Physical activity and sedentary behaviors in bariatric surgery patients: A scoping review

Hazzaa M Al-Hazzaa

doi:10.4103/sjo.sjo_8_22

REVIEW ARTICLE

Year : 2019 | Volume : 7 | Issue : 2 | Page : 39-67

Physical activity and sedentary behaviors in bariatric surgery patients: A scoping review

Hazzaa M Al-Hazzaa
Lifestyle and Health Research Center, Health Sciences Research Center, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia

Date of Submission	09-Nov-2022
Date of Acceptance	09-Nov-2022
Date of Web Publication	02-Feb-2023

Correspondence Address:
Hazzaa M Al-Hazzaa
Lifestyle and Health Research Center, Health Sciences Research Center, Princess Nourah Bint Abdulrahman University, Riyadh
Saudi Arabia

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/sjo.sjo_8_22

Abstract

The present review was to evaluate the available evidences for the health impact of physical activity (PA) and sedentary behaviors (SB) in obese adults at pre-and post-bariatric surgery (BS). Articles were identified through electronic search using PubMed and Google Scholar databases. The search terms included “bariatric surgery,” “weight loss surgery,” “obesity surgery,” “weight reduction surgery,” “physical activity, “exercise,” “resistance training,” “weight training,” “strength training,” and “sedentary”. Inclusion terms were human, adults 18+ years, have clear description of PA, and published in a peer-reviewed English journal within the past 10 years. Potential articles were initially screened by titles and abstracts. Then, relevant articles were assessed, and data were extracted from the eligible articles. The initial search identified 833 records. However, after reading the titles and abstracts and removing duplicates, 62 articles remained. The findings showed that almost all studies on PA interventions before BS improved physical function and capacity, and quality of life. BS by itself increases PA among patients post-surgery. The increased PA during the first year of post-surgery were mostly maintained through several years later. However, in one study, PA at year seven post-surgery was still below PA recommendations. Another study observed little time spent in light intensity PA or in moderate to vigorous PA (MVPA) after BS. Despite that, there appears a dose-response association between more steps/more MVPA and greater weight loss. The average steps/day was between 6375 and 9108. A substantial increase in activity energy expenditure was reported from 345.4 ± 172.8 MET-min/week preoperatively to 672.8 ± 227.8 MET-min/week at 6 months postoperatively. The correlation between self-reported and sensor-based MVPA was weak. Components of the interventions in the present review were varied; some studies involved supervised exercise programs with fair details, whilst others were counselling based trials with little monitoring of PA intensity. In some of the studies investigating weight loss caused by exercise following BS, the training program is poorly reported, and the sample size, selection criteria, and follow-up time vary greatly across studies. Most self-reported changes in PA predicted postoperative weight loss. However, their validity has been questioned. Moreover, daily time spent in SB among obese patients appears excessive. In general, research supports the importance of increased PA and reduced SB in the context of BS as each is being associated with more favorable weight loss and improved health outcomes.

Keywords: Bariatric surgery, exercise, exercise prescription, obesity, physical activity, sedentary behaviors, weight loss

How to cite this article:
Al-Hazzaa HM. Physical activity and sedentary behaviors in bariatric surgery patients: A scoping review. Saudi J Obesity 2019;7:39-67

How to cite this URL:
Al-Hazzaa HM. Physical activity and sedentary behaviors in bariatric surgery patients: A scoping review. Saudi J Obesity [serial online] 2019 [cited 2023 Jun 2];7:39-67. Available from: https://www.saudijobesity.com/text.asp?2019/7/2/39/369035

Introduction

Obesity has become a significant public health concern at both global^[1] and regional^[2] scales. It is well recognized that obesity is a major risk factor for numerous non-communicable diseases, such as cardiovascular diseases, metabolic diseases like diabetes mellitus and dyslipidemia, musculoskeletal diseases, and mental disorders, as well as increased mortality.^[1] The therapeutic approach for overweight and obesity is based on lifestyle and behavioral modification, the use of medication, or bariatric surgery (BS).^[3] Lifestyle changes include a combination of reduced dietary intake and increased physical activity (PA). Exercise improves metabolic health and contributes to weight reduction and therefore is part of post-BS patient’s follow-up recommendations.^[4] However, there is a large inter-individual variability in weight loss response, and not all subjects respond in a predicted and similar way to the same intervention.^[5]

It is well acknowledged that BS induces marked weight reduction in individuals with severe obesity.^[6] Indeed, BS is the most effective and sustainable treatment for patients with morbid and complex obesity, resulting in clinically significant weight loss in the long term.^[7],[8],[9] However, based on years of follow up, surgery is not always a perfect solution, as a significant number of patients experience weight regain following BS procedure.^[5],[10] Consequently, there is an increasing emphasis on post-surgical lifestyle interventions, focusing on expanding PA and increasing energy expenditure, thus helping patients to sustain the benefits of BS and improve health outcomes.^{[4],[11],[12],[13]}

PA is considered a behavior. It is defined as any bodily movement produced by the skeletal muscles that expends energy above the resting value.^[14] The benefits of PA are well established as one of the protective lifestyle behaviors against chronic conditions such as coronary heart disease, type 2 diabetes, and many types of cancer.^[14] In addition, greater increases in levels of total PA and time spent in moderate- to vigorous-intensity PA (MVPA) after BS predicted better weight loss and larger reductions in fat mass and waist circumference.^{[15],[16],[17],[18]} Participants who reported achieving PA ≥ 150 minutes per week had smaller percentage of weight regain compared with less active participants.^[19] However, not all studies found an association between increased PA and greater weight loss beyond that induced by BS alone.^[20] Further, supervised resistance training leads to improvements in muscle strength,^[21],[22] quality of life,^{[15],[23],[24],[25]} and cardiopulmonary fitness,^{[20],[26],[27]} thus, increasing the patient’s capacity to perform activities of daily living after bariatric surgery. Adherence to PA is a determinant of the effectiveness of weight Loss among patients undergoing BS.^[28] Additionally, improvement in skeletal muscle insulin sensitivity appears related to those patients who reported increases in their PA postoperatively.^[29]

Sedentary behaviors (SB) are increasingly becoming common nowadays. SB has been defined as “any waking behavior characterized by an energy expenditure ≤ 1.5 metabolic equivalents (METs) while in a sitting or reclining posture,” excluding sleep time.^[30] SB is considered an important risk factor for mortality and several chronic diseases, including cardiovascular disease and type 2 diabetes, independent of PA levels.^[31],[32] In addition, evidence from epidemiological research showed that sitting is associated with cardiovascular disease biomarkers, such as waist circumference, high blood pressure, and abnormal levels of lipids profile.^[33] Also, a recent prospective study found that a long-term reduction in sedentary behavior improved peripheral vascular function and cerebral blood flow in peoples with high cardiovascular risk.^[34] All this has recently prompted the World Health Organization to issue recommendations to decrease SB at all ages as part of their PA and SB guidelines.^[14] SB is believed to be associated with adverse health outcomes in a way that is thought to be different from those attributed to physical inactivity.^[35] Therefore, it is possible to be both physically active and sedentary at the same time if one is able to achieve the minimum amount of MVPA per week through structured exercise and also spends prolonged periods of time sitting.^[36] Attention to SB among patients after BS is important, as one study observed that the mean sitting time among BS patients was over 13 hours per day.^[37] In another study, SB appears to be adversely related to obesity severity among the bariatric patients.^[38]

Given the potential benefits of increased PA and reduced SB for the BS patients, and with the increased proliferation of research outputs on this topic in the past few years, this scoping review aimed to assess the impacts of PA and SB in adults with obesity undergoing BS. Such information would allow clinicians and practitioners to clearly determine the potential influence of structured PA interventions on pre- and post-BS weight loss and maintenance as well as other postoperative physical function outcomes.

Materials and methods

This review represents a scoping review. Scoping reviews are considered an ideal means to determine the scope or coverage of a body of literature on a specific topic and provides strong indication of the volume of existing studies and literature and their emphasis. As appose to systematic reviews, scoping reviews appears as valuable approach to examine emerging or developing evidence when addressing specific questions. Indeed, scoping reviews have recently arose as a valid approach with rather different indications to those for systematic reviews.^[39]

Search strategy

Articles were identified through electronic searches using PubMed and Google Scholar databases. The search included relevant documents from August 8, 2012 up to August 8, 2022 (10 year-period). The search terms included “physical activity” AND “bariatric surgery,” “physical activity” AND “weight loss surgery,” “physical activity” AND “obesity surgery,” “physical activity” AND “weight reduction surgery,” “exercise” AND “bariatric surgery,” “resistance training” AND “bariatric surgery,” “weight training” AND “bariatric surgery,” “strength training” AND “bariatric surgery,” and “sedentary” AND “bariatric 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.

Inclusion/exclusion criteria and data extraction

The search included any intervention (that sought to increase PA or reduce SB), prospective, observational, or cross sectional studies that described PA levels or sedentary time of obese patients, or related to the impact/associations of PA on health outcomes such as reducing BMI, improving well-being, or enhancing physical function and cardiorespiratory fitness of patients awaiting or undergone bariatric surgery. For inclusion, a study must involve human, adults 18 + years, within the last 10 year-period, have clear description of PA assessment, be published in a peer-reviewed journal, and in English language. PA measures included self-reported and objective methods (e.g. accelerometer, pedometer). Studies were excluded from the search if they were not published in English, involved children or adolescents, focused on populations with specific conditions, such as heart diseases or cancer, or were considered qualitative interview studies. Potentially relevant articles were initially selected by screening titles and abstracts. If abstracts did not provide enough information, the full article was retrieved and screened. Then, relevant articles were assessed, and data were extracted from the eligible articles. The reported characteristics of the extracted data for the present study included the following items: names of authors, year of publication, type of the study, sample size, gender, age, body mass index (BMI), description of the study’s methodology, and the main findings.

Results

The initial literature search identified a total of 833 records. However, after reading the titles and the abstracts and removing duplicate studies and irrelevant papers (based on inclusion/exclusion criteria), 62 articles remained.^{[11],[12],[13],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[37],[38],[40],[41],[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[57],[58],[59],[60],[61],[62],[63],[64],[65],[66],[67],[68],[69],[70],[71],[72],[73],[74],[75],[76],[77],[78],[79],[80],[81],[82],[83],[84]} Among these remaining articles, 16 are related to PA and pre-bariatric surgery, 42 articles are linked to PA and post-bariatric surgery, and 12 papers deal with SB and bariatric surgery, including some studies having assessed both PA and SB at the same time. [[Tables 1] to 3] present the descriptive characteristics of the analyzed studies. Intervention studies including randomized controlled trials represent 27 papers. Cross sectional studies are 22. Prospective (and longitudinal) studies are 15. Observational studies are five and one study is a quasi-experimental paper. The following paragraphs summarize the overall findings of the current review, which were shown in more details in [Table 1] to [Table 2] [Table 3].

Table 1: Descriptions of the physical activity studies conducted before bariatric surgery

Click here to view

Table 2: Descriptions of studies on physical activity conducted after bariatric surgery

Click here to view

Table 3: Descriptions of studies on sedentary behaviors conducted before or after bariatric surgery

Click here to view

Physical activity studies conducted before bariatric surgery

Almost all studies on PA interventions before bariatric surgery showed improvements in physical function, quality of life, functional capacity (aerobic power and other fitness components such as muscle strength and endurance performance) as well as an increase in maximal fat oxidation during exercise.

Some studies, mostly using subjective PA assessment, observed an increase in self-reported PA and that such self-reported changes in PA were predictive of postoperative weight loss after bariatric surgery.^[23],[51]

Some studies showed increases in the number of steps per day and time spent per day in light and moderate PA in the intervention group for up to one year after bariatric surgery compared to the reference group.^[47],[49]

Studies, especially cross-sectional and observational studies, found inadequate levels of PA among patients awaiting bariatric surgery.^[45],[52] Also, one studies found that the majority of patients who were awaiting bariatric surgery were sedentary.^[52] In addition, a study found that almost two thirds of the subjects waiting for bariatric surgery reported limitations with walking several blocks.^[54]

Higher levels of preoperative PA participation were associated with improved weight loss outcomes following bariatric surgery.^[53] Also, two studies found reductions in body weight and BMI and improvement in body composition compared to the control group.^[46],[50] However, two other studies showed no change in body weight loss, BMI, or waist circumference above that was due to bariatric surgery.^[44],[48]

Physical activity studies conducted after bariatric surgery

An observational study showed significant increases in PA (from 77 to 106 min/week) during the first year of post-surgery, which are maintained through 3 years.^[77] In a prospective study, a mean PA level at year seven post-surgery was still below PA recommendations for health. However, there was a dose-response association between more steps, and higher moderate to vigorous PA (MVPA) with greater weight loss. Despite small increases in objectively-measured PA level after RYGB, PA was independently associated with weight outcomes throughout 7 years of follow-up.^[55]

In a longitudinal study, little time was spent in light intensity PA (nearly 21%) and almost no time in moderate-to-vigorous intensity PA (about 5%) after bariatric surgery. Step count and cardiovascular fitness were also unchanged.^[13] Also, in a cross sectional study and objective assessment of PA, patients did not change their moderate to vigorous PA (min/day) significantly at 35 days post-surgery (2.6 ± 5.6) compared with 12 days pre-operative (1.5 ± 2.1).^[63] In another cross sectional study, participants averaged 7403 ± 3243 steps per day and that median moderate to vigorous PA (MVPA) time was only 5.6 min/day.^[56] In one report, participants averaged 6375 ± 2690 steps per day.^[78] Higher steps were reported, however, among 40 females 12 to 18 months after laparoscopic sleeve gastrectomy where median daily step count was 9108 ± 4360, but very little time (5%) was spent in moderate to vigorous PA.^[79]

The correlation between self-reported and sensor-based MVPA was weak (0.072).^[56] In another study, mean (SD) PA time (min/day) before surgery was 38.98 (26.50), at 3 months post-surgery was 41.86 (34.37), at 6 months post-surgery was 45.64 (37.30), and at 12 months post-surgery reached 46.66 (42.39).^[57] However, Sivas, et al., 2020^[65] observed a substantial increase in PA from 345.4 ± 172.8 metabolic equivalent (MET)-min per week preoperatively to 672.8 ± 227.8 MET-min/week at 6 months postoperatively.

One study found no significant differences in PA from 3 months pre-surgery to 9 months post-surgery among women undergoing RYGB.^[76] Another prospective study resulted in no pre- to postoperative improvements in PA.^[17] However, greater increases in levels of total PA and time spent in moderate to vigorous PA from 3 months before surgery to 6 months post-surgery predicted better weight loss and larger reductions in fat mass and waist circumference.^[17] Additional study observed that Roux-en-Y gastric bypass (RYGB) improves health related quality of life, but fails to increase the patients’ overall PA level over time when objectively assessed.^[25] Further, a prospective study showed that the majority of bariatric surgery candidates were physically inactive pre-surgery, with no significant change in subjectively or objectively measured PA at follow-up.^[69]

Significant associations between moderate to vigorous PA and weight loss outcomes were found among 303 Roux-en-Y Gastric Bypass (RYGB) patients.^[16] Increases in overall PA and steps per day were also related to weight loss, and higher high-density lipoprotein cholesterol and insulin sensitivity.^[74] Further, weight loss between the start and the end of a 12-month exercise program was greater among participants in the intervention than among treatment as usual patients, and that participants in the intervention group increased their levels of habitual PA, quality of life, and physical fitness..^[61]

Adherence to good lifestyle habits is important. After one year of bariatric surgery, weight loss differed significantly between good and poor weight-loss-responders. The odd of losing weight was higher among the adherent group (4.37 more odds (95% CI: 2.19, 8.88)) compared with less adherent one. Further, those patients practicing muscle-strengthening activities were the most significant weight loss respondents at 3, 6, and 12 months after bariatric surgery.^[28] Moreover, using IPAQ-SF short-form questionnaire that was collected at one-year post-bariatric surgery, those who lost above 50% of their excess weight (EWL) performed an average of 420 min of total activity per week versus 300 min for those lost less than 50% of their excess weight. The ≥ 50% EWL group engaged in 120 minutes of vigorous activity, 150 minutes of moderate activity, and 233 minutes of walking compared to 40, 68, and 188 minutes, respectively, for the <50% EWL group.^[81]

Another study confirmed the important of exercise adherence in weight loss port-BS. Compared with the patients who did not adhere to PA, weight loss was higher in the adherent group at 6 months (29 ± 4% vs. 26 ± 5%; P = 0.01) and 3 years (32 ± 8% vs. 26 ± 6%, P = 0.005).^[15]

In one study, weight, fat mass, and fat-free mass were reduced significantly at 3 and 6 months, without any additive impact of training in the exercise group.^[20] However, another study showed that fat-free mass was lower ((-7.9 kg) at 9 months after RYBG compared to pre-surgery than RYGB plus training group (-4.9 kg; p < 0.01).^[58] In one randomized Intervention study, the exercise group showed reductions in fat mass (-2.5 ± 2.6 kg, P < 0.05), glycaemia (-13.4 ± 8.7 mg·dL-1, p < 0.01) and blood cholesterol (-24.6 ± 29.1 mg·dL-1, p < 0.05), whereas the control group during the same period showed increases in weight (1.5 ± 1.3 kg, p < 0.05) and fat mass (1.8 ± 0.9, p < 0.01).^[62] Additional randomized control study showed a significant difference (5.6 kg) between groups in body mass change from baseline to 24 weeks favoring the exercise group.^[73] Moreover, a randomized intervention study found that patients in the highest quartiles of steps change per day lost more fat mass (p < 0.05) and abdominal adipose tissue (p < 0.05), and maintained skeletal muscle mass (p < 0.05) compared to the lowest quartiles.^[71] Also, an intervention study found that weight, percent body fat, and fat mass reduced greater in the intervention group compared with the control group (p < 0.05).^[72] Accelerometer-determined MVPA and steps per day were inversely associated with percent fat (r = -0.53, -0.46), and abdominal fat (r = -0.36, -0.40), and directly associated with VO₂ max (r = .36).^[80]

It appears that regular exercise in excess of 200 min/week was shown to associate with greater medium-term weight loss following laparoscopic bariatric surgery.^[67] In an intervention study, participants who reported physical activity ≥ 150 min/week had smaller percent weight regain compared with less active participants, and had considerably higher quality of life.^[24] Furthermore, a PA program following Roux-en-Y Gastric Bypass improves weight loss and cardiovascular health, as one study observed that supervised PA intervention resulted in a 4.2 kg lower body weight in the intervention group compared with the control group at the end of 26 week period (p = 0.042).^[68]

A 12-week supervised training program has an additive benefit on cardiorespiratory fitness for patients who undergone bariatric surgery. Although V̇O₂ peak increased significantly from 3 to 6 months in both exercise and control groups, the increase was higher among the exercise group.^[20] Also, applying a physical training program to a group of obese women after 3 months of bariatric surgery promoted a significant increase in cardiopulmonary fitness (VO₂ peak and total cardiopulmonary testing duration).^[27]

Surgery resulted in a similar reduction in lower-limb muscle strength in RYGB and RYGB plus exercise training (-26% vs. -31%). Also, patients in RYGB plus training had greater absolute (214 vs. 120 kg, P < 0.01) and relative to body weight muscle strength compared with RYGB alone at 9 months post surgery, and that the muscles of exercised patients resembled that of healthy lean individuals..^[58] In one study involving bariatric surgery patients with morbid obesity, adherence to resistance training appears relatively high (84%).^[21] Supervised resistance training seems to lead to improvements in strength and physical functioning, increasing the patient’s capacity to perform activities of daily living after bariatric surgery.^[21] Moreover, combined resistance training and adequate protein intake through supplementation can increase fat-free mass and skeletal muscle mass.,^[59] or can overcome the loss in muscle mass observed after bariatric surgery.^[22],[70]

Self-reported changes in physical activity were predictive of postoperative weight loss after bariatric surgery.^[18] However, several studies found discrepancy between self-reported PA and device-measured PA. In one study and in comparison with pre-surgery, self-reported MVPA increased by 46.9% and 36.5% from pre- to 9- and 48 months, respectively, whereas changes were a 6.1% increase and 3.5% decrease with accelerometers. The correlations between self-reported and accelerometer-measured MVPA were poor at all measurement points.^[64] Other studies showed similar findings.^{[56],[85],[86]}

Sedentary behaviors studies conducted before and after bariatric surgery

Among 142 patients with a history of bariatric surgery, the mean sitting time was 796.0 (SD = 47.0) min/day.^[37] In another study, the bariatric female patients spent most of their time sedentary, averaging 832 min/day.^[56] Also, the mean sedentary time (min/day) assessed objectively before surgery, at 3 months post-surgery, at 6 months post-surgery, and at 12 months post-surgery were 634, 630, 611, and 574, respectively, with no significant differences across times after adjusting for average daily wear time.^[57]

Obese patients, scheduled to undergo Roux-en-Y gastric bypass/sleeve gastrectomy, showed an accumulated mean sedentary time per day (standard deviation) of 10.5 (2.1) hours and that more sitting time correlated with sever obesity.^[38] Similarly, patients who have undergone bariatric surgery 8.9 ± 3.8 years earlier, displayed an average setting time of 9.7 ± 2.3 hours/day.^[78] Slightly lower mean sitting time of 7 ± 4 hours/day was reported for 303 Roux-en-Y Gastric Bypass patients.^[16]

Over 70% of adults 12 to 18 months after laparoscopic adjustable gastric banding or 6 to 18 months after laparoscopic sleeve gastrectomy were sedentary. Half of the time in sedentary behaviors was accumulated in uninterrupted bouts ≥ 30 minutes.^[79]

Among 52 bariatric surgery candidates, television-viewing was the most frequently type of sedentary behaviors (2.7 ± 1.6 hours/day), followed by paper or computer work (1.9 ± 1.8 hours/day), driving/riding in automobile (1.2 ± 1.1 hours/day), and sitting/talking on telephone (1.1 ± 1.2 hours per day).^[83] Longer sedentary time occurred more frequently in those with high rates of weight regain and longer time since bariatric surgery. Also, sedentary time self-reported versus objective measures were correlated (p < 0.001).^[60]

Patients who were assessed at 1–3 months after RYGB surgery and again at 9 months post-surgery decreased their sedentary time (-47.9 ± 101.0 min/day, p = 0.002). However, 39% increased sedentary behaviors (p < .001). Decreasing sedentary time was related to decreased fat mass (rho = 0.35, p = .012) but not to other cardiometabolic risk factors.^[74]

An observational study showed that over the first year, sedentary time decreased from 573 to 545 minutes per day among 473 participants who undergone bariatric surgery..^[77] Also, a randomized controlled study showed that after one year of gastric bypass surgery, TV viewing time decreased significantly (p < 0.05) from 3.0 (SD: 1.6) to 2.4 (SD: 1.4) hours/day. The study attributed this decrease in sedentary behaviors to favorable changes in body composition after the surgery.^[84]

On the contrary to the above mentioned studies, amongst 41 obese patients undergoing Roux-en-Y gastric bypass or sleeve gastrectomy, there were no pre- to postoperative improvements in objectively measured sedentary behaviors.^[17] Among 303 Roux-en-Y Gastric Bypass patients, sitting time was independently inversely associated with total weight loss (kg) and percent weight loss.^[16]

Discussion

The present scoping review aimed to review the available evidences for the health impact of PA and SB in adults with obesity at pre-and post-BS. The findings of this review showed that almost all studies on PA interventions before BS improved physical function, quality of life, functional capacity as well increased maximal fat oxidation during exercise. Also, BS mostly leads to an increase in PA among patient post-surgery.^{[15],[23],[24],[65]} The increased PA during the first year of post-surgery were maintained through 3 years.^[77] There appears a dose-response relationship between more steps and more MVPA and greater weight loss.^[55] On the contrary, one study observed little time was spent even in light intensity PA, almost no time in moderate-to-vigorous intensity PA, and that step count and cardiovascular fitness were also unchanged after bariatric surgery.^[13] Objective assessment of PA indicated that patients did not change their moderate to vigorous PA significantly post-surgery compared with pre-operative.^[63] The average steps/day was between 6375 and 9108.^{[56],[78],[79],[82]} The correlation between self-reported and sensor-based MVPA was weak..^[57],[65] However, a substantial increase in activity energy expenditure in metabolic equivalent (MET) was reported from 345.4 ± 172.8 MET-min/week preoperatively to 672.8 ± 227.8 MET-min/week at 6 months postoperatively.^[65] Components of the interventions reported in the present review were varied; some studies involved repeated supervised exercise programs with fair details of the structured exercise sessions, whilst others were counselling based trials with little monitoring of the intensity of PA. Further, in many of the studies that have investigated weight loss caused by exercise following bariatric surgery, the training program is poorly reported, the exercise type, volume, and intensity are briefly mentioned, and the sample size, selection criteria, and follow-up time vary greatly across studies.^[87] In addition, although self-reported outcome measures were consistently showing an increase in PA post-surgery, the heterogeneity of measurement tools makes comparisons between studies very challenging.^[88] Both objective and self-reported tools were used to measure PA and SB in the reviewed studies. The questionnaires are inexpensive, more easily available and with good reliability. Self-reported changes in physical activity were shown to predict postoperative weight loss after bariatric surgery.^[18] However, their validity has been questioned, as the correlations between self-reported and accelerometer-measured MVPA were low at all measurement points.^{[56],[64],[85],[86]} In one study for instance, objective measures (by ActiGraph GT3X+ accelerometer) showed that 17.9% of the participants met the recommended level of MVPA of ≥ 150 min/week, whereas 80.2% met the recommended level according to self-reported measures.^[85] A meta-analysis of the effect of BS on PA showed significant improvement in a population with obesity up to 3 years post-surgery. Objective measurement of PA did not show significant improvement within 6 months of BS, but started to improve at >6 months, whereas self-reported assessment of PA begins to display improvement within 6 months of a BS.^[89] Further, objectively measured movement behaviors do not improve after bariatric surgery despite a substantial weight loss,^[17] and that the discrepancy between self-reported and objectively assessed MVPA within the same individual is high.^[64] In addition, pre- to post-RYGB surgery increases in self-reported PA were not confirmed by accelerometer-measured PA.^[86]

PA prior to BS

The current scoping review is an update on earlier narrative reviews focusing on feasibility and implementation of pre-surgical PA interventions among obese patients awaiting bariatric surgery.^[90],[91] The findings of the present review indicated that a pre-surgical intervention targeting PA among patients awaiting bariatric surgery has the potential to increase their engagement in PA postoperatively.^[49],[53] In addition, higher levels of preoperative PA or physical fitness were associated with lower post-surgical complications and a shorter length of stay in the hospital.^[92] The current review also revealed that higher levels of preoperative PA may improve weight loss outcomes following laparoscopic surgery.^[51],[53] Moreover, incorporating a behavioral lifestyle modification including PA program before the surgery, can improve fitness, increase PA and help patients make the necessary lifestyle changes at post-surgical procedures.^{[44],[47],[49],[50]} In a randomized clinical trial, a preoperative medically supervised weight management program showed a positive influence on postoperative PA level, despite no significant postoperative difference in weight loss.^[93] In addition, a systematic review assessed the effect of a pre-operative exercise intervention on short- and long-term health and clinical outcomes for adult patients undergoing BS and concluded that pre-operative exercise can induce significant short- and long-term improvements in cardiorespiratory fitness (VO₂ max) in individuals with obesity, however, pre-BS exercise intervention had no significant effect on percentage total weight loss post-BS.^[94] The American Society for Metabolic and Bariatric Surgery (ASMBS) emphasized that pre-surgical behavioral intervention can support weight loss and that lifestyle change is the standard of care.^[95]

The Bari-Active study, a randomized controlled trial, tested the efficacy for a pre-surgical intervention to increase PA levels in a group of bariatric surgical patients.^[82],[96] The 6-week behavioral PA intervention intended to increase moderate intensity walking exercise by 30 minutes per day and to increase daily step counts by 5,000. The findings indicated that compared to baseline, there was an increase of 21 minutes per day in moderate-to-vigorous PA after 6 weeks in the intervention group, whereas the control group exhibited no change in minutes of moderate-to vigorous PA. Step counts increased by over 2,000 in the PA intervention group compared to 200 in the controls. By the end of the study, 30% of participants in the PA intervention and 14.3% in control groups met the recommended guideline of 150 minutes per week of moderate-to-vigorous PA.^[82],[96]

PA and weight loss after BS

An important finding reported by numerous studies was that the changes in overall PA and steps per day were associated with greater loss in body weight and fat mass.^{[15],[16],[27],[18],[26],[61],[62],[67],[68],[71],[73],[74],[80],[81]} An earlier systematic review showed that the contribution of exercise training following bariatric surgery appears to result in additional weight loss of over 4% of BMI after one year postoperative period.^[97] A meta-analysis of randomized controlled trials concluded that engaging in PA after bariatric surgery offers 1.94 kg additional weight loss and 29.67 meters longer distance in the 6 minutes walking test compared with surgery alone. Moreover, participating in exercise program one year or longer after surgery, which includes a combined aerobic and resistance training sessions may result in greater weight loss.^[98] Another study reported that taking part in a minimum of 150 min/week of MVPA was associated with greater postoperative weight loss at six (5.5%) and 12 (5.7%) months postoperatively.^[99] Increased PA had also been linked to smaller percentage in weight regain,^[19] and a lower reduction (or an increase) in fat-free mass compared with less active patients.^{[55],[58],[59],[70],[72]} A systematic review reported that compared with the control group without exercise, postoperative exercise training led to higher weight loss, fat loss, and an increase in VO₂ max.^[100] However, one study did not show any additive impact of exercise training on weight, fat mass, or fat-free mass.^[20] In addition, supervised resistance training leads to improvements in muscle strength,^[21],[22] quality of life,^{[15],[24],[25]} and cardiopulmonary fitness,^{[20],[26],[27]} increasing the patient’s capacity to perform activities of daily living after bariatric surgery. It can also enhances weight loss.^[28]

PA and cardiopulmonary fitness after BS

The present review indicated that exercise training leads to improvements in cardiopulmonary fitness,^{[20],[26],[27]} which contribute to the patient’s capacity to perform activities of daily living after bariatric surgery. Reduced cardiorespiratory fitness levels were shown to associate with increased short-term complications after bariatric surgery. In one study, cardiorespiratory fitness was evaluated in 109 patients with morbid obesity prior to laparoscopic Roux-en-Y gastric bypass surgery.^[92] Their mean age and BMI were 46.4 years and 48.7, respectively. The findings indicated that the combined complication rate was 16.6% and 2.8% (p = 0.02) among patients with peak oxygen uptake of less than 15.8 ml/kg-min or above 15.8 ml/kg-min, respectively. In addition, the results showed that the length of stay in the hospital was highest among those patients with lower peak oxygen uptake and that peak oxygen uptake was a significant predictor of complications (odd ratio = 1.61; 95 CI = 1.19–2.28, p = 0.002).^[92] Consequently, improving cardiorespiratory fitness before bariatric surgery should highly be considered in order to reduce postoperative complications. Other studies also showed similar findings with the previous results. They concluded that, for a number of types of surgeries including bariatric surgery, higher post-surgical risks and a longer length of stay in the hospital were related to low pre-operative peak oxygen uptake or low anaerobic threshold, as measured by a graded cardiopulmonary stress test.^[101],[102] Indeed, even among general obese population, the prognostic value of exercise capacity (higher cardiorespiratory fitness level) was found to be highly significant.^[103] The age-adjusted relative risk (aRR) of death for obese patients achieving a peak exercise capacity of less than 5 metabolic equivalent of task or (METs) was 2.23, and from 5 to 8 METs the aRR = 1.6, which were much higher than those achieving a peak of more than 8 METs (aRR = 1.0). These findings clearly indicate that the relative risks of death from obesity (BMI > 30) significantly increases as exercise capacity decreases.^[103] Furthermore, 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 (VO₂ peak) relative to body weight increased from 21 ± 1 ml/kg-min to 29 mL/kg-min (p < 0.001), however, absolute VO₂ max slightly but significantly (p = 0.02) decreased from 2713 ± 126 ml/min to 2609 ± 187 mL/min. Furthermore, self-perceived limitations to perform physical activity decreased and self-perceived physical fitness increased after the weight reduction surgery.^[104]

PA and musculoskeletal function after BS

A recent study, using bioelectrical impedance analysis, showed that the prevalence of excessive fat-free mass (FFM) loss was high and that patients lost most of FFM within 3 to 6 months post-BS.^[105] Additionally, patients were found to experience substantial decreases (−13% ± 6%) in total lean mass after 12 months following Roux-en-Y gastric bypass.^[106] A meta-analysis review carried out on a large number of data of patients with morbid obesity after BS showed that BS was associated with sustained declines in FFM at 1, 3, 6, and 12 months after the surgery (-3.47 kg, -5.59 kg, -6.61 kg, and 12 -8.34 kg), respectively.^[107] High FFM values before surgery and being a male predicted a more severe FFM loss after laparoscopic sleeve gastrectomy.^[108] Findings from a systematic review and meta-analysis revealed an increase in muscle strength, but no significant effect was found on lean body mass.^[100] In another study conducted on patients after Roux-en-Y gastric bypass surgery, lean mass and absolute grip strength declined after the BS, however, relative muscle strength and physical function improved meaningfully.^[106] Moreover, a systematic review investigated the resistance exercise impacts on post-metabolic and BS patients and found that resistance training consistently prevented strength loss particularly when performed by younger population (about 35 years) and also prevented lean mass loss. However, combined aerobic and resistance exercise, but not strength training independently, was found to promote body fat mass loss.^[109] Also, exercise interventions already improved both upper (effect size, 0.71) and lower (effect size, 1.37) limb muscle strength, as measured by repetition maximum tests, but not handgrip test (effect size, 0.11).^[110]

Further, in recent years, accumulating evidences suggests that Roux-en-Y gastric bypass is associated with a greater reduction in bone mineral density (BMD) and higher fracture risk.^[111] All this emphasize the need for more vigorous approaches to counteract FFM loss and reduced BMD after BS. Therefore, it is recommended that before and after all bariatric procedures, sufficient calcium, vitamin D and protein intake, and adequate weight bearing PA are needed to counteract these negative impacts.^[111] A recent randomized controlled trial has reported that an exercise program was an effective strategy to ameliorate bone health in post-BS patients.^[112] Also, a 6-month supervised exercise training program after Roux-en-Y gastric bypass was shown to mitigate bariatric surgery-induced bone loss.^[113]

PA and energy expenditure after BS

It is well recognized that resting energy expenditure (REE) decreases after weight loss more than expected according to body composition changes.^[114],[115] The main reason for this reduction in REE is the large weight loss as well as the reduced lean body mass. It is believed that the reduction in REE plays an important role in unsatisfactory weight loss effect by contributing to positive energy balance.^[116] A recent study observed that patients after sleeve gastrectomy exhibited a weight loss of 31.5 ± 7.4% at the end of the first month and a weight regain of 8.9 ± 7.5% at the fifth months. Fat mass showed a slight and significant increase from month one to month five (p = 0.011), whereas free fat mass remained unchanged (p = 0.304). PA increased at month one (p < 0.001), but remained stable at month five (p = 0.9). Measured REE showed a 31.2% decrease with a corresponding reduction of the predicted REE of 21.4% at month one, compared with fifth month (p = 0.005).^[114] The maintenance of FFM was found to be an important factor linking percentage of total weight loss and relative REE (REE/body weight) in Chinese patients six months after laparoscopic sleeve gastrectomy.^[116] Further, there is a growing evidence from preclinical and clinical studies suggesting that Roux-en-Y gastric bypass and sleeve gastrectomy may enhance brown and beige adipose tissue thermogenesis.^[117] Brown and beige adipose tissues have emerged as major regulators of whole-body energy metabolism in humans.^[118] In a study on mice, high intensity exercise was found effective for the browning of white adipose tissue and the increase of fibroblast growth factor 21 in skeletal muscle.^[119] Additionally, weight-adjusted non-exercise activity thermogenesis (NEAT), which is an energy expended from lifestyle PA of daily living, correlated inversely with body mass index among patient with obesity aiming at bariatric surgery.^[120]

Other benefits of PA after BS

There are so many benefits to losing excess weight and increasing PA after BS. Indeed, patients observe improvements in musculoskeletal function after weight loss that translate into more mobility and higher strength improvements, thus facilitating more activities of daily living.^[82] Meeting the PA recommendations^[24] and overall engaging in more MVPA^[15],[62] were associated with higher health-related quality of life among BS patients with obesity. Further, in a prospective study conducted on patients who underwent BS, it was shown that BS resulted in lower depression scores, as measured by the Beck Depression Inventory (20.2 ± 8.5 preoperatively and 9.9 ± 7.4 postoperatively) and higher PA levels, as measured by the International Physical Activity Questionnaire (345.4 ± 172.8 METs-min/week preoperatively and 672.8 ± 227.8 METs-min/week postoperatively).^[65] In addition, the increase in habitual PA after BS appears to result in improvements in skeletal muscle insulin sensitivity and the loss of visceral fat mass.^[29] On contrast, lower MVPA and higher sitting time are associated with more appetite disinhibition.^[57] Adults undergoing bariatric surgery, who engage in approximately one hour of MVPA per week, were found less likely to have recently received treatment for depression or anxiety compared to less active counterparts.^[121]

Reducing sedentary behaviors (SB) after BS

Nowadays, there is a growing evidence SB is a distinct risk factor for weight gain, cardio-metabolic disease, and mortality independent of PA participation.^{[31],[32],[122]} A reduction in SB appears to improve peripheral vascular function and cerebral blood flow in peoples with high cardiovascular risk.^[34] A longitudinal Danish study indicated that after adjusting for physical activity levels, total sitting time remained a risk factor for diabetes only in inactive and obese populations.^[123] Research evidence suggests that interventions need to be tailored to not only increase moderate-to vigorous PA among obese patients, but also to reduce screen time as well.^{[37],[38],[83]} Several studies, employing objective and subjective monitoring of SB, were consistent in showing that the daily time spent being sedentary among obese patients was between 9.5 and 11 hours.^{[83],[124],[125]} In fact, BS candidates appeared to spend over 80% of their time in sedentary behaviors.^[124] A recent study involved adults who participated in the National Health and Nutrition Examination Survey (2013–2018) and self-identified a history of bariatric surgery, indicated that the mean sitting time among BS patients was 796.0 minutes per day.^[37] In another study, SB appears to be adversely related to obesity severity among bariatric patients who accumulated a mean of 10.5 hours of sitting time per day.^[38] As to the difference in SB between pre- and post-BS, no significant differences were seen in objectively measured changes (Actigraph accelerometer) in time spent sedentary when comparing 3 months pre-surgery and 9 months post-surgery among Swedish women who underwent Roux-en-Y gastric bypass and were able to reduce their BMI by 11.7 kg/m² during the 9 month period.^[76] In contrast to the previous finding, BS patients were able to make small reductions in sedentary behaviors and increased their physical activity during the first post-surgery year while maintaining such levels of activity afterward through 3 years.^[77]

Practical implications for clinical practice

The following sections present some practical implications of PA prescription including PA recommendations for weight loss among BS patients, most common barriers to engaging in exercise training for the BS patients, the Five A’s counselling model, and assessing and promoting PA via Mobile health.

PA recommendations for weight loss in BS patients

There are numerous benefits for adopting an exercise training by the post-BS patients. [Box 1] illustrates a summary of such benefits. It appears that most of the improved health benefits due to increased PA occur within the initial 60 minutes of moderate- to vigorous-intensity daily PA.^[14],[126] Among obese patients, however, the American Society for Metabolic and Bariatric Surgery (ASMBS) recommends light aerobic exercise and resistance training for 20 minutes per day, 3 to 4 days per week preoperatively to enhance cardiorespiratory fitness, decrease the risk of surgical complications and improve postoperative recovery.^[127] A similar preoperative exercise recommendations, of low- to moderate-intensity physical activity for at least 20 minutes per day for 3 to 4 days per week, was also endorsed by the American Heart Association.^[128] In addition, 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 daily PA of at least 30 minutes per day.^[95] 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 minutes per week in order to induce clinically substantial weight loss.^[129]

When prescribing PA for obese patients, emphasis should be placed on aerobic exercise. Such activity not just provides higher amount of energy expenditure but also offers the greatest cardiovascular health benefits and risk reduction.^[129] Besides, adults with excess body fat may greatly benefit from a program of resistance exercise after BS.^{[21],[22],[129]} Strength training can also improve muscular strength and endurance, something that can aid obese patients in their daily living activities. Moreover, flexibility exercises that increase range of motion can also be incorporated in a preoperative PA program. In order to increase patient’s exercise compliance, especially with severely deconditioned patient, aerobic activity can be divided into two or more bouts of exercise of 10 minutes each. The European Association for the Study of Obesity Physical Activity Working Group has issued a set of recommendations regarding exercise training in the management of overweight and obesity in adults^[130] and are shown in [Box 2]. The working group has included high intensity interval training (HIIT) as an effective exercise training for preventing and managing obesity, however, this type of exercise requires the patient to be of low cardiovascular risk. Evidently, light to moderate-intensity exercise is generally safe, so symptom-limited moderate-intensity physical activity can be safely recommended unless patients have medical contraindications to exercise.^[131]

Barriers to PA in the BS patients

Although many peoples with obesity may be motivated to lose weight, they often face some barriers and challenges when trying to change their current lifestyle behaviors. Numerous barriers to PA have been observed among obese patients. Among these barriers are lack of time, low self-efficacy, low motivation, not much support from family and friends, 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.^[132] It is interesting that not all the perceived barriers are related to obesity itself. A one-on-one in-depth qualitative interview of 19 obese adults before they underwent bariatric surgery revealed that barriers to physical activity included bodily pain, physical limitation and self-presentational concerns, as obesity related barriers, whereas non-obesity-related barriers included lack of motivation, environment and restricted resources.^[133] Preoperative musculoskeletal pain was found highly common among candidates for bariatric surgery. However, most individuals with pre-surgical pain experience significant improvement postoperatively.^[134] Further, a common barrier among overweight or obese population, especially in women, was their feeling of having too much fat to engage in exercise, as significant association was found between being too fat as a barrier and being too embarrassed to perform exercise.^[135] Also, barriers among women with average of 15 months posts-BS included weight-restricted mobility, side effects of surgery, body dissatisfaction, compromised psychological health, competing responsibilities, a lack of exercise self-efficacy and social support, reduced access to accommodating facilities, lack of exercise knowledge, and northern climate.^[136] Moreover, among patients who were split into preoperative and postoperative groups, the preoperative group had a higher score of barriers to engage in PA, as well as environment and family discouragement, when compared to the postoperative group. Those with higher education scored more in the lack of time. The factors most determinants were physical inactivity, BMI over 36.9 kg/m², age 42 years old or under, and higher education.^[137] An interesting finding reported as a barrier to PA among women after BS was the presence of excess skin. However, the study concluded that the main reason women with excess skin avoid PA because of psychosocial inconveniences.^[138]

The Five A’s counselling model

The Five A’s counselling model (Assess, Advise, Agree, Assist and Arrange) is an effective, concise counseling techniques addressing health risk behaviors..^[139],[140] The five A’s is a very helpful tool for structuring physical activity counseling when caring for obesity weight loss.^[141] It has been widely used in a variety of medical care settings and well adapted for the purpose of individually tailored exercise prescription for patients.^[140],[142] The topic of physical activity and exercise should be discussed as part of each encounter between a health professional and any patient with overweight or obesity. The recommendations from the United States Preventive Services Task Force (USPSTF) urge physicians to provide intensive counseling for their obese patients in order to promote sustained weight loss.^[143] A survey was conducted on 40 primary care physicians and 461 of their overweight or obese patients to inquire about the use of the Five A’s counselling model by the physicians with their patients. 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 suggested that physicians should be encouraged to increase their use of the Five A’s when counseling patients for weight loss.^[142]

Written information about the benefits of PA should be handed to the patients. An assessment of habitual PA and patient’s fitness can take place as well as dietary and lifestyle evaluation. If the patient has some cardiovascular risk factors, a referral to maximal stress test can be issued. Counseling is best when tailored to the individual needs of the patients, taking into account physical fitness, co-morbidities, stage of change regarding PA, barriers to PA, and opportunities offered in the living environment. A major challenge is how to increase adherence an active lifestyle over time.^[130] Additionally, the use of pedometer or today’s phone applications by patient to track daily activity may encourage and enhance patient’s level of PA. A recent computer-tailored, pedometer-based PA intervention was shown to be effective in increasing both pedometer-based and self-reported levels of PA among at-risk participants.^[144][Box 3] provides a more detailed description of the Five A’s counselling model, as it relates to PA prescription for obese patients.

Mobile health for assessing and promoting PA in BS patients

Mobile health approaches to assessment of PA and SB hold a great promise for collecting accurate and detailed information on free-living physiological and behavioral parameters.^[145],[146] Indeed, the use of electronic devices and mobile applications can be extended to enhance PA promotion as well. The use of objective monitoring of PA has been recommended with bariatric surgery patients.^[145],[147] Using a variety of sensors, it is possible, for example, to obtain highly accurate minute-by-minute estimates of time spent in various intensities of PA, caloric expenditure, heart rate measurement, skin temperature measurement, and SB assessment by inclinometer showing sitting, standing, or lying positions. Such measurement can be taken directly without recall bias or social desirability effect.^{[147],[148],[149]} In addition, a systematic review and meta-analysis study showed that utilizing a consumer-based wearable activity tracker in PA intervention studies has the potential to increase PA participation, and that consumer-based wearable activity tracker can provide an effective tool to assist health professionals in monitoring a variety of health outcomes.^[150]

A recent study incorporating mobile health technologies (objective monitors), to assess PA and SB in real time and in the natural environment, showed that most patients were inactive and highly sedentary pre-operatively and only made modest changes in such behaviors postoperatively. The study concluded that researchers and clinicians should be encouraged to consider the benefits of using mobile health technology when monitoring or prescribing PA and SB in bariatric surgery patients.^[147]

In another study aimed to assess the feasibility of using mobile health tools when supporting PA post-BS, Klasnja, et al.,^[151] conducted a quality-improvement optimization pilot of BariFit, a mobile health intervention that combines commercial devices and custom text messages. The study enrolled 51 bariatric patients in a 16-week optimization pilot of BariFit. To assess feasibility, pre-post changes in PA were assessed using the device activPAL (objective measurement). In addition, SMS-delivered activity suggestions were used for five times a day for each participant. Adherence to using study equipment was over 95% at 16 weeks. Participants increased their PA by 1,866 steps from baseline to end-of-study (p < 0.007). Participants who received variable step goals averaged 1,141 more steps per day (p = .096) than those who received 60th percentile goals. Activity suggestions had no effect. They concluded that Mobile health interventions are feasible for supporting PA post-BS.^[151]

Furthermore, the feasibility and effect of Pre-Surgical Exercise Training (PreSET) delivered in-home via telehealth (TelePreSET) were assessed in subjects awaiting BS. The in-home TelePreSET program, which was consisted of 12-weeks of endurance and strength training, was supervised twice weekly using videoconferencing. Physical fitness, quality of life, exercise beliefs, anthropometric measures and telehealth perception were evaluated before and after 12-weeks. The TelePreSET participants attended 96% of the exercise sessions, and were very satisfied by the TelePreSET. The baseline telehealth perception score was high, and increased significantly after the intervention. The TelePreSET group significantly increased their physical fitness compared to the usual care group. No significant change was seen in other outcomes. It was concluded that the TelePreSET is feasible and seems effective to improve the physical fitness of women awaiting BS.^[48]

Conclusion

The present review aimed to evaluate the available evidences for the health impact of PA and SB in obese adults at pre-and post-BS. The findings showed that almost all studies on PA interventions before BS improved physical function, quality of life, functional capacity as well increased maximal fat oxidation during exercise. BS by itself seems to increase PA among patients post-surgery. The increased PA during the first year of post-surgery were mostly maintained through several years later. However, in one study, PA at year seven post-surgery was still below PA recommendations for health. Another study observed little time was spent even in light intensity PA, or in MVPA after BS. Despite that, there appears a dose-response association between more steps and more MVPA with greater weight loss. The average steps/day was reported between 6375 and 9108. A substantial increase in activity energy expenditure was reported from 345.4 ± 172.8 MET-min/week preoperatively to 672.8 ± 227.8 MET-min/week at 6 months postoperatively. The correlation between self-reported and sensor-based MVPA was weak. Components of the interventions in the present review were varied; some studies involved repeated supervised exercise programs with fair details of the exercise sessions over a prolonged period, whilst others were counselling based trials with little monitoring of PA intensity. Further, in some of the studies that investigating weight loss caused by exercise following BS, the training program is poorly reported, and the sample size, selection criteria, and follow-up time vary greatly across studies. In addition, the heterogeneity of measurement tools makes comparisons between studies challenging. Most self-reported changes in PA predicted postoperative weight loss. However, their validity has been questioned. Moreover, daily time spent in sedentary behaviors among obese patients appears quite excessive. All in all, it seems that research supports the importance of increased PA and reduced SB in the context of BS as each is being associated with more favorable weight loss and health outcomes.

Ethical statement

Not applicable.

Financial support and sponsorship

Nil.

Conflicts of interest

The author reports no conflicts of interest.

References

1.	World health statistics 2022. Monitoring Health for the SDGs, Sustainable Development Goals. Geneva: World Health Organization; 2022.
2.	Okati-Aliabad H, Ansari-Moghaddam A, Kargar S, Jabbari N Prevalence of obesity and overweight among adults in the middle east countries from 2000 to 2020: A systematic review and meta-analysis. J Obes 2022;2022:8074837.
3.	Lavie CJ, Laddu D, Arena R, Ortega FB, Alpert MA, Kushner RF Healthy weight and obesity prevention: JACC health promotion series. J Am Coll Cardiol 2018;72:1506-31.
4.	O’Kane M, Parretti HM, Hughes CA, Sharma M, Woodcock S, Puplampu T, et al. Guidelines for the follow-up of patients undergoing bariatric surgery. Clin Obes 2016;6:210-24.
5.	Sjöström L Review of the key results from the Swedish Obese Subjects (SOS) trial – a prospective controlled intervention study of bariatric surgery. J Intern Med 2013;273:219-34. doi: 10.1111/joim.12012
6.	Yumuk V, Tsigos C, Fried M, Schindler K, Busetto L, Micic D, et al; Obesity Management Task Force of the European Association for the Study of Obesity. European guidelines for obesity management in adults. Obes Facts 2015;8:402-24.
7.	Adams TD, Davidson LE, Litwin SE, Kim J, Kolotkin RL, Nanjee MN, et al. Weight and metabolic outcomes 12 years after gastric bypass. N Engl J Med 2017;377:1143-55.
8.	Courcoulas AP, Gallagher JW, Neiberg RH, Eagleton EB, DeLany JP, Lang W, et al. Bariatric surgery vs lifestyle intervention for diabetes treatment: 5-year outcomes from a randomized trial. J Clin Endocrinol Metab 2020;105:866-76. doi: 10.1210/clinem/dgaa006.
9.	Hong YR, Yadav S, Suk R, Lee AM, Newsome FA, Johnson-Mann CN, et al. Assessment of physical activity and healthy eating behaviors among Us adults receiving bariatric surgery. Jama Netw Open 2022;5:e2217380.
10.	Eghbali F, Bahardoust M, Pazouki A, Barahman G, Tizmaghz A, Hajmohammadi A, et al. Predictors for weight loss after roux-en-Y gastric bypass: The trend and associated factors for weight loss. Bmc Surg 2022;22:310.
11.	Cena H, De Giuseppe R, Biino G, Persico F, Ciliberto A, Giovanelli A, et al. Evaluation of eating habits and lifestyle in patients with obesity before and after bariatric surgery: A single italian center experience. Springerplus 2016;5:1467.
12.	Hansen D, Decroix L, Devos Y, Nocca D, Cornelissen V, Dillemans B, et al. Towards optimized care after bariatric surgery by physical activity and exercise intervention: A review. Obes Surg 2020;30:1118-25.
13.	Zabatiero J, Smith A, Gucciardi DF, Hamdorf Am JM, Taylor SF, Hill K Patterns of change in device-based physical activity and sedentary time following bariatric surgery: A longitudinal observational study. Obes Surg 2021;31:3015-25.
14.	World Health Organization. WHO Guidelines on Physical Activity and Sedentary Behavior. Geneva, Switzerland: WHO; 2020; Available online: https://www.who.int/publications/i/item/9789240015128.
15.	Fontana AD, Lopes AD, Lunardi AC Bariatric surgery associated with practice of moderate to intense physical activity related to weight loss, activity level in daily life, dyspnea, and quality of life of sedentary individuals with morbid obesity: A prospective longitudinal study. Obes Surg 2019;29:2442-8.
16.	Herman KM, Carver TE, Christou NV, Andersen RE Keeping the weight off: Physical activity, sitting time, and weight loss maintenance in bariatric surgery patients 2 to 16 years postsurgery. Obes Surg 2014;24:1064-72.
17.	Nielsen MS, Alsaoodi H, Hjorth MF, Sjödin A Physical activity, sedentary behavior, and sleep before and after bariatric surgery and associations with weight loss outcome. Obes Surg 2021;31:250-9.
18.	Tettero OM, Aronson T, Wolf RJ, Nuijten MAH, Hopman MTE, Janssen IMC Increase in physical activity after bariatric surgery demonstrates improvement in weight loss and cardiorespiratory fitness. Obes Surg 2018;28:3950-7.
19.	Hanvold SE, Vinknes KJ, Løken EB, Hjartåker A, Klungsøyr O, Birkeland E, et al. Does lifestyle intervention after gastric bypass surgery prevent weight regain? A randomized clinical trial. Obes Surg 2019;29:3419-31.
20.	Auclair A, Harvey J, Leclerc J, Piché ME, O’Connor K, Nadreau É, et al. Determinants of cardiorespiratory fitness after bariatric surgery: Insights from a randomised controlled trial of a supervised training program. Can J Cardiol 2021;37:251-9.
21.	Huck CJ Effects of supervised resistance training on fitness and functional strength in patients succeeding bariatric surgery. J Strength Cond Res 2015;29:589-95.
22.	Oppert JM, Bellicha A, Roda C, Bouillot JL, Torcivia A, Clement K, et al. Resistance training and protein supplementation increase strength after bariatric surgery: A randomized controlled trial. Obesity (Silver Spring) 2018;26:1709-20.
23.	Bond DS, Thomas JG, King WC, Vithiananthan S, Trautvetter J, Unick JL, et al. Exercise improves quality of life in bariatric surgery candidates: Results from the bari-active trial. Obesity (Silver Spring) 2015;23:536-42.
24.	Sellberg F, Possmark S, Willmer M, Tynelius P, Persson M, Berglind D Meeting physical activity recommendations is associated with health-related quality of life in women before and after roux-en-Y gastric bypass surgery. Qual Life Res 2019;28:1497-507.
25.	Stolberg CR, Mundbjerg LH, Bladbjerg EM, Funch-Jensen P, Gram B, Juhl CB Physical training following gastric bypass: Effects on physical activity and quality of life-a randomized controlled trial. Qual Life Res 2018;27:3113-22. doi: 10.1007/s11136-018-1938-9.
26.	Bellicha A, Ciangura C, Roda C, Torcivia A, Portero P, Oppert JM Changes in cardiorespiratory fitness after gastric bypass: Relations with accelerometry-assessed physical activity. Obes Surg 2019;29:2936-41.
27.	Onofre T, Carlos R, Oliver N, Felismino A, Fialho D, Corte R, et al. Effects of a physical activity program on cardiorespiratory fitness and pulmonary function in obese women after bariatric surgery: A pilot study. Obes Surg 2017;27:2026-33.
28.	Miranda-Peñarroya G, Zerón-Rugerio MF, Vallejo-Gracia M, Sorio-Fuentes R, Saenger-Ruiz F, Izquierdo-Pulido M Adherence to healthy lifestyle habits is a determinant of the effectiveness of weight loss among patients undergoing endoscopic bariatric therapies. Nutrients 2022;14:2261. doi: 10.3390/nu14112261.
29.	Savolainen AM, Karmi A, Immonen H, Soinio M, Saunavaara V, Pham T, et al. Physical activity associates with muscle insulin sensitivity postbariatric surgery. Med Sci Sports Exerc 2019;51:278-87.
30.	Tremblay MS, Aubert S, Barnes JD, Saunders TJ, Carson V, Latimer-Cheung AE, et al. Sedentary Behavior Research Network (SBRN)—Terminology Consensus Project process and outcome. Int J Behav Nutr Phys Act 2017;14:75.
31.	Biswas A, Oh PI, Faulkner GE, Bajaj RR, Silver MA, Mitchell MS, et al. Sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults: A systematic review and meta-analysis. Ann Intern Med 2015;162:123-32.
32.	Wilmot EG, Edwardson CL, Achana FA, Davies MJ, Gorely T, Gray LJ, et al. Sedentary time in adults and the association with diabetes, cardiovascular disease and death: Systematic review and meta-analysis. Diabetologia 2012;55:2895-905.
33.	Pinto Pereira SM, Ki M, Power C Sedentary behaviour and biomarkers for cardiovascular disease and diabetes in mid-life: The role of television-viewing and sitting at work. Plos One 2012;7:e31132.
34.	Hartman YAW, Tillmans LCM, Benschop DL, Hermans ANL, Nijssen KMR, Eijsvogels TMH, et al. Long-term and acute benefits of reduced sitting on vascular flow and function. Med Sci Sports Exerc 2021;53:341-50.
35.	Tremblay MS, Colley RC, Saunders TJ, Healy GN, Owen N Physiological and health implications of a sedentary lifestyle. Appl Physiol Nutr Metab 2010;35:725-40.
36.	van der Ploeg HP, Hillsdon M Is sedentary behaviour just physical inactivity by another name? Int J Behav Nutr Phys Act 2017;14:142.
37.	Yu Y, Ma Q, Groth SW Desire to lose weight was associated with the adoption of weight control strategies but not healthier lifestyle behaviours among post-bariatric surgery patients: Nhanes 2013-2018. Clin Obes 2022;12:e12511.
38.	Schumacher LM, Thomas JG, Vithiananthan S, Webster J, Jones DB, Bond DS Prolonged sedentary time adversely relates to physical activity and obesity among preoperative bariatric surgery patients. Surg Obes Relat Dis 2020;16:562-7.
39.	Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, Aromataris E Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. Bmc Med Res Methodol 2018;18:143.
40.	Hardy K, Kwok K, Bouchard DR, Bharti N, Gamey D, Vergis A Impact of a preoperative exercise program on general fitness in patients awaiting bariatric surgery: A pilot randomized trial. Cureus 2022;14:e22566.
41.	Picó-Sirvent I, Manresa-Rocamora A, Aracil-Marco A, Moya-Ramón M A combination of aerobic exercise at fatmax and low resistance training increases fat oxidation and maintains muscle mass, in women waiting for bariatric surgery. Obes Surg 2022;32:1130-40.
42.	Tokgoz G, Arman N, Seyit H, Karabulut M Effects of pre-surgical aerobic dance-based exercise on lower extremity in people with morbid obesity awaiting bariatric surgery: Randomized controlled study. Clin Obes 2022;12:e12529.
43.	Arman N, Tokgoz G, Seyit H, Karabulut M The effects of core stabilization exercise program in obese people awaiting bariatric surgery: A randomized controlled study. Complement Ther Clin Pract 2021;43:101342.
44.	Gilbertson NM, Eichner NZM, Khurshid M, Rexrode EA, Kranz S, Weltman A, et al. Impact of pre-operative aerobic exercise on cardiometabolic health and quality of life in patients undergoing bariatric surgery. Front Physiol 2020;11:1018.
45.	Alexandrino EG, Marçal DFDS, Antunes MD, Oliveira LP, Massuda EM, Bertolini SMMG Physical activity level and lifestyle perception in prebariatric surgery patients. Einstein (Sao Paulo) 2019;17:eAO4619.
46.	Picó-Sirvent I, Aracil-Marco A, Pastor D, Moya-Ramón M Effects of a combined high-intensity interval training and resistance training program in patients awaiting bariatric surgery: A pilot study. Sports (Basel) 2019;7:72. doi: 10.3390/sports7030072.
47.	Baillot A, Vallée CA, Mampuya WM, Dionne IJ, Comeau E, Méziat-Burdin A, et al. Effects of a pre-surgery supervised exercise training 1 year after bariatric surgery: A randomized controlled study. Obes Surg 2018;28:955-62.
48.	Baillot A, Boissy P, Tousignant M, Langlois MF Feasibility and effect of in-home physical exercise training delivered via telehealth before bariatric surgery. J Telemed Telecare 2017;23:529-35.
49.	Bond DS, Thomas JG, Vithiananthan S, Unick J, Webster J, Roye GD, et al. Intervention-related increases in preoperative physical activity are maintained 6-months after bariatric surgery: Results from the bari-active trial. Int J Obes (Lond) 2017;41:467-70.
50.	Marcon ER, Baglioni S, Bittencourt L, Lopes CL, Neumann CR, Trindade MR What is the best treatment before bariatric surgery? Exercise, exercise and group therapy, or conventional waiting: A randomized controlled trial. Obes Surg 2017;27:763-73.
51.	Ledoux S, Sami O, Breuil MC, Delapierre M, Calabrese D, Msika S, et al. Relevance of self-reported behavioral changes before bariatric surgery to predict success after surgery. Obes Surg 2017;27:1453-9.
52.	Rioux BV, Sénéchal M, Kwok K, Fox J, Gamey D, Bharti N, et al. Association between physical activity intensity and physical capacity among individuals awaiting bariatric surgery. Obes Surg 2017;27:1277-83.
53.	Browning MG, Baugh NG, Wolfe LG, Kellum JK, Maher JW, Evans RK Evaluation of pre- and postoperative physical activity participation in laparoscopic gastric banding patients. Obes Surg 2014;24:1981-6.
54.	King WC, Engel SG, Elder KA, Chapman WH, Eid GM, Wolfe BM, et al. Walking capacity of bariatric surgery candidates. Surg Obes Relat Dis 2012;8:48-59.
55.	King WC, Hinerman AS, White GE, Courcoulas AP, Saad MAB, Belle SH Associations between physical activity and changes in weight across 7 years after roux-en-Y gastric bypass surgery: A multicenter prospective cohort study. Ann Surg 2022;275:718-26.
56.	Kuipers E, Timmerman J, van Det M, Vollenbroek-Hutten M The need for objective physical activity measurements in routine bariatric care. Obes Surg 2022;32:2975-86.
57.	Bond DS, Smith KE, Schumacher LM, Vithiananthan S, Jones DB, Webster J, et al. Associations of physical activity and sedentary behavior with appetite sensations and eating regulation behaviors before and during the initial year following bariatric surgery. Obes Sci Pract 2022;8:164-75.
58.	Gil S, Kirwan JP, Murai IH, Dantas WS, Merege-Filho CAA, Ghosh S, et al. A randomized clinical trial on the effects of exercise on muscle remodelling following bariatric surgery. J Cachexia Sarcopenia Muscle 2021;12:1440-55.
59.	Lamarca F, Vieira FT, Lima RM, Nakano EY, da Costa THM, Pizato N, et al. Effects of resistance training with or without protein supplementation on body composition and resting energy expenditure in patients 2-7 years postroux-en-Y gastric bypass: A controlled clinical trial. Obes Surg 2021;31:1635-46.
60.	Romagna EC, Lopes KG, Mattos DMF, Farinatti P, Kraemer-Aguiar LG Physical activity level, sedentary time, and weight regain after bariatric surgery in patients without regular medical follow-up: A cross-sectional study. Obes Surg 2021;31:1705-13.
61.	Gallé F, Marte G, Cirella A, Di Dio M, Miele A, Ricchiuti R, et al. An exercise-based educational and motivational intervention after surgery can improve behaviors, physical fitness and quality of life in bariatric patients. Plos One 2020;15:e0241336.
62.	Marc-Hernández A, Ruiz-Tovar J, Aracil A, Guillén S, Moya-Ramón M Impact of exercise on body composition and cardiometabolic risk factors in patients awaiting bariatric surgery. Obes Surg 2019;29:3891-900.
63.	Ouellette KA, Mabey JG, Eisenman PA, Shaw JM, Brusseau TA, Hatfield DL, et al. Physical activity patterns among individuals before and soon after bariatric surgery. Obes Surg 2020;30:416-22.
64.	Possmark S, Sellberg F, Willmer M, Tynelius P, Persson M, Berglind D Accelerometer-measured versus self-reported physical activity levels in women before and up to 48 months after roux-en-Y gastric bypass. Bmc Surg 2020;20:39.
65.	Sivas F, Moran M, Yurdakul F, Ulucaköy Koçak R, Başkan B, Bodur H Physical activity, musculoskeletal disorders, sleep, depression, and quality of life before and after bariatric surgery. Turk J Phys Med Rehabil 2020;66:281-90.
66.	Costa Pereira LM, Aidar FJ, de Matos DG, de Farias Neto JP, de Souza RF, Sobral Sousa AC, et al. Assessment of cardiometabolic risk factors, physical activity levels, and quality of life in stratified groups up to 10 years after bariatric surgery. Int J Environ Res Public Health 2019;16:1975. doi: 10.3390/ijerph16111975.
67.	Kerrigan DJ, Carlin AM, Munie S, Keteyian SJ A cross-sectional study of reported exercise and medium-term weight loss following laparoscopic bariatric surgery. Obes Surg 2018;28:3923-8.
68.	Mundbjerg LH, Stolberg CR, Bladbjerg EM, Funch-Jensen P, Juhl CB, Gram B Effects of 6 months supervised physical training on muscle strength and aerobic capacity in patients undergoing roux-en-Y gastric bypass surgery: A randomized controlled trial. Clin Obes 2018;8:227-35.
69.	Afshar S, Seymour K, Kelly SB, Woodcock S, van Hees VT, Mathers JC Changes in physical activity after bariatric surgery: Using objective and self-reported measures. Surg Obes Relat Dis 2017;13:474-83.
70.	Campanha-Versiani L, Pereira DAG, Ribeiro-Samora GA, Ramos AV, de Sander Diniz MFH, De Marco LA, et al. The effect of a muscle weight-bearing and aerobic exercise program on the body composition, muscular strength, biochemical markers, and bone mass of obese patients who have undergone gastric bypass surgery. Obes Surg 2017;27:2129-37.
71.	Carnero EA, Dubis GS, Hames KC, Jakicic JM, Houmard JA, Coen PM, et al. Randomized trial reveals that physical activity and energy expenditure are associated with weight and body composition after Rygb. Obesity (Silver Spring) 2017;25:1206-16.
72.	Hassannejad A, Khalaj A, Mansournia MA, Rajabian Tabesh M, Alizadeh Z The effect of aerobic or aerobic-strength exercise on body composition and functional capacity in patients with Bmi ≥35 after bariatric surgery: A randomized control trial. Obes Surg 2017;27:2792-801.
73.	Herring LY, Stevinson C, Carter P, Biddle SJH, Bowrey D, Sutton C, et al. The effects of supervised exercise training 12-24 months after bariatric surgery on physical function and body composition: A randomised controlled trial. Int J Obes (Lond) 2017;41:909-16.
74.	Wefers JF, Woodlief TL, Carnero EA, Helbling NL, Anthony SJ, Dubis GS, et al. Relationship among physical activity, sedentary behaviors, and cardiometabolic risk factors during gastric bypass surgery-induced weight loss. Surg Obes Relat Dis 2017;13:210-9.
75.	Creel DB, Schuh LM, Reed CA, Gomez AR, Hurst LA, Stote J, et al. A randomized trial comparing two interventions to increase physical activity among patients undergoing bariatric surgery. Obesity (Silver Spring) 2016;24:1660-8.
76.	Berglind D, Willmer M, Eriksson U, Thorell A, Sundbom M, Uddén J, et al. Longitudinal assessment of physical activity in women undergoing roux-en-Y gastric bypass. Obes Surg 2015;25:119-25.
77.	King WC, Chen JY, Bond DS, Belle SH, Courcoulas AP, Patterson EJ, et al. Objective assessment of changes in physical activity and sedentary behavior: Pre- through 3 years post-bariatric surgery. Obesity (Silver Spring) 2015;23:1143-50.
78.	Reid RE, Carver TE, Andersen KM, Court O, Andersen RE Physical activity and sedentary behavior in bariatric patients long-term post-surgery. Obes Surg 2015;25:1073-7.
79.	Chapman N, Hill K, Taylor S, Hassanali M, Straker L, Hamdorf J Patterns of physical activity and sedentary behavior after bariatric surgery: An observational study. Surg Obes Relat Dis 2014;10:524-30.
80.	Ramirez-Marrero FA, Miles J, Joyner MJ, Curry TB Self-reported and objective physical activity in postgastric bypass surgery, obese and lean adults: Association with body composition and cardiorespiratory fitness. J Phys Act Health 2014;11:145-51.
81.	Mundi MS, Lorentz PA, Swain J, Grothe K, Collazo-Clavell M Moderate physical activity as predictor of weight loss after bariatric surgery. Obes Surg 2013;23:1645-9.
82.	King WC, Hsu JY, Belle SH, Courcoulas AP, Eid GM, Flum DR, et al. Pre- to postoperative changes in physical activity: Report from the longitudinal assessment of bariatric surgery-2 (Labs-2). Surg Obes Relat Dis 2012;8:522-32.
83.	Bond DS, Thomas JG, Unick JL, Raynor HA, Vithiananthan S, Wing RR Self-reported and objectively measured sedentary behavior in bariatric surgery candidates. Surg Obes Relat Dis 2013;9:123-8.
84.	Vatier C, Henegar C, Ciangura C, Poitou-Bernert C, Bouillot JL, Basdevant A, et al. Dynamic relations between sedentary behavior, physical activity, and body composition after bariatric surgery. Obes Surg 2012;22:1251-6.
85.	Bergh I, Kvalem IL, Mala T, Hansen BH, Sniehotta FF Predictors of physical activity after gastric bypass-a prospective study. Obes Surg 2017;27:2050-7.
86.	Berglind D, Willmer M, Tynelius P, Ghaderi A, Näslund E, Rasmussen F Accelerometer-measured versus self-reported physical activity levels and sedentary behavior in women before and 9 months after roux-en-Y gastric bypass. Obes Surg 2016;26:1463-70.
87.	Artero EG, Ferrez-Márquez M, Torrente-Sánchez MJ, Martínez-Rosales E, Carretero-Ruiz A, Hernández-Martínez A, et al. Supervised exercise immediately after bariatric surgery: The study protocol of the Efibar randomized controlled trial. Obes Surg 2021;31:4227-35.
88.	Herring LY, Stevinson C, Davies MJ, Biddle SJ, Sutton C, Bowrey D, et al. Changes in physical activity behaviour and physical function after bariatric surgery: A systematic review and meta-analysis. Obes Rev 2016;17:250-61.
89.	Adil MT, Jain V, Rashid F, Al-Taan O, Al-Rashedy M, Jambulingam P, et al. Meta-analysis of the effect of bariatric surgery on physical activity. Surg Obes Relat Dis 2019;15:1620-31.
90.	Al-Hazzaa HM Physical activity prescription before bariatric surgery: Feasibility, health impacts and practical implications. Saudi J of Obesity 2016;4:3-12. doi: 10.4103/2347–2618.184935.
91.	Al-Hazzaa HM Exercise training prior to weight reduction surgery: A brief review. Obesity Open Access 2016;2: http://dx.doi.org/10.16966/2380–5528.116.
92.	McCullough PA, Gallagher MJ, Dejong AT, Sandberg KR, Trivax JE, Alexander D, et al. Cardiorespiratory fitness and short-term complications after bariatric surgery. Chest 2006;130:517-25.
93.	Parikh M, Dasari M, McMacken M, Ren C, Fielding G, Ogedegbe G Does a preoperative medically supervised weight loss program improve bariatric surgery outcomes? A pilot randomized study. Surg Endosc 2012;26:853-61.
94.	Durey BJ, Fritche D, Martin DS, Best LMJ The effect of pre-operative exercise intervention on patient outcomes following bariatric surgery: A systematic review and meta-analysis. Obes Surg 2022;32:160-9.
95.	Mechanick JI, Apovian C, Brethauer S, Timothy Garvey W, Joffe AM, Kim J, et al. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: Cosponsored by american association of clinical endocrinologists/american college of endocrinology, the obesity society, american society for metabolic and bariatric surgery, obesity medicine association, and american society of anesthesiologists. Obesity (Silver Spring) 2020;28:O1-O58.
96.	Bond DS, Vithiananthan S, Thomas JG, Trautvetter J, Unick JL, Jakicic JM, et al. Bari-active: A randomized controlled trial of a preoperative intervention to increase physical activity in bariatric surgery patients. Surg Obes Relat Dis 2015;11:169-77.
97.	Livhits M, Mercado C, Yermilov I, Parikh JA, Dutson E, Mehran A, et al. Exercise following bariatric surgery: Systematic review. Obes Surg 2010;20:657-65.
98.	Ren ZQ, Lu GD, Zhang TZ, Xu Q Effect of physical exercise on weight loss and physical function following bariatric surgery: A meta-analysis of randomised controlled trials. Bmj Open 2018;8:e023208.
99.	Evans RK, Bond DS, Wolfe LG, Meador JG, Herrick JE, Kellum JM, et al. Participation in 150 min/wk of moderate or higher intensity physical activity yields greater weight loss after gastric bypass surgery. Surg Obes Relat Dis 2007;3:526-30.
100.	Bellicha A, van Baak MA, Battista F, Beaulieu K, Blundell JE, Busetto L, et al. Effect of exercise training before and after bariatric surgery: A systematic review and meta-analysis. Obes Rev 2021;22 Suppl 4:e13296.
101.	Hennis PJ, Meale PM, Grocott MP Cardiopulmonary exercise testing for the evaluation of perioperative risk in non-cardiopulmonary surgery. Postgrad Med J 2011;87:550-7.
102.	Hennis PJ, Meale PM, Hurst RA, O’Doherty AF, Otto J, Kuper M, et al. Cardiopulmonary exercise testing predicts postoperative outcome in patients undergoing gastric bypass surgery. Br J Anaesth 2012;109:566-71.
103.	Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood JE Exercise capacity and mortality among men referred for exercise testing. N Engl J Med 2002;346:793-801.
104.	Lund MT, Hansen M, Wimmelmann CL, Taudorf LR, Helge JW, Mortensen EL, et al. Increased post-operative cardiopulmonary fitness in gastric bypass patients is explained by weight loss. Scand J Med Sci Sports 2016;26:1428-34.
105.	Nuijten MAH, Monpellier VM, Eijsvogels TMH, Janssen IMC, Hazebroek EJ, Hopman MTE Rate and determinants of excessive fat-free mass loss after bariatric surgery. Obes Surg 2020;30:3119-26.
106.	Alba DL, Wu L, Cawthon PM, Mulligan K, Lang T, Patel S, et al. Changes in lean mass, absolute and relative muscle strength, and physical performance after gastric bypass surgery. J Clin Endocrinol Metab 2019;104:711-20.
107.	Haghighat N, Kazemi A, Asbaghi O, Jafarian F, Moeinvaziri N, Hosseini B, et al. Long-term effect of bariatric surgery on body composition in patients with morbid obesity: A systematic review and meta-analysis. Clin Nutr 2021;40:1755-66.
108.	Guida B, Cataldi M, Busetto L, Aiello ML, Musella M, Capone D, et al. Predictors of fat-free mass loss 1 year after laparoscopic sleeve gastrectomy. J Endocrinol Invest 2018;41:1307-15.
109.	Morales-Marroquin E, Kohl HW 3rd, Knell G, de la Cruz-Muñoz N, Messiah SE Resistance training in post-metabolic and bariatric surgery patients: A systematic review. Obes Surg 2020;30:4071-80.
110.	Vieira FT, de Oliveira GS, Gonçalves VSS, Neri SGR, de Carvalho KMB, Dutra ES Effect of physical exercise on muscle strength in adults following bariatric surgery: A systematic review and meta-analysis of different muscle strength assessment tests. Plos One 2022;17:e0269699.
111.	Paccou J, Caiazzo R, Lespessailles E, Cortet B Bariatric surgery and osteoporosis. Calcif Tissue Int 2022;110:576-91.
112.	Diniz-Sousa F, Veras L, Boppre G, Sa-Couto P, Devezas V, Santos-Sousa H, et al. The effect of an exercise intervention program on bone health after bariatric surgery: A randomized controlled trial. J Bone Miner Res 2021;36:489-99.
113.	Murai IH, Roschel H, Dantas WS, Gil S, Merege-Filho C, de Cleva R, et al. Exercise mitigates bone loss in women with severe obesity after roux-en-Y gastric bypass: A randomized controlled trial. J Clin Endocrinol Metab 2019;104:4639-50.
114.	Bettini S, Milan G, Favaretto F, Fabris R, Dal Prà C, Quinto G, et al. Metabolic slowing vanished 5 years after sleeve gastrectomy in patients with obesity and prediabetes/diabetes. J Clin Endocrinol Metab 2022;107:e3830-40.
115.	Wilms B, Ernst B, Thurnheer M, Schmid SM, Spengler CM, Schultes B Resting energy expenditure after roux-en Y gastric bypass surgery. Surg Obes Relat Dis 2018;14:191-9.
116.	Li K, Zheng L, Guo J, Shi W, Zhao F, Yang C, et al. Increased resting energy expenditure/body weight and decreased respiratory quotient correlate with satisfactory weight loss after sleeve gastrectomy: A 6-month follow-up. Obes Surg 2020;30:1410-6.
117.	Hankir MK, Seyfried F Do bariatric surgeries enhance brown/beige adipose tissue thermogenesis? Front Endocrinol (Lausanne) 2020;11:275.
118.	Denis R Brown fat biology and thermogenesis. Front Biosci 2011;16:1233.
119.	Tanimura R, Kobayashi L, Shirai T, Takemasa T Effects of exercise intensity on white adipose tissue browning and its regulatory signals in mice. Physiol Rep 2022;10:e15205.
120.	Elbelt U, Ahnis A, Riedl A, Burkert S, Schuetz T, Ordemann J, et al. Associations of physical activity with depressiveness and coping in subjects with high-grade obesity aiming at bariatric surgery: A cross-sectional study. Biopsychosoc Med 2015;9:16.
121.	King WC, Kalarchian MA, Steffen KJ, Wolfe BM, Elder KA, Mitchell JE Associations between physical activity and mental health among bariatric surgical candidates. J Psychosom Res 2013;74:161-9.
122.	Katzmarzyk PT, Church TS, Craig CL, Bouchard C Sitting time and mortality from all causes, cardiovascular disease, and cancer. Med Sci Sports Exerc 2009;41:998-1005.
123.	Petersen CB, Bauman A, Tolstrup JS Total sitting time and the risk of incident diabetes in danish adults (the Danhes cohort) over 5 years: A prospective study. Br J Sports Med 2016;50:1382-7.
124.	Bond DS, Unick JL, Jakicic JM, Vithiananthan S, Pohl D, Roye GD, et al. Objective assessment of time spent being sedentary in bariatric surgery candidates. Obes Surg 2011;21:811-4.
125.	Unick JL, Bond DS, Jakicic JM, Vithiananthan S, Ryder BA, Roye GD, et al. Comparison of two objective monitors for assessing physical activity and sedentary behaviors in bariatric surgery patients. Obes Surg 2012;22:347-52.
126.	Powell KE, King AC, Buchner DM, Campbell WW, DiPietro L, Erickson KI, et al. The Scientific Foundation for the Physical Activity. Guidelines for Americans, 2nd Edition. J Phys Act Health 2019;16:1-11.
127.	Mechanick JI, Youdim A, Jones DB, Timothy Garvey W, Hurley DL, Molly McMahon M, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient–2013 update: Cosponsored by american association of clinical endocrinologists, the obesity society, and american society for metabolic & bariatric surgery. Surg Obes Relat Dis 2013;9:159-91.
128.	Poirier P, Cornier MA, Mazzone T, Stiles S, Cummings S, Klein S, et al; American Heart Association Obesity Committee of the Council on Nutrition, Physical Activity, and Metabolism. Bariatric surgery and cardiovascular risk factors: A scientific statement from the american heart association. Circulation 2011;123:1683-701.
129.	Donnelly JE, Blair SN, Jakicic JM, Manore MM, Rankin JW, Smith BK; American College of Sports Medicine. American college of sports medicine position stand. Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Med Sci Sports Exerc 2009;41:459-71.
130.	Oppert JM, Bellicha A, van Baak MA, Battista F, Beaulieu K, Blundell JE, et al. Exercise training in the management of overweight and obesity in adults: Synthesis of the evidence and recommendations from the european association for the study of obesity physical activity working group. Obes Rev 2021;22 Suppl 4:e13273.
131.	Liguori G, American College of Sports Medicine (ACSM). Guidelines for Exercise Testing and Prescription. 11th ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins; 2021.
132.	King WC, Bond DS The importance of preoperative and postoperative physical activity counseling in bariatric surgery. Exerc Sport Sci Rev 2013;41:26-35.
133.	Zabatiero J, Hill K, Gucciardi DF, Hamdorf JM, Taylor SF, Hagger MS, et al. Beliefs, barriers and facilitators to physical activity in bariatric surgery candidates. Obes Surg 2016;26:1097-109.
134.	Speck RM, Bond DS, Sarwer DB, Farrar JT A systematic review of musculoskeletal pain among bariatric surgery patients: Implications for physical activity and exercise. Surg Obes Relat Dis 2014;10:161-70.
135.	Ball K, Crawford D, Owen N Too fat to exercise? Obesity as a barrier to physical activity. Aust N Z J Public Health 2000;24:331-3.
136.	Dikareva A, Harvey WJ, Cicchillitti MA, Bartlett SJ, Andersen RE Exploring perceptions of barriers, facilitators, and motivators to physical activity among female bariatric patients: Implications for physical activity programming. Am J Health Promot 2016;30:536-44.
137.	de Aguiar JB, Gurgel LA, Santos ALB, Arruda SPM Barriers to physical exercise and associated factors in the pre- and postoperative periods of bariatric surgery. Obes Surg 2021;31:1696-704.
138.	Baillot A, Asselin M, Comeau E, Méziat-Burdin A, Langlois MF Impact of excess skin from massive weight loss on the practice of physical activity in women. Obes Surg 2013;23:1826-34.
139.	Meriwether RA, Lee JA, Lafleur AS, Wiseman P Physical activity counseling. Am Fam Physician 2008;77:1129-36.
140.	Wharton S, Lau DCW, Vallis M, Sharma AM, Biertho L, Campbell-Scherer D, et al. Cmaj 2020;192:E1757-75.
141.	Vallis M, Piccinini-Vallis H, Sharma AM, Freedhoff Y Clinical review: Modified 5 as: Minimal intervention for obesity counseling in primary care. Can Fam Physician 2013;59:27-31.
142.	Alexander SC, Cox ME, Boling Turer CL, Lyna P, Østbye T, Tulsky JA, et al. Do the five A’s work when physicians counsel about weight loss? Fam Med 2011;43:179-84.
143.	United States Preventive Services Task Force. Screening for obesity in adults: Recommendations and rationale. Am J Nurs 2004;104:94-5, 97-8, 100.
144.	Compernolle S, Vandelanotte C, Cardon G, De Bourdeaudhuij I, De Cocker K Effectiveness of a web-based, computer-tailored, pedometer-based physical activity intervention for adults: A cluster randomized controlled trial. J Med Internet Res 2015;17:e38.
145.	Ramirez E, Marinsek N, Bradshaw B, Kanard R, Foschini L Continuous digital assessment for weight loss surgery patients. Digit Biomark 2020;4:13-20.
146.	Wright SP, Hall Brown TS, Collier SR, Sandberg K How consumer physical activity monitors could transform human physiology research. Am J Physiol Regul Integr Comp Physiol 2017;312:R358-67. doi: 10.1152/ajpregu.00349.2016.
147.	Bond DS, Thomas JG Measurement and intervention on physical activity and sedentary behaviours in bariatric surgery patients: Emphasis on mobile technology. Eur Eat Disord Rev 2015;23:470-8.
148.	Carmichael H, Overbey DM, Hosokawa P, Goode CM, Jones TS, Barnett CC Jr, et al. Wearable technology-A pilot study to define “normal” postoperative recovery trajectories. J Surg Res 2019;244:368-73.
149.	Symer MM, Abelson JS, Milsom J, McClure B, Yeo HL A mobile health application to track patients after gastrointestinal surgery: Results from a pilot study. J Gastrointest Surg 2017;21:1500-5.
150.	Brickwood KJ, Watson G, O’Brien J, Williams AD Consumer-based wearable activity trackers increase physical activity participation: Systematic review and meta-analysis. Jmir Mhealth Uhealth 2019;7:e11819.
151.	Klasnja P, Rosenberg DE, Zhou J, Anau J, Gupta A, Arterburn DE A quality-improvement optimization pilot of barifit, a mobile health intervention to promote physical activity after bariatric surgery. Transl Behav Med 2021;11:530-9.