Impact of bariatric surgery on physical functioning in obese adults

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.

Short-Term Effect of Bariatric Surgery on Cardiorespiratory Response at Submaximal, Ventilatory Threshold, and Maximal Exercise in Women with Severe Obesity

PURPOSE

People with obesity have varying degrees of cardiovascular, pulmonary, and musculoskeletal dysfunction that affect aerobic exercise testing variables. Short time after bariatric surgery, these dysfunctions could affect both peak oxygen consumption ([Formula: see text] O₂ peak), the gold standard for assessing cardiorespiratory fitness (CRF) and aerobic capacity evaluated with ventilatory threshold (VT1). The purpose of this study was to evaluate the short-term effect of bariatric surgery, i.e. before the resumption of physical activity, on submaximal, at VT1 and maximal cardiorespiratory responses in middle-aged women with severe obesity.

MATERIALS AND METHODS

Thirteen middle-aged women with severe obesity (age: 36.7 ± 2.3 years; weight: 110.5 ± 3.6 kg, BMI: 41.8 ± 1.1 kg/m²) awaiting bariatric surgery participated in the study. Four weeks before and 6 to 8 weeks after surgery, body composition was determined by bioelectrical impedance. The participants performed an incremental cycling test to [Formula: see text] O₂ peak.

RESULTS

After bariatric surgery, all body composition parameters were reduced, absolute [Formula: see text] O₂ peak and peak workload decline with a lower VT1. Relative [Formula: see text] O₂ at peak and at VT1 (ml/min/kg or ml/min/kg of FFM) remained unchanged. Ventilation was lower after bariatric surgery during exercise with no change in cardiac response.

CONCLUSION

Our results showed that weight loss alone at short-term after bariatric surgery decreased CRF as seen by a decrease in absolute [Formula: see text] O₂ peak, and peak workload with lower VT1, whereas relative [Formula: see text] O₂ (ml/min/kg or ml/min/kg of FFM) during exercise remained unchanged in women with obesity. Rapid FFM loss affects cardiorespiratory responses at submaximal and maximal.

The Influence of Weight Loss in Postural Control in Women Undergoing Sleeve Gastrectomy

BACKGROUND

Bariatric surgery is the most effective procedure for obesity management, with a greater body weight loss and the remission of several diseases. The aim of this study was to analyze the relationships between the anthropometric profile and postural control outcomes in a group of obese adult women, and the effect of bariatric surgery on postural control.

METHODS

eighty-eight women candidates for bariatric surgery were recruited. Static balance was measured with the ARGO stabilometric platform under two conditions: open eyes (OE) and closed eyes (CE).

RESULTS

Multiple linear regression indicated BMI as the first predictor for postural control in all parameters, except for APO in open eyes, predicted mainly by height. Changes in body weight and BMI showed no statistically significant correlations with modification of postural control parameters (OE), while they appeared to exert an influence under closed eyes conditions.

CONCLUSIONS

Before surgery, obese patients with a higher BMI showed a better postural control. After surgery, the sway path and antero-posterior oscillation improved under open eyes conditions, while the magnitude of weight loss was negatively correlated with differences in postural control.

Musculoskeletal effects of obesity and bariatric surgery – a narrative review

Obesity affects several areas of the human body, leading to increased morbidity and mortality and the likelihood of other diseases, such as type 2 diabetes mellitus, cardiovascular diseases and musculoskeletal disorders. These conditions predispose to bone fractures and sarcopenic obesity, defined by the presence of an obesity-associated decrease in muscle mass and strength. Both bone fragility and sarcopenic obesity disease are consequences of several factors, such as a low degree of chronic inflammation, insulin resistance, hormonal changes, nutritional deficiencies, ectopic fat deposits and sedentary lifestyle. The diagnosis of obesity-related musculoskeletal disorders is limited by the lack of sarcopenia criteria and lower accuracy of bone mineral density measurement by dual-energy X-ray absorptiometry in overweight people. Reducing body weight provides undeniable benefits to this population, however treating cases of severe obesity with bariatric surgery can cause even greater damage to bone and muscle health, especially in the long term. The mechanisms involved in this process are not yet fully understood, but factors related to nutrient malabsorption and mechanical discharge as well as changes in gut hormones, adipokines and bone marrow adiposity should be taken into account. Depending on the surgical technique performed, greater musculoskeletal damage may occur, especially in cases of malabsorptive surgeries such as Roux-en-Y gastric bypass, when compared to restrictive techniques such as sleeve gastrectomy. This difference is probably due to greater weight loss, nutrient malabsorption and important hormonal changes that occur as a consequence of the diversion of intestinal transit and loss of greater absorptive surface. Thus, people undergoing bariatric procedures, especially malabsorptive ones, should have their musculoskeletal health supervised to allow early diagnosis and appropriate therapeutic interventions to prevent osteoporotic fractures and preserve the functionality of the skeletal muscles.

Sarcopenia after Roux-en-Y Gastric Bypass: Detection by Skeletal Muscle Mass Index vs. Bioelectrical Impedance Analysis

Background: In sarcopenic patients the skeletal muscle reduction is the primary symptom of age- or disease-related malnutrition, which is linked to postoperative morbidity and mortality. The skeletal muscle mass index (SMI) from magnet resonance imaging (MRI) is increasingly used as a prognostic factor in oncologic and surgical patients, but under-represented in the field of obesity surgery. The bioelectrical impedance analysis (BIA), on the other hand is a commonly used method for the estimation of the body composition of bariatric patients, but still believed to be inaccurate, because of patient-related and environmental factors. The aim of this study was to compare the postoperative SMI values as a direct, imaging measured indicator for muscle mass with the BIA results in patients undergoing Roux-en-Y gastric bypass (RYGB). Methods: We performed a prospective single-center trial. Patients undergoing RYGB between January 2010 and December 2011 at our institution were eligible for this study. MRI and BIA measurements were obtained 1 day before surgery and at 6, 12 and 24 weeks after surgery. Results: A total of 17 patients (four male, 13 female, average age of 41.9 years) were included. SMI values decreased significantly during the postoperative course (p < 0.001). Comparing preoperative and postoperative measurements at 24 weeks after surgery, increasing correlations of SMI values with body weight (r = 0.240 vs. r = 0.628), phase angle (r = 0.225 vs. r = 0.720) and body cell mass (BCM, r = 0.388 vs. r = 0.764) were observed. Conclusions: SMI decreases significantly after RYGB and is correlated to distinct parameters of body composition. These findings show the applicability of the SMI as direct imaging parameter for the measurement of the muscle mass in patients after RYGB, but also underline the important role of the BIA, as a precise tool for the estimation of patients’ body composition at low costs. BIA allows a good overview of patients’ status post bariatric surgery, including an estimation of sarcopenia.

Resistance Training Improves Muscle Strength and Function, Regardless of Protein Supplementation, in the Mid- to Long-Term Period after Gastric Bypass

Inadequate protein intake and low levels of physical activity are common long-term sequelae after bariatric surgery and can negatively affect muscle strength (MS) and physical function (PF). The study investigated the effects of resistance training with or without protein supplementation on MS and PF. The study, which involved a 12-week controlled trial (n = 61) of individuals 2-7 years post-Roux-en-Y gastric bypass (RYGB), comprised four groups: whey protein supplementation (PRO; n = 18), maltodextrin placebo (control [CON]; n = 17), resistance training combined with placebo (RTP; n = 11), and resistance training combined with whey protein supplementation (RTP+PRO; n = 15). An isokinetic dynamometer was used to measure MS (peak torque at 60°/s and 180°/s). PF was measured with the 30-s sit-to-stand (30-STS), 6-min walk (6-MWT), and timed up-and-go (TUG) tests. There were improvements in the absolute and relative-to-bodyweight peak torque at 60°/s and 180°/s, TUG, 6-MWT and 30-STS in the RTP and RTP+PRO groups, but not in the CON and PRO groups. Changes in MS were significantly correlated with changes in PF between the pre- and post-intervention periods. A supervised resistance training program, regardless of protein supplementation, improved MS and PF in the mid-to-long-term period after RYGB and can lead to clinical benefits and improved quality of life.

Assessment of Cardiorespiratory and Metabolic Responses in Women with Obesity After Surgically Induced Weight Loss: Results from a Pilot Study

PURPOSE

Bariatric surgery is effective in controlling severe obesity. However, studies investigating the impact of surgically induced weight loss on cardiorespiratory and metabolic responses during maximal effort are controversial. The aim of this study was to assess cardiorespiratory and metabolic responses in women with obesity after bariatric surgery.

MATERIALS AND METHODS

We performed a secondary analysis on data from a pilot study with women with obesity submitted to bariatric surgery and who did not participate in a controlled physical training program. Anthropometry, pulmonary function (spirometry), and cardiorespiratory fitness (cardiopulmonary exercise testing [CPX]) were assessed before and after bariatric surgery.

RESULTS

Thirty-four women were included (38.7 ± 9.6 years, body mass index = 44.1 ± 6.3 kg/m²). Postoperative assessment was conducted 9.4 ± 2.7 months after surgery. After surgery, we observed a reduction in all anthropometric measurements (mean loss of 28.6 kg, p < 0.001), and improvement in spirometry values (p < 0.001). Relative VO_2peak (mL/kg/min) increased slightly (Δ = 1.7; p = 0.06); however, absolute VO_2peak (L/min) reduced significantly (Δ =  - 0.398; p < 0.001). We also observed an increase of 1.3 min (p < 0.001) in CPX duration, a reduction of 11.3 bpm (p < 0.001) in resting heart rate, and a decrease of systolic (p = 0.02) and diastolic (p < 0.001) blood pressures at peak effort.

CONCLUSION

Surgically induced weight loss without exercise training improved cardiac reserve, ventilatory response, blood pressure, and resting heart rate. Cardiorespiratory fitness reflected by relative VO_2peak increased slightly, despite increased tolerance to CPX.

Relationship between cardiorespiratory fitness and preoperative evaluation findings in patients with morbid obesity undergoing sleeve gastrectomy: A cross-sectional study

Evaluating various parameters, including preoperative cardiorespiratory fitness markers, is critical for patients with morbid obesity. Also, clinicians should prescribe suitable exercise and lifestyle guideline based on the tested parameters. Therefore, we investigated cardiorespiratory fitness and its correlation with preoperative evaluation in patients with morbid obesity scheduled for laparoscopic sleeve gastrectomy.A retrospective cross-sectional study was conducted with 38 patients (13 men and 25 women; mean age, 34.9 ± 10.9 years) scheduled for laparoscopic sleeve gastrectomy. Cardiopulmonary exercise stress tests were also performed. Measured cardiopulmonary responses included peak values of oxygen consumption (VO2), metabolic equivalents (METs), respiratory exchange ratio, heart rate (HR), and rate pressure product. Body composition variables were analyzed using bioimpedance analysis, laboratory parameters (hemoglobin A1c, lipid profile, inflammatory markers), and comorbidities. In addition, self-reported questionnaires were administered, including the Beck Depression Inventory (BDI), Hamilton Depression Rating Scale (HDRS), Short-Form Health Survey (SF-36), and Moorehead-Ardelt Quality of Life Questionnaire (MAQOL).The average body mass index (BMI) and percent body fat were 39.8 ± 5.7 kg/m-2 and 46.2 ± 6.1%, respectively. The VO2peak/kg, METs, RERpeak, HRpeak, RPPpeak, age-predicted HR percentage, and VO2peak percentage were 18.6 ± 3.8 mL/min-1/kg-1, 5.3 ± 1.1, 1.1 ± 0.1, 158.5 ± 19.8, 32,414.4 ± 6,695.8 mm Hg/min-1, 85.2 ± 8.8%, and 76.1 ± 14.8%, respectively. BMI (P = .026), percent body fat (P = .001), HRpeak (P = .018), erythrocyte sedimentation rate (P = .007), total BDI (P = .043), HDRS (P = .025), SF-36 (P = .006), and MAQOL (P = .007) scores were significantly associated with VO2peak/kg. Body fat percentage (P < .001) and total SF-36 score (P < .001) remained significant in the multiple linear regression analysis.Various cardiorespiratory fitness markers were investigated in patients with morbid obesity who underwent the sleeve gastrectomy. Peak aerobic exercise capacity was significantly associated with preoperative parameters such as body fat composition and self-reported quality of life in these patients. These results could be utilized for preoperative and/or postoperative exercise strategies in patients with morbid obesity scheduled for laparoscopic sleeve gastrectomy.

Place Work on a Scale: What Do We Know About the Association Between Employment Status and Weight Loss Outcomes After Bariatric Surgery?

Despite the initial successful weight loss after bariatric surgery, a significant amount of patients experience weight loss failure and weight regain. Several factors are known to contribute to this, though the impact of employment status is unknown. The objective of this systematic review was to examine the impact of employment status on post-surgical weight loss outcomes. Eight studies were included with a follow-up ranging between 2 and 10 years. Employed patients seemed to present more weight loss (9.0-11.0% EWL, 1.3-1.6% BMI loss) compared to unemployed patients, but none of these numbers were statistically significant. Moreover, there were contrasting findings in terms of weight regain. This review may highlight the importance of working status after bariatric surgery and warrants further investigation on this topic.

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.

Ventilatory Response at Rest and During Maximal Exercise Testing in Patients with Severe Obesity Before and After Sleeve Gastrectomy

INTRODUCTION

Sleeve gastrectomy (SG) has become a widespread treatment option in patients affected by severe obesity. However, studies investigating the impact of the subsequent weight loss on the ventilatory response at rest and during physical exercise are lacking.

METHODS

This is an observational study on 46 patients with severe obesity (76% females), comparing parameters of ventilatory function 1 month before and 6 months after SG. Patients were first evaluated by resting spirometry and subsequently with an incremental, maximal cardiopulmonary exercise test (CPET) on treadmill.

RESULTS

The important weight loss of 26.35 ± 6.17% of body weight (BMI from 43.59 ± 5.30 to 32.27 ± 4.84 kg/m2) after SG was associated with a significant improvement in lung volumes and flows during forced expiration at rest, while resting ventilation and tidal volume were reduced (all p ≤ 0.001). CPET revealed decreased ventilation during incremental exercise (p < 0.001), with a less shallow ventilatory pattern shown by a lower increase of breathing frequency (∆BFrest to AT p = 0.028) and a larger response of tidal volume (∆TVAT to Peak p < 0.001). Furthermore, a concomitant improvement of the calculated dead space ventilation, VE/VCO2 slope and peripheral oxygen saturation was shown (all p ≤ 0.002). Additionally, the increased breathing reserve at peak exercise was associated with a lower absolute oxygen consumption but improved exercise capacity and tolerance (all p < 0.001).

CONCLUSION

The weight loss induced by SG led to less burdensome restrictive limitations of the respiratory system and to a reduction of ventilation at rest and during exercise, possibly explained by an increased ventilatory efficiency and a decrease in oxygen demands.

MANAGEMENT OF ENDOCRINE DISEASE: Bone complications of bariatric surgery: updates on sleeve gastrectomy, fractures, and interventions

Despite well recognized improvements in obesity-related comorbidities, increasing evidence implicates bariatric surgery in the onset of adverse skeletal health outcomes. The purpose of this review is to provide a focused update in three critical areas: (i) emergent data on sleeve gastrectomy and bone loss, (ii) evidence linking bariatric surgery to incident fracture, and (iii) intervention strategies designed to mitigate surgical bone loss. Better understanding of these issues will inform our treatment of skeletal health for patients planning bariatric surgery.

Cardiorespiratory function and VO2 kinetics after sleeve gastrectomy: a follow-up analysis

Although poor cardiorespiratory function is a powerful predictor of mortality in patients with obesity, functional evaluation has been given little attention after laparoscopic sleeve gastrectomy (LSG). The aim of this study was thus to investigate the impact of LSG on functional capacity analysing a shorter and longer post-surgical follow-up. In this observational study, 24 patients with severe obesity (BMI 44.04 ± 5.84 kg/m², age 47.0 ± 9.0 years) performed cardiopulmonary exercise testing 7 months pre-, 6 and 16 months post-LSG. Exercise capacity, oxygen uptake and VO₂ kinetics were analysed during treadmill exercise testing. Although patients showed an improved peak work capacity after LSG, parameters of maximal absolute aerobic capacity demonstrated a significant decrease, which was confirmed also in the follow-up analysis. Furthermore, the time constant Tau (τ) of the fundamental component of VO₂ kinetics was altered by LSG, however, within the 16 months of follow-up it returned towards baseline values. It can thus be concluded that LSG improved peak work capacity along with a lower maximal absolute aerobic capacity, which might be due to a loss of muscle mass and potentially impaired peripheral oxidative muscle metabolism. However, VO₂ kinetics might suggest an initial restoration of peripheral oxidative muscle capacity after a longer follow-up.

Gastric Bypass But Not Sleeve Gastrectomy Increases Risk of Major Osteoporotic Fracture: French Population-Based Cohort Study

The objective of this work was to investigate the risk of major osteoporotic fracture (MOF; hip, proximal humerus, wrist and distal forearm, and clinical spine) in bariatric surgery patients versus matched controls. Bariatric surgery is associated with an increase in fracture risk. However, it remains unclear whether the same degree of fracture risk is associated with sleeve gastrectomy, which has recently surpassed gastric bypass. Records from the French National Inpatient database were used from 2008 to 2018. Bariatric surgery patients, aged 40 to 65 years, with BMI ≥40 kg/m² , hospitalized between January 1, 2010 and December 31, 2014, were matched to one control (1:1) by age, sex, Charlson comorbidity index, year of inclusion, and class of obesity (40 to 49.9 kg/m² versus ≥50 kg/m² ). We performed a Cox regression analysis to assess the association between the risk of any MOF and, respectively, (i) bariatric surgery (yes/no) and (ii) type of surgical procedure (gastric bypass, gastric banding, vertical banded gastroplasty, and sleeve gastrectomy) versus no surgery. A total of 81,984 patients were included in the study (40,992 in the bariatric surgery group, and 40,992 matched controls). There were 585 MOFs in the surgical group (2.30 cases per 1000 patient-year [PY]) and 416 MOFs in the matched controls (1.93 cases per 1000 PY). The risk of MOF was significantly higher in the surgical group (hazard ratio [HR] 1.22; 95% CI, 1.08-1.39). We observed an increase in risk of MOF for gastric bypass only (HR 1.70; 95% CI, 1.46-1.98) compared with the matched controls. In patients aged 40 to 65 years, gastric bypass but not sleeve gastrectomy or the other procedures increased risk of major osteoporotic fractures. © 2020 American Society for Bone and Mineral Research.

Physical capacity outcomes in patients with severe obesity after 12 months of physician-led multidisciplinary team care: A case series from a public hospital clinical obesity service

Impaired physical capacity is common in people with severe levels of obesity. We aimed to investigate changes in physical capacity outcomes in patients with severe obesity following 12 months of physician-led multidisciplinary care from a "real world" Australian public hospital setting using a case series study design. We extracted data from medical records for all of the eligible patients referred to our clinical obesity service from 2010 to 2015 (69 of 239). We found significant (P < .05) pre-test/post-test (mean ± SD) improvements in the 6-minute walk test (6MWT) (339 ± 120 to 417 ± 112 m); 30-second sit-to-stand test (11 ± 4 to 15 ± 6 counts) and sit-and-reach test (-12 ± 13 to -8 ± 15 cm). Using linear mixed-effects models adjusting for repeated measurements over time (baseline vs 12 months) and testing for potential predictors, we found: mean 6MWT was associated with 12-month time period (56 m), body mass index (BMI, -3 m), no walking aid over 12 months (106 m) and no opioid analgesics (75 m); mean sit-to-stand was associated with 12-month time period (3 counts), age at referral (-0.2 counts), BMI (-0.2 counts), and diabetes (3 counts); and mean sit-and-reach was associated with 12-month time period (5 cm), female gender (5 cm) and total medications (-0.9 cm). Using causal mediation analysis, our results show that total exercise classes partially mediates change in walking capacity among those with cardiovascular disease. Our study shows that significant and clinically important improvements in physical capacity outcomes in patients with severe obesity can be achieved following 12 months of intensive specialist obesity services, such as ours.

The Impact of Bariatric Surgery on Cardiopulmonary Function: Analyzing VO2 Recovery Kinetics

PURPOSE

To assess cardiopulmonary capacity, autonomic heart function, and oxygen recovery kinetics during exercise testing before and after bariatric surgery.

METHODS

This is a prospective cohort study. Symptom-limited cardiopulmonary exercise testing was performed with 24 patients, 1 week before and 4 months after bariatric surgery. The main variables were maximum oxygen uptake (VO₂ max), the time elapsed until the appearance of the first ventilatory threshold (TLV1), and VO₂ oxygen kinetics during recovery with a 50% reduction in peak oxygen uptake in the recovery period after exercise (50%VO₂RP).

RESULTS

The study demonstrated that the peak VO₂\kg increased significantly after bariatric surgery. When analyzed without adjusting for weight, the peak VO₂ paradoxically and significantly decreased after the surgical procedure (p = 0.007). The exercise time until the anaerobic threshold was longer after surgical procedure than before it (p = 0.001). Regarding post-exercise oxygen recovery kinetics, there was a faster reduction in the peak oxygen uptake after bariatric surgery than before the procedure (p < 0.001).

CONCLUSIONS

There was an obvious cardiac autonomic improvement after surgery. Despite the improvement in exercise tolerance, patients undergoing bariatric surgery had lower maximum oxygen consumption in the analysis not corrected for body weight. The mean VO₂RP before bariatric surgery was 141 s and was 111 s after the surgical procedure (p < 0.001). These results suggest an improvement in the recovery kinetics of oxygen consumption, a novel index of cardiac reserve capacity, on patients undergoing bariatric surgery.

Supervised exercise following bariatric surgery in morbid obese adults: CERT-based exercise study protocol of the EFIBAR randomised controlled trial

BACKGROUND

There is increasing evidence of weight regain in patients after bariatric surgery (BS), generally occurring from 12 to 24 months postoperatively. Postoperative exercise has been suggested to ad long-term weight maintenance and to improve physical function in BS patients. However, there are a limited number of intervention studies investigating the possible benefits of exercise in this population. The aim of the current report is to provide a comprehensive CERT (Consensus on Exercise Reporting Template)-based description of the rationale and details of the exercise programme implemented in the EFIBAR Study (Ejercicio FÍsico tras cirugía BARiátrica), a randomised controlled trial investigating the effects of a 16-week supervised concurrent (aerobic and strength) exercise intervention program on weight loss (primary outcome), body composition, cardiometabolic risk, physical fitness, physical activity and quality of life (secondary outcomes) in patients with severe/morbid obesity following bariatric surgery.

METHODS

A total of 80 BS patients [60-80% expected women, aged 18 to 60 years, body mass index (BMI) ≥ 40 kg/m2 or ≥ 35 kg/m2 with comorbid conditions)] will be enrolled in the EFIBAR Randomized Control Trial (RCT). Participants allocated in the exercise group (n = 40) will undertake a 16-week supervised concurrent (strength and aerobic) exercise programme (three sessions/week, 60 min/session), starting 7 to 14 days after surgery. The rationale of the exercise programme will be described following the CERT criteria detailing the 16 key items. The study has been reviewed and approved by the Ethics Committee of the Torrecárdenas University Hospital (Almería, Spain) (ref. N° 76/2016).

DISCUSSION

The present study details the exercise programme of the EFIBAR RCT, which may serve: 1) exercise professionals who would like to implement an evidence-based exercise programme for BS patients, and 2) as an example of the application of the CERT criteria.

TRIAL REGISTRATION

The trial was prospectively registered at Clinicaltrials.gov NCT03497546 on April 13, 2018.

Psychometric Characteristics of the Revised Illness Perception Questionnaire (IPQ-R) in People Undergoing Weight Loss Surgery

The Illness Perception Questionnaire-Revised (IPQ-R) has been used extensively across many health conditions to measure patient illness and treatment perceptions. The constructs have an association with treatment adaptation and adherence which, in turn, are considered core factors involved in bariatric surgery outcome. This study examines the factorial validity and internal reliability of a modified (IPQ-R) in bariatric surgery candidates. After wording modifications, participants (N = 310) completed the IPQ-R as part of standard pre-surgery assessments. After removal of two items, confirmatory factor analysis (CFA) supported the original 7-factor solution of the Beliefs scale, with good to marginal subscale internal consistency. Exploratory factor analysis (EFA), with two items removed only partially supported the original 5-factor Causal Attributions scale. Internal consistency was unacceptably low for two subscales. Further research is needed to generate new items which better fit the IPQ-R to this population before research can explore the relevance of illness perceptions.

Changes in Lean Mass, Absolute and Relative Muscle Strength, and Physical Performance After Gastric Bypass Surgery

CONTEXT

Bariatric surgery results in reduced muscle mass as weight is lost, but postoperative changes in muscle strength and performance are incompletely understood.

OBJECTIVE

To examine changes in body composition, strength, physical activity, and physical performance following Roux-en-Y gastric bypass (RYGB).

DESIGN, PARTICIPANTS, OUTCOMES

In a prospective cohort of 47 adults (37 women, 10 men) aged 45 ± 12 years (mean ± SD) with body mass index (BMI) 44 ± 8 kg/m2, we measured body composition by dual-energy X-ray absorptiometry, handgrip strength, physical activity, and physical performance (chair stand time, gait speed, 400-m walk time) before and 6 and 12 months after RYGB. Relative strength was calculated as absolute handgrip strength/BMI and as absolute strength/appendicular lean mass (ALM).

RESULTS

Participants experienced substantial 12-month decreases in weight (-37 ± 10 kg or 30% ± 7%), fat mass (-48% ± 12%), and total lean mass (-13% ± 6%). Mean absolute strength declined by 9% ± 17% (P < 0.01). In contrast, relative strength increased by 32% ± 25% (strength/BMI) and 9% ± 20% (strength/ALM) (P < 0.01 for both). There were clinically significant postoperative improvements in all physical performance measures, including mean improvement in gait speed of >0.1 m/s (P < 0.01) and decrease in 400-m walk time of nearly a full minute.

CONCLUSIONS

In the setting of dramatic weight loss, lean mass and absolute grip strength declined after RYGB. However, relative muscle strength and physical function improved meaningfully and are thus noteworthy positive outcomes of gastric bypass.

The Amount of Weight Loss Six Months after Bariatric Surgery: It Makes a Difference

BACKGROUND

Bariatric surgery, especially Roux-en-Y gastric bypass (RYGB), has become the most frequently used therapy for morbid obesity.

OBJECTIVES

The aim of this study was to examine the effects of surgically induced weight loss on cardiopulmonary function 6 months after the procedure, as well as the effect of such an intervention on well-known risk factors for cardiovascular diseases.

METHODS

This is a cross-sectional study on 66 morbidly obese patients (BMI ≥40 or ≥35 kg/m2 with present comorbidities), comparing their cardiopulmonary function prior to and 6 months after RYGB surgery.

RESULTS

The substantial amount of weight loss (29.80 ± 13.27 kg) after RYGB surgery was associated with significant reduction of comorbidities, especially diabetes and sedentary lifestyle (p = 0.005 and p = 0.002, respectively). Regarding functional capacity, there was significant increase in peak oxygen uptake (VO2 peak, p = 0.003), duration of exercise testing, metabolic equivalents (exercise time and METs, p < 0.001), and in peak O2 pulse. These findings were particularly pronounced in a group of patients who had lost more than 18% of initial weight.

CONCLUSIONS

Reduction of body weight after RYGB surgery is associated with significantly improved cardiorespiratory function 6 months after surgery, especially in patients who lost more than 18% of their initial body weight. In addition, substantial decreases in body weight were also associated with a reduction of cardiovascular risk factors such as diabetes, smoking, hypertriglyceridemia, and sedentary lifestyle.

Go with the FLOW: Implementation of a psychological skills intervention in an exercise program for post-bariatric surgery patients

Bariatric surgery is an effective obesity treatment; however, most individuals regain weight following surgery. Following a Lifestyle of Wellness (FLOW) is a psychological skills intervention with strategies designed to increase self-efficacy and promote living a healthy lifestyle including regular physical activity. Eleven participants completed FLOW. Results indicated participants enjoyed the program and intended to continue this lifestyle upon program completion. Interviews indicated FLOW was effective for improving self-perceptions, and exercise motivation. The most effective sessions were goal setting, future planning, and stress management. Suggestions for program improvement were provided. This information can be used to improve the FLOW program and for implementation into other settings.

Meta-analysis of the effect of bariatric surgery on physical function

BACKGROUND

Obesity leads to an impairment of physical function that limits the ability to perform basic physical activities affecting quality of life. Literature on the effect of bariatric surgery on physical function is confounding and generally of low quality.

METHODS

A comprehensive search was undertaken using MEDLINE, Scopus (including Embase), CENTRAL, PubMed, SPORTDiscus, Scirus and OpenGrey for published research and non-published studies to 31 March 2017. Studies employing objective measurement and self-reporting of physical function before and after bariatric surgery were included. The magnitude of experimental effect was calculated in terms of the standardized mean difference (MD), and confidence intervals were set at 95 per cent to reflect a significance level of 0·05.

RESULTS

Thirty studies including 1779 patients met the inclusion criteria. Physical function improved after bariatric surgery at 0-6 months (MD 0·90, 95 per cent c.i. 0·60 to 1·21; P < 0·001), more than 6 to 12 months (MD 1·06, 0·76 to 1·35; P < 0·001) and more than 12 to 36 months (MD 1·30, 1·07 to 1·52; P < 0·001). Objective assessment of physical function after bariatric surgery showed improvement at 0-6 months (MD 0·94, 0·57 to 1·32; P < 0·001), more than 6 to 12 months (MD 0·77, 0·15 to 1·40; P = 0·02) and more than 12 to 36 months (MD 1·04, 0·40 to 1·68; P = 0·001). Self-reported assessment of physical function showed similar improvements at 0-6 months (MD 0·80, 0·12 to 1·47; P = 0·02), more than 6 to 12 months (MD 1·42, 1·23 to 1·60; P < 0·001) and more than 12 to 36 months (MD 1·41, 1·20 to 1·61; P < 0·001) after a bariatric procedure.

CONCLUSION

Bariatric surgery improves physical function significantly within 6 months of the procedure and this effect persists over time to 36 months after surgery, whether measured objectively or by self-reporting.

Evaluation of an exercise programme for post-bariatric surgery patients: views of participants

OBJECTIVE

Exercise programmes typically are evaluated with fitness assessments and psychological survey measures but seldom include participants' insights. The purpose of this study was to evaluate the benefits, facilitators and barriers of a 12-week exercise programme for post-bariatric surgery patients from the participants' perspective.

METHOD

Over a 2-year period, 20 patients recently having undergone bariatric surgery completed a 12-week programme that included participation in structured exercise and in focus groups designed to supplement standard evaluation data and provide insight into participants' views.

RESULTS

Participants were highly adherent to the programme, and focus group results reflected a clear positive evaluations. Benefits included helpful information, developing commitment, physical fitness and social support; notably, weight was seldom mentioned. Participants cited structure, accountability and group support as facilitators of exercise. Participants cited few barriers, although very few had set plans for continuing exercise after programme completion.

CONCLUSION

Participants saw many benefits to the exercise programme, and those benefits reflected lifestyle changes rather than a focus on weight. Programme structure, accountability and the support of the group were facilitators to exercise. Participants cited few barriers. However, the lack of plans for continued exercise suggested the need for a transition phase to help participants continue an active lifestyle after the 12-week structured programme.

Depressive Symptoms in Bariatric Surgery Patients with Multiple Sclerosis

BACKGROUND

Bariatric surgery has been shown to be a safe and effective intervention for patients with comorbid obesity and multiple sclerosis (MS); however, this sub-population may be at heightened risk for pre- and postoperative depressive symptoms.

OBJECTIVE

This current exploratory study aims to describe the prevalence and nature of depressive symptoms in a sample of patients with MS who undergo bariatric surgery.

METHODS

Medical records were retrospectively reviewed to identify patients who received bariatric surgery and had a diagnosis of MS (n = 31) and a control sample of non-surgical MS patients with severe obesity (n = 828). Longitudinal outcome measures included the Patient Health Questionnaire-9 (PHQ-9) and Multiple Sclerosis Performance Scale (MSPS).

RESULTS

There were no significant differences in PHQ-9 total and item scores between groups at baseline. PHQ-9 scores significantly improved at years 1 (p < 0.01) and 2 (p = 0.03) post-bariatric surgery when compared to non-surgical controls. Higher BMI (p = 0.03) and worse overall quality of life (p < 0.01) were associated with worsening of PHQ-9 scores in the bariatric group. When compared to controls, the bariatric group demonstrated improved MSPS scores on a trend level 1 year post-surgery (p = 0.08).

CONCLUSIONS

Consistent with the literature on more general bariatric surgery populations, current findings highlight the possible early benefits of bariatric surgery for reducing depressive symptoms in this population when compared to controls. Importantly, results should be viewed as preliminary and additional research is needed to examine bariatric surgery and associations with depressive symptoms and performance in the MS population.

Preserving Healthy Muscle during Weight Loss

Weight loss is the cornerstone of therapy for people with obesity because it can ameliorate or completely resolve the metabolic risk factors for diabetes, coronary artery disease, and obesity-associated cancers. The potential health benefits of diet-induced weight loss are thought to be compromised by the weight-loss-associated loss of lean body mass, which could increase the risk of sarcopenia (low muscle mass and impaired muscle function). The objective of this review is to provide an overview of what is known about weight-loss-induced muscle loss and its implications for overall physical function (e.g., ability to lift items, walk, and climb stairs). The currently available data in the literature show the following: 1) compared with persons with normal weight, those with obesity have more muscle mass but poor muscle quality; 2) diet-induced weight loss reduces muscle mass without adversely affecting muscle strength; 3) weight loss improves global physical function, most likely because of reduced fat mass; 4) high protein intake helps preserve lean body and muscle mass during weight loss but does not improve muscle strength and could have adverse effects on metabolic function; 5) both endurance- and resistance-type exercise help preserve muscle mass during weight loss, and resistance-type exercise also improves muscle strength. We therefore conclude that weight-loss therapy, including a hypocaloric diet with adequate (but not excessive) protein intake and increased physical activity (particularly resistance-type exercise), should be promoted to maintain muscle mass and improve muscle strength and physical function in persons with obesity.

The effects of supervised exercise training 12-24 months after bariatric surgery on physical function and body composition: a randomised controlled trial

BACKGROUND

Bariatric surgery is effective for the treatment of stage II and III obesity and its related diseases, although increasing evidence is showing weight regain ~12-24 months postsurgery. Weight regain increases the risk of physical function decline, which negatively affects an individual's ability to undertake activities of daily living. The study assessed the effects of a 12-week supervised exercise intervention on physical function and body composition in patients between 12 and 24 months post bariatric surgery.

METHODS

Twenty-four inactive adult bariatric surgery patients whose body mass index remained ⩾30 kg m² 12 to 24 months post surgery were randomised to an exercise intervention (n=12) or control group (n=12). Supervised exercise consisted of three 60-min gym sessions per week of moderate intensity aerobic and resistance training for 12 weeks. Control participants received usual care. The incremental shuttle walk test (ISWT) was used to assess functional walking performance after the 12-week exercise intervention, and at 24 weeks follow-up. Measures of anthropometric, physical activity, cardiovascular and psychological outcomes were also examined. Using an intention-to-treat protocol, independent t-tests were used to compare outcome measures between groups.

RESULTS

Significant improvements in the exercise group were observed for the ISWT, body composition, physical function, cardiovascular and self-efficacy measures from baseline to 12 weeks. A large baseline to 12-week change was observed for the ISWT (exercise: 325.00±117.28 m; control: 355.00±80.62 m, P<0.001). The exercise group at 24 weeks recorded an overall mean improvement of 143.3±86.6 m and the control group recorded a reduction of -32.50±75.93 m. Findings show a 5.6 kg difference between groups in body mass change from baseline to 24 weeks favouring the exercise group.

CONCLUSIONS

A 12-week supervised exercise intervention led to significant improvements in body mass and functional walking ability post intervention, with further improvements at the 24-week follow-up.

Change in Pain and Physical Function Following Bariatric Surgery for Severe Obesity

IMPORTANCE

The variability and durability of improvements in pain and physical function following Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric banding (LAGB) are not well described.

OBJECTIVES

To report changes in pain and physical function in the first 3 years following bariatric surgery, and to identify factors associated with improvement.

DESIGN, SETTING, AND PARTICIPANTS

The Longitudinal Assessment of Bariatric Surgery-2 is an observational cohort study at 10 US hospitals. Adults with severe obesity undergoing bariatric surgery were recruited between February 2005 and February 2009. Research assessments were conducted prior to surgery and annually thereafter. Three-year follow-up through October 2012 is reported.

EXPOSURES

Bariatric surgery as clinical care.

MAIN OUTCOMES AND MEASURES

Primary outcomes were clinically meaningful presurgery to postsurgery improvements in pain and function using scores from the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) (ie, improvement of ≥5 points on the norm-based score [range, 0-100]) and 400-meter walk time (ie, improvement of ≥24 seconds) using established thresholds. The secondary outcome was clinically meaningful improvement using the Western Ontario McMaster Osteoarthritis Index (ie, improvement of ≥9.7 pain points and ≥9.3 function points on the transformed score [range, 0-100]).

RESULTS

Of 2458 participants, 2221 completed baseline and follow-up assessments (1743 [78.5%] were women; median age was 47 years; median body mass index [BMI] was 45.9; 70.4% underwent RYGB; 25.0% underwent LAGB). At year 1, clinically meaningful improvements were shown in 57.6% (95% CI, 55.3%-59.9%) of participants for bodily pain, 76.5% (95% CI, 74.6%-78.5%) for physical function, and 59.5% (95% CI, 56.4%-62.7%) for walk time. Additionally, among participants with severe knee or disability (633), or hip pain or disability (500) at baseline, approximately three-fourths experienced joint-specific improvements in knee pain (77.1% [95% CI, 73.5%-80.7%]) and in hip function (79.2% [95% CI, 75.3%-83.1%]). Between year 1 and year 3, rates of improvement significantly decreased to 48.6% (95% CI, 46.0%-51.1%) for bodily pain and to 70.2% (95% CI, 67.8%-72.5%) for physical function, but improvement rates for walk time, knee and hip pain, and knee and hip function did not (P for all ≥.05). Younger age, male sex, higher income, lower BMI, and fewer depressive symptoms presurgery; no diabetes and no venous edema with ulcerations postsurgery (either no history or remission); and presurgery-to-postsurgery reductions in weight and depressive symptoms were associated with presurgery-to-postsurgery improvements in multiple outcomes at years 1, 2, and 3.

CONCLUSIONS AND RELEVANCE

Among a cohort of participants with severe obesity undergoing bariatric surgery, a large percentage experienced improvement, compared with baseline, in pain, physical function, and walk time over 3 years, but the percentage with improvement in pain and physical function decreased between year 1 and year 3.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00465829.

The Impact of Vitamin D, Calcium, Protein Supplementation, and Physical Exercise on Bone Metabolism After Bariatric Surgery: The BABS Study

Laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are common and effective methods to treat severe obesity, but these procedures can adversely influence bone metabolism and areal bone mineral density (aBMD). This was a prospective 24-month single-center interventional two-arm study in 220 women and similarly aged men (median age 40.7 years) with a body mass index (BMI) >38 kg/m(2) after RYGB and SG procedures. Patients were randomized into: 1) an intervention group receiving: 28,000 IU cholecalciferol/wk for 8 weeks before bariatric surgery, 16,000 IU/wk and 1000 mg calciummonocitrate/d after surgery, daily BMI-adjusted protein supplementation and physical exercise (Nordic walking, strength perseverance, and equipment training); 2) a non-intervention group: no preoperative loading, nutritional supplementation, or obligatory physical exercise. At study endpoint, when comparing the intervention group to the non-intervention group, the relative percentage changes of serum levels of sclerostin (12.1% versus 63.8%), cross-linked C-telopeptide (CTX, 82.6% versus 158.3%), 25-OH vitamin D (13.4% versus 18.2%), phosphate (23.7% versus 32%, p < 0.001 for all), procollagen type 1 amino-terminal propeptide (P1NP, 12% versus 41.2%), intact parathyroid hormone (iPTH, -17.3% versus -7.6%), and Dickkopf-1 (-3.9% versus -8.9%, p < 0.05 for all) differed. The decline in lumbar spine, total hip and total body aBMD, changes in BMI, lean body mass (LBM), as well as changes in trabecular bone score (TBS) values (p < 0.005 for all) were less, but significantly, pronounced in the intervention group. We conclude that vitamin D loading and ongoing vitamin D, calcium, and BMI-adjusted protein supplementation in combination with physical exercise decelerates the loss of aBMD and LBM after bariatric surgery. Moreover, the well-known increases of bone turnover markers are less pronounced.

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

Although physical activity performed after bariatric surgery is associated with enhanced weight loss outcomes, there is limited information on patients' physical activity behaviour in this context. This systematic review and meta-analysis assessed pre-operative to post-operative changes in physical activity and physical function outcomes among obese adults undergoing bariatric surgery. A total of 50 studies met inclusion criteria with 26 papers reporting data for meta-analysis. Increases in both objectively recorded and self-reported physical activity at 12 months were demonstrated. Studies indicated that there was a shift towards a greater amount of active time, but of a lower intensity within the first 6 months of bariatric surgery, suggested by a reduction in moderate to vigorous physical activity but an increase in step count. A standardized mean difference (SMD) of 1.53 (95% CI: 1.02-2.04) based on nine studies indicated improved walking performance at 12 months. Similarly, analysis of five studies demonstrated increased musculoskeletal function at 3-6 months (SMD: 1.51; 95% CI: 0.60-2.42). No relationship was identified between changes in weight and walking performance post-surgery. More studies assessing physical activity, physical function and weight loss would help understand the role of physical activity in optimizing post-operative weight and functional outcomes.

Comprehensive assessment of physical functioning in bariatric surgery candidates compared with subjects without obesity

BACKGROUND

Obesity appears to be associated with reduced physical performance, but comprehensive assessments of physical functioning are lacking in subjects with severe obesity, in particular in comparison with subjects without obesity. This precludes an objective assessment of the degree of impairment.

OBJECTIVE

To compare motor skills and cardiopulmonary fitness between subjects with severe obesity (OB) (i.e., candidates for bariatric surgery) and control subjects without obesity (non-OB).

SETTING

Cantonal Hospital, Switzerland.

METHODS

Flexibility, movement speed, balance, maximal isometric strength, and cardiopulmonary fitness were tested in 45 OB (body mass index: 42.6±.9 kg/m(2); age: 35±1.7 years; 33 women) and 32 non-OB (body mass index: 23±.4 kg/m(2); age: 38.5±2.1 years; 25 women) subjects.

RESULTS

In comparison with the non-OB group, the OB group showed reduced shoulder flexibility (P<.001) but comparable hamstrings flexibility (P = .3). Speed-related tasks (i.e., timed up-and-go test and timed lying-to-standing test) indicated that the OB group was slower than the non-OB group (all P<.007). Strength-related tasks indicated a greater absolute back muscle and knee-extensor strength (all P<.002) in the OB group with no difference in knee-flexor strength (both P>.8). However, when related to weight, the OB group showed reduced maximal strength (all P<.002). Bicycle spiroergometry indicated that absolute oxygen consumption at peak exercise and at the anaerobic threshold did not differ between groups (both P>.06). Related to weight, however, values were lower in the OB than in the non-OB group (both P< .001).

CONCLUSION

Data indicate a differential pattern of functional impairment in bariatric surgery candidates compared with subjects without obesity. These findings might help to establish tailored intervention protocols to improve physical performance in such subjects.