obesity reviews doi: 10.1111/obr.12740 Obesity Treatment Effectiveness of exercise training after bariatric surgery —a systematic literature review and meta-analysis A. Bellicha1,2 , C. Ciangura2,3, C. Poitou2,3,4, P. Portero1 and J.- M. Oppert2,3 1Laboratory Bioengineering, Tissues and Summary Neuroplasticity (BIOTN EA7377), University We aimed to conduct a systematic review and meta-analysis of controlled trials Paris-Est, Créteil, France; 2Institute of assessing exercise training programs in patients with obesity undergoing bariatric Cardiometabolism and Nutrition (ICAN), surgery. We systematically searched exercise training studies performed after Sorbonne University, Paris, France; 3AP-HP, bariatric surgery published up to June 2017. Studies reporting changes in body Pitie-Salpetriere University Hospital, composition, physical fitness, functional capacity, objectively measured physical Department of Nutrition, Sorbonne University, activity, quality of life or relevant health outcomes were included. The review Centre for Research on Human Nutrition Ile-de- protocol is available from PROSPERO (CRD42017069380). Meta-analyses were France (CRNH IdF), Paris, France; and conducted using random-effects models when data were available from at least 4INSERM, UMRS NutriOmics Team, Paris, five articles. Twenty articles were included, describing 16 exercise training pro- France grams, of which 15 were included in the meta-analysis. Overall, exercise training was associated with higher weight loss (mean difference: À2.4 kg, 95% CI: À4.2; Received 21 February 2018; revised 18 May À0.6, I2 = 49%, n = 12), higher fat mass loss (À2.7 kg, 95% CI: À4.5; À1.0, 2018; accepted 9 June 2018 2 I = 50%, n = 8) and improved VO2max and functional walking (standardized mean difference: 0.86, 95% CI: 0.29; 1.44, I2 = 57%, n = 6; 1.45, 95% CI: Address for correspondence: J-M Oppert, MD, 0.32; 2.58, I2 = 89%, n = 6, respectively). Exercise training was not associated PhD, AP-HP, Pitie-Salpetriere University with lean body mass changes. In conclusion, exercise training programs Hospital, Department of Nutrition, Sorbonne performed after bariatric surgery were found effective to optimize weight loss University, Centre for Research on Human and fat mass loss and to improve physical fitness, although no additional effect Nutrition Ile-de-France (CRNH IdF), Hôpital on lean body mass loss was found. Pitié-Salpêtrière, Service de Nutrition, 47-83 Boulevard de l’Hôpital, 75013 Paris, France. Keywords: Bariatric surgery, exercise training, obesity, physical activity. E-mail: [email protected] Introduction positive relationship between self-reported physical activity and the amount of weight loss has been described in a Bariatric surgery is increasingly performed in patients with previous review published in 2011 (7). However, evidence severe obesity worldwide and in Europe (1). Bariatric surgery came from observational studies only. Two recent reviews leads to marked weight loss, decreased morbidity and mortal- published in 2015, synthesizing findings from five (8) and ity, and improved quality of life and physical function (2–4). eight (9) intervention studies published at that time, Clinical guidelines emphasize the need for lifestyle changes, suggested that exercise performed before or after surgery including regular physical activity, to enhance health benefits might improve physical fitness and metabolic health, (5). Objectively measured physical activity data indicate that without additional benefits on anthropometry and body most patients undergoing obesity surgery have insufficient composition (8,9). However, both controlled and non- levels of physical activity (6), suggesting important potential controlled studies were included, which represents a major benefits of physical activity interventions in these patients. bias given that bariatric surgery in itself is associated with Emerging evidence suggests that physical activity might decreased fat mass and lean body mass (10), improved car- provide important health benefits after obesity surgery. A diorespiratory fitness (4) and decreased muscle strength (4). © 2018 World Obesity Federation Obesity Reviews 2 Exercise training and bariatric surgery A. Bellicha et al. obesity reviews In addition, the number of studies was insufficient to con- Quality assessment duct a meta-analysis. Most recently, a number of controlled The methodological quality of included studies was scored trials have described the effects of exercise training on using the Physiotherapy Evidence Database (PEDro) scale various outcomes related to body composition, physical (https://www.pedro.org.au/) (22). The PEDro scale has been capacity or health status (11–20). Therefore, a systematic used extensively to assess rehabilitation programs and updated overview of this topic, complemented by a meta- exercise training interventions (9,23). The PEDro scale is analysis, is relevant. an 11-item checklist (specification of eligibility criteria, The aim of this review was to propose an updated overview random allocation, concealed allocation, baseline compara- and meta-analysis of the effectiveness of exercise training in bility, blind subjects, blind therapists, blind assessor, patients with severe obesity undergoing bariatric surgery. adequate follow up, intention-to-treat-analysis, between groups comparisons, point estimates and variability) receiv- Materials and methods ing a ‘yes’ or ‘no’ rating. The total score ranges from 0 to 10 since the first item is not included in the calculation. Trials Literature search, selection of studies and data with a score < 4 were classified as poor-quality, 4–5as extraction fair-quality, 6–8 as good-quality and ≥ 9 as excellent-quality (9). Quality of each included study was assessed indepen- The systematic review protocol is available from PROSPERO dently by two reviewers (AB, JMO). When opinions (PROSPERO 2017: CRD42017069380). The literature search differed, consensus was reached through discussion. was performed in June 2017, using four electronic databases (PubMed, Web of Science, Cochrane Library and EMBASE). Combinations of terms related to bariatric surgery (‘bariatric Reporting of findings surgery’, ‘obesity surgery’, ‘metabolic surgery’, ‘Roux-en-Y’, ‘gastric bypass’, ‘sleeve gastrectomy’, ‘gastric banding’, ‘duo- We reported changes in anthropometry, body composition, denal switch’) and to physical activity (‘physical activity’, ‘ex- physical fitness, functional capacity, objectively measured ercise’, ‘sedentary’, ‘endurance’, ‘resistance training’, physical activity, quality of life and health outcomes after ex- ‘aerobic’, ‘fitness’, ‘muscle strength’, ‘physical capacity’)were ercise training for each individual study (Table S1). Physical used in the search. The reference lists of included articles and fitness included cardiorespiratory fitness (assessed by a maxi- review articles were also scanned for further eligible studies. mal exercise test) and maximal muscle strength. Functional The initial inclusion criterion was the implementation of an ex- capacity was assessed with field-based fitness assessments ercise training program in adult patients with obesity undergo- (e.g. 6-min walk test, sit-to-stand test, half-squat test, arm curl ing bariatric surgery. Other inclusion criteria were as follows: test, chair sit-and-reach test, 8-foot up-and-go). Functional (1) articles written in English, (2) controlled trials comparing walking refers to the distance walked during walking tests. patients undergoing bariatric surgery receiving either usual To facilitate the synthesis of results, we grouped related meta- care or usual care and exercise training, (3) patients undergo- bolic outcomes into broader categories, e.g. fasting or post- ing gastric bypass, sleeve gastrectomy, gastric banding, prandial glucose and insulin, HOMA-IR, insulin sensitivity, biliopancreatic diversion or duodenal switch, (4) intervention insulin responsiveness were grouped into a category named ‘ ’ conducted after bariatric surgery and (5) pre-intervention to glucose metabolism ; or total, LDL-cholesterol or HDL- ‘ ’ post-intervention changes reported for at least one of the fol- cholesterol and triglycerides into the lipid profile category. lowing outcomes: anthropometry or body composition, objec- When several follow-up measurements were conducted, we tively measured physical activity or physical capacity, health- reported results from the first assessment after the end of the related quality of life, relevant other health outcomes. exercise training. When results of a single trial were reported The characteristics of included articles were extracted by in several studies (e.g. the trial by Coen et al. (24) was followed one reviewer (AB) and checked by a second reviewer by a series of studies (12,18,25,26)), we selected results from (JMO), and included authors, journal, year of publication, the parent trial or from the study with the largest sample size. study design, sample size, surgical procedure, description of intervention, outcomes, assessment tools, times of Data analysis measurement and main findings. Emphasis was placed on the description of intervention. The TIDierR checklist We performed meta-analyses using Review Manager ver- (including 12 items: brief name, why, what materials and sion 5.3 when data were available from at least five studies. procedures, who provided, how, where, when and how We reported the mean and standard deviation (SD) of abso- much, tailoring, modification of intervention