Exercise Program in Patients After Bariatric Surgery: A Systematic Review

Abstract

Background:

The aim of this review was to determine the optimal exercise program to prevent weight gain and maintain weight loss in patients after undergoing bariatric surgery.

Materials and Methods:

We conducted a systematic review in accordance with the PRISMA guidelines. We systematically investigated exercise training studies performed after bariatric surgery published from 2008 through 2018. Studies reporting changes in body composition, muscular strengths, aerobic capacity, functional capacity, walking distance, or relevant health outcomes were included. The review protocol is available from PROSPERO (CRD42018110174).

Results:

Seven articles were included in the review. The included studies reported data on 255 patients. The duration of intervention was between 4 and 26 weeks. The frequency of the session was two to five times per week and each session was ∼30–80 min. Three studies used aerobic exercise for the intervention group, two studies planned resistance training, one study used an outpatient physiotherapy program that included breathing, strengthening, and stretching exercises, and one study used a combination of endurance and strengthening exercises.

Conclusions:

Introduction

Obesity is a problem that is experienced around the world, which brings with it many diseases, such as diabetes, dyslipidemia, hypertension, cancer, and cardiovascular diseases,^1–3 and is associated with significantly higher all-cause mortality.⁴ Therefore, it is very important to decide the most appropriate treatment method in the treatment of obesity.

Bariatric surgery has become an accepted method in the treatment of obesity in recent years because it helps in the treatment of diseases that develop secondary to obesity.⁵ Changes in hormones of the gut and the associated calorie reduction are some of the ways through which weight is lost after bariatric surgery.⁶ This surgery results in significant weight loss and has positive effects on diabetes in many patients.⁷ Although bariatric surgery is the most commonly used method and the long-term effects of obesity treatment are well known,^8,9 weight loss after surgery is difficult to maintain and weight gain might even occur.^10–12

Exercise programs after bariatric surgery are recommended for patients because of the benefits in preventing weight regain and maintaining weight loss.^13,14 Thus, exercise after bariatric surgery is an important step for treatment. However, there is no clear exercise program that has been determined in terms of intensity, frequency, or duration for patients after bariatric surgery.

The aim of this review was to determine the optimal exercise program to prevent weight gain and maintain weight loss for patients who have undergone bariatric surgery.

Materials and Methods

Literature search

This review was planned to investigate and determine the optimal exercise program for patients who have undergone bariatric surgery. We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. In this systematic review, PubMed (NLM), Pedro, and the Web of Science databases were searched for articles published from January 2008 through September 2018. Search terms included the following: [(bariatric surgery OR gastric bypass OR gastroplasty OR jejunoileal bypass OR lypectomy) and (rehabilitation OR exercise therapy)]. The search terms were determined using the MeSH browser. Searches were restricted to articles published in the English language and included randomized controlled trials. A total of 1552 articles were found.

Interest outcomes

Studies were reviewed for the following outcomes of interest: weight loss and body composition (7 included), muscular strength (3 included), functional capacity (3 included), aerobic capacity (1), and walking distance (4 included).

Inclusion criteria

The inclusion criteria for review were as follows; an exercise therapy program should be included after bariatric surgery, the exercise therapy program should be defined, patients should be 18–65 years of age, the efficacy of the exercise program should be measured by appropriate methods, study length should be more than 4 weeks, include both preoperative and postoperative data collection, studies must be randomized controlled trial and published in English, and multimodal programs with exercise components should be included.

Exclusion criteria

The exclusion criteria were as follows: studies with a sample size of less than 10 and PEDro scale less than 4 points.

Quality of studies

The full text of the articles was evaluated using a standardized article screener by two of the researchers. Disagreements between the two authors were resolved by discussion and by consultation with all authors of the review until consensus was reached. The methodologic quality of all studies was independently assessed by the reviewer using the PEDro scale, which consists of 11 criteria, with a maximum score of 10 (range 0–10); the first item (the specification of the eligibility criteria) is not included in the total score. For rating the methodologic quality, the following classification was used: a PEDro score of 4 indicated poor methodologic quality, a score of 4–5 indicated fair quality, a score of 6–8 was good quality, and a score of 9–10 indicated excellent quality.¹⁵

Results

One thousand five hundred fifty-two articles that matched the search criteria were found in the initial literature search. The abstracts of these publications were screened and 44 that met the inclusion criteria were obtained in full. Thirty-seven articles were then excluded for reasons stated in the PRISMA flowchart (Fig. 1) and seven articles were included in the final review. This process, including reasons for exclusion, is detailed in Figure 1.

FIG. 1.

Flow chart.

Characteristics of included studies

The distribution of studies according to years was two articles in 2011, one article for each of 2013, 2016, and 2017, and two articles in 2018. The included characteristics are shown in Table 1. The included studies mainly focused on three different surgery types: Roux-en-Y gastric bypass, gastric bypass, and gastric band.

Table 1.

Study Characteristics

Study	Definition of exercise	Exercise sessions	Patients	Durations/exercise onset time	PEDro score	Primary outcomes	Results
Castello et al.³⁰	Aerobic exercise training; • Exercise on treadmill with speed and inclination varying according to the behavior of HR	60-min workout/session • 5 min of stretching the upper and lower limbs, diaphragmatic breathing, and awareness of proper posture • 5 min of warm-up on a treadmill at 3 km/h • 40 min of exercise on treadmill (gradually 50–60–70% of HR peak/10 min) • 1 min recovery at 3 km/h 10 min of the same initial stretching and diaphragmatic breathing	Postop GBS IG; n = 11 female CG; n = 10 female	3 times/week, for 12 weeks, totally 36 sessions/first month	5/10	Weight loss FVC FEV1 FEV1/FVC HRV Walking distance Skinfold thickness Circumferences	Only the TG demonstrated a significant increase in all indexes of HRV and 6MWT distance and decrease in diastolic blood pressure after aerobic exercise training
Shah et al.³¹	High-volume exercise program • Treadmill/cycle ergometer/rowing machine	Moderate-intensity aerobic exercise at 60–70% of maximal energy consumption ≥2000 kcal/week	Postop RYGB IG; n = 21 CG; n = 12	At least 5 days a week, 12 weeks/—	6/10	VO_2max Physical activity level Resting energy expenditure Dietary intake Lipids, lipoproteins, glucose, and insulin concentrations Body weight, waist and hip circumference, and body composition	Reported time spent and energy expended during moderate physical activity and maximal oxygen consumption relative to weight, were significantly improved over 12 weeks in the HVEP group compared with controls. Changes in weight, energy and macronutrient intake, REE, fasting lipids and glucose, and fasting and postprandial insulin concentrations were not different between the two groups
Castello-Simões et al.³²	Aerobic exercise training; • Exercise on treadmill with speed and inclination varying according to the behavior of HR	60 min workout/session • 5 min of stretching the upper and lower limbs, diaphragmatic breathing and awareness of proper posture • 5 min of warm-up on a treadmill at 3 km/h • 40 min of exercise on treadmill (gradually 50–60–70% of HR peak/10 min) • 1 min recovery at 3 km/h • 10 min of the same initial stretching and diaphragmatic breathing	Postop GBS IG; n = 9 female CG; n = 10 female EG; n = 12 female	3 times/week, for 12 weeks, total 36 sessions/first month	5/10	Weight loss FVC FEV1 FEV1/FVC HRV Walking distance	IG and CG groups demonstrated a significant slowing of HR kinetics during the 6MWT when compared with EG. Only the TG demonstrated a significant improvement in HRV indexes, walking distance, faster time constant, and mean response time of HR during 6MWT after training
Oliveira et al.³³	Out-patient physiotherapy • Warm-up breathing exercise with pursed lip • low-intensity strengthening, stretching exercise	40 min workout/session • 10 min walk as a warm-up, • Breathing exercises with diaphragmatic • breathing with deep inhales and exhales with pursed lips, and three-phased fractioned inhalation • Arms stretching along the body • Diaphragmatic breaths • Trunk bending • low-intensity strengthening, stretching exercise	Postoperative RYGB IG; n = 20 CG; n = 23	2 sessions/week, 4 weeks/first month	4/10	Weight loss Maximum respiratory pressures Walking distance Perceived exertion rate	6MWT significantly increased in intervention group in comparison with the control group. Both groups had significant and similar weight loss after surgery
Coleman et al.³⁴	Group exercise • Functional resistance exercise Self-directed exercise	At least 150 min/week • Functional strength • Flexibility • Aerobic activities • Resistance with own body weight 3 days/week of self-directed exercise • daily pedometer • recording of steps and activities	Postop gastric sleeve, bypass, adjustable gastric band survivals IG; n = 26 CG; n = 25	5 days/week, 24 weeks/sixth month	6/10	Aerobic fitness, BMI, Balance, Mobility, and coordination, Strength and muscular endurance	Yards walked in 6 min, seconds for 8-foot up-and-go, number of arm curls, and distance in inches for chair sit and reach improved significantly in intervention group in comparison with the control group
Daniels et al.³⁵	Resistance training; core exercises • Squats • Lunges • leg press/curl/extension • Lat pull down • Shoulder press • Bench press • Bent or seated rows	60–80 min workout/session • 5–10 min warm-up and dynamic stretching • 50–60 min resistance exercise • 5–10 min cool-down 3 gradual period First period (first 2 weeks): 50–60% 1-RM Second period (2–7 weeks): 70–80% 1-RM Last period (last 5 weeks): >80% 1-RM	Postop RYGB IG; n = 8 female CG; n = 8 female	12 weeks/eighth month	4/10	Weight loss Strengths; leg press, leg extension, quadriceps cross-sectional area, whole thigh cross-sectional area, muscle quality leg press, muscle quality leg extension	Significantly greater improvements in: • leg press strength, • leg extension strength • leg press muscle quality in the intervention group compared with the control group No changes in fat-free mass or muscle cross-sectional area between groups
Mundjberg et al.³⁶	Bike training Resistance training; • For the upper extremities, lateral raises, lateral pull-downs, and chest press Optional training; • Stair climbing, • Treadmill • Walking • Rowing machine Recommended a minimum of 3.5 h of physical activity/week	40 min workout/session • 15 min bike training • 10 min, 20–15–10 repetitions gradually resistance training • 15 min optional training 3 gradual period • First period (first 8 weeks): 50% of VO_2max for bike training and 60% 1-RM for resistance training, 50% of VO_2max for optimal training • Second period (9–18 weeks): 50–70% of VO_2max for bike training, 65% 1-RM for resistance training (15 repetitions), 50–70% of VO_2max for optimal training • Last period (last 5 weeks): 70% of VO_2max for bike training, 75% 1-RM for resistance training (10 repetitions), 70% of VO_2max for optimal training	Postop RYGB IG; n = 32 CG; n = 28	2 times/week/26 weeks	6/10	Anthropometry Aerobic capacity Muscle strength Sit to stand test Stair climb test	Significant increase in VO_2max, muscle strength in the hip adductor and Stair Climb Test in intervention group. The effects were not maintained at follow-up.

BMI, body mass index; CG, control group; FEV1, forced expiratory volume; FVC, forced vital capacity; GBS, gastric bypass surgery; HR, heart rate; HRV, heart rate variability; HVEP, high volume exercise program; IG, intervention group; REE, resting energy expenditure; RM, repeated maximum; RYGB, Roux-en-Y gastric bypass; TG, training group.

The included studies reported data on 255 patients. The mean number of patients within each study ranged from 16 to 60 (33.9 ± 13.11) years. In general, the patient population was middle aged (41.94 ± 9.11 years) and follow-up ranged from 4 weeks to 24 months. There were more women than men in all of the studies. Three studies included only female patients, the other studies had more than 80% female participants. The study characteristics are shown in Table 1.

Exercise programs

The duration of intervention was between 4 and 26 weeks. The frequency of the session was two to five times per week and each session was ∼30–80 min. The average duration since surgery ranged from 1 month to 3.5 years in the intervention group. Three studies used aerobic exercise for the intervention group, two studies planned resistance training, one study used an outpatient physiotherapy program that included breathing, strengthening, and stretching exercises, and one study used a combination of endurance and strengthening exercises.

Discussion

In this review, we aimed to determine the optimal exercise program after bariatric surgery. Seven studies were included in the review and the effects of exercise on interested parameters after bariatric surgery were examined.

No adverse or negative effects of exercise after bariatric surgery were reported.^16,17 In previous literature, the effects of exercise on weight loss, physical fitness, and wellness have been clearly defined.¹⁸ However, consensus as to what constitutes an exercise program, and what is the intensity, duration, or volume after bariatric surgery remains uncertain. The current recommendations for exercise, derived from an extensive review of data pertaining to nonsurgical patients by the American College of Sports Medicine (ACSM), suggest a minimum of 30 min per day, totaling at least 150 min per week. On the other hand, the ACSM also recommends 60 min of moderate-intensity exercise for at least 5 days per week (300 min of exercise/week) to achieve substantial weight loss.¹⁹ Based on the ACSM recommendations, the optimal exercise program should be planned for a minimum 300 min per week to achieve and protect weight loss.²⁰ In previous literature, low–moderate-intensity or a combination of low and moderate-intensity exercise programs were recommended.^21,22

All of the studies included in this review focused on postoperative exercise. It is unclear if preoperative exercise would have an additional positive effect in the postoperative period. Therefore, preoperative exercise planning should be done and this subject would contribute to the literature.²³

There was no common exercise type in the included studies, which are largely heterogenic. There is no uniformity with regard to outcome variables and little is known about the effect of exercise programs on weight regain after bariatric surgical interventions. Stretching and strengthening exercise have a positive effect on muscle strength and walking distance.^24,25 Also, aerobic exercise has benefits on energy consumption and heart rate variability.^26,27 While preparing exercise programs, depending on the aim, such as weight regain or muscle strengthening, researchers can choose or combine these types of exercises.

In the majority of studies on exercise in the bariatric population, exercise has no adverse effects and positive effects on functional capacity, physical and cardiorespiratory fitness, body composition, muscle strength, and energy consumption have been described.^16,28,29 Based on the ACSM's recommendations, a minimum 150–300 min per week, gradually increasing low–moderate-intensity, and a combination of aerobic, strength, and stretching-type exercise should be planned in postoperative patients who have undergone bariatric surgery.²⁰ Forty-eighty–minute workouts, including a 5-min warm-up and 1-min recovery period is appropriate for such patients. Their program frequency can be planned 2–5 days per week, for 4–24 weeks in total. The intensity can be set as 50–70% of heart rate peak exercise or it can be adjusted to lose ≥2000 kcal/week. Aerobic exercise training should be included in addition to breathing, stretching, strengthening, and core exercises.

In light of the results of this review and ACSM, we recommended the exercise program, which includes warm-up sessions, strengthening training, aerobic training, breathing exercises, stretching exercises, and cool-down sessions at least for 12 weeks for bariatric surgery patients. In addition, we recommend that the exercise program and physical activity be continued after the 12th week to achieve long-term weight control, reduce cardiometabolic risks, and produce behavior modification. The recommended 12 weeks exercise program was given in Table 2.

Table 2.

The Recommended 12 Weeks Exercise Program

Preoperative
Type	Frequency
Strengthening training	3–5 times/week
Aerobic exercise
Breathing exercise
Stretching exercise
Intensity	Time
Gradually 50–60–70% of HR peak/10 min	30–60 min
5 repetitions for each breathing exercise
20 repetitions for each resistance exercise
3 repetitions for each stretching exercise
Postoperative
From the second to fourth week
Type	Frequency
Strengthening training	2–3 times/week
Aerobic exercise
Breathing exercise
Intensity	Time
50% of VO_2max for aerobic exercise	30 min
50–60% 1-RM and 20 repetitions for each resistance exercise
5 repetitions for each breathing exercise
From the fifth to eighth week
Type	Frequency
Strengthening training	3–4 times/week
Aerobic exercise	3–4 times/week
Intensity	Time
60–70 of VO_2max for aerobic exercise	40 min
60–70% 1-RM and 20 repetitions for each resistance exercise	40 min
From the 9th to 12th week
Type	Frequency
Strengthening training	5 times/week
Aerobic exercise
Stretching exercise
Intensity	Time
70–80% of VO_2max for aerobic exercise	50–60 min
70–75% 1-RM and 20 repetitions for each resistance exercise	50–60 min

Conclusions

Gradually increasing low–moderate-intensity exercise, and a combination of aerobic, strength, and stretching-type exercise should be planned comprising a minimum 150–300 min per week in postoperative bariatric surgery patients to prevent weight gain and maintain weight loss. The consensus on the optimal exercise prescription for the bariatric populations is not yet clear. For this reason, further studies examining the type, duration, and long-term effects of exercise are needed.

Ethics Approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Footnotes

Author Disclosure Statement

No competing financial interests exist. There are no conflicts of interest.

Funding Information

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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