery method, as it accounted for 49.3% of the bariatric procedures in 2018. Post-surgery, various psychosocial outcomes typically improves, such as health-related quality of life (HRQoL), but unfortunately the improvements for some outcomes do not remain long-term. Currently, no psychosocial support is offered by the Swedish healthcare post-surgery. Physical activity is important post-surgery as it can improve several outcomes of the surgery, but majority of patients are not sufficiently physically active, and they also in general overestimate their physical activity. There is a knowledge-gap whether the large overestimation of physical activity persists long-term post-surgery, as well as qualitative research about bariatric patients’ perceptions of physical activity long-term post-surgery.

Aims: The overall aim of this thesis was to investigate if a dissonance-based intervention could prevent a decline in HRQoL and improve other psychosocial outcomes and physical activity in women two years after RYGB surgery. Additional aims were to investigate the discrepancy between self-reported and objectively measured physical activity 48-months post-RYGB and to explore RYGB-treated women’s perceptions of physical activity five years after surgery.

Methods: A randomized controlled trial (RCT), where women undergoing RYGB surgery between 2015-2017, were randomized to either an intervention or a control group. The intervention consisted of four dissonance-based group sessions about physical activity, eating behavior, social- and intimate relationships, conducted three months post-RYGB. Questionnaires and GT3X+ accelerometers were used to assess psychosocial outcomes and physical activity at pre-, one- and two-years post-RYGB. A longitudinal cohort study recruited women undergoing RYGB surgery between 2012-2013, and pre-, nine- and 48-months post-RYGB they wore accelerometers and self-reported their physical activity levels via a self-administered questionnaire. Some of these women also participated in an interview study five years post-RYGB about their perceptions and experiences of physical activity. A grounded theory approach, inspired by Corbin & Strauss, was applied.

Results: A total of 259 women were recruited to the RCT, of which 156 women were randomized to intervention and 103 to control group. At the two-years follow-up, 203 participants had complete questionnaire data and 167 had valid accelerometer measurements. Seventy-one percent of the participants in the intervention group with valid questionnaire data attended at least one group session. Two years post-RYGB, the effects of the intervention were poor (Cohen’s d = 0.00 - 0.36) and no significant differences (of clinical relevance) were seen in HRQoL, eating behavior, body esteem, social adjustment or physical activity levels between the intervention and control groups. In the longitudinal cohort, 26 women with valid questionnaire and accelerometer measurements from all data assessments were included. They overestimated their time spent in MVPA to a greater extent post-compared to pre-RYGB. Self-reported physical activity increased with 36.5% from pre- to 48-months post-RYGB, while accelerometer measurements instead showed a decrease of 3.5%. Interviews with 11 women five years post-RYGB revealed that women who had positive attitudes towards physical activity, together with high social support, perceived themselves as regularly physically active. The opposite was seen in women with negative attitudes who experienced low social support. Some of the women presented shifting attitudes, moving between episodes of physical activity with positive attitudes and episodes of inactivity, and with support from e.g. partners but not in the way they had preferred. Also, majority of the women perceived exercise and physical activity only as a mean to lose weight.

Conclusions: A dissonance-based group intervention did not have any effect on HRQoL, eating behavior, body esteem, social adjustment or physical activity levels two years post-RYGB. However, longer follow-up time might be necessary in order to see any effects, as all psychosocial outcomes for both groups improved from pre- to one-year and were maintained at the two-years follow-up. The greater discrepancy between subjective and objective measured physical activity post-bariatric surgery, previously seen up to nine months post-RYGB, remained at 48-months post-RYGB. Attitudes towards physical activity post-RYGB, together with social support, seems to be related to RYGB-treated women’s perceived levels of physical activity five years post-RYGB. A majority of the women expressed that physical activity was just necessary when wanting to lose weight.

List of scientific papers

I. Possmark S, Sellberg F, Ghaderi A, Tynelius P, Willmer M, Rasmussen F, Persson M, Berglind D. Outcomes of a dissonance-based intervention targeting health-related quality of life, body esteem, eating behaviors and social adjustment in women after Roux-en-Y Gastric Bypass: A 2-year follow-up of a randomized controlled trial. [Submitted]

II. Possmark S, Sellberg F, Ghaderi A, Tynelius P, Willmer M, Rasmussen F, Persson M, Berglind, D. Physical activity in women attending a dissonance-based intervention after Roux-en-Y Gastric Bypass: A 2-year follow-up of a randomized controlled trial. [Submitted]

III. Possmark S, Sellberg F, Willmer M, Tynelius P, Persson M, Berglind D. Accelerometer-measured versus self-reported physical activity levels in women before and up to 48 months after Roux-en-Y Gastric Bypass. BMC Surgery. 2020;20(1):39.
https://doi.org/10.1186/s12893-020-00699-7

IV. Possmark S, Berglind D, Sellberg F, Ghaderi A, Persson M. To be or not to be active - a matter of attitudes and social support? Women's perceptions of physical activity five years after Roux-en-Y Gastric Bypass surgery. International journal of qualitative studies on health and well-being. 2019;14(1):1612704.
https://doi.org/10.1080/17482631.2019.1612704