Effects of Exercise in Subjects with Morbid Obesity Awaiting Bariatric Surgery: A Systematic Review

Abstract

Background:

Morbid obesity treatment includes medical and surgical options. Surgical treatment is a more effective method in terms of weight loss and sustainability. This systematic review aimed to investigate the effectiveness of exercise training for subjects with morbid obesity awaiting bariatric surgery (SMOABS) in the preoperative period and whether presurgical exercise practices have an effect on postsurgery.

Materials and Methods:

In our study, “Cochrane Library,” “Pedro,” “PubMed,” and “Google Scholar” databases were searched using keyword synonyms “Bariatrics” or “Bariatric surgery” and “Obesity” or “Morbid obesity,” and “Physical Therapy” or “Physiotherapy” or “Exercise.” The review protocol is available from PROSPERO ID CRD42020164078.

Results:

As a result of the research, 195 articles were found to meet the criteria. Thirteen of these articles included presurgical exercise for morbidly obese individuals. This study reports the results of 328 SMOABS. Most of the studies focused on aerobic exercise and functional capacity and physical fitness evaluated, and the effectiveness of the 12-week exercise program was investigated in most of the studies. In the protocols used in the studies, there were differences in terms of the number of sessions, the duration of the intervention, the outcome criteria, and the sample size, etc.

Conclusion:

As a result of this study, it was found that there is a limited number of studies investigating the effects of preoperative exercise training in SMOABS. Research shows that exercise training provides positive improvements in functional capacity and physical fitness for SMOABS. To increase the level of evidence, interventions, evaluation methods, and results should be standardized in future studies.

Introduction

The World Health Organization (WHO) defines obesity as an abnormal and excessive increase in the amount of fat at a level that poses a risk to health.¹ According to the recent data of WHO and the Centers for Disease Control and Prevention, while 18.5–24.9 kg/m² is defined as the normal body mass index (BMI), ≥25 kg/m² is defined as overweight and ≥30 kg/m² is defined as obese.² Another form of obesity, defined as morbid obesity (grade III or severe obesity), is BMI ≥40 kg/m². Morbid obesity is associated with increased mortality and risk of chronic diseases, such as diabetes mellitus, hypertension, sleep apnea, cardiovascular, kidney, lung and musculoskeletal diseases, and dyslipidemias.^3,4

Morbid obesity treatment includes medical and surgical options. Medical treatment includes nutrition education, physical activity, counseling, cognitive-behavioral techniques, lifestyle modifications, and pharmacotherapy.⁵ Bariatric surgery, a surgical option, has been reported to be the most effective and sustainable method in the long term in achieving weight control in individuals with morbid obesity.⁶ Bariatric surgery provides improvements in metabolic regulation and obesity complications, as well as weight loss, and decreases mortality and morbidity rates.^7,8 Besides, it greatly improves the physical capacity, quality of life, and comorbidities of people with severe obesity.^9,10

The critical point in bariatric surgery is the postsurgical follow-up process. Follow-up should include medical and psychological guidance, including dietary advice and maintenance of a physical exercise regimen.¹¹ Besides, to optimize the results of bariatric surgery and reduce perioperative morbidity, experts recommend adapting to a healthy lifestyle intervention before and after surgery.^12–14 Thus, exercise is strongly recommended in multidisciplinary medical and surgical management for people with morbid obesity. The literature highlights that individuals who practice exercise before and after surgery achieve better weight loss and maintenance.^15–17 However, there is no clear exercise program that has been determined in terms of intensity, frequency, or duration for subjects with morbid obesity awaiting bariatric surgery (SMOABS) in the preoperative period. Besides, it is unclear whether preoperative exercise would have an additional positive effect in the postoperative (post-op) period. Therefore, it is predicted that studies investigating the long-term effects of preoperative exercise programs will provide significant contributions to the literature.¹¹

This systematic review aimed to investigate the effectiveness of exercise training for SMOABS in the preoperative period and what kind/type/mode of exercise should a subject with morbid obesity be advised. Therefore, the research questions of our study were: What is the recommended exercise program for SMOABS in the preoperative period? Do presurgical exercise practices have effect on postsurgery, and if so, what are these effects?

Materials and Methods

Literature search

This review was planned to investigate the effectiveness of exercise training for SMOABS in the preoperative period and what kind/type/model of exercise should a subject with morbid obesity be advised. We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. In this systematic review, “Cochrane Library,” “Pedro,” “PubMed,” and “Google Scholar” databases were searched using keyword synonyms “Bariatrics” or “Bariatric surgery” and “Obesity” or “Morbid obesity,” and “Physical Therapy” or “Physiotherapy” or “Exercise.” Cochrane Library, PubMed, Pedro, and Google Scholar were searched from the last decade 2009 up to 2019 for each database.

Inclusion criteria

The inclusion criteria of the review were as follows: patients must be awaiting bariatric surgery with a BMI of ≥40 or ≥35 with comorbidities

Patients must be over 18 years of age and an exercise program must be included for morbid obese individuals

Awaiting bariatric surgery, the exercise program should be defined appropriate; methods should measure the efficacy of the exercise program; the studies must be published in the last 10 years from 2009 up to 2019

The studies must be randomized controlled trials, prospective trials, or case–control studies

A description of an exercise program whose effectiveness is investigated (strength training, aerobic training, etc.)

Registration of evaluation criteria (physical fitness, body composition, quality of life, etc.).

Published in English.

The studies were researched taking into consideration the publication date, research type, sample groups, intervention groups, exercise protocol, outcomes (body composition, physical fitness, functional capacity etc.), and results.

Exclusion criteria

The exclusion criteria for this systematic review were studies that do not report the outcome weight; studies in which the population investigated are nonhumans, as in the case of reviews, guidelines, interviews, comments, or case studies were also excluded. Studies were excluded if they were written in languages other than English and if they did not describe an intervention. The titles and abstracts were individually screened on relevance by the reviewers (G.T. and N.A.). The literature review was independently and simultaneously performed by two reviewers (G.T. and N.A.). Disagreements between the researchers were sorted out through consensus.

Quality of studies

All studies' methodologic quality was independently assessed by the reviewer using the Critical Appraisal Skills Programme (CASP) checklists. One author (D.G.), created a modified scale based on various CASP checklists.¹⁸ Articles were assessed on each quality listed in Table 1. The study assessed as “1” indicating quality, “0” indicating it did not, and “–1” indicating that the given quality was not applicable. Studies subdivided into “1+,” “1,” and “1–” reflecting good, adequate, and less than adequate attributes, respectively (Table 1).

Table 1.

Evaluation of the Quality of the Studies According to Critical Appraisal Skills Programme Checklists

	CASP categories
Study	1	2	3	4	5	6	9	10	11
Marcon et al (2016)²⁶
Türk et al (2017)²⁷
Li et al (2013)²⁸
Baillot et al (2016)²⁹
Marc-Hernández et al (2019)³⁰
Baillot et al (2016)²⁹
Barbalho-Moulim et al (2011)³²
Baillot et al (2017)³¹
Picó-Sirvent et al (2019)³⁴
Lloréns et al (2014)³⁵
Gilbertson et al (2020)³⁶
Arman et al (2021)³⁷
Picó-Sirvent et al (2022)³⁸

Representation of the agreed-upon ratings for the modified CASP Quality Appraisal Scale. Gray boxes represent a rating of 0, indicating that the article did not address the domain assessed; black boxes represent a rating of −1, indicating that the domain assessed was not applicable to the given article; and white boxes represent a rating of 1, indicating that the article did address the domain assessed.

CASP, Critical Appraisal Skills Programme.

Results

Characteristics of included studies

The primary search produced 328 results, including 82 duplicates. Twenty studies were identified as possibly relevant and underwent a full-text critical appraisal, resulting in seven exclusions. One study investigated exercise programs for adolescents,¹⁹ two articles were only available in Spanish,^20,21 one publication appeared to be a case report,²² and one study investigated the effectiveness of exercise program without surgery in a super obese patient²³ and two studies did not meet the CASP criteria.^24,25 The flow chart of the study is shown in Figure 1 and Table 1 shows the quality of the studies according to (CASP) checklists.

FIG. 1.

PRISMA flowchart. From: Page et al.⁴⁶ For more information, visit: www.prisma-statement.org/ PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Participants

This study reports the results of 328 morbidly obese patients awaiting bariatric surgery in 13 trials. Most of the individuals in the studies were female.

Outcome measures

The studies used outcome measures such as anthropometric measurements, physical fitness, and vital signs. Table 2 shows the evaluation parameters used in the studies. The most commonly used evaluation parameters were anthropometric measurements, functional capacity, physical fitness parameters, and quality of life. In the studies, the balance was evaluated objectively in only one study,³⁷ and biochemical analysis was found in three studies.^26,36,38

Table 2.

Evaluation Parameters Used in the Trials

Author, year	Anthropometric measurements	Physical fitness	Functional capacity	Vital signs	Biochemical analysis	QoL	Respiratory function	Balance	Number of daily steps	Surgical outcomes
Marcon et al (2016)²⁶
Türk et al (2017)²⁷
Li et al (2013)²⁸
Baillot et al (2016)²⁹
Marc-Hernández et al (2019)³⁰
Baillot et al (2016)²⁹
Barbalho-Moulim et al (2011)³²
Baillot et al (2017)³¹
Picó-Sirvent et al (2019)³⁴
Lloréns et al (2014)
Gilbertson et al (2020)³⁶
Arman et al (2021)³⁷
Picó-Sirvent et al (2022)³⁸

▪: Yes: □: No.

QoL, quality of life.

Exercise program

Table 3 shows the summary of exercise training trials in morbidly obese individuals awaiting bariatric surgery. Nine studies^{26–31,33,34,38} investigated the effectiveness of aerobic exercise training. Seven studies^{26,28–31,33,34} investigated the effectiveness of strengthening exercise training, two studies^32,35 investigated the effectiveness of respiratory exercise training, and one study investigated the effectiveness of core stabilization exercise program.³⁷ We found that three studies used high-intensity interval training (HIIT) aerobic exercise.^27,30,34 Picó-Sirvent et al gradually progressed from moderate (MIIT) to high intensity (HIIT).³⁴ Besides, it is noteworthy that home-based exercise practices were used in some studies.^28,31,32,36 Two of these studies applied both supervised and home-based exercises as a hybrid model.^31,32 Besides, it draws attention that hybrid model telerehabilitation applications were made in the study of Baillot et al.³¹

Table 3.

Summary of Trials Exercise Training in Morbidly Obese Individuals Awaiting Bariatric Surgery

	Author, year	Research	Sample	Intervention groups	Exercise regime and duration	Outcome measurements	Results
1	Marcon et al (2016)²⁶	RCT	57 morbidly obese awaiting bariatric surgery	1. Exercise training (22)2. Exercise training + cognitive behavior program (17)3. Control group (18)	1. Aerobic exercise and strengthening training,25 min/2 days/16 weeks + Group Therapy for Lifestyle Modification	Body weightWalking distanceVO2maxResting HRHR after exercise	Respectively, changes in body weight were −7.4; −4,2; and 2.9, and the BMI change (kg/m²) was −2.7; −1.4; and 1.1. The change in the EXs was significant compared to the control group but there was no significant difference between the two EXs.While functional capacity and cardiometabolic parameters improved significantly in exercise therapy groups, it worsened in the control group but there was no significant difference between the two exercise groups
2	Türk et al (2017)²⁷	N-RCTPilot	11 morbidly female obese awaiting bariatric surgery	1. Exercise training (4)2. Control group (7)	HIIT aerobic exercise supervised by a physiotherapist 40–60 min/3 days/12 weeks	ACQAQLQBMIFEV16MWDVO2maxDaily step count	After 12 weeks of exercise training, there were improvements in asthma control, asthma QoL, VO2max, and 6MWD after 3 months of PR.Furthermore, there was a decrease in the median BMI before undergoing bariatric surgery. During 6 months of follow-up after bariatric surgery, the improvements in ACQ, AQLQ, and 6MWD persisted.
3	Li et al (2013)²⁸	RCTPilot	22 morbidly obese awaiting bariatric surgery	1. Supervised exercise program (7)2. Home-based exercise program (8)3. Control group (7)	1. Aerobic exercise and strengthening trainingAerobic training 30 min/3 days/8 weeksStrengthening training 2 days/8 weeks	Body weightFat-free massAerobic capacity	Respectively, weight loss was 7 ± 7, 1 ± 5, 1 ± 3 in the groups. There was a significant change in the supervised exercise program group but not in other groups.Weight loss at post-op 10 weeks was 31 ± 11, 33 ± 5, 25 ± 8, respectively. Exercise training had no effect on weight loss during this period. Similarly, the supervised EX tended to increase preoperative aerobic capacity, but this tendency did not persist in the 10 post-op week.
4	Baillot et al (2016)²⁹	RCT	29 morbidly obese awaiting bariatric surgery	1. Exercise training (8)2. Control group (21)	1. Aerobic training and strength training 80 min/3 days/12 weeks	Walking distancePhysical fitnessPhysical activity level	Fat mass, heart cost after 6MWT, sit-to-stand repetition, half squat time, arm curl repetition, and maximal aerobic capacity significantly increased in the intervention group in comparison with the control group.
5	Marc-Hernández et al (2019)³⁰	ProspectiveN-RCT	18 morbidly obese awaiting bariatric surgery	1. Exercise training (8)2. Control group (10)	1. HIIT aerobic training and strength training60 min/first 4 weeks 2 days, 4 weeks 3 days, last 4 weeks 3 days/12 weeksThe intensity of the exercise started at 60% of MHR and increased to 80% as the sessions progress.	Anthropometry and body compositionBasal metabolic rateLipid profileCardiorespiratory fıtnessPhysical fitness	After exercise training, FFM and BMR levels were maintained, and total body weight, fat mass, waist circumference, HbA1c, SBP, and DBP values were significantly decreased. There was an improvement in QoL.
6	Baillot et al (2016)³¹	N-RCTCase–control study	29 morbidly obese awaiting bariatric surgery	1. TelePreSET exercise training (6)2. PreSET exercise training (12)3. Control group (11)	Aerobic training and strength training 1.80 min/3 days (2 days supervised 1 day homebased)/12 weeks (TelePreSET)2.80 min/3 days/12 weeks (PreSET)	Anthropometry and body composition6MWTPhysical fitness	Significant increase in functional capacity and physical fitness. 6MWT, sit-up and half-squat test, arm-curl test results significantly increased compared to the control group.There was no significant change in anthropometric measurement, body composition, and blood pressure in both EXs compared to the control group and no significant difference between the EXs.
7	Barbalho-Barbalho-Moulim et al (2011)³²	RCT	32 morbidly obese awaiting bariatric surgery	1. Exercise training (15)2. Control group (17)	İnspiratory muscle strengthening training with threshold 15 min/6 days (2 days supervised by physiotherapist, 4 days home-based)/4 weeks	Respiratory muscle strengthLung volumes	There was no significant difference in post-op 1 day, number of days in the hospital, VAS, PPC. There was a significant decrease in MIP and MEP in both groups. However, this rate was 28% in the EX, 47% in the control group. Although there was a significant decrease in lung volumes VC, IRV, FVC, FEV1, and MVV in both groups, ERV did not change only in the EX and VT did not decrease in both groups.
8	Baillot et al (2017)³³	RCT	25 morbidly obese awaiting bariatric surgery	1. PreSET exercise training (13)2. Control group (12)	Aerobic training and strength training 80 min/3 days/12 weeksThe intensity of the exercise started with 55% of MHR and the rate increased to 85% as the sessions progress.	6MWTSit-to-standHalf squatArm curl testWRQOL	After exercise training, in the EX 6MWT, half-squat test and BMI changes were significantly higher than in the control group. Furthermore, in 1 year after bariatric surgery, the number of daily steps (EG: 7460/CG: 4287) and time spent at mild and moderate physical activity levels were higher.
9	Picó-Picó-Sirvent et al (2019)³⁴	PilotCase–control study	6 morbidly obese awaiting bariatric surgery	1. Exercise training (3)2. Control group (3)	MIIT and HIIT aerobic training and strength trainingFirst 3 months 60 min-Last 3 months 70 min/first month 2 days, 2 month 3 days, last 4 months 4 days/6 monthsExercise intensity started at 60% of MHR, the rate was increased to 95% as the sessions progress.	Anthropometry, Body composition CRF measurementsCardıorespiratory fıtness measurementMuscle strength	There was a significant difference in EBW in the EX compared to the control group. In addition, the change in BMI was significantly higher in the EX.The nondominant hamstring muscle strength MDS and quadriceps muscle strength MIS were higher in the EX compared to the control group.
10	Lloréns et al (2014)³⁵	RCT	44 morbidly obese awaiting bariatric surgery	1. Exercise training (23)2. Control group (21)	Inspiratory muscle strengthening training with Threshold and use of incentive spirometry 20 min/7 days/4 weeksThe intensity of the exercise started at 30% of MIP and increased over time.	Arterial blood gases,FVCFEV1MIPMEPEnd-expiratory lung volume	Post-op 1 and 12 h PaO2/FiO₂ values increased in the EX compared to the control group. Post-op hypoxemia was higher in the control group. MIP and MEP decreased in both groups compared to the preoperative time and were higher in the EX, but these differences were not statistically significant (MIP CG 53.3 ± 27.7 and EG 58.26. ± 27.6, MEP CG 63.3 ± 37.4 EG 72.3 ± 30.9).
11	Gilbertson et al (2020)³⁶	ProspectiveN-RCT	14 morbidly obese awaiting bariatric surgery	1. EG (7) + SC2. SC group alone (7)	Exercise training consisted of home walking 30 min/day, 5 days/week at 65–85% heart rate peak monitored withAn activity tracker for 30 days. Exercise adherence was monitored by the research team using an exercise diary and an A300 Polar fitness and activity tracker.	Body compositionCardıorespiratory fıtnessAerobic fitnessMetabolic outcomes and adipokines.	SC tended to increase percent body fat after the intervention compared to EX+SC. Although SC and EX+SC tended to raise insulin sensitivity, EX+SC enhanced metabolic flexibility, reduced total adiponectin with no change in high molecular weight adiponectin, and decreased the length of hospital stay compared to SC. Adding preoperative aerobic exercise to SC may improve surgical outcomes through fitness and adipose tissue derived mechanism.
12	Arman et al (2021)³⁷	ProspectiveRCT	21 morbidly obese awaiting bariatric surgery	1. EG + physical activity counseling (10)2. Control group only physical activity counseling (11)	CSEP consisted of three parts: warm-up, loading and cooling down. CSEP consisted of a combination of strengthening, endurance and balance exercises. CSEP performed for 8 weeks.The exercises for each major muscle group were conducted for two cycles of between 7 and 10 reps at a moderate intensity of 50% repetition maximum.	Functional capacityPhysical fitnessPhysical activityFatigue and QoL	After 8 weeks, the results showed significant improvements in all parameters except for body composition for the EX, compared to the control group (effect size = 0.40–0.87, p < 0.05).Implementing an 8-week adding CSEP to physical activity counseling provided significant improvements in functional capacity, physical fitness, physical activity, fatigue, and QoL compared to physical activity counseling in obese people awaiting bariatric surgery.
13	Picó-Sirvent et al (2022)³⁸	ProspectiveN-RCT	20 morbidly obese awaiting bariatric surgery	1. EG + Presurgical care (10)2. Only presurgical care (10)	Combined CAT was conducted for the 12 weeks, frequency progressed from 2 d/w during the first month to 3 d/w during the second month, and then to 4 d/w until the end of the PAP.The sessions lasted 60 min for the first 2 months and 70 min for the third month.	Anthropometry and body compositionResting metabolic rate and Substrate oxidation Cardiorespiratory fitness measurements and Substrate oxidation during exercise	A PAP that combines aerobic exercise at Fatmax with low resistance training may counteract some of the deleterious side effects of the standard presurgical care of women waiting for bariatric surgery and in maximal fat oxidation during exercise.After the PAP, maximal fat oxidation during exercise increased in the EG but resting fat oxidation did not. In addition, the resting metabolic rate in the EG was also unchanged. No significant changes were observed in the CG.

6MWD, 6-minute walk distance; 6MWT, 6-minute walk test; ACQ, Asthma Control Questionnaire; BMI, body mass index; BMR, basal metabolism rate; CAT, continuous aerobic training; CRF, cardiometabolic risk factors; CSEP, Core Stabilization Exercise Program; d/w, days/week; DBP, diastolic blood pressure; EBW, excess body weight; ERV, expiratory reserve volume; EG, exercise group; FFM, free-fat mass; FEV1, forced expiratory volume; FVC, functional vital capacity; HbA1c, glycolyzed hemoglobin; HIIT, high-intensity interval training; HR, heart rate; IRV, Inspiratory reserve volume; MCID, minimal clinically important difference; MDS, maximal dynamic strength; MEP, maximum expiratory pressure; MHR, maximal heart rate; MIIT, medium intensity interval training; MİP, maximum inspiratory pressure; MIS, maximal isokinetic strength; MVV, maximum voluntary ventilation; N-RCT, non-randomized controlled trial; PAP, physical activity program; post-op, postoperative; PPC, post-op pulmonary complication; PreSET, preoperative training; RCT, randomized controlled trial; SBP, systolic blood pressure; TelePreSET, video conference-based preoperative exercise training; VAS, visual pain scale; VC, vital capacity; VT, tidal volume; WRQOL, weight related quality of life.

Exercise duration

The effectiveness of exercise training was investigated for 12 weeks in six trials,^{27,29–31,33,38} 6-month period in one trial,³⁴ and 4-week period in two trials^32,35 and 8-week period in one trial.³⁷ As a result of the research, it was seen that only 6 of the 13 studies researched the effects of preoperative exercise training on the post-op process.^{27,28,32,33,35,36} According to the findings, the protocols used in the studies were different in terms of the number of sessions, the duration of the intervention, the outcome criteria, the sample size, etc. The studies found that the exercise programs lasted 4 weeks to 6 months, the frequency of the sessions was between 2 and 7 per week, and the session duration was 15–80 min, with a wide distribution.

Discussion

We aimed to investigate the effects of exercise training in SMOABS in this review. Thirteen studies that examined the effects of exercise for SMOABS were included. Our main findings were that a wide range of exercise programs are available in terms of the exercise type, duration, outcome measurements, and number of sessions for SMOABS. In most studies, the female gender is more than the male gender. Besides, we observed that some studies were completed only with the female gender.^27,32,39 It may be explained that morbid obesity prevalence was higher in the female gender due to economic, cultural, and psychosocial reasons. Female SMOABS may be more willing than men to participate in regular exercise programs.

Preoperative weight loss reduces risk factors in surgery by reducing cardiometabolic risk and liver fat ratio. In accordance with the literature to determine the physical health, physical fitness and functional capacity were evaluated in many studies. Most studies used anthropometric measurements. In most studies, these evaluation parameters may have been preferred to provide feedback to the individual in preparation for bariatric surgery. There is some variability between individuals in bariatric surgery results but decreased inflammation, elevated insulin sensitivity, and greater fitness at the time of surgery are linked to improved surgical outcomes.⁴⁰ Thus, enhancing metabolic and physical health before surgery may improve patient outcomes.³⁶

Comorbid diseases in morbid obesity increase the risk of developing complications and negatively affect treatment.¹³ As a result of the research, we found that vital signs, respiratory functions, and biochemical analysis were investigated in some studies.^{26,29,31,33–35} In this population accompanied by chronic diseases, the evaluation of these parameters can direct the treatment and its results. For this reason, we recommend that these evaluations be added to the studies to create and maintain a safe exercise program, especially for cardiac and pulmonary signs. It was found that the number of daily steps, which is an essential criterion for individuals, was evaluated in two studies.^27,33 Daily step count tracking is a suitable evaluation parameter to have information about the level of activity in daily life and to interpret the effect of exercise programs on daily life. An effective strategy is to provide activity tracking devices to patients. Pedometers and wearable devices can increase physical activity and improve health.⁴¹ Therefore, we believe that daily step count tracking provides good feedback and motivation to transform exercise into a lifestyle and make it sustainable. Monitoring the number of daily steps with objective evaluation methods such as wearable technologies is an effective approach to obesity.⁴²

According to our research, objective or subjective balance assessment was limited.³⁸ We think that this is due to the primary focus on the concept of weight loss in obesity rehabilitation and the secondary consideration of the concepts of balance/falling problems and quality of life. We recommend objectively investigating the static and dynamic balance in studies for clinicians and researchers, especially for morbid obesity.

The preoperative waiting period may represent an ideal opportunity to facilitate healthy lifestyle change, as patients are engaged in the process of preparing for surgery and are not yet facing post-op recovery challenges.¹⁷ Experts emphasize that to increase the effectiveness of bariatric surgery and reduce complications and perioperative morbidity, individuals should make cognitive and physical preparation for the surgery and learn and adopt healthy life interventions in the presurgical period.¹³ Examples of interventions that increase the physical activity level of SMOABS are individual exercises and group exercises.¹⁴ In the literature, aerobic, strengthening, flexibility and balance-proprioceptive exercises, dance, and underwater exercises are recommended to treat obesity.^43,44 However, randomized controlled studies investigating the type, intensity, content, and short- and long-term effects of exercise in SMOABS are limited,^26,28,29 and there is no consensus about exercise programs. Besides, studies investigating the effects of presurgical exercises on the post-op period are also limited. The studies emphasize that presurgical exercise treatments positively affect functional capacity, physical fitness, body composition, and quality of life in morbid obese individuals. As a result of our research, it was found that there are many exercise programs in SMOABS, but the most commonly used exercise program was aerobic and strength training. Türk et al investigated the pulmonary effects of aerobic exercise therapy for 40–60 min/3 days/12 weeks in the presence of a physiotherapist with 11 SMOABS; it was found that the respiratory functions and daily step count of the individuals in the treatment group were superior to control group in the third and sixth months after surgery and there was no difference in asthma control and quality of life.²⁷ Baillot et al investigated the effectiveness of combined exercise therapy for 80 min/3 days/12 weeks with 25 SMOABS; it was found that the functional capacity, daily step count, and mild and moderate physical activity durations of the individuals in the treatment group were higher than the control group in 1 year after surgery.³³ According to research, while the time of the exercises extended from 25 to 80 min, the average duration was 12–16 weeks.^{26,27,29–32} We think that this is since aerobic exercise programs for large muscle groups have positive effects on weight loss and physical health. Although a positive relationship between exercise and body composition has been established, few studies support the efficacy of exercise alone to achieve weight loss. However, even when exercise does not result in weight loss, it has been shown to confer significant health benefits to people who are overweight or obese.⁴⁵ In addition, studies do support the efficacy of exercise to prevent weight gain.⁵

While most studies^26,28,30,31 investigating the effect of aerobic exercise programs on body composition did not achieve significant improvement, only one study³⁴ achieved significant improvement. Picó-Sirvent et al significantly improved BMI and body composition by an aerobic exercise program that progressed from moderate to high intensity for 6 months. We think that this result is due to the duration of aerobic exercise.

Study limitations

This study has several limitations that should be addressed in future works. The moderate methodological quality of some articles, the inability to blind patients and reviewers, and the existence of nonrandomized studies carry the risk of confusion. In addition, some included articles have a small sample size and the follow-up period is relatively short. As a result, the interpretation of the results of the present systematic review is limited due to the heterogeneity of the interventions and study outcomes. However, the strengths of our study are that it provides an overview of the current literature and guides future studies.

Conclusion

As a result of the research, it was found that there are limited studies investigating the effects of preoperative exercise training in SMOABS. Studies show that supervised 12–16 weeks of aerobic and strengthening (combined) training provides positive improvements in functional capacity and physical fitness in SMOABS. To increase the level of evidence, future studies should be searched in larger sample groups, interventions, and evaluation methods, and results should be standardized. In addition, future studies should investigate the effects of pre-op exercise training to post-op time. Our study provides both clinicians and researchers with current information on optimal exercise prescription at the presurgical time for SMOABS.

Footnotes

Authors' Contributions

G.T. was involved in literature search, methodology, conceptualization, statistical analysis, writing—original draft, writing—review and editing. N.A. was involved in methodology, conceptualization, statistical analysis, writing—review and editing. All authors were involved in writing the article and had final approval of the submitted and published versions.

Ethical Approval

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

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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