Pre-operative Exercise and Nutrition Therapy on Cardio-metabolic Health in Patients Undergoing Bariatric Surgery

Role of Pre-operative Exercise and Nutrition Therapy on Insulin Resistance and Vascular Health in Patients Undergoing Bariatric Surgery

Obesity is a major health concern that has been associated with an estimated 2.8 million deaths worldwide each year. The number of individuals considered obese with a Body Mass Index (BMI) above 30 kg/m2 has grown to more than 500 million. The increased morbidity and mortality associated with obesity stems from a long list of comorbidities, including hypertension, coronary artery disease, stroke, cancer, and type 2 diabetes (T2D). Bariatric surgery is an emerging intervention that has been used frequently to induce weight loss for obese individuals and it has been shown to improve glycemic control and insulin resistance in people at risk for type 2 diabetes. Surgery may also lead to healthy improvements in inflammation, immune cells and vascular health. It is already known that exercise and weight loss from lifestyle modification can improve glycemic control, insulin resistance, inflammation, and arterial stiffness. However, no work has been done to examine a combination of bariatric surgery and pre-surgery exercise. Recent work by the team has evidence demonstrating that health status pre-surgery has an impact on post-surgery outcomes. Such findings suggest that improvements in health status from exercise before surgery may improve surgery outcomes as well as surgery-induced health outcomes. To date, no study has systematically examined the role of exercise on the prevalence of surgery complications or on post-surgery weight loss, glycemic control, and insulin resistance. Moreover, no work currently exists on exercise, with or without bariatric surgery on adipose tissue derived inflammation. Therefore, the purpose of this study is to investigate the effect of pre-surgery lifestyle intervention with exercise on bariatric surgery outcomes. To test this objective, subjects will participate in a match paired study, based on BMI. Subjects will undergo testing of blood chemistry and related measures of health before (pre-test) and after (post) intervention. Then all subjects will receive bariatric surgery. Post surgery outcomes will be assessed by examining surgery operating time, changes in blood chemistry, adipose tissue biopsies and other measures indicative of glucose and vascular health. After this surgery, subjects will return for testing about 30d later.

Inclusion Criteria:

• Males and Females, 18-70 years of age
• BMI >30 and <70 kg/m2
• Sedentary (Not currently participating in exercise training: >30 min. of physical activity per day, >3 days/week)
• HCT for women > 36%, Men >38%
• Non-pregnant (women).-self reported
• Smoker (if bariatric surgery patient) or non-smoker (enrolled for the dietary portion of the study)
• Has the ability/willingness to participate in the study and agree to any of the arms involved in the study.
• No prior surgical procedure for obesity with the exception of a laparoscopic adjustable gastric banding (LAGB) under the condition that the band had not been adjusted in less than or equal to 1 year

Exclusion Criteria:

• Currently participating in exercise training: >30 min. of physical activity per day, >2 days/week)
• Cigarette smoking (presently or in the past 6 months), drug or alcohol abuse
• Pregnancy or breastfeeding
• History of congestive heart failure, ischemic heart disease, severe pulmonary disease.
• History of cancer (within 5 years)
• Diagnosed as insulin-dependent diabetes.
• Change in psychotropic medication dosage in past six weeks
• AST or ALT > 3 times normal range
• Currently involved in any active weight loss treatment program (other than self-directed attempt at calorie restricting diet) or lean patients (BMI <29 kg/m2).
• Current purging behavior occurring > once a week over the past six weeks (self-induced vomiting for weight control purposes, laxative or diuretic abuse)
• Revisional bariatric procedures including a RYGB reversal to a SG or a LAGB revision to a SG or RYGB if the band has been adjusted in greater than or equal to 1 year.
• Active psychotic illness, including bipolar affective disorders.
• Evidence of current suicidality or homicidality
• Conditions associated with significant cognitive dysfunction (e.g. dementia) or medical instability that puts the participant at risk
• Contraindication to exercise (severe/uncontrolled CVD; inability to walk 2 blocks, bone or joint problems )
• Allergy to "caine" family drugs (e.g. lidocaine).
• Currently taking active weight suppression medication (e.g. phentermine,bupropion SR, topiramate).
• On medication known to cause substantial weight gain (e.g. atypical antipsychotics such as olanzapine, sodium valproate, steroid therapy). This would not include medications commonly used in this population that usually result in only mild weight loss (e.g. SSRIs).