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Year : 2016  |  Volume : 4  |  Issue : 1  |  Page : 3-12

Physical activity prescription before bariatric surgery: Feasibility, health impacts, and practical implications

Pediatric Exercise Physiology Research Laboratory, King Saud University, Riyadh, Saudi Arabia

Date of Web Publication29-Jun-2016

Correspondence Address:
Prof. Hazzaa M Al-Hazzaa
Pediatric Exercise Physiology Research Laboratory, King Saud University, P.O. Box: 93216, Riyadh 11673
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2347-2618.184935

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Obesity is a challenging health problem. For people with morbid obesity who cannot lose weight, using conventional weight loss methods, they may resort to bariatric surgery. However, despite increasing evidence that physical activity (PA) can reduce weight and improve postsurgical outcomes, most preoperative obese patients are inactive. Therefore, the aim of the present paper was to review the evidence for the feasibility and beneficial health impact of prebariatric surgery PA program for obese patients and to discuss the practical implications of PA counseling and exercise prescription to healthcare providers. A systematic electronic search was conducted utilizing keywords related to PA, exercise, and prebariatric surgery using MEDLINE databases. The findings of this review indicated that a presurgical intervention targeting PA among obese patients awaiting bariatric surgery is feasible and has the potential to increase patient's engagement in PA postoperatively. In addition, higher levels of preoperative PA or physical fitness were associated with lower postsurgical complications and a shorter length of stay in hospital. There is also evidence to support that higher levels of preoperative PA may improve weight loss outcomes following laparoscopic surgery. Research showed that the daily time spent being sedentary among obese patients was quite excessive. In adult population, the available evidence demonstrates a dose-response relationship between the amount of moderate-to-vigorous intensity PA and reduced weight loss and increased health benefits. It is recommended that healthcare providers to increase their use of the five A's (Assess, Advise, Agree, Assist, and Arrange) counseling model when counseling obese patients about PA and weight loss. Finally, the future studies must seek to make PA more effective and compliant for obese patients and focus on identifying major barriers that are preventing most patients from assuming active lifestyles.

Keywords: Bariatric surgery, exercise, exercise counseling, obesity, physical activity, weight loss

How to cite this article:
Al-Hazzaa HM. Physical activity prescription before bariatric surgery: Feasibility, health impacts, and practical implications. Saudi J Obesity 2016;4:3-12

How to cite this URL:
Al-Hazzaa HM. Physical activity prescription before bariatric surgery: Feasibility, health impacts, and practical implications. Saudi J Obesity [serial online] 2016 [cited 2023 Jun 2];4:3-12. Available from:

  Introduction Top

Obesity has become a major public health challenge. [1] Indeed, morbid obesity was shown to be associated with reduced functional capacity, multiple comorbidities, and higher overall mortality. [2] When morbidly obese patient (body mass index [BMI] ≥40 kg/m 2 ) does not lose weight using conventional weight reduction strategies, it is advisable that bariatric surgery be considered. [3] It is believed that bariatric surgery is the most effective treatment for morbid obesity in long-term weight loss. [3],[4],[5] The procedure has been shown to result in a considerable weight loss. Bariatric surgery in the United Kingdom healthcare system, for instance, was shown to produce a dramatic weight loss, which was sustained for at least 4 years after surgery, and this weight loss is accompanied by substantial improvements in preexisting comorbidities. [6] In the United States, the annual rate of inpatient bariatric surgeries has increased to reach 47.3 procedures/100,000 adults by the year 2012. [7] Although bariatric surgery has been identified as an effective treatment for weight loss in the morbidly obese, [3],[4],[6] some patients still regain weight postoperatively. [3]

A pretreatment program that focuses on adopting an active lifestyle can facilitate improved postsurgical outcomes. [8],[9] In fact, it is believed that the preoperative period may provide a golden opportunity for patients to get motivated and alter their lifestyle behaviors, in order to have a successful surgery and more effective postsurgical outcomes. [9] In addition, obese patients seem to find a preoperative behavior modification program significantly useful in assisting them to assume the necessary changes during postsurgical procedures. [8] Moreover, a randomized control study showed that participation in a preoperative medically supervised weight management program appears to have a positive influence on postoperative physical activity (PA) level. [10] King et al. [11] assessed PA among obese patients before and after bariatric surgery for 310 participants who wore the activity monitors for at least 10 h/day for 3 or more days/week. The findings showed that after controlling for a surgical procedure, gender, age, and BMI, preoperative PA level independently predicted postoperative physically active participants.

Evidence suggest that increasing preoperative PA may decrease surgical complications, [2] and ample support shows that regular PA is the most important predictor of long-term weight loss maintenance. [12] However, despite the increasing evidence that PA can augment weight loss and enhances other health outcomes after bariatric surgery, most preoperative obese patients are insufficiently active and appear less successful in making significant increases in their postoperative PA levels. [13] Indeed, one interventional study reported that only 30% of obese participants met the recommended guideline of 150 weekly minutes of moderate-to-vigorous PA in adults. [14] In the present paper, a review of the available evidence for the feasibility and beneficial health impact of a prebariatric surgery PA program was examined. It was also the intent of this review to provide the healthcare providers with some practical implications of PA counseling in obese patients and to discuss exercise prescription recommendations relative to obesity management.

  Materials and Methods Top

A systematic search was conducted utilizing keywords such as PA, exercise, aerobic exercise, resistance training, obesity surgery, bariatric surgery, and weight reduction surgery, using MEDLINE databases. The search included relevant documents from January 01, 2000, up to December 31, 2015. The electronic search was conducted using the combinations of the following terms: "physical activity" AND "before bariatric surgery;" "exercise" AND "before bariatric surgery;" "physical activity" AND "before weight loss surgery;" "physical activity" AND "before obesity surgery;" "aerobic" AND "before bariatric surgery;" "resistance training" AND "bariatric surgery;" and "physical activity" AND "before weight reduction surgery." For additional relevant papers, the reference lists within the articles obtained in the electronic search were also examined for possible inclusion in this search. The inclusion criteria were articles in English literature, involved adults, used human subjects, have a clear description of PA assessment and focused on prebariatric patients who eventually underwent the bariatric surgery regardless of the procedures method performed. Full articles were then obtained for all the inclusive studies and were thoroughly read and analyzed.

  Results Top

The initial literature search using the keywords mentioned earlier identified 62 citations. However, after fully examining these 62 articles, only 15 articles met the inclusion criteria including three reviews and therefore were accepted and included in the analyses. They comprised some observational and few experimental studies. [2],[8],[9],[10],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23] Further, a few of the papers were reporting on different aspects of the same original studies. The above studies were varied in their design and methodological procedures, and there were relatively limited numbers among these studies that implemented a randomized controlled presurgery PA interventional program.

The literature search showed that reduced cardiorespiratory fitness levels were associated with increased short-term complications after bariatric surgery. Cardiorespiratory fitness was evaluated in 109 patients with morbid obesity prior to laparoscopic Roux-en-Y gastric bypass surgery. [2] Their mean age and BMI were 46.4 years and 48.7, respectively. Findings revealed that the combined complication rate was 16.6% and 2.8% (P = 0.02) among patients with peak oxygen uptake of < 15.8 mL/kg/min or above 15.8 mL/kg/min, respectively. The results also showed that the length of stay in hospital was highest among those patients with less peak oxygen uptake and that peak oxygen uptake was a significant predictor of complications (odd ratio = 1.61; 95 confidence interval = 1.19-2.28, P = 0.002). [2] Therefore, improving cardiorespiratory fitness before bariatric surgery should highly be considered in order to reduce postoperative complications. Other studies also agreed with the previous findings. In effect, for a number of types of surgeries including bariatric surgery, higher postsurgical risks, and a longer length of stay in the hospital were associated with low preoperative peak oxygen uptake or low anaerobic threshold (AT), as measured by a graded cardiopulmonary exercise test. [18],[19] Indeed, as [Figure 1] clearly shows that low preoperative AT levels were associated with greater postoperative complications and a longer length of stay in the hospital, despite no significant difference in body mass. [19] Further, even among the general obese population, the prognostic value of exercise capacity (higher fitness level) was found to be highly significant. [24] The age-adjusted relative risks of death for obese patients achieving a peak exercise capacity of <5 (aRR = 2.23) metabolic equivalent of task (MET) and 5-8 METs (aRR = 1.6) were much higher than those achieving a peak of more than 8 METs (aRR = 1.0). Such findings clearly indicate that the relative risks of death from obesity (BMI >30) significantly increases as exercise capacity decreases in such obese patients. [24]
Figure 1: Low versus high anaerobic threshold in prebariatric surgery patients and postoperative complications and hospital length of stay [19]

Click here to view

A study by Bond et al. [17] revealed that a presurgical intervention targeting PA among obese patients awaiting bariatric surgery has the potential to increase their engagement in PA. The study was conducted at the initial presurgical visit and again after 3 months just 1-2 weeks prior to surgery. Both PA readiness questionnaire and the International Physical Activity Questionnaire were administered at both visits. The findings showed that PA readiness and PA levels increased among the gastric bypass patients, as more patients were in the action and preparation stages and very few in the contemplation and precontemplation stages at the second visit compared to the first one. [17]

Higher levels of preoperative PA were shown to associate with improved weight loss outcomes following laparoscopic adjustable gastric banding in 172 obese patients (mean age: 43.3 years and mean BMI: 43.8 kg/m 2 ) who were assessed prior to and 3, 6, and 12 months after the surgery. [16] The study also showed that prior to the weight loss procedure, <40% of the patients were active, however, 31% of those who were inactive prior to the surgery became active at 6-month time. [16]

One of the review paper, which was based on a multidatabase search, evaluated studies that investigated the aspects of exercise before or after bariatric surgery. [22] The review identified a total of eight prospective studies, four studies focused on training before, and the other four on training after a bariatric surgery. Exercises description varied from 45 min of treadmill exercise up to full exercise programs. Findings indicated that in the majority of the reported studies in the prospective bariatric patients, significant improvement was noticed in anthropometrics, cardiovascular risks, and physical fitness variables. However, the study observed that the findings were not unanimous, with a wide range of exercise programs and perioperative timing, resulting in less than adequate practical guidance. [22]

In a study aimed to evaluate the feasibility of a supervised presurgical exercise training and its short-term clinical impacts in patients awaiting bariatric surgery, eight women and four men, with a mean age of 40.8 (range: 37.6-47.5) years and a BMI of 51.4 (range: 43.8-53.1) kg/m 2 , were subjected to combined endurance and strength training. [15] Patients were instructed to perform three PA sessions per week during 12-week period, with at least two sessions/week on site and making up any missed sessions at home. Results showed that the subjects took part in 57.3% of the total supervised exercise sessions with high satisfaction rates. Moreover, the program resulted in a significant improvement in weight (P = 0.007), fitness levels (P ≤ 0.05), and quality of life score (P = 0.012). Emotions, social interactions, and sexual life subscales were also improved (P < 0.03). In addition, fear of injury (P = 0.028) and embarrassment during PA (P = 0.028) were significantly decreased. However, there was no significant change in exercise efficacy or in beliefs in exercise benefits after the program. [15]

A prebariatric surgery program focusing on altering lifestyle behaviors could facilitate enhanced postsurgical outcomes. In a study incorporated a 6-week behavioral lifestyle modification before the surgery, for which exercise was a single component, it was found that the preoperative program was well perceived as useful by the patients. [8] Moreover, at 1-year postsurgery, a self-reported questionnaire by the patients revealed that the program helped them in making the necessary lifestyle changes at postsurgical procedures. [8]

Utilizing a randomized clinical trial, Parikh et al.[10] tested the effect of a medically supervised weight management program before obesity surgery in a total of 55 patients enrolled in the study. Data analyses included both intention-to-treat and completers' analyses. The findings fairly showed that participation in a preoperative medically supervised weight management program appear to have a positive influence on postoperative PA level, despite no significant postoperative difference in weight loss. [10]

The Bari-Active study, a randomized controlled trial, tested the efficacy for a presurgical intervention to increase PA in bariatric surgical patients. [14],[20] This 6-week behavioral PA intervention was compared to a standard care control group. The study examined the changes in the number of minutes of moderate-to-vigorous PA, quality of life, physical function, and number of daily steps. The intervention goals were to increase moderate-intensity walking exercise by 30 min/day and to increase daily step counts by 5000. The findings showed that compared to baseline, there was an increase of 21 min/day in moderate-to-vigorous PA after 6 weeks in the intervention group, while the control group showed no change in moderate-to-vigorous PA minutes. Step counts increased by over 2000 in the PA intervention group compared to 200 in the controls. At the end of the study, only 30% and 14.3% of participants in the PA intervention and control groups, respectively, met the national guideline of 150 min/week of moderate-to-vigorous PA. The study, however, did not examine the effect of the intervention on postoperative outcomes. [14],[20]

  Discussion Top

This systematic review aimed to review the available evidence for the feasibility and beneficial health impact of a prebariatric surgery PA program and to discuss the practical implications of PA prescription for obese subjects intending to lose excess weight. The findings of this review revealed that a presurgical intervention targeting PA among obese patients awaiting bariatric surgery is feasible and has the potential to increase their engagement in PA postoperatively. In addition, higher levels of preoperative PA or physical fitness were associated with lower postsurgical complications and a shorter length of stay in the hospital. The review also revealed that there was some evidence supporting the view that higher levels of preoperative PA may improve weight loss outcomes following laparoscopic surgery. Moreover, incorporating a behavioral lifestyle modification including PA program before the surgery can improve fitness and help patients make the necessary lifestyle changes at postsurgical procedures.

The American Society for Metabolic and Bariatric Surgery (ASMBS) highlighted that presurgical behavioral intervention to support weight loss and lifestyle change is considered the standard of care. [3] This type of interventional support is also provided by the majority of large comprehensive bariatric surgery programs. [21] In addition, being physically active during postsurgically period appears to improve long-term weight loss outcome. [25] This was clearly shown in a meta-analysis that included six nonrandomized studies, with a total of 492 participants, reporting that the physically active participants had initially lost 21 kg, while the physically inactive participants lost 22 kg. However, after 2.7 years, the weight loss in the physically active group was 15 kg whereas that in the physically inactive group was only 7 kg, demonstrating how PA is important in maintaining body weight after weight loss. [25]

A Cochrane review that evaluated 41 randomized controlled trials with a total of 3476 overweight or obese participants has concluded that PA alone induced significant weight loss, whereas PA in combination with a diet restriction and dietary counseling was more effective. [26] Further, the review found that high-intensity PA was more effective than moderate intensity activity. The findings of this Cochrane review support the use of exercise as a weight loss intervention, especially when combined with dietary change. [26] Needless to say thought that exercise is associated with improved cardiometabolic disease risk factors even if no weight is lost. Moreover, recent research indicates that despite the limited effects on BMI, exercise was associated with beneficial effects on body composition. [27]

It is interesting that weight loss among patient's candidates for bariatric surgery appears significantly less than that among medical patients undergoing weight loss. A recent study was conducted on the two groups of patients seen in the setting of a comprehensive weight loss program and supervised by a medical bariatrician and followed for a period of 4 months. [28] Basic data showed that there were no differences in mean initial BMI between surgical and medical patients (41.7 ± 4.55 and 41.6 ± 8.54 kg/m 2 , respectively) or participation time in the weight loss program (120 vs. 133 days). The findings showed that BMI reduction was 4.03 ± 3.99 kg/m 2 in the surgical patient versus 7.75 ± 4.90 kg/m 2 in the medical patients (P < 0.05). However, there was no information available on factors affecting weight loss among the two groups of weight loss patients. [28]

Exercise recommendations and weight loss

It is well recognized that PA reduces total mortality, significantly decreases cardiovascular risks and improves lipids profile, prevents and controls type 2 diabetes, decreases the incidence of some types of cancers, increases bone density, and improves psychological health and well-being. [29],[30] Furthermore, in adult population, the available evidence demonstrates a dose-response relationship between the amount of moderate-to-vigorous-intensity PA and increased health benefits. [31],[32] It appears that most of the augmented health benefits happen within the initial 60 min of moderate- to-vigorous-intensity daily PA. [29] Among obese patients, however, the ASMBS recommends light aerobic exercise and resistance training for 20 min/day, 3-4 days/week preoperatively to enhance cardiorespiratory fitness, decrease the risk of surgical complications, and improve postoperative recovery. [33] A similar preoperative exercise recommendations, of low-to-moderate-intensity PA for at least 20 min/day for 3-4 days/week, was also endorsed by the American Heart Association. [34] Finally, the joint guidelines from the ASMBS, the Obesity Society, and the American Association of Clinical Endocrinologists recommend that all postoperative patients should follow the general recommendations for health-enhancing lifestyle, including PA for at least 30 min/day. [3] However, evidence-based PA recommendations for overweight or obese adults indicate that the amount of exercise that is needed for weight loss and long-term maintenance in adults seems to be much higher than the previous guidelines, as the American College of Sports Medicine position stand has recommended a moderate intensity PA above 250 min/week in order to induce clinically substantial weight loss. [12]

High-intensity interval training and obese patients

In recent decades, a growing body of evidence has revealed that high-intensity interval training (HIIT) appears to be comparable or even superior to moderate intensity continuous training (MIT) in improving cardiometabolic health outcomes in healthy and diseased populations. [35] In fact, HIIT could potentially be an alternative type of exercise that provides health benefits in a time-efficient manner, especially when knowing that lack of time is among the most commonly cited barrier to exercise adherence in overweight and obese patients. In a study conducted on patients with type 2 diabetes, HIIT in the form of high-intensity interval walking was shown to be feasible and most importantly effective. [36] The findings showed that fat mass and visceral fat decreased in the interval walking group but not in the control group or low intensity continuous walking. Moreover, glycemic control improved in the interval walking group, while it was either worsened in the control group or not changed in the continuous walking group. [36]

However, not all of the studies have observed superior effects for HIIT compared with MIT. A recent study found that HIIT and isocaloric moderate-intensity continuous training exerted similar body composition, metabolic and cardiovascular improvements in obese participants. [37] Another study conducted on previously sedentary overweight or obese young men has also concluded that both exercise conditions were associated with temporal improvements in body fat percent, total cholesterol, triglycerides, insulin sensitivity, and aerobic power with no clear advantage between the two training protocols. [38] Furthermore, in a 12 weeks randomized controlled design study comparing HIIT, MIT, and placebo in overweight adults, HIIT was found not to confer the same benefit to body fat levels as continuous exercise training. [39] High-intensity exercise, though effective and time efficient, is nevertheless, not suitable for all patients. HIIT is only appropriate for low cardiovascular risk people or moderate-risk individuals who have been cleared for vigorous intensity exercise by a medical professional.

Reducing sedentary behaviors

Nowadays, there is growing evidence that sedentary behaviors are a distinct risk factor for weight gain and cardiometabolic disease independent of PA participation. [40],[41],[42],[43] Utilizing objective and subjective monitoring, several studies were consistent in showing that the daily time spent being sedentary among obese patients was between 9.5 and 11 h. [44],[45],[46] For instance, using the SenseWear Pro2 Armband, bariatric surgery candidates appeared to spend over 80% of their time in sedentary behaviors. [44] The study concluded that reducing such sedentary behaviors may assist in increasing levels of PA among these obese patients. Moreover, no significant differences were seen in objectively measured (ActiGraph accelerometer) changes in time spent sedentary or physically active when comparing 3 months presurgery and 9 months postsurgery among Swedish women that underwent Roux-en-Y gastric bypass and were able to reduce their BMI by 11.7 kg/m 2 during the 9-month period. [47]

In a recent study, King et al.[20] assessed sedentary behaviors and PA in bariatric surgery patients using activity monitors and found that, on average, bariatric surgical patients made small reductions in sedentary behaviors and increased their PA during the first postsurgery year, and they maintained such levels of activity afterward through 3 years. In addition, using a telephone questionnaire on 303 Roux-en-Y gastric bypass patients with a mean age of 47 years, it was found that sitting time was inversely associated with total (kg) weight loss, percent of weight loss, and percent of excess weight loss. [48] The preceding researches suggest that interventions must be tailored to not only increase moderate-to-vigorous PA among obese patients, but also to reduce screen time (television, computers, and hand-held devices) as well.

Implications for physical activity prescription

The way patients with severe obesity experience PA is an important aspect of planning and implementing PA program for obese patients awaiting bariatric surgery. Findings from the research showed that PA was experienced positively among adults with severe obesity. [23] Many patients experienced well-being after PA. However, numerous difficulties exist that influence patients' capacity and their determination. Support for obese patients appears necessary not just in initiating PA, but also to maintain it. The same study mentioned above also found that most patients were uncomfortable with appearing in public wearing exercise clothing. In addition, patient's motivation was increased when exercising together with someone at the same level of fitness. [23]

Despite all of the positive benefits of PA, many bariatric surgery candidate patients have a difficult time adhering to the prescribed PA recommendations. Therefore, the medical care team should offer help and support for the patients to comply with the exercise prescription by providing them with assistance in selecting the appropriate type of activity along with a most feasible monitoring technique. Considerations for selecting appropriate activities include personal preference, age, current weight, present aerobic fitness, range of motion, and comorbidity. Weight-bearing activity like walking is often endorsed as a simple and practical way to start an exercise. However, those patients with significant problems in their lower body joints may select activities that are with less impact on their joints, such as cycling, swimming, or elliptical exercise. Irrespective of the type of PA, an obese patient has higher energy expenditure during exercise compared with the lean person. [49] The increased energy cost can be observed at nonweight bearing exercise as well, such as during unloaded and loaded pedaling using cycle ergometer. [49] This increased energy cost of exercise seems to occur even at an early age, as research in obese children revealed that obese child expends during exercise more energy, as measured by oxygen uptake, compared with the lean child. [50] As shown in [Figure 2], the oxygen cost of running on a treadmill increased significantly in obese children more than in lean peers, especially at higher levels of intensity relative to maximal heart rate reserve. [50]
Figure 2: Oxygen consumption (mL/min) in obese and lean boys at different maximal heart rate reserve levels [50]

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However, after bariatric surgery, aerobic capacity of the obese patient significantly improves as a result of weight reduction. In a group of obese patients who underwent Roux-en-Y gastric bypass and lost an average of 37 kg 18 months after the procedure, peak oxygen uptake (VO 2 peak) relative to body weight increased from 21 ± 1 mL/kg/min to 29 mL/kg/min (P < 0.001), however, absolute VO 2 max slightly but significantly (P = 0.02) decreased from 2713 ± 126 mL/min to 2609 ± 187 mL/min. Furthermore, self-perceived limitations to perform PA decreased and self-perceived physical fitness increased after the weight reduction surgery. [51]

When prescribing PA for obese patients, emphasis should be placed on aerobic exercise. Such activity not just provide a higher amount of energy expenditure, but also offer the greatest cardiovascular health benefits and risk reduction. [12],[52] In addition, adults with excess body fat may greatly benefit from a program of resistance exercise. [12],[27] Strength training can also improve muscular strength and endurance, something that can help obese patients in their daily living activities. Moreover, flexibility exercises can also be included in preoperative PA program. Such exercise can be beneficial in increasing the range of motion. In order to increase patient's exercise compliance, especially with severely deconditioned person, aerobic activity can be divided into two or more bouts of exercise of at least 10 min each (for beginners, these exercise periods can be of 5 min each).

While many obese people intend to lose weight, they often have difficulty changing their current lifestyle behaviors. A common barrier among overweight/obese population, especially in women, was their feeling of too fat to engage in exercise, as the significant association was found between being too fat as a barrier and being too embarrassed to perform exercise. [53] Other known barriers to PA which have been observed among obese patients are lack of time, not much support from family and friends, low motivation, low self-efficacy, lack of self-discipline/self-management skills, excessive fatigue/dyspnea with activity, low level of aerobic capacity, the presence of musculoskeletal problems, and the absence of safe and convenient activity environment. [13] It is interesting that not all the perceived barriers are related to obesity itself. Zabatiero et al.[54] studied 19 obese adults through a one-on-one in-depth qualitative interview before they underwent bariatric surgery. The findings revealed that barriers to PA included bodily pain, physical limitation and self-presentational concerns (obesity related barriers), and lack of motivation, environment, and restricted resources, as nonobesity related barriers. [54]

Physical activity counseling for obese patients

The United States Preventive Services Task Force recommendations urge physicians to provide intensive counseling for their obese patients in order to promote sustained weight loss. [55] A study conducted on forty primary care physicians and 461 of their overweight or obese patients to examine the use of the five A's (Assess, Advise, Agree, Assist, and Arrange) counseling model by the physicians with their patients. Meetings were coded for physician use of the five A's, and patients' motivation and confidence were evaluated before and directly after the encounter. Patient changes in dietary fat intake, exercise, and body weight were measured 3 months later. [56] The findings showed that the physicians routinely asked and advised their patients to lose access weight, but they hardly assessed, assisted, or arranged. The study recommended that physicians should be encouraged to increase their use of the five A's when counseling patients for weight loss. [56]

The five A's counseling model (Assess, Advise, Agree, Assist, and Arrange) is an effective, concise counseling techniques addressing health risk behaviors, which have been used in a variety of medical care setting and different disciplines. [56],[57],[58] The five A's organizational construct is a very helpful tool for structuring PA counseling when caring for obesity weight loss. [59] The following paragraphs provide a brief description of the five A's counseling model as it relates to PA prescription for obese patients.


It means assessing PA level of the obese patient. That is estimating the frequency, intensity, and duration of PA of the patient, so healthcare provider can determine if the patient meets the minimal PA recommendations or not. More details on PA clinical assessment tools can be found elsewhere. [57] Furthermore, knowing the type of PA (weight bearing or none weight bearing; utilizing major or small muscle groups; aerobic or resistance exercise) may help in a more targeted exercise prescription. If the patient is not active, healthcare provider must assess the patient's attitude toward PA and his/her readiness to engage in PA, through the use of the transtheoretical model of stages of change (precontemplation, contemplation, preparation, action, and maintenance). More details about the use of the transtheoretical model for promoting PA are found in the following references. [60],[61]


Healthcare provider must make sure to provide the obese patient with important and relevant information on the benefits of PA and how the patient can safely engage in the preferred activity of choice for the recommended daily amount of exercise prescription (which can be divided into two or three bouts of exercise at a time). Because of the extra weight carried by the obese patient and for the sake of reducing impact load on lower body joints, total energy expenditure of PA appears more important than intensity. Patient should also be reminded that regular exercise is important for health benefits as well as for weight loss and maintenance and that resistant training can aid in maintaining muscle mass. Giving the patient an appropriately written exercise prescription with specific goals can increase compliance. Exercise is medicine initiative by the American College of Medicine has many helpful tools and resources that can be utilized by the healthcare providers ( In addition, for more PA information, and patient's handout, visit the center for disease control and prevention web page at ( Try to dispel the notion that if the patient does not have a gym membership, he or she cannot effectively exercise. Advise the patient to reduce sedentary behaviors in addition to increasing daily PA. Evidently, light-to-moderate-intensity exercise is generally safe, so symptom-limited moderate-intensity PA can be safely recommended unless patients have medical contraindications to exercise. [62] Acknowledge patient's previous success in making lifestyle changes. This can lift up the patient's confidence and encourage him/her to continue embracing more active lifestyle behaviors.


The healthcare provider and the obese patient must agree on specific behavior changes related to PA and sedentary lifestyle that to be considered. Once agreed upon, they worked together to define specific goals and means of achieving such goals. Make sure the goals are SMART (Specific, Measurable, Achievable, Realistic, and Time-bound). When counseling for PA and sedentary behaviors, the goals should be short and measurable so that the patient can see progress. If goals are set too far or too high, the patient may lose interest early in the behavioral change process. A collaborative approach and active listening that emphasize patient's choice and autonomy are critical in PA counseling. Patients who are dynamically involved in the healthcare decision-making process have a greater sense of personal control. Further, actively engaging the patient in such agreement can prevent any resistance to changes further along the process of behavior counseling. Within exercise counseling, patients can select engaging in PA of their choices and the fitness or wellness facility that seems most convenient and practical for their daily schedule.


When counseling a patient, avoid prescriptive statement such as "you should." Use patient-centered nonjudgmental counseling. Make direct eye contact with the patient. Consider the patient's choices and selections. It is also important to tailor patient's counseling to the individual stage of change. Adapting process changes may likely to be more successful. Increase the effectiveness of PA prescription by providing specific written materials that support and enhance verbal counseling. Consider increasing patient's lifestyle activity in addition to structured PA prescription. Reducing daily sitting time is also crucial for increasing daily energy expenditure. The use of pedometer or today's phone applications by the patient to track daily activity may encourage and increase patient's level of activity. A recent computer-tailored, pedometer-based PA intervention was found to be effective in increasing both pedometer-based and self-reported levels of PA among at-risk participants. [63] Healthcare provider can, also, address PA barriers with the patients and work with him/her to overcome such barriers, including increasing patient's motivation, helping to improve attitude toward PA, or learn managing time or coping skills. Such supports may be provided through a referral to other healthcare staff within the clinic or to a larger healthcare system or community health promotion services.


The healthcare provider should arrange for follow-up visit to monitor patient's adherence to exercise. In general, follow-up is best scheduled within a relatively short time period. [60] This will ensure reinforcing any progress made in changing activity behaviors. However, after initial follow-up, future contacts are often spaced at sequentially longer intervals to provide needed further support and continuity. The healthcare provider needs to make a clear description of the supports and services that can be offered to the patient as relate to PA promotional services. Other arrangements can be fulfilled by referring the patient to exercise specialists for additional assistance that alert him/her to other choices like hospital adult fitness or wellness facility, nearby community resources or exercise group with a similar goal. Incorporating PA counseling with nutritional support may sometimes send a more coherent message to the patients. Some patients may require more supervision during the initial phase of becoming active. In addition, consider family and social supports when counseling for PA. Utilize telephone, email, and social media for reminding, encouraging, and reinforcing PA counseling. [60] Try to address patient's musculoskeletal problems and resolve them by arranging with a physical therapist or foot care specialist before starting a formal PA program. Follow-ups can also take place by telephone calls or other methods of contact between the patient and the healthcare provider.

  Summary and Conclusion Top

This systematic review showed that a presurgical intervention targeting PA among obese patients awaiting bariatric surgery is feasible and has the potential to increase patient's engagement in PA postoperatively. In addition, higher levels of preoperative PA or physical fitness were associated with lower postsurgical complications and a shorter length of stay in the hospital. The review also revealed that there were some evidences supporting the view that higher levels of preoperative PA may improve weight loss outcomes following laparoscopic surgery. Moreover, incorporating a behavioral lifestyle modification including exercise program before the surgery can aid patients make the necessary lifestyle changes at postsurgical procedures. The daily time spent in sedentary behaviors among obese patients appears quite excessive. Furthermore, in adult population, the available evidence demonstrates a dose-response relationship between the amount of moderate-to-vigorous-intensity PA and increased health benefits including weight loss. It is also recommended that healthcare providers to increase their use of the five A's counseling model (Assess, Advise, Agree, Assist, and Arrange) when counseling patients about PA for weight loss. Finally, the future studies should explore the most effective and practical PA prescription that is likely going to be most feasible and compliant for obese patients prior to bariatric surgery and identify major barriers that are preventing most patients from adopting active lifestyle, which can lead to long-term weight loss and health benefits.

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Conflicts of interest

There are no conflicts of interest.

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