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Meeting physical activity recommendations is associated with health-related quality of life in women before and after Roux-en-Y gastric bypass surgery

Meeting physical activity recommendations is associated with health-related quality of life in... Purpose Meeting physical activity (PA) recommendations is positively associated with health-related quality of life (HRQoL), but it is still unclear whether PA (specifically objectively measured) is associated with HRQoL in bariatric surgery candidates, both before and after surgery. Thus, the aim of this study was to examine the cross-sectional association between meeting objectively measured PA recommendations and HRQoL before and after Roux-en-Y gastric bypass (RYGB) surgery. Methods Sixty-six women undergoing RYGB with pre-surgery and 62 women with post-surgery valid PA and HRQoL data were included from the control group of a RCT study aiming at improving HRQoL and PA post-RYGB surgery. Measures before and 12 months after RYGB included the Short Form Health Survey (SF-36) and objectively measured PA, sedentary time (ST), and step counts with GT3X+ accelerometers. Multiple linear regression models were used to analyze the associa- tions between PA and HRQoL. Results Participants who engaged in more than 150 min of moderate to vigorous PA (MVPA)/week (PA recommendations) had considerably higher SF-36 scores (HRQoL) than those who did not, both pre and 12-month post-surgery, with greatest difference in the subscale bodily pain, 15.5 (p = 0.021) higher score (higher scores means less pain) pre-surgery and a 19.7 (p = 0.004) higher score post-surgery. Higher LPA and step counts and lower ST also showed positive associations in some of the subscales of SF-36. Conclusions Meeting the PA recommendations and overall engaging in more PA was associated with higher HRQoL, pre-, and post-RYGB surgery, highlighting the importance of PA both pre- and post-surgery. Keywords Health-related quality of life · Physical activity · Bariatric surgery · Gastric bypass · Sedentary time · Step counts Electronic supplementary material The online version of this article (https ://doi.org/10.1007/s1113 6-019-02120 -0) contains supplementary material, which is available to authorized users. * Fanny Sellberg Department of Public Health Sciences (PHS), Karolinska fanny.sellberg@ki.se Institutet, K9, Social Medicin, 171 77 Stockholm, Sweden Sofie Possmark Department of Health and Caring Sciences, University sofie.possmark@ki.se of Gävle, 801 76 Gävle, Sweden Mikaela Willmer Centre for Epidemiology and Community Medicine, mikaela.willmer@hig.se Stockholm County Council, Box 45436, 104 31 Stockholm, Sweden Per Tynelius per.tynelius@ki.se Department of Nursing, Umeå University, 901 87 Umeå, Sweden Margareta Persson margareta.persson@umu.se Daniel Berglind daniel.berglind@ki.se Vol.:(0123456789) 1 3 1498 Quality of Life Research (2019) 28:1497–1507 The aim of this study was to examine the association Introduction between meeting physical activity recommendations, light PA (LPA), ST and step counts (objectively measured), and Meeting the physical activity (PA) recommendations of HRQoL before and 12 months after RYGB surgery. A sec- at least 150 min of moderate to vigorous PA (MVPA) per ondary aim was to explore the association between pattern week is associated with a wide range of positive health and intensity of PA and HRQoL changes pre- and 12-month outcomes across all weight ranges, including reduced post-RYGB. risk of heart disease, type 2 diabetes, some cancers, and improved mental health [1, 2]. Furthermore, meeting the PA recommendations and higher duration, intensity, and Materials and methods bout length of PA are positively associated with health- related quality of life (HRQoL) [3–5]; a multidimensional For the current study, we used the control group of an measure of physical, mental, functional, and social well- ongoing randomized controlled intervention, to study the being, in the general population [6]. Less is known about association between PA and HRQoL. The study, named sedentary time (ST) and PA associations with HRQoL in WELL-RYGB, has been described in detail in a previ- individuals suffering from obesity [7 , 8] and few studies ously published protocol paper [25]. In short, the WELL- have used objectively measured PA and ST [9]. RYGB is a randomized controlled trial examining the Individuals suffering from obesity often show lower effects of a dissonance-based post-RYGB intervention, on levels of HRQoL compared to the general normal weight HRQoL and PA at 12- and 24-month follow-up. The study population [10]. Weight loss has been associated with was approved by the regional ethics committee of Stock- increases in HRQoL [11], especially rapid weight loss holm (Dnr:2013/1847–31/2). The trial has also been reg- induced by bariatric surgery [12–14], where Roux-en-Y istered at http://www.isrct n.org with identification number gastric bypass (RYGB) is the most commonly performed ISRCTN16417174 and all participants have given oral and bariatric surgery procedure in Sweden [15]. Greatest written consent to participate. improvements of HRQoL, induced by weight loss, are often seen on the physical part of the measurement scale, Participants probably caused by the reduced physical complaints after losing weight, but the mental part has also been shown to Women were recruited from waiting lists for RYGB sur- improve [12, 13]. gery from five different hospitals in Sweden (Örebro Uni- Peak improvements in HRQoL after bariatric surgery versity Hospital, Akademiska Hospital, Ersta Hospital, are typically observed during the first years of follow-up, St. Görans Hospital, and Danderyds Hospital). Inclusion followed by a small decline that usually stabilizes approxi- criteria were being eligible for RYGB surgery [body mass mately 5 years postoperatively [16, 17]. Although HRQoL index (BMI) > 35 with complications from the obesity or improves substantially after bariatric surgery, PA usually BMI > 40, conducted several serious attempts to lose weight does not increase (despite great weight loss) [18–20], with other methods, and usually over 18  years old] and except when self-reported PA is used as an outcome enough Swedish language skills to be a part of an inter- measure [20]. The discrepancy between self-reported and vention in Swedish and answer questionnaires in Swedish. objectively measured PA in this patient group is large, and Interested patients were sent informed consent forms, a tends to increase post-RYGB [21]. Consequently, objec- questionnaire measuring HRQoL and demographic char- tively measured PA is the preferred method for assessing acteristics, and an accelerometer before surgery. Partici- actual levels of PA in this patient category. pants were included if they returned the informed consent. Interventions aiming to increase PA pre-bariatric sur- The same questionnaires and an accelerometer were sent gery have been shown to also improve HRQoL pre-sur- 12 months after surgery, yielding two measure points: base- gery [22], but not post-surgery [23]. However, it is still line (approximately 1 month before RYGB) and 12-month unclear whether objectively measured PA is associated follow-up. We only included the control group in this sub- with HRQoL before and after bariatric surgery in candi- study since the intervention aimed at improving HRQoL and dates receiving regular care (in a non-intervention setting). PA and may therefore, if included in the current study, bias Thus far, 10-year follow-up data from the Swedish Obese the results. Additionally, there were only women included in Subjects (SOS) study have shown that HRQoL is improved the original intervention study because of power concerns. and associated with weight loss after bariatric surgery. The intervention might affect men and women differently, However, the self-reported data on PA, with its inherent therefore creating the need for stratification, and it was not bias [24], limit any interpretation on associations between possible to collect the double number of participants in order PA and HRQoL before and after RYGB. to obtain enough power, especially as approximately 77% of 1 3 Quality of Life Research (2019) 28:1497–1507 1499 all Swedish RYGB patients are women [15]. All participants questionnaire data at baseline and at 1-year follow-up were had RYGB surgery between April 2015 and June 2017. In used to assess current occupation (categorized as work- the current sub-study, we included 66 women with pre-sur- ing or not working) and level of education (categorized as gery and 62 women with 12-month post-surgery valid PA university level or lower). Long-term sickness was defined and HRQoL data, only 39 women had valid accelerometer by a question asking if participants had a chronic disease, data for both measure points. difficulty after an accident, reduced physical function, or long-term health condition. If the respondent answered yes, HRQoL the following question was asked: does this condition result in reduced work capacity or limit your regular occupation? HRQoL was measured using the Short Form (36) Health With response options (1) “not at all,” (2) “yes, to some Survey (SF-36). The SF-36 is divided into eight domains: degree,” and (3) “yes, to a high degree.” BMI was calculated 2 2 vitality (VT), physical functioning (PF), bodily pain (BP), as weight (kg)/ height (m ). general health perceptions (GH), physical role functioning (RP), emotional role functioning (RE), social role function- Statistical analysis ing (SF), and mental health (MH), and can be summarized into two summary scores: physical summary score (PCS) Data in table one and two are presented as means and stand- and mental summary score (MCS). Scoring ranges from 0 ard deviation (SD) or in numbers and percentages. Two- to 100 with higher scores indicating better quality of life. tailed T tests were used to test for differences in BMI and PA The instrument performs well in a general population [26] over time. Multiple regression models were used to analyze and is commonly used in obese populations [11]. SF-36 was the associations between LPA and HRQoL, step counts and scored using the Quality Metric scoring Software 8.6.12. HRQoL, ST and HRQoL, and between meeting the MVPA pptx and the “maximum data recovery” setting was used recommendations and HRQoL, with MVPA categorized into for missing values. two groups, more or less than 150 min of MVPA/week. A similar approach was used for MVPA performed in 10-min Physical activity bouts since the recommendation for PA is at least 150 min of MVPA performed in 10-min bouts (or longer) per week PA, LPA, step counts, and ST were measured objectively [30]. However, we also analyzed MVPA in non-bouts, since with an accelerometer (ActiGraph GT3X+), worn on the MVPA independent of how it is accumulated, is associated right hip. Participants were asked to wear the accelerom- with numerous health benefits [31]. BMI, percent weight eter for all waking hours for seven consecutive days. We loss, and age were not significant confounders and were used vector magnitude activity counts (V ), calculated as therefore not included in the adjusted models. Education, the square root of the sum of the counts on all three axes, occupation, and long-term sickness showed significant recorded in 10-s epochs and then converted into counts per confounding effects in several models and were therefore minutes (cpm). Measurements were accepted as valid if par- included in all adjusted analyses of MVPA recommenda- ticipants had worn the accelerometer for at least 10 h per tions and HRQoL as well as wear time. For the association day during at least 3 days. The number of participants with between LPA, step counts, ST, and HRQoL, only occupa- valid measure at one of the two measure points is reported in tion and long-term sickness were found to be significant Table 2. Wear time, MVPA, and classification of bouts were confounders and therefore included in the adjusted mod- computed using ActiLife v.6.13.3. For wear time, we used an els, as well as wear time. The majority of the participants algorithm by Choi et al. [27]. If there were no counts for 60 only had PA measured at one time-point and there could be consecutive minutes or more, with a maximum break of two systematic differences between those with PA measured at minutes with non-zero counts, it was classified as non-wear one or two time points. Therefore, sensitivity analyses were time [28] and consequently removed from analyses. MVPA performed for the group of participants who had valid PA minutes were calculated as minutes per day in total and also measures both pre- and post-surgery (n = 39) (Supplemen- in 10 min bouts. ST was defined as any minute showing tary Tables 1 and 2). All statistical analyses were performed < 100 cpm, light physical activity (LPA) was defined as with STATA.15.1 (StataCorp). 100–3207 cpm, and MVPA as 3208 cpm or more [29]. Other variables Results Weight and height were objectively measured at the hos- Out of the 103 included participants in the study, 90 women pitals, in a standardized manner, pre- and 12-month post- had valid accelerometer data for at least one of the measure- surgery and obtained from medical records. Self-reported ments, before or 12 months after RYGB. Sixty-six of those 1 3 1500 Quality of Life Research (2019) 28:1497–1507 had valid accelerometer data and HRQoL data pre-surgery, significant p = 0.334. Step counts increased significantly by whereas 62 had valid data on the same measures at 12-month 1162.8 steps/day (p = 0.014) for those with valid data at one post-RYGB. Thirty-nine women had valid data at both meas- measure point, see Table 2. A similar pattern was found for ure points. Characteristics of participants pre- and 12-month participants with valid accelerometer PA data at both meas- post-RYGB are presented in Table 1. Participants with both ure points (data not shown). Ten percent of the participants valid accelerometer measurement had overall slightly higher reached the PA recommendation of ≥ 150 min of MVPA in SF-36 scores pre-surgery, suffered from long-term sickness 10-min bouts per week pre-surgery and 15% at 12-month to a greater extent, and had higher levels of education com- post-surgery, see Fig. 1. pared to those with only one valid accelerometer measure- Table 3 shows the mean SF-36 scores comparing partici- ment. Mean percentage weight loss at 12-month post-sur- pants engaging in more or less than 150 min MVPA/week gery was 47.2% (SD = 16.8) and prevalence of long-term or more or less than 150 min MVPA in 10 min bouts/week. sickness was also reduced to 27% at 12-month post-surgery Participants who engaged in more than 150 min MVPA/ compared with 59% pre-surgery. week had considerably higher SF-36 scores than those who Table  2 shows participants’ levels of PA, LPA, step did not, both pre- and post-surgery. These differences varied counts, and ST pre- and 12-month post-surgery. Mean greatly for different sub-scores, see Table  3, and most of the MVPA min/day pre-surgery were 26.4 (SD = 21.0) and found associations decreased or disappeared when adjusting 29.6 (SD = 22.4) min/day 12 months after surgery. Partici- for confounders, in particular long-term sickness. Looking pants also increased their time spent in MVPA in 10-min at the summary scores, PCS showed stronger associations bouts from 7.5 (SD = 12.6) pre-surgery to 11.6 (SD = 14.6) with all levels of PA than MCS after surgery but a strong min/day 12-month post-surgery, although not statistically association between LPA and MCS was found pre-surgery Table 1 Participants’ characteristics and health-related quality of life (HRQoL) before and 12  months after Roux-en-Y gastric bypass surgery (RYGB) Variables Pre-surgery (n = 66) 12-month post-surgery Pre-surgery with valid 12-month post-surgery with (n = 62) PA measurements at valid PA measurements at both both time points (n = 39) time points (n = 39) BMI (kg/m ) 40.9 (5.3) (n = 65) 28.1 (4.2) (n = 59) 40.7 (4.3) (n = 38) 28.2 (3.9) (n = 37) % weight loss − 47.2% (16.8) − 45.7% (15.3) Age (years) 44.5 (9.7) 47.5 (10.0) 45.8 (9.9) 46.8 (9.9) Education at university level 21 (32%) 15 (25%) 14 (36%) 13 (33%) Working 50 (76%) 51 (82%) 31 (79%) 31 (79%) Suffering from long-term sick - 39 (59%) 17 (27%) 24 (62%) 14 (36%) ness Long-term sickness with no 8 (12%) 6 (10%) 8 (21%) 4 (10%) limitations Long-term sickness with some 18 (27%) 7 (11%) 8 (21%) 6 (15%) limitations Long-term sickness with a high 13 (20%) 4 (6%) 8 (21%) 4 (10%) degree of limitations SF-36 subscales  PF, physical functioning 56.1 (24.1) 89.6 (15.0) 56.5 (25.7) 86.9 (17.8)  RP, physical role functioning 70.6 (30.7) 90.1 (18.5) 73.9 (29.2) 88.8 (19.5)  BP, bodily pain 43.8 (27.6) 75.4 (27.5) 46.0 (26.8) 70.5 (21.8)  GH, general health 50.9 (21.2) 79.1 (19.5) 50.8 (19.4) 77.9 (21.2)  VT, vitality 37.7 (21.3) 64.3 (21.1) 38.6 (20.1) 65.2 (21.9)  SF, social role functioning 62.7 (28.5) 90.7 (19.2) 66.0 (27.6) 90.4 (20.2)  RE, emotional role functioning 76.4 (30.3) 91.4 (18.0) 75.9 (30.6) 90.4 (17.4)  MH, mental health 62.9 (20.9) 81.7 (14.1) 64.1 (19.3) 81.0 (15.5)  PCS, physical summary score 41.5 (9.2) 53.7 (7.6) 42.1 (8.5) 52.5 (8.6)  MCS, mental summary score 45.2 (11.2) 53.5 (7.8) 45.6 (10.1) 53.7 (8.1) Data presented as mean (SD) or number (percentage) BMI Body mass index, SF-36 the Short Form (36) Health Survey 1 3 Quality of Life Research (2019) 28:1497–1507 1501 Table 2 Physical activity Variables Pre-surgery (n = 66) 12-month post- Difference between pre- (PA), sedentary time (ST), and surgery (n = 62) and post-surgery (n = 39) step counts for participants pre-surgery and 12-month post- Mean wear time h/day 14.0 (1.2) 14.8 (1.4) 0.4 (1.6) surgery p = 0.089 Mean counts/min 583.9 (229.2) 598.8 (180.0) 6.5 (183.9) p = 0.826 MVPA in 10 bouts, min/day 7.5 (12.6) 11.6 (14.6) 2.7 (16.9) p = 0.334 MVPA min/day 26.4 (21.0) 29.6 (22.4) 2.1 (22.6) p = 0.566 LPA min/day 359.0 (88.2) 400.7 (78.0) 19.6 (93.3) p = 0.197 ST min/day 455.0 (99.3) 457.3 (100.6) 5.1 (94.3) p = 0.737 Step counts steps/day 5971.0 (2776.5) 7511.7 (2989.0) 1162.8 (2829.3) p = 0.014 Data presented as mean (SD) MVPA moderate to vigorous physical activity, LPA light physical activity, ST sedentary time engaging in ≥ 150 min MVPA/week in 10 min bouts were Percent of participants that reach PA recommendations 29.5 (p = 0.008). Supplementary Table  2 shows associa- 70% tions between LPA, ST, step counts, and HRQoL for par- 60% ticipants with valid PA measures at both measure points; 50% the table shows similar results to the analyses including all participants. 40% Pre-surgery Additionally, we also checked for if changes in physical 30% 1 year post-surgery activity (going from active, meeting PA recommendations, 20% to inactive, not meeting PA recommendations, or the other 10% way around) were associated with changes in HRQoL in 0% these 39 participants. Unfortunately, there were too few par- >150min/week >150min/week in 10 bouts ticipants to see any valid results, see Supplementary Mate- rial 3. However, we saw no relevant differences in changes Fig. 1 Percentage of participants meeting physical activity recom- in HRQoL between participants being active before surgery mendations, pre-, and post-RYGB surgery compared to inactive (mean improvement in MCS = 7.4 (SD = 8.3) vs. 8.7 (SD = 9.7) and for PCS = 9.7 (SD = 6.6) vs. 11.1 (SD = 8.6), respectively). with a 2.6-point increase in MCS for each hour increase in LPA, see Table 4. The results in Table 4 are presented as Moreover, we run the same analyses as above including all participants with accelerometer data (without any criteria change in SF-36 score per hour increase in LPA or ST and per 1000 increased steps/day. of wear time). This only added two participants and did not change any of the results substantially. Sensitivity analyses Sensitivity analyses of mean scores of SF-36 comparing Discussion more or less than 150 min/week of MVPA and more or less than 150 min of MVPA in 10 min bouts/week for partici- Meeting the PA recommendations of ≥ 150 min of MVPA per week in non-bouts and in 10-min bouts was associated pants with valid PA measures at both measure points can be found in Supplementary Table 1 (n = 39). In general, there with higher HRQoL summary scores as well as in many of the subscales pre- and post-RYGB and associations were slightly weaker associations pre-surgery, and in almost all subscales the associations 12-month post-surgery were were found to be stronger post-surgery. Additionally, we also found associations for LPA, ST, and step counts with stronger, with bodily pain showing very strong associa- tion engaging in ≥ 150 min MVPA/week, in average 29.1 HRQoL pre- and post-RYGB. However, most of the asso- ciations were decreased or diminished when adjusting for (p = 0.001) higher score in bodily pain (i.e., meaning less pain) compared to those who did not; same numbers for relevant confounders, especially when adjusting for living 1 3 1502 Quality of Life Research (2019) 28:1497–1507 1 3 Table 3 Multiple regression analysis: difference in HRQoL by meeting recommendations of either 150 min/week of MVPA in general and in 10 min bouts or not Variables MCS PCS PF RP BP GH VT SF RE MH Pre-surgery (n = 66) 150 min/week 5.2 (p = 0.060) 5.1 (p = 0.022) 13.5 (p = 0.022) 12.5 (p = 0.098) 15.5 (p = 0.021) 10.6 (p = 0.053) 15.2 (p = 0.003) 14.8 (p = 0.034) 5.4 (p = 0.475) 13.1 (p = 0.010) MVPA 150 min/ 4.0 (p = 0.126) 0.3 (p = 0.850) 4.7 (p = 0.408) − 2.9 (p = 0.585) 3.4 (p = 0.571) 3.7 (p = 0.445) 9.6 (p = 0.040) 10.9 (p = 0.123) − 2.1 (p = 0.768) 10.4 (p = 0.037) week MVPA adjusted 150 min/week 3.5 (p = 0.443) 2.4 (p = 0.525) 7.5 (p = 0.440) 10.9 (p = 0.380) 8.8 (p = 0.426) − 1.7 (p = 0.843) 6.8 (p = 0.431) 13.8 (p = 0.229) 3.8 (p = 0.759) 7.9 (p = 0.346) MVPA (10 bouts) 150 min/week 4.8 (p = 0.232) 1.2 (p = 0.650) 7.1 (p = 0.408) 9.4 (p = 0.246) 6.2 (p = 0.502) − 3.8 (p = 0.598) 8.2 (p = 0.258) 15.8 (p = 0.142) 4.5 (p = 0.677) 10.1 (p = 0.190) MVPA (10 bouts) adjusted 12-month post-surgery (n = 62) 150 min/week 0.6 (p = 0.758) 6.9 (p < 0.001) 15.4 (p < 0.001) 10.4 (p = 0.027) 19.7 (p = 0.004) 10.1 (p = 0.042) 5.3 (p = 0.334) 10.6 (p = 0.029) 6.6 (p = 0.153) 1.4 (p = 0.709) MVPA 150 min/ − 1.7 (p = 0.375) 4.0 (p = 0.003) 10.2 (p = 0.001) 3.7 (p = 0.278) 10.0 (p = 0.088) 2.4 (p = 0.480) 1.3 (p = 0.789) 4.0 (p = 0.355) 0.0 (p = 0.998) − 3.1 (p = 0.368) week MVPA adjusted 150 min/week 3.1 (p = 0.255) 7.1 (p = 0.006) 12.4 (p = 0.015) 10.3 (p = 0.107) 23.6 (p = 0.012) 15.2 (p = 0.022) 16.5 (p = 0.022) 9.6 (p = 0.150) 8.3 (p = 0.187) 5.1 (p = 0.294) MVPA (10 bouts) 150 min/week − 0.5 (p = 0.841) 3.1 (p = 0.096) 5.8 (p = 0.166) 0.5 (p = 0.917) 9.7 (p = 0.214) 3.5 (p = 0.446) 9.5 (p = 0.125) − 0.2 (p = 0.971) − 1.6 (p = 0.770) − 1.2 (p = 0.785) MVPA (10 bouts) adjusted Data presented as β (p-value) MVPA moderate to vigorous physical activity, PF physical functioning, RP physical role functioning, BP bodily pain, GH general health perceptions, VT vitality, SF social role functioning, RE emotional role functioning, MH mental health, PCS physical summary score, MCS mental summary score Adjusted for occupation, education, wear time, and long-term sickness Quality of Life Research (2019) 28:1497–1507 1503 1 3 Table 4 Multiple regression analysis: linear association between HRQoL and light physical activity (LPA, per 60 min), sedentary time (ST, per 60 min), or step counts (per 1000 steps) Variables MCS PCS PF RP BP GH VT SF RE MH Pre-surgery (n = 66)  LPA 2.6 (p = 0.005) 1.7 (p = 0.030) 4.1 (p = 0.041) 3.4 (p = 0.193) 5.6 (p = 0.016) 5.0 (p = 0.004) 6.1 (p < 0.001) 9.2 (p < 0.001) 2.4 (p = 0.362) 5.1 (p = 0.003)  LPA adjusted 1.7 (p = 0.055) 0.3 (p = 0.565) 1.6 (p = 0.399) − 2.2 (p = 0.211) 2.5 (p = 0.230) 2.7 (p = 0.087) 3.6 (p = 0.019) 7.2 (p = 0.002) − 1.2 (p = 0.603) 3.5 (p = 0.037)  ST − 1.1 (p = 0.171) − 0.6 (p = 0.414) − 1.4 (p = 0.436) − 0.0 (p = 0.990) − 2.4 (p = 0.253) − 1.8 (p = 0.270) − 3.7 (p = 0.021) − 4.7 (p = 0.026) − 0.6 (p = 0.806) − 1.4 (p = 0.365)  ST adjusted − 1.0 (p = 0.191) − 0.0 (p = 0.999) − 0.5 (p = 0.753) 2.0 (p = 0.193) − 1.2 (p = 0.495) − 0.7 (p = 0.596) − 2.9 (p = 0.029) − 4.1 (p = 0.040) 0.4 (p = 0.856) − 1.2 (p = 0.424)  Step counts 1.2 (p = 0.015) 1.3 (p = 0.001) 2.9 (p = 0.006) 4.1 (p = 0.002) 3.4 (p = 0.006) 2.7 (p = 0.003) 2.8 (p = 0.002) 4.0 (p = 0.001) 2.5 (p = 0.070) 2.4 (p = 0.010)  Step counts 0.7 (p = 0.166) 0.4 (p = 0.271) 1.2 (p = 0.244) 0.5 (p = 0.604) 1.3 (p = 0.268) 1.2 (p = 0.190) 1.1 (p = 0.198) 2.7 (p = 0.038) 0.4 (p = 0.786) 1.5 (p = 0.104) adjusted 12-month post-surgery (n = 62)  LPA 1.3 (p = 0.097) 1.5 (p = 0.041) 2.6 (p = 0.081) 3.9 (p = 0.029) 3.9 (p = 0.148) 3.8 (p = 0.045) 5.0 (p = 0.015) 3.8 (p = 0.045) 3.2 (p = 0.069) 1.2 (p = 0.375)  LPA adjusted 0.5 (p = 0.538) − 0.1 (p = 0.851) − 0.2 (p = 0.838) 0.4 (p = 0.753) − 1.2 (p = 0.587) 0.1 (p = 0.970) 2.7 (p = 0.130) 1.1 (p = 0.522) 0.6 (p = 0.714) − 0.5 (p = 0.719)  ST − 0.6 (p = 0.332) − 1.3 (p = 0.024) − 1.6 (p = 0.169) − 3.3 (p = 0.017) − 3.7 (p = 0.076) − 2.3 (p = 0.127) − 3.5 (p = 0.030) − 2.8 (p = 0.054) − 2.2 (p = 0.113) 0.2 (p = 0.842)  ST adjusted − 0.1 (p = 0.788) − 0.8 (p = 0.055) − 1.1 (p = 0.268) − 2.1 (p = 0.025) − 1.9 (p = 0.281) − 0.5 (p = 0.619) − 1.9 (p = 0.155) − 2.0 (p = 0.114) − 1.3 (p = 0.270) 1.0 (p = 0.312)  Step counts 0.2 (p = 0.546) 1.3 (p < 0.001) 2.5 (p < 0.001) 2.6 (p = 0.001) 3.6 (p = 0.002) 2.2 (p = 0.010) 1.4 (p = 0.128) 1.5 (p = 0.071) 1.9 (p = 0.019) 0.2 (p = 0.775)  Step counts − 0.4 (p = 0.277) 0.6 (p = 0.013) 1.3 (p = 0.023) 0.5 (p = 0.457) 1.5 (p = 0.182) 0.4 (p = 0.526) 0.3 (p = 0.731) 0.3 (p = 0.742) 0.0 (p = 0.993) − 1.0 (p = 0.120) adjusted Data presented as β (p value) LPA light physical activity, ST sedentary time, PF Physical functioning, RP Physical role functioning, BP Bodily pain, GH General health perceptions, VT vitality, SF Social role functioning, RE Emotional role functioning, MH Mental health, PCS Physical summary score, MCS Mental summary score Adjusted for education, wear time, and long-term sickness 1504 Quality of Life Research (2019) 28:1497–1507 with long-term sickness. In general, participating women were able to and were active ≥ 150 min of MVPA per week. improved their HRQoL substantially from pre- to 12-month When taking into account long-term sickness, the associa- post-RYGB, especially on subscales connected to the physi- tion between meeting the PA recommendations and HRQoL cal part of HRQoL. became weaker, supporting this theory. For the subgroup of Pre-surgery, women’s HRQoL scores were considerably 39 women who had accelerometer data at both measurement lower than among the general population [32]. However, points, the association between meeting PA recommenda- at 12-month post-RYGB, scores were similar, and in some tions and HRQoL was somewhat stronger. They also had a subscales even higher, than among the general population somewhat higher prevalence of long-term sickness, which is [32]. All intensity levels of PA were higher 12-month post- in line with the theory above. However, the mean levels of surgery compared to pre-surgery, although not statistically PA in this patient group did not increase post-surgery. Thus, significant, except for step counts. Great improvements in the slightly increased association might also be a function HRQoL after bariatric surgery, in line with our results, have of weight loss, although this is only speculative. The strong been seen in several previous studies [12, 13, 23], with a associations seen between meeting the 150 min of MVPA peak improvement at 12-month post-surgery [33]. Con- per week recommendations and SF-36 were also seen for trary to previous studies on objectively measured PA after LPA, step counts, and ST, although difficult to compare bariatric surgery [34, 35], participants in the current study since they were analyzed as continuous outcomes. However, increased both MVPA and LPA at 12-month post-surgery. increasing LPA with 1 h or increasing with 1000 steps per However, this increase was quite small and statistically non- day might be preferred for some patients. Thus, an increase significant. Pre-surgery, approximately 50% meet the recom- in both MVPA, LPA, and step counts could be recommended mended levels of ≥ 150 min of MVPA per week, compared for this patient group. with 55% 12-month post-surgery. On the other hand, only A previous PA intervention study with objectively meas- 10% pre- and 15% 12-month post-surgery met the recom- ured PA, in 75 pre- bariatric surgery patients, showed that mended levels of ≥ 150 min of MVPA per week performed patients who reached larger increases in MVPA also dis- in 10-min bouts, as stated in the PA recommendations [30]. played greater improvements in HRQoL, especially for the These proportions of participants meeting the PA recom- physical health subscales (physical function, bodily pain, mendations are similar to those reported in a previous study general health, and overall physical health) regardless of with objectively measured PA in women undergoing RYGB age, degree of obesity, and initial baseline levels of MVPA [36], with the exception of fewer women meeting 150 min and HRQoL [38]. A similar study also found higher levels MVPA per week pre-surgery in the current study. of some parts of HRQoL (general health and role physical) As stated before, the general recommendation for PA for after a 24-week physical training intervention compared to the age group 17–64 is at least 150 min of weekly MVPA a control group [23]. Another study assessing associations performed in bouts of at least 10 min [30]. We chose to addi- between PA and HRQoL before and after bariatric surgery tionally look at 150 min of MVPA per week in non-bouts, found that patients who were inactive before and became since few participants met the PA recommendation and due active after surgery and those who were active before and to the fact that recently published data show that MVPA, after surgery reported greater improvements in HRQoL, independent of how it is accumulated throughout the day, especially in the physical health scores, compared with is associated with numerous health benefits [31]. Although patients who were active before and became inactive after meeting the recommended levels of PA is an appropriate surgery and those who were inactive both before and after long-term goal for most RYGB patients, this may be too surgery [39]. However, those findings have limited compa- challenging for many patients. Thus, setting realistic, achiev- rability with results from the current study since the study able, assessable short-term goals (e.g., 150 min MVPA per used self-reported data on PA which has shown large dis- week in non-bouts), and gradually increasing the amount and crepancies compared to objective measures of PA, which intensity of PA over time may be a conceivable strategy [37]. seem to be even greater after, compared to before, bariatric In general, the associations between meeting the PA rec- surgery [24]. Future research should consider intervention ommendations of ≥ 150 min of MVPA per week and higher settings where levels of PA are manipulated at pre- and post- HRQoL tended to be stronger at 12-month post-RYGB com- RYGB (and measured objectively) to study potential effects pared to pre-surgery, both for general HRQoL scores and on HRQoL. for the different subscales. Both levels of MVPA and scores for the subscales connected to the physical part of HRQoL Limitations increased 12-month post-surgery. This could be due to the importance of physical health among severely obese indi- The results of the current study should be interpreted in viduals, where for example, bodily pain was scored much light of its limitations. The inclusion criteria used to assess higher (high scores indicate less pain) for participants that participants’ eligibility to enroll in the study purposefully 1 3 Quality of Life Research (2019) 28:1497–1507 1505 excluded those with < 10 h of daily accelerometer wear time a standardized manner, in a hospital setting, both pre- and data for <3 days; this was not a problem since including post-RYGB, which ensures the accuracy of weight loss data. those two participants with less accelerometer data than 10 h at least 3 days did not change the results. Additionally, par- ticipants in these analyses arise from RYGB patients that Conclusions wanted to participate in a RCT improving HRQoL and PA after surgery and may therefore have influenced the findings The current study found a strong association between meet- of the study. We cannot tell whether increased PA results ing guideline PA levels of at least 150 min of MVPA per in better HRQoL or if better HRQoL makes people more week and higher HRQoL both pre- and 12-month post- active, since the analyses are cross-sectional and we lacked RYGB surgery. Similar results were found for LPA, ST, and statistical power to do longitudinal analyses. However, step counts both pre- and post-surgery. There were over- a previous study on obese individuals waiting for RYGB all higher scores on subscales measuring the physical part surgery showed greater improvements in HRQoL in an of HRQoL, compared to mental parts (both with strongest intervention group who increased their PA compared to a association for bodily pain and vitality and no relevant asso- control group who did not increase their levels of PA [22]. ciations for the subscale measuring emotional role function- Secondly, we adjusted for long-term sickness which could ing). These results raise a hypothesis of a possible effect of act as a moderator, rather than a confounder. However, we PA, especially meeting the recommendations of ≥ 150 min still believe that long-term sickness can affect PA levels and MVPA per week either in non-bouts or in 10-min bouts, for HRQoL and therefore can be seen as a confounder. Thirdly, obese individuals in general but also after RYGB surgery to the majority of participants only had valid accelerometer improve and keep a higher quality of life. data at one measure point and there could be systematic differences in descriptive and outcome variables between Acknowledgements We would like to thank the staff involved in this these participants and those who had valid PA data at both study from the v fi e hospitals, Danderyds Hospital, Ersta Hospital, Upp - measure points. However, we conducted sensitivity analyses sala University Hospital, Örebro University Hospital, and St. Görans Hospital, for their help in recruiting study participants and to the study using this subgroup and there were indeed differences both participants that participated in the data collection. in the baseline characteristics and the association between PA, step counts, ST, and SF-36 scores, although this could Funding This study was funded by a grant to Daniel Berglind from the be due to unstable results because of the small sample size in Swedish Scientific Council (Vetenskapsrådet) with Grant No. 2015- the sensitivity analyses (n = 39). At baseline, long-term sick- 02621, Erling-Persson Family Foundation, and the Research School of Caring Sciences, Karolinska Institutet. ness was more prevalent; education levels were higher; and HRQoL scores were slightly higher among those with both Compliance with ethical standards valid PA measurement points. Fourth, one potential limita- tion from using objectively accelerometer measured PA and Conflict of interest The authors declare that they have no conflict of ST is that the method is not able to specify specific domains interest. or types of PA and ST (e.g., occupational/transportation PA/ ST or sitting vs. standing still). A final potential limitation Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the insti- related to the lack of consensus on how to define intensities tutional and/or national research committee and with the 1964 Helsinki of PA via accelerometer data intensity cut-offs. This limits Declaration and its later amendments or comparable ethical standards. the comparability with other studies having used different The study was approved by the regional ethics committee of Stockholm cut-offs to define PA intensities. (Dnr:2013/1847–31/2). The trial has also been registered at http://www. isrct n.org with identification number ISRCTN16417174. Strengths Informed consent Informed consent was obtained from all individual participants included in the study. This study also shows several strengths. The main strength is the objectively measured PA and ST in 66 obese individu- Open Access This article is distributed under the terms of the Crea- als pre-RYGB and 62 individuals at 12-month follow-up. tive Commons Attribution 4.0 International License (http://creat iveco Another strength is that we were able to examine 12-month mmons.or g/licenses/b y/4.0/), which permits unrestricted use, distribu- tion, and reproduction in any medium, provided you give appropriate post-surgery data, i.e., a period when most RYGB patients credit to the original author(s) and the source, provide a link to the have recovered well enough from the surgery to be active Creative Commons license, and indicate if changes were made. again. However, a longer follow-up than 12 month would be of interest since it is known that HRQoL decreases again 1–2 years post-surgery [33]. Further strengths include the objective height and weight measures which were made in 1 3 1506 Quality of Life Research (2019) 28:1497–1507 20. Herring, L. Y., et al. (2016). Changes in physical activity behav- References iour and physical function after bariatric surgery: A systematic review and meta-analysis. Obesity Reviews, 17(3), 250–261. 1. Warburton, D. E., Nicol, C. W., & Bredin, S. S. (2006). Health 21. Berglind, D., et al. (2016). Accelerometer-measured versus self- benefits of physical activity: The evidence. CMAJ, 174(6), reported physical activity levels and sedentary behavior in women 801–809. before and 9 months after roux-en-Y gastric bypass. Obesity Sur- 2. Arem, H., et al. (2015). Leisure time physical activity and mortal- gery, 26(7), 1463–1470. ity: A detailed pooled analysis of the dose-response relationship. 22. Bond, D. 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Obesity Surgery, 28(6), 1665–1671. 1 3 Quality of Life Research (2019) 28:1497–1507 1507 39. Bond, D., et al. (2009). Becoming physically active after bariatric surgery is associated with improved weight loss and health-related quality of life. Obesity (Silver Spring), 17(1), 78–83. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. 1 3 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Quality of Life Research Springer Journals

Meeting physical activity recommendations is associated with health-related quality of life in women before and after Roux-en-Y gastric bypass surgery

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Springer Journals
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Copyright © 2019 by The Author(s)
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Medicine & Public Health; Quality of Life Research; Sociology, general; Public Health; Quality of Life Research
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0962-9343
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1573-2649
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10.1007/s11136-019-02120-0
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Abstract

Purpose Meeting physical activity (PA) recommendations is positively associated with health-related quality of life (HRQoL), but it is still unclear whether PA (specifically objectively measured) is associated with HRQoL in bariatric surgery candidates, both before and after surgery. Thus, the aim of this study was to examine the cross-sectional association between meeting objectively measured PA recommendations and HRQoL before and after Roux-en-Y gastric bypass (RYGB) surgery. Methods Sixty-six women undergoing RYGB with pre-surgery and 62 women with post-surgery valid PA and HRQoL data were included from the control group of a RCT study aiming at improving HRQoL and PA post-RYGB surgery. Measures before and 12 months after RYGB included the Short Form Health Survey (SF-36) and objectively measured PA, sedentary time (ST), and step counts with GT3X+ accelerometers. Multiple linear regression models were used to analyze the associa- tions between PA and HRQoL. Results Participants who engaged in more than 150 min of moderate to vigorous PA (MVPA)/week (PA recommendations) had considerably higher SF-36 scores (HRQoL) than those who did not, both pre and 12-month post-surgery, with greatest difference in the subscale bodily pain, 15.5 (p = 0.021) higher score (higher scores means less pain) pre-surgery and a 19.7 (p = 0.004) higher score post-surgery. Higher LPA and step counts and lower ST also showed positive associations in some of the subscales of SF-36. Conclusions Meeting the PA recommendations and overall engaging in more PA was associated with higher HRQoL, pre-, and post-RYGB surgery, highlighting the importance of PA both pre- and post-surgery. Keywords Health-related quality of life · Physical activity · Bariatric surgery · Gastric bypass · Sedentary time · Step counts Electronic supplementary material The online version of this article (https ://doi.org/10.1007/s1113 6-019-02120 -0) contains supplementary material, which is available to authorized users. * Fanny Sellberg Department of Public Health Sciences (PHS), Karolinska fanny.sellberg@ki.se Institutet, K9, Social Medicin, 171 77 Stockholm, Sweden Sofie Possmark Department of Health and Caring Sciences, University sofie.possmark@ki.se of Gävle, 801 76 Gävle, Sweden Mikaela Willmer Centre for Epidemiology and Community Medicine, mikaela.willmer@hig.se Stockholm County Council, Box 45436, 104 31 Stockholm, Sweden Per Tynelius per.tynelius@ki.se Department of Nursing, Umeå University, 901 87 Umeå, Sweden Margareta Persson margareta.persson@umu.se Daniel Berglind daniel.berglind@ki.se Vol.:(0123456789) 1 3 1498 Quality of Life Research (2019) 28:1497–1507 The aim of this study was to examine the association Introduction between meeting physical activity recommendations, light PA (LPA), ST and step counts (objectively measured), and Meeting the physical activity (PA) recommendations of HRQoL before and 12 months after RYGB surgery. A sec- at least 150 min of moderate to vigorous PA (MVPA) per ondary aim was to explore the association between pattern week is associated with a wide range of positive health and intensity of PA and HRQoL changes pre- and 12-month outcomes across all weight ranges, including reduced post-RYGB. risk of heart disease, type 2 diabetes, some cancers, and improved mental health [1, 2]. Furthermore, meeting the PA recommendations and higher duration, intensity, and Materials and methods bout length of PA are positively associated with health- related quality of life (HRQoL) [3–5]; a multidimensional For the current study, we used the control group of an measure of physical, mental, functional, and social well- ongoing randomized controlled intervention, to study the being, in the general population [6]. Less is known about association between PA and HRQoL. The study, named sedentary time (ST) and PA associations with HRQoL in WELL-RYGB, has been described in detail in a previ- individuals suffering from obesity [7 , 8] and few studies ously published protocol paper [25]. In short, the WELL- have used objectively measured PA and ST [9]. RYGB is a randomized controlled trial examining the Individuals suffering from obesity often show lower effects of a dissonance-based post-RYGB intervention, on levels of HRQoL compared to the general normal weight HRQoL and PA at 12- and 24-month follow-up. The study population [10]. Weight loss has been associated with was approved by the regional ethics committee of Stock- increases in HRQoL [11], especially rapid weight loss holm (Dnr:2013/1847–31/2). The trial has also been reg- induced by bariatric surgery [12–14], where Roux-en-Y istered at http://www.isrct n.org with identification number gastric bypass (RYGB) is the most commonly performed ISRCTN16417174 and all participants have given oral and bariatric surgery procedure in Sweden [15]. Greatest written consent to participate. improvements of HRQoL, induced by weight loss, are often seen on the physical part of the measurement scale, Participants probably caused by the reduced physical complaints after losing weight, but the mental part has also been shown to Women were recruited from waiting lists for RYGB sur- improve [12, 13]. gery from five different hospitals in Sweden (Örebro Uni- Peak improvements in HRQoL after bariatric surgery versity Hospital, Akademiska Hospital, Ersta Hospital, are typically observed during the first years of follow-up, St. Görans Hospital, and Danderyds Hospital). Inclusion followed by a small decline that usually stabilizes approxi- criteria were being eligible for RYGB surgery [body mass mately 5 years postoperatively [16, 17]. Although HRQoL index (BMI) > 35 with complications from the obesity or improves substantially after bariatric surgery, PA usually BMI > 40, conducted several serious attempts to lose weight does not increase (despite great weight loss) [18–20], with other methods, and usually over 18  years old] and except when self-reported PA is used as an outcome enough Swedish language skills to be a part of an inter- measure [20]. The discrepancy between self-reported and vention in Swedish and answer questionnaires in Swedish. objectively measured PA in this patient group is large, and Interested patients were sent informed consent forms, a tends to increase post-RYGB [21]. Consequently, objec- questionnaire measuring HRQoL and demographic char- tively measured PA is the preferred method for assessing acteristics, and an accelerometer before surgery. Partici- actual levels of PA in this patient category. pants were included if they returned the informed consent. Interventions aiming to increase PA pre-bariatric sur- The same questionnaires and an accelerometer were sent gery have been shown to also improve HRQoL pre-sur- 12 months after surgery, yielding two measure points: base- gery [22], but not post-surgery [23]. However, it is still line (approximately 1 month before RYGB) and 12-month unclear whether objectively measured PA is associated follow-up. We only included the control group in this sub- with HRQoL before and after bariatric surgery in candi- study since the intervention aimed at improving HRQoL and dates receiving regular care (in a non-intervention setting). PA and may therefore, if included in the current study, bias Thus far, 10-year follow-up data from the Swedish Obese the results. Additionally, there were only women included in Subjects (SOS) study have shown that HRQoL is improved the original intervention study because of power concerns. and associated with weight loss after bariatric surgery. The intervention might affect men and women differently, However, the self-reported data on PA, with its inherent therefore creating the need for stratification, and it was not bias [24], limit any interpretation on associations between possible to collect the double number of participants in order PA and HRQoL before and after RYGB. to obtain enough power, especially as approximately 77% of 1 3 Quality of Life Research (2019) 28:1497–1507 1499 all Swedish RYGB patients are women [15]. All participants questionnaire data at baseline and at 1-year follow-up were had RYGB surgery between April 2015 and June 2017. In used to assess current occupation (categorized as work- the current sub-study, we included 66 women with pre-sur- ing or not working) and level of education (categorized as gery and 62 women with 12-month post-surgery valid PA university level or lower). Long-term sickness was defined and HRQoL data, only 39 women had valid accelerometer by a question asking if participants had a chronic disease, data for both measure points. difficulty after an accident, reduced physical function, or long-term health condition. If the respondent answered yes, HRQoL the following question was asked: does this condition result in reduced work capacity or limit your regular occupation? HRQoL was measured using the Short Form (36) Health With response options (1) “not at all,” (2) “yes, to some Survey (SF-36). The SF-36 is divided into eight domains: degree,” and (3) “yes, to a high degree.” BMI was calculated 2 2 vitality (VT), physical functioning (PF), bodily pain (BP), as weight (kg)/ height (m ). general health perceptions (GH), physical role functioning (RP), emotional role functioning (RE), social role function- Statistical analysis ing (SF), and mental health (MH), and can be summarized into two summary scores: physical summary score (PCS) Data in table one and two are presented as means and stand- and mental summary score (MCS). Scoring ranges from 0 ard deviation (SD) or in numbers and percentages. Two- to 100 with higher scores indicating better quality of life. tailed T tests were used to test for differences in BMI and PA The instrument performs well in a general population [26] over time. Multiple regression models were used to analyze and is commonly used in obese populations [11]. SF-36 was the associations between LPA and HRQoL, step counts and scored using the Quality Metric scoring Software 8.6.12. HRQoL, ST and HRQoL, and between meeting the MVPA pptx and the “maximum data recovery” setting was used recommendations and HRQoL, with MVPA categorized into for missing values. two groups, more or less than 150 min of MVPA/week. A similar approach was used for MVPA performed in 10-min Physical activity bouts since the recommendation for PA is at least 150 min of MVPA performed in 10-min bouts (or longer) per week PA, LPA, step counts, and ST were measured objectively [30]. However, we also analyzed MVPA in non-bouts, since with an accelerometer (ActiGraph GT3X+), worn on the MVPA independent of how it is accumulated, is associated right hip. Participants were asked to wear the accelerom- with numerous health benefits [31]. BMI, percent weight eter for all waking hours for seven consecutive days. We loss, and age were not significant confounders and were used vector magnitude activity counts (V ), calculated as therefore not included in the adjusted models. Education, the square root of the sum of the counts on all three axes, occupation, and long-term sickness showed significant recorded in 10-s epochs and then converted into counts per confounding effects in several models and were therefore minutes (cpm). Measurements were accepted as valid if par- included in all adjusted analyses of MVPA recommenda- ticipants had worn the accelerometer for at least 10 h per tions and HRQoL as well as wear time. For the association day during at least 3 days. The number of participants with between LPA, step counts, ST, and HRQoL, only occupa- valid measure at one of the two measure points is reported in tion and long-term sickness were found to be significant Table 2. Wear time, MVPA, and classification of bouts were confounders and therefore included in the adjusted mod- computed using ActiLife v.6.13.3. For wear time, we used an els, as well as wear time. The majority of the participants algorithm by Choi et al. [27]. If there were no counts for 60 only had PA measured at one time-point and there could be consecutive minutes or more, with a maximum break of two systematic differences between those with PA measured at minutes with non-zero counts, it was classified as non-wear one or two time points. Therefore, sensitivity analyses were time [28] and consequently removed from analyses. MVPA performed for the group of participants who had valid PA minutes were calculated as minutes per day in total and also measures both pre- and post-surgery (n = 39) (Supplemen- in 10 min bouts. ST was defined as any minute showing tary Tables 1 and 2). All statistical analyses were performed < 100 cpm, light physical activity (LPA) was defined as with STATA.15.1 (StataCorp). 100–3207 cpm, and MVPA as 3208 cpm or more [29]. Other variables Results Weight and height were objectively measured at the hos- Out of the 103 included participants in the study, 90 women pitals, in a standardized manner, pre- and 12-month post- had valid accelerometer data for at least one of the measure- surgery and obtained from medical records. Self-reported ments, before or 12 months after RYGB. Sixty-six of those 1 3 1500 Quality of Life Research (2019) 28:1497–1507 had valid accelerometer data and HRQoL data pre-surgery, significant p = 0.334. Step counts increased significantly by whereas 62 had valid data on the same measures at 12-month 1162.8 steps/day (p = 0.014) for those with valid data at one post-RYGB. Thirty-nine women had valid data at both meas- measure point, see Table 2. A similar pattern was found for ure points. Characteristics of participants pre- and 12-month participants with valid accelerometer PA data at both meas- post-RYGB are presented in Table 1. Participants with both ure points (data not shown). Ten percent of the participants valid accelerometer measurement had overall slightly higher reached the PA recommendation of ≥ 150 min of MVPA in SF-36 scores pre-surgery, suffered from long-term sickness 10-min bouts per week pre-surgery and 15% at 12-month to a greater extent, and had higher levels of education com- post-surgery, see Fig. 1. pared to those with only one valid accelerometer measure- Table 3 shows the mean SF-36 scores comparing partici- ment. Mean percentage weight loss at 12-month post-sur- pants engaging in more or less than 150 min MVPA/week gery was 47.2% (SD = 16.8) and prevalence of long-term or more or less than 150 min MVPA in 10 min bouts/week. sickness was also reduced to 27% at 12-month post-surgery Participants who engaged in more than 150 min MVPA/ compared with 59% pre-surgery. week had considerably higher SF-36 scores than those who Table  2 shows participants’ levels of PA, LPA, step did not, both pre- and post-surgery. These differences varied counts, and ST pre- and 12-month post-surgery. Mean greatly for different sub-scores, see Table  3, and most of the MVPA min/day pre-surgery were 26.4 (SD = 21.0) and found associations decreased or disappeared when adjusting 29.6 (SD = 22.4) min/day 12 months after surgery. Partici- for confounders, in particular long-term sickness. Looking pants also increased their time spent in MVPA in 10-min at the summary scores, PCS showed stronger associations bouts from 7.5 (SD = 12.6) pre-surgery to 11.6 (SD = 14.6) with all levels of PA than MCS after surgery but a strong min/day 12-month post-surgery, although not statistically association between LPA and MCS was found pre-surgery Table 1 Participants’ characteristics and health-related quality of life (HRQoL) before and 12  months after Roux-en-Y gastric bypass surgery (RYGB) Variables Pre-surgery (n = 66) 12-month post-surgery Pre-surgery with valid 12-month post-surgery with (n = 62) PA measurements at valid PA measurements at both both time points (n = 39) time points (n = 39) BMI (kg/m ) 40.9 (5.3) (n = 65) 28.1 (4.2) (n = 59) 40.7 (4.3) (n = 38) 28.2 (3.9) (n = 37) % weight loss − 47.2% (16.8) − 45.7% (15.3) Age (years) 44.5 (9.7) 47.5 (10.0) 45.8 (9.9) 46.8 (9.9) Education at university level 21 (32%) 15 (25%) 14 (36%) 13 (33%) Working 50 (76%) 51 (82%) 31 (79%) 31 (79%) Suffering from long-term sick - 39 (59%) 17 (27%) 24 (62%) 14 (36%) ness Long-term sickness with no 8 (12%) 6 (10%) 8 (21%) 4 (10%) limitations Long-term sickness with some 18 (27%) 7 (11%) 8 (21%) 6 (15%) limitations Long-term sickness with a high 13 (20%) 4 (6%) 8 (21%) 4 (10%) degree of limitations SF-36 subscales  PF, physical functioning 56.1 (24.1) 89.6 (15.0) 56.5 (25.7) 86.9 (17.8)  RP, physical role functioning 70.6 (30.7) 90.1 (18.5) 73.9 (29.2) 88.8 (19.5)  BP, bodily pain 43.8 (27.6) 75.4 (27.5) 46.0 (26.8) 70.5 (21.8)  GH, general health 50.9 (21.2) 79.1 (19.5) 50.8 (19.4) 77.9 (21.2)  VT, vitality 37.7 (21.3) 64.3 (21.1) 38.6 (20.1) 65.2 (21.9)  SF, social role functioning 62.7 (28.5) 90.7 (19.2) 66.0 (27.6) 90.4 (20.2)  RE, emotional role functioning 76.4 (30.3) 91.4 (18.0) 75.9 (30.6) 90.4 (17.4)  MH, mental health 62.9 (20.9) 81.7 (14.1) 64.1 (19.3) 81.0 (15.5)  PCS, physical summary score 41.5 (9.2) 53.7 (7.6) 42.1 (8.5) 52.5 (8.6)  MCS, mental summary score 45.2 (11.2) 53.5 (7.8) 45.6 (10.1) 53.7 (8.1) Data presented as mean (SD) or number (percentage) BMI Body mass index, SF-36 the Short Form (36) Health Survey 1 3 Quality of Life Research (2019) 28:1497–1507 1501 Table 2 Physical activity Variables Pre-surgery (n = 66) 12-month post- Difference between pre- (PA), sedentary time (ST), and surgery (n = 62) and post-surgery (n = 39) step counts for participants pre-surgery and 12-month post- Mean wear time h/day 14.0 (1.2) 14.8 (1.4) 0.4 (1.6) surgery p = 0.089 Mean counts/min 583.9 (229.2) 598.8 (180.0) 6.5 (183.9) p = 0.826 MVPA in 10 bouts, min/day 7.5 (12.6) 11.6 (14.6) 2.7 (16.9) p = 0.334 MVPA min/day 26.4 (21.0) 29.6 (22.4) 2.1 (22.6) p = 0.566 LPA min/day 359.0 (88.2) 400.7 (78.0) 19.6 (93.3) p = 0.197 ST min/day 455.0 (99.3) 457.3 (100.6) 5.1 (94.3) p = 0.737 Step counts steps/day 5971.0 (2776.5) 7511.7 (2989.0) 1162.8 (2829.3) p = 0.014 Data presented as mean (SD) MVPA moderate to vigorous physical activity, LPA light physical activity, ST sedentary time engaging in ≥ 150 min MVPA/week in 10 min bouts were Percent of participants that reach PA recommendations 29.5 (p = 0.008). Supplementary Table  2 shows associa- 70% tions between LPA, ST, step counts, and HRQoL for par- 60% ticipants with valid PA measures at both measure points; 50% the table shows similar results to the analyses including all participants. 40% Pre-surgery Additionally, we also checked for if changes in physical 30% 1 year post-surgery activity (going from active, meeting PA recommendations, 20% to inactive, not meeting PA recommendations, or the other 10% way around) were associated with changes in HRQoL in 0% these 39 participants. Unfortunately, there were too few par- >150min/week >150min/week in 10 bouts ticipants to see any valid results, see Supplementary Mate- rial 3. However, we saw no relevant differences in changes Fig. 1 Percentage of participants meeting physical activity recom- in HRQoL between participants being active before surgery mendations, pre-, and post-RYGB surgery compared to inactive (mean improvement in MCS = 7.4 (SD = 8.3) vs. 8.7 (SD = 9.7) and for PCS = 9.7 (SD = 6.6) vs. 11.1 (SD = 8.6), respectively). with a 2.6-point increase in MCS for each hour increase in LPA, see Table 4. The results in Table 4 are presented as Moreover, we run the same analyses as above including all participants with accelerometer data (without any criteria change in SF-36 score per hour increase in LPA or ST and per 1000 increased steps/day. of wear time). This only added two participants and did not change any of the results substantially. Sensitivity analyses Sensitivity analyses of mean scores of SF-36 comparing Discussion more or less than 150 min/week of MVPA and more or less than 150 min of MVPA in 10 min bouts/week for partici- Meeting the PA recommendations of ≥ 150 min of MVPA per week in non-bouts and in 10-min bouts was associated pants with valid PA measures at both measure points can be found in Supplementary Table 1 (n = 39). In general, there with higher HRQoL summary scores as well as in many of the subscales pre- and post-RYGB and associations were slightly weaker associations pre-surgery, and in almost all subscales the associations 12-month post-surgery were were found to be stronger post-surgery. Additionally, we also found associations for LPA, ST, and step counts with stronger, with bodily pain showing very strong associa- tion engaging in ≥ 150 min MVPA/week, in average 29.1 HRQoL pre- and post-RYGB. However, most of the asso- ciations were decreased or diminished when adjusting for (p = 0.001) higher score in bodily pain (i.e., meaning less pain) compared to those who did not; same numbers for relevant confounders, especially when adjusting for living 1 3 1502 Quality of Life Research (2019) 28:1497–1507 1 3 Table 3 Multiple regression analysis: difference in HRQoL by meeting recommendations of either 150 min/week of MVPA in general and in 10 min bouts or not Variables MCS PCS PF RP BP GH VT SF RE MH Pre-surgery (n = 66) 150 min/week 5.2 (p = 0.060) 5.1 (p = 0.022) 13.5 (p = 0.022) 12.5 (p = 0.098) 15.5 (p = 0.021) 10.6 (p = 0.053) 15.2 (p = 0.003) 14.8 (p = 0.034) 5.4 (p = 0.475) 13.1 (p = 0.010) MVPA 150 min/ 4.0 (p = 0.126) 0.3 (p = 0.850) 4.7 (p = 0.408) − 2.9 (p = 0.585) 3.4 (p = 0.571) 3.7 (p = 0.445) 9.6 (p = 0.040) 10.9 (p = 0.123) − 2.1 (p = 0.768) 10.4 (p = 0.037) week MVPA adjusted 150 min/week 3.5 (p = 0.443) 2.4 (p = 0.525) 7.5 (p = 0.440) 10.9 (p = 0.380) 8.8 (p = 0.426) − 1.7 (p = 0.843) 6.8 (p = 0.431) 13.8 (p = 0.229) 3.8 (p = 0.759) 7.9 (p = 0.346) MVPA (10 bouts) 150 min/week 4.8 (p = 0.232) 1.2 (p = 0.650) 7.1 (p = 0.408) 9.4 (p = 0.246) 6.2 (p = 0.502) − 3.8 (p = 0.598) 8.2 (p = 0.258) 15.8 (p = 0.142) 4.5 (p = 0.677) 10.1 (p = 0.190) MVPA (10 bouts) adjusted 12-month post-surgery (n = 62) 150 min/week 0.6 (p = 0.758) 6.9 (p < 0.001) 15.4 (p < 0.001) 10.4 (p = 0.027) 19.7 (p = 0.004) 10.1 (p = 0.042) 5.3 (p = 0.334) 10.6 (p = 0.029) 6.6 (p = 0.153) 1.4 (p = 0.709) MVPA 150 min/ − 1.7 (p = 0.375) 4.0 (p = 0.003) 10.2 (p = 0.001) 3.7 (p = 0.278) 10.0 (p = 0.088) 2.4 (p = 0.480) 1.3 (p = 0.789) 4.0 (p = 0.355) 0.0 (p = 0.998) − 3.1 (p = 0.368) week MVPA adjusted 150 min/week 3.1 (p = 0.255) 7.1 (p = 0.006) 12.4 (p = 0.015) 10.3 (p = 0.107) 23.6 (p = 0.012) 15.2 (p = 0.022) 16.5 (p = 0.022) 9.6 (p = 0.150) 8.3 (p = 0.187) 5.1 (p = 0.294) MVPA (10 bouts) 150 min/week − 0.5 (p = 0.841) 3.1 (p = 0.096) 5.8 (p = 0.166) 0.5 (p = 0.917) 9.7 (p = 0.214) 3.5 (p = 0.446) 9.5 (p = 0.125) − 0.2 (p = 0.971) − 1.6 (p = 0.770) − 1.2 (p = 0.785) MVPA (10 bouts) adjusted Data presented as β (p-value) MVPA moderate to vigorous physical activity, PF physical functioning, RP physical role functioning, BP bodily pain, GH general health perceptions, VT vitality, SF social role functioning, RE emotional role functioning, MH mental health, PCS physical summary score, MCS mental summary score Adjusted for occupation, education, wear time, and long-term sickness Quality of Life Research (2019) 28:1497–1507 1503 1 3 Table 4 Multiple regression analysis: linear association between HRQoL and light physical activity (LPA, per 60 min), sedentary time (ST, per 60 min), or step counts (per 1000 steps) Variables MCS PCS PF RP BP GH VT SF RE MH Pre-surgery (n = 66)  LPA 2.6 (p = 0.005) 1.7 (p = 0.030) 4.1 (p = 0.041) 3.4 (p = 0.193) 5.6 (p = 0.016) 5.0 (p = 0.004) 6.1 (p < 0.001) 9.2 (p < 0.001) 2.4 (p = 0.362) 5.1 (p = 0.003)  LPA adjusted 1.7 (p = 0.055) 0.3 (p = 0.565) 1.6 (p = 0.399) − 2.2 (p = 0.211) 2.5 (p = 0.230) 2.7 (p = 0.087) 3.6 (p = 0.019) 7.2 (p = 0.002) − 1.2 (p = 0.603) 3.5 (p = 0.037)  ST − 1.1 (p = 0.171) − 0.6 (p = 0.414) − 1.4 (p = 0.436) − 0.0 (p = 0.990) − 2.4 (p = 0.253) − 1.8 (p = 0.270) − 3.7 (p = 0.021) − 4.7 (p = 0.026) − 0.6 (p = 0.806) − 1.4 (p = 0.365)  ST adjusted − 1.0 (p = 0.191) − 0.0 (p = 0.999) − 0.5 (p = 0.753) 2.0 (p = 0.193) − 1.2 (p = 0.495) − 0.7 (p = 0.596) − 2.9 (p = 0.029) − 4.1 (p = 0.040) 0.4 (p = 0.856) − 1.2 (p = 0.424)  Step counts 1.2 (p = 0.015) 1.3 (p = 0.001) 2.9 (p = 0.006) 4.1 (p = 0.002) 3.4 (p = 0.006) 2.7 (p = 0.003) 2.8 (p = 0.002) 4.0 (p = 0.001) 2.5 (p = 0.070) 2.4 (p = 0.010)  Step counts 0.7 (p = 0.166) 0.4 (p = 0.271) 1.2 (p = 0.244) 0.5 (p = 0.604) 1.3 (p = 0.268) 1.2 (p = 0.190) 1.1 (p = 0.198) 2.7 (p = 0.038) 0.4 (p = 0.786) 1.5 (p = 0.104) adjusted 12-month post-surgery (n = 62)  LPA 1.3 (p = 0.097) 1.5 (p = 0.041) 2.6 (p = 0.081) 3.9 (p = 0.029) 3.9 (p = 0.148) 3.8 (p = 0.045) 5.0 (p = 0.015) 3.8 (p = 0.045) 3.2 (p = 0.069) 1.2 (p = 0.375)  LPA adjusted 0.5 (p = 0.538) − 0.1 (p = 0.851) − 0.2 (p = 0.838) 0.4 (p = 0.753) − 1.2 (p = 0.587) 0.1 (p = 0.970) 2.7 (p = 0.130) 1.1 (p = 0.522) 0.6 (p = 0.714) − 0.5 (p = 0.719)  ST − 0.6 (p = 0.332) − 1.3 (p = 0.024) − 1.6 (p = 0.169) − 3.3 (p = 0.017) − 3.7 (p = 0.076) − 2.3 (p = 0.127) − 3.5 (p = 0.030) − 2.8 (p = 0.054) − 2.2 (p = 0.113) 0.2 (p = 0.842)  ST adjusted − 0.1 (p = 0.788) − 0.8 (p = 0.055) − 1.1 (p = 0.268) − 2.1 (p = 0.025) − 1.9 (p = 0.281) − 0.5 (p = 0.619) − 1.9 (p = 0.155) − 2.0 (p = 0.114) − 1.3 (p = 0.270) 1.0 (p = 0.312)  Step counts 0.2 (p = 0.546) 1.3 (p < 0.001) 2.5 (p < 0.001) 2.6 (p = 0.001) 3.6 (p = 0.002) 2.2 (p = 0.010) 1.4 (p = 0.128) 1.5 (p = 0.071) 1.9 (p = 0.019) 0.2 (p = 0.775)  Step counts − 0.4 (p = 0.277) 0.6 (p = 0.013) 1.3 (p = 0.023) 0.5 (p = 0.457) 1.5 (p = 0.182) 0.4 (p = 0.526) 0.3 (p = 0.731) 0.3 (p = 0.742) 0.0 (p = 0.993) − 1.0 (p = 0.120) adjusted Data presented as β (p value) LPA light physical activity, ST sedentary time, PF Physical functioning, RP Physical role functioning, BP Bodily pain, GH General health perceptions, VT vitality, SF Social role functioning, RE Emotional role functioning, MH Mental health, PCS Physical summary score, MCS Mental summary score Adjusted for education, wear time, and long-term sickness 1504 Quality of Life Research (2019) 28:1497–1507 with long-term sickness. In general, participating women were able to and were active ≥ 150 min of MVPA per week. improved their HRQoL substantially from pre- to 12-month When taking into account long-term sickness, the associa- post-RYGB, especially on subscales connected to the physi- tion between meeting the PA recommendations and HRQoL cal part of HRQoL. became weaker, supporting this theory. For the subgroup of Pre-surgery, women’s HRQoL scores were considerably 39 women who had accelerometer data at both measurement lower than among the general population [32]. However, points, the association between meeting PA recommenda- at 12-month post-RYGB, scores were similar, and in some tions and HRQoL was somewhat stronger. They also had a subscales even higher, than among the general population somewhat higher prevalence of long-term sickness, which is [32]. All intensity levels of PA were higher 12-month post- in line with the theory above. However, the mean levels of surgery compared to pre-surgery, although not statistically PA in this patient group did not increase post-surgery. Thus, significant, except for step counts. Great improvements in the slightly increased association might also be a function HRQoL after bariatric surgery, in line with our results, have of weight loss, although this is only speculative. The strong been seen in several previous studies [12, 13, 23], with a associations seen between meeting the 150 min of MVPA peak improvement at 12-month post-surgery [33]. Con- per week recommendations and SF-36 were also seen for trary to previous studies on objectively measured PA after LPA, step counts, and ST, although difficult to compare bariatric surgery [34, 35], participants in the current study since they were analyzed as continuous outcomes. However, increased both MVPA and LPA at 12-month post-surgery. increasing LPA with 1 h or increasing with 1000 steps per However, this increase was quite small and statistically non- day might be preferred for some patients. Thus, an increase significant. Pre-surgery, approximately 50% meet the recom- in both MVPA, LPA, and step counts could be recommended mended levels of ≥ 150 min of MVPA per week, compared for this patient group. with 55% 12-month post-surgery. On the other hand, only A previous PA intervention study with objectively meas- 10% pre- and 15% 12-month post-surgery met the recom- ured PA, in 75 pre- bariatric surgery patients, showed that mended levels of ≥ 150 min of MVPA per week performed patients who reached larger increases in MVPA also dis- in 10-min bouts, as stated in the PA recommendations [30]. played greater improvements in HRQoL, especially for the These proportions of participants meeting the PA recom- physical health subscales (physical function, bodily pain, mendations are similar to those reported in a previous study general health, and overall physical health) regardless of with objectively measured PA in women undergoing RYGB age, degree of obesity, and initial baseline levels of MVPA [36], with the exception of fewer women meeting 150 min and HRQoL [38]. A similar study also found higher levels MVPA per week pre-surgery in the current study. of some parts of HRQoL (general health and role physical) As stated before, the general recommendation for PA for after a 24-week physical training intervention compared to the age group 17–64 is at least 150 min of weekly MVPA a control group [23]. Another study assessing associations performed in bouts of at least 10 min [30]. We chose to addi- between PA and HRQoL before and after bariatric surgery tionally look at 150 min of MVPA per week in non-bouts, found that patients who were inactive before and became since few participants met the PA recommendation and due active after surgery and those who were active before and to the fact that recently published data show that MVPA, after surgery reported greater improvements in HRQoL, independent of how it is accumulated throughout the day, especially in the physical health scores, compared with is associated with numerous health benefits [31]. Although patients who were active before and became inactive after meeting the recommended levels of PA is an appropriate surgery and those who were inactive both before and after long-term goal for most RYGB patients, this may be too surgery [39]. However, those findings have limited compa- challenging for many patients. Thus, setting realistic, achiev- rability with results from the current study since the study able, assessable short-term goals (e.g., 150 min MVPA per used self-reported data on PA which has shown large dis- week in non-bouts), and gradually increasing the amount and crepancies compared to objective measures of PA, which intensity of PA over time may be a conceivable strategy [37]. seem to be even greater after, compared to before, bariatric In general, the associations between meeting the PA rec- surgery [24]. Future research should consider intervention ommendations of ≥ 150 min of MVPA per week and higher settings where levels of PA are manipulated at pre- and post- HRQoL tended to be stronger at 12-month post-RYGB com- RYGB (and measured objectively) to study potential effects pared to pre-surgery, both for general HRQoL scores and on HRQoL. for the different subscales. Both levels of MVPA and scores for the subscales connected to the physical part of HRQoL Limitations increased 12-month post-surgery. This could be due to the importance of physical health among severely obese indi- The results of the current study should be interpreted in viduals, where for example, bodily pain was scored much light of its limitations. The inclusion criteria used to assess higher (high scores indicate less pain) for participants that participants’ eligibility to enroll in the study purposefully 1 3 Quality of Life Research (2019) 28:1497–1507 1505 excluded those with < 10 h of daily accelerometer wear time a standardized manner, in a hospital setting, both pre- and data for <3 days; this was not a problem since including post-RYGB, which ensures the accuracy of weight loss data. those two participants with less accelerometer data than 10 h at least 3 days did not change the results. Additionally, par- ticipants in these analyses arise from RYGB patients that Conclusions wanted to participate in a RCT improving HRQoL and PA after surgery and may therefore have influenced the findings The current study found a strong association between meet- of the study. We cannot tell whether increased PA results ing guideline PA levels of at least 150 min of MVPA per in better HRQoL or if better HRQoL makes people more week and higher HRQoL both pre- and 12-month post- active, since the analyses are cross-sectional and we lacked RYGB surgery. Similar results were found for LPA, ST, and statistical power to do longitudinal analyses. However, step counts both pre- and post-surgery. There were over- a previous study on obese individuals waiting for RYGB all higher scores on subscales measuring the physical part surgery showed greater improvements in HRQoL in an of HRQoL, compared to mental parts (both with strongest intervention group who increased their PA compared to a association for bodily pain and vitality and no relevant asso- control group who did not increase their levels of PA [22]. ciations for the subscale measuring emotional role function- Secondly, we adjusted for long-term sickness which could ing). These results raise a hypothesis of a possible effect of act as a moderator, rather than a confounder. However, we PA, especially meeting the recommendations of ≥ 150 min still believe that long-term sickness can affect PA levels and MVPA per week either in non-bouts or in 10-min bouts, for HRQoL and therefore can be seen as a confounder. Thirdly, obese individuals in general but also after RYGB surgery to the majority of participants only had valid accelerometer improve and keep a higher quality of life. data at one measure point and there could be systematic differences in descriptive and outcome variables between Acknowledgements We would like to thank the staff involved in this these participants and those who had valid PA data at both study from the v fi e hospitals, Danderyds Hospital, Ersta Hospital, Upp - measure points. However, we conducted sensitivity analyses sala University Hospital, Örebro University Hospital, and St. Görans Hospital, for their help in recruiting study participants and to the study using this subgroup and there were indeed differences both participants that participated in the data collection. in the baseline characteristics and the association between PA, step counts, ST, and SF-36 scores, although this could Funding This study was funded by a grant to Daniel Berglind from the be due to unstable results because of the small sample size in Swedish Scientific Council (Vetenskapsrådet) with Grant No. 2015- the sensitivity analyses (n = 39). At baseline, long-term sick- 02621, Erling-Persson Family Foundation, and the Research School of Caring Sciences, Karolinska Institutet. ness was more prevalent; education levels were higher; and HRQoL scores were slightly higher among those with both Compliance with ethical standards valid PA measurement points. Fourth, one potential limita- tion from using objectively accelerometer measured PA and Conflict of interest The authors declare that they have no conflict of ST is that the method is not able to specify specific domains interest. or types of PA and ST (e.g., occupational/transportation PA/ ST or sitting vs. standing still). A final potential limitation Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the insti- related to the lack of consensus on how to define intensities tutional and/or national research committee and with the 1964 Helsinki of PA via accelerometer data intensity cut-offs. This limits Declaration and its later amendments or comparable ethical standards. the comparability with other studies having used different The study was approved by the regional ethics committee of Stockholm cut-offs to define PA intensities. (Dnr:2013/1847–31/2). The trial has also been registered at http://www. isrct n.org with identification number ISRCTN16417174. Strengths Informed consent Informed consent was obtained from all individual participants included in the study. This study also shows several strengths. The main strength is the objectively measured PA and ST in 66 obese individu- Open Access This article is distributed under the terms of the Crea- als pre-RYGB and 62 individuals at 12-month follow-up. tive Commons Attribution 4.0 International License (http://creat iveco Another strength is that we were able to examine 12-month mmons.or g/licenses/b y/4.0/), which permits unrestricted use, distribu- tion, and reproduction in any medium, provided you give appropriate post-surgery data, i.e., a period when most RYGB patients credit to the original author(s) and the source, provide a link to the have recovered well enough from the surgery to be active Creative Commons license, and indicate if changes were made. again. 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