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. Author manuscript; available in PMC: 2025 Dec 4.
Published in final edited form as: Contemp Clin Trials. 2025 Oct 2;158:108098. doi: 10.1016/j.cct.2025.108098

Motivating Increases in Physical Activity to Prevent Recurrence of Weight Gain after Metabolic Bariatric Surgery: The Exercise Values of Life and Vitality Everyday (EVOLVE) Trial

Dale S Bond 1, Pavlos K Papasavas 1, Yin Wu 1, Michael E Levin 2, Shira I Dunsiger 3, David B Sarwer 4, Leah M Schumacher 4, Dahlia Saad-Pendergrass 5, Anna Schwartz 1, Jason Lillis 6
PMCID: PMC12516807  NIHMSID: NIHMS2116446  PMID: 41045988

Abstract

Background:

Recurrence of significant weight gain after metabolic and bariatric surgery (MBS) is common and can lead to physical and psychological complications. Although patients are encouraged to increase moderate-to-vigorous intensity physical activity (MVPA) to prevent weight recurrence, many report low motivation. This study tests whether targeting autonomous motivation through an Acceptance and Commitment Therapy (ACT)-based intervention can produce durable increases in MVPA to prevent postoperative weight recurrence.

Study Design:

A total of 164 adults who are 6–20 months post-MBS with stable weight (<10% regain from maximum weight loss) are randomly assigned to one of two 12 months programs: an ACT intervention (Physical Activity [PA]-ACT) or a contact-matched education control (PA-EDU). PA-ACT uses values clarification and acceptance strategies to foster autonomous motivation for self-determined MVPA goals. PA-EDU provides didactic instruction on PA, related health topics, and cognitive-behavioral strategies for prescribed MVPA goals. Both conditions receive group-based workshops and individual counseling delivered via video conferencing and email micro-interventions. The conditions will be compared on changes in MVPA and weight recurrence (primary outcomes) and autonomous motivation and acceptance (secondary outcomes) from baseline to 12 months (end-of-treatment) and 18 months (follow-up). Mediators of MVPA (motivation, acceptance) and weight recurrence (MVPA) will also be explored.

Conclusion:

This is the first study to examine whether an ACT-based intervention can foster autonomous motivation for sustained MVPA to prevent weight recurrence after MBS. The results may inform more robust guidelines for PA in MBS and support integration of these strategies into clinical practice to prevent significant weight recurrence.

ClinicalTrials.gov Registration:

NCT037604

Keywords: physical activity, motivation, self-determination, metabolic bariatric surgery, weight loss maintenance, Acceptance and Commitment Therapy

INTRODUCTION

Obesity (Body Mass Index [BMI] ≥30 kg/m2) prevalence among U.S. adults has stabilized around 40%, yet severe obesity (BMI ≥40 kg/m2) is rising and could become the most common category for women, Black non-Hispanic adults, and low-income adults by 2030 [1–3]. Recent data also show BMI ≥60 kg/m2 was the fastest growing category from 2001–2004 to 2021–2023 [2]. These trends place strain on health care systems because severe obesity often involves co-occurring conditions and requires specialized care [4, 5].

Metabolic bariatric surgery (MBS) is a front-line treatment for severe obesity, with ~280,000 U.S. operations performed annually [6]. The most common procedures, sleeve gastrectomy (SG) and Rouxen-Y gastric bypass (RYGB), alter gastrointestinal anatomy and physiology, affecting biological factors like gut hormones and microbiota that influence relevant metabolic and behavioral processes [7–9]. SG leads to a mean 23% decrease in initial body weight at 1-year, while RYGB yields 28%; these weight losses are often accompanied by remission of co-occurring conditions (e.g., type 2 diabetes) [10, 11].

At five years, SG and RYGB patients maintain about 70% and 76%, respectively, of their one-year weight loss. [11]. However, many MBS patients experience clinically significant weight recurrence (≥20% of maximum weight lost) within 2–3 years of reaching their weight nadir [12], often accompanied by the return of co-occurring conditions and symptoms [12–14].

Physical activity (PA) may counter the biological drive to regain weight after MBS. Following weight loss, metabolic and hormonal adaptations increase appetite and decrease energy expenditure, creating an “energy gap” in which calorie intake exceeds needs and weight recurrence occurs [15–17]. Increasing PA may narrow this energy gap by boosting energy expenditure, enhancing satiety signaling, and reducing overeating, allowing for increased caloric intake with lower risk of significant weight recurrence [16–20].

Research suggests PA may limit weight recurrence after MBS. A recent review found that 75% of observational studies, most using device-based PA measures, linked higher PA levels with lower weight recurrence [21]. However, because many studies were cross-sectional, it remains unclear whether higher PA prevents weight recurrence or if smaller weight gain leads to more PA. Additionally, only two randomized intervention trials were identified, and issues such as inconsistent definitions of weight recurrence, unclear objectives regarding weight recurrence prevention or reversal, and imprecise PA measures and outcomes limited definitive conclusions. Finally, only one of the interventions offered strategies to incorporate PA into daily life [21].

These limitations highlight the need for strategies that help patients adopt regular PA to prevent weight recurrence after MBS. Although guidelines recommend increasing moderate-to-vigorous intensity PA (MVPA) to limit weight recurrence [22, 23], many are insufficiently active preoperatively and do not achieve meaningful increases postoperatively [24–26]. Most rarely perform MVPA in bouts of ≥10 minutes (i.e., bouted MVPA) [24, 27–29], suggesting that structured activities (e.g., exercise) may be needed to reach higher MVPA levels [30, 31]. Consequently, postoperative weight and health improvements appear inadequate to motivate lasting PA behavior change [32, 33]. Preoperatively, patients often report low PA motivation that persists even after substantial weight loss and health gains, with many not intending to perform MVPA or struggling to follow through on intentions [34, 35].

This paper describes the Exercise Values of Life and Vitality (EVOLVE) trial, which tests an Acceptance and Commitment Therapy (ACT)-based intervention designed to foster autonomous motivation for sustaining higher MVPA levels and preventing weight recurrence after MBS. Autonomous motivation involves “wanting to” participate in MVPA because it is enjoyable and aligns with personal values, instead of “having to” participate to avoid negative emotions, follow rules, or appease others [36–38]. When anchored in personal values, autonomous motivation predicts sustained engagement in PA [38–40]. Through ACT, PA goals are linked to core values such as having energy for parenting, social engagement, and longevity [39, 41]. A recent meta-analysis of seven studies found that ACT-based PA interventions produced a moderate-to-large effect on PA across various target populations, including young and middle-aged adults, and in diverse settings such as college, community, and outpatient environments. However, most studies used open-trial designs, and none targeted a post-MBS population [42]. In a pilot study, our team found that ACT helped individuals with obesity increase and maintain MVPA, with higher autonomous motivation correlating with these changes [39]. This trial extends that work and other ACT-based approaches [39, 42], while addressing limitations of previous post-MBS PA interventions that targeted weight recurrence [21, 43].

METHODS

Study design and aims

The design of this National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)-sponsored study is depicted in Figure 1. A total of 164 adults who are 6–20 months post-MBS and have reached their nadir weight without significant weight recurrence will be randomly assigned to a 12-month ACT intervention (PA-ACT) or an educational control (PA-EDU).

Figure 1.

Figure 1.

Figure 1.

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Study Flow and Frequency and Timing of Intervention and Assessment Components

PA-ACT provides experiential training in values clarification and employing acceptance strategies to support self-determined MVPA goals. PA-EDU provides didactic instruction on PA, related health topics, and cognitive-behavioral strategies for prescribed MVPA goals. Both groups will complete group-based workshops through remote video conferencing, email-based micro-interventions/assignments, and individual counseling video calls.

The two conditions will be compared on changes in the co-primary outcomes—total and bouted MVPA minutes/day and percentage weight recurrence (%WR)—as well as the secondary outcomes of autonomous motivation and PA acceptance, from baseline to 12- (primary endpoint) and 18-months (follow-up). Potential mediators of MVPA (autonomous motivation and PA acceptance) and weight recurrence (MVPA) will also be explored.

The study aims are:

  1. Compare PA-ACT and PA-EDU on mean changes in MVPA and %WR
    1. Hypothesis: PA-ACT will demonstrate greater increases in MVPA and lower %WR than PA-EDU from baseline to 12- and 18-months.
  2. Compare PA-ACT and PA-EDU on mean changes in autonomous motivation and PA acceptance.
    1. Hypothesis: PA-ACT will report greater increases in autonomous motivation and PA acceptance than PA-EDU from baseline to 12- and 18-months.
  3. Explore potential mechanisms of the treatment effects on MVPA and %WR.
    1. Hypothesis: Greater increases in MVPA for PA-ACT will be a function of higher autonomous motivation and PA acceptance.
    2. Hypothesis: Lower %WR for PA-ACT will be a function of higher MVPA levels.

Participant eligibility criteria

Adults aged 18 to 64 years, 6–20 months post-MBS (SG or RYGB), who have reached their nadir weight and regained <10% of their maximum weight loss are eligible. We adopted a broad recruitment window regarding time since MBS to capture variability in weight stability across all patients and between surgery types, since some patients will reach their nadir weight between 6- and 12-months post-surgery, particularly after SG. Exclusions include: (1) inability to walk independently; (2) insufficient English fluency; (3) pregnancy or related conditions; (4) participation in additional weight programs beyond standard care; (5) any recent changes (i.e., additions, discontinuations, or alterations in dosage or dosing frequency) to medications for weight management (e.g., semaglutide and tirzepatide) or medications that affect weight (e.g., Wellbutrin and Metformin) within two months of enrollment; and (6) any condition or situation preventing study adherence (e.g., relocation, psychiatric issues, or lack of Internet). These criteria ensure participants are at a similar point in their weight trajectory but vary in their capacity for PA behavior change, reflecting the broader MBS population. Any medication changes after enrollment will be accounted for in statistical models and will not affect eligibility.

Participant recruitment, eligibility screening, and enrollment

Participants are being recruited from Hartford Hospital in Hartford, CT and from other MBS centers in the Hartford HealthCare (HHC) system. Advertisements are displayed in clinics and exam rooms and posted on social media. Surgeons and their teams also refer potential participants. Those who may be eligible are contacted via email or traditional mail. A QR code links to a pre-screening questionnaire, where they authorize study staff to review their electronic medical record (EMR) to: (1) retrieve a clinic-measured weight (6–18 months post-surgery) that establishes the anchor for determining nadir weight, maximum weight loss, and weight stability during the subsequent screening phase; and (2) verify surgical and medical information.

After confirming pre-eligibility, study personnel distribute an electronic informed consent form and schedule a HIPAA-compliant virtual meeting. They guide patients through the consent form and administer a short quiz to verify study comprehension before participants sign.

Next, participants enter the subsequent screening phase to confirm weight stability. Because nadir weight is challenging to track without frequent measurements [44], a clinic-measured anchor weight and ≥2 weights measured 20–40 days apart on a study-issued cellular scale are used to determine whether weight is stable or increasing. Participants with <10% WR proceed to the baseline assessment, while those with ≥10% WR are ineligible. Any participant who has not reached their nadir weight may choose to continue measuring weight until qualifying for the current or a future cohort.

Baseline Assessment

Participants receive a home-delivered package with an ActiGraph wGT3X-BT research-grade activity monitor (Ametris, LLC, Pensacola, FL, USA) to measure the co-primary MVPA outcomes. Study staff schedule a virtual visit to explain monitor use, required wear time, data uploads, and return in a self-addressed package. They also provide instructions for completing questionnaires/surveys via the HIPAA-compliant Research Electronic Data Capture (REDCap) web application. Once participants return the monitor and complete all measures, they receive a gift card. These same procedures repeat at 3-, 6-, 12-and 18-months post-randomization.

Randomization

After the baseline assessment is complete and a sufficiently sized cohort is formed, participants are randomly assigned to PA-ACT or PA-EDU on a 1:1 ratio. The study biostatistician creates the randomization schedule for each treatment cohort based on a permuted block procedure with small, random-sized blocks and uploads it to REDCap through the randomization module, ensuring the study assessor remains blinded to the full allocation plan.

Interventions

Before the first workshop, participants in both conditions: (1) receive an EVOLVE study toolkit with a Fitbit Inspire 3 health and fitness tracker (San Franciso, CA, USA) to monitor PA goal progress and resistance bands for strength training exercises modeled by an exercise physiologist during intervention workshops; (2) learn their group assignment; and (3) attend a virtual meeting to measure baseline weight using the study-provided scale, learn how to use the Fitbit, and review a summary of baseline data collected from a separate research-grade activity monitor to set personalized MVPA goals during the intervention.

Over 12 months, all participants attend six 2-hour group-based virtual workshops, each led by one of a group of trained interventionists with diverse backgrounds (e.g., exercise physiologist, psychologist and psychiatrist). They also receive email-based micro-interventions reinforcing workshop content and 15-minute individual video calls with an interventionist focused on barriers to goal implementation (Figure 1 shows the frequency and timing of these components). Each cohort has 8–16 participants (4–8 in each condition). Although both conditions receive the same contact time, their strategies and content differ (Table 1). The goal is to test PA-ACT against a comparator that matches participant expectations and clinical attention. Both PA-ACT and PA-EDU encourage moderate-intensity activities, follow PA guidelines to prevent weight recurrence (≥250 MVPA minutes/week), and emphasize safe, gradual increases in MVPA. The study physician (PKP) oversees participant health throughout the study.

Table 1.

Overview of Interventions

PA-ACT PA-EDU
Main Group Workshops
  • Primary strategies
    • Values clarification
    • Linking MVPA to optimal functioning in other life domains
    • Commitment techniques
  • Primary strategies
    • Education on MVPA, weight recurrence, barriers to MVPA, and strategies to increase MVPA
    • Prescription of MVPA goals and progression
  • Supportive strategies
    • Distancing from negative thoughts
    • Tolerating discomfort
    • Acceptance of emotions
  • Supportive strategies
    • Self-monitoring
    • Incremental goal-setting
    • Problem-solving barriers
Booster Group Workshops

  • Review key values clarification & commitment strategies

  • Discuss implementation barriers

  • Review goals, self-monitoring, and problem-solving strategies

  • Discuss implementation barriers
Email Micro-interventions

  • Brief survey

  • Feedback on goal achievement

  • ACT micro-intervention

  • Brief survey

  • Feedback on goal achievement

  • Educational (knowledge recall) intervention
Individual Calls

  • Discuss implementation barriers with a focus on autonomous motivation

  • Discuss implementation barriers with a focus on problem-solving
Real-time MVPA monitoring

  • Participants receive a Fitbit activity tracker to monitor MVPA and progress towards self-determined goals

  • Participants receive a Fitbit activity tracker to monitor MVPA and progress towards prescribed goals
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Note. PA-ACT = Physical Activity-Acceptance and Commitment Therapy Condition; PA-EDU = Physical Activity Education Control Condition

PA-ACT fosters values-based autonomous motivation to achieve sustainable increases in MVPA. Skills training in its key components—values clarification, values commitment, and acceptance—is experiential and involves frequent processing of thoughts and emotions (Figure 2 shows an email-based micro-intervention example designed to clarify and connect with values-based motivators for PA).

Figure 2.

Figure 2.

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Example of ACT-PA email-based micro-intervention

Values clarification strategies help participants identify core personal values, anchored by actions they wish to embody (e.g., being healthy, active, supportive, engaged, or productive) in meaningful domains such as work, family, friendships, and community. This process connects values to behavior change and encourages values-consistent actions. For example, a participant might choose “being a caring and present parent” as a core value, enabling behaviors that move toward (e.g., playing with the child) or away from (e.g., using social media around the child) that value. Participants also learn how PA supports values-consistent behavior by improving energy, mood, focus, and stamina for active play with children. Linking PA behavior change to core personal values fosters autonomous motivation and satisfaction in meeting PA goals. Strategies like free-writing, group brainstorming, and guided imagery (e.g., envisioning life in 10 years) help clarify values [39, 41].

Values commitment strategies help participants define desired behavior patterns aligned with their values, create values-based goals, implement action plans, and assess how their behaviors match those values. For example, participants list ‘towards’ and ‘away’ behaviors related to a specific health value, such as “being healthy and active.” ‘Towards’ moves are both proximal (walking outside for 30 minutes) and distal (obtaining proper walking shoes). ‘Away’ moves are also proximal (e.g., watching TV on the couch) and distal (e.g., neglecting to schedule exercise time) [39, 41].

Acceptance strategies help participants address barriers to implementing values-based skills. Acceptance involves being actively aware of and embracing thoughts and emotions without attempting to change or control them—for instance, viewing PA-related discomfort as a transient state that can be tolerated. Participants learn to be more aware of, and detached from, negative thoughts (e.g., “I will always fail”) rather than trying to change or eliminate them, making it easier to act in line with their values and meet PA goals [39, 41].

PA-EDU workshops present information on core PA concepts (e.g., Frequency, Intensity, Time, and Type [FITT]), the physiology of weight recurrence (including risk factors and consequences), PA guidelines for health and weight management, monitoring PA intensity, and safely increasing MVPA. Cognitive-behavioral strategies support progress towards meeting the ≥250 MVPA minutes/week guideline. Booster workshops revisit earlier content and introduce new topics, including reducing sedentary time and examining PA’s influence on mental health and longevity. Unlike PA-ACT, PA-EDU is primarily didactic, with participants learning new material, completing knowledge recall activities, and discussing goals and barriers without engaging in skills practice or receiving personalized feedback.

Treatment Fidelity

Multiple strategies ensure PA-ACT and PA-EDU are delivered according to protocol. All interventionists read the patient and counselor manuals. PA-ACT training involves an intensive 8-hour workshop plus eight 1-hour group sessions led by the MPI (JL). PA-EDU consists of one orientation session led by the PI (DSB). Interventionists complete fidelity checklists following PA-EDU and PA-ACT workshops. All PA-ACT and PA-EDU sessions are recorded and reviewed by senior study team members (i.e., DSB, JL, and YW) to verify treatment fidelity.

Participant adherence and retention

Common barriers to adherence and retention are addressed by allowing all intervention and assessment tasks to be completed remotely. Additional strategies include confirming participants’ understanding of study requirements during informed consent, collecting multiple contact methods, using the baseline assessment as a behavioral run-in to gauge commitment, and offering flexible assessment windows. Participants receive gift cards for completing study assessments: $90 for completion, $45 for partial completion, and a $100 bonus for completing all assessments. During the no-treatment follow-up phase, study staff keep participants engaged through small tokens of appreciation, newsletters, activity ideas, and brief summaries of relevant research.

Assessment Components

Co-primary outcomes (MVPA, %WR) and secondary outcomes (autonomous motivation, PA acceptance), as well as dietary intake and relevant medications (covariates), are assessed at baseline and at 3-, 6-, 12- and 18-months post-randomization by staff who are blinded to condition assignment. Sociodemographic information, co-occurring conditions, health history, type of MBS, and weight prior to study enrollment are collected via questionnaires and the EMR.

Co-primary outcomes: MVPA and %WR.

Total and bouted MVPA min/day are monitored over 10 days at each assessment with the Actigraph wGT3X-BT device (Actigraph, LLC, Pensacola, FL, USA) worn on the hip when awake and on the wrist when asleep. Data are processed with the GGIR R accelerometry package using the Euclidean Norm Minus One (ENMO) threshold value of 258.7 to define MVPA [45–47]. Participants must wear the monitor for ≥16 hours/day on ≥7 days for inclusion in analysis [46].

%WR is calculated at each assessment point as ([baseline weight – weight at assessment]/baseline weight *100). Weight is measured at home to the nearest 0.1 kg on two consecutive mornings using a study-issued Withings Body Pro cellular smart scale (Withings Health Solutions, Inc., Boston, MA, USA), with participants weighing without clothing before eating or drinking and after voiding. Data automatically synch to the Withings HIPAA Cloud and are accessed by the research team via the Withings API connection. Research shows strong concordance between e-scales and calibrated clinical scales, regardless of sex, BMI, race, and age [48–50].

Secondary outcomes: autonomous motivation and PA acceptance.

Autonomous motivation is assessed using the Exercise Self-Regulation Questionnaire [51, 52], which evaluates reasons for engaging in PA that reflect different levels of autonomy. Items yield an overall Relative Autonomy Index score. This measure has demonstrated reliability, validity, and predictive utility [39, 51, 52]. PA acceptance is measured by the Physical Activity Acceptance Questionnaire [53], which examines how participants accept or tolerate discomfort associated with PA. This measure has shown reliability and validity and is sensitive to change in clinical studies [53, 54].

Key covariates: dietary intake and medications.

Dietary intake is assessed through three 24-hour recalls using the Automated Self-Administered 24-hour recall system (ASA-24™) [55–57]. The system employs the USDA’s validated Multiple Pass Method to capture foods and beverages consumed during the preceding day, producing estimates comparable to interview-led recalls [55–57]. One recall is conducted with staff support, and two recalls are completed independently on randomly selected days within a 7-day period. Variables of interest include daily macronutrient and total kilocalorie intake. Participants also report any new medication changes that could influence weight loss or gain.

Statistical Design and Power

Power/sample size considerations.

Power and sample size were calculated using G*Power and MPlus Monte Carlo estimation based on our previous work [39, 58]. We aimed to detect between-group differences in MVPA and %WR from baseline to 18-months. Mixed Effects Model simulations (N=164) included modest covariate effects, a nesting-by-cohort factor, and 25% missing data. Models converged with low parameter bias and considered intraclass coefficients (ICCs) from 0.2 to 0.8.

For the Primary Aim, even with 25% assumed missing data, we have >86% power to detect small-medium effects in %WR (f2=0.10), corresponding to a 3%−5% difference in WR between groups. This surpasses the effect size observed in the pilot ACT study where 18-month %WR favored ACT (f2=0.15) [58]. Prior work also showed medium-large ACT-related effects on within-person changes in total and bouted MVPA minutes/day (d=0.57 and 0.73) [39]. Assuming small but significant MVPA increases in PA-EDU and N=164, we retain >86% power to detect differences—as small as a 10 min/day difference in bouted MVPA between groups over 18 months. Secondary aims (autonomous motivation, PA acceptance) are also fully powered for small-medium effects (f2=0.08–0.15), with an assumed significance level of α=0.05. With 82 participants per arm (PA-ACT vs. PA-EDU), we have ≥80% power to detect group differences in the co-primary and secondary outcomes.

Statistical Analysis.

We will summarize sociodemographic and baseline measures and compare groups using t-tests for continuous variables, chi-squared analyses for categorical variables, and non-parametric tests when appropriate. Any variable not balanced by randomization and correlated with the outcome (p<.30) will be considered a confounder. We will assess multicollinearity (correlations, variance inflation factor) and evaluate outcome distributions with parametric and graphical methods, applying transformations if needed. We will adjust for multiple comparisons across outcomes using the Hommel method [59]. This method orders p-values from smallest to largest and determines the largest integer values for which pn−i,k>kαj, for all k = 1,2,…., i. If no such integer value exists, all hypotheses are rejected. When the integer is identifiable, we reject all hypotheses for which pi≤αj, where i indicates hypothesis number. This approach does not require independent hypotheses and is more powerful than several other common adjustments (e.g., Hochberg).

For Aim 1, we will compare changes in the co-primary outcomes using longitudinal mixed effects regression models that adjust for nesting by cohort. Outcomes at 12- (primary endpoint) and 18-months will be regressed on baseline values, treatment, time, treatment × time, and covariates. We will examine cohort-by-treatment interactions and estimate ICC to quantify between-cohort variance. Weight recurrence models will adjust for surgery type, pre-surgery weight, maximum weight loss, dietary intake and weight-impacting medications. MVPA models will adjust for ActiGraph wear time. For Aim 2, we will assess treatment effects on secondary outcomes using a similar longitudinal mixed effects approach with subject-specific intercepts. For Aim 3, we will explore potential mediators of the treatment effect on MVPA and %WR using a multiple mediation approach [60]. We will estimate path coefficients with bootstrapped standard errors and consider temporal ordering (e.g., autonomous motivation at 3-months predicting MVPA at later time points and MVPA at 6-months predicting %WR at later time points).

Missing data.

All analyses will use the intent-to-treat sample. We will first apply a two-step inverse probability weighting method with propensity scores, which provides unbiased estimates if data are missing at random. If assumptions are not met, we will use pattern mixture models that assume separate outcome distributions for participants who complete follow-up and those who do not.

DISCUSSION

The EVOLVE trial is the first to test whether an ACT approach can increase MVPA and help prevent weight recurrence after MBS. The study addresses a clinical and research gap because many MBS patients are insufficiently active before surgery and struggle to adopt lasting changes in PA—particularly MVPA—after surgery [24, 25, 27, 28, 34]. Patients who remain insufficiently active face a higher risk for significant weight recurrence [21, 26], which often coincides with the return of co-occurring conditions, diminished physical function and pain relief, lower satisfaction with surgery, and psychosocial and behavioral concerns such as body dissatisfaction, shame, loneliness, alcohol use, maladaptive eating, and sedentary behavior [12–14, 61–64]. ACT may help by targeting autonomous motivation, guiding patients to align PA behavior with core values. This process may also enhance psychological flexibility when facing PA-related discomfort, promoting consistent PA participation over time [39, 41, 53, 54, 65].

This study incorporates several innovative features and methodological strengths that can advance research in this field. First, past interventions for weight recurrence in MBS have used broad inclusion criteria, creating diverse patient groups in terms of time since surgery and the extent of weight recurrence [66–69]. Patients who have already experienced clinically significant weight recurrence can differ biologically, psychologically, and behaviorally from those who are relatively weight stable [13, 64, 70, 71]. As a result, they may face unique barriers, motivations, and abilities related to PA and may need tailored strategies. Clarifying whether an intervention aims to prevent or reverse weight recurrence and aligning its timing accordingly can strengthen its impact and clarify PA’s role. To address this, this study is designed to prevent weight recurrence and integrates both clinic-based and remote weight measurements to identify the weight nadir, confirm weight stability, and begin treatment before substantial weight recurrence develops [44].

Second, many prior behavioral interventions to reduce weight recurrence after MBS have been short in duration (<6 months), had few assessment points, relied on subjective measures of targeted behaviors, and not evaluated maintenance of effects [66–69]. These factors limit understanding of the degree of behavior change, how long changes last, and how these changes relate to weight recurrence over time. The current study will track changes in objectively measured MVPA at four time points during a 12-month treatment phase and a 6-month maintenance phase. It will also examine changes in secondary theoretical outcomes (autonomous motivation and PA acceptance) and explore whether they mediate the treatment’s effects on MVPA and whether MVPA, in turn, mediates effects on weight recurrence. This will clarify how the intervention influences PA and subsequent weight recurrence.

Third, few adjunctive behavioral interventions for MBS patients have used strategies that are easily integrated into clinical practice, often due to high patient burden and the need for extensive clinical resources. In contrast, this study adopts a lower-touch workshop approach that reduces demands on interventionists and eases participation barriers by delivering content through video conferencing, email micro-interventions, and brief individual video calls. ACT is amenable to brief formats because it emphasizes in vivo practice of skills that build on each other, making concentrated sessions feasible [39]. This format may be more adaptable to MBS clinical settings.

Finally, few studies have considered potential confounders, making it difficult to isolate intervention effects on weight recurrence after MBS. This study will account for factors such as dietary intake, maximum weight loss, psychological variables, and sociodemographic characteristics. The increasing availability of obesity management medications (e.g., semaglutide and tirzepatide) and the rise of multi-modal treatments that combine these medications with MBS [72, 73] could complicate efforts to disentangle the role of PA. Therefore, this study will ensure participants are on stable doses of these medications (i.e., no changes in the type, dosage, or dosing frequency) within two months of study enrollment, monitor any medication changes, and treat medication use as a time-varying covariate. Ongoing medication monitoring remains necessary due to high discontinuation rates and the potential reversal of weight and cardiometabolic benefits [74, 75].

CONCLUSION

MBS is an effective treatment for severe obesity, which continues to rise among U.S. adults. However, many patients experience significant weight recurrence, often accompanied by the return of co-occurring conditions and diminished physical and mental health gains. Although guidelines urge patients to increase MVPA to prevent weight recurrence, most patients do not meet this recommendation, and available interventions rarely address low motivation for MVPA. This study is the first to test whether a low-touch, ACT-based approach focused on autonomous motivation for MVPA can produce sustainable increases in MVPA and reduce weight recurrence after MBS. The findings may inform stronger recommendations on using PA for weight management in MBS and other obesity treatments and encourage broader application of ACT strategies in MBS practice to help prevent weight recurrence.

Highlights.

Metabolic and bariatric surgery is an effective treatment for severe obesity.

Postoperative weight recurrence is common and can become a serious complication.

Physical activity may help minimize weight recurrence.

Patients report low motivation for engaging in regular physical activity.

This intervention targets physical activity motivation to prevent weight recurrence.

ACKNOWLEDGEMENTS

We acknowledge the contributions of Chloe David, BS, Darren Tishler, MD, Janet Huehls, MS, Aimee Fucci, MSN, Connie Santana-Landry, MBA, and Aziz Benbrahim, MD

FUNDING SOURCE

The EVOLVE Trial is supported by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases (R01 DK135463). Dr. Sarwer is also supported by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases (R01 DK133264).

Footnotes

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DECLARATION OF COMPETING INTEREST

The authors have no potential conflicts of interest to disclose.

Declaration of Interest Statement

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

DATA STATEMENT

Because this trial is still ongoing, no suitable data are available for sharing at the time of this submission.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Because this trial is still ongoing, no suitable data are available for sharing at the time of this submission.

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