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 Table of Contents  
REVIEW ARTICLE
Year : 2019  |  Volume : 7  |  Issue : 2  |  Page : 39-67

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


Lifestyle and Health Research Center, Health Sciences Research Center, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia

Date of Submission09-Nov-2022
Date of Acceptance09-Nov-2022
Date of Web Publication02-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
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjo.sjo_8_22

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  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 Mar 26];7:39-67. Available from: https://www.saudijobesity.com/text.asp?2019/7/2/39/369035




  Introduction Top


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 Top


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 Top


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

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

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

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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 Top


    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 Top


    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.



     
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