This blog provides free general information for anyone who is seeking to understand more about physical activity and exercise after bariatric surgery, not intended as a medical consult. Please seek appropriate medical and allied health advice for individual assessment and management.

 

The crucial learning points are:

• Recognizing that weight regain is not unexpected after bariatric surgery due to many reasons. To achieve optimal long term results successful weight loss surgery needs to be accompanied by a permamnet lifestyle change and behaviour modification.
• Understand the benefits of a regular physical training program and some of the barriers to exercise, to help patients overcome this problem.
• Explain the important contribution from an exercise physiologist in assisting post op weight loss, improve physical fitness and endurance.

 

 

 

 

The need for lifestyle modification after laparoscopic sleeve gastrectomy

Weight regain is expected after laparoscopic sleeve gastrectomy (LSG) and in fact after any bariatric operations. It has been reported in one paper that over 60% of patients achieve less than 50% excess weight loss (EWL) 5 years after their initial surgery.

Conclusions from other studies include:

• The 3rd International Summit for LSG (reporting on the results of 19,605 LSG cases) published that the mean %EWL at 5 years was 60%.
• One study reported that EWL was 70% at 3 years but dropped to 57% by 5 years.
• Another study reported that the mean %EWL was 72% at 3 years and 64% at 5 years.

 

The reasons for weight re-gain are multifactorial and difficult to pin point exactly. From a technical (or surgical) perspective, possible reasons for weight regain include remnant stomach dilation and the complex neuro-hormonal changes post LSG, leading to loss of appetite suppression months or years after surgery. The removal of the ghrelin-secreting gastric fundus is eventually overcome by a compensatory increase or activation of previously silent ghrelin-producing cells distributed throughout the rest of the gastrointestinal tract.

The most crucial factor is possibly the lack of lifestyle change or behavioral modification after bariatric surgery. For long-term success, all patients are strongly advised to alter their lifestyle. These technical reasons listed above may be unavoidable or inevitable with time, this is the body physiological adaptation after surgery but certainly compliance to dietary plans and the level of participation in physical training and exercise is within the control of the patients.

 

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Preventable factors against weight regain

 

Weight regain is mainly attributed to the two main factors, bad nutrition habits and lack of exercise in the later years after the procedure. Studies have revealed two groups of people:

• The first group is patients who are compliant with post op advice and changes but overtime, ceased to do so and regained weight.
• The second group is those who did not make any of the changes at all and therefore exhibited insufficient weight loss from the very beginning.

 

Unfortunately with time delay, the chances of success (in terms of further weight loss) after the 3 to 5 years mark by dieting, exercise or other conservative measures without revisional bariatric surgery, are not very high. Hence the habit needs to be cultivated from the very early stage in the patient’s weight loss journey, ideally just after the surgery.

It is well known that with weight loss there are significant improvements in pre-existing obesity related co-morbidities, enhancement of quality of life and reduction in complications. Conversely it is also understood that some of these gains in health may be lost with time and the main reason for this decline is weight regain.

Already allude to in other sections, there are many different benefits that can be derived from LSG, which can’t be measured in terms of absolute weigh loss alone. Please refer to “Defining successful results after surgery”.

 

However this particular section is to discuss how to achieve adequate weight loss in the long term and placing emphasis on maintenance of weight loss (and health improvements indirectly) for the duration, highlighting the benefits of a permanent lifestyle change by:

• Behavioural modification
• Improved nutrition (controlled food portions and good food choices)
• Avoiding eating disorders (good eating habits)
• Maintain regular physical activity and exercise
• Increased patient awareness about nutrition and health

 

Please also refer to other sections in this blog such as “Understanding visceral obesity and chronic inflammation” and “Understanding visceral obesity and metabolic syndrome”.

 

 

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The benefits of physical activity and exercise

Having a consistent level of physical activity has been established as an important predictor of weight loss maintenance in the long term after bariatric surgery. Those who did not return to any regular exercise or increase their level of physical activity following surgery were less likely to achieve any successful result, arbitrarily defined as over 50% excess weight loss.

Physical Activity Guidelines for Americans published in the US recommends approximately 150 minutes per week of moderate-intensity cardiorespiratory exercise and 2–3 days per week of both resistance training and flexibility training. Obviously this is almost impossible for obese patients to accomplish by themself.

Regular low impact aerobic exercise or physical training helps to preserve lean muscle mass and basal metabolic rate during the initial rapid weight loss phase in the first few months after bariatric surgery, which is essential to ensure ongoing weight loss and improvement in medical conditions such as Type 2 diabetes.

Not only does physical training contribute to better exercise tolerance, overall fitness and endurance, it also enhances mental health and social wellbeing. The added advantage is that group meetings at a gym or by having the special personalized attention from an exercise physiologist, helps patients focus on maintaining a healthy lifestyle, provide patients with the crucial education on how to exercise properly and safely, maintain motivation, offers encouragement and social support.

 

 

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Understand some of the barriers to exercise

The common barriers to exercise in the early stages after bariatric surgery are often wound pain and lack of energy. During the rapid weight loss phase, massive reduction in calories plus the inability to drink large quantities of fluids often leads to fatigue and dehydration. The first month in the post-operative period may the most difficult time for patients, most take two weeks off work to recover and moderate intense physical activity during this time is rarely possible.

Also we need to acknowledge that some patients will not be able to undergo strenuous exercise, for example those with certain physical conditions, especially degenerative joint disease.

Research has indicated that lack of time, energy and motivation as the three most frequently cited barriers to exercise. It is well known that obese patients with motivation problems before surgery will continue to struggle with motivation to exercise after surgery. By mentioning these issues, we hope to raise awareness and facilitate a change in mental attitude towards physical activity. In other words please don’t think of “exercise” as a dirty word.

Common cited patient factors contributing to lack of exercise include:

• Lack of awareness and priority placed on exercise and physical activity.
• Lack of motivation, enjoyment or self esteem and being embarrass to be out in public due to the obesity.
• Lack of energy or ability to exercise due to reduced exercise tolerance, endurance or physical limitations from obesity.
• Failure of previous dieting and exercise programs attempts.

 

Medical practitioners need assistance to design a more effective service or intervention to improve the patient’s exercise habits above and beyond what is considered minimal standard after bariatric surgery, to enhance long-term positive outcomes such as weight loss maintenance and wellbeing.

Patients also often report on the benefits of having readily accessible community-based facilities and the assistance of a professional exercise physiologist.

Medical practitioners including bariatric surgeons should:

• Educate patients about the necessity of post op exercise and physical training starting from the first time they meet the patient (the pre-op consult).
• Encourage the patient to make plans to see a dietician and exercise physiologist early on after surgery.
• Ensure that the patient is receiving professional exercise physiologist assistance that they are entitled to as part of their weight loss program.

 

 

 

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An exercise physiologist

The many roles of an exercise physiologist includes:

• Offering a wide range of exercise for return to work programs after physical injuries.
• Acute injury and chronic disease management and prevention of future impairment.
• Supervise weight loss and resistance training programs, including post bariatric surgery lean muscle mass preservation and endurance training, which is important not only for maintaining basal metabolic rate but also body toning to help reduce excess skin after massive weight loss.

 

The greatest benefit of having a personal exercise physiologist is to have a tailored exercise program to suit according to the individual’s physical ability, as well as providing ongoing encouragement to make the appropriate lifestyle changes to maximize results. The individual session can be scheduled to provide opportunities for a trainer to observe the patient’s ability to exercise in a safe and efficient manner, allowing them the privacy that is needed unlike a crowded commercial fitness gym.

Firstly and most importantly having an exercise trainer is to remind the patients to place priority on having a proper exercise program and to maintain a consistent habit. In other words having accountability and commitment. As mentioned above the barriers to exercise are often lack of awareness or motivation.

Secondly weight loss after surgery is often facilitated by preservation of lean muscle mass and having an enhanced basal metabolic rate, which leads to better weight loss results in the long term. This is important in the context of inadequate post op weight loss. Some studies report that 20–30 % of patients fail to lose significant amounts of weight following surgery and some regain weight after a short period of time.

It is anticipated that a significant number of patients need help to overcome motivational barriers, including how they perceive themselves as being part of a group undertaking fitness training. Thus the set up of the facilities is important to allow patients to become familiar and comfortable with the sets of exercise and the environment.

An exercise physiologist is trained not only to detect for lack of enthusiasm or identify those struggling with motivation but more importantly recognize those who have physical limitations associated with obesity and unable to exercise fluidly. The personal trainer can help set up a more appropriate training regime to avoid potential physical injuries during the exercise routine.

In addition by providing a more tailored program specific to individual needs, this may increase the likelihood that bariatric patients will establish lifelong exercise habits to achieve long-term weight loss maintenance, health improvement and positive self esteem (confidence).

Building one-on-one relationships between patients and exercise physiologist or with other patients that visit the same facility not only help them constantly gauge their progress with each other but also allow opportunities for social interaction.