Applied Nursing Research xxx (2014) xxx–xxx

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Applied Nursing Research

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Feasibility of implementing a meditative movement intervention withbariatric patients

Lisa L. Smith, MS, ACSM a,⁎, Linda Larkey, PhD b,1,Melisa C. Celaya, MS c,2, Robin P. Blackstone, MD, FACS c,2

a Arizona State University, 500 N. 3rd Street, Phoenix, Arizona 85004, Physical Activity, Nutrition and Wellness, School of Nutrition and Health Promotionb College of Nursing and Health Innovation, Arizona State University, 500 N. 3rd Street, Room 324, Phoenix, AZ 85004, USAc Scottsdale Healthcare Bariatric Center, 10200 N. 92nd Street, Suite 225, Scottsdale, AZ 85258, USA

a b s t r a c ta r t i c l e i n f o

All research was conducted at the Scottsdale Bariatricin Scottsdale, AZ. The studywas not fundedorfinancially suinstitution.⁎ Corresponding author. Tel.: +1 480 255 7682 (mob

E-mail addresses: llsmith6@asu.edu (L.L. Smith), larkmcortes@shc.org (M.C. Celaya), rblackstone@shc.org (R.

1 Tel.: +1 602 821 2366 (Mobile).2 Tel.: +1 480 391 3885; fax: +1 480 391 3898.

0897-1897/$ – see front matter © 2014 Elsevier Inc. Alhttp://dx.doi.org/10.1016/j.apnr.2014.02.009

Please cite this article as: Smith, L.L., et alApplied Nursing Research (2014), http://d

Article history:Received 5 December 2013Revised 5 February 2014Accepted 7 February 2014Available online xxxx

Keywords:Bariatric surgeryMeditative movementPhysical activity

Successful interventions are needed to help improve obesity rates in the United States. Roughly two-thirdsof adults in the United States are overweight, and almost one-third are obese. In 1991, the National Institutesof Health released a consensus statement endorsing bariatric surgery as the onlymeans for sustainable weightloss for severely obese patients. However, approximately one-third of bariatric patients will experience significantpost surgical weight gain.Purpose of study: This study is designed to determine if meditative movement (MM) would be a feasible physicalactivity (PA) modality to initiate weight loss in bariatric surgery patients who have re-gained weight.Methods used: A feasibility study was recently completed in 39 bariatric patients at Scottsdale Bariatric Center(SBC) during regularly scheduled bariatric support groups at SBC. A short demonstration of MM was presentedafter which a short focus group was conducted to gauge interest level, acceptability and the potential demandfor MM programs in this population. Attitudes and intentions surrounding MM were also collected.Findings: Approximately 75% of participants indicated they would consider practicing MM as part of their postsurgical PA routine.Conclusions:MMmay be a feasible PAmodality in bariatric patients to improve bariatric surgeryweight outcomes.

Center, at Scottsdale Healthcarepported by any organization or

ile).eylite@msn.com (L. Larkey),P. Blackstone).

l rights reserved.

., Feasibility of implementing a meditativex.doi.org/10.1016/j.apnr.2014.02.009

© 2014 Elsevier Inc. All rights reserved.

1. Introduction

1.1. Statement of the problem

While obesity rates have plateaued within the last decade (Flegal,Carroll, Ogden, & Curtin, 2010), two-thirds of the United Statespopulation is currently classified as overweight (defined as a BMI of25–29.9 kg/m2) or obese (a BMI greater than 30 kg/m2) (Flegal, Carroll,Ogden, & Curtin, 2010). Obesity is a serious issue, not only because of itsimpact on morbidity and mortality rates, but also due to the financialburden it puts on both the individual and society.

Obesity is associated with increases in cardiometabolic disease,certain types of cancer, premature death, osteoarthritis, and breathingproblems (CDC, 2010). Additionally, in 2005, an estimated $190 billion,

or approximately 21%of theUnited States health care expenditures,wasspent on obesity-related issues (Cawley & Meyerhoefer, 2012).

In general, surgical interventions are more effective than behavioraltreatments in both the short and long term (Buchwald & Williams,2004; NIH, 1998). However, for certain bariatric patients, between thefirst and second years following surgery, weight loss often stabilizes anda substantial proportion of individuals begin to regain lost weight (Hsu,Sullivan, & Benotti, 1997;Hsu et al., 1998). It is estimated thatmore than20% of bariatric surgery patients will regain a significant amount ofweight thatwas initially lost (Meguid, Glade, &Middleton, 2008).Whilestatistics vary per procedure and intervention, approximately 30–40%ofsurgically treated patients regain up to one-third of their initial weightloss long term (Bond et al., 2008) at the 5-year mark.

1.2. Physical activity (PA) and bariatric surgery

Although PA is recognized as an integral part of the non-surgicalmanagement of obesity for weight loss and weight loss maintenance(Jakicic et al. 2001; Wing & Phelan, 2005), the relationship betweenPA levels and weight loss or maintenance following bariatric surgeryis unknown. There are currently no randomized controlled trialsof physical activity and weight loss in bariatric patients, however

movement intervention with bariatric patients,

2 L.L. Smith et al. / Applied Nursing Research xxx (2014) xxx–xxx

observational studieshave found thatpost-surgical exercise is positivelyassociated with improved weight outcomes.

There are currently no standard PA recommendations for bariatricsurgery patients; however walking to the point of volitional fatiguewith small increases in daily step counts is a common recommendation(Petering & Webb, 2009). The American College of Sports Medicine(ACSM)has no specific guidelines for bariatric patients but does indicatethat aerobic exercise should be the focus of a post-bariatric surgeryprogram, as it burns the most calories and is the best way for apreviously sedentary individual to ease into physical activity (ACSM,2011). Additionally, the American Society for Bariatric Surgery (ASBS)recommends initiating walking from postoperative day one (Silver,Torquati, Jensen, & Richards, 2006).

1.3. Meditative movement

Alternative forms of exercise are gaining in popularity in thegeneral population, especially those that include a focused, meditativeor mind–body component (La Forge, 2005). Meditative movement(MM) has recently been proposed as a category of exercise with someelements of practice that differ substantially fromconventional versionsof exercise (Larkey, Jahnke, Etnier, & Gonzalez, 2009). In contrast tomany other forms of PA, many of the MM practices are low impact, andmoderate- to low-intensity and encourage people to move slowly andgently. The most current comprehensive definition of MM wasgenerated by Larkey et al., 2009 and includes four components: focusof the mind; some form of body movement or postural positions; focuson breathing and a deep state of relaxation. Some of the most commonexamples of MM are tai chi (TC), qigong (QG) and yoga. These typesof meditative activities may be beneficial and more feasible to initiatefor physically de-conditioned individuals such as the overweight/obeseor in bariatric patients.

Tai chi easy (TCE) is a simple MM form that was developed by Dr.Roger Jahnke and formulated into a standardized research interven-tion protocol by a team of researchers (Jahnke, Larkey, & Rogers,2010). The TCE intervention combines simplified TC movements withQGmethods that include gentle flowingmovements and slow shifts ofbodyweight while incorporating deep, soothing breathing. It has beenused in several prior projects (Jahnke, Larkey, & Rogers, 2010; Larkeyet al., 2012) and one recently completed randomized controlledtrial (RCT) with breast cancer survivors showing reduction in fatigueand depression, and improved sleep and physical function (Larkeyet al., 2011).

There is growing evidence that MM practices may help withweight loss and/or maintenance in overweight or obese populations,possibly by reducing maladaptive eating behaviors. A 12-week yogaprogram reduced incidences of binge eating in a group of obese females(McIver, O'Halloran, & McGartland, 2009). Specifically, women per-ceived an overall reduction in the quantity of food they consumed,decreased eating speed, and an improvement in food choices through-out the program. Ameditation-based intervention also found significantdecreases (p b .001) in binge eating disorder in obese females, and timespent meditating was significantly associated (p b .01) with less bingeeating episodes (Kristeller &Hallett, 1999). And in bariatric patients, thepractice ofmindful eating has been shown to be effective inmaintainingweight loss post surgery (Engstrom, 2007).

Given the absence of interventions using MM in the bariatricpopulation, a feasibility study was conducted to determine the overallinterest in, acceptability of and potential demand for MM programsin bariatric surgery patients as well as their attitudes and intentionstowards MM using a questionnaire based on the theory of plannedbehavior (TPB) (Ajzen, 2006). According to the TPB, behavioral beliefsproduce a favorable or unfavorable attitude toward the behavior;normative beliefs result in perceived social pressure or subjectivenorm; and control beliefs give rise to perceived behavioral control.When combined, attitude toward the behavior, subjective norm, and

Please cite this article as: Smith, L.L., et al., Feasibility of implementiApplied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.201

perception of behavioral control lead to the formation of a behavioralintention (Fig. 1). In general, the more favorable the attitude andsubjective norm, and the greater the perceived control, the strongershould be the person's intention to perform the behavior in question.Intention, when supported by these predictors, is more likely then toresult in behavior change. Our study was designed to explore bariatricpatients' responses to a direct experience of TCE and to rate TPB factorsthat could best predict enrollment and adherence to such an intervention.

2. Methods

2.1. Recruitment sites and study population

This is a cross-sectional study with a qualitative component in aconvenience sample of 39 bariatric patients at Scottsdale BariatricCenter (SBC), located in the southwestern United States. The SBCperforms bariatric surgery on approximately 350 men and womenannually (Blackstone & Cortes, 2010). The mean age of the studyparticipants was 49.42 ± 14.41 years. Reflecting the demographicstatistics of the SBC population, 67% of the subjects were female, and80% were White, non-Hispanics.

Participants were recruited by research staff during ongoing andregularly scheduled post surgical support group meetings at SBC.Three separate support groups were invited to participate in the studywith purposeful selection across time post-surgery: 1) 0–4 months 2)1 month; and 3) N 4 months. The largest study support groupwas the1- month post-surgery group (n = 16), followed by 0–4 months(n = 13). Individuals over 4 months post-surgery had the smallestattendance (n = 10). These decreasing numbers of participants isconsistent with how the SBC program usually observes decliningparticipation in the support process over time.

2.2. Ethical considerations

The institutional review boards associated with the universitythat conducted this research and the hospital where the data werecollected approved this study, and all participants were provided awritten information letter. An informed consent was not necessary forthis study and not provided.

2.3. Procedures

During regularly scheduledweekly support groups, an informationletter was placed on the chairs when participants entered the roomwith a description of the study as “…testing the feasibility of engagingbariatric patients in a meditative movement intervention as apotential strategy for continued weight loss.” Participants were toldthat they were invited to participate in a demonstration of MM at theend of their session that day, and then join in a brief focus group toshare their responses, and a short survey, and that theywerewelcometo join or simply leave at the end of the support group session if theypreferred not to participate.

At the end of the support group session, for those that remained,members of the research team described the current study andanswered questions regarding the study. The research team includedthe principal investigator and a research assistant. A brief, 2–3 minuteoral presentation was given on MM, including what it is and whatbenefits have been shown in a wide variety of participants. Afteranswering any questions, a short demonstration using a 5–7 minuteprotocol based on Tai chi easy (TCE) (Jahnke, Larkey, & Rogers, 2010)was presented with an invitation to the support group members toparticipate if physically able and/or interested. Approximately 95% ofthose that remained after the support group participated in the study.

ng a meditative movement intervention with bariatric patients,4.02.009

Fig. 1. Theory of planned behavior model.

3L.L. Smith et al. / Applied Nursing Research xxx (2014) xxx–xxx

2.4. Study measures

A standardized group of questions was developed for the post-surgical focus groups to obtain their thoughts, feelings and intentionsaround MM (Fig. 2).

Demographic data were obtained and includes age, gender,ethnicity and race. Subjects were asked if they had participated in PA(not defined) over the past 30 days, and the answerwas coded as yes/no.A questionnaire reflecting TPB constructs was utilized to collectparticipant information on the perceptions of being “able” to performMM, attitudes about the movements introduced, and expectations thatothers would support them in the practice of MM. The current studyinstrument, which we entitled the MM and TPB Questionnaire, was aslightly modified version of ameasure validated in a bariatric populationusing TPB to predict general exercise intentions and behaviors (Hunt &Gross, 2009). The original question itemswere predominantly left intact,with the word “exercise” being replaced by “MM.” For example, thequestion “Most people who are important to me want me to exerciseregularly over the next twoweeks”was revised to “Thepeople importantto me would support my learning about MM.”

For the construct of attitude, the internal consistency reliability(Cronbach's alpha) ranged from 0.78 to 0.90. For the construct ofsubjective norms, internal consistency values ranged from 0.58 to 0.80,with the values for the subjective factor score being significantly higher(Cronbach's alpha 0.90 to 0.94). For the construct of perceived behavioralcontrol, the Cronbach's alpha ranged from 0.78 to 0.82.

The feasibility study TPB questionnaire was broken down intothe standard components of attitude, subjective norms, perceivedbehavioral control and intention. The TPB component of behavioralattitudes was broken down into two 5-question measures: attitudesabout learning and attitudes about trying MM. The subjective normcomponent was comprised of 2 questions, and both the subjective

1. What is meditative movement (MM)? How wou2. What are the groups’ thoughts and feelings aroun3. Based on the demonstration, is MM doable?4. What are the perceived benefits of MM?5. What did you like about the MM demonstration?6. What are the perceived barriers of MM?7. What did you not like about the MM demonstrat8. What would keep you doing MM? 9. What would make you stop doing MM?10. Would you participate in a structured MM class?11. What would stop you from participating in a MM12. Are there any other comments or feedback on M

Fig. 2. Focus grou

Please cite this article as: Smith, L.L., et al., Feasibility of implementiApplied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.201

norms and perceived behavioral control sections each contained 3questions. All of the questions were 5-point scales; 1 indicating “leastlikely,” “strongly disagree” and the “most negative” of responses. Ananswer of 5 indicated a “very positive” response, “strongly agree,” or“most likely.” Each of the components and subcomponentswere summedinto a total score for that specific TPB construct with higher scoresrepresenting a more positive attitude toward regular exercise behavior(Table 1). A complete list of study questions is presented in Fig. 3.

3. Data analysis

Descriptive statistics were run to determine patterns andfrequencies of participant characteristics and responses. Additionally,Spearman's rho correlations were run to examine potential associa-tions among TPB constructs and participant characteristics. Differ-ences in TPB questionnaire responses by post-surgical groups wereexplored using a Kruskal–Wallis one-way analysis of variance(ANOVA). Based on the mean age, subjects were separated intothose ≤ 48 years and those ≥ 49 years and TPB construct scoreswere compared between the groups. Data are presented as means andstandard deviations and an α-level of 0.05 was used to determinestatistical significance.

4. Results

Data were analyzed using PASW (Predictive Analytics Software)Version 18 for Windows (Chicago, IL). Demographic characteristicsof the study subjects are reported in Table 2. The results indicated that71% of participants indicated a positive attitude about learning moreabout MM, and 65% reported a positive attitude about trying MM inthe short term.

ld you define it?d the MM demonstration?

ion?

class?

M that have not been discussed?

p questions.

ng a meditative movement intervention with bariatric patients,4.02.009

Table 1Theory of planned behavior component score totals.

TPB component Total n = 39 Score mean (SD) Total score possible

Attitude–Learning 39 21.08 (7.05) 30Attitude–Trying 20 19.60 (6.81) 30Subjective norm 20 7.45 (1.64) 10Perceived behavioral control 20 11.20 (3.02) 15Intention 39 10.36 (3.52) 15

4 L.L. Smith et al. / Applied Nursing Research xxx (2014) xxx–xxx

All associations between age, group status, PA participation in the30 days prior to the study and TPB construct scoreswere non-significantexcept for a weak inverse correlation between group assignmentand PA participation (r = −0.41; p = 0.01). Those patients 1-monthpost surgery had the highest incidence of reported PA. There were nosignificant differences or discernable trends betweenpost surgical groupstatus and any of the TPB constructs measured. Additionally, separatingthe groups into those above and below the mean age resulted in nosignificant associations between the two in termsof PA, groupassignmentor the TPB questionnaire responses.

Sample responses to the open-ended focus group questions wereas follows: (a) regarding physical sensations, a common response of

1. AttitudeFor me, the idea of learning about Meditative Movebe…Very Disagreeable --1---2---3---4---5-- Very AgreeaVery Annoying --1---2---3---4---5-- Very InterestingVery Unpleasant --1---2---3---4---5-- Very Pleasant

Very Tiring --1---2---3---4---5-- Very Energizing Very Useless --1---2---3---4---5-- Very Useful Very Unsatisfying --1---2---3---4---5-- Very satisfyi

For me, the idea of trying (MM) during the next 3 mVery Disagreeable --1---2---3---4---5-- Very AgreeaVery Annoying --1---2---3---4---5-- Very InterestingVery Unpleasant --1---2---3---4---5-- Very Pleasant Very Tiring --1---2---3---4---5-- Very Energizing Very Useless --1---2---3---4---5-- Very Useful Very Unsatisfying --1---2---3---4---5-- Very satisfyi

2. Subjective normThe people important to me would support my learnStrongly Disagree --1---2---3---4---5-- Strongly Agr

I think that people who are like me are interested in Strongly disagree --1---2---3---4---5-- Strongly Agre

3. Perceived Behavioral ControlFor me, to participate in MM during the next 3 monVery Difficult --1---2---3---4---5-- Very Easy

I think I would be able to participate in MM during Strongly Disagree --1---2---3---4---5-- Strongly Agr

I am confident that I can overcome obstacles that conext 3 months.Strongly Disagree --1---2---3---4---5-- Strongly Agr

4. IntentionI will learn more about MM during the next 3 monthVery Unlikely --1---2---3---4---5-- Very Likely

I would be willing to consider practicing MM regulaVery Unlikely --1---2---3---4---5-- Very Likely

I will try to practice MM regularly during the next 3Very Unlikely --1---2---3---4---5-- Very Likely

Fig. 3. TPB Que

Please cite this article as: Smith, L.L., et al., Feasibility of implementiApplied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.201

participants was that the MM exercises were “relaxing,” “peaceful”and “gentle.” One subject indicated that the movements were “toogentle” and that she preferred more high intensity activities after hersurgery. Being physically active was a new and exciting state for her,and doing low-impact activities reminded her of her “old life” thatshe wanted to leave behind. Many others in the groups echoedthis sentiment as well. (b) A large proportion of subjects indicateda willingness to incorporate MM into their post surgical exerciseregimes given its low impact nature. However, one male participantwho reported being retired military explained the movements remindedhim of Middle Eastern religious practices and that he was unwilling toengage in TCE under any circumstances. (c) The demonstration exerciseswere described as “perfect” for after surgery, “very gentle” and “helpfulfor breathing.”

Seventy-five percent of the participants provided high scores,i.e., scores closer to 5, on the subjective norm questions of socialsupport around MM practice and questions surrounding perceivedbehavioral control. Aggregate questions asking about intention to practiceMM scored the lowest, i.e., scores closer to 1, among participants, withonly 69% indicating a positive intention towards the behavior. However,75% of individuals answered positively on the individual question within

ment (MM) during the next 3 months would

ble

ng

onths would be…ble

ng

ing more about MM.ee

trying out practices like MM. e

ths would be…

the next 3 months.ee

uld hamper my participation in MM during the

ee

s.

rly during the next 3 months.

months.

stionnaire.

ng a meditative movement intervention with bariatric patients,4.02.009

Table 2Demographics characteristics of feasibility participants.

Demographics Total n = 39

Gender (n = 37)Males 11Females 26

Age (years) (n = 36) 49.4 ± 14.4Range 18–76

Ethnicity (n = 34)Hispanic 7Non-Hispanic 27

Race (n = 33) 33 WhiteGroup status⁎

Group 1 16Group 2 13Group 3 10

PA in last month (n = 38)Yes 31No 07

⁎ Group 1 = 1 month post surgery; group 2 = 0–4 months post surgery; group 3=N4 months post surgery.

5L.L. Smith et al. / Applied Nursing Research xxx (2014) xxx–xxx

the intention component, “I would be willing to consider practicing MMregularly during the next 3 months.”

5. Discussion

In this feasibility study to determine if MM would be a viable PAmodality in post bariatric patients, approximately 75% of participantsindicated a positive attitude towards MM in general and a willingnessto engage inMMpost-surgery. These results are promising as bariatricpatients may regain up to one-third of their initial excess weight loss(Bond et al., 2008) by post-surgical year five.

There are currently no standard PA guidelines in terms of frequency,intensity, duration or even mode of exercise for bariatric patientsalthough walking to volitional exhaustion is a common recommenda-tion. MM is an appealing PA modality for this population that shouldbe explored for several reasons. Immediately after surgery, patientsare typically weak and frail with limited range of motion. MM,and specifically TCE, is a gentle, low impact activity suitable fordeconditioned individuals in the recuperative process. MMhas beenshown to lead to additional andmore vigorous PA (Dechamps, Lafont, &Bourdel-Marchasson, 2007), which can contribute to attenuatedweightre-gain in this population. PA has been positively associated with thesuccessful maintenance of surgical weight loss (Livhits et al., 2010a,2010b). Finally, MM may cultivate mindfulness and healthier eatingpatterns, which could also be associated with longer-term weight lossfor bariatric surgery patients.

While the study obtained positive feedback on MM in a bariatricsurgery population, the sample was small (n = 39), and manyparticipants did not provide complete answers to study questionnaires,limiting the implications of this research. However, the researchers findit encouraging that the questions that were answered suggest that MMmay be a viable PA modality in bariatric patients.

Correlational analyses found no significant associations betweenthe subject characteristics of age, group or participation in PA duringthe 30 days prior to the study and to any of the TPB constructquestions and may reflect a small sample size. There was a weakinverse correlation between PA and group (r = − .41; p = 0.01),but the meaning of this relationship, if any, is unclear. As expected,all of the individual TPB questions were significantly associated witheach other. Those subjects that felt more positive and supportedaround MM expressed that same positivity across all of the TPBvariables. Surprisingly, the question “For me, the idea of trying MMover the next 3 months would be very disagreeable to very agreeable”

Please cite this article as: Smith, L.L., et al., Feasibility of implementiApplied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.201

was not significantly related to any other TPB question. Reasons for thisanomalous result are unclear.

Future randomized controlled trials are needed to fully explorethe relationship between MM and post-surgical weight gain. Andalthough the current study participants were predominantly White(80%) and female (69%), this does reflect the national statistics forbariatric surgery patients (Martin, Beekley, Kjorstad, & Sebesta, 2009).Trials with larger sample sizes and varying control groups will beimportant to conduct so that the true impact of MM on post-surgicalweight gain, if any, can be ascertained.

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