International Journal of Obesity www.nature.

com/ijo

REVIEW ARTICLE
Bariatric Surgery

Do patients with obesity undergoing bariatric surgery modify

their objectively measured physical activity? A systematic
review and meta-analysis
1,2 ✉ 3
Murilo Bastos , Camila Gonsalves , Bruno Pedrini de Almeida1,4, Timothy G. Cavazzotto3 and Michael Pereira da Silva 1,4,5

© The Author(s), under exclusive licence to Springer Nature Limited 2023

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.
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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.
International Journal of Obesity; https://doi.org/10.1038/s41366-023-01452-9

INTRODUCTION comorbidities, lipid profile, respiratory function, sleep disorders,

Bariatric surgery (BS) is considered one of the most effective
methods for treating severe obesity, as it brings sustainable
weight loss and improves associated comorbidities [1–3]. In 2016,
it was estimated that around 600,000 BS were performed
worldwide [4], with more women undergoing this type of
procedure than men [5], even with the similar prevalence of
obesity between sexes [6]. Considering that obesity affects around
650 million people worldwide [7], BS seems to be an efficient
intervention for weight loss, even though it is an invasive
procedure.
BS is a term used for surgical techniques to reduce the caloric
intake of obese individuals [8]. BS is an effective obesity treatment
indicated for individuals aged over 18 years, with BMI ≥40, <40
and ≥35 kg/m2 with comorbidity, or with BMI <35 and ≥30 kg/m2
with diabetes or refractory hypertension [3, 9–12]. In addition to
weight loss, some studies have shown a reduction in levels of
anxiety and depression [13–15], a reduction in bulimic behavior
[15], a significant increase in quality of life [16], a decrease in
medication use [17], and an improvement in obesity-related
degenerative joint disease, infections, among others [18].
In addition to reducing body fat, weight loss induced by BS may
also impact fat-free tissues, such as muscle and bone mass, which
typically occur between 33% and 50% of the total weight loss [19].
Thus, the period following surgery may adversely affect muscle
function and strength, increasing the risk of osteoporotic fractures
[20, 21]. Increasing physical activity (PA) is a necessary interven-
tion to avoid possible adverse effects after BS, since, in addition to
contributing to improvements in surgical results [21], it protects
against the development or worsening of DM2 through increasing
insulin sensitivity [22], acts in the maintenance and additional
weight loss [2, 23], and prevents osteoporotic fractures [20].
Along with obesity, physical inactivity is one of the main risk
factors associated with premature mortality, and cardiometabolic
diseases [24]. Engagement in regular PA, especially in moderate to
vigorous intensity (MVPA), increases cardiorespiratory fitness, which
is more important to reduce morbidity and mortality in people with
overweight and obesity than the weight loss itself [25]. However,
the literature shows inconsistent results about changes of PA after

1
Physical Activity and Public Health Research Group (GPASP), Rio Grande, Brazil. 2Pharmaceutical Sciences Sector – Midwestern State University (UNICENTRO), Guarapuava, Brazil.
3
Physical Education Department – Midwestern State University (UNICENTRO), Guarapuava, Brazil. 4Graduate Program in Health Sciences – FAMED – FURG, Rio Grande, Brazil.
5
Graduate Program in Public Health – FAMED – FURG, Rio Grande, Brazil. ✉email: murilo_bastos@yahoo.com.br

Received: 27 April 2023 Revised: 5 December 2023 Accepted: 14 December 2023

 M. Bastos et al.
2
the BS, with some studies finding an increase [9, 26–28], a decrease
[29], and others without significant PA changes [30–33].
A lifestyle change related to increased PA levels is highlighted
as a non-pharmacological strategy that allows individuals to
maximize the health benefits after undergoing bariatric surgery.
Understanding the changes in the PA of individuals who undergo
BS is essential, considering its potential increase of protective
effect on the weight loss associated with the BS. Moreover, PA
may increase quality of life, social and mental health in this
population [13–16, 34].
Therefore, this systematic review and meta-analysis aimed to
evaluate changes in objectively measured PA in bariatric surgery
patients. The restriction to objective measured protects against
the recall bias and overestimation commonly seen in self-report
PA [35]. We hypothesized that individuals increased their PA after
BS, irrespective of PA intensity.
METHODS
This systematic review of the literature followed the criteria
suggested by Preferred Reporting Items for Systematic Reviews
and Meta-Analysis (PRISMA) for systematic reviews [36].
Eligibility criteria
Eligible studies included patients aged between 18 and 65 years
who underwent a bariatric surgery procedure (gastric banding,
gastric bypass, sleeve gastrectomy, or biliopancreatic diversion)
and provided both pre- and post-BS PA objective measures (i.e.,
accelerometers or pedometers).
Information sources and search strategy
We initially conducted a search in September 2020, utilizing the
PUBMED, EMBASE, Web of Science, and Science Direct databases.
Subsequently, we updated the search in August 2023, using the
following descriptors: adult, middle-aged, bariatric surgery,
bariatric medicine, motor activity, exercise, and physical activity.
The search terms were (Adult OR Middle Aged) AND (Bariatric
Surgery OR Bariatric Medicine) AND (Motor Activity OR Exercise OR
Physical Activity OR Training*). The Boolean operators AND and
OR were used. Language restrictions were not applied, and no
specific period was delimited.
Selection process
Two independent researchers carried out the selection of titles,
abstracts, and full-text reading. The software Rayyan [37] handled
the title and abstract selection process. Conflicts were solved by
consensus.
We included studies with adults who underwent a surgical
procedure and performed objective PA measures before and after
BS. Studies lacking a PA objective measure, those omitting details
about the device employed for its assessment, and those lacking
comprehensive information on PA levels, both pre- and post-
bariatric surgery, were excluded.
Data collection process
Information from the selected studies was manually extracted and
tabulated in Excel® software. The following information was
extracted from the studies: Study design, age group, sample size,
the instrument used for measuring PA, measurement time (pre-
and post-BS), PA type and intensity level, and both pre- and post-
surgery PA level. We selected studies that objectively evaluated
PA, considering it in steps by day (Pedometer), light-intensity
physical activity (LPA), and moderate to vigorous physical activity
(MVPA), using accelerometers.
Study risk of bias assessment
We evaluated the methodological quality using the
Newcastle–Ottawa Scale [38] for cohort studies. The assessment
was performed by two researchers and discussed in a consensus
meeting. The scale evaluates three domains (selection, compar-
ability, and outcome) with specific criteria. Each criterion in the
Selection and Outcome topics has a maximum attribution of one
star, while the Comparability topic, with only one criterion, has a
maximum attribution of 2 stars. To convert the number of stars
into a quality scale, the following standard was adopted: High
Quality: 7–9 stars/points; Fair Quality: 4–6 stars/points; Low
Quality: 0–3 stars [38, 39].
Statistical analysis
Statistical analysis was performed using the statistical software R
3.6.0 and RStudio interface (Version 1.2.1335). The meta-analysis
used the “meta” package and the “metacont” command. Means
and standard deviations of physical activity variables were
extracted from pre- and post-BS data and pooled using fixed
and random effect models expressed by mean differences (MD).
Heterogeneity between studies was assessed using the Q test and
the I2 test. The I2 represents the amount of total variation that is
explained by variation between studies. I2 values of approximately
25%, 50%, and 75% indicate low, moderate, and high hetero-
geneity. Analyses were stratified according to type and physical
activity intensity (steps by day, light physical activity (LPA), and
moderate to vigorous physical activity (MVPA)).
In addition, a meta-regression was performed to identify the
influence of time (in months) of measurement after surgery on the
observed mean differences. The power of the meta-analysis was
tested using the “metapower” package of the statistical software
R 3.6.0.
Reporting bias assessment
Publication bias was tested by visually inspecting the Funnel Plots,
and the effects of small studies were assessed using Trim & Fill
method.
RESULTS
Studies selection
The systematic search resulted in 419 records. After excluding 103
duplicate records, 316 were selected for title and abstract reading.
After this initial phase, 84 articles were selected for full-text
reading. The full-text reading step excluded 75 studies, of which
33 did not have a PA objective measure, 31 did not measure PA
before and after surgery, 5 did not report the measurement
instrument and how it was performed, 5 was a nonsurgical
procedure, and 1 did not have the full-text available (Fig. 1).
Risk of bias in studies
The risk of bias assessment is shown in Table 1. None of the
selected studies met the domain for comparability, impairing the
overall score. On the other hand, regarding the selection domain,
all selected studies fully complied. Lastly, the outcome domain
was not fully met in two studies [24, 25] since the device used to
measure the PA had not been validated until this review was
carried out [40]. Therefore, as the comparability domain is
essential to guarantee a high level of quality, the methodological
quality assessment of the selected studies was defined as
moderate quality (score equal to 4–6).
Studies characteristics
Table 2 summarizes the study’s characteristics. The samples
ranged from 20 [9] to 473 [27] participants. Most of the study
participants were women, with a proportion ranging from 73% to
100%. The sample’s age ranged from 36 to 47 years old. One of
the selected studies did not describe the mean age of participants
[31].
Among the surgical procedures performed in the 10 included
studies, 4 evaluated only one type of procedure (Gastric Bypass,
International Journal of Obesity
 M. Bastos et al.
3

Fig. 1 Flowchart of the study selection steps. The figure shows the steps of the study selection, where in the identification step shows the
records by database and removal of duplicates, the screening step shows the records screened and the reasons of the exclusion, and the final
step (inclusion) showing the number of studies selected.

Table 1. Newcastle–Ottawa methodological quality assessment.

Study Selection Comparability Outcome Total score
Afshar et al. [30] 2 0 3 5
Berglind et al. [31] 2 0 3 5
Bond et al. [32] 2 0 3 5
Creel et al. [33] 2 0 3 5
Josbeno et al. [9] 2 0 3 5
King et al. [26] 2 0 2 4
King et al. [27] 2 0 2 4
Ibacache et al. [35] 2 0 3 5
Nielsen et al. [29] 2 0 3 5
Sellberg et al. [28] 2 0 3 5
The definition/explanation of the Newcastle–Ottawa Scale [38] is available from (http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp).

Gastric Sleeve, or Roux-en-Y Gastric Bypass) [9, 28, 31, 41]. The
other studies evaluated samples that performed a greater variety
of procedures. The Roux-en-Y gastric bypass was the most
common surgical procedure among the selected studies.
Physical activity measurements
The interval between the first PA assessment and the surgical
procedure ranged from 1–2 weeks to 3 months [9, 26, 29, 31], but
5 of the studies did not inform the period in which the first
assessment was performed [28, 30, 33, 34, 41]. Post-procedure
evaluations ranged from 1 month [41] to 3 years [27]. The devices
used for the objective assessment of the PA were accelerometers,
used in 7 studies [28–33, 41], and the pedometer, used in 3 studies
[9, 26, 27].
Among the PA measures evaluated, 7 studies measured the
amount of MVPA [27–32, 41], measured in minutes/day or per
week, 3 studies evaluated the number of steps taken per day
(steps by day) [9, 26, 27], 3 studies evaluated the daily amount of

International Journal of Obesity

 4
Table 2. Summary of evidence from selected studies (n = 10).
Study N Age (years) Methods Device Surgical Weight lost PA before surgery PA post-surgery Result
procedure post-surgery
Afshar 22 (73% 46.2 ± 8.1 Data were collected Triaxial 17 LRYGB; 4 SG; 1 27.4 ± 9.2 kg MVPA (min/day) MVPA (min/day) 0
et al. [30] women) before surgery, accelerometer intragastric balloon 24.2 ± 7.5% = 11.5 ± 13.9 = 11.6 ± 13.1
without informing (GENEActiv,
how long before Activinsights Ltd.
and 6 months after
surgery
a
Berglind 43 Patients were Accelerometer LRYGB 32.3 ± 8.3 kg MVPA MVPA 31.3 ± 21.0 min/day 0
et al. [31] women instructed to use the (GT3X) 31.1 ± 17.7 min/day
accelerometer 3
months before the
procedure and
9 months later
Bond 20 (88% 47.1 ± 9.6 Patients used the Accelerometer 13 laparoscopic- – MVPA MVPA 151.2 ± 118.3 min/week 0
et al. [32] women) accelerometer for 8 RT3 (Stayhealthy, adjustable gastric 186.0 ± 169.0 min/
days before the Monrovia, CA) banding, 7 LRYGB week
procedure, without
informing how long
before and
6 months after the
procedure
Creel 52 (85% 41.86 ± 10.8 Participants were Accelerometer 9.4% SG; 5.7% 38.4 ± 2.8 kg LPA Dispended time 2 months – 36.6 (2.9) 0
et al. [33] women) randomized (1:1:1) (GT3X) LRYGB, 5.7%; (%) (±SE) – 32.9 (2.1) 4 months – 35.5 (2.9)
into 3 groups revision LRYGB; 6 months – 33.1 (2.4)
(Standard care, 3.8% duodenal
M. Bastos et al.

Pedometer use, and switch

Exercise
counseling). All
groups were
monitored with an
accelerometer for 2
weeks, in the pre-
surgery period,
without informing
how long before.
After surgery (2, 4,
and 6 months later),
all were evaluated
for 2 weeks with the
accelerometer
Josbeno 20 (90% 41.6 ± 9.8 Subjects were Pedemeter (Digi- Laparoscopic 24.4 ± 5.6 kg 4621 ± 3701.18 7370 ± 4240.14 steps/day +
et al. [9] women) instructed to wear a walker SW-200) gastric bypass 39.5 ± 7.1% steps/d
pedometer daily for
1 week prior to the
procedure and for
1 week prior to the
scheduled 3-month
follow-up
assessment
King 310 (78% 46 (19–76) The mean number Activity Monitor LRYGB – 214 – 7563 (1552–21,349) 1 year – 8788 (1502–24,121) +
et al. [26] women) of steps/d, active StepWatch 3 (69.0%); steps/day steps/day
min/day, and high laparoscopic-
cadence min/ adjustable gastric
without PA pre, 30 banding – 67
days before the (21.6%); Others –
procedure, and 29 (9.4%)
postoperative, 1

International Journal of Obesity

year after
 Table 2. continued
Study N Age (years) Methods Device Surgical Weight lost PA before surgery PA post-surgery Result
procedure post-surgery
King 473 (79% 47 (37–55) A subset of Activity Monitor LRYGB − 3 29 1 year 7687.5 Steps/day – 1 year: 8958.8 + in the
et al. [27] women) participants in an StepWatch 3 (69.6); 29% (95% CI: (7400.7–7974.2) (8623.4–9294.2); 2 years: steps/
observational study laparoscopic- 29–30) steps/day; 9214.3 (8847.6–9581.0); 3 day and
wore an activity adjustable gastric MVPA -77.3 years 8935.4 (8565.1–9305.7) MVPA
monitor pre-surgery, banding – 108 (70.9–84.2) min/ MVPA min/week 1 year: 106.0 all
30 days before the (22.8) week (97.8–116.4); 2 years: 112.5 times
procedure, and at Biliopancreatic (99.8–123.0): 3 years 98.5
1–3 annual diversion with (88.0–110.0)

International Journal of Obesity

assessments duodenal switch –
afterward 7 (1.5)
SG – 26 (5.5)
Banded gastric
bypass – 3 (0.6)
Ibacache 23 36 ± 11.1 PA assessment was Accelerometer SG 1 month LPA – 95.6 1 month – 0
et al. [41] women performed before ActiGraph GT3X+ 9.8 ± 10.6 kg (89.3–98.0) LPA – 96.3 (92.3–97.4);
the procedure, (counts/min) 3 months MPA – 4.1 (1.9–10.2) MPA – 3.6 (2.6–7.2)
without informing 17.6 ± 10.0 kg VPA −0.2 (0.1–0.5) LPA – 0.1 (0.0–0.4)a
how long before MVPA – 4.3 MVPA – 3.7 (2.6–7.6)
and after 1 and 3 (2.0–10.7) 3 months
months of the LPA – 95.7 (89.3–97.6)
procedure MPA – 4.0 (1.4–10.2)
LPA – 0.2 (0.1–1.0)
MVPA – 4.2 (2.4–10.7)
Nielsen 41 (85% 39.6 ± 9.5 PA assessment in 4 Accelerometer LRYGB – 31 and 10 6 months later 3 months pre- 6 months after –
et al. [29] women) moments: 3 months ActiGraph GT3X+ – SG 34.2 ± 1.9 kg surgery (N = 39) = 22.6 ± 3.0 min/
and 1–2 weeks (min/d) 18 27.6 ± 3.0 min/day day MVPA
before surgery; 6 months later 1–2 weeks pre – 18 months later
and 18 months after 42.0 ± 1.9 kg 30.4 ± 3.0 min/ (N = 28) = 21.3 ± 3.4
surgery, for 6 days day MVPA
and 7 nights
Sellberg et 39 45.8 ± 9.9 Assessment through Accelerometer LRYGB 47.2 ± 16.8% 26.4 ± 21 min/day 12 months later AFL – 0
al. [28] women questionnaire and ActiGraph GT3X+ LPA 26.6 ± 22.4 min/day +
device performed (min/day; steps/ 26.4 ± 21.0 min/day
M. Bastos et al.

MVPA – 29.6 (22.4) min/day

before, without day) MVPA Steps – 7511.7 (2989.0) steps/
informing how long, 5971.0 ± 2776.5 day
and 12 months after steps/day
surgery, measuring
the amount of
physical activity and
sedentary time
PA physical activity, LPA light physical activity, MPA moderate physical activity, VPA vigorous physical activity, MVPA moderate to vigorous physical activity, LRYGB laparoscopic roux-en-Y gastric bypass, SG sleeve
gastrectomy.
+ indicates PA increase; 0 indicates PA stabilization; – indicated PA decrease.
a
The study did not show the age of the participants.
5
 M. Bastos et al.
6
Fig. 2 Forest plot for the mean differences between pre- and post-bariatric surgery. A Steps, B LPA, and C MVPA.
LPA [28, 33, 41]. One of the studies evaluated both steps by day
and MVPA [27], and another evaluated the amount of LPA and
MVPA [41].
Physical activity changes
Of the selected studies, 6 did not find changes in the amount of
PA when comparing the pre- and post-surgical procedure
[28, 30–33, 41], 3 verified an increase in PA [9, 26, 27], and one
found a decrease in PA after the surgical procedure [29].
META-ANALYSIS
Figure 2 shows the meta-analysis results for mean differences in
steps (2A), LPA (2B), and MVPA (2C) between pre- and post-
bariatric surgery. The number of steps by day increased by about
1340 steps after bariatric surgery (95% CI = 933.90; 1745.35,
p < 0.001). There was no heterogeneity between studies (I2 = 0%,
Q3 = 1.44, p = 0.70), and the power for the fixed effects model
was 0.99. The time the measurement was taken after surgery did
not influence the mean differences observed (β = –160.95; 95% CI:
–438.80; 116.90, p = 0.25). The Trim & Fill method identified
publication bias with the effect of small studies (Supplementary
File 1). The corrected effects indicated a smaller but still significant
mean difference between pre- and post-BS (MD = 1272.79; 95%
CI = 890.69; 1654.89, p < 0.001).
LPA increased by about 16.8 min/day after bariatric surgery
(95% CI = 2.60; 30.98, p = 0.02). Heterogeneity between studies
was low (I2 = 26%, Q2 = 2.69, p = 0.26), and the power for the
fixed effects model was 0.43. The time the measurement was
taken after surgery did not influence the mean differences
observed (β = 2.61; 95% CI = –0.99; 6.22, p = 0.15). The Trim &
Fill method identified publication bias with the effect of small
studies (Supplementary File 1). The corrected effects indicated a
reduction in the mean difference between pre and post surgery
(MD = 11.52; 95% CI = –1.61; 24.65; p = 0.08) and loss of statistical
significance.
MVPA remained stable between pre and post surgery (MD =
0.24; 95% CI = –0.08; 1.57, p = 0.92). Heterogeneity between
studies was high (p < 0.01; I2 = 98%; Q2 = 316.41, p < 0.001), and
the power for the random effects model was 0.09. The time the
measurement was taken after surgery did not influence the mean
differences observed (β = –0.08; 95% CI = –0.29; 0.12 p = 0.45).
There was no publication bias for the MVPA measure (Supple-
mentary File 1).
DISCUSSION
This study verified that patients who underwent bariatric surgery
increased their steps by day and the time spent in LPA; however,
the time spent in MVPA remained stable after the surgery.
International Journal of Obesity

There was a predominance of women in the included studies,
with a proportion ranging from 73% to 100%. A recent systematic
review also indicated that women are commonly more prevalent
in BS studies [42]. Obesity worldwide prevalence between genders
is similar [43]. However, there are studies indicating a trend
toward a higher prevalence of severe obesity (BMI ≥40 kg/m2) in
women [44], and surgical procedure is encouraged at this stage of
the disease. The greater search for bariatric surgery procedures
observed among women can also be explained by cultural aspects
encompassing health care between genders, with women’s
greater participation in health services, which is a determining
difference in the consumption of services [45].
Analysis grouped by PA type (MVPA, LPA or Steps by day)
showed significant differences when steps by day [9, 26–28] and
LPA were evaluated [28, 33, 41]. However, no significant
differences were found in MVPA [27]. Changes in PA evaluated
as steps by day between pre and post surgery may come from LPA
[46], given that a more significant amount of basic daily functional
movements, such as walking, sitting down, getting up, or carrying
heavy objects, may be related to the mobility gain attributed to
the weight reduction by surgery, especially in individuals with
severe obesity and impaired mobility [47]. Thus, better conditions
are promoted for performing LPA reflecting the increase in the
number of steps by day evidenced in the analyzed studies.
The literature presents evidence that higher PA levels are more
effective in preventing weight regain [48]. The evidence from this
systematic review and meta-analysis suggests a stability in time
spent in MVPA and an increase in walking-related activities. This
stability in MVPA may be related to an increasing PA before BS, as
part as the pre-surgical guidance [49], suggesting that in the long
term, similar strategies need to be adopted to maintain the amount
of PA. In addition, this may demonstrate the importance of ongoing
professional guidance, to prevent weight regain and ensure greater
health benefits for individuals who have undergone BS [50, 51].
However, only one study evaluated the amount of PA more than
once in the pre-surgery period (3 months and 1–2 weeks before BS)
and did not find differences between measures [29], indicating that
the pre-surgery PA could reflect the real-life behavior of the patients.
More studies, with more PA pre-surgery measurements are needed
to better understand this behavior.
Bariatric surgery without promoting health behavioral aspects in
the postoperative period can result in unfavorable health outcomes,
such as an increase in alcohol abuse [52, 53], depression [54], and
sarcopenia [55]. Therefore, interventions targeting lifestyle changes
post-BS, such as increasing PA, are essential, since the higher PA
level seems to favor a better quality of life, fewer body image
concerns, and lower depressive symptoms [56]. Furthermore, it is
observed that participation in physical exercise programs reduces
weight and body fat and increases cardiorespiratory fitness, walking
functionality, and muscle strength. Even that, it does not show
morphological changes in muscle mass [57].
Strength and limitations
This systematic review evaluated only studies that performed an
objective measure of physical activity. This might avoid bias
resulting from self-report measures, which usually overestimate
the physical activity level [35].
Some aspects of the methodological quality assessment of the
included studies may impact the results of this study. The score
achieved in the Ottawa scale ranged from 4 to 5, indicating a
moderate methodological quality, mainly because of the “compar-
ability” domain, which was not scored by any study. However, this
was a characteristic of all the included studies, with an
observational design and without a comparison group.
It was not possible to attribute the changes found in steps by
day and LPA to the BS since other aspects could influence these
changes, but they were not collected and analyzed by the
included studies. Future studies may fill this gap.
International Journal of Obesity
M. Bastos et al.
7
The high heterogeneity, as well as the low power of the
analyses of the studies included in this meta-analysis, may limit
the inference of the findings, requiring more standardized studies
with larger samples to improve this situation. However, perform-
ing a meta-analysis of the data included in this systematic review
is a strength of this study, even if the statistical power was low. It
allows an overview of PA behavior in BS patients. However, further
studies are needed to fill methodological gaps and improve the
statistical power of future meta-analyses.
Research and practical implications
It was observed that patients after undergoing BS were more likely
to increase light physical activities (steps by day and LPA) but did
not change their engagement in PA of moderate to vigorous
intensity, which was already low at the baseline.
Despite the known benefits of low-intensity PA [58, 59], further
improvements in cardiometabolic profile (i.e., cardiorespiratory
fitness, glucose and lipid profile) [25], as well as the healthy weight
loss after BS (i.e., preserving muscle functionality) [60] is more
related to MVPA. Promoting engagement in more intense PA
should be included in the after-surgery strategies, not only because
of its benefits on weight loss, but to promote a healthier lifestyle.
This is even more important since evidence shows that PA is lower
at 5 years after surgery when compared to 1 year after BS [61].
Some studies did not inform the period in which the first PA
assessment was performed and only one study provided multiple
PA measurements pre BS. Understanding the timing of the
measurements and whether patients had already increased their
PA before undergoing bariatric surgery is crucial for interpreting
the results presented in this systematic review and meta-analysis.
Furthermore, it may predict changes after BS. Future studies
should describe changes in PA before BS since increasing PA is
part of pre-surgical preparation.
CONCLUSION
Patients undergoing bariatric surgery improved their steps by day
and LPA between the pre- and post-surgery periods; however,
they did not change the amount of MVPA. This change might be
attributed to an increase in light-intensity activities related to
walking distributed in several domains from PA. Given the above,
periodic follow-ups after the surgical procedure may be crucial in
maintaining the weight loss induced by the surgery and
improving patients’ general health. In addition, other studies with
interventions in patients after surgery can contribute to the
creation of specific treatment guidelines to health professionals so
that they can help individuals to adopt a healthier lifestyle.
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AUTHOR CONTRIBUTIONS
MB and CG were the authors responsible for the conceptualization, methodology,
search and selection, data extraction and writing of the original draft. BPdA
performed the writing and review. TGC performed a written review and meta-
analysis. MPdS was the research coordinator and performed the meta-analysis,
conceptualization, writing and review of the original draft preparation.
International Journal of Obesity
M. Bastos et al.
9
COMPETING INTERESTS
The authors declare no competing interests.
ADDITIONAL INFORMATION
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available at https://doi.org/10.1038/s41366-023-01452-9.
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