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Consider Emotional Barriers When Encouraging Physical Activity After Metabolic/Bariatric Surgery

Key findings

  • Researchers at Massachusetts General Hospital are in the process of developing an emotion-focused intervention to help patients increase their physical activity after metabolic/bariatric surgery
  • The first phase, the first qualitative study of its kind, is aimed at understanding the emotions these patients experience during exercise and the contexts that lead to positive and negative emotions
  • Among 23 patients who completed psychological questionnaires and an interview with a clinical psychologist, the most common negative emotions during exercise were anxiety, fatigue and frustration
  • Some contributors to negative affect were "all-or-nothing" thinking, including the belief that activity is valuable only if it produces weight loss or reaches a certain threshold; depression; and negative body image due to high weight or excess skin
  • Exercise interventions for patients who have undergone metabolic/bariatric surgery should target emotional barriers and build positive affect

Difficulties in meeting recommended levels of physical activity are common across the general population. However, patients who have undergone metabolic/bariatric surgery (MBS) may have unique psychological barriers, such as exercise avoidance due to body image concerns.

Massachusetts General Hospital researchers are developing an emotion-focused intervention to help patients increase activity after MBS. The first phase, a quantitative study, suggested that while contexts leading to positive emotions during exercise are similar to those in the general population, contexts leading to negative emotions are more specific to patients who have undergone MBS.

Emily H. Feig, PhD, a staff psychologist in the Department of PsychiatryJeff C. Huffman, MD, associate chief of clinical services in the department, Christina Psaros, PhD, associate director of the Behavioral Medicine Program in the department, and colleagues detail the results in Obesity Surgery.


Between September 2019 and October 2020, the researchers recruited 23 adults (18 women) who had undergone MBS at Mass General within the past two years. Via an online survey, participants completed validated questionnaires about optimism, affective state, depression and anxiety, barriers to being active, self-efficacy for exercise, and internalized weight bias.

Dr. Feig then conducted a semi-structured interview with each participant by telephone. Nine interviews were conducted after the COVID-19 pandemic began.

Positive Affect

Frequently noted positive emotions were excitement, determination, pride, accomplishment and joy. Many participants reported an improvement in mood during or after physical activity. Factors that contributed to positive affect were much the same as those reported previously in the general population:

  • Enjoyment of particular activities (in some cases because of feeling productive, as with yardwork or walking for transportation)
  • Social connection
  • Taking a mindful approach (e.g., reflecting on having more stamina than before MBS)
  • Tracking improved performance

Negative Affect

The negative emotions reported most commonly were anxiety, fatigue and frustration. Contexts that contributed to negative affect were:

  • "All-or-nothing" thinking, including the belief that activity is valuable only if it produces weight loss or reaches a certain threshold
  • Depression
  • Weight loss as the primary reason for exercise
  • Negative body image due to high weight or excess skin
  • The COVID-19 pandemic, which for some participants interfered with access to preferred activities or resulted in anxiety and depression

In most cases, negative emotion decreased during the workout and was gone by the time the person finished. Sometimes, though, persistent negative emotion led participants to shorten their workout compared with what they had planned.

Three participants described thoroughly negative experiences. They were unable to describe any emotion about exercise, they noted a general strong dislike of physical activity, the activities they chose were boring to them and they relied on distraction (e.g., television) to get through a workout. The activities they enjoyed could not be accessed regularly (e.g., downhill skiing, being physically active at a social event that occurs only annually).

These participants reported <150 minutes/week of moderate to vigorous physical activity, and two had not been successful in weight loss.

The Upward Spiral Theory

According to the Upward Spiral Theory of lifestyle change, positive affect during a new health behavior is crucial to the reinforcement of the behavior, which further heightens the positive affect. Individuals with principally negative affect lack that reinforcement.

These study results provide helpful information about interventions for post-MBS patients who note negative affect during exercise:

  • Guide patients to find activities that bring them joy
  • Ask them to note what emotions they feel during exercise; they may be ignoring positive responses
  • Target all-or-nothing thinking with cognitive reappraisal techniques
  • Address overuse of distraction with mindfulness training
  • Provide education and values exercises to overcome an excessive focus on exercise only for weight loss
  • Teach strategies for coping with negative body image, where indicated

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