Changes in physical activity behaviour and physical function after bariatric surgery: a systematic review and meta-analysis

Inter-Session Reliability of Functional Performance and Muscle Power in Adults With Severe Obesity

Reliable and sensitive testing of physical function is crucial for assessing the effects of treatment or exercise intervention in various patient populations. The present study investigated the test-retest reliability and sensitivity (smallest detectable difference: SDD) of selected physical performance tests commonly used in clinical rehabilitation, including tests of habitual and maximal walking speed, walking endurance capacity, handgrip strength (HGS), and lower limb muscle power (Sit-to-Stand (STS), stair climb) in adults with severe obesity meeting the criteria for bariatric surgery. Thirty-two adults (BMI 43.8 ± 6.6 kg/m2) were enrolled in the study. Participants were assessed in three separate test sessions performed at the same time of day (±2 h) separated by 3 to 7 days. Habitual and maximal walking speed, walking endurance capacity, lower limb muscle power evaluated by stair climb and STS performance, and HGS demonstrated good-to-excellent inter-session reproducibility (ICC: 0.84-0.98, CV and SEM: 2.9%-11.3%) with individual sensitivity (SDD) ranging from 11.8% to 31.2%. Systematic learning effects from test session 1-2 were observed for the STS test and the 3- and 10-m habitual walk speed tests, manifested by increases of 6%-9%, 7%, and 3%, respectively (p < 0.05). Performing a familiarization session (test 1) fully prevented these learning effects (test 2 vs. 3). A majority of physical function tests showed improved reproducibility and sensitivity after the familiarization session. In conclusion, physical function can be assessed in a reliable manner in adults with severe obesity. Further, familiarization sessions prior to actual testing result in improved test-retest reliability and increased sensitivity.

Effects of a 6-month physical activity behavioral intervention in patients following metabolic bariatric surgery: a randomized controlled trial

BACKGROUND

Promoting habitual physical activity (PA) among bariatric patients is crucial for long-term surgery success, yet it poses a significant challenge for healthcare practitioners.

OBJECTIVES

This randomized controlled trial (RCT) aimed to examine the effectiveness of a theory-based behavioral intervention on PA level in post-metabolic bariatric surgery (MBS) patients.

SETTING

University Hospital, Israel METHODS: Forty-four patients undergoing MBS were randomized to the intervention (n = 22) or control group (n = 22). The intervention group received a 6-month PA counseling program based on self-determination theory (SDT) and the 5 A's framework, while the control group received usual care. PA level and self-efficacy for exercise (SEE) were assessed pre- (baseline, preintervention) and postoperatively (14 and 28 weeks follow-ups). Anthropometrics, physical function, cardiovascular, and biochemical outcomes were measured at all time points.

RESULTS

The intervention group showed greater increases in PA levels across time compared to the control group. A significant increase in step counts from baseline to 14 weeks was observed (P = .003). Significant differences favoring the intervention group were observed in self-reported PA changes from baseline to 14- and 28-week follow-ups (P = .020 and P = .024, respectively). Additionally, Physical function, as assessed by the 6-minute walk test (6MWT) and the 5 sit-to-stand (5STS) test, significantly improved in the intervention group throughout the follow-up period (P < .05 for all), However, no between-group differences were observed in SEE, anthropometrics, cardiovascular, or biochemical parameters.

CONCLUSIONS

A 6-month behavioral intervention post-MBS significantly enhanced patients' PA levels and physical function. Given its theory-based approach and structured protocol, this intervention could be disseminated to support MBS clinicians and centers. Further research with longer follow-up period is warranted to confirm these findings and assess the long-term effects.

Systematic development of a complex intervention: a theory and evidence-based physiotherapist led group intervention to increase physical activity and reduce sedentary behaviour following bariatric surgery (PARIS)

OBJECTIVES

To describe the systematic development of a physiotherapist led group behaviour change intervention targeting physical activity and sedentary behaviour in individuals who have undergone bariatric surgery.

STUDY DESIGN

Intervention development including evidence synthesis, qualitative research and mapping of intervention components, using the 2008 MRC framework for complex interventions.

METHODS

We conducted a systematic review to identify the evidence for promising interventions and components to increase physical activity and reduce sedentary behaviour following bariatric surgery. We also conducted primary qualitative research exploring these behaviours with three key stakeholder groups: patients, clinicians and commissioners. We selected two contemporary behaviour change frameworks to inform intervention development and developed a conceptual matrix in which intervention objectives were defined to inform selection of appropriate behaviour change techniques, proposed mechanisms of action(s), and mode of delivery. We also developed two intervention handbooks for participants and facilitators to support delivery and receipt of the intervention.

RESULTS

We have developed a behaviour change intervention targeting physical activity and sedentary behaviour in patients following bariatric surgery. Eight intervention objectives were defined and mapped to the Behaviour Change Wheel and Theoretical Domains Framework. We identified what the intervention must be able to do (intervention functions), behaviour change techniques that could be used to achieve this, the proposed mechanism of action, and mode of delivery. This intervention will be subject to a feasibility study, with the intervention delivered online over a six-week period to participants who have had bariatric surgery within the previous five years. CONTRIBUTION OF THE PAPER.

Effects of bariatric surgery on muscle strength and quality: A systematic review and meta-analysis

Obesity is a major health burden worldwide. Although bariatric surgery (BS) is recognized as an effective strategy for weight loss and comorbidities improvement, its impact on muscle strength and quality is still unclear. We aimed to examine postoperative changes in muscle strength and quality and their relationship with body mass index (BMI) changes among adults undergoing BS. To this end, we systematically searched the WoS, PubMed, EBSCO, and Scopus databases. The meta-analyses, which included 24 articles (666 participants), showed that BS reduces absolute lower-limb isometric strength (ES = -0.599; 95% CI = -0.972, -0.226; p = 0.002). Subjects who experienced a more significant reduction in BMI after BS also suffered a higher loss of absolute muscle strength. Similarly, absolute handgrip strength showed a significant decrease (ES = -0.376; 95% CI = -0.630, -0.121; p = 0.004). We found insufficient studies investigating medium- and long-term changes in muscle strength and/or quality after BS. This study provides moderate-quality evidence that BS-induced weight loss can reduce the strength of appendicular muscles in the short term, which should be addressed in management these subjects. More high-quality studies are needed to evaluate the impact of BS on muscle strength and the different domains of muscle quality in the medium and long term (registered on PROSPERO CRD42022332581).

Impact of Laparoscopic Sleeve Gastrectomy on Fatigue in Obese Patients

Background: Fatigue with obesity negatively affects the motivation to lose weight and causes failure of treatment. So, obesity and fatigue are two related entities that worsen each other in a vicious circle. This study aimed to examine the changes in fatigue levels in obese patients undergoing laparoscopic sleeve gastrectomy (LSG). Methods: Preoperative and postoperative BMI, fat percentage, and obesity degree were determined based on Tanita test results, and the rates of change were calculated. The Fatigue Assessment Scale (FAS) was used to assess the impact of obesity on mental and physical fatigue. Results: Six months after LSG, there was a 29.7% decrease in Body Mass Index (BMI) across all patients (45.0 to 31.4, p < 0.001). Significant reductions in the percentage of body fat, obesity grade, and HgA1C were observed in both women and men and overall (p < 0.001 for all comparisons). Scores on the Fatigue Assessment Scale (FAS) for total, mental, and physical scales decreased significantly for women, men, and all participants (p < 0.001 for all comparisons). There was a weak but significant positive correlation between the percentage change in FAS total and FAS physical scale scores and the change in BMI% (p = 0.015 and 0.004; r = 0.089, 0.106, respectively). Change in obesity grade and FAS physical subscale scores negatively correlated (p = 0.029, r = 0.080). Conclusions: LSG not only leads to significant weight reduction but also improves fatigue levels in patients with obesity.

Effect of Corrective Exercise on Static Balance, Food Consumption, and Body Composition in the Early Period After Bariatric Surgery

PURPOSE

To determine the impact of corrective exercise program applied during the period of rapid weight loss following bariatric surgery on static balance, dietary intake, and body composition.

MATERIALS AND METHODS

Participants who had undergone Sleeve Gastrectomy (SG) surgery were divided into as Corrective Exercise Group (CEG), and Control Group (CG). CEG underwent a 12-week supervised corrective exercise program. Body composition and static balance of all participants were assessed before and after the study. Their physical activity levels and dietary intake were also evaluated.

RESULTS

Following of the corrective exercise program, both groups exhibited significant reductions in body weight, BMI, fat mass, fat percentage, muscle mass, waist circumference-to-height ratio, and visceral adiposity values (p < 0.05). Additionally, the CEG showed increase in lean body mass percentage (p < 0.001). In measurements related to static balance, values for eyes-closed perimeter (p = 0.015), eyes-closed (p = 0.006), eyes-open (p = 0.028) ellipses area, average F-B speed, and eyes-open center of pressure in the X-axis (C.O.P.X.) sway distance significantly decreased in both groups (p = 0.025). However, the difference in eyes-open C.O.P.X. sway distance was found to be higher in the CG (mean difference = 8.67; p = 0.034). Postoperatively, there were significant decreases in energy, protein, fat, CHO (carbohydrate), CHO percentage, fiber, and iron values, while protein percentage (p < 0.001), vitamin D (p = 0.003), and B12 (p < 0.001) values increased.

CONCLUSION

It has been observed that the corrective exercise program implemented in the early postoperative period following SG surgery had a positive impact on eyes-open static balance.

Do patients with obesity undergoing bariatric surgery modify their objectively measured physical activity? A systematic review and meta-analysis

BACKGROUND

Obesity is a chronic disease associated with adverse outcomes and its prevalence is increasing, which makes it a concern. One of the obesity treatment options is bariatric surgery, which effectively reduces calorie absorption and total body mass, but its effects on physical activity (PA) levels need to be clarified, considering the protective effect of the PA against cardiovascular disease, independently of the weight loss alone.

OBJECTIVES

To carry out a systematic review and meta-analysis of observational studies that evaluated PA in pre- and post-bariatric surgery periods through objective evaluation.

METHODS

A systematic search was carried out following the PRISMA criteria of studies with adult individuals who underwent bariatric surgery and were objectively evaluated for PA pre- and post-surgery. Studies with interventions were excluded.

RESULTS

A total of 419 records were found, and after excluding duplicates and applying the eligibility criteria, 10 studies remained. This meta-analysis found a significant increase in the steps by day (MD = 1340; 95% CI = 933.90; 1745.35, p < 0.001) and the light physical activity level (MD = 16.8 min/day; 95% CI = 2.60; 30.98, p = 0.02), but not in moderate to vigorous physical activity (MD = 0.24; 95% CI = -0.08; 1.57, p = 0.92).

CONCLUSIONS

Patients undergoing bariatric surgery increased their steps by day and light physical activity but did not increase moderate to vigorous physical activity.

Resistance Training in Patients After Metabolic and Bariatric Surgery: Protocol for a Systematic Review

BACKGROUND

Resistance training has been consistently shown to have multiple health benefits, especially for patients who have undergone bariatric surgery. Patients who have undergone bariatric surgery are recommended to participate in resistance exercise; however, protocols and guidelines for resistance training remain poorly implemented.

OBJECTIVE

This is a protocol for a systematic review and possibly a meta-analysis that will synthesize evidence of the effects of resistance exercise on changes in body composition, muscular strength, overall weight loss or maintenance of weight loss, and quality of life in patients after metabolic and bariatric surgery (MBS). The findings of this study may provide practice recommendations for resistance training among patients who have undergone MBS.

METHODS

We registered this systematic review on PROSPERO (CRD42023464928) on September 18, 2023. A systematic search of electronic databases (Embase, PubMed, Scopus, Web of Science, and CINAHL) was conducted on studies published from January 1, 1991, to May 15, 2023, to identify English-language human studies on adult patients who have undergone MBS that include a resistance training intervention and describe outcome measurements of body composition or strength. Screening will be performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, and relevant data elements will be extracted.

RESULTS

Searches and screenings commenced in May 2023. Data extraction and analyses will be completed by the end of December 2023, after which findings will be synthesized and reported by the end of March 2024.

CONCLUSIONS

This systematic review will summarize the evidence regarding resistance training in patients after MBS. The findings from this systematic review and possible meta-analysis may provide practice recommendations for resistance training protocols in this patient population and identify characteristics of protocols with the best adherence and outcomes. With these results, we anticipate that we will gain a deeper understanding of the role of resistance training after MBS.

TRIAL REGISTRATION

PROSPERO CRD42023464928; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=464928.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/49513.

Preserved Muscle Strength Despite Muscle Mass Loss After Bariatric Metabolic Surgery: a Systematic Review and Meta-analysis

BACKGROUND

Contrary to the previously known concept of muscle mass decrease following bariatric metabolic surgery, changes in muscle strength have been poorly investigated in systematic reviews. In this meta-analysis, we evaluated changes in handgrip strength (HGS) and lean mass (LM) after undergoing bariatric metabolic surgery.

METHODS

A systematic literature review using the PubMed, Embase, and Cochrane Library databases was conducted in November 2022. Longitudinal studies reporting HGS change after bariatric metabolic surgery were eligible. Pooled estimates for changes in HGS, body mass index (BMI), LM, and fat mass (FM) were calculated. Changes from baseline to the point closest to 6 months postoperatively were analyzed in trials with multiple follow-up examinations. The risk of bias was assessed using the Joanna Briggs Institute critical appraisal checklist.

RESULTS

Three randomized controlled trials and seven prospective cohort studies involving 301 patients were included. Follow-up evaluations were conducted 6 months postoperatively in all trials except for two, whose follow-up visits were at 18 weeks and 12 months, respectively. Pooled analysis showed reduced BMI (- 10.8 kg/m2; 95% confidence interval: - 11.6 to - 9.9 kg/m2), LM (- 7.4 kg; - 9.3 to - 5.4 kg), and FM (- 22.3 kg; - 25.1 to - 19.6 kg) after bariatric metabolic surgery, whereas the change in HGS was not statistically significant (- 0.46 kg; - 1.76 to 0.84 kg).

CONCLUSION

Despite the decreased body composition parameters, including muscle mass, strength was not impaired after bariatric metabolic surgery; this indicates that bariatric metabolic surgery is an effective weight management intervention that does not compromise strength.

Fostering physical activity-related health competence after bariatric surgery with a multimodal exercise programme: A randomised controlled trial

Regular physical activity (PA) supports the long-term success of bariatric surgery. However, integrating health-enhancing physical activity in daily life requires specific competences. In this study, we evaluated a multimodal exercise programme to build these competences.Forty adults who underwent bariatric surgery were randomised to a multimodal exercise programme or control group. Primary outcomes were the facets of PA-related health competences, namely the control competence for physical training, PA-specific affect regulation, motivational competence and PA-specific self-control. Secondary outcomes were PA behaviour and subjective vitality. Outcomes were assessed before, directly after the intervention and at 3 months follow-up.Significant treatment effects were found for control competence for physical training and PA-specific self-control but not for PA-specific affect regulation and motivational competence. Significant treatment effects were further observed for self-reported exercise and subjective vitality, all in favour of the intervention group. In contrast, no treatment effect was found for device-based PA. Overall, this study provides a foundation for future research to optimise long-term post bariatric surgery outcomes.

Physical activity and exercise for weight loss and maintenance in people living with obesity

Physical activity and exercise training programs are integral part of a comprehensive obesity management approach. In persons with overweight or obesity, exercise training, specifically aerobic (i.e. endurance) training, is associated with significant additional weight loss compared to the absence of training. However the magnitude of effect remains modest amounting to only 2-3 kg additional weight loss on average. Comparable effects have been observed for total fat loss. Exercise training, specifically aerobic training, is also associated with decreased abdominal visceral fat as assessed by imaging techniques, which is likely to benefit cardiometabolic health in persons with obesity. Based on data from controlled trials with randomization after prior weight loss, the evidence for weight maintenance with exercise training is as yet not conclusive, although retrospective analyses point to the value of relatively high-volume exercise in this regard. Resistance (i.e. muscle-strengthening) training is specifically advised for lean mass preservation during weight loss. Given the relatively limited effect of exercise training on weight loss as such, the changes in physical fitness brought about by exercise training cannot be overlooked as they provide major health benefits to persons with obesity. Aerobic, as well as combined aerobic and resistance training, increase cardiorespiratory fitness (VO2max) while resistance training, but not aerobic training, improves muscle strength even in the absence of a significant change in muscle mass. Regarding the overall management strategy, adherence in the long term to new lifestyle habits remains a challenging issue to be addressed by further research.

Insights into the Paradox of the Weak Association Between Sleeve Gastrectomy and Barrett's Esophagus

Sleeve gastrectomy (SG) is deemed a refluxogenic operation but with a low incidence of postoperative Barrett´s esophagus (BE). We aimed to shed some light on the potential paradox of the weak association between SG, BE and esophageal adenocarcinoma (EAC). The high incidence of GERD after SG is not followed by an increased rate of BE and EAC, as these rates are similar to the general population. We hypothesized that this paradox may occur due to a difference in the gastro-esophageal reflux composition secondary to a lower content of bile, to a decrease in inflammation due to weight loss and hormonal changes, and to acquisition of healthier habits such as exercise, smoking cessation, and better eating behavior.

The effects of weight-lowering pharmacotherapies on physical activity, function and fitness: A systematic review and meta-analysis of randomized controlled trials

Weight-lowering pharmacotherapies provide an option for weight management; however, their effects on physical activity, function, and cardiorespiratory fitness are not fully understood. We conducted a systematic review and meta-analysis of randomized controlled trials to investigate the effect of licensed weight loss pharmacotherapies on physical activity, physical function, and cardiorespiratory fitness in individuals with obesity. Fourteen trials met our prespecified inclusion criteria: Five investigated liraglutide, four semaglutide, three naltrexone/bupropion, and two phentermine/topiramate. All 14 trials included a self-reported measure of physical function, with the pooled findings suggesting an improvement favoring the pharmacotherapy intervention groups (SMD: 0.27; 95% CI: 0.22 to 0.32) and effects generally consistent across different therapies. Results were also consistent when stratified by the two most commonly used measures: The Short-Form 36-Item Questionnaire (SF-36) (0.24; 0.17 to 0.32) and the Impact of Weight on Quality Of Life-Lite (IWQOL-Lite) (0.29; 0.23 to 0.35). Meta-regression confirmed a significant association between pharmacotherapy induced weight loss and improved physical function for IWQOL-Lite (p = 0.003). None of the studies reported a physical activity outcome, and only one study reported objectively measured cardiorespiratory fitness. Improvements in self-reported physical function were observed with weight loss therapy, but the effect on physical activity or objectively measured physical function and fitness could not be determined.

Long-term Engagement in Physical Activity Among Bariatric Surgery Patients: Associations with Treatment Outcomes at 5-Year Follow-up

PURPOSE

Physical activity studies involving bariatric surgery patients tend to be short-term or cross-sectional investigations. Longer-term studies are limited and typically consist of relatively brief objective measurement periods used to generalize activity patterns. Very little research combines objective measurements with structured interviews to determine both the patterns and related factors of long-term physical activity among patients undergoing bariatric surgery.

MATERIALS AND METHODS

Previous volunteers in a perioperative physical activity study were invited to participate in a mixed methods study investigating physical activity among bariatric patients over a 5-year postoperative period. Fifty-one patients (M_age = 45.4 years; 76.5% female, 90.2% White; 86.3% Roux-en-Y procedure) provided interview, survey, accelerometer, and anthropometric data.

RESULTS

Participants were divided into four exercise quartiles, based on self-report of their length of regular exercise involvement from 1 year before through 5 years after surgery. Those reporting the most periods of regular exercise took the most measured steps per day, had greater moderate-to-vigorous physical activity and more bout-related activity, experienced the largest decrease in BMI, and reported the most adherence to nutritional guidelines. Participants reporting the most and least physical activity found the measurement periods to be most similar to their normal activity patterns. While physical activity increased significantly after surgery, measured physical activity did not reach recommended levels for steps or exercise bout minutes.

CONCLUSIONS

Measured physical activity and self-reported physical activity show congruent trends among patients undergoing bariatric surgery. More research is needed to determine optimal long-term monitoring and promotion of physical activity among patients.

Mitochondrial adaptations to calorie restriction and bariatric surgery in human skeletal muscle: a systematic review with meta-analysis

OBJECTIVE

We performed a meta-analysis to determine the changes induced by calorie restriction (CR) and bariatric surgery on human skeletal muscle mitochondria.

METHODS

A systematic search of Medline and Web of Science was conducted. Controlled trials exploring CR (≥14 days) and mitochondrial function and/or content assessment were included. Moreover, studies analyzing weight loss following gastric surgery were included for comparison purposes. Human muscle data from 28 studies assessing CR (520 muscle samples) and from 10 studies assessing bariatric surgery (155 muscle samples) were analyzed in a random effect meta-analysis with three a priori chosen covariates.

MAIN RESULTS

We report a decrease (p < 0.05) (mean (95 % CI)) in maximal mitochondrial state 3 respiration in response to CR (-0.44 (-0.85, -0.03)) but not in response to surgery (-0.33 (-1.18, 0.52)). No changes in mitochondrial content were reported after CR (-0.05 (-0.12, 0.13)) or in response to surgery (0.23 (-0.05, 0.52)). Moreover, data from CR subjects showed a reduction in complex IV (CIV) activity (-0.29 (-0.56, -0.03)) but not in CIV content (-0.21 (-0.63, 0.22)). Similar results were obtained when the length of the protocol, the initial body mass index, and the estimated energy deficit were included in the model as covariates.

CONCLUSION

The observation of reduced maximal mitochondrial state 3, uncoupled respiration, and CIV activity without altering mitochondrial content suggests that, in human skeletal muscle, CR mainly modulates intrinsic mitochondrial function.

Changes of Facial Features After Bariatric Surgery: a Systematic Review

This study aims to provide an overview of the facial features and structure after bariatric surgery in the existing literature. A systematic literature search was performed in electronic databases until 15th February 2022. Four cohort studies including 129 patients from 3 countries were included between time period 2011 and 2020. Overall, bariatric surgery would promote massive weight loss associated with positive effects on facial aging. Analysis revealed a proportional relationship between body mass index (BMI) and faster facial aging and more attractive. Undergoing bariatric surgery would result in facial skin sagging and a favorable effect on the upper airway. Bariatric surgery was found to have a significant impact on changes in facial features but the current evidence remains inconclusive and further studies are required to illustrate facial changes post-bariatric surgery.

Environmental Factors Determining Body Mass Index (BMI) within 9 Months of Therapy Post Bariatric Surgery-Sleeve Gastrectomy (SG)

Treatment of obesity should be multidirectional and include, in addition to bariatric surgery, changing the key factors of lifestyle and eating habits. The study aimed to assess the impact of bariatric surgery and dietary care on anthropometric measurements, blood pressure, changes in lifestyle, and eating habits of patients within 9 months after the procedure, with the selection of environmental factors determining BMI variation. The study included 30 SG patients before surgery (month zero) and at 1, 3, 6, and 9 months after SG. Patients completed a questionnaire regarding age, sex, place of residence, education, professional activity, number of family members, financial situation, family history of obesity, previous forms of therapy, self-assessment of nutritional knowledge, receiving and following nutritional recommendations, eating habits, frequency of body weight control, leisure time. Body weight, height, waist and hip circumference, and systolic and diastolic pressure were measured, and BMI and WHR (Waist to Hip Ratio) were calculated. Within 9 months after the procedure, the patients' body weight and BMI decreased on average by 26%. Post bariatric surgery, patients changed their eating habits. The influence of bariatric SG surgery and time after surgery was decisive for the normalization of BMI and explained the 33% variation in BMI up to 9 months after the procedure. Other factors important for the normalization of BMI after surgery were: male gender, older age of patients, family obesity (non-modifiable factors), as well as previous forms of therapy related to weight loss before surgery, shortening the intervals between meals and stopping eating at night (modifiable factors). The tested model explained 68% of the BMI variation after SG surgery for all assessed factors. Changes in lifestyle and eating habits in bariatric patients are crucial to maintaining the effect of bariatric surgery.

Effects of Exercise Mode on Improving Cardiovascular Function and Cardiorespiratory Fitness After Bariatric Surgery: A Narrative Review

ABSTRACT

Obesity affects 600 million people globally and increases the risk of developing cardiovascular disease, stroke, diabetes, and cancer. Bariatric surgery is an increasingly popular therapeutic intervention for morbid obesity to induce rapid weight loss and reduce obesity-related comorbidities. However, some bariatric surgery patients, after what is considered a successful surgical procedure, continue to manifest obesity-related health issues, including weight gain, reduced physical function, persistent elevations in blood pressure, and reduced cardiorespiratory fitness. Cardiorespiratory fitness is a strong predictor of mortality and several health outcomes and could be improved by an appropriate exercise prescription after bariatric surgery. This review provides a broad overview of exercise training for patients after bariatric surgery and discusses cardiorespiratory fitness and other potential physiological adaptations in response to exercise training.

Effects of physical training on physical and functional fitness, physical activity level, endothelial function, hemodynamic variables, bone metabolism, and quality of life of post-bariatric patients: study protocol for a randomized controlled trial

BACKGROUND

Evidence of the benefits induced from resistance exercise on health markers of post-bariatric patients is limited. The study will investigate the effects of a resistance training (RT) program on muscle mass and strength, bone metabolism biomarkers, bone mineral density (BMD), bone microarchitecture, and endothelial function of patients subjected to Roux-en-Y gastric bypass.

METHODS/DESIGN

This randomized controlled trial will include 60 post-bariatric patients, physically inactive, aging 18 to 50 years, with a post-surgery period ≥ 12 months. They will be randomly assigned into two groups: (i) the non-exercised control group, which will receive the standard clinical follow-up, or (ii) the intervention group which will consist of RT (60 min/session; 3 times/week, for 6 months). The primary outcomes will include muscle mass and strength, bone metabolism biomarkers, BMD, and bone microarchitecture. The secondary outcomes will be anthropometry, hemodynamic measurements, cardiovascular risk factors, health-related quality of life (QoL), and endothelial function. Outcomes will be assessed by blood biomarkers of bone formation and reabsorption, dual X-ray absorptiometry, repetition maximum and handgrip strength tests, high-resolution peripheral quantitative computed tomography, 36-Item Short-Form Health Survey, venous occlusion plethysmography, and nailfold videocapillaroscopy.

DISCUSSION

It is expected that there are greater benefits from the RT program, possibly improving muscle mass and strength, bone metabolism, density and microarchitecture, QoL, and cardiovascular risk.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04193397. Registered on 7 December 2019.

Physical Exercise to Improve Functional Capacity: Randomized Clinical Trial in Bariatric Surgery Population

Background: Bariatric surgery is a safe and effective method to lose weight over time. However, some patients fail to achieve healthy weight losses. We aimed to determine if a moderate-intensity physical exercise intervention in patients who underwent bariatric surgery increases their functional capacity thus improving bariatric surgery results. Methods: We conducted a parallel-group non-blinded randomized controlled trial at a surgery clinic in Talca, Chile. A total of 43 participants with obesity and scheduled bariatric surgery completed the six months follow-up. A physical exercise program was conducted in exercise group participants one month after bariatric surgery. Walked distance in the six-minute walk test, BMI, Borg scale of perceptive exertion results and cardiovascular variables were evaluated. Results: Patients’ weight significantly decreased after bariatric surgery but there was no difference between the groups of study. The exercise group progressed from a base value of 550 ± 75 m walked in the six-minute walk test to a sixth-month value of 649.6 ± 68.5 m (p < 0.05), whilst the control group yielded base values of 554.4 ± 35.1 and a sixth-month walked distance of 591.1 ± 75.34 (p > 0.05). Conclusions: Physical exercise in obese patients undergoing bariatric surgery increased functional capacity independently of weight losses resulting from bariatric surgery.

Effect of exercise training after bariatric surgery: A 5-year follow-up study of a randomized controlled trial

Background and objectives

We previously showed in a 6-month randomized controlled trial that resistance training and protein supplementation after bariatric surgery (Roux-en-Y gastric bypass, RYGB) improved muscle strength without significant effect on weight loss and body composition changes. We performed a 5-year follow-up study in these subjects with the aim 1) to assess the long-term effect of this exercise training intervention and 2) to analyze associations between habitual physical activity (PA) and weight regain at 5 years.

Methods

Fifty-four out of 76 initial participants (follow-up rate of 71%) completed the 5-year follow-up examination (controls, n = 17; protein supplementation, n = 22; protein supplementation and resistance training, n = 15). We measured body weight and composition (DXA), lower-limb strength (leg-press one-repetition maximum) and habitual PA (Actigraph accelerometers and self-report). Weight regain at 5 years was considered low when <10% of 12-month weight loss.

Results

Mean (SD) time elapse since RYGB was 5.7 (0.9) y. At 5 years, weight loss was 32.8 (10.1) kg, with a mean weight regain of 5.4 (SD 5.9) kg compared with the 12-month assessment. Moderate-to-vigorous PA (MVPA) assessed by accelerometry did not change significantly compared with pre-surgery values (+5.2 [SD 21.7] min/d, P = 0.059), and only 4 (8.2%) patients reported participation in resistance training. Muscle strength decreased over time (overall mean [SD]: -49.9 [53.5] kg, respectively, P<0.001), with no statistically significant difference between exercise training intervention groups. An interquartile increase in MVPA levels was positively associated with lower weight regain (OR [95% CI]: 3.27 [1.41;9.86]).

Conclusions

Early postoperative participation in a resistance training protocol after bariatric surgery was not associated with improved muscle strength after 5 years of follow-up; however, increasing physical activity of at least moderate intensity may promote weight maintenance after surgery. PA may therefore play an important role in the long-term management of patients with obesity after undergoing bariatric procedure.

Effect of physical exercise on muscle strength in adults following bariatric surgery: A systematic review and meta-analysis of different muscle strength assessment tests

Individuals following bariatric surgery are considered at high risk for the development of sarcopenic obesity (excess fat mass, low muscle mass and low physical function), and exercise may play an important role in its prevention and treatment. We systematically reviewed 5 scientific databases (Embase, Medline, Scopus, SPORTDiscus, and Web of Science) and 2 grey literature databases (ProQuest and Google Scholar) for clinical trials that evaluated the effect of exercise on muscle strength in adults following bariatric surgery and conducted a separate meta-analysis for studies that used different muscle strength tests. Random-effect models, restricted maximum likelihood method and Hedges' g were used. The review protocol was registered at the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42020152142). Fifteen studies were included (638 patients), none had a low risk of bias, and all were included in at least 1 of the 5 meta-analyses (repetition maximum [lower and upper limbs], sit-to-stand, dynamometer, and handgrip tests). Exercise interventions improved both upper (effect size, 0.71; 95% CI, 0.41-1.01; I2 = 0%) and lower (effect size, 1.37; 95% CI, 0.84-1.91; I2 = 46.14) limb muscle strength, as measured by repetition maximum tests. Results were similar for the sit-to-stand (effect size, 0.60; 95% CI, 0.20-1.01; I2 = 68.89%) and dynamometer (effect size, 0.46; 95% CI, 0.06-0.87; I2 = 31.03%), but not for the handgrip test (effect size, 0.11; 95% CI, -0.42-0.63; I2 = 73.27%). However, the certainty level of the meta-analyses was very low. Exercise with a resistance training component performed post bariatric surgery may improve muscle strength, which is related to sarcopenic obesity, functional capacity, and mortality risk, therefore should be included in the follow-up.

Assessment of Physical Activity and Healthy Eating Behaviors Among US Adults Receiving Bariatric Surgery

IMPORTANCE

Bariatric surgery effectively treats severe obesity and metabolic diseases. However, individual outcomes vary depending on sustainable lifestyle change. Little is known about lifestyle patterns after bariatric surgery among the US population.

OBJECTIVE

To compare the level of physical activity and eating behavior among postbariatric surgery patients, individuals eligible for surgery, and those with normal weight.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study using nationally representative survey data from National Health and Nutrition Examination Survey 2015-2018. Respondents included for analysis were age 18 years or older, and categorized by individuals with normal weight, individuals who received bariatric surgery, and individuals clinically eligible for bariatric surgery. Analyses were performed from February to October 2021.

MAIN OUTCOMES AND MEASURES

Self-reported measures were used to assess physical activity (moderate-to-vigorous physical activity [MVPA], sedentary activity, and whether PA guidelines were met) and eating behaviors (total energy intake and Healthy Eating Index [HEI]-2015 diet quality scores).

RESULTS

Of 4659 study participants (mean [SD] age, 46.1 [18.6] years; 2638 [weighted percentage, 58.8%] women; 1114 [weighted percentage, 12.7%] Black, 1570 [weighted percentage, 68.6%] White), 132 (3.7%) reported that they had undergone any bariatric surgery. Median (IQR) time since surgery was 7 (3-10) years. After propensity-score weighting, individuals who underwent bariatric surgery reported more time spent in MVPA than those eligible for surgery (147.9 min/wk vs 97.4 min/wk). Among respondents with normal weight, 45.6% (95% CI, 40.8% to 52.4%) reported meeting PA guidelines, almost 2 times higher than those in the bariatric surgery (23.1%; 95% CI, 13.8% to 32.4%) or in the surgery-eligible group (20.3%; 95% CI, 15.6% to 25.1%). Propensity-score weighted overall HEI was higher for individuals with normal weight (54.4; 95% CI, 53.0 to 55.9) than those who underwent bariatric surgery (50.0; 95% CI, 47.2 to 52.9) or were eligible for the surgery (48.0; 95% CI, 46.0 to 50.0). Across all HEI components, mean scores were similar between the bariatric surgery and surgery-eligible groups. Total energy intake was the lowest among those who underwent bariatric surgery (1746 kcal/d; 95% CI, 1554 to 1937 kcal/d), followed by those with normal weight (1943 kcal/d; 95% CI, 1873 to 2013 kcal/d) and those eligible for bariatric surgery (2040 kcal/d; 1953 to 2128 kcal/d).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, individuals who underwent bariatric surgery had beneficial lifestyle patterns compared with those eligible for surgery; however, these improvements seemed suboptimal based on the current guidelines. Efforts are needed to incorporate benefits of physical activity and a healthy, balanced diet in postbariatric care.

A systematic review of interventions to increase physical activity and reduce sedentary behaviour following bariatric surgery

Background

Objectives

Eligibility

Study appraisal and synthesis methods

Results

Limitations

Conclusion and implications of key findings

Systematic review registration number

Physical activity and obesity spectrum disorders in post-bariatric surgery patients: A systematic review and Meta-analysis

OBJECTIVES

This systematic review and meta-analysis is based on randomized controlled trials evaluating the effect of physical activity on weight loss in adults undergoing bariatric surgery. The study compared certain biomarkers for individuals with and without physical activity after bariatric surgery. Secondary, the study identified potential successful interventions for the target population.

METHOD

PubMed, Embase, OVID, CINAHL, and Cochrane Library were searched from January 2000 to December 2020. Intervention studies on the effect of physical activity in adults after bariatric surgery were selected, included, and analyzed following the PRISMA guidelines. The primary outcome was weight loss followed by selected biomarkers.

RESULTS

Two independent reviewers extracted data and conducted quality assessments. Of the 11 studies included, six reported BMI, two reported fat-free mass, three reported fat mass, two reported waist-hip ratio, and two reported waist circumference. Six studies measuring change from baseline BMI reported a significant intervention effect: SMD = -0.93 (-1.65;-0.20) with high heterogeneity of included trials (I2 = 72%). There was no significant difference between control and intervention groups for other outcomes.

CONCLUSION

BMI as a measure of physical activity positively impacts the target population. Large-scale studies with better criteria and a longer evaluation follow-up may finalize pronounced outcomes.

Does Exercise Improve the Cardiometabolic Risk Profile of Patients with Obesity After Bariatric Surgery? A Systematic Review and Meta-analysis of Randomized Controlled Trials

We aimed to determine the effects of different exercise types, duration, and onset after bariatric surgery (BS) on cardiometabolic risk factors (CMRFs). A systematic search was conducted up to July 2021. Eleven studies were identified (n = 618 participants). Overall, exercise induced reductions in systolic blood pressure (SBP; - 5.33 mmHg; 95%CI - 8.99, -1.66; p < 0.01). Combined exercises elicited reductions on SBP (- 7.18 mmHg; 95%CI - 12.42, - 1.94; p < 0.01) and triglycerides (- 17.56 mg/dL; 95%CI - 34.15, - 0.96; p = 0.04). SBP reductions were also observed on interventions starting > 6 months post-BS (- 7.71 mmHg; 95%CI - 13.12, - 2.31; p < 0.01), and on > 12-week protocols (- 5.78 mmHg; 95%CI - 9.91, - 1.66; p < 0.01). Overall exercise and particularly aerobic plus resistance protocols were an effective therapy to reduce CMRFs post-BS. Benefits were also observed with interventions starting > 6 months post-BS and with > 12-week duration. Trial registration: CRD42020161175 .

Physical activity, patient-reported symptoms, and clinical events: Insights into postprocedural recovery from personal digital devices

Background

Personal digital devices may offer insights into patient recovery and an approach for remote monitoring after procedures.

Objective

To examine associations between activity measured using personal digital devices, patient-reported outcome measures (PROMs), and clinical events among patients after catheter ablation for atrial fibrillation (AF) or bariatric surgery.

Methods

We aggregated personal digital device, PROM, and electronic health record data in a study conducted at 2 health systems. We used Fitbit devices for step count assessments, KardiaMobile for cardiac rhythm assessments, and PROMs for pain and palpitations over 5 weeks.

Results

Among 59 patients, 30 underwent AF ablation and 29 bariatric surgery. Thirty-six patients (63%) reported pain. There was no difference in median [interquartile range] daily steps between patients with and those without pain (4419 [3286–7041] vs 3498 [2609–5888]; P = .23). Among AF ablation patients, 21 (70%) reported palpitations. Median daily steps were lower among those with palpitations than among those without (4668 [3021–6116] vs 8040 [6853–10,394]; P = .03). When accounting for within-subject correlation, recordings of AF were associated with a significant mean decrease in median daily steps (–351; 95% confidence interval –524 to –177; P <.01). Patients who received a new antiarrhythmic drug prescription had AF recorded in a median of 5 [5–5] of 5 total weeks, whereas patients who did not receive a new antiarrhythmic recorded AF in a median of 1 [0–3] week (P = .02).

Conclusion

Personal digital device and PROM data can provide insight into postprocedural recovery outside of usual clinical settings and may inform follow-up and clinical decision-making. (ClinicalTrials.gov Identifier: NCT03436082)

Food Addiction and Binge Eating Impact on Weight Loss Outcomes Two Years Following Sleeve Gastrectomy Surgery

BACKGROUND

Emerging evidence suggest that problematic eating behaviors such as food addiction (FA) and binge eating (BE) may alter following bariatric surgery (BS) and impact weight outcomes. We aimed to examine the prevalence of FA and BE and their associations with weight outcomes 2 years post-sleeve gastrectomy (SG).

METHODS

Forty-five women (mean age 32.4 ± 10.9 years) who underwent SG and completed 24 months of follow-up were evaluated prospectively at pre-, 3-, 6-, 12-, and 24-month post-SG. Data collected included anthropometrics, nutritional intake, and lifestyle patterns. The Yale Food Addiction Scale (YFAS) and the Binge Eating Scale (BES) were used to characterize FA and BE, respectively.

RESULTS

Pre-surgery FA and BE were identified in 40.0% and 46.7% of participants, respectively. Following SG, FA and BE prevalence was 10.0%, 5.0%, 29.4%, and 14.2% (P = 0.007), and 12.5%, 4.9%, 18.4%, and 19.4% (P < 0.001) at 3, 6, 12, and 24 months, respectively. Women with BE at baseline gained significantly more weight from the nadir compared to non-BE women at baseline (P = 0.009). There was no relationship between FA at baseline and weight (P = 0.090). Weight regained from the nadir positively correlated with BES scores at baseline (r = 0.374, P = 0.019).

CONCLUSIONS

FA and BE tend to decrease during the early postoperative period, but remains in a notable rates return by 2 years post-SG. Moreover, pre-surgical BE was related to higher weight-regain. Proper management pre-BS should include a comprehensive eating pathologies assessment, as these pathologies may remain or re-emerge post-surgery and lead to worse weight outcomes.

Role of nutritional ketosis in the improvement of metabolic parameters following bariatric surgery

BACKGROUND

Ketone bodies (KB) might act as potential metabolic modulators besides serving as energy substrates. Bariatric metabolic surgery (BMS) offers a unique opportunity to study nutritional ketosis, as acute postoperative caloric restriction leads to increased lipolysis and circulating free fatty acids.

AIM

To characterize the relationship between KB production, weight loss (WL) and metabolic changes following BMS.

METHODS

For this retrospective study we enrolled male and female subjects aged 18-65 years who underwent BMS at a single Institution. Data on demographics, anthropometrics, body composition, laboratory values and urinary KB were collected.

RESULTS

Thirty-nine patients had data available for analyses [74.4% women, mean age 46.5 ± 9.0 years, median body mass index 41.0 (38.5; 45.4) kg/m², fat mass 45.2% ± 6.2%, 23.1% had diabetes, 43.6% arterial hypertension and 74.4% liver steatosis]. At 46.0 ± 13.6 d post-surgery, subjects had lost 12.0% ± 3.6% of pre-operative weight. Sixty-nine percent developed ketonuria. Those with nutritional ketosis were significantly younger [42.9 (37.6; 50.7) years vs 51.9 (48.3; 59.9) years, P = 0.018], and had significantly lower fasting glucose [89.5 (82.5; 96.3) mg/dL vs 96.0 (91.0; 105.3) mg/dL, P = 0.025] and triglyceride levels [108.0 (84.5; 152.5) mg/dL vs 152.0 (124.0; 186.0) mg/dL, P = 0.045] vs those with ketosis. At 6 mo, percent WL was greater in those with postoperative ketosis (-27.5% ± 5.1% vs 23.8% ± 4.3%, P = 0.035). Urinary KBs correlated with percent WL at 6 and 12 mo. Other metabolic changes were similar.

CONCLUSION

Our data support the hypothesis that subjects with worse metabolic status have reduced ketogenic capacity and, thereby, exhibit a lower WL following BMS.

Bone Response to Weight Loss Following Bariatric Surgery

Obesity is a global health challenge that warrants effective treatments to avoid its multiple comorbidities. Bariatric surgery, a cornerstone treatment to control bodyweight excess and relieve the health-related burdens of obesity, can promote accelerated bone loss and affect skeletal strength, particularly after malabsorptive and mixed surgical procedures, and probably after restrictive surgeries. The increase in bone resorption markers occurs early and persist for up to 12 months or longer after bariatric surgery, while bone formation markers increase but to a lesser extent, suggesting a potential uncoupling process between resorption and formation. The skeletal response to bariatric surgery, as investigated by dual-energy X-ray absorptiometry (DXA), has shown significant loss in bone mineral density (BMD) at the hip with less consistent results for the lumbar spine. Supporting DXA studies, analyses by high-resolution peripheral quantitative computed tomography (HR-pQCT) showed lower cortical density and thickness, higher cortical porosity, and lower trabecular density and number for up to 5 years after bariatric surgery. These alterations translate into an increased risk of fall injury, which contributes to increase the fracture risk in patients who have been subjected to bariatric surgery procedures. As bone deterioration continues for years following bariatric surgery, the fracture risk does not seem to be dependent on acute weight loss but, rather, is a chronic condition with an increasing impact over time. Among the post-bariatric surgery mechanisms that have been claimed to act globally on bone health, there is evidence that micro- and macro-nutrient malabsorptive factors, mechanical unloading and changes in molecules partaking in the crosstalk between adipose tissue, bone and muscle may play a determining role. Given these circumstances, it is conceivable that bone health should be adequately investigated in candidates to bariatric surgery through bone-specific work-up and dedicated postsurgical follow-up. Specific protocols of nutrients supplementation, motor activity, structured rehabilitative programs and, when needed, targeted therapeutic strategies should be deemed as an integral part of post-bariatric surgery clinical support.

Changes in bone mineral density following laparoscopic sleeve gastrectomy: 2-year outcomes

BACKGROUND

Emerging evidence suggests that sleeve gastrectomy (SG) leads to significant bone mineral density (BMD) losses, but there is a paucity of studies evaluating skeletal consequences beyond 12-months post-operatively.

OBJECTIVES

To evaluate BMD changes 2 years postoperatively.

SETTING

A university hospital.

METHODS

Thirty-three women (mean age: 34.4 ± 12.3 years) who underwent SG and completed 24 months of follow-up were evaluated prospectively at baseline and at 3 (M3), 6 (M6), 12 (M12), and 24 (M24) months postoperatively. Data collected included BMD at the total hip, femoral neck, and lumbar spine measured by dual-energy x-ray absorptiometry and anthropometrics, biochemical, nutritional, and physical activity parameters.

RESULTS

At M24, patients achieved a mean body mass index and excess weight loss of 32.4 ± 5.1 kg/m² and 64.5 ± 21.4%, respectively; however, weight stabilized at M12. Femoral neck BMD decreased significantly from baseline to M24 (.924 ± .124 versus .870 ± .129 g/cm², P < .001), with no change between M12 and M24 (P = .273). Total hip BMD decreased significantly from baseline to M24 (1.004 ± .105 versus .965 ± .132 g/cm², P < .001) but increased between M12 and M24 (P = .001). No significant changes were noted in lumbar spine BMD. The percentage of changes in the femoral neck and the total hip BMD from baseline to M24 positively correlated with postoperative excess weight loss (r = .352, P = .045, and r = .416, P = .018, respectively).

CONCLUSION

Despite notable weight loss, women who underwent SG experienced significant bone loss at the total hip and femoral neck more than 2 years postoperatively. Future studies should investigate intervention strategies to attenuate skeletal deterioration after SG.

PARIS: protocol for a prospective single arm, theory-based, group-based feasibility intervention study to increase Physical Activity and reduce sedentary behaviouR after barIatric Surgery

INTRODUCTION

Increased physical activity and reduced sedentary behaviour can encourage favourable outcomes after bariatric surgery. However, there is a lack of evidence as to how to support patients with behaviour change. The aim of this study is to assess the feasibility of a physiotherapist led, online group-based behaviour change intervention to increase physical activity and reduce sedentary behaviour following bariatric surgery.

METHODS AND ANALYSIS

Single arm feasibility study of a theory and evidence-based group behaviour change intervention based on the Behaviour Change Wheel and Theoretical Domains Framework using behaviour change techniques from the Behaviour Change Technique Taxonomy v1. The intervention has eight objectives and specifies behaviour change techniques that will be used to address each of these. Groups of up to eight participants who have had surgery within the previous 5 years will meet weekly over 6 weeks for up to 1½ hours. Groups will be held online led by a physiotherapist and supported by an intervention handbook. Feasibility study outcomes include: rate of recruitment, retention, intervention fidelity, participant engagement and acceptability. Secondary outcomes include: physical activity, sedentary behaviour, body composition, self-reported health status and will be analysed descriptively. Change in these outcomes will be used to calculate the sample size for a future evaluation study. Qualitative interviews will explore participants' views of the intervention including its acceptability. Data will be analysed according to the constant comparative approach of grounded theory.

ETHICS AND DISSEMINATION

This study has National Health Service Research Ethics Committee approval; Haydock 20/NW/0472. All participants will provide informed consent and can withdraw at any point. Findings will be disseminated through peer-reviewed journals, conference and clinical service presentations.

TRIAL REGISTRATION NUMBER

ISRCTN31524689.

The effect of bariatric surgery on gravitational loading and its impact on bone mass

INTRODUCTION

Mechanical unloading associated with weight loss might be one of the main causes for bariatric surgery (BS) induced bone loss. However, no study has tested this hypothesis through objectively measured accelerometry-derived gravitational loading. We aimed to assess how gravitational loading changes following BS and how this correlates with bone mass losses.

METHODS

Twenty-one patients submitted to gastric bypass were assessed before, 1, 6 and 12 months after BS for areal bone mineral density (BMD), calciotropic hormones, sclerostin, body composition and daily physical activity. Gravitational loading was determined as the sum of ground reaction forces assessed by accelerometer which considered the interaction between weight and daily ambulation.

RESULTS

Mechanical stimuli promoted through the significant increase in steps number counterbalanced the gravitational loading decreases derived from the significant weight loss after BS. Gravitational loading volume decreased between pre-BS and 1 month post-BS (-2215 kN·d^-1; p = .023), but remained stable between 6 and 12 months post-BS, despite decreases on hip (-7.0%; p < .001), femoral neck (-8.8%; p < .001) and lumbar spine (-5.2%; p < .001) BMD. Serum sclerostin increased from pre-BS to 1 month post-BS (+0.118 ng·mL^-1; p = .021), returning to pre-BS levels 6 months after surgery. Neither vitamin D nor parathyroid hormone were affected by BS. Weight variation was a predictor of BMD decreases at total hip (R² = 0.06; p = .026) and femoral neck (R² = 0.12; p = .022), whereas daily gravitational loading volume was not. Fat and lean mass changes were also predictors of BMD decrease at total hip (R² = 0.05; p = .031) and femoral neck (R² = 0.14; p = .010), respectively.

CONCLUSION

Our findings suggest that gravitational loading only decreased during the first month after surgery remaining stable thereafter, and these changes do not seem to explain BS-induced bone loss. The association between weight and bone loss seems to result from other physiological aspects, fat and lean mass loss, rather than from gravitational loading decrease.

Is weight stigma associated with physical activity? A systematic review

OBJECTIVE

Weight stigma is associated with impaired health, attributed in part to reductions in health-promoting behaviors. This review analyzed evidence of the association between weight stigma and physical activity (PA) in adults and youth.

METHODS

Three databases were searched for terms related to weight stigma and PA. Eligible studies reported the quantitative association between at least one measure of weight stigma and one behavioral measure of PA.

RESULTS

A total of 38 studies met eligibility criteria. Of the 29 studies of adults, 3 used objective PA measures, and 79% used an observational, cross-sectional design. Findings of the relationship between weight stigma and PA were mixed. Everyday weight discrimination and internalizing weight stigma were associated with reduced PA in most studies. Several studies found indirect, and not direct, effects of weight stigma on PA when analyses included other individual-level factors. In the nine studies of youth, two used objective PA measures, all were observational, and only one study was longitudinal. Most youth studies found a relationship between weight-based teasing and reduced PA.

CONCLUSIONS

Weight teasing, everyday discrimination, and internalization were associated with reduced PA. However, associations were inconsistent and often indirect. Future studies should include objective PA measures with larger samples and longitudinal assessments.

Obesity treatment: Weight loss versus increasing fitness and physical activity for reducing health risks

We propose a weight-neutral strategy for obesity treatment on the following grounds: (1) the mortality risk associated with obesity is largely attenuated or eliminated by moderate-to-high levels of cardiorespiratory fitness (CRF) or physical activity (PA), (2) most cardiometabolic risk markers associated with obesity can be improved with exercise training independent of weight loss and by a magnitude similar to that observed with weight-loss programs, (3) weight loss, even if intentional, is not consistently associated with lower mortality risk, (4) increases in CRF or PA are consistently associated with greater reductions in mortality risk than is intentional weight loss, and (5) weight cycling is associated with numerous adverse health outcomes including increased mortality. Adherence to PA may improve if health care professionals consider PA and CRF as essential vital signs and consistently emphasize to their patients the myriad benefits of PA and CRF in the absence of weight loss.

The impact of preoperative vitamin administration on skeletal status following sleeve gastrectomy in young and middle-aged women: a randomized controlled trial

BACKGROUND

The appropriate strategies to minimize skeletal deterioration following bariatric surgeries are inconclusive. This randomized controlled trial evaluated the effect of preoperative vitamin supplementation on bone mineral density (BMD) and biochemical parameters in females post-sleeve gastrectomy (SG).

METHODS

Participants were randomized to a 2-month preoperative treatment with a multivitamin and vitamin D 4000 IU/d (intervention arm) or 1200 IU/d (control arm). Preoperative and 12-month postoperative follow-up evaluations included anthropometrics, biochemical parameters, and dual energy X-ray absorptiometry (DEXA).

RESULTS

Sixty-two females (median age 29.7 years and median BMI 43.4 kg/m²) were recruited, 87% completed the 12-month follow-up. For the intervention and control arms, significant and similar reductions at 12-months post-surgery were observed in BMD of the hip (-6.8 ± 3.7% vs. -6.0 ± 3.6%; P = 0.646) and of the femoral neck (-7.1 ± 5.8% vs. -7.2 ± 5.5%; P = 0.973). For the intervention compared to the control arm, the 25 hydroxyvitamin D (25(OH)D) increment was greater after 2 months treatment, and vitamin D deficiency rates were lower at 3 and 6-months follow-up (P < 0.016). However, at 12-months postoperative, 25(OH)D values and vitamin D deficiency were comparable between the arms (P > 0.339). Predictors for BMD decline in the total hip were the percentage of excess weight-loss, age>50 years, and lower initial BMI (P ≤ 0.003).

CONCLUSIONS

SG was associated with a significant decline in BMD of the hip and femoral neck in young and middle-aged women, and was unaffected by preoperative vitamin D supplementation. Females who are peri-menopausal or with greater postoperative weight-loss should be particularly followed for BMD decline.

Effect of exercise training before and after bariatric surgery: A systematic review and meta-analysis

We aimed to assess the effectiveness of exercise training programs in adults with severe obesity undergoing bariatric surgery. A systematic search of controlled trials published up to October 2019 that assigned participants to either a preoperative or postoperative exercise training group or a nonexercise group was performed. Meta-analyses were conducted using random-effects models. Twenty-two training programs were assessed (18 performed after bariatric surgery). The effect of preoperative exercise training on postsurgery outcomes was reported in only one study. Compared with the control condition without exercise, postoperative exercise training led to higher weight loss (N = 14, mean difference [95% CI] = -1.8 [-3.2; -0.4] kg, P = 0.01), fat loss (N = 9, P = 0.01), increase in VO₂ max (N = 8, P < 0.0001), and increase in muscle strength (N = 9, P < 0.0001). No significant effect was found on lean body mass (N = 11). Preliminary evidence suggests a beneficial effect of postoperative exercise training on bone mineral density (N = 3, P < 0.001) and weight maintenance after the end of the intervention (N = 2, P < 0.001) but no significant effect on quality of life (N = 2), habitual physical activity (N = 2), or cardiometabolic outcomes (N < 4). In conclusion, exercise training performed after bariatric surgery improves physical fitness and leads to a small additional weight and fat loss and may prevent bone loss and weight regain after bariatric surgery.

Whole-body electrical stimulation as a strategy to improve functional capacity and preserver lean mass after bariatric surgery: a randomized triple-blind controlled trial

BACKGROUND/OBJECTIVES

Bariatric surgery (BS) is a successful, long-lasting treatment option for obese. The early postoperative (PO) period is followed by dietary restriction and physical inactivity, leading to declines in muscle mass and functional capacity. Whole-body electromyostimulation (WB-EMS) may be a feasible and potential early rehabilitation strategy post BS. The aim was to evaluate the effects of WB-EMS with exercise training (Fe) on functional capacity, body composition, blood biomarkers, muscle strength, and endurance post BS.

SUBJECTS/METHODS

This is a randomized, triple-blind, sham-controlled trial. Thirty-five volunteers underwent a Roux-en-Y gastric bypass and were randomized into a WB-EMS (WB-EMSG) or control group (ShamG). Preoperative evaluations consisted of maximal and submaximal exercise testing, body composition, blood biomarkers, quadriceps strength, and endurance. After discharge, functional capacity and body composition were obtained. Exercise training protocols in both groups consisted of 14 dynamic exercises, 5 days per week, completing 30 sessions. The WB-EMSG also underwent an electrical stimulation protocol (Endurance: 85 Hz, 350 ms, 6 s of strain, 4 f of rest; Strength: 30 Hz, 350 ms, 4 s of strain, 10 seconds of rest, with bipolar electrical pulse). After intervention, subjects were reevaluated.

RESULTS

The protocol started on average 6.7 ± 3.7 days after discharge. Both groups presented with a decline in functional capacity after BS (p < 0.05) and a reduction in all body composition measurements (p < 0.05). The exercise training program led to significant improvements in functional capacity (ShamG - PO: 453.8 ± 66.1 m, Post: 519.2 ± 62.8 m; WB-EMSG- PO: 435.9 ± 74.5, Post: 562.5 ± 66.4 m, p < 0.05), however, only the WB-EMSG demonstrated significant changes of distance walked (interaction time vs group effect, p < 0.05). In addition, adiponectin significantly increased only in the WB-EMSG (p < 0.05). The WB-EMSG was also able to preserve muscle strength, endurance, and fatigue index, while the ShamG demonstrated significant decline (p < 0.05).

CONCLUSION

WB-EMS + Fe can be an attractive and feasible method following BS to enhance functional capacity and prevent deterioration of muscle function in the early PO.

CLINICAL TRIAL REGISTRATION

ReBEC, RBR-99qw5h, on 20 February 2015.

Low bone mineral density following gastric bypass is not explained by lifestyle and lack of exercise

BACKGROUND

Bariatric surgery, Roux-en-Y gastric bypass (RYGBP) in particular, is associated with weight loss as well as low bone mineral density. Bone mineral density relies upon multiple factors, some of which are lifestyle factors. The aim of this study was to compare lifestyle factors in order to eliminate them as culprits of the suspected difference in BMD in RYGBP operated and controls.

MATERIALS AND METHODS

Study participants included 71 RYGBP-operated women (42.3 years, BMI 33.1 kg/m2) and 94 controls (32.4 years, BMI 23.9 kg/m2). Each completed a DEXA scan, as well as survey of lifestyle factors (e.g. physical activity in daily life, corticosteroid use, and calcium intake). All study participants were premenopausal Caucasian women living in the same area. Blood samples were taken in RYGBP-patients.

RESULTS

BMD was significantly lower in RYGBP, femoral neck 0.98 vs. 1.04 g/cm2 compared to controls, despite higher BMI (present and at 20 years of age) and similar physical activity and calcium intake. In a multivariate analysis, increased time since surgery and age were negatively associated with BMD of the femoral neck and total hip in RYGBP patients.

CONCLUSION

Despite similar lifestyle, RYGBP was followed by a lower BMD compared to controls. Thus, the reduced BMD in RYGBP cannot be explained, seemingly nor prevented, by lifestyle factors. As the reduction in BMD was associated with time since surgery, strict follow-up is a lifelong necessity after bariatric surgery, and especially important in younger bariatric patients.

Changes in relationship status following bariatric surgery

BACKGROUND AND OBJECTIVE

Bariatric surgery is a major event associated with psychological changes such as improvements in self-esteem, increased autonomy, and better self-value. Such changes could affect the patient's interpersonal relationships; however, little is known about the impact of bariatric surgery on changes in relationship status. In this paper, we aim to test the hypothesis that bariatric surgery is associated with changes in interpersonal relationships such as becoming single for those who were in a relationship or entering a relationship among those who were single before surgery.

METHODS

This register-based cohort study consisted of 12,493 patients undergoing bariatric surgery (95% gastric bypass) from 2005 to 2013 and a reference group of 15,101 individuals with obesity between the age of 18-63 with a body mass index between 32 and 60 kg/m². Transitions between married, divorced, widowed, never-married single, and living with a partner without being married were analyzed by Poisson regression. Additionally, the outcome was dichotomized, and transitions between being single and being in a relationship were also analyzed. All analyses were weighted using inverse probability of treatment weighting based on propensity scores.

RESULTS

The overall incidence rate ratio (IRR) of changing status from being single to in a relationship was 2.03 (95% CI: 1.18-2.28), and the overall IRR of changing status from being in a relationship to single was 1.66 (95% CI: 1.50-1.83).

CONCLUSION

Bariatric surgery is associated with a higher chance of finding a partner among single individuals, and a higher risk of separating from a partner among individuals in a relationship.

Towards Optimized Care After Bariatric Surgery by Physical Activity and Exercise Intervention: a Review

Although there is growing evidence on the importance of physical activity and exercise intervention after bariatric surgery, it remains to be clarified as to why and how post-operative exercise intervention should be implemented. In this narrative and practically oriented review, it is explained why exercise interventions and physical activity are important after bariatric surgery, how to prescribe exercise and monitor physical activity and how and when physical fitness, muscle strength, fat (-free) mass and bone mineral density could be assessed during follow-up. It is suggested that the inclusion of physical activity and exercise training in the clinical follow-up trajectory could be of great benefit to bariatric surgery patients, since it leads to greater improvements in body composition, bone mineral density, muscle strength and physical fitness.

How Does Bariatric Surgery Affect Fall Risk Factors?

PURPOSE

This study aimed to assess bariatric surgery (BS) effect on fall risk factors.

MATERIALS AND METHODS

Fifteen patients undergoing BS (intervention group, IG) and 10 non-surgical obese patients (control group, CG) were recruited. IG was assessed at pre-surgery and 6 months after BS, while CG was assessed at baseline and reassessed after 6 months. At both time-points, anthropometry, lower limbs muscle strength (isokinetic dynamometer), balance in bipedal stance (force platform), daily physical activity (accelerometry), and health-related quality of life (SF-36 questionnaire) were assessed.

RESULTS

At baseline, there were no differences between CG and IG for all parameters analyzed. Compared to CG, 6 months post-BS, the IG decreased weight, body mass index, waist and hip circumference. Balance showed limited improvements, with gains observed only on antero-posterior and total center of pressure velocity. Muscle strength displayed a divergent evolution 6 months after BS, with a decrease in absolute strength but an increase in relative strength. Although BS did not induce significant changes in time spent in different physical activity intensities, it decreased time in sedentary behavior and increased number of daily steps. Post-BS patients reported substantial improvements in quality-of-life, especially in physical function.

CONCLUSION

Patients seem to overestimate their actual physical fitness improvements attained after BS, which combined with increases in physical activity, might increase the likelihood of engaging in risky daily tasks to what they are physically not prepared to, consequently increasing fall risk.

Addiction Transfer and Other Behavioral Changes Following Bariatric Surgery

Despite its important treatment implications for obesity and related comorbidities, bariatric surgery requires several behavioral changes that warrant comprehensive evaluation and support before and after surgery. This article outlines emerging scientific and anecdotal evidence for addiction transfer after bariatric surgery. Other common behavioral changes that impact adherence, weight loss, and psychiatric risk after surgery are also reviewed. Last, recommendations for presurgical psychological evaluation and postoperative support are provided.

The transtheoretical model (TTM) to gain insight into young women's long-term physical activity after bariatric surgery: a qualitative study

BACKGROUND

Over the long term, people who have undergone bariatric surgery (BS) remain overly sedentary with inadequate physical activity (PA). The purpose of this study was to apply the transtheoretical model (TTM) to (1) explore in-depth how PA is experienced years after BS and (2) identify the barriers to and facilitators of PA involved at each stage of change (SOC).

METHODS

Seventeen women with a mean age of 32.5 ± 3.3 years and a percentage of total weight loss of 29.6 ± 12.4 were interviewed at a mean of 9.4 ± 3.6 years after BS. Interviews were audio-recorded, transcribed verbatim, and analyzed using thematic analysis.

RESULTS

The distribution of barriers to and facilitators of PA differed with the SOC. In progressing from the precontemplation and contemplation stages to the preparation stage, the women experienced changes in their decisional balance, supported by processes of self-reevaluation and environmental reevaluation. In shifting from preparation to the action and maintenance stages, they experienced intrinsic motivation and self-liberation processes. The relapse stage was associated with a decrease in self-efficacy to cope with life constraints.

CONCLUSIONS

This study presents an in-depth theory-based exploration of the dynamics of long-term engagement in PA after BS in young women, with clinical implications for providing them with better guidance toward a more physically active lifestyle.

Increased Cardiopulmonary Fitness Is Associated with a Greater Reduction in Depression among People Who Underwent Bariatric Surgery

The aim of this study was to determine the effect of changes in cardiopulmonary fitness on the mental health of patients with severe obesity who underwent gastric bypass surgery (prior to and 1, 3, and 6 months after surgery). Study participants were recruited from among patients of a regional hospital in Czechia who underwent gastric bypass surgery between April 2018 and October 2019. They were eligible if they (a) were between 18 and 65 years old, (b) provided written informed consent, and (c) were able to walk independently. Twenty-six patients (age 45.4 ± 9.0 years, body mass index 45.1 ± 7.4 kg·m⁻², body fat 43.8 ± 4.8%) were included in the analysis. The key finding revealed that the greater the increase in cardiopulmonary fitness (i.e., longer distance walked in the six-minute walk test, 6MWT), the better the improvement in depression score among patients who underwent bariatric surgery. In particular, increments of 10 m in the 6MWT lead to the improvement of 0.5 points on the depression subscale of the Hospital Anxiety and Depression Scale (HADS) questionnaire. As the main implication, these results suggest that patients should participate in exercise training programs to increase their fitness status for optimal physical and mental outcomes of bariatric surgery.

Colorectal Cancer Risk Following Bariatric Surgery in a Nationwide Study of French Individuals With Obesity

Importance

Although bariatric surgery is effective against morbid obesity, the association of this surgery with the risk of colorectal cancer remains controversial.

Objective

To assess whether bariatric surgery is associated with altered risk of colorectal cancer among individuals with obesity.

Design, Setting, and Participants

This retrospective, population-based, multicenter, cohort study based on French electronic health data included 1 045 348 individuals with obesity, aged 50 to 75 years, and free of colorectal cancer at baseline. All inpatients with obesity having data recorded during a hospital stay between 2009 and 2018 by the French national health insurance information system database were followed up for a mean (SD) of 5.3 (2.1) years for those who did not undergo bariatric surgery and 5.7 (2.2) years for those who underwent bariatric surgery. Two groups of patients comparable in terms of age, sex, body mass index, follow-up, comorbidities, and conditions who did or did not undergo surgery were also obtained by propensity score matching.

Exposures

Bariatric surgery (n = 74 131), including adjustable gastric banding, sleeve gastrectomy, gastric bypass; or no bariatric surgery (n = 971 217).

Main Outcomes and Measures

Primary outcome was incident colorectal cancer. Standardized incidence ratios were calculated using age-, sex-, and calendar year-matched colorectal cancer incidence among the general French population during the corresponding years. Secondary outcome was incident colorectal benign polyps.

Results

Among a total of 1 045 348 patients, the mean (SD) age was 57.3 (5.5) years for the 74 131 patients in the surgical cohort vs 63.4 (7.0) years for the 971 217 patients in the nonsurgical cohort. The mean (SD) follow-up was 6.2 (2.1) years for patients who underwent adjustable gastric banding, 5.5 (2.1) years for patients who underwent sleeve gastrectomy, and 5.7 (2.2) years for patients who underwent gastric bypass. In total, 13 052 incident colorectal cancers (1.2%) and 63 649 colorectal benign polyps were diagnosed. The rate of colorectal cancer was 0.6% in the bariatric surgery cohort and 1.3% in the cohort without bariatric surgery. In the latter cohort, 9417 cases were expected vs 12 629 observed, a standardized incidence ratio of 1.34 (95% CI, 1.32-1.36). In the bariatric surgery cohort, 428 cases were expected and 423 observed, a standardized incidence ratio of 1.0 (95% CI, 0.90-1.09). Propensity score-matched hazard ratios in comparable operated vs nonoperated groups were 0.68 (95% CI, 0.60-0.77) for colorectal cancer and 0.56 (95% CI, 0.53-0.59) for colorectal benign polyp. There were fewer new diagnoses of colorectal cancer after gastric bypass (123 of 22 343 [0.5%]) and sleeve gastrectomy (185 of 35 328 [0.5%]) than after adjustable gastric banding (115 of 16 460 [0.7%]), and more colorectal benign polyps after adjustable gastric banding (775 of 15 647 [5.0%]) than after gastric bypass (639 of 20 863 [3.1%]) or sleeve gastrectomy (1005 of 32 680 [3.1%]).

Conclusion and Relevance

The results of this nationwide cohort study suggested that following bariatric surgery, patients with obesity share the same risk of colorectal cancer as the general population, whereas for patients with obesity who do not undergo bariatric surgery, the risk is 34% above that of the general population.

Long-term effects of physical activity prescription after bariatric surgery: A randomized controlled trial

PURPOSE

This study examined the effects of physical activity prescription (PAP) in patients after gastric bypass surgery. Patients' physical activity (PA) levels and outcomes were followed over their first postoperative year.

METHODS

Patients slated for bariatric surgery were randomized to a control group (n = 64) (basic information about postoperative PA) or an intervention group (n = 57) (also received physical therapist-prescribed PAP). Outcome measures were self-reported PA/exercise and sedentary time; and weight, waist circumference, blood pressure, and blood lipids; recorded pre-operatively and at 2, 6, and 12 months postoperatively. Follow-ups were conducted by nurses/dieticians. Trial registration: "Research and Development in Sweden" number 107371.

RESULTS

There were no differences between the groups except for higher level of PA (579 vs. 182 minutes/week) six months after surgery (p = .046) and a larger decrease in cholesterol (-24 vs. -8%) after a year (p = .017) in the intervention group. Patients in both groups lost considerable weight, had reduced waist circumference, and increased PA (p < .001).

CONCLUSION

Although marked differences between groups were not observed over one year, the intervention group increased its PA 6-months postoperatively, but not at other time points. Whether long-term outcomes of PAP use are more robust with physical therapist participation across follow-ups warrants study.