Introduction - University of Pittsburgh
THE IMPACTS OF LIFESTYLE INTERVENTIONS IN BARIATARIC PATIENTS: A LITERATURE REVIEWbySha WuB.S., Peking University Health Science Center, China, 2008Submitted to the Graduate Faculty ofDepartment of Epidemiology Graduate School of Public Health in partial fulfillment of the requirements for the degree ofMaster of Public Health University of Pittsburgh2015UNIVERSITY OF PITTSBURGHGRADUATE SCHOOL OF PUBLIC HEALTHThis essay is submittedbySha WuonApril, 29, 2015and approved byEssay Advisor:Wendy King, PhD ______________________________________Research Associate ProfessorDepartment of EpidemiologyGraduate School of Public HealthUniversity of PittsburghEssay Reader:Marnie Bertolet, PhD ______________________________________Assistant ProfessorDepartment of EpidemiologyGraduate School of Public HealthUniversity of PittsburghEssay Reader:Candace Kammerer, PhD ______________________________________Assistant ProfessorDepartment of Human GeneticsGraduate School of Public HealthUniversity of PittsburghCopyright ? by Sha Wu2015ABSTRACTWendy King, PhDTHE IMPACTS OF LIFESTYLE INTERVENTIONS IN BARIATRIC PATIENTS: A LITERATURE REVIEWSha Wu, MPHUniversity of Pittsburgh, 2015Background: The epidemic of obesity threatens the health of millions of people. When uncontrolled, obesity may progress to severe obesity (Body Mass Index ≥35 kg/m2). Bariatric surgery can induce substantial weight loss via gastric restriction and/or malabsorption and now is a viable treatment for severe obesity. The outcomes following surgery are variable. The long-term health of adults who have undergone bariatric surgery is influenced by how they reshape their lifestyles. Therefore, lifestyle modifications to diet, activity and related behaviors have great public health significance. This literature review summarizes findings from clinical studies on the effects of lifestyle interventions in bariatric surgery patients. Methods: A literature search was conducted in PubMed for English articles of clinical trials published between 1980 and 2015 that (1) enrolled adult (age ≥18 years) bariatric patients; (2) applied, either pre-operatively or post-operatively, a behavioral intervention aimed to improve patients’ diet, physical activity, or both that was delivered through counseling or educational sessions; (3) had a comparison group; (4) assessed any of the following outcomes: changes in weight, comorbidity status, cardiometabolic risk factors or targeted behaviors, such as physical activity.Results: The search using key terms yielded a total of 5944 articles, among which 15 met the eligibility criteria. Four studies assessing pre-operative interventions suggested the effectiveness of interventions on increasing pre-operative physical activity level. Eleven studies (3 lifestyle, 3 diet and 5 activity) examined post-operative interventions. The three studies with post-operative lifestyle interventions found the interventions effective at improving weight loss. None of the 3 diet studies observed difference in the weight loss between groups. The five studies with activity intervention observed effectiveness of intervention on increasing post-operative physical activity. The findings may not be valid due to their low quality.Conclusions: There is moderate evidence suggesting the effectiveness of pre-operative or post-operative lifestyle interventions on increasing activity level and of post-operative lifestyle interventions on improving weight loss. Due to heterogeneity in the design of the included studies, this review cannot conclude on the overall impacts of lifestyle interventions in bariatric patients. Future studies with high quality are needed to provide more evidence in this area.TABLE OF CONTENTS TOC \o "2-4" \h \z \t "Heading 1,1,Appendix,1,Heading,1" 1.0Introduction PAGEREF _Toc434431503 \h 11.1Obesity PAGEREF _Toc434431504 \h 11.2bariatric surgery PAGEREF _Toc434431505 \h 21.2.1TYPES OF BARIATRIC SURGERY PAGEREF _Toc434431506 \h 31.2.2OUTCOMES OF BARIATRIC SURGERY PAGEREF _Toc434431507 \h 71.2.3RISKS AND COMPLICATIONS OF BARIATRIC SURGERY PAGEREF _Toc434431508 \h 91.3LIFESTYLE INTERVENTIONs PAGEREF _Toc434431509 \h 101.3.1TYPICAL STRUCTURE OF LIFESTYLE INTERVENTION PAGEREF _Toc434431510 \h 101.3.2EFFICACY OF LIFESTYLE INTERVENTION PAGEREF _Toc434431511 \h 111.3.3LIFESTYLE INTERVENTIONS FOR ENHANCING THE OUTCOMES OF BARIATRIC SURGERY PAGEREF _Toc434431512 \h 121.4Public health significance PAGEREF _Toc434431513 \h 132.0methods PAGEREF _Toc434431514 \h 142.1search strategy PAGEREF _Toc434431515 \h 142.2eligibility criteria PAGEREF _Toc434431516 \h 152.3Study selection PAGEREF _Toc434431517 \h 152.4Data extraction PAGEREF _Toc434431518 \h 162.5Quality assessment AND STRENGTH OF EVIDENCE PAGEREF _Toc434431519 \h 183.0RESULTS PAGEREF _Toc434431520 \h 203.1study selection PAGEREF _Toc434431521 \h 203.2Characteristics of included studies PAGEREF _Toc434431522 \h 203.3quality assessment PAGEREF _Toc434431523 \h 213.4findings regarding the impacts of preoperative lifestyle interventions in bariatric patients PAGEREF _Toc434431524 \h 253.5findings regarding post-operative lifestyle interventions in bariatric surgery PAGEREF _Toc434431525 \h 314.0DIscussion PAGEREF _Toc434431526 \h 414.1strengths and limitations of this review PAGEREF _Toc434431527 \h 414.2implications for research PAGEREF _Toc434431528 \h 415.0conclusions PAGEREF _Toc434431529 \h 43BIBLIOGRAPHY PAGEREF _Toc434431530 \h 44List of tables TOC \h \z \c "Table" Table 1. Quality Assessment of Included Clinical Trials testing lifestyle, dietary or physical activity interventions in bariatric surgery patients PAGEREF _Toc434431531 \h 23Table 2. Descriptions of pre-operative lifestyle interventions in bariatric patients PAGEREF _Toc434431532 \h 27Table 3. Findings of the studies examining the impact of pre-operative lifestyle interventions in bariatric patients PAGEREF _Toc434431533 \h 29Table 4. Descriptions of post-operative lifestyle interventions in bariatric patients PAGEREF _Toc434431534 \h 33Table 5. Findings of the studies examining the impact of post-operative lifestyle interventions in bariatric patients PAGEREF _Toc434431535 \h 36List of figures TOC \h \z \c "Figure" Figure 1.Roux-en-Y gastric bypass PAGEREF _Toc434431536 \h 4Figure 2. AdjustableGastric Band Procedure PAGEREF _Toc434431537 \h 5Figure 3.Sleeve gastrectomy PAGEREF _Toc434431538 \h 6Figure 4.Duodenal Switch PAGEREF _Toc434431539 \h 7Figure 5. Key search terms PAGEREF _Toc434431540 \h 14Figure 6. Flow chart of article selection process PAGEREF _Toc434431541 \h 17IntroductionObesityThe epidemic of obesity, a chronic disorder primarily determined by excessive body weight (Body Mass Index (BMI) ≥ 30 kg/m2), threatens the health of millions of people ADDIN EN.CITE <EndNote><Cite><Author>James</Author><Year>2008</Year><RecNum>257</RecNum><DisplayText>[1]</DisplayText><record><rec-number>257</rec-number><foreign-keys><key app="EN" db-id="dfssaxv035z00aexpd9ptsz8s5wapvtfdtz2" timestamp="1427214316">257</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>James, W. P.</author></authors></contributors><auth-address>London School of Hygiene and Tropical Medicine, International Obesity TaskForce, London, UK. JeanHJames@</auth-address><titles><title>WHO recognition of the global obesity epidemic</title><secondary-title>Int J Obes (Lond)</secondary-title><alt-title>International journal of obesity (2005)</alt-title></titles><periodical><full-title>Int J Obes (Lond)</full-title><abbr-1>International journal of obesity (2005)</abbr-1></periodical><alt-periodical><full-title>Int J Obes (Lond)</full-title><abbr-1>International journal of obesity (2005)</abbr-1></alt-periodical><pages>S120-6</pages><volume>32 Suppl 7</volume><edition>2009/01/16</edition><keywords><keyword>Cardiovascular Diseases/*etiology/prevention & control</keyword><keyword>Cost of Illness</keyword><keyword>*Global Health</keyword><keyword>Humans</keyword><keyword>Obesity/complications/*epidemiology</keyword><keyword>*World Health Organization</keyword></keywords><dates><year>2008</year><pub-dates><date>Dec</date></pub-dates></dates><isbn>0307-0565</isbn><accession-num>19136980</accession-num><urls></urls><electronic-resource-num>10.1038/ijo.2008.247</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[1]. 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ADDIN EN.CITE.DATA [2, 3]. In the U.S., more than half of the population is overweight or obese: the prevalence of overweight (BMI ≥ 25 kg/m2) in 2011-2012 was 71.7% (95% CI: 68.0%-74.2%) among adult men and 65.6% (95% CI: 61.8%-63.9%) among adult women ADDIN EN.CITE <EndNote><Cite><Author>An</Author><Year>2014</Year><RecNum>35</RecNum><DisplayText>[4]</DisplayText><record><rec-number>35</rec-number><foreign-keys><key app="EN" db-id="pe9d0v9f10xwv2ex5f8xsde6vsf0prddzzfp" timestamp="1427475433">35</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>An, R.</author></authors></contributors><auth-address>College of Applied Health Sciences, University of Illinois at Urbana-Champaign, George Huff Hall Room 2013, 1206 South 4th Street, Champaign, IL 61820, USA.</auth-address><titles><title>Prevalence and Trends of Adult Obesity in the US, 1999-2012</title><secondary-title>ISRN Obes</secondary-title><alt-title>ISRN obesity</alt-title></titles><periodical><full-title>ISRN Obes</full-title><abbr-1>ISRN obesity</abbr-1></periodical><alt-periodical><full-title>ISRN Obes</full-title><abbr-1>ISRN obesity</abbr-1></alt-periodical><pages>185132</pages><volume>2014</volume><edition>2014/07/09</edition><dates><year>2014</year></dates><isbn>2090-9446</isbn><accession-num>25002986</accession-num><urls><related-urls><url>;[4]. In 2009-2010, the prevalence of obesity among U.S. adult men was 35.5% (95% CI: 31.9%-39.2%), while among U.S. adult women, it is 35.8% (95% CI: 34.0%-37.7%) ADDIN EN.CITE <EndNote><Cite><Author>Flegal</Author><Year>2012</Year><RecNum>6</RecNum><DisplayText>[5]</DisplayText><record><rec-number>6</rec-number><foreign-keys><key app="EN" db-id="pe9d0v9f10xwv2ex5f8xsde6vsf0prddzzfp" timestamp="1427157387">6</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Flegal, K. M.</author><author>Carroll, M. D.</author><author>Kit, B. K.</author><author>Ogden, C. L.</author></authors></contributors><auth-address>National Center for Health Statistics, Centers for Disease Control and Prevention, 3311 Toledo Rd, Room 4315, Hyattsville, MD 20782, USA. kmf2@</auth-address><titles><title>Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010</title><secondary-title>Jama</secondary-title><alt-title>Jama</alt-title></titles><periodical><full-title>Jama</full-title><abbr-1>Jama</abbr-1></periodical><alt-periodical><full-title>Jama</full-title><abbr-1>Jama</abbr-1></alt-periodical><pages>491-7</pages><volume>307</volume><number>5</number><edition>2012/01/19</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>*Body Mass Index</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Nutrition Surveys</keyword><keyword>Obesity/*epidemiology</keyword><keyword>Prevalence</keyword><keyword>Sex Factors</keyword><keyword>United States/epidemiology</keyword><keyword>Young Adult</keyword></keywords><dates><year>2012</year><pub-dates><date>Feb 1</date></pub-dates></dates><isbn>0098-7484</isbn><accession-num>22253363</accession-num><urls></urls><electronic-resource-num>10.1001/jama.2012.39</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[5]. A total of 10 million Americans are living with severe obesity (BMI ≥ 35-40 kg/m2) ADDIN EN.CITE <EndNote><Cite><Year>2010</Year><RecNum>255</RecNum><DisplayText>[6]</DisplayText><record><rec-number>255</rec-number><foreign-keys><key app="EN" db-id="dfssaxv035z00aexpd9ptsz8s5wapvtfdtz2" timestamp="1427213671">255</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors></contributors><titles><title>Vital signs: state-specific obesity prevalence among adults --- United States, 2009</title><secondary-title>MMWR Morb Mortal Wkly Rep</secondary-title><alt-title>MMWR. Morbidity and mortality weekly report</alt-title></titles><periodical><full-title>MMWR Morb Mortal Wkly Rep</full-title><abbr-1>MMWR. Morbidity and mortality weekly report</abbr-1></periodical><alt-periodical><full-title>MMWR Morb Mortal Wkly Rep</full-title><abbr-1>MMWR. Morbidity and mortality weekly report</abbr-1></alt-periodical><pages>951-5</pages><volume>59</volume><number>30</number><edition>2010/08/07</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>African Continental Ancestry Group/statistics & numerical data</keyword><keyword>Age Factors</keyword><keyword>Aged</keyword><keyword>Behavioral Risk Factor Surveillance System</keyword><keyword>Educational Status</keyword><keyword>Female</keyword><keyword>Healthy People Programs</keyword><keyword>Hispanic Americans/statistics & numerical data</keyword><keyword>Humans</keyword><keyword>Income</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Obesity/*epidemiology/*ethnology/prevention & control</keyword><keyword>Prevalence</keyword><keyword>United States/epidemiology</keyword><keyword>Young Adult</keyword></keywords><dates><year>2010</year><pub-dates><date>Aug 6</date></pub-dates></dates><isbn>0149-2195</isbn><accession-num>20689500</accession-num><urls></urls><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[6]. 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ADDIN EN.CITE.DATA [9]. The American Medical Association’s acknowledgement of obesity as a disease in 2013 marked the elevated awareness among medical professionals of the threat that obesity posees to the health of the nation ADDIN EN.CITE <EndNote><Cite><Author>Association</Author><Year>2013</Year><RecNum>14</RecNum><DisplayText>[10]</DisplayText><record><rec-number>14</rec-number><foreign-keys><key app="EN" db-id="pe9d0v9f10xwv2ex5f8xsde6vsf0prddzzfp" timestamp="1427216150">14</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>American Medical Association</author></authors></contributors><titles><title>Business of the American Medical Association host of delegates 2013 annual meeting. Annotated reference committee reports.</title></titles><pages>-meeting. page</pages><number>Reference Committee D.</number><edition>Accessed on July,15,2014</edition><dates><year>2013</year><pub-dates><date>Accessed on July,15,2014</date></pub-dates></dates><urls></urls></record></Cite></EndNote>[10]. Adiposity is linked to the development of a range of morbidities: cardiovascular diseases, hypertension, type 2 diabetes mellitus (T2DM), dyslipidemia, metabolic syndrome, reproductive disease, psychosocial problems, osteoarthritis and some types of cancer PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XYW5nPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA [11-19]. Obesity also is associated with social discrimination and an impaired quality of life. It has been shown that the impacts of obesity on the increase in the number of chronic conditions are significantly larger than the impacts of current or past smoking or problem drinking (p<0.001) ADDIN EN.CITE <EndNote><Cite><Author>Sturm</Author><Year>2002</Year><RecNum>24</RecNum><DisplayText>[20]</DisplayText><record><rec-number>24</rec-number><foreign-keys><key app="EN" db-id="pe9d0v9f10xwv2ex5f8xsde6vsf0prddzzfp" timestamp="1427221455">24</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Sturm, R.</author></authors></contributors><auth-address>Economic and Policy Research Program, UCLA/RAND Managed Care Center for Psychiatric Disorders, CA, USA.</auth-address><titles><title>The effects of obesity, smoking, and drinking on medical problems and costs</title><secondary-title>Health Aff (Millwood)</secondary-title><alt-title>Health affairs (Project Hope)</alt-title></titles><periodical><full-title>Health Aff (Millwood)</full-title><abbr-1>Health affairs (Project Hope)</abbr-1></periodical><alt-periodical><full-title>Health Aff (Millwood)</full-title><abbr-1>Health affairs (Project Hope)</abbr-1></alt-periodical><pages>245-53</pages><volume>21</volume><number>2</number><edition>2002/03/20</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Alcoholism/complications/*economics/epidemiology</keyword><keyword>Chronic Disease/*economics/epidemiology</keyword><keyword>Health Care Costs/*statistics & numerical data</keyword><keyword>Health Services/utilization</keyword><keyword>Health Status Indicators</keyword><keyword>Humans</keyword><keyword>Middle Aged</keyword><keyword>Obesity/complications/*economics/epidemiology</keyword><keyword>Prevalence</keyword><keyword>Risk Factors</keyword><keyword>Sickness Impact Profile</keyword><keyword>Smoking/adverse effects/*economics/epidemiology</keyword><keyword>Time</keyword><keyword>United States/epidemiology</keyword></keywords><dates><year>2002</year><pub-dates><date>Mar-Apr</date></pub-dates></dates><isbn>0278-2715 (Print)
0278-2715</isbn><accession-num>11900166</accession-num><urls></urls><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[20].Obesity can be costly. The annual medical expenditures on the treatments of obesity and its comorbidities in the U.S. were estimated to be US$147 billion in 2008 ADDIN EN.CITE <EndNote><Cite><Author>Finkelstein</Author><Year>2009</Year><RecNum>25</RecNum><DisplayText>[21]</DisplayText><record><rec-number>25</rec-number><foreign-keys><key app="EN" db-id="pe9d0v9f10xwv2ex5f8xsde6vsf0prddzzfp" timestamp="1427221517">25</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Finkelstein, E. A.</author><author>Trogdon, J. G.</author><author>Cohen, J. W.</author><author>Dietz, W.</author></authors></contributors><auth-address>RTI International, Research Triangle Park, North Carolina, USA. finkelse@</auth-address><titles><title>Annual medical spending attributable to obesity: payer-and service-specific estimates</title><secondary-title>Health Aff (Millwood)</secondary-title><alt-title>Health affairs (Project Hope)</alt-title></titles><periodical><full-title>Health Aff (Millwood)</full-title><abbr-1>Health affairs (Project Hope)</abbr-1></periodical><alt-periodical><full-title>Health Aff (Millwood)</full-title><abbr-1>Health affairs (Project Hope)</abbr-1></alt-periodical><pages>w822-31</pages><volume>28</volume><number>5</number><edition>2009/07/29</edition><keywords><keyword>Adult</keyword><keyword>Body Mass Index</keyword><keyword>Female</keyword><keyword>Health Care Costs/statistics & numerical data/trends</keyword><keyword>Health Care Surveys</keyword><keyword>Health Expenditures/*statistics & numerical data</keyword><keyword>Humans</keyword><keyword>Insurance, Health/economics</keyword><keyword>Male</keyword><keyword>Obesity/*economics/epidemiology</keyword><keyword>Prevalence</keyword><keyword>Regression Analysis</keyword><keyword>United States/epidemiology</keyword></keywords><dates><year>2009</year><pub-dates><date>Sep-Oct</date></pub-dates></dates><isbn>0278-2715</isbn><accession-num>19635784</accession-num><urls></urls><electronic-resource-num>10.1377/hlthaff.28.5.w822</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[21]. Excess medical expenditures spent on health care surrounding obesity are enormous: the increase in cost for in-patient and ambulatory care incurred by an individual with obesity is $395 per year ADDIN EN.CITE <EndNote><Cite><Author>Sturm</Author><Year>2002</Year><RecNum>26</RecNum><DisplayText>[20]</DisplayText><record><rec-number>26</rec-number><foreign-keys><key app="EN" db-id="pe9d0v9f10xwv2ex5f8xsde6vsf0prddzzfp" timestamp="1427222264">26</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Sturm, R.</author></authors></contributors><auth-address>Economic and Policy Research Program, UCLA/RAND Managed Care Center for Psychiatric Disorders, CA, USA.</auth-address><titles><title>The effects of obesity, smoking, and drinking on medical problems and costs</title><secondary-title>Health Aff (Millwood)</secondary-title><alt-title>Health affairs (Project Hope)</alt-title></titles><periodical><full-title>Health Aff (Millwood)</full-title><abbr-1>Health affairs (Project Hope)</abbr-1></periodical><alt-periodical><full-title>Health Aff (Millwood)</full-title><abbr-1>Health affairs (Project Hope)</abbr-1></alt-periodical><pages>245-53</pages><volume>21</volume><number>2</number><edition>2002/03/20</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Alcoholism/complications/*economics/epidemiology</keyword><keyword>Chronic Disease/*economics/epidemiology</keyword><keyword>Health Care Costs/*statistics & numerical data</keyword><keyword>Health Services/utilization</keyword><keyword>Health Status Indicators</keyword><keyword>Humans</keyword><keyword>Middle Aged</keyword><keyword>Obesity/complications/*economics/epidemiology</keyword><keyword>Prevalence</keyword><keyword>Risk Factors</keyword><keyword>Sickness Impact Profile</keyword><keyword>Smoking/adverse effects/*economics/epidemiology</keyword><keyword>Time</keyword><keyword>United States/epidemiology</keyword></keywords><dates><year>2002</year><pub-dates><date>Mar-Apr</date></pub-dates></dates><isbn>0278-2715 (Print)
0278-2715</isbn><accession-num>11900166</accession-num><urls></urls><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[20]. This translates to a total increase of 44.24 billion, given that 111.9 million people in the U.S. are obese. Of serious concern is that the annual medical spending on an individual with obesity is estimated to be growing at a rate of 37.4 % ADDIN EN.CITE <EndNote><Cite><Author>Finkelstein</Author><Year>2003</Year><RecNum>31</RecNum><DisplayText>[22]</DisplayText><record><rec-number>31</rec-number><foreign-keys><key app="EN" db-id="pe9d0v9f10xwv2ex5f8xsde6vsf0prddzzfp" timestamp="1427224357">31</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Finkelstein, E. A.</author><author>Fiebelkorn, I. C.</author><author>Wang, G.</author></authors></contributors><auth-address>RTI International, Research Triangle Park, North Carolina, USA.</auth-address><titles><title>National medical spending attributable to overweight and obesity: how much, and who's paying?</title><secondary-title>Health Aff (Millwood)</secondary-title><alt-title>Health affairs (Project Hope)</alt-title></titles><periodical><full-title>Health Aff (Millwood)</full-title><abbr-1>Health affairs (Project Hope)</abbr-1></periodical><alt-periodical><full-title>Health Aff (Millwood)</full-title><abbr-1>Health affairs (Project Hope)</abbr-1></alt-periodical><pages>W3-219-26</pages><volume>Suppl Web Exclusives</volume><edition>2003/10/07</edition><keywords><keyword>Cost of Illness</keyword><keyword>Health Care Surveys</keyword><keyword>Health Expenditures/*statistics & numerical data</keyword><keyword>Humans</keyword><keyword>Insurance, Health/economics/*utilization</keyword><keyword>Medicaid/economics/*utilization</keyword><keyword>Medicare/economics/*utilization</keyword><keyword>Obesity/*economics/epidemiology</keyword><keyword>Regression Analysis</keyword><keyword>United States/epidemiology</keyword></keywords><dates><year>2003</year><pub-dates><date>Jan-Jun</date></pub-dates></dates><isbn>0278-2715 (Print)
0278-2715</isbn><accession-num>14527256</accession-num><urls></urls><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[22].To conquer the battle against obesity, a number of guidelines and strategies have been set forth. The successful treatment for obesity necessitates a multidisciplinary regimen encompassing a meal plan with low-calorie recipes, an exercise program to enhance physical activity, behavior modifications, pharmacologic medications and weight-loss operations. Among them, surgical approaches are scientifically proven to be the most effective method for adults with severe obesity, resulting in sustainable long-term weight loss and resolutions of obesity- attributed comorbidities ADDIN EN.CITE <EndNote><Cite><Year>1992</Year><RecNum>32</RecNum><DisplayText>[23]</DisplayText><record><rec-number>32</rec-number><foreign-keys><key app="EN" db-id="pe9d0v9f10xwv2ex5f8xsde6vsf0prddzzfp" timestamp="1427238030">32</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors></contributors><titles><title>Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus Development Conference Statement</title><secondary-title>Am J Clin Nutr</secondary-title><alt-title>The American journal of clinical nutrition</alt-title></titles><periodical><full-title>Am J Clin Nutr</full-title><abbr-1>The American journal of clinical nutrition</abbr-1></periodical><alt-periodical><full-title>Am J Clin Nutr</full-title><abbr-1>The American journal of clinical nutrition</abbr-1></alt-periodical><pages>615s-619s</pages><volume>55</volume><number>2 Suppl</number><edition>1992/02/01</edition><keywords><keyword>Consensus Development Conferences, NIH as Topic</keyword><keyword>Gastric Bypass/standards</keyword><keyword>Gastroplasty/standards</keyword><keyword>Humans</keyword><keyword>Obesity, Morbid/epidemiology/*surgery/therapy</keyword><keyword>Risk Factors</keyword><keyword>United States/epidemiology</keyword></keywords><dates><year>1992</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>0002-9165 (Print)
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ADDIN EN.CITE.DATA [26].TYPES OF BARIATRIC SURGERYAccording to their respective mechanisms, bariatric surgery procedures can be categorized into three types: restrictive, mal-absorptive or mixed. Most widely applied techniques worldwide are Roux-en-y gastric bypass (RYGB) (46.6%), Sleeve gastrectomy (27.8%), laparoscopic adjustable gastric banding (LAGB) (17.8%), and biliopancreatic diversion with duodenal switch (2.2%) The application of LAGB is declining while the use of Gastrectomy Sleeve is on the rise ADDIN EN.CITE <EndNote><Cite><Author>Buchwald</Author><Year>2013</Year><RecNum>39</RecNum><DisplayText>[27]</DisplayText><record><rec-number>39</rec-number><foreign-keys><key app="EN" db-id="pe9d0v9f10xwv2ex5f8xsde6vsf0prddzzfp" timestamp="1427570479">39</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Buchwald, H.</author><author>Oien, D. M.</author></authors></contributors><auth-address>Department of Surgery, University of Minnesota, 420 Delaware Street SE, MMC 290, Minneapolis, MN 55455, USA. buchw001@umn.edu</auth-address><titles><title>Metabolic/bariatric surgery worldwide 2011</title><secondary-title>Obes Surg</secondary-title><alt-title>Obesity surgery</alt-title></titles><periodical><full-title>Obes Surg</full-title><abbr-1>Obesity surgery</abbr-1></periodical><alt-periodical><full-title>Obes Surg</full-title><abbr-1>Obesity surgery</abbr-1></alt-periodical><pages>427-36</pages><volume>23</volume><number>4</number><edition>2013/01/23</edition><keywords><keyword>Bariatric Surgery/*statistics & numerical data/*trends</keyword><keyword>Diabetes Mellitus, Type 2/epidemiology/*metabolism/prevention & control/*surgery</keyword><keyword>Electronic Mail</keyword><keyword>Female</keyword><keyword>Gastrectomy/statistics & numerical data/trends</keyword><keyword>Gastric Bypass/statistics & numerical data/trends</keyword><keyword>*Global Health</keyword><keyword>Health Care Surveys</keyword><keyword>Humans</keyword><keyword>Laparoscopy</keyword><keyword>Male</keyword><keyword>Obesity, Morbid/epidemiology/*metabolism/prevention & control/*surgery</keyword><keyword>Questionnaires</keyword><keyword>Weight Loss</keyword></keywords><dates><year>2013</year><pub-dates><date>Apr</date></pub-dates></dates><isbn>0960-8923</isbn><accession-num>23338049</accession-num><urls></urls><electronic-resource-num>10.1007/s11695-012-0864-0</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[27]. All of these procedures are targeted at the reduction in the size of stomach, the induction of satiation while eating and the malabsorption of nutrients. Consequently, the intake of nutrients and energy are limited.Roux-en-Y-gastric bypass, the gold standard of bariatric surgery, is a mixed laparoscopic procedure (Figure 1). First, a small stomach pouch is sectioned out through stapling the rest of the stomach off so that the size of the stomach was reduced. Second, the pouch is connected directly to the distal small intestine to bypass the rest part of stomach and the upper part of the small intestine. By this way, both food intake and nutrient absorption are restrained since the amount of food that the stomach can accept and the distance that food can pass in the small intestine, where nutrients are absorbed, are both reduced. Also the redirecting of the food pathway leads to favorable changes in gut hormones that can facilitate satiety and suppress appetite ADDIN EN.CITE <EndNote><Cite><Author>Hng</Author><Year>2012</Year><RecNum>37</RecNum><DisplayText>[28]</DisplayText><record><rec-number>37</rec-number><foreign-keys><key app="EN" db-id="pe9d0v9f10xwv2ex5f8xsde6vsf0prddzzfp" timestamp="1427486820">37</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hng, K. N.</author><author>Ang, Y. S.</author></authors></contributors><auth-address>Salford Royal NHS Foundation Trust. keng_ngee@</auth-address><titles><title>Overview of bariatric surgery for the physician</title><secondary-title>Clin Med</secondary-title><alt-title>Clinical medicine (London, England)</alt-title></titles><periodical><full-title>Clin Med</full-title><abbr-1>Clinical medicine (London, England)</abbr-1></periodical><alt-periodical><full-title>Clin Med</full-title><abbr-1>Clinical medicine (London, England)</abbr-1></alt-periodical><pages>435-40</pages><volume>12</volume><number>5</number><edition>2012/10/30</edition><keywords><keyword>Bariatric Surgery/*adverse effects/*methods</keyword><keyword>Energy Metabolism</keyword><keyword>Female</keyword><keyword>Homeostasis</keyword><keyword>Humans</keyword><keyword>Nutrition Disorders/etiology</keyword><keyword>Obesity, Morbid/metabolism/mortality/*surgery</keyword><keyword>Peptide Hormones/metabolism</keyword><keyword>Pregnancy</keyword><keyword>Weight Loss</keyword></keywords><dates><year>2012</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>1470-2118 (Print)
1470-2118</isbn><accession-num>23101143</accession-num><urls></urls><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[28]. SEQ Figure \* ARABIC 1.Roux-en-Y gastric bypassLaparoscopic adjustable gastric banding is a solely restrictive procedure performed laparoscopically with the least invasive level and lowest mortality (Figure 2). Carried out through the placement of an inflatable silicone band-that can be adjusted by the filling or removal of saline to an attached subcutaneous port-around the upper part of the stomach, LAGB is reversible. With the compression of gastric cardia, satiety effect and the feeling of fullness are triggered after taking only a small amount of food. In this way, the craving for food is curbed ADDIN EN.CITE <EndNote><Cite><Author>Smith</Author><Year>2011</Year><RecNum>34</RecNum><DisplayText>[29]</DisplayText><record><rec-number>34</rec-number><foreign-keys><key app="EN" db-id="pe9d0v9f10xwv2ex5f8xsde6vsf0prddzzfp" timestamp="1427246824">34</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Smith, B. R.</author><author>Schauer, P.</author><author>Nguyen, N. T.</author></authors></contributors><auth-address>University of California, Irvine Medical Center, Orange, CA, USA.</auth-address><titles><title>Surgical approaches to the treatment of obesity: bariatric surgery</title><secondary-title>Med Clin North Am</secondary-title><alt-title>The Medical clinics of North America</alt-title></titles><periodical><full-title>Med Clin North Am</full-title><abbr-1>The Medical clinics of North America</abbr-1></periodical><alt-periodical><full-title>Med Clin North Am</full-title><abbr-1>The Medical clinics of North America</abbr-1></alt-periodical><pages>1009-30</pages><volume>95</volume><number>5</number><edition>2011/08/23</edition><keywords><keyword>Bariatric Surgery/adverse effects/*methods</keyword><keyword>Blood Glucose/physiology</keyword><keyword>Body Mass Index</keyword><keyword>Endocrine System/metabolism</keyword><keyword>Energy Intake</keyword><keyword>Hemoglobin A, Glycosylated/metabolism</keyword><keyword>Humans</keyword><keyword>Obesity/metabolism/*surgery</keyword><keyword>Patient Selection</keyword><keyword>Treatment Outcome</keyword><keyword>Weight Loss</keyword></keywords><dates><year>2011</year><pub-dates><date>Sep</date></pub-dates></dates><isbn>0025-7125</isbn><accession-num>21855705</accession-num><urls></urls><electronic-resource-num>10.1016/j.mcna.2011.06.010</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[29]. SEQ Figure \* ARABIC 2. AdjustableGastric Band ProcedureSleeve gastrectomy, an irreversible restrictive laparoscopic procedure, is gaining wide popularity in North America (Figure 3). It is performed by resecting a large proportion of the stomach along its greater curvature. The remaining section of stomach, which is then stapled, resembles the shape of a “tube” or so called “sleeve” ADDIN EN.CITE <EndNote><Cite><Author>Pories</Author><Year>2008</Year><RecNum>36</RecNum><DisplayText>[30]</DisplayText><record><rec-number>36</rec-number><foreign-keys><key app="EN" db-id="pe9d0v9f10xwv2ex5f8xsde6vsf0prddzzfp" timestamp="1427484095">36</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pories, W. J.</author></authors></contributors><auth-address>East Carolina University, Greenville, North Carolina 27834, USA. pories@</auth-address><titles><title>Bariatric surgery: risks and rewards</title><secondary-title>J Clin Endocrinol Metab</secondary-title><alt-title>The Journal of clinical endocrinology and metabolism</alt-title></titles><periodical><full-title>J Clin Endocrinol Metab</full-title><abbr-1>The Journal of clinical endocrinology and metabolism</abbr-1></periodical><alt-periodical><full-title>J Clin Endocrinol Metab</full-title><abbr-1>The Journal of clinical endocrinology and metabolism</abbr-1></alt-periodical><pages>S89-96</pages><volume>93</volume><number>11 Suppl 1</number><edition>2008/12/04</edition><keywords><keyword>Bariatric Surgery/*adverse effects/contraindications/*methods</keyword><keyword>Body Weight/physiology</keyword><keyword>Diabetes Mellitus, Type 2/etiology/surgery</keyword><keyword>Humans</keyword><keyword>Models, Biological</keyword><keyword>Obesity, Morbid/complications/*surgery</keyword><keyword>Risk</keyword><keyword>Therapies, Investigational</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2008</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>0021-972X (Print)
0021-972x</isbn><accession-num>18987275</accession-num><urls></urls><custom2>Pmc2729256</custom2><electronic-resource-num>10.1210/jc.2008-1641</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[30]. The effects of the surgery involves the restriction in the volume of food that can be consumed and the alteration in the gut hormones that can influence the sense of hunger and satiety ADDIN EN.CITE <EndNote><Cite><Author>Karmali</Author><Year>2010</Year><RecNum>38</RecNum><DisplayText>[31]</DisplayText><record><rec-number>38</rec-number><foreign-keys><key app="EN" db-id="pe9d0v9f10xwv2ex5f8xsde6vsf0prddzzfp" timestamp="1427497132">38</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Karmali, S.</author><author>Schauer, P.</author><author>Birch, D.</author><author>Sharma, A. M.</author><author>Sherman, V.</author></authors></contributors><auth-address>The Centre for Advancement of Minimally Invasive Surgery and the Weight Wise Bariatric Centre, University of Alberta, Edmonton, AB. shahzeer@ualberta.ca</auth-address><titles><title>Laparoscopic sleeve gastrectomy: an innovative new tool in the battle against the obesity epidemic in Canada</title><secondary-title>Can J Surg</secondary-title><alt-title>Canadian journal of surgery. Journal canadien de chirurgie</alt-title></titles><periodical><full-title>Can J Surg</full-title><abbr-1>Canadian journal of surgery. Journal canadien de chirurgie</abbr-1></periodical><alt-periodical><full-title>Can J Surg</full-title><abbr-1>Canadian journal of surgery. Journal canadien de chirurgie</abbr-1></alt-periodical><pages>126-32</pages><volume>53</volume><number>2</number><edition>2010/03/26</edition><keywords><keyword>Gastrectomy/adverse effects/*methods</keyword><keyword>Gastric Balloon</keyword><keyword>Humans</keyword><keyword>*Laparoscopy</keyword><keyword>Obesity/*surgery</keyword></keywords><dates><year>2010</year><pub-dates><date>Apr</date></pub-dates></dates><isbn>0008-428x</isbn><accession-num>20334745</accession-num><urls><related-urls><url>;[31]. SEQ Figure \* ARABIC 3.Sleeve gastrectomyBiliopancreatic Diversion with Duodenal Switch (BPD/DS), as a modification to the biliopancreatic diversion, is an irreversible maladaptive procedure, comprising of three steps (Figure 4). Firstly, similar to the sleeve gastrectomy, a stomach resection is performed, creating a tubular stomach pouch; Secondly, this small stomach pouch is connected to the distal portion of small intestine with three-fourths of the small intestine divided and thus bypassed; Thirdly, the bypassed segment of small intestine, which produces most of enzymes needed for absorption, is reconnected to the distal portion of small intestine so that the digestive chemicals can mix with food course. The procedure results in a combined effect featuring the restriction of food intake due to the decrease in the size of stomach and the malabsorption owing to the shortened distance that food can move through in small intestine during the process of digestion ADDIN EN.CITE <EndNote><Cite><Author>Navarrete Aulestia</Author><Year>2012</Year><RecNum>44</RecNum><DisplayText>[32]</DisplayText><record><rec-number>44</rec-number><foreign-keys><key app="EN" db-id="pe9d0v9f10xwv2ex5f8xsde6vsf0prddzzfp" timestamp="1427587702">44</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Navarrete Aulestia, S.</author></authors></contributors><auth-address>Universidad Central de Venezuela, Hospital Universitario de Caracas, Caracas, Venezuela. jimo0610@</auth-address><titles><title>[Duodenal switch: a comprehensive view of a biliopancreatic diversion in metabolic surgery]</title><secondary-title>Nutr Hosp</secondary-title><alt-title>Nutricion hospitalaria</alt-title></titles><periodical><full-title>Nutr Hosp</full-title><abbr-1>Nutricion hospitalaria</abbr-1></periodical><alt-periodical><full-title>Nutr Hosp</full-title><abbr-1>Nutricion hospitalaria</abbr-1></alt-periodical><pages>1380-90</pages><volume>27</volume><number>5</number><edition>2013/03/13</edition><keywords><keyword>Anastomosis, Roux-en-Y</keyword><keyword>Bariatric Surgery/*methods</keyword><keyword>Biliopancreatic Diversion/adverse effects/*methods/mortality</keyword><keyword>Diabetes Mellitus/epidemiology/surgery</keyword><keyword>Duodenum/*surgery</keyword><keyword>Humans</keyword><keyword>Obesity/complications/mortality/*surgery</keyword><keyword>Postoperative Complications/epidemiology</keyword><keyword>Quality of Life</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2012</year><pub-dates><date>Sep-Oct</date></pub-dates></dates><orig-pub>Cruce duodenal: vision integral de una derivacion biliopancreatica en cirugia metabolica.</orig-pub><isbn>0212-1611</isbn><accession-num>23478682</accession-num><urls></urls><electronic-resource-num>10.3305/nh.2012.27.5.5901</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>spa</language></record></Cite></EndNote>[32]. 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ADDIN EN.CITE.DATA [33]. These results translate to a more than 20% reduction from original BMI. When expressed in the form of %EWL (Percentage of excess weight loss= [(operative weight-follow-up weight)/operative excess weight] ×100, where excess weight =actual weight-ideal weight), a measure for gauging the magnitude of weight loss, the estimates remained high (41.6%) at year 5 post-operative PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DaGFuZzwvQXV0aG9yPjxZZWFyPjIwMTQ8L1llYXI+PFJl
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ADDIN EN.CITE.DATA [33].The resolution of obesity-attributable comorbidities can also be achieved following bariatric surgery. In a meta-analysis involving 53 articles and 9243 patients, the synthesized data shows that after surgery hypertension was resolved in 61.7% of patients and obstructive sleep apnea was resolved in 85.7% of patients. Moreover, hyperlipidemia improved in 70% of patients [34]. However, the remission of type 2 diabetes is the most remarkable. Also from this meta-analysis, 92% patients in clinical trials and 86% patients in observational studies had alleviation in their diabetes, which is manifested in their discontinuation in the use of all diabetes-related medications and in the control of blood glucose levels within the normal range ADDIN EN.CITE <EndNote><Cite><Author>Buchwald</Author><Year>2004</Year><RecNum>48</RecNum><DisplayText>[34]</DisplayText><record><rec-number>48</rec-number><foreign-keys><key app="EN" db-id="pe9d0v9f10xwv2ex5f8xsde6vsf0prddzzfp" timestamp="1427645089">48</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Buchwald, H.</author><author>Avidor, Y.</author><author>Braunwald, E.</author><author>Jensen, M. D.</author><author>Pories, W.</author><author>Fahrbach, K.</author><author>Schoelles, K.</author></authors></contributors><auth-address>Department of Surgery, University of Minnesota, Minneapolis 55455, USA. buchw001@umn.edu</auth-address><titles><title>Bariatric surgery: a systematic review and meta-analysis</title><secondary-title>Jama</secondary-title><alt-title>Jama</alt-title></titles><periodical><full-title>Jama</full-title><abbr-1>Jama</abbr-1></periodical><alt-periodical><full-title>Jama</full-title><abbr-1>Jama</abbr-1></alt-periodical><pages>1724-37</pages><volume>292</volume><number>14</number><edition>2004/10/14</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>*Biliopancreatic Diversion</keyword><keyword>Comorbidity</keyword><keyword>Female</keyword><keyword>*Gastric Bypass</keyword><keyword>*Gastroplasty</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Obesity, Morbid/*surgery</keyword><keyword>Treatment Outcome</keyword><keyword>Weight Loss</keyword></keywords><dates><year>2004</year><pub-dates><date>Oct 13</date></pub-dates></dates><isbn>0098-7484</isbn><accession-num>15479938</accession-num><urls></urls><electronic-resource-num>10.1001/jama.292.14.1724</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[34]. The surgical approach to treating diabetes has also been found to be a cost-effective: compared to traditional therapy, surgery enabled an average 9.3 years longer lifetime remission of diabetes and 1.2 additional quality-adjusted life-years per patient PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LZWF0aW5nPC9BdXRob3I+PFllYXI+MjAwOTwvWWVhcj48
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ADDIN EN.CITE.DATA [35].Outcomes achieved after operations such as weight loss and the remission of comorbidities may largely stem from changes in hormones. The gastrointestinal hormones— such as leptins from fat tissue, cholecystokinin (CCK), glucagon-like peptide-l (GLP-1), peptide YY3–36 (PYY3–36) from the intestine, ghrelin from the stomach and insulin from the pancreas—signal the brain about eating behavior, food intake and energy balance and thus influence the sense of satiety through the interplay of the neuro-hormonal signaling network and gut-brain axis. The removal or repositioning of the stomach and the upper portion of intestine inevitably alter the secretion and distribution of these hormones, resulting in a re-balance in the energy homeostasis PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5PY2huZXI8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA [41].However, the outcomes of bariatric surgery can be highly variable, with 20-30% of patients experiencing the suboptimal weight loss PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MaXZoaXRzPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MaXZoaXRzPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48
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ADDIN EN.CITE.DATA [42]. Large pre-operative BMI, a history of sexual abuse and a history of depression are correlated with poorer weight loss following surgery PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MaXZoaXRzPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48
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ADDIN EN.CITE.DATA [44]. RISKS AND COMPLICATIONS OF BARIATRIC SURGERYBariatric surgery can lead to a number of complications such as haemorrhage, dumping syndrome, diarrhea, intra-abdominal bleeding, obstruction, anastomotic leak, wound infection, respiratory failure, gallstones, emotional disorders and metabolic abnormalities PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Nb25raG91c2U8L0F1dGhvcj48WWVhcj4yMDA5PC9ZZWFy
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ADDIN EN.CITE.DATA [45, 46]. The problem of nutritional deficiency may also arise after surgery— particularly among patients who underwent mal-absorptive procedures, featuring low level of vitamins and calcium and justifying post-surgical nutrient supplementation ADDIN EN.CITE <EndNote><Cite><Author>Cannon-Diehl</Author><Year>2010</Year><RecNum>58</RecNum><DisplayText>[47]</DisplayText><record><rec-number>58</rec-number><foreign-keys><key app="EN" db-id="pe9d0v9f10xwv2ex5f8xsde6vsf0prddzzfp" timestamp="1427661230">58</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cannon-Diehl, M. R.</author></authors></contributors><auth-address>Department of Anesthesiology, Sanford-MeritCare North Health Services Division, Fargo, North Dakota, USA. roseanncannon@</auth-address><titles><title>Emerging issues for the postbariatric surgical patient</title><secondary-title>Crit Care Nurs Q</secondary-title><alt-title>Critical care nursing quarterly</alt-title></titles><periodical><full-title>Crit Care Nurs Q</full-title><abbr-1>Critical care nursing quarterly</abbr-1></periodical><alt-periodical><full-title>Crit Care Nurs Q</full-title><abbr-1>Critical care nursing quarterly</abbr-1></alt-periodical><pages>361-70</pages><volume>33</volume><number>4</number><edition>2010/09/10</edition><keywords><keyword>*Bariatric Surgery</keyword><keyword>Critical Care/*organization & administration</keyword><keyword>Humans</keyword><keyword>Obesity/*complications/*surgery</keyword><keyword>*Postoperative Complications</keyword></keywords><dates><year>2010</year><pub-dates><date>Oct-Dec</date></pub-dates></dates><isbn>0887-9303</isbn><accession-num>20827069</accession-num><urls></urls><electronic-resource-num>10.1097/CNQ.0b013e3181f64a07</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[47].Mortality rate and reoperation rate following bariatric surgery are low PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CdWNod2FsZDwvQXV0aG9yPjxZZWFyPjIwMDc8L1llYXI+
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ADDIN EN.CITE.DATA [33, 48, 49]. The longitudinal assessment of bariatric surgery found a 30-day mortality of 0.3% for 4,610 patients who underwent RYGB or LAGB, with only 4.3% experiencing adverse events within 30 days post-operative PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GbHVtPC9BdXRob3I+PFllYXI+MjAwOTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA [51].LIFESTYLE INTERVENTIONs Comprehensive lifestyle interventions, which refer to a set of behavioral tools designed to help people modify their eating, activity and cognitive habits, should take precedence over other treatments for obesity ADDIN EN.CITE <EndNote><Cite><Author>Wadden</Author><Year>2012</Year><RecNum>68</RecNum><DisplayText>[52]</DisplayText><record><rec-number>68</rec-number><foreign-keys><key app="EN" db-id="pe9d0v9f10xwv2ex5f8xsde6vsf0prddzzfp" timestamp="1427682125">68</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Wadden, T. A.</author><author>Webb, V. L.</author><author>Moran, C. H.</author><author>Bailer, B. A.</author></authors></contributors><auth-address>Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA. Wadden@mail.med.upenn.edu</auth-address><titles><title>Lifestyle modification for obesity: new developments in diet, physical activity, and behavior therapy</title><secondary-title>Circulation</secondary-title><alt-title>Circulation</alt-title></titles><periodical><full-title>Circulation</full-title><abbr-1>Circulation</abbr-1></periodical><alt-periodical><full-title>Circulation</full-title><abbr-1>Circulation</abbr-1></alt-periodical><pages>1157-70</pages><volume>125</volume><number>9</number><edition>2012/03/07</edition><keywords><keyword>Diet, Reducing</keyword><keyword>Health Behavior</keyword><keyword>Health Promotion/*methods</keyword><keyword>Humans</keyword><keyword>*Life Style</keyword><keyword>Motor Activity</keyword><keyword>Obesity/epidemiology/*prevention & control</keyword><keyword>*Risk Reduction Behavior</keyword></keywords><dates><year>2012</year><pub-dates><date>Mar 6</date></pub-dates></dates><isbn>0009-7322</isbn><accession-num>22392863</accession-num><urls><related-urls><url>;[52]. As early as 2003, the US Preventive Services Task Force issued guidelines indicating that primary care clinicians should refer obese patients to intensive, multicomponent behavioral interventions PEVuZE5vdGU+PENpdGU+PFllYXI+MjAwNDwvWWVhcj48UmVjTnVtPjY0PC9SZWNOdW0+PERpc3Bs
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ADDIN EN.CITE.DATA [53, 54]. In 2011, the U.S. Centers for Medicare & Medicaid Services endorsed the prescription of intensive behavioral counseling with 14 face-to-face sessions over 6 months for obese treatment in primary care ADDIN EN.CITE <EndNote><Cite><Author>Services</Author><RecNum>66</RecNum><DisplayText>[55]</DisplayText><record><rec-number>66</rec-number><foreign-keys><key app="EN" db-id="pe9d0v9f10xwv2ex5f8xsde6vsf0prddzzfp" timestamp="1427681698">66</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Centers for Medicare & Medicaid Services</author></authors></contributors><titles><title>Decision memo for intensive behavioral therapy for obesity</title></titles><dates><pub-dates><date>July 15</date></pub-dates></dates><urls><related-urls><url> 14,2013</access-date></record></Cite></EndNote>[55]. In 2014, the American College of Cardiology released their guideline, in which the provision of a high-intensity dietitian-led comprehensive lifestyle intervention, including low calorie diet, regular aerobic physical activity training sessions and behavioral strategies counseling to enhance engagement in diet and exercise, was specified PEVuZE5vdGU+PENpdGU+PFllYXI+MjAxNDwvWWVhcj48UmVjTnVtPjY3PC9SZWNOdW0+PERpc3Bs
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ADDIN EN.CITE.DATA [56].TYPICAL STRUCTURE OF LIFESTYLE INTERVENTIONLifestyle intervention, termed interchangeably as behavioral treatment, or behavioral therapy and lifestyle modification, was first introduced in 1967 ADDIN EN.CITE <EndNote><Cite><Author>Stuart</Author><Year>1996</Year><RecNum>255</RecNum><DisplayText>[57]</DisplayText><record><rec-number>255</rec-number><foreign-keys><key app="EN" db-id="dfssaxv035z00aexpd9ptsz8s5wapvtfdtz2" timestamp="1430312404">255</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Stuart, R. B.</author></authors></contributors><titles><title>Behavioral control of overeating. 1967</title><secondary-title>Obes Res</secondary-title><alt-title>Obesity research</alt-title></titles><periodical><full-title>Obes Res</full-title><abbr-1>Obesity research</abbr-1></periodical><alt-periodical><full-title>Obes Res</full-title><abbr-1>Obesity research</abbr-1></alt-periodical><pages>411-7</pages><volume>4</volume><number>4</number><edition>1996/07/01</edition><keywords><keyword>*Behavior Therapy/methods</keyword><keyword>History, 20th Century</keyword><keyword>Humans</keyword><keyword>Hyperphagia/*therapy</keyword></keywords><dates><year>1996</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>1071-7323 (Print)
1071-7323</isbn><accession-num>8822767</accession-num><urls></urls><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[57]. Now it has evolved into a comprehensive package encompassing the following principal components: (1) goal-setting: interventionists help participants to specify the concrete elements of their daily exercise plan regarding what, when, where, how and for how long they need to engage in their behaviors; (2) skills development: interventionists instruct on the knowledge about healthy dietary and physical activity habits and help participants build the skills needed for the engagement in targeted behaviors; (3) self-monitoring and self-evaluation: participants are given homework assignments such as recording of food intakes and daily exercise; (4) review of progress: the records of food intake, physical activity and body weight are reviewed by the interventionists to identify both the improvements achieved and the efforts still need to be made; (5) problem-solving: interventionists help participants overcome the difficulties they faced during their behavioral modification process; (6) relapse prevention: interventionists provide follow-up contact to reinforce the skills taught and to facilitate the maintenance of achievements PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XYWRkZW48L0F1dGhvcj48WWVhcj4yMDAwPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA [58-60].A lifestyle modification program typically is provided at a study center to a group of participants or to an individual by a trained or registered interventionist such as a dietitian, a physician or a psychologist. The intervention sessions are delivered on a regular (e.g., weekly or monthly) basis over a time span of up to 6 months in the forms of face-to-face counseling and educational seminars. Each session usually lasts 60 to 90 minutes. Follow–up visits aimed to enhance maintenance of the behaviors and the reduced weight are idealy carried out biweekly or bimonthly over an additional period of 3-6 months ADDIN EN.CITE <EndNote><Cite><Author>Wadden</Author><Year>2007</Year><RecNum>259</RecNum><DisplayText>[61]</DisplayText><record><rec-number>259</rec-number><foreign-keys><key app="EN" db-id="dfssaxv035z00aexpd9ptsz8s5wapvtfdtz2" timestamp="1430315128">259</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Wadden, T. A.</author><author>Butryn, M. L.</author><author>Wilson, C.</author></authors></contributors><auth-address>University of Pennsylvania School of Medicine, Department of Psychiatry, Philadelphia, Pennsylvania 19104, USA. wadden@mail.med.upenn.edu</auth-address><titles><title>Lifestyle modification for the management of obesity</title><secondary-title>Gastroenterology</secondary-title><alt-title>Gastroenterology</alt-title></titles><periodical><full-title>Gastroenterology</full-title><abbr-1>Gastroenterology</abbr-1></periodical><alt-periodical><full-title>Gastroenterology</full-title><abbr-1>Gastroenterology</abbr-1></alt-periodical><pages>2226-38</pages><volume>132</volume><number>6</number><edition>2007/05/15</edition><keywords><keyword>Animals</keyword><keyword>Body Weight</keyword><keyword>*Diet Therapy</keyword><keyword>Diet, Reducing</keyword><keyword>Humans</keyword><keyword>Internet</keyword><keyword>*Life Style</keyword><keyword>Obesity/*therapy</keyword><keyword>Randomized Controlled Trials as Topic</keyword><keyword>Risk Factors</keyword><keyword>Weight Gain</keyword></keywords><dates><year>2007</year><pub-dates><date>May</date></pub-dates></dates><isbn>0016-5085 (Print)
0016-5085</isbn><accession-num>17498514</accession-num><urls></urls><electronic-resource-num>10.1053/j.gastro.2007.03.051</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[61].EFFICACY OF LIFESTYLE INTERVENTIONIt has been shown that group treatment may be more cost-effective than individual care at reducing weight ADDIN EN.CITE <EndNote><Cite><Author>Renjilian</Author><Year>2001</Year><RecNum>260</RecNum><DisplayText>[62]</DisplayText><record><rec-number>260</rec-number><foreign-keys><key app="EN" db-id="dfssaxv035z00aexpd9ptsz8s5wapvtfdtz2" timestamp="1430317230">260</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Renjilian, D. A.</author><author>Perri, M. G.</author><author>Nezu, A. M.</author><author>McKelvey, W. F.</author><author>Shermer, R. L.</author><author>Anton, S. D.</author></authors></contributors><auth-address>Department of Psychology, Marywood University, USA.</auth-address><titles><title>Individual versus group therapy for obesity: effects of matching participants to their treatment preferences</title><secondary-title>J Consult Clin Psychol</secondary-title><alt-title>Journal of consulting and clinical psychology</alt-title></titles><periodical><full-title>J Consult Clin Psychol</full-title><abbr-1>Journal of consulting and clinical psychology</abbr-1></periodical><alt-periodical><full-title>J Consult Clin Psychol</full-title><abbr-1>Journal of consulting and clinical psychology</abbr-1></alt-periodical><pages>717-21</pages><volume>69</volume><number>4</number><edition>2001/09/12</edition><keywords><keyword>Adult</keyword><keyword>Body Mass Index</keyword><keyword>*Choice Behavior</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Obesity/psychology/*therapy</keyword><keyword>Outcome and Process Assessment (Health Care)</keyword><keyword>Patient Satisfaction</keyword><keyword>*Psychotherapy</keyword><keyword>*Psychotherapy, Group</keyword><keyword>Weight Loss</keyword></keywords><dates><year>2001</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>0022-006X (Print)
0022-006x</isbn><accession-num>11550739</accession-num><urls></urls><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[62]. Multiple reviews have suggested that a comprehensive lifestyle modification program alone may help participants achieve an average weight loss of about 7 to 10 kg in 6 months (7% to 10% reduction of initial weight) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XYWRkZW48L0F1dGhvcj48WWVhcj4yMDA3PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA [61, 63]. The weight loss can be maintained when follow-up sessions, in which the support are provided to the participants to improve the compliance with their behaviors, are offered ADDIN EN.CITE <EndNote><Cite><Author>Acharya</Author><Year>2009</Year><RecNum>262</RecNum><DisplayText>[64]</DisplayText><record><rec-number>262</rec-number><foreign-keys><key app="EN" db-id="dfssaxv035z00aexpd9ptsz8s5wapvtfdtz2" timestamp="1430318403">262</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Acharya, S. D.</author><author>Elci, O. U.</author><author>Sereika, S. M.</author><author>Music, E.</author><author>Styn, M. A.</author><author>Turk, M. W.</author><author>Burke, L. E.</author></authors></contributors><auth-address>School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA.</auth-address><titles><title>Adherence to a behavioral weight loss treatment program enhances weight loss and improvements in biomarkers</title><secondary-title>Patient Prefer Adherence</secondary-title><alt-title>Patient preference and adherence</alt-title></titles><periodical><full-title>Patient Prefer Adherence</full-title><abbr-1>Patient preference and adherence</abbr-1></periodical><alt-periodical><full-title>Patient Prefer Adherence</full-title><abbr-1>Patient preference and adherence</abbr-1></alt-periodical><pages>151-60</pages><volume>3</volume><edition>2009/11/26</edition><keywords><keyword>adherence</keyword><keyword>biomarkers</keyword><keyword>diet</keyword><keyword>exercise</keyword><keyword>obesity</keyword><keyword>self-monitoring</keyword></keywords><dates><year>2009</year></dates><isbn>1177-889x</isbn><accession-num>19936157</accession-num><urls><related-urls><url>;[64]. According to a representative study, the participants who attended twice the monthly group maintenance sessions maintained 13.0 kg of their 13.2 kg end-of-treatment weight loss compared to those without the attendance who maintained only 5.7 kg of a 10.8 kg initial weight loss ADDIN EN.CITE <EndNote><Cite><Author>Perri</Author><Year>1988</Year><RecNum>263</RecNum><DisplayText>[65]</DisplayText><record><rec-number>263</rec-number><foreign-keys><key app="EN" db-id="dfssaxv035z00aexpd9ptsz8s5wapvtfdtz2" timestamp="1430318952">263</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Perri, M. G.</author><author>McAllister, D. A.</author><author>Gange, J. J.</author><author>Jordan, R. C.</author><author>McAdoo, G.</author><author>Nezu, A. M.</author></authors></contributors><titles><title>Effects of four maintenance programs on the long-term management of obesity</title><secondary-title>J Consult Clin Psychol</secondary-title><alt-title>Journal of consulting and clinical psychology</alt-title></titles><periodical><full-title>J Consult Clin Psychol</full-title><abbr-1>Journal of consulting and clinical psychology</abbr-1></periodical><alt-periodical><full-title>J Consult Clin Psychol</full-title><abbr-1>Journal of consulting and clinical psychology</abbr-1></alt-periodical><pages>529-34</pages><volume>56</volume><number>4</number><edition>1988/08/01</edition><keywords><keyword>Adult</keyword><keyword>Aftercare/*methods</keyword><keyword>Behavior Therapy/*methods</keyword><keyword>Exercise</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Obesity/psychology/*therapy</keyword><keyword>Professional-Patient Relations</keyword></keywords><dates><year>1988</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>0022-006X (Print)
0022-006x</isbn><accession-num>2848874</accession-num><urls></urls><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[65]. LIFESTYLE INTERVENTIONS FOR ENHANCING THE OUTCOMES OF BARIATRIC SURGERYDespite the noticeable efficacy of lifestyle interventions in helping reducing weight, the outcomes from behavioral modifications vary considerably for each individual and some participants with severe obesity may be irresponsive to those interventions. When individuals with a body mass index above 35 kg/m2 had failed all other treatments for obesity, bariatric surgery should be considered.However, we should also see that operations are not an “easy way out”: a small proportion of bariatric surgery patients have suboptimal weight loss or experience significant weight regain. Bariatric surgery should be viewed as a stage amid the long-term clinical care for obesity: from initial clinical evaluation, through extensive behavioral education, medical treatment and surgical procedures, to post-operative lifestyle management. Surgery approaches serve as a tool to help patients achieve lifestyle changes. For instance, bariatric surgery patients are recommended to adopt an active lifestyle to optimize long-term weight loss and other surgical outcomes PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LaW5nPC9BdXRob3I+PFllYXI+MjAxMzwvWWVhcj48UmVj
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AG==
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AG==
ADDIN EN.CITE.DATA [67]. Thus, the combination of surgical approaches and behavioral modifications can be even powerful for helping people with obesity to achieve substantial long-term weight loss. Some health insurance companies mandate bariatric surgery candidates to participate in a 6-month physician supervised diet and activity program as a pre-requisite for surgery. But, there has been a lack of empirical support regarding the effectiveness of lifestyle interventions in bariatric surgery patients. Thus the goal of this systematic review is to determine whether lifestyle interventions impact the outcomes following bariatric surgery, with a focus on evidence gained from randomized clinical trials.Public health significanceDetermining whether lifestyle interventions improve the outcomes of bariatric surgery is an important step in understanding the optimal treatment of severe obesity, which now affects 10 million Americans. In addition, any interventions intended to nurture healthy lifestyles have great public health values, because many diseases besides obesity found their roots in problematic lifestyle. Thus, the promotion of a robust way of living will have profound impacts on the health of the nation. methodssearch strategy ("Exercise"[MeSH Terms] OR "exercise"[Title/Abstract]) OR (("physical"[Title/Abstract] AND activity" [Title/Abstract]) OR "physical activity"[Title/Abstract]) OR("Diet"[MeSH Terms] OR "diet"[Title/Abstract]) OR ("eating"[MeSH Terms] OR "eating"[Title/Abstract] OR "eating behavior "[Title/Abstract] OR "feeding behavior"[MeSH Terms] OR "feeding"[Title/Abstract] AND "behavior"[Title/Abstract] OR "feeding behavior"[Title/Abstract] OR "eating"[Title/Abstract] AND "behavior"[Title/Abstract] OR "eating behavior"[Title/Abstract] ) OR ("nutritional status"[MeSH Terms] OR ("nutritional"[Title/Abstract] AND "status"[Title/Abstract]) OR "nutritional status"[Title/Abstract] OR "nutrition"[Title/Abstract] OR "nutritional sciences"[MeSH Terms] OR ("nutritional"[Title/Abstract] AND "sciences"[Title/Abstract]) OR "nutritional sciences"[Title/Abstract]) OR (“calorie” [Title/Abstract] ) OR("life style"[MeSH Terms] OR ("life"[Title/Abstract] AND "style"[Title/Abstract]) OR "life style"[Title/Abstract] OR "lifestyle"[Title/Abstract])) OR ("behavior” [Title/Abstract] OR "behavior"[Title/Abstract] OR "behavioral"[Title/Abstract] OR “intervention” OR "counselling"[Title/Abstract] OR "counseling"[MeSH Terms] OR "counseling"[Title/Abstract] OR “modification”)AND(("bariatric surgery"[MeSH Terms] OR ("bariatric"[Title/Abstract] AND "surgery"[Title/Abstract] ) OR "bariatric surgery"[Title/Abstract] ) OR ( "gastric bypass " [Title/Abstract] OR ("gastric"[Title/Abstract] AND "bypass"[Title/Abstract] ) OR “gastric bypass"[MeSH Terms] ) OR ("gastrectomy"[MeSH Terms] OR "sleeve gastrectomy"[Title/Abstract] ) OR ("Gastroplasty"[Mesh Terms] OR “Gastroplasty” [Title/Abstract] ) OR ("gastric banding ”[Title/Abstract]) OR ("biliopancreatic diversion"[MeSH Terms] OR "biliopancreatic diversion"[ Title/abstract] OR “duodenal switch”[Title/abstract]) OR (“Weight Loss Surgery” [Title/Abstract] OR “bariatric patients” [Title/Abstract] OR “maladaptive surgery” [Title/Abstract] OR “obesity surgery" [Title/Abstract] OR “Metabolic surgery”[Title/Abstract] )This review complies with major requirements in the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) ADDIN EN.CITE <EndNote><Cite><Author>Liberati</Author><Year>2009</Year><RecNum>255</RecNum><DisplayText>[68]</DisplayText><record><rec-number>255</rec-number><foreign-keys><key app="EN" db-id="dfssaxv035z00aexpd9ptsz8s5wapvtfdtz2" timestamp="1427677124">255</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Liberati, A.</author><author>Altman, D. G.</author><author>Tetzlaff, J.</author><author>Mulrow, C.</author><author>Gotzsche, P. C.</author><author>Ioannidis, J. P.</author><author>Clarke, M.</author><author>Devereaux, P. J.</author><author>Kleijnen, J.</author><author>Moher, D.</author></authors></contributors><auth-address>Universita di Modena e Reggio Emilia, Modena, Italy. alesslib@mailbase.it</auth-address><titles><title>The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration</title><secondary-title>J Clin Epidemiol</secondary-title><alt-title>Journal of clinical epidemiology</alt-title></titles><periodical><full-title>J Clin Epidemiol</full-title><abbr-1>Journal of clinical epidemiology</abbr-1></periodical><alt-periodical><full-title>J Clin Epidemiol</full-title><abbr-1>Journal of clinical epidemiology</abbr-1></alt-periodical><pages>e1-34</pages><volume>62</volume><number>10</number><edition>2009/07/28</edition><keywords><keyword>Evidence-Based Medicine/standards</keyword><keyword>Humans</keyword><keyword>*Meta-Analysis as Topic</keyword><keyword>Publishing/*standards</keyword><keyword>Quality Control</keyword><keyword>*Review Literature as Topic</keyword><keyword>Terminology as Topic</keyword></keywords><dates><year>2009</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>0895-4356</isbn><accession-num>19631507</accession-num><urls></urls><electronic-resource-num>10.1016/j.jclinepi.2009.06.006</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[68]. A search of relevant articles was performed independently in the PubMed database to identify English articles published between Jan, 1, 1980 and Jan, 01, 2015. Public health informationist Ms. Barbara L. Folb (MM, ML, MPH) and advisor Dr. Wendy C. King (PhD) were consulted for advice on the search strategy (Figure 5.). Figure SEQ Figure \* ARABIC 5. Key search termseligibility criteria The PICOTS elements (i.e., population, interventions, comparators, outcomes, timing and setting) were used to form the inclusion and exclusion criteria ADDIN EN.CITE <EndNote><Cite><Author>Brian Haynes</Author><Year>2006</Year><RecNum>45</RecNum><DisplayText>[69]</DisplayText><record><rec-number>45</rec-number><foreign-keys><key app="EN" db-id="pe9d0v9f10xwv2ex5f8xsde6vsf0prddzzfp" timestamp="1427589749">45</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Brian Haynes, R.</author></authors></contributors><auth-address>Clinical Epidemiology and Biostatistics, McMaster Health Sciences Centre, McMaster University, 1200 Main Street West, Room 2C10b, Hamilton, Ontario, Canada L8N 3Z5. bhaynes@mcmaster.ca</auth-address><titles><title>Forming research questions</title><secondary-title>J Clin Epidemiol</secondary-title><alt-title>Journal of clinical epidemiology</alt-title></titles><periodical><full-title>J Clin Epidemiol</full-title><abbr-1>Journal of clinical epidemiology</abbr-1></periodical><alt-periodical><full-title>J Clin Epidemiol</full-title><abbr-1>Journal of clinical epidemiology</abbr-1></alt-periodical><pages>881-6</pages><volume>59</volume><number>9</number><edition>2006/08/10</edition><keywords><keyword>Clinical Medicine/*education</keyword><keyword>Costs and Cost Analysis</keyword><keyword>Data Collection/economics/*methods</keyword><keyword>*Epidemiologic Research Design</keyword><keyword>Epidemiology/*education</keyword><keyword>Evaluation Studies as Topic</keyword><keyword>Evidence-Based Medicine</keyword><keyword>Humans</keyword><keyword>Reproducibility of Results</keyword></keywords><dates><year>2006</year><pub-dates><date>Sep</date></pub-dates></dates><isbn>0895-4356 (Print)
0895-4356</isbn><accession-num>16895808</accession-num><urls></urls><electronic-resource-num>10.1016/j.jclinepi.2006.06.006</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[69]. Studies are clinical trials that may or may not be randomized and must exhibit the following features: (1) A study population of adult bariatric surgery patients; (2) An evaluation of behavioral intervention targeting at modifications to dietary intake and eating behaviors, physical activity, or both (i.e., aggregately known as lifestyle intervention); (3) A comparison group that does not receive a behavioral modification intervention; (4) At least one of the following outcomes is assessed: change in weight (e.g., change in kg., change in BMI, % weight change, % excess weight loss), change in comorbidity status (e.g., diabetes, dyslipidemia), change in cardiometabolic risk factors (e.g., systolic blood pressure, waist circumference), or change in targeted behaviors (e.g., calories consumed, participation in moderate-to-vigorous physical activity). Changes can be measured from pre-intervention to post-intervention or from pre-surgery to post-surgery; (5) The intervention can occur pre-operatively, post-operatively or both; (6) The delivery method can be individual or group counseling or educational sessions by an interventionist (in-person or remote), with or without supervised activities; (7) a total sample size of 10 or more.Study selectionBased on the eligibility criteria, all search results were screened independently. First, all case-reports, systematic reviews, meta-analyses, guidelines, animal studies, non-English articles, articles published earlier than Jan, 1st,1980 were ruled out electronically using filters in PubMed. Second, for the remaining articles, the abstracts were reviewed manually as per inclusion criteria and their references were extracted into a spreadsheet to note down inclusion/exclusion status and the reasons for the exclusions. Duplicates were removed. Third, full text of each remaining record was collected and screened thoroughly according to eligibility criteria. The process is detailed in a flow chart. (Figure 6.)Data extractionThe extraction of data was performed manually for specific information including (1) author, country, publication year, design and sample size per arm (2) subject characteristics at baseline (mean age, mean BMI, mean pre-surgical weight, gender and race) (3) description of lifestyle intervention (goal, method of delivery, number of sessions and interventional tools) (4) outcome of interest, data collection time points, length of follow-up, statistical analysis methods, results and the directions of the findings. For results, summary statistics, p values and strength of correlations or associations were also reported.The included articles were then classified into two groups depending on the timing of intervention: pre-operative or post-operative. The studies of each group were summarized in two tables with one describing study characteristics (Tables 2 and 4) and the other covering the findings (Tables 3 and 5). Each table was divided into three sections on the basis of types of the interventions: lifestyle/behavioral intervention or exercise alone or diet alone.Figure SEQ Figure \* ARABIC 6. Flow chart of article selection processQuality assessment AND STRENGTH OF EVIDENCEThe quality assessment of the included studies is performed using a rating system established upon the evidence synthesis process in prior reviews of clinical trials PEVuZE5vdGU+PENpdGU+PEF1dGhvcj52YW4gU2x1aWpzPC9BdXRob3I+PFllYXI+MjAwNDwvWWVh
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ADDIN EN.CITE.DATA [70, 71]. The following is a list of criteria for assessing the quality of included clinical trials (also shown in Table 1): (1) Are participants randomized? (2) Does a comparison group from the same population who did not receive any intervention exist? (3) Are the intervention group and comparison group similar at baseline regarding their characteristics? If not a randomized clinical trial, is the similarity statistically tested? If differences are identified, are they addressed in the subsequent analyses? (4) Are the interventionists trained and qualified? (5) Is retention reported per study group? Are the drop-out rates of both arms less than 20%? (6) Are the researchers/assessors blinded to the study assignment? (7) Did the length of post-operative follow-up reach one year? (8) Are sample size calculation stated in the article? (9) Is the Intention-to-treat principle followed in statistical analyses? (10) Are the effects of group-by-time interactions evaluated in the analyses if the study has more than two time points for outcome assessment? A study is rated as having high quality if it scored positive on at least 6 out of the 10 items listed above, moderate quality if positive on 4-5 items and low quality if positive on less or equal to three items. If, for example, the description of study method in an article fails to provide a clear answer to question 6 about blinding, then it is viewed as not having been carried out. This is a negative trait, which is marked by a minus sign “-” in Table 1. However, on the contrary, if the answer is yes, then a positive point, which is marked by a plus sign “+”, is attributed to the article.Due to the heterogeneity of the designs of the included studies, a meta-analysis is not feasible. The conclusion on the impacts of lifestyle interventions in bariatric surgery patients in this review is largely based on the strength of evidence, which is determined by the number of included studies with consistent positive findings. The quality of evidence is graded into four levels: (1) high quality evidence: multiple high quality randomized clinical trials reported consistent positive results; (2) moderate quality evidence: one high quality randomized clinical trial and one or more low-quality randomized clinical trial reported consistent positive results; (3) limited evidence: included studies reported inconsistent results. (4) no evidence: included studies reported consistent negative results.RESULTSstudy selectionThe initial search using the key search terms returned a total of 5994 articles. Among them, 5152 records that do not meet inclusion criteria were eliminated electronically by filters in PubMed. After a review of abstracts and full-text manuscripts, fifteen full-text papers, including 4 reporting on pre-operative interventions PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Cb25kPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA [76-86], were included in this review. Details of the selected articles are described in the Table 2 to Table 5. Characteristics of included studiesAll included studies (n=15) were published between 2010 and 2015 with sample sizes varying from 15 to 316 and totaling in 2598. Thirteen trials are randomized clinical trials while the other two are non-randomized clinical trials. Ten were conducted in the United States. Across the trials, a majority of the participants were women. Age ranged from 28 to 60 years old and pre-operative BMI from 35 and 60 kg/m2 (Table 2 and table 4).Among the studies that employed pre-operative interventions, 3 provided lifestyle program [73-75] and 1 offered an exercise program [72] (Table 2). In contrast, among the studies that applied post-operative interventions, 3 studies provided lifestyle program [76-78], 3 administered a diet program [83-85] and 5 implemented an exercise program [79-82, 86] (Table 4). The trials differed in the time span of the tested interventions: the length of programs across studies varied from 6 weeks to 6 months and the duration of each intervention session, from 15 minutes to 3 hours. The most frequently reported outcome of interest was weight change, which is present in 11 studies in the forms of change in kg, or reduction in BMI, or the percentage of excess weight loss, or the percentage of subjects who lost at least 5% of initial weight. The secondary outcome, the change in daily physical activity level, is documented in 8 studies. Other outcomes included changes in dietary components, improvements in cardiometabolic measurements and the improvements in muscle functions and strength.quality assessment Nine of the 15 included studies (3 pre-operative and 6 post-operative) can be rated as having relatively high quality based on the specified criterion set forth previously for assessing the quality of studies (Table. 1) [72, 73, 75-78, 80, 83, 85,]. Thirteen out of the 15 studies employed an adequate randomization process PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LYWxhcmNoaWFuPC9BdXRob3I+PFllYXI+MjAxMzwvWWVh
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ADDIN EN.CITE.DATA [82, 84]. Thirteen of the 15 studies had similar baseline characteristics between groups [72-78, 80-83, 85, 86], while the other 2 differed in either the pre-operative weight or the prevalence of diabetes at randomization [80, 84], and the potential effects of these imbalances were not accounted for in the subsequent analyses. The interventionists involved in all studies were well qualified dietitians, physicians or psychiatrists. However, the included studies all somewhat suffer from problems that could impair their internal validity such as low retention rate, the lack of blinded effect measurement and non-compliance with the “Intention-to-treat” principle in statistical analysis. Among the 14 studies that reported on retention, only four had drop-out rates of less than 20% [72, 76, 80, 82]. Only 2 studies mentioned blinded effect measurement [80, 85]. Only 8 studies followed the “Intention-to-treat” principle. The risk of observer bias runs high for these studies because the non-blinded assessors of outcomes may generate biased effect sizes in favor of the intervention group, or to the contrary, the conscientious non-blinded assessors may overcompensate for the potential bias. The evaluation of group-by-time interaction was involved in four studies [74, 79, 82, 83]. This application of the mixed effect model, though not necessary for the statistical analysis of every study, allows the trends in the weight changes among participants to be examined and is a positive attribute.Furthermore, some additional aspects of study design can also weaken the internal validity of the included studies. Although all studies engaged a control group or a comparison group that came from the same patient population as the intervention group, only 7 studies sufficiently justified their sample size [72, 73, 77, 78, 80, 81, 86] and only 7 studies had post-operative follow up longer than 1 year [75-69, 78, 83-85]. If the sample size is not large enough, the studies may be underpowered to detect clinically meaningful differences. Since obesity is a chronic condition and patients need some time to reach rebalance in metabolism after the maladaptation induced by surgeries, the reliable post-operative assessments of the outcomes and relapse requires long term follow-up, which can also minimize the possibility of bias towards overestimation of the intervention effectiveness. Table SEQ Table \* ARABIC 1. Quality Assessment of Included Clinical Trials testing lifestyle, dietary or physical activity interventions in bariatric surgery patientsPro/postinterventionAuthor, Country,DesignRandomizationComparison groupSimilarity at BaselineQualification ofinterventionistRetentionBlindingFollow-upSample sizeanalysisIntention-to-treatInteractionOverallqualityPre-operativeinterventionKalarchianet al,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LYWxhcmNoaWFuPC9BdXRob3I+PFllYXI+MjAxMzwvWWVh
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ADDIN EN.CITE.DATA [81]2012,++++-NR-+NRN/AModerateStegen,et al, ADDIN EN.CITE <EndNote><Cite><Author>Stegen</Author><Year>2011</Year><RecNum>81</RecNum><DisplayText>[82]</DisplayText><record><rec-number>81</rec-number><foreign-keys><key app="EN" db-id="pe9d0v9f10xwv2ex5f8xsde6vsf0prddzzfp" timestamp="1427766052">81</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Stegen, S.</author><author>Derave, W.</author><author>Calders, P.</author><author>Van Laethem, C.</author><author>Pattyn, P.</author></authors></contributors><auth-address>Department Movement and Sport Sciences, Ghent University, Watersportlaan 2, 9000 Ghent, Belgium. sanne.stegen@ugent.be</auth-address><titles><title>Physical fitness in morbidly obese patients: effect of gastric bypass surgery and exercise training</title><secondary-title>Obes Surg</secondary-title><alt-title>Obesity surgery</alt-title></titles><periodical><full-title>Obes Surg</full-title><abbr-1>Obesity surgery</abbr-1></periodical><alt-periodical><full-title>Obes Surg</full-title><abbr-1>Obesity surgery</abbr-1></alt-periodical><pages>61-70</pages><volume>21</volume><number>1</number><edition>2009/12/10</edition><keywords><keyword>Adult</keyword><keyword>Exercise</keyword><keyword>Exercise Therapy</keyword><keyword>Exercise Tolerance</keyword><keyword>Female</keyword><keyword>*Gastric Bypass</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Muscle Strength</keyword><keyword>Obesity, Morbid/*surgery/therapy</keyword><keyword>Physical Fitness</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2011</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>0960-8923</isbn><accession-num>19997987</accession-num><urls></urls><electronic-resource-num>10.1007/s11695-009-0045-y</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[82]2009,-+NR++NR-NRNR+ModerateN/A=Not applicable; NR=Not reported; “-”=No and “+”= Yes. (1) The column “Randomization” indicates whether the participants were randomized. (2) The column “Comparison group” indicates whether comparison group came from the same population as the intervention group. (3) The column “Similarity at Baseline” indicates whether intervention and control groups are similar at baseline regarding their characteristics and the similarity is tested. If differences are identified, they are addressed in following analyses. (4) The column “Qualification of interventionist” indicates the interventionists are trained and educated dietitians, psychologists and physicians. (5) The column “Retention” indicates whether the drop-out rates for both arms are less than 20%. (6) The column “Blinding” indicates whether researchers/assessors are blinded to the study assignment. (7) The column “follow-up” indicates whether the length of post-surgical follow-up is longer than 1 year. (8) The column “sample size analysis” indicates whether the concerns about sample size and power are properly addressed in the study. (9) The column “Intention-to-treat principle” indicates whether the Intention-to-treat principle is followed. (10) The column “Interaction” indicates whether the effect of group by time interactions is evaluated in the analyses if the study has a longitudinal design and multiple outcome assessments.Table 1 Continuedfindings regarding the impacts of preoperative lifestyle interventions in bariatric patientsFour experimental studies assessed the impacts of preoperative behavioral interventions in bariatric surgery patients [72-75]. Among those trials, three prescribed lifestyle interventions that addressed diet and/or physical activity [73-75] (Table 2). However, the findings from these 3 studies are not consistent. For example, Kalarchian et al.[74], involving a 6-month long behavioral strategy instructional intervention program, reported that the intervention was a significant predictor of weight loss before surgery in a multivariate model with an intervention effect (β=4.93, t=5.2, p<0.0001) and resulted in a higher likelihood of losing at least 5% of initial weight (OR=4.98, p<0.0001). But this study had moderate quality due to its low retention rate, short follow-up period, and the lack of blinded effect assessment, sample size calculation and the application of “Intention-to-treat” principle (Table 1). The other two studies, which had high quality [73, 75] (Table 1), found no difference in magnitude of weight loss between intervention group and control group (Table 3). The Bond et al PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Cb25kPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA [72], which is of high quality and evaluated the effect of a pre-operative physical activity intervention on increasing daily moderate-to-vigorous physical activity level, showed that the intervention group attained an increase in moderate-to-vigorous physical activity level compared to comparison group (an average increase of 21.0± 26.9 min/day in intervention group versus the insignificant change in the control group, p=.001). These four studies PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Cb25kPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA [72-75] differed in the number of intervention sessions and the length of the intervention programs (Table 2), making the synthesis and generalization of study results impossible. However, the Bond et al [72] suggests that the increase in pre-operative physical activity level can be achieved through preoperative physical activity intervention. Table SEQ Table \* ARABIC 2. Descriptions of pre-operative lifestyle interventions in bariatric patientsLifestyle interventionAuthor, Country, DesignSample Characteristics Intervention descriptionControlGoalMethod of Delivery, # Sessions and Timing Components of Behavioral InterventionKalarchian et al,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LYWxhcmNoaWFuPC9BdXRob3I+PFllYXI+MjAxMzwvWWVh
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ADDIN EN.CITE.DATA [74]2013,United States,RCTBehavioral lifestyle intervention Group: (n=121 )Usual care group: (n=119)Age, 45.2 ± 11yrs;BMI,47.9 ±6.7 km/m2;Women, 86.7%;White, 82.9%;Routine pre-surgical care--To reduce calorie intake through diet-To intensify energy expenditure through physical activity.-To instill goals regarding pre-op weight loss (5% of initial body weight or 1-2 pounds per week).8 weekly face-to-face sessions of 1 hour each followed by 16 weeks of alternating face-to-face sessions and telephone coaching which lasted 15-20 mins;-Pre-op 6 months interventionBehavioral strategies (e.g., prescription of exercise program, assistance in self-monitoring, problem-solving on factors related post-op weight control , goal setting for limiting energy intake, developing daily action plan, process reviewing and skills reinforcing ) Lieret al,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MaWVyPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA [75]2011,Norway,RCTCounseling group (n=49)Control Group (n=48)Reference Group (n=44)Age, 43.5 ± 11.1yrs;BMI,45.5 ±4.3 km/m2;Women, 74%;White, not reported;Age, 42.4 ± 9.1yrs;BMI,45.1 ±5.9km/m2;Women, 67%;White, not reported;Age, 39.8 ± 10.7yrs;BMI,44.8 ±5.6 km/m2;Women, 80%;White, not reported;Treatment as usual: one pre-op and one post-op educational seminar covering surgery info, dietary strategies and beneficial behaviors -To help improve weight loss and adherence to treatment guidelines post-op-6 weekly in-person pre-op group sessions of 3 hours each -3 post-op group sessions (at month 6, year 1 and year 2)Behavioral-cognitive treatment program plus mindfulness training (e.g. self-monitoring of daily food intake and exercise, problem solving skills, mindfulness training on stress reduction, and education about bariatric surgery and appropriate lifestyle change)A successful bariatric case was also shared in one session..Parikhet al,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QYXJpa2g8L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA [73]2012,UnitedStates,Pilot RCTMedically supervised weight management MSWM(n=29)Usual care(n=26)Age, 44.1± 12.1yrs;BMI,46.3±5.5km/m2;Women, 90%;White, 4%;Age, 46.2 ± 12.7yrs;BMI,44.7 ±7.1km/m2;Women, 77%;White, 8%;Standard pre-surgical care: session(s) with nutritionist for dietary management and a 2-week preoperative liquid protein diet treatment-To investigate if the participation in a medically supervised weight management program can help improve post-op outcomes The intervention was given either individually or in group,including:-1 initial visit for medical evaluation and-5 monthly individual or group follow-up visits with instructions and counseling Medically supervised weight management (e.g. behavioral counseling, goal-setting and review of participants’ active medical issues, current medications, current dietary and physical activity level.For group intervention, only education on dietary, physical activity and behavior modification strategies were provided.Table 2 ContinuedExercise Author, Country, DesignSample CharacteristicsControl Intervention description GoalMethod of Delivery, # Sessions and TimingComponents of Exercise therapyBondet al,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Cb25kPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA [72]2014,United States,RCTPre-op physical activity intervention group:(n=40)Standard pre-surgical care group:(n=35)Age, 44.2 ± 9.2yrs;BMI,45.6 ±7.0km/m2;Women, 85.0%;White, 77.5%;Age, 48.1 ± 8.1yrs;BMI,44.4 ±5.8km/m2;Women, 88.6%;White, 80.0%Standard pre-surgical care: attended pre-op clinical visits and received standard pre-op care -To increase participation in moderate intensity physical activity by 150 min/week-To examine the feasibility of the intervention 6 weekly individual face to face sessions of 30-45 mins each initiated on avg. 4.5 months pre-op (interval between assessment and surgery is on avg. 90.0±64.5 days pre-op).Behavioral and cognitive strategies and instructions (e.g., self-monitoring on progress, problem-solving, goal setting for exercise, skills building, developing daily action plan to increase PA and homework assignments on the application of the strategies to achieve goals)-Pedometer and diary used for self-monitoring -Discussion on the fulfillment of goalsTable SEQ Table \* ARABIC 3. Findings of the studies examining the impact of pre-operative lifestyle interventions in bariatric patients Behavioral lifestyle interventionAuthor, country designOutcomesMonths of follow-up & Outcome evaluationTime pointAnalysis MethodsResultsFindingsKalarchian et al, PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LYWxhcmNoaWFuPC9BdXRob3I+PFllYXI+MjAxMzwvWWVh
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ADDIN EN.CITE.DATA [74]2013,United states,RCT-Pre-op WL from pre to post-intervention -Pre-op WL of at least 5% of initial body weight-Data collected preoperatively at baseline and at 6 months when intervention ended.-Longitudinal model with fixed terms -Multivariate linear regression models -A similar multivariate logistic regression model -Significant condition by time interaction: LIFESTYLE group achieved on average 4.98 kg more WL than USUAL CARE group from baseline to 6 months [8.3 ±7.8 kg vs. 3.3 ±5.5 kg; F(1,182) = 23.6, p < 0.0001];-In a linear regression model, the comparison of percent WL between LIFESTYLE group vs. USUAL CARE group is [6.3% ± 5.8% vs. 2.5% ± 4.0%; t (1,182) = 5.01, p < 0.0001];-53.4% of LIFESTYLE group vs.21.0% of USUAL CARE group lost at least 5% of initial body weight.--Group was a significant predictor of weight loss in multivariate model. There was a significant intervention effect (β = 4.93, t = 5.2, p <0.0001);-In logistic models, lifestyle group was more likely to lose at least 5% of initial weight than usual care group (OR=4.98, p<0.0001)Lier et al, PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MaWVyPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA [75]2011,Norway,RCT-Post-op WL -50%EWL-PA (average of 30 minutes each day) -Meals each day (5-7)-Recommended vitamins per day-Attendance to follow-up assessment-Data collected at pre-op baseline and one year after surgery -Two way contingency table analysis was used to compare the differences between groups in Ca-V such as adherence to recommended behaviors after surgery.-One way ANOVA -Weight loss 46.1±9.9kg in treatment group vs.42.9± 12.7kg in control group vs. 44.5±9.9 kg in reference group, p=0.540);-The percentages of group members who lost 50% EWL (91% in treatment group vs. 85% in control group vs. 86% in reference group, p=0.774);- The percentages of group members attained daily exercise at a volume of 30 minutes (31% in treatment group vs.42% in control group vs. 39% in reference group, p=0.654);-The percentages of group members took 5-7 meals each day (70% in treatment group vs. 81% in control group vs. 71% in reference group, p=0.580);-The percentages of group members took the recommended vitamins each day (87% in treatment group vs.86% in control group vs. 88% in reference group, p=0.981);- The attendance at the follow-up assessment higher in preoperative treatment group than in the Control group and the Reference group (90%, 70% and 68%, respectively, p=0.047)-No difference between groups was observed in weight loss, physical activity, dietary habits and adherence to recommended behaviors one year after surgery.-Attendance at the follow-up assessment was higher in treatment groupParikh et al, PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QYXJpa2g8L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA [73]2012,United states,Pilot RCT-Body mass index (BMI)-Medication adherence-Eating behavior change-Patient activation/health beliefs-physical activity-Data collected at pre-op baseline before intervention, at 6 months after intervention (pre-surgery) and at 6 months after surgery.-T-tests -“Intention-to-treat” and “completed as” principles were followed;-Fisher’s exact tests.-Compared with the decrease in the activity level from baseline to 6th month post-operative in the USUAL-CARE group (-46%), MSWM group showed a significant increase in physical activity level (+10%) from baseline to 6th month post-operative (p=0.031) in “completed as” analysis ;-No difference between MSWM group and USUAL CARE group was observed regarding the changes in mean BMI, medication adherence, eating behavior, patient activation score, and physical activity level from baseline to either 6 months pre-op or 6 months post-op;-Positive effect of MSWM on post-op physical activity level.Exercise Bond et al, PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Cb25kPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA [72]2014,United states RCT-Pre-op Increase in daily bout-related and total moderate-to-vigorous PA (MVPA) minutes; -Pre-op Increase in number of daily steps -Data collected at baseline and at the end of the 6-week intervention period(pre-op)- ANCOVA - Intention-To-Treat -The Bout-related MVPA in the PAI group increased from baseline to post-intervention an average of 16.6±20.7 min/d during follow-up versus no change in the SC group (p=0.001);-The total MVPA in the PAI group increased an average of 21.0± 26.9 min/d versus no change in the SC group(p=.001);-The daily steps in the PAI group increased an averages of 2027.6±1886.9 steps/d compared to the average change of 202.7±1374.3 steps/d in SC group (p<0.001).-The physical activity intervention is effective at increasing moderate-to-vigorous physical activity level and daily steps compared to usual care groupRCT=Randomized controlled trial; UCT=uncontrolled clinical trial; Pre-op=Pre-operative; Post-op=Post-operative; OP=operation time; WL=weight loss; BW=Body weight; BP=Blood pressure; BMI=Body mass index; HLOS=Hospital length of stay; %EWL=Percentage of excess weight loss; Con-V=Continuous variables; Table 3 Continuedfindings regarding post-operative lifestyle interventions in bariatric surgery Nine randomized clinical trials [76-81, 83, 85, 86] and 2 non-randomized clinical trials [82, 84] investigated the effects of post-operative lifestyle interventions in bariatric surgery patients. Among those studies, three assessed lifestyle interventions (all of high quality) [76-78], three[83-85] evaluated dietary counseling sessions ( 2 of high quality[83,84] and 1 of low quality[76]) and five examined exercise training programs [79-82,86] (1 of high quality[80] and 1 of low quality [82]) ( Table 1). Of the three studies [76-78] that employed lifestyle interventions and addressed diet and physical activity, two [77, 78] found the intervention effective at improving weight loss and physical activity (Table 5). For example, Papalazarou et al. [78] reported that the intervention group was the only factor that was statistically associated with weight loss and physical activity level after intervention. Nijamkin et al. [77] reported greater percentage excess weight loss, BMI reduction, increase in physical activity and increase in mean protein intake in the intervention group compared with the control group. Provided that 2 out of these 3 high-quality studies that assessed post-operative lifestyle intervention had positive findings, there is moderate evidence to suggest the benefits of post-operative lifestyle interventions. None of the three studies [83-85] that administered post-operative dietary interventions reported a difference in the outcomes of weight loss between groups (Table 5). For example, Sarwer et al [83] that applied post-operative dietary counseling sessions (e.g. education about the importance of adherence to healthy diet and proper daily energy and food intake) and used repeated measures mixed effects models to test for differences in the trajectory of changes in weight over the follow-up period of 24 months between groups, found no significant difference between groups in the trends of percentage of change in weight. These results imply that interventions targeted at dietary changes alone may not be effective in improving weight loss after surgery.All of the five trials [79-82, 86] that contained exercise training programs reported favorable findings (Table 5). For example, Castello et al. [86] and Sim?es et al.[81] reported significant improvements in heart rate variability indexes and walking distance in 6 minute walk test in the intervention group only. Coen et al.[80] found a significant improvement in glucose effectiveness in the intervention group only. Shah et al. [79] observed an increase in maximal oxygen consumption relative to weight in thee intervention group only. Stegen et al. [82] observed the deterioration in muscle strength in the control group only compared to insignificant decrease in the intervention group. But due to the low quality of most of these studies (Table 1) (only Coen et al. [80] had high quality), the heterogeneity in the reported outcomes and the short follow up periods, (the longest being 6 months after intervention), no conclusion on the effects of post-operative exercise training programs alone can be consolidated. Overall, the evidence to date hints on the beneficial impacts of comprehensive post-operative lifestyle interventions as well as exercise interventions in bariatric surgery patients.Table SEQ Table \* ARABIC 4. Descriptions of post-operative lifestyle interventions in bariatric patientsLifestyle interventionAuthor, (Country), DesignSample Characteristics Intervention DescriptionControlGoalsMethod of delivery &#sessions and timingComponents of Behavioral interventionKalarchian,et al,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LYWxhcmNoaWFuPC9BdXRob3I+PFllYXI+MjAxMjwvWWVh
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ADDIN EN.CITE.DATA [76]2011,Unitedstates,RCT,Behavioralintervention groupn=18Control groupN=18Age, 51.0 ± 7.6yrs;BMI,54.3 ±8.8km/m2;Women, 83.3%;White,77.8%;Pre-op weight,150.5±32.9 kgAge, 53.9± 6.6yrs;BMI,52.1 ±8.8km/m2;Women, 94.4%;White, 72.2%Pre-op weight, 139.8±26.1 kgNot reported-To maintain a balanced diet while controlling energy intake to 1200-1400 calories-To enhance energy expenditure through physical activity.-To help achieve weight loss (5-10% of the initial body weight or 1-2 lb/wk)12 weekly face-to-face group counseling sessions of 1hr each followed by 5 biweekly telephone coaching sessions of 15-20 mins each, spanning about 6 months on avg. 6.6 years post-op since surgery Behavioral and cognitive strategies (e.g., self-monitoring of exercise and food intake journals and homework, problem-solving, goal setting for lifestyle change, developing daily action plan PA, and skills-strengthening) -Energy intake restricted to1200–1400 calories per day while maintaining a balanced diet in line with post-op dietary guidelines-Exercise program prescribed based on their choice of activity with an emphasis on increasing daily lifestyle activities.Nijamkinet al,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5OaWphbWtpbjwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+
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ADDIN EN.CITE.DATA [78]2010,Greece,RCTLifestyle intervention(LS) groupN=72Usual care(UC) groupN=72Age, 32.7± 1.6 yrs;BMI,48.5 ±2.1 km/m2;Women, 100%;Age, 33.4± 2.0yrs;BMI,49.8 ±1.6 km/m2;Women, 100%;Not reported -To help control patients’ body weight through lifestyle modifications12 weekly in-person individual sessions with a dietitian during the first 3 months postoperatively, 6 biweekly sessions during the next 3 months, 6 monthly during the following 6 months, 4 during the second post-op year and 2 during the third post-op year with each lasting for 40 minutes.(Total number of sessions=30) Each session included three parts: nutrition education, dietary intake and physical activity. Patient-centered collaborative approach plus Behavior modification techniques (e.g., self-monitoring, self-evaluation, problem-solving, goal-setting, reinforcement, self-motivation, stimulus control and relapse prevention) Table 4 ContinuedDietAuthor, (Country), DesignSample Characteristics Intervention DescriptionControl Goals Method of delivery & #Sessions and timingComponents of Diet therapySarwer,et at,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TYXJ3ZXI8L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA [83]2012,UnitedStates,RCTN=84 post-op patientsDietary counseling (DC) groupN=41Standard post-op (SP)groupN=43Age, 42.0 ± 9.9 yrs;BMI,51.64±9.2 km/m2;Women, 63.1%;White, 60.0%;Pre-op weight152.7±33.7 kgStandard post-op care-To help patients transition through the 4 phrases of the post-op diet;-To foster heathy diet habits such as increasing protein intake, reducing the intake of sugar and fat -To prevent overeating, vomiting and dumping;8 biweekly in-person counseling sessions or phone interviews with dietitians of 15 minutes each given during the first 4 months post-opPost-op dietary counseling sessions (e.g., education about the importance of adherence to healthy diet, proper daily energy and food intake, and daily nutrition needs)Patients were encouraged to self-monitor their daily food intake. Singhal,et at,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaW5naGFsPC9BdXRob3I+PFllYXI+MjAxMDwvWWVhcj48
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ADDIN EN.CITE.DATA [85]2012,UnitedStates,RCTLow-carbohydrate/high-protein diet teachingN=19Low-fat control dietN=13Age, 41.7 ± 9.8 yrs;BMI,50.7±8.7 km/m2;Women, 94.7%;White, 78.9 %;Pre-op weight197.5±85kgAge, 39.7 ± 7.6 yrs;BMI,46.3±9.4 km/m2;Women, 84.6%;White, 92.3 %;Pre-op weight166.5±71kg-The standard university of Virginia post-op diet -Instructions on dietary planand low-fat cookingtechniques-To evaluate the effect of a low-carbohydrate/high protein diet on promoting weight reduction among post-op bariatric patients-2 weeks of strict phase of diet with minimal carbohydrate intake, high protein intake and moderate fat intake after recovery from surgery; -At 1 to 2 pre-op visits, orat post-op clinic visits at 1, 3, 6, and 12 months, all patients received in-person individual one-on-one counseling sessions with a nutritionist-Low carbohydrate/high-protein diet consisting of minimal carbohydrate intake, high protein intake and moderate fat intake; Diet instructions centered around different types of fats, avoidance of saturated fat, emphasis on the use of mono-and polyunsaturated fats and promotion of high protein/low carbohydrate diets;Exercise Table 4 ContinuedAuthor, (Country), DesignSample Characteristics Intervention DescriptionControlGoalsMethod of delivery & #sessions and timingComponents of Exercise therapyCastelloet al, ADDIN EN.CITE <EndNote><Cite><Author>Castello</Author><Year>2011</Year><RecNum>79</RecNum><DisplayText>[86]</DisplayText><record><rec-number>79</rec-number><foreign-keys><key app="EN" db-id="pe9d0v9f10xwv2ex5f8xsde6vsf0prddzzfp" timestamp="1427765979">79</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Castello, V.</author><author>Simoes, R. P.</author><author>Bassi, D.</author><author>Catai, A. M.</author><author>Arena, R.</author><author>Borghi-Silva, A.</author></authors></contributors><auth-address>Cardiopulmonary Physiotherapy Laboratory, Nucleus of Research in Physical Exercise, Federal University of Sao Carlos, Rod. Washington Luis, km 235, 13565-905, Sao Carlos, Sao Paulo, Brazil.</auth-address><titles><title>Impact of aerobic exercise training on heart rate variability and functional capacity in obese women after gastric bypass surgery</title><secondary-title>Obes Surg</secondary-title><alt-title>Obesity surgery</alt-title></titles><periodical><full-title>Obes Surg</full-title><abbr-1>Obesity surgery</abbr-1></periodical><alt-periodical><full-title>Obes Surg</full-title><abbr-1>Obesity surgery</abbr-1></alt-periodical><pages>1739-49</pages><volume>21</volume><number>11</number><edition>2010/11/26</edition><keywords><keyword>Adult</keyword><keyword>*Exercise</keyword><keyword>Female</keyword><keyword>*Gastric Bypass</keyword><keyword>Heart Rate/*physiology</keyword><keyword>Humans</keyword><keyword>Middle Aged</keyword><keyword>Obesity, Morbid/*surgery</keyword><keyword>Physical Fitness/*physiology</keyword><keyword>Prospective Studies</keyword><keyword>Time Factors</keyword><keyword>Young Adult</keyword></keywords><dates><year>2011</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>0960-8923</isbn><accession-num>21104041</accession-num><urls></urls><electronic-resource-num>10.1007/s11695-010-0319-4</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[86]2010,Brazil,RCTTraining groupN=11Control groupN=10Age, 38 ± 4yrs;BMI,45.64 ±1.51 km/m2;Women 100%;Pre-op Weight, 117 ±4.kgAge, 36± 4yrs;BMI,44.46 ±0.96 km/m2;Women 100%;Pre-op Weight 117± 6kgControl: Non-To investigate whether a 12-week aerobic exercise program improves heart rate variability (HRV) and functional capacity after gastric bypass surgery in a female cohort.36 in-person individual aerobic exercise training sessions of 1 hour each after surgery spanning 12 weeksOnly TG group underwent an aerobic exercise training program on a treadmill beginning 1 month after GBS including-initial 5 min of stretching-5 min of warm up-40 min of exercise on treadmill-1 min of recovery-10 min of stretching and diaphragmatic breathingCoenet al, ADDIN EN.CITE <EndNote><Cite><Author>Coen</Author><Year>2015</Year><RecNum>80</RecNum><DisplayText>[80]</DisplayText><record><rec-number>80</rec-number><foreign-keys><key app="EN" db-id="pe9d0v9f10xwv2ex5f8xsde6vsf0prddzzfp" timestamp="1427766007">80</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Coen, P. M.</author><author>Tanner, C. J.</author><author>Helbling, N. L.</author><author>Dubis, G. S.</author><author>Hames, K. C.</author><author>Xie, H.</author><author>Eid, G. M.</author><author>Stefanovic-Racic, M.</author><author>Toledo, F. G.</author><author>Jakicic, J. M.</author><author>Houmard, J. A.</author><author>Goodpaster, B. H.</author></authors></contributors><titles><title>Clinical trial demonstrates exercise following bariatric surgery improves insulin sensitivity</title><secondary-title>J Clin Invest</secondary-title><alt-title>The Journal of clinical investigation</alt-title></titles><periodical><full-title>J Clin Invest</full-title><abbr-1>The Journal of clinical investigation</abbr-1></periodical><alt-periodical><full-title>J Clin Invest</full-title><abbr-1>The Journal of clinical investigation</abbr-1></alt-periodical><pages>248-57</pages><volume>125</volume><number>1</number><edition>2014/12/02</edition><dates><year>2015</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>0021-9738</isbn><accession-num>25437877</accession-num><urls></urls><electronic-resource-num>10.1172/jci78016</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[80]2015,United states,RCTSemi-supervised moderate exercise protocol(EX)n=66Health education control(CON)n=62Age, 41.3 ± 9.7yrs;BMI,38.8 ±6.1 km/m2;Women 89.39%;White,81.81%;Pre-intervention Weight, 107.3 ±19.9kgAge, 41.9 ± 10.3yrs;BMI,38.3 ±6.9 km/m2;Women 87.09%;White 83.87%;Pre-intervention Weight, 105.7±25.1kgControl: 6 monthly educational lectures, discussions and instructions covering topics including medication use, nutrition and upper-body stretching-To evaluate whether exercise and post-op weight loss would improve S1 and other cardiometabolic factors in a group of patients who recently underwent RYGB surgery 3 to 5 semi- supervised exercise sessions per week among which at least 1 was under direct supervision (started on avg. 75±64.5 days after surgery).During the first 4 weeks, the amount exercise reached 10-15 min per session at an intensity level of 60% to 70% of their maximal heart rate. 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ADDIN EN.CITE.DATA [79]2011,UnitedStates,RCTHigh-volume Exercise Program(HVEP)N=21Control groupN=12Age, 47.3 ± 10.0yrs;BMI,42.4 ±6.9 km/m2;Women,90%;White 43%;Age, 53.9 ± 8.8yrs;BMI,41.0 ±3.7 km/m2;Women,92%;White 75%;Individual dietary counseling on dietary guidelinesplus behavioral therapy -To evaluate whether a high-volume exercise program is effective at limiting weight regain in post-bariatric surgery patients-To expend ≥2,000 kcal/week in moderate-intensity aerobic exercise at60-70% of maximal oxygen consumption (VO2 max)-To improve diet and prevent nutritional deficiencies-Semi-supervised intervention exercise sessions 5 days/week with at least one completed at the fitness center; the exercise and heart rate diary are reviewed every 2 weeks;-6 biweekly Individual behavioral therapy counseling in-person or by phone-Exercise interventions: Instructions on gradually achieving the goal in moderate-intensity aerobic exercise at 60-70% of maximal oxygen consumption; Once achieved, patients were asked to elevate their exercise intensity. Exercise and heart rate self-monitoring were also required;-Diet intervention: dietary guidelines for post-op bariatric patients plus individual dietary counseling advice on limitation on energy intake to about 1,200-1,500 kcal/day, on limitation on food intake and on modification to eating habits; -Behavioral cognitive strategies including goal-setting, self-monitoring, problem-solving and relapse prevention, stimulus control, eating behavior recommendations and stress management.Table 4 ContinuedSim?eset al,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYXN0ZWxsby1TaW1vZXM8L0F1dGhvcj48WWVhcj4yMDEz
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ADDIN EN.CITE.DATA [81]2012,United states,RCTTrained group(TG) n=9Control group(CG)n=10Eutrophic group(EG)n=12Age, 32.0 ± 4.0yrs;BMI,45.5±1.7 km/m2;Women 100%;Pre-op Weight, 115.0 ±6.9kgAge, 31.0 ± 2.0 yrs;BMI, 43.6±1km/m2;Women 100%;Pre-op Weight, 113.0 ±4.7kgAge, 25.0 ± 0.6 yrs;BMI,21.8 ±0.6 km/m2;Women 100%;Pre-op Weight, 60.0±8.4kgCG: no physical activity requirementEG: only in one evaluation -To examine whether a transition from resting to 6MWT alters HR kinetics response in women with severe obesity compared to eutrophic group-To determine if the 12-week aerobic post-op exercise training program improved the heart rate kinetics and heart rate variability TG: 36 sessions of 1 hour each on alternate days for 12 weeks starting 1 month after surgery;TG: aerobic training program including - 5 mins of the upper and lower limbs stretching, diaphragmatic breathing , and proper standing and sitting posture awareness;- 5 mins of warm-up on a treadmill at a rate of 3 km/h;-40 min of exercise on treadmill with changing speed and inclination as per the behavior of HR;-1 min recovery;-10 min of the same stretching and diaphragmatic breathing as initial.Stegen,et al, ADDIN EN.CITE <EndNote><Cite><Author>Stegen</Author><Year>2011</Year><RecNum>81</RecNum><DisplayText>[82]</DisplayText><record><rec-number>81</rec-number><foreign-keys><key app="EN" db-id="pe9d0v9f10xwv2ex5f8xsde6vsf0prddzzfp" timestamp="1427766052">81</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Stegen, S.</author><author>Derave, W.</author><author>Calders, P.</author><author>Van Laethem, C.</author><author>Pattyn, P.</author></authors></contributors><auth-address>Department Movement and Sport Sciences, Ghent University, Watersportlaan 2, 9000 Ghent, Belgium. sanne.stegen@ugent.be</auth-address><titles><title>Physical fitness in morbidly obese patients: effect of gastric bypass surgery and exercise training</title><secondary-title>Obes Surg</secondary-title><alt-title>Obesity surgery</alt-title></titles><periodical><full-title>Obes Surg</full-title><abbr-1>Obesity surgery</abbr-1></periodical><alt-periodical><full-title>Obes Surg</full-title><abbr-1>Obesity surgery</abbr-1></alt-periodical><pages>61-70</pages><volume>21</volume><number>1</number><edition>2009/12/10</edition><keywords><keyword>Adult</keyword><keyword>Exercise</keyword><keyword>Exercise Therapy</keyword><keyword>Exercise Tolerance</keyword><keyword>Female</keyword><keyword>*Gastric Bypass</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Muscle Strength</keyword><keyword>Obesity, Morbid/*surgery/therapy</keyword><keyword>Physical Fitness</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2011</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>0960-8923</isbn><accession-num>19997987</accession-num><urls></urls><electronic-resource-num>10.1007/s11695-009-0045-y</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[82]2009,Belgium,RCTGastric bypass without exerciseN=7Gastric bypass with exercise(GB+E)N=8Age, 43.1 ± 5.6yrs;BMI,40.4 ±8.1 km/m2;Women 57.14%;Pre-op Weight, 126.5 ±24.7kgAge, 39.9 ± 9.9yrs;BMI,45.3 ±2.7 km/m2;Women 87.5 %;Pre-op Weight, 130.8 ±17.8 kg No participation in exercise program-To evaluate the effect of gastric bypass surgery on physical fitness in terms of muscle strength, and aerobic and functional capacity-To investigate the feasibility of an post-op exercise program 36 individual supervised exercise sessions of 75 min each spanning 12 weeks and starting 1 month after surgeryGastric bypass with exercise: Every training session comprised of 10 min of cardiovascular warming up, 25 min of strength training, 30 min of endurance training and 10 min of cooling-down period.-Strength exercises conducted with stack-weight equipment with a gradually increasing intensity;-Endurance training including cycling (10min), walking (10min) and stepping (10min) with a gradually increasing intensity.Table SEQ Table \* ARABIC 5. Findings of the studies examining the impact of post-operative lifestyle interventions in bariatric patients Behavioral interventionAuthor, (country) and designOutcomes/Target behaviorMonths of follow-up & Outcome evaluationTime pointAnalysis MethodsResultsFindingsKalarchian,et al,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LYWxhcmNoaWFuPC9BdXRob3I+PFllYXI+MjAxMjwvWWVh
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ADDIN EN.CITE.DATA [76]2011,United states,RCT,-%EWLData collected at baseline(pre-intervention) and 6 months (post-intervention) and 12 months (follow-up)-Mixed effect models used for examination of the percentage of EWL -Spearman’s correlation coefficients -%EWL in intervention group > in control group at 6 months (6.6% ± 3.4% versus 1.6% ±3.1%, p =0.29) and at 12 months (5.8% ± 3.5% versus .9% ± 3.2%, p = 0.32).-The patient who are more depressive (p=0.005) and had less weight regain (p=0.05) in intervention group had greater %EWL.-The number of group sessions attended was unrelated to %EWL in the intervention group;-Age, gender, race, years since surgery, and surgery type were unrelated to %EWL in either group;Table 5 ContinuedNijamkinet al,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5OaWphbWtpbjwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+
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ADDIN EN.CITE.DATA [77]2011,United States,RCT-%EWL- BMI reductions-Changes in PA over time-Protein intake-Depression-Data collected at the baseline and at month 6 and month 12 after surgery-t-test- χ2 test-Wilcoxon signed rank-Mann-Whitney U test-ITT-%EWL at 1 year post-op in intervention group > in Comparison group (80 % vs 64% from preoperative excess weight; p<0.001);-BMI reduction in intervention group> in comparison group (6.48± 4.37 vs 3.63± 3.41, p<0.001);-Intensity of PA in intervention group >in comparison group (+14 min/wk vs -4 min/wk; p<0.001);-Significant increase in mean time and intensity of exercise from 6 to 12 months post-op in intervention group but not in comparison group(p=0.019 and p<0.001, respectively);-The mean intake of protein in the intervention group>in comparison group (p=0.02).-% of those depressed subjects who had symptoms relieved at 12 months post-op among in intervention group > in comparison group( 24% vs. 6%, p<0.001)- %EWL, BMI reduction, increase in PA, increase in mean protein intake and percentage of subjects with relieved depression symptoms in intervention group > in comparison group;-The intervention is effective at improving weight loss and physical activity between 6 months and 12 months post-op.Papalazarou,et al,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QYXBhbGF6YXJvdTwvQXV0aG9yPjxZZWFyPjIwMTA8L1ll
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L0VuZE5vdGU+
ADDIN EN.CITE.DATA [78]2010,Greece,RCT-%EWL-Dietary habits-Eating behavior changes-PA levelData collected at baseline and at 12 months, 24 months and 36 months after surgery-One-way Repeated measures ANOVA-Levene’s test used to test for quality of variances between groups.-Bonferroni criterion used for post hoc comparisons between groups-Multiple repeated measures ANOVA for fixed effects) -%EWL at 12 months, 24 months and 36 months in LS group > in UC group (76.4 ±4.1% vs. 57.5 ±4.1%), (74.4 ±4.6% vs. 52.2 ±4.6%) and (74.4 ±4.6% vs. 52.2 ±4.6%);-The scores for total DEBQ and Restraint eating and external eating scales in LS group <in UC group (p<0.001);-Fruit and vegetable daily intakes (increase) in LS group < in UC group (p<0.05);-Sweet consumption(decrease) in LS group < in US group (p=0.07);-PA level in LS group > in UC group (p=0.001)-Group was the only statistically significant factor associated with either weight loss or %EWL at 12, 24 and 36 months while controlling for age, marital status, PA level and total DEBQ in multivariate analysis showed thatDietarySarwer,et al,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TYXJ3ZXI8L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA [84]2012,UnitedKingdom,Observational-Excess percent BMI lossData collected at baseline and 3, 6, 12, and 24 months after surgery- Mann–Whitney U test-Excess percent BMI loss in dietitian-led group <in surgeon-led group (21.8 ± 10.9 vs. 26.7 ± 13.8, p <0.01 at 3 months; 29.1 ± 18.7 vs. 36.1 ± 20.4, p< 0.01 at 6 months; 34 ± 17.2 vs. 40.3 ± 22.3, p=0.055; 38 ± 22.5 vs. 51.3 ± 26.6, p=0.056) -No significant difference in excess BMI loss between groups was found at 12 months and 24 months post-op.Table 5 ContinuedSwenson,et al,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Td2Vuc29uPC9BdXRob3I+PFllYXI+MjAwNzwvWWVhcj48
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ADDIN EN.CITE.DATA [85]2012,UnitedStates,RCT-Reduction in BMI-%EWLData collected at pre-op baseline and at 3,6,12 months after surgery.-Wilcoxon matched-pairs signed-ranks test used for the comparison of changes in body composition and exercise within diet groups - Reduction in BMI at 12 months in low fat diet group <in low carbohydrate group (-14.0 ±5.5% vs. -17.0 ±4.5%; p= 0.15); –%EWL at 12 months in low-fat diet group >in low carbohydrate group 60.3 ± 15.3% vs. low carbohydrate, 59.6±13.0%; p = 0.96).-No statistical differences were observed in BMI and excess body weight lost over time between the two diet groupsExerciseCastelloEt al, ADDIN EN.CITE <EndNote><Cite><Author>Castello</Author><Year>2011</Year><RecNum>79</RecNum><DisplayText>[86]</DisplayText><record><rec-number>79</rec-number><foreign-keys><key app="EN" db-id="pe9d0v9f10xwv2ex5f8xsde6vsf0prddzzfp" timestamp="1427765979">79</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Castello, V.</author><author>Simoes, R. P.</author><author>Bassi, D.</author><author>Catai, A. M.</author><author>Arena, R.</author><author>Borghi-Silva, A.</author></authors></contributors><auth-address>Cardiopulmonary Physiotherapy Laboratory, Nucleus of Research in Physical Exercise, Federal University of Sao Carlos, Rod. Washington Luis, km 235, 13565-905, Sao Carlos, Sao Paulo, Brazil.</auth-address><titles><title>Impact of aerobic exercise training on heart rate variability and functional capacity in obese women after gastric bypass surgery</title><secondary-title>Obes Surg</secondary-title><alt-title>Obesity surgery</alt-title></titles><periodical><full-title>Obes Surg</full-title><abbr-1>Obesity surgery</abbr-1></periodical><alt-periodical><full-title>Obes Surg</full-title><abbr-1>Obesity surgery</abbr-1></alt-periodical><pages>1739-49</pages><volume>21</volume><number>11</number><edition>2010/11/26</edition><keywords><keyword>Adult</keyword><keyword>*Exercise</keyword><keyword>Female</keyword><keyword>*Gastric Bypass</keyword><keyword>Heart Rate/*physiology</keyword><keyword>Humans</keyword><keyword>Middle Aged</keyword><keyword>Obesity, Morbid/*surgery</keyword><keyword>Physical Fitness/*physiology</keyword><keyword>Prospective Studies</keyword><keyword>Time Factors</keyword><keyword>Young Adult</keyword></keywords><dates><year>2011</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>0960-8923</isbn><accession-num>21104041</accession-num><urls></urls><electronic-resource-num>10.1007/s11695-010-0319-4</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[86]2010,Brazil,RCT -Anthropometric variables-Heart Rate-R-R intervals-6-min walk test (6MWT)-Data collected at 1 week before surgery and 4 months after surgery- The Kolmogorov-Smirnov test for examining data distribution-unpaired student t test for comparison of the differences between the TG and CG.- Post-op axillary, xiphoid, hip, waist and thigh circumferences in TG group significantly lower than in CG group (p<0.05);- Significant improvement in all indexes of heart rate variability(e.g. SDNN, RMSSD,NN50,pNN50,SD1 and SD2) in only TG group (p<0.05); And the post-op indexes in TG are significantly higher than the post-op indexes in CG group(p<0.05)- Increase in 6MWT distance in only TG group (p<0.05)-Significant differences between groups in the post-op indexes of heart rate variability were found and only TG group improved significantly in all of these indexes (e.g. SDNN, RMSSD, NN50, pNN50, SD1 and SD2).Coenet al, ADDIN EN.CITE <EndNote><Cite><Author>Coen</Author><Year>2015</Year><RecNum>80</RecNum><DisplayText>[80]</DisplayText><record><rec-number>80</rec-number><foreign-keys><key app="EN" db-id="pe9d0v9f10xwv2ex5f8xsde6vsf0prddzzfp" timestamp="1427766007">80</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Coen, P. M.</author><author>Tanner, C. J.</author><author>Helbling, N. L.</author><author>Dubis, G. S.</author><author>Hames, K. C.</author><author>Xie, H.</author><author>Eid, G. M.</author><author>Stefanovic-Racic, M.</author><author>Toledo, F. G.</author><author>Jakicic, J. M.</author><author>Houmard, J. A.</author><author>Goodpaster, B. H.</author></authors></contributors><titles><title>Clinical trial demonstrates exercise following bariatric surgery improves insulin sensitivity</title><secondary-title>J Clin Invest</secondary-title><alt-title>The Journal of clinical investigation</alt-title></titles><periodical><full-title>J Clin Invest</full-title><abbr-1>The Journal of clinical investigation</abbr-1></periodical><alt-periodical><full-title>J Clin Invest</full-title><abbr-1>The Journal of clinical investigation</abbr-1></alt-periodical><pages>248-57</pages><volume>125</volume><number>1</number><edition>2014/12/02</edition><dates><year>2015</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>0021-9738</isbn><accession-num>25437877</accession-num><urls></urls><electronic-resource-num>10.1172/jci78016</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[80]2015,United states,RCT-S1(insulin sensitivity)-SG-BMI,-Waist circumference-Total and depot-specific fat mass -Subcutaneous and visceral fat depot-SBP,DBP-Cholesterol (total, LDL and HDL)-Triglycerides-VO2 peakData collected before and after the 6-month interventions44 out of 66 in EX group and -The multiple imputation (MI) method with Markov chain Monte Carlo (MCMC) algorithms used for missing data-The general linear mixed model with repeated measures;-ITT and PP principles were both followed in analyses-In PP analysis, a significantly greater improvement in S1 in the EX group(who performed more than 120 min/wk of exercise in the final 3 months) compared to in the CON group (EX vs. CON; +2.69 vs. +1.57, min–1/μU/ml, p = 0.019);-In ITT analysis, a main effect of surgery/time (p<0.001) and greater improvement in SG in the EX group (EX vs. CON; +0.0063 vs. +0.0023 min–1, p = 0.009). In PP analysis, the exercise effect was also significant (EX vs. CON; +0.0071 vs. +0.0023 min–1, p = 0.011).-Reductions in BP, cholesterol, triglycerides, total and depot-specific fat mass, subcutaneous and visceral fat depot were similar in both groups.-VO2 peak significantly improved in EX group compared with CON group (p<0.01).-Significant effect of regular post-op exercise on glucose effectiveness (The ability of glucose per se to elicit glucose uptake).-Significant improvement in VO2 peakin intervention group;- No significant differences between groups were observed in BMI, waist circumference, total and depot-specific fat mass, loss of subcutaneous and visceral fat depots, and proportionate weight loss between fat depots, in in analyses with either ITT or PP approach.Table 5 ContinuedShah,Et al,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaGFoPC9BdXRob3I+PFllYXI+MjAxMTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA [79]2011,UnitedStates,RCT-Maximal oxygen consumption relative to weight-Changes in weight,-Reported time spent and energy expended during moderate physical activity-Energy intake -Health-related quality of life- resting energy expenditure (REE)-fasting lipids and glucose, and fasting and postprandial insulin concentrations-Data collected at baseline before intervention, at 6 weeks during the intervention and at the end of the intervention at 12 weeks-Mixed effect modelFor repeated measures-ITT analyses-The maximal oxygen consumption relative to weight significantly improved in intervention group (p=0.001) with a group-by-week interaction (p = 0.009) vs. no change in control group; -The number of steps/day increased significantly in intervention group (p<0.0001) with a group-by-week interaction (p=0.03) vs. no change in control group;-The reported time spent and energy expenditure during moderate physical activity increased by more than three times in intervention group (p<0.0001) with a group-by-week interaction (p=0.02) vs. no change in control group.-Change in body weight similar in both groups; -Energy intake decreased significantly in intervention group(p=0.02) vs. no change in the control group (p=0.07);-Improvement in intervention group in quality of life indexes such as emotional well-being only(p=0.001),energy levels (p=0.0002) and metal quality of life total score (p=0.006) vs. no change in control group-Significant improvements in only intervention group in maximal oxygen consumption relative to weight, the number of steps/day and the energy expenditure during moderate physical activity;-No difference was observed in changes in weight, energy and macronutrient intake, resting energy expenditure (REE), fasting lipids and glucose, and fasting and postprandial insulin concentrations between the two groups.Sim?eset al,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYXN0ZWxsby1TaW1vZXM8L0F1dGhvcj48WWVhcj4yMDEz
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ADDIN EN.CITE.DATA [81]2012,United states,RCT-Walking distance-Heart rate variability -Heart rate KineticsData collected at 1 week before surgery and 4 months after surgery-One way ANOVA for between groups. If significant, Tukey-Kramer post hoc used to identify differences.-Pearson correlation analysis for BMI (kg/m2) and walking distance relationship.-A significant increase in walking distance only in TG group at 4 months post-op compared to pre-op ( 515.0 ±41.0 post-op vs.470.0±23.9 pre-op, p<0.05);-Significant increases in Heart rate variability only in TG group at 4 months post-op compared to pre-op: mean HR 124 ± 5.9 post-op vs 132.3 ± 6.0 pre-op, p<0.05; SD1 9.6 ± 3.0 post-op vs 3.8 ± 0.7 pre-op, p<0.05; RMSSD 5.1 ± 0.3 post-op vs 2.9 ± 0.3 pre-op, p<0.05);-SD1 after surgery at 4 months post-op significantly higher in TG group compared to CG group (9.6± 3.0 in TG group vs.3.1± 0.2 in CG group).-Reduction in Heart rate kinetics index MRT in only TG group at 4 months post-op compared with pre-op (36.5±5.6 post-op vs. 64.1 ± 8.8 pre-op, p<0.05)-Only TG showed substantial within-group (1 week before vs. 4 months after surgery) improvements in all of the following indexes: HRV indexes (RMSSD, Mean HR and SD1), walking distance, faster time constant and mean response time of HR amid 6MWT following training sessions (p<0.05)Stegen,et al, ADDIN EN.CITE <EndNote><Cite><Author>Stegen</Author><Year>2011</Year><RecNum>81</RecNum><DisplayText>[82]</DisplayText><record><rec-number>81</rec-number><foreign-keys><key app="EN" db-id="pe9d0v9f10xwv2ex5f8xsde6vsf0prddzzfp" timestamp="1427766052">81</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Stegen, S.</author><author>Derave, W.</author><author>Calders, P.</author><author>Van Laethem, C.</author><author>Pattyn, P.</author></authors></contributors><auth-address>Department Movement and Sport Sciences, Ghent University, Watersportlaan 2, 9000 Ghent, Belgium. sanne.stegen@ugent.be</auth-address><titles><title>Physical fitness in morbidly obese patients: effect of gastric bypass surgery and exercise training</title><secondary-title>Obes Surg</secondary-title><alt-title>Obesity surgery</alt-title></titles><periodical><full-title>Obes Surg</full-title><abbr-1>Obesity surgery</abbr-1></periodical><alt-periodical><full-title>Obes Surg</full-title><abbr-1>Obesity surgery</abbr-1></alt-periodical><pages>61-70</pages><volume>21</volume><number>1</number><edition>2009/12/10</edition><keywords><keyword>Adult</keyword><keyword>Exercise</keyword><keyword>Exercise Therapy</keyword><keyword>Exercise Tolerance</keyword><keyword>Female</keyword><keyword>*Gastric Bypass</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Muscle Strength</keyword><keyword>Obesity, Morbid/*surgery/therapy</keyword><keyword>Physical Fitness</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2011</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>0960-8923</isbn><accession-num>19997987</accession-num><urls></urls><electronic-resource-num>10.1007/s11695-009-0045-y</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[82]2009,United states,RCT-Muscle strength-Functional and aerobic capacityData collected before and 4 months after surgery-Repeated-measures ANOVA to evaluate interaction and time effects-The decrease in Static muscle strength (handgrip strength kg) in non-exercise group was significant (95.9±24.9 pre-op vs. 78.7±22.2 post-op, p=0.043) vs. not significant in exercise group (76.5±30.3 pre-op vs. 67.6±20.2 post-op, p=0.131);-The improvement in 6-min walk test, a measure of functional capacity, is significant in exercise group (485.9±28.8 pre-op vs. 537.9±40.6 post-op, p=0.002) vs. not significant in non-exercise group(475.2±58.8 pre-op vs. 505.2±86.8 post-op, p=0.330)-Differences in the decrease in static muscle strength and in improvement in 6-min walk test between groups were found suggesting the effectiveness of an intensive exercise program on preventing the deterioration in muscle strength and physical function following surgery. HR=Heart rate; SDNN= standard deviation of all N-N normal intervals, RMSSD= square root of the difference in the sum of squares between R-R intervals on the record, divided by the determined time minus one; NN50= the number of R-R intervals differing by more than 50 ms; pNN50 (%)= percentual of R-R intervals differing by more than 50 ms; SD1=standard deviation of instantaneous R-R interval variability; SD2= standard deviation of long term continuous R-R interval variability; 6MWT=6-min walk test; BP= blood pressure, S1=Insulin sensitivity; SG=glucose effectiveness; ITT=intention to treat, PP=per protocol, ↑=increase, ↓=decrease; DEBQ= Dutch Eating Behavior Questionnaire; HRV= heart rate variability; EG= eutrophic group; TG= trained group; CG= control group; BL= baseline; Amp= amplitude; τ= time constant; MRT= mean response time (τ + TD); RCT=Randomized controlled trial; UCT=uncontrolled clinical trial; Pre-op=Pre-operative; Post-op=Post-operative; OP=operation time; WL=weight loss; BW=Body weight; BP=Blood pressure; BMI=Body mass index; HLOS=Hospital length of stay; %EWL=Percentage of excess weight loss; Con-V=Continuous variables;Table 5 ContinuedDIscussionstrengths and limitations of this review This is the first review that appraises the existing evidence regarding the effects of lifestyle interventions in bariatric patients. The focus on randomized clinical trials allows the assessment of evidence to be less influenced by the imbalance between the study groups. This review conducted a systematic search and summarization of related literature with references only to original studies in electronic databases.Due to the limited number of studies and the heterogeneity in the assessed interventions and the outcomes measurements of the included studies, meta-analysis or systematic comparisons across studies were not performed. Also, this review reported mainly on the effects of lifestyle interventions on primary health outcomes such as weight loss and physical activity; the effects on some secondary outcomes such as the incidence of cancer and gallstones, length of hospitalization and operative time were not evaluated. Furthermore, the possibility of publication bias and investigator bias cannot be ruled out.implications for researchThis review highlights the need for future high quality research that employs adequate methodological justifications, including appropriate statistical tools for data analysis with sufficient power, and has longer follow-up. The studies that specifically targeted physical activity should examine the relationship between the intervention and weight loss, in addition to evaluating the changes in physical activity. Furthermore, in order for the study findings to be more generalizable, future research should be conducted in diverse bariatric surgery populations with larger sample sizes. Finally, the assessment of cost-efficacy and adverse effects should be incorporated into further studies to inform health professionals and policy makers on decision making.conclusionsDue to the heterogeneity in the design and outcomes measurements of the included studies, this review cannot provide a consolidated conclusion regarding the overall impact of lifestyle interventions in bariatric surgery patients. But there is moderate evidence suggesting the benefits of post-operative lifestyle interventions, whereas intervening on dietary modification alone does not appear to be as effective as comprehensive lifestyle intervention. There is also moderate evidence that pre-operative and post-operative exercise programs have positive effects on fitness, strength and activity-related outcomes. However, it is unclear whether they improve surgery induced weight loss or weight loss maintenance. 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